AC 439(1) HARR 28 BOROUGH OF HARROW Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1961 CARYL THOMAS M.D. B.Sc., D.PH. BARRISTER-AT-LAW BOROUGH OF HARROW Annual Report OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1961 CARYL THOMAS M.D. B.Sc., D.PH. BARRISTER-AT-LAW TABLE OF CONTENTS PAGE General Statistics 8 Deaths from Accidents 13 Cancer of the Lung 15 General Health Services Hospitals 18 Nursing Homes 22 Establishments for Massage and Special Treatment 23 Nursing, etc., in the Home 24 Day Nurseries 25 Clinics and Treatment Centres 25 Provision for Special Classes of Person 28 The Aged 30 Laboratory Facilities 34 Ambulances 35 Legislation 37 Sanitary Circumstances 38 Water 38 Fluoridation 39 Drainage 40 Public Cleansing 41 Public Conveniences 44 Disposal of the Dead 45 Sanitary Inspection 47 Housing 50 Factories 54 Shops Act 57 Atmospheric Pollution 59 Hazards of Radiation 61 Inspection and Supervision of Food 66 Hygiene of Food 72 Infectious and Other Diseases 74 Prevention and Control 74 Poliomyelitis 90 Tuberculosis 99 B.C.G 102 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 1961. The vital statistics were much those of the previous year, the main differences being a fall in the infant mortality rate to 18.1 and the unwelcome rise to 18 in the number of deaths from influenza. No cases of poliomyelitis were contracted in the district. The rise in the number of deaths from cancer of the lung which has been a feature of recent years, was arrested; but not too much comfort can be obtained from this, and it must be hoped that the interest stirred by the publication of the report of the Royal College of Physicians on "Smoking and Health" will be sustained and translated into action which can lead to a checking of the damage caused by heavy cigarette smoking. The Public Health Inspectors have continued their routine work, attending to conditions which were the subject of complaints, carrying out the examination of carcases of every animal killed at the local slaughter-houses, keeping a watchful eye on all places in which food is handled or dealt with in any way. Some progress was made in dealing with those out-worn houses in the district which are still occupied; this progress is still impeded by too small numbers of new Council houses becoming available. The year saw the coming-into-operation of the district's first Smoke Control Order; another was confirmed and much of the preparatory work was done for the introduction of the third order. From what has been learnt from the work in connection with these orders, and because additional staff has been engaged, it is hoped that a programme can be prepared which will see the whole district covered by orders within a few years. Even in a district such as this where it is not considered the air is heavily contaminated, the prevention of smoke pollution will undoubtedly benefit many people susceptible to bronchitis and other inflamatory conditions of the respiratory system who suffer much in the winter months. Whatever personal services might be provided or even curative services, 'he health of the district depends primarily on the basic environmental conditions, the services provided by the District Council, though not limited to those provided by the staff of the Public Health Department. When the future of the slaughter-houses in the district was being considered, both the Planning Committee and the Public Health Committee hoped that a suitably-sited slaughterhouse could be erected which would lead to the present ones no longer being used. A suitable site 6 could not be found in time to avoid the necessity of the work of improving those slaughterhouses which were being used being done by the agreed date of January 1st, 1962. It is hoped though that in spite of the delay this will be the solution, and that it will be possible to discontinue the use of the existing slaughterhouses which, however high their standards might be, must be an undesirable feature in the localities they are in. The publicity given to the coming into force of the Noise Abatement Act has led people to believe that local authorities have much greater powers to stop nuisances of the kind to which they object, than in fact they have. The powers are not all that much different from those which have been in force in this district under Section 313 of the Middlesex County Council Act 1944. If only because of the creation of some noises such as those by aircraft which are a real nuisance to those in the neighbourhood, it is certain that increased attention will be given to this subject and those of the Public Health Department will be approached about other less damaging noises. It will be of interest to see to what extent action by the Public Health Department of local authorities will become the accepted means of abating noise nuisances which no one claims are causing the injury or danger to health referred to in the Middlesex County Council Act, could be classed as. There were further developments during the year in the services for the aged. Some of the various forms of help now available to the elderly are in their nature preventive services; others are for the assistance of those really in need and are more in the nature of palliative services. In the public health field, the endeavour is always, by the application of preventive measures, to hold back the rising tide of disability and so avoid the breakdown which leads to the need for in-patient or out-patient treatment. Much of what is being done for the aged is comparable to the provision of a treatment service of the health arrangements which are designed to help those who have broken down. These services are very necessary for those individual old people and for as long as the need is there, it is to be hoped that they will be continued and if necessary expanded. On the other hand though, the really important service is the one which will prevent these people ever reaching that stage, or at least postponing that time as long as possible. The organisation which can provide this must be sufficiently large that it can deal with the day-to-day patch-work affairs and yet maintain the other most important preventive service. In October 1960 the Royal Commission on the Local Government of Greater London submitted their recommendations. Last year the Government endorsed the proposals of the Commission that the borough should in future be the primary unit of local government for the Greater London area and suggested it would be desirable to aim at a minimum population of around 200,000. Towards the end of the year they submitted a suggestion on how the area might be divided into boroughs ol this size; in this Harrow is the only district, except for the City of London, which these proposals leave as it stands, with no additions or subtractions. Everyone can look forward to the day, in some three years' time, when the 7 Council will again become responsible for the administration of the personal health services and so bring to an end the unsatisfactory arrangement of so-called delegation under which some of these services have been administered for the last 14 years. Anticipating that it would be my last, in the introduction of the report for 1960 I referred to the changes which had taken place since the District was created in 1934; there has been no marked change in this last year. I have the honour to be Your obedient servant, CARYL THOMAS, Medical Officer of Health. Council Offices, Kynaston Court, Harrow Weald. 16th May, 1962. 8 STATISTICAL AND SOCIAL CONDITIONS OF THE AREA Area (in acres) 12,555 Registrar-General's estimate of resident population, mid-year, 1961 209,580 Rateable Value (1st April, 1961) £3,973,767 Sum represented by a penny rate (1st April, 1961) £16,001 Total number of occupied houses and flats 65,005 Extracts from Vital Statistics for the Year: Live Births:— Male Female Total Legitimate 1,447 1,502 2,949 Illegitimate 67 69 136 Total 1,514 1,571 3,085 Live birth rate per 1,000 population 14.7 Illegimate live births per cent of total live births 4.4 Stillbirths:— Male Female Total Legitimate 21 25 46 Illegitimate — — — Total 21 25 46 Stillbirth rate per 1,000 live and stillbirths 14.7 Total live and stillbirths 3131 Deaths:— Number 2,146 Death rate per 1,000 population 10.2 Deaths of infants under one year of age 56 Infant mortality rate per 1,000 live births 18.1 Legitimate I.M. rate per 1,000 legit, live births 17.6 Illegitimate I.M. rate per 1,000 illegit. live births 29.4 Neonatal mortality rate per 1,000 live births 12.6 Early neonatal mortality rate (deaths under 1 week) 11.6 Perinatal mortality rate 26.4 Maternal deaths (including abortions) 1 Maternal mortality rate per 1,000 live and stillbirths 03 Deaths from Cancer 451 Measles 0 Whooping Cough 0 Tuberculosis 11 Population. The mid-year population of the district was estimated to be 209,580. This includes members of the armed forces stationed in the district. 9 In each of the post-war years the population of the district increased to reach the highest figure of 220,300 in 1950. From that time there was a slight fall each year in the estimated population. The mid-year figure for 1961 is the lowest estimated figure of population since the war. The natural increase in population, which is the excess of births over deaths, last year was 803. Births. The total number of live births registered during the year was 3,085 (1,514 male and 1,571 female). Of these 136 were illegitimate, being a percentage of total births of 4.4. The numbers of live births registered in the five years from 1956 onwards were: 2,791, 2,783, 2,830, 2,931 and 3,117. 944 births occurred in the district (938 live, 6 stillbirths). Of this number 35 were to residents of other districts. 2,261 (2,215 live and 46 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 14.7. The local comparability factor for births is 1.04. The corrected birth rate was therefore 15.3. That for the country as a whole was 17.4, the highest rate since 1948. 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 Offices of those districts. These numbers are added to the deaths in those districts, corresponding deductions being made of the deaths allocated to any district in respect of those who died in those districts, but who normally resided elsewhere. While certain types of institutions are not regarded in ordinary circumstances as the usual residence of those living there, there are many institutions which are so regarded. 1,268 persons died in this district in 1961. This figure includes the members of the armed forces stationed here. Of these, 155 were of persons who were not resident in this area. 206 deaths took place in the various local hospitals, eighty-seven in Roxbourne, twenty-six in Oxhey Grove and sixty-two persons died in non-transferable institutions. Of the 1,032 deaths of the local residents which occurred outside the district, most took place in institutions, 374 being at the Edgware General Hospital. 272 deaths took place in hospitals just outside the district, including seventeen in nearby isolation hospitals, and 272 in various London hospitals. Thirty-five deaths were of infants born in hospitals outside the district. 10 The total number of deaths was 2,146. The death rate was 10.2 per thousand population. The rates for the last five years were 8.8, 8.9, 9.2, 9.7 and 9.4. The rate for the country as a whole was 12.0. Liability to death varies at different ages. Any changes in the agedistribution of a population then affect the death rate. In the same way 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 RegistrarGeneral calculates a comparative mortality index based on the 1951 census population. When the death rate figure is multiplied by this, a figure is obtained which would have been the death rate for the district had the age and sex distribution of the population been that of the country as a wholein 1961. The index figure is 1.16; the adjusted death rate is 11.9. The following is the Registrar-General's abridged list of causes of death in this district:— Male Female Male . Female Resp. tuberculosis 3 6 Other heart disease 74 187 Other tuberculosis 1 1 Other circulatory disease 68 86 Syphilitic disease 3 1 Influenza 10 8 Diphtheria — — Pneumonia 41 41 Whooping cough — — Bronchitis 85 31 Meningococcal infections — 1 Other respiratory disease 11 9 Acute poliomyelitis — — Peptic Ulcer 12 2 Measles — — Gastritis, enteritis 6 6 Other infective diseases 2 3 Nephritis 6 8 Cancer of stomach 32 25 Hyperplasia of prostate 7 — Cancer of lung 111 19 Pregnancy, etc — 1 Cancer of breast — 46 Congenital Malformation 9 10 Cancer of uterus — 15 Other diseases 58 74 Cancer of other sites 104 99 Motor vehicle accidents 17 8 Leukaemia 11 10 Other accidents 18 13 Diabetes 5 9 Suicide 12 6 Vascular diseases of nervous system 102 163 Homicide 1 1 Coronary disease, angina 252 151 Total 1074 1072 Hypertension 13 32 1,314 deaths were due to diseases of the circulatory system, vascular diseases of the central nervous system and to cancer, a percentage of 61 of the total deaths. The following are the numbers of persons who were of different ages at the time of death : under one year, 54; over one but under five years, 13; five to fourteen years, 5; fifteen to twenty-four years,16; twenty-five to forty-four years, 52; forty-five to sixty-four years, 577; sixty-five to seventyfour years, 518; seventy-five years and over, 908. Of these local deaths, fifty-nine per cent of those of males were of persons of sixty-five or over, thirty-one per cent of seventy-five and over, and eighty-five and over eight per cent. The corresponding figures for females were seventy-four, fifty-four and twenty. Of the local residents who 11 died last year forty-two per cent had reached the age of seventy-five, and fourteen per cent had reached the age of eighty-five. 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 enviromental conditions are not satisfactory, this rate is not these days the index it used to be of the general healthiness of the district. Most of 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 than to environment. The local rates have constantly been below the national rates; with the rapid fall in the rates for the country as a whole, the gap is narrowing. Last year, fifty-six (31 male, 25 female) infants living in the district or born to mothers ordinarily resident here died under one year of age, a slight fall on the figure of fifty-eight in 1960. The infant mortality rate was therefore 18.1 as compared with that of 18.6 in 1960. The rate for the country as a whole was 21.4, a figure 0.5 below that of 1960, the previous lowest. Of these fifty-six deaths, thirty-nine occurred in infants under one month of age. The neonatal rate therefore was 12.6, comprising sixtynine per cent of the infant mortality rate. Of the twenty-four infants who failed to survive twenty-four hours, only one was born at home; the Coroner's verdict of the cause of death was atelectasis. Of those born to mothers in hospital or nursing homes, in nine, the infant was prematurely born; seven died of developmental abnormalities and five from birth injuries. Twelve infants survived twenty-four hours but failed to live one week. None of these was born to mothers confined in their own homes. Three of the infants were born prematurely; three suffered from birth injuries and three had congenital abnormalities. Only one infant who survived one week, failed to reach one month; be had some developmental abnormality. Nineteen infants reached the age of one month but failed to reach the age of one year. In nine, the deaths were due to respiratory trouble and in six to some developmental abnormality. In reply to a question put to him in the House, the Minister of Health gave some information about the infant mortality rates of certain towns for each of the previous 10 years. The following table sets out the rates for each year for the country as a whole and the three areas whether County Boroughs, Municipal Boroughs or Urban Districts with populaions of 200,000 or over with the lowest rates:— 12 Area 1951 1952 1953 1954 1955 ENGLAND 29.4 27.2 26.5 25.1 24.5 Areas with the lowest rates Crovdon CB 19.1 Croydon CB 19.6 Harrow UD 16.9 Harrow UD 16.8 Harrow MB 17.0 Bristol CB 20.4 Bristol CB 21 .5 Croydon CB 20.5 Croydon CB 19.5 Bristol CB 191 Harrow UD 21 .8 Harrow UD 21 .9 Bristol CB 21 .8 Bristol CB 20.7 Crovdon CB 20.5 Area 1956 1957 1958 1959 1960 ENGLAND 23.3 22.8 22.3 22.0 21.6 Plymouth CB 17.5 Harrow MB 14.0 Harrow MB 17.0 Harrow MB 15.2 Portsmouth CB 15.7 Areas with the lowest rates Croydon CB 18.6 Leicester CB 17.7 Croydon CB 17.9 Sheffield CB 17.0 Harrow MB 18.5 Bristol CB 19.3 Croydon CB 18.0 Plymouth CB 20.0 Bristol CB 19.6 Bristol CB 19.8 Harrow appeared in each year but one, being the only District mentioned this number of times. Stillbirths. 46 stillbirths were registered last year. This was a rate per thousand population of 0.22, and a rate per thousand live and stillbirths of 14.7. The rate per thousand total births for the country as a whole was 18.7. Of the fifty-three stillbirths about which particulars are known, nine were to mothers confined at home. In three there were developmental abnormalities. Four births were premature; in one of these, the mother had toxaemia and in another placental heamorrhage. Of the forty-four stillbirths to mothers confined in hospital, in nine there were malformations. Labour was premature in eighteen instances; in six tor no apparent cause; in three because of placenta praevia; two through toxaemia; in two the mother had diabetes and in another four she was ill. There was difficulty in labour in seven. In eight instances there was no apparent reason for the death of the foetus. Peri-natal Mortality. Very much the same conditions are responsible for many of the stillbirths and for the deaths of infants in their first week, the early neo-natal period. So much is this the case that it is almost a matter of chance as to 13 whether the loss has to be recorded to one or the other group. For some years now these losses have been classed under the term of peri-natal mortality, a rate which is calculated as the number of stillbirths and deaths under one week combined per thousand total live and stillbirths. The rate for this district for last year was 26.4 comprised of 11.6 the early neo-natal rate and 14.8 due to stillbirths. The corresponding figures for 1960 were 30.4, 12.2 and 18.2. Death of Infants one to five years of age. Six infants of one year of age died. Four suffered from respiratory trouble and two from infections, four other children died after reaching their second but before reaching their fifth birthday. Maternal Mortality. One death occurred as a result of pregnancy, being due to toxaemia which developed about the twenty-eighth week of pregnancy. Deaths from Accidents. The three main causes of deaths from accidents are those on the road in which a motor vehicle is mostly involved, a variety of deaths occurring in the home, and falls. Apart from those falling in one of these categories, accidents caused seven deaths, of which two were from drowning and two were on the railway. Deaths from Falls. Of the twelve deaths from falls, seven were the result of falls of elderly persons occurring in their own homes or in the institutions in which they were living. The other five were mostly of younger persons at work or at recreation. Road Accidents. There were twenty-five deaths of local residents during the year from road accidents. Eleven fatal road accidents occurred locally, though not all to local residents. The local figures of road accidents (excluding those not affected by layout or conditions of highways) for last year were again slightly higher than in the previous year. The monthly average of accidents was 45.5 (main roads 34.0, other roads 11.5). Of the monthly average of 62.5 of the injured, 52.6 were slight (37.6 on main roads, 15.0 on others), and 10.0 serious (7.2 on main roads, 2.7 on others). There were five fatalities, tour being on main roads and one on other roads. Accidents in the Home. The local deaths from accidents in the home last year included seven of persons who died as the result of a fall when in their homes or institutions in which they were living; all were over seventy-seven years of age. Six adults, three of each sex, died from consuming poisons. Nine adults, three men and six women, died from coal gas poisoning. 14 The Home Safety Act, 1961 empowers a local authority to promote home safety by publishing information and giving advice and to make grants to any non-profit-making body whose activities aim at promoting home safety. These powers will strengthen the influence of the Health Advisory Council which is concerned with the question of safety in the home and the prevention of accidents in the home. The Council took part in the National Fire Prevention Week from October 30th to November 4th which was sponsored jointly by the Fire Prevention Association and by the Royal Society for the Prevention of Accidents. "Few anniversaries can be accompanied by such a trail of injury and suffering throughout the length and breadth of the country." This is taken from an article by a surgeon of the Burns Unit of a hospital on injuries from fireworks. The subject was discussed at the Health Advisory Council and resulted in the Public Health Committee expressing to the Royal' Society for the Prevention of Accidents their concern about the danger and nuisance caused by the irresponsible letting-off of fireworks particularly in the streets before and on the 5th November; and enquiring whether an approach had been made or was contemplated to the Home Secretary with a view to the prohibition of the sale of fireworks until a few days before November 5th, and also whether the amount of explosive in the manufacture of the present day fireworks was not excessive. The risks from oil burners used in the home led to the passing of the Oil Burners (Standards) Act which came into operation on January 1st, 1961. This gave powers to the Secretary of State to make regulations for the prohibition of sale of those not conforming and to arrangements being made for the inspection and testing of the burners. The Public Health inspectors keep under observation shops at which heating appliences are sold. There were no infringements of the Heating Appliances Fireguards Act in regard to new appliances offered for sale. Two second hand dealers had to be warned for exhibiting for sale two gas fires and one electric radiator not properly guarded as required by the 1953 Regulations. Deaths from Suicide. About twenty persons living in this district commit suicide each year. This last year the number was only eighteen, twelve men and six women. Coal gas poisoning was as usual the most common method used, being chosen by five men and one woman. Most unusually the railway came next being chosen by two men and two women. Poisoning which usually occupies second place came next, being the method chosen by three women. The other deaths were caused one each by drowning, hanging, cut throat, cut wrists and car exhaust. Two of these deaths took place in each of the months of May, June and November. There was one in each of the other months except May 15 and August. Four of these people were in their fifties and three each in their thirties, forties, sixties and seventies. One woman was only twentyfour and one man was over eighty. Deaths from Cancer. Of the 2,146 deaths of residents in this district, 451 were due to cancer. This disease caused 23 per cent of the deaths of males and 19 per cent of the deaths of females. In the country as a whole, cancer in 1960 caused 98,788 deaths, being responsible for 19 per cent from all causes. These days then one person in five dies from cancer. In women the standard mortality rate had fallen from 101 in 1950 to 97 in 1960. In men on the other hand, the figure increased from 98 to 108. The age distribution of these deaths in the two sexes is different. In women 44.5 per cent of the deaths were in the age group 45 to 50 and 42.4 per cent in the group 50 to 55. In men though, 28.4 per cent of the deaths were in the group 50 to 55 and 28.9 in the group 55 to 60. The increase in the numbers of deaths from cancer amongst women is due entirely to the larger numbers of the population reaching the age at which they are prone to cancer. Men, however, show an increase in the standard mortality rate which means that at any given age the risk today of a man dying from cancer is greater than it was before. The worsening of the position is almost entirely due to the rapid rise in the number of deaths amongst men from cancer of the lung. Of the 247 deaths from this cause amongst males, in 111 the site was the lung, in 32 the stomach. Of the deaths amongst females the breast was the site in 46, the stomach in 25, the lung in 19 and the uterus in 15. Cancer of the Lung. In 1958, 71 men living in this district died from cancer of the lung. In 1959 the number was 91; in 1960 it was 118; last year it was 111. Cancer of the lung was the cause of death of one out of every nine of the men in this district who died in this last year. In the country as a whole, for a number of years there has been in each an increase of nearly one thousand deaths from cancer of the lung in Men. In 1951 the figure was 13,000. By 1960 it had reached 22,000. Many years ago it was anticipated that this steady increase would continue until this malady was killing 25,000 men each year. Cancer of the lung and bronchi is now the greatest killer, being responsible for one third of all cancer deaths in men. Of all cancer deaths in men in 1960, 18,882 or 35.8 per cent were attributable to lung cancer. This was 701 or 3.9 per cent more than in 1959. Over the years of number of deaths amongst men from cancer of the lung has risen from a figure of 206 per million living in 1940 to 856 in 1959. The rate for women has increased even more steeply. 3,118 16 women died fron lung cancer, an increase of 238 or 8.2 per cent. This higher rate suggests that the death rate of women from cancer of the lung is accelerating. Amongst them the rate per million living has increased from the figure of 49 in 1940 to 132 in 1960. All investigations on the subject point to there being some association between the incidence of this disease and smoking. The experience of Jersey is of interest. This island records the highest male lung cancer death rate in the world, as well as an exceptionally high rate for women. It is claimed that more tobacco is consumed per head of population in Jersey than anywhere else in the world. There is no air pollution in Jersey (air pollution is considered to be a factor in the incidence of this disease in this country and may account for 20 per cent of the deaths). No cases of lung cancer were recorded in a non-smoker in the years 1957 to 1959. These findings amongst the population of this island give further pointers to the association between smoking of cigarettes and cancer of the lung. Experimentally, the case against cigarettes is not strong. All epidemiological studies though point to the fact that if no cigarettes were smoked, the incidence of bronchial cancer would be only about one-eighth what it is today. These facts are well known, but this knowledge does not seem to affect the amount of smoking. Some feel that to bring about any reduction in the amount of smoking it is necessary to deal with children. Amongst them today cigarette smoking is appallingly common. If they could be persuaded only to delay starting to smoke, this would perhaps lead to some not taking it up at all and to others smoking less heavily. The question of smoking and school children was considered by the Health and the Education Committees of the County Council and by the Joint Consultative Committee for Primary and Secondary Education. As a result, a leaflet was prepared which was to be distributed to schools with children over nine years of age. A county poster competition for school children was to be organised and it was hoped that teachers in their school lessons would use the statistical evidence which has been adduced about the relationship of smoking and cancer of the lung. It was also hoped that the Head Teachers would invite the County Health Education Officer to lecture on the subject to their pupils. He would too be prepared to talk to Parent/Teachers Associations and to special meetings of parents, more especially parents of secondary school children. Whether this method of approach is likely to achieve any real benefit is a matter of doubt. It is certainly easier to get into touch with a child than with the adult, but it is doubtful whether he will do what he is exhorted to do. In the case of some, there will be the contrary effect in that he joins those who are reacting against authority. In 1960 a tna of the effect of education as a means of influencing children not to smoe was undertaken at two secondary modern schools which had comparatle 17 social backgrounds. One of the schools was subjected to a vigorous antismoking campaign, the other was used as a control. The smoking habits of the pupils at the two schools were the same at the beginning of the campaign, and proved to be the same at the end. Some feel that the Government might help more but are reluctant to do so because of a taxation revenue of £600,000,000. Others feel that advertisement, which entails expenditure of some £20,000,000 a year plays its part. There again, the question is whether that merely determines what is smoked rather than that anything is smoked. Rather than to attempt to get people to give up or not to take up smoking, might the better line not be to try to attain moderation ? The risk of a moderate smoker developing cancer of the lung is something greater than that of the non-smoker. It is though the heavy smoker who is really exposed to this risk. It is the responsibility of health authorities to ensure that every adult knows of the association between heavy smoking and cancer of the lung. A campaign which urged smoking in moderation rather than the prohibition of smoking in general would probably be easier to conduct and perhaps be more effective. Deaths from Infectious Diseases. There were eleven deaths from tuberculosis and eighteen from influenza. There were none from measles, whooping cough or poliomyelitis. 18 HEALTH SERVICES OF THE AREA HOSPITALS General Hospital Service. Most of the hospitals in or serving this district are in the region covered by the North West Regional Hospital Board. The No. 11 or Hendon Group Hospital Management Committee (Secretary, J. Fielding, Edgware General Hospital, Tel. No. Edgware 8181) comprises the Edgware General Hospital (647 beds and 64 maternity cribs), Hendon District Hospital (63 beds), Colindale Hospital (205 beds), West Hendon Hospital (112 beds), Bushey Maternity Hospital (36 lying-in and 14 ante-natal beds), Stanmore Cottage Hospital (10 beds), Roxbourne Hospital (50 beds) and Oxhey Grove (42 beds). The Hospital Management Committee also administers the Harrow Chest Clinic, 199 Station Road, Harrow and the Edgware Chest Clinic at the Edgware General Hospital. Because it was expected that the Charing Cross Hospital would move out to Northwick Park, the Harrow Hospital (122 beds) was attached to it. When, however, it was decided that the Charing Cross Hospital would move not to Northwick Park but to Fulham, Harrow Hospital became a member of the Harefield and Northwood Group. In this also are the Pinner, Northwood and District Hospital (36 beds), Mount Vernon Hospital and Radium Institute (427 beds) and the Grimsdyke Rehabilitation Unit, Harrow Weald (50 beds). The Stanmore Orthopaedic Hospital is a teaching hospital and is under its own management. When it was decided that Charing Cross Hospital would not move out to Northwick Park, it became the responsibility of the Regional Hospital Board to provide a new hospital there to meet the shortage of beds in Harrow and Wembley. This new hospital has figured in a number ot programmes but as yet, no proposals have got beyond the planning stage. In 1958 the Minister of Health announced his decision to include the first phase of the new Charing Cross Hospital at Northwick Park in the 1960/61 programme. Towards the end of 1959 it was understood that the Minister was giving top priority to the building by the North West Metropolitan Regional Hospital Board of a 254 bed regional hospital at the Northwick Park site. The Board later revised their ideas and decided it would be better to provide a larger unit than that originally contemplated. The estimated cost was expected to be double the original figure which suggested a much larger building for the first phase of the hospital. These changes resulted in some delay in the scheme. About the middle of the year, the Hospital Board submitted to the Minister a Ten-year Development Programme for 19 the Hospital and Specialist Services in the Region. The Board aims to provide in each area as complete a service as possible for the community. As part of the programme two new hospitals have been approved and planning is preceeding. One of these is the hospital at Northwick Park, the other a hospital in North Hertfordshire in Stevenage. In January 1961 the Minister of Health issued details of the twenty-nine major building schemes scheduled to start by 1964/65. The list includes these new hospitals of which a 400 bed hospital at Stevenage is one. There was no mention though of the Northwick Park Hospital in that list. In March the Minister announced that the hospital is to be associated with a Clinical Medical Centre which the Medical Research Council is to establish. "The new plans for Northwick Park clearly fall into line with the Council's (M.RC.) idea that the Research Centre should form an integral part of a hospital dealing with current medical problems and thus keeping in touch with the trends and changing disease patterns in day-to-day medical practice." The report of the Medical Research Council for 1959/60 refers to plans for a Clinical Research Centre which will be associated with the proposed new district hospital in Harrow. The Hospital appeared again in the White Paper "A Hospital Plan for England and Wales," a programme for 1961 to 1971. Accommodation for the Infectious. At one time an accepted standard of accommodation for the infectious sick of the district was one bed per thousand population. It was on this basis that the Harrow Urban District Council prepared their plans for a new hospital to be built in Harrow Weald. Before a start could be made on the erection of the building the war supervened. The experience of some ten years showed that the district did not need that number of beds for this purpose. Towards the end of the war then the Harrow Council approached the Councils of Hendon and Wembley about a proposal that the Hendon Isolation Hospital should be enlarged to a size which would enable it to accept the infectious sick from the three districts. These discussions were proceeding when the changes to be brought about by the National Health Service Act became known. The needs of the district were at that time being met by the accommodation at the South Harrow Isolation Hospital so the Harrow Council planned to adapt the Stanmore Isolation Hospital as a residential nursery, partly for the children of unmarried mothers, it being intended that some of the mothers should be admitted as well to help to run the nursery. As a result of this, the hospital passed into the hands of the County Council to become in time a residential nursery administered by the Children's Department. The South Harrow Isolation Hospital passed into the hands of the Minister of Health and became in time the Roxbourne Hospital for elderly patients. The infectious sick from this district then were admitted to the Hendon Isolation Hospital or as it became known the West Hendon Hospital. In general its 112 beds proved adequate to meet demands, though on occasion Patients had to be admitted to our hospitals. This comparatively small 20 hospital was able to meet the needs of a large population for a number of reasons. One was that the number of cases of diphtheria, largely as the result of a high proportion of the children being protected by inoculation, fell to small numbers and then to none. At the same time scarlet fever, though at times exhibiting marked capacity for spreading, became an innocuous complaint. The result of this was that whereas before the war, it was customary for most of those suffering from this infection to be removed to isolation hospitals, after 1948 removal to hospital became quite the exception. As all the beds were not being used for the infectious sick, some were allotted for general medical purposes and some for shortterm gynaecological cases. Patients suspected to be suffering from smallpox or typhus fever are admitted to a special hospital. Chest Hospitals. Most of the patients suffering from respiratory tuberculosis are admitted to Clare Hall, South Mimms, to Harefield Hospital or to Colindale Hospital. There are also beds for those suffering from this complaint at the Edgware General Hospital and at Hillingdon Hospital. Only a few years ago there was a marked shortage of beds for those suffering from pulmonary tuberculosis, with the unfortunate result that there was at times a waiting list for those needing admission. The fall in the incidence of tuberculosis has completely altered the position, so markedly indeed that in some parts of the country some of these hospitals have been closed. Mental and Mental Deficiency Hospitals. Most of those in this district who suffer from mental illness, for which they need to be treated in hospital, are admitted to Shenley Hospital, near St. Albans. There are three observation wards in general hospitals (North Middlesex, Central Middlesex and West Middlesex Hospitals) to which patients may be admitted for short periods of observation. In the main, mental defectives are admitted to Harperbury Hospital, near St. Albans and to a lesser extent at Leavesdon Hospital, Abbots Langley. Maternity Hospitals. Most of the expectant mothers from this district who wish to be confined in hospital are admitted to the maternity ward of the Edgware General Hospital (sixty beds), or to the Bushey Maternity Hospital (thirtysix lying-in and fourteen ante-natal beds) which lies just outside the northern boundary of the district and which is an annexe to the Edgware General Hospital. Just over the boundary in another direction in 21 bley is the Kingsbury Maternity Hospital (fifty-six beds) associated with the Charing Cross Group of Hospitals. This accommodation has to serve a large population living in a very large area, and is insufficient to meet the demands. Even with strict control over early bookings, all beds are booked well before the times they are to be used. This makes it very difficult, if not impossible, for the hospital to accept late applicants even though their circumstances make it most necessary that the confinement should take place in hospital. Accommodation for the Aged. There are thirty-eight beds for geriatric patients at the Edgware General Hospital; fifty-two at Roxbourne Hospital; thirty-two at Oxhey Grove Hospital; fourteen at Stanmore Cottage Hospital; twenty-three at Orme Lodge; twenty-four at Glebe House and twenty-six at St. Elizabeth's Hospital which is administered by the Barnet Group Hospital Management Committee. Contractual arrangements exist for fifteen beds at Springbok House which is provided by the National Corporation for the Elderly, and four at the Avenue Nursing Home. There are now three hospitals to which patients can be admitted direct from their homes these being Edgware General Hospital. Roxbourne Hospital and St. Andrews. To meet the needs of the area there are 267 beds scattered over a wide area in eleven different establishments. Not only is the number of beds well below what is needed to meet the demands of the district, but the fact that they are divided amongst a number of institutions, some of them of small size, makes them less serviceable and valuable than they would if they were concentrated in a small number of hospitals. Convalescent and Recuperative Homes. Arrangements for the admission to convalescent homes of persons who need nursing or medical treatment while they are at the homes are made by the hospital almoners on behalf of the Regional Hospital Boards. Persons who need only supervision and rest in homes which do not provide nursing or medical treatment are admitted to homes by arrangements made by the local health authority. These arrangements are intended for those in whom a period of rest in a home would speed up their recovery from some recent illness or perhaps make the recovery more complete. An application is submitted by the patient's doctor to the Area Medical Officer, being then passed to the County Medical Officer who decides on the home the person should go to. Recommendations made by the hospital staffs in respect of out-patients are not now accepted, the procedure being for the patient to be referred by the hospital to his own doctor. As contrasted with the arrangements for convalescence made by the hospitals, for this service a charge is made, but not in the case of pupils attending maintained schools. 22 NURSING HOMES These are private establishments which provide accommodation for various types of patients. Section 187 of the Public Health Act, 1936 requires that these homes shall be registered with the local health authority. The County Council decided that the responsibility for registering and supervising them should rest not with the local Area Committee but with the Health Committee of the County Council. Applications for registration have to be made to the Clerk of the County Council. One of the effects of the National Health Service Act was to reduce the numbers of these homes, this reduction being particularly marked in regard to maternity beds. At the end of 1947 there were in this district 19 registered homes with 183 beds. Twelve of the homes admitted maternity patients, though not limiting admissions to this type of patient, and of the total number of beds, about half were for maternity patients, most of the other half being for medical, surgical, borderline mental and chronic patients. At the end of 1960 there were 12 registered homes with 172 beds, of which only 3 were for maternity cases. There has over the years been a reduction in the number of beds for acute medical and surgical patients but an increase in the number of those for chronic patients. During the year, Bowden House, which was registered for 22 patients, became registered for acceptance of mental patients and ceased to be registered under Section 187. It is now under the supervision of the staff of the Mental Health Section of the Health Department of the County Council. A home of 20 beds for medical or chronic cases was closed during this year. Another home of 10 beds closed as a nursing home towards the end of the year becoming a home for elderly people, to be supervised by the welfare authority. The result of this is that at the end of 1961 there were only 9 registered nursing homes with 120 beds, of which only 3 were for maternity patients. The following tables set out the particulars of the various homes registered at the end of the year, with details of their ownership and their accommodation:— Beds Type of Case Bermuda House, Mount Park, Mrs. A. M. Elphick Mr. A. E. Elphick 13 Medical or Chronic Beverley Maternity Home, 170 Whitchurch Lane, Edgware Miss C. Dear 2 Maternity 2 Chronic Brockenhurst Nursing Home, Hindes Road, Harrow Mrs. T. O'Donnell 6 Chronic Calvary Nursing Home, Sudbury Hill Mother Superior 46 Medical or Chronic Culverlands Nursing Home, Green Lane, Stanmore Mrs. O. M. Vosper 11 Chronic Glenleigh Nursing Home, 85 Marlborough Hill, Wealdstone Mrs. Woodman 16 Chronic 23 Heywood Nursing Home, London Road, Stanmore Mrs. M. Guyatt 4 Medical 1 Maternity St. Michael's Nursing Home, 11 Hindes Road, Harrow Mrs. T. O'Donnell 8 Medical or Chronic The Hall, Harrow Weald Dr. Lincoln Williams 11 Mental(borderline) Before the war, most of the accommodation in the local nursing homes was for those suffering from acute medical and acute surgical conditions and maternity cases; relatively few beds were for the aged. Most of those that there were, were the small numbers of beds in the houses of some retired nurses. The charges at these homes were substantially below those of the other homes and they met a very real need. These homes have all gone. At the same time, most of the accommodation of the homes still remaining is occupied by the elderly. Many of these people are not permanently bedridden and could be accepted at old people's homes. Some might with advantage be transferred to such homes because in many nursing homes there is a lack of sitting room and dining room accommodation with the result that relatively able-bodied people have to be confined, if not to their beds, at least to their bedrooms, because there is nowhere else for them. The responsibility of a local authority in regard to nursing homes is not well defined. It is easy enough to specify the number of beds the room of known dimensions should have; it is easy too to decide on the number of staff for a home of a specified number of beds. The lavatories and the kitchens can be inspected. What is difficult though is supervision of the management of the home. In general, inspections can be carried out as a routine only about twice a year in the ordinary homes, though those where there are maternity patients are inspected four times a year. These infrequent visits, although made without previous warning, do not really give an indication of whether the patients are really getting the service they need. If there are shortcomings, the remedy lies mostly in the hands of the patients' doctors who perhaps cannot do much for those patients who are in, but their knowledge of such shortcomings must influence their decision about which homes to recommend. 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 Physiotherapists and for members of the medical Profession. 24 At the begining of the year, twenty-nine establishments were licensed, four were discontinued, so the number at the end of the year was twentyfive. In addition, certificates were lodged by two members of the Chartered Society of Physiotherapists. NURSING, MIDWIFERY, ETC., IN THE HOME General Nursing. 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. M. Bromley, who works at the Area Health Office at Kynaston Court. At the end of the year, there were some 20 whole-time nurses and 6 part-time nurses who worked mostly in the mornings, an equivalent of 24 whole-time staff. During the year they paid in all 63,126 visits. 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 39 Sheepcote Road. Midwifery and Maternity Nursing. The midwifery service is administered locally by the local Area Committee. Most of the midwives live in their own homes and the districts which they cover are 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. M. Bromley of 213 Exeter Road, South Harrow (Telephone No. Pinner 5752). Last year the midwives attended the confinements of 882 women in their homes (in 158 instances a doctor was present, in the other 724 not). Home Helps. This service 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 it has gradually become one of providing help to the aged and those suffering from some long-standing illness. The assistance which can be given to these people is of the greatest importance, as even moderate help enables some of them to continue to live at home who, without it could not have managed, and would have had to have been admitted to an institution, either Part III welfare accommodation or even a hospital. 25 The average number of home helps was one full-time and 63 part-time, being an equivalent of 39 full-time helps. They gave assistance in 1,349 households. In 381 of these the patient helped was a maternity case, in 17 was one suffering from tuberculosis, in 299 was one suffering from an acute condition and in 652, was a long term case. 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 fifty places and the Walton Avenue, South Harrow, Nursery with its sixty. 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. All Saint's Hall, Roche Avenue, Edgware Thur. and Fri. p.m. Elmwood Clinic, Elmwood Avenue, Kenton Mon. and Wed. p.m. Elstree Clinic, "Schopwick," Elstree, Herts. 2nd and 4th Wed. p.m. Greenwood Hall, Rickmansworth Road, Pinner Wed. p.m. Memorial Hall, H.gh Road, Harrow Weald Thur. p.m. The Clinic, Honeypot Lane, Stanmore Mon. and Wed. p.m. The Clinic, Kenmore Road, Kenton Wed. a.m. and p.m. Methodist Church Hall, Love Lane, Pinner Fri. p.m. Methodist Church Hall, Walton Ave., S Harrow Thur. p.m. St. Alban's Church Hall, North Harrow Thur. a.m. St. Anselm's Hall, Hatch End Thur. p.m. St. George's Hall, Pinner View, Harrow Tue. and Fri. p.m. St. Hilda's Hall, Northolt Road, S. Harrow Tue. and Thur. p.m. Spiritualist Church Hall, Vaughan Rd., Harrow Wed. p.m. Stanmore Park (R.A.F.) Station Thur. 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 Thur. p.m. All Saint's Hall, Roche Avenue, Edgware Fri. a.m. Elmwood Clinic, Elmwood Avenue, Kenton Tue. p.m. Elstree Clinic, "Schopwick," Elstree, Herts. 2nd and 4th Wed. p.m. Memorial Hall, High Road, Harrow Weald Tue. p.m. he Clinic, Honeypot Lane, Stanmore Tue. p.m. 26 The Clinic, Kenmore Road, Kenton Fri. p.m. 76 Marlborough Hill, Wealdstone Mon. p.m. Methodist Church Hall, Love Lane, Pinner Mon. p.m. Methodist Church Hall, Walton Ave., S. Harrow Thur. 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 Thur. a.m. Spiritualist Church Hall, Vaughan Rd., Harrow Wed. a.m. The Clinic, Whittlesea Road, Harrow Weald Fri. p.m. Toddlers' Clinics. The Clinic, Alexandra Avenue, South Harrow Mon. a.m. All Saint's Hall, Roche Avenue, Edgware Thur. 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 Thur. a.m. Spiritualist Church 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 and Marriage Guidance. Sessions of the Family Planning Association clinic are held at the Elmwood Avenue Clinic on Monday evenings on Thursday afternoons, and on the second and fourth Wednesday evening each month. The marriage Guidance Council have their offices at 7 Lyon Road, Harrow, (HARrow 8694). School Minor Ailment Clinics. 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. Thur. & Sat. a.m. All Saints Church Hall, Roche Avenue, Edgware Thur. 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 Thur. a.m. The Clinic, Whittlesea Road, Harrow Weald Wed. a.m. Children attend at the request of the parents or of the teachers, or they are referred by school medical officers. Not only are those who nee treatment for minor ailments seen at the clinics, but children are kep 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. 27 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 clinics 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 ispection of children at the schools, to need treatment. Only those who attend by appointment can be seen, except those referred b> the head teachers of the schools for urgent or emergency treatment. 28 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 was provided by the local health authority for children attending maintained schools, for nursing and expectant mothers, and for children under school age. Appointments were made at sessions held at the various permanent clinic buildings in the district. In 1960, arrangements were started by which those in certain priority groups who needed treatment for conditions of their feet could receive this. These were the expectant and nursing mothers, children under five, the physically handicapped and the elderly. Chest Clinic. The Chest Clinic serving most of the district is that at 199 Station Road, Harrow, (Telephone 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 (Telephone No. Edgware 4467). The pyhsician-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. (Telephone 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 29 local health authority include responsibility for the initial care and conveyance to hospital of patients who need to be dealt with under the Mental Health Act, and for the ascertainment and community care of mental defectives. The Health Committee of the County Council is responsible for the mental health functions of the Authority. Harrow is part of the central division of the County which is served by Shenley Hospital. The Mental Welfare Officer, Mr. W. J. Pedel, and other officers, work at Balnacraig Avenue, Neasden, N.W.10 (Dollis Hill 7722). 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 County Fire Control (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 consulting clinic is attended on the mornings of the fourth Wednesday in each month at the clinic, Elmwood Avenue, Kenton, 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 eductionally 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. Persons in Need of Care and Attention. The powers of the County Council to provide welfare services are set out in Section 29 of the National Assistance Act which reads:— "The local authority shall have power to make arrangements for promoting the welfare of persons to whom this Section applies, namely, persons who are blind, deaf or dumb, or other persons who are substantially and permanently handicapped by illness, injury or congenital deformity or such other disabilities as may be prescribed by the Minister." The County Council in the administration of the service for the blind and the partially sighted have continued to draw on the help of the voluntary associations who provided these services before 1948. In regard to the schemes for the handicapped persons other than the blind and the partially sighted, the first step is for the handicapped person 30 (who must be substantially handicapped) to Register. This he does by communicating with the Chief Welfare Officer at 1 Queen Anne's Gate Buildings, Dartmouth Street, S.W.I. For the adminstration 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. Section 47 of the National Assistance Act, 1948, enables the Court, on the application of the Medical Officer of Health, to grant an Order for the removal of a person to a Welfare Home or Hospital. This Section can be invoked for the compulsory removal of a person who (a) is suffering from grave chronic disease or being aged, infirm or physically incapacitated, is living in insanitary conditions, and (b) is unable to devote to himself, and is not receiving from others, proper care and attention. The Aged. The same services as were previously available to the aged continued to be offered during the year. Some new developments were considered and in some instances introduced. Luncheon Clubs. The new Assembly Hall at Tenby Road was opened at the end of the year. This provides a luncheon service for a part of the district distinct from that served by the existing clubs at the Belmont and the North Harrow Assembly Halls. In the year ending March 31st, 1961, 46,278 meals were served. Meals on Wheels. The Council increased their contribution to enable the Old People's Welfare Committee to purchase a new van to extend this service provided by the Womens Voluntary Service. The Trustees of the Greater Harrow District Nursing Association Trust agreed to provide another van to enable the service to be extended. Holiday Scheme. This service, which enables a number of old people to have a holiday at the sea-side, was started this year. Workshops for the Elderly. The Old People's Welfare Committee discussed the possibility of workshops being opened in the Borough where old age pensioners could be employed. Premises at Marlboroug Road, Wealdstone were considered and also some in Palmerston Road. Wealdstone. 31 Window Cards. In a number of districts arrangements are made for the aged people to have cards which they can exhibit in their front windows in case of emergency. The Old People's Welfare Committee resolved to introduce such an arrangement in this district. Chiropody. Although the Middlesex County Council agreed to provide a chiropody service for certain priority classes, which include the aged, the service they have been able to offer has been restricted because of their inability to recruit staff to hold sessions at their clinics. Many of the local chiropodists practising in the area would have been prepared to help by accepting the elderly for treatment at their own surgeries, but they were not prepared to take sessions at the clinics. On the other hand, the County Council would not agree to arrangements being made for these old people to be treated on their behalf at the practitioners' surgeries. Up to the time that the County Council provided the service, the British Red Cross Society were the only body who offered treatment. They received grants from the authorities for this work. When, however, the County Council assumed responsibility for this service, they set a limit to the number of cases the Red Cross Society could take on. In view of the very limited service the Authority could offer, owing to limitation of staff, this was especially unfortunate as it prevented any expansion of the service by the Society who it seems were able to do what the County Council could not in obtaining local chiropodists willing to attend their clinics. Still more unfortunate was the effect on the homebound people who needed treatment. The Red Cross Society used to arrange this but had to discontinue accepting any more patients. On the other hand, the local authority was not able to send the choripodist to treat these homebound patients as such work could have been done only at the expense of the numbers who could have been treated at the clinic at that time. Laundry. For some years the Harrow Council has used its very restricted powers under Section 84 of the Public Health Act which enables authorities to arrange for articles to be cleansed in certain circumstances. The Hendon Group Hospital Management Committee agreed to arrange for the actual work of treating the articles of clothing and bedding to be done if the District Council would meet the cost. The present charge is 5fd. per article. At the beginning of last year, ten persons were being helped. During the year there were requests to help a further sixteen cases. Because of death or removal from the district, the number provided with help at the end of the year was eighteen. A number of local launderettes operate a special service to old age Pensioners at reduced charges. In addition to the Belmont and Harrow eald launderettes which previously helped in this way, assistance can now be given to those in the Honeypot Lane, Hatch End and Pinner areas. Housing. The Housing Committee decided that safety rails be fitted to the baths in the dwellings of old people. 32 Many people and many bodies provide different services for the aged. The District Council is concerned as the Public Health Inspectors might be called in by a relative or neighbour because of the insanitary state of the house. The condition could be sufficiently serious for the Medical Officer of Health to have to decide whether he ought to apply under Section 47 of National Assistance Act, for a Court Order for the compulsory removal of the person to a home or hospital. He has too, whether as Medical Officer of Health or as Area Medical Officer, a wide responsibility in the case of any person who seems to be in need of help because of illness or unfitness or poor habitation or any one of a host of troubles. The health visitor comes into the picture in some cases because of her general concern with people who need help. Home nurses devote much of their time to the aged, as do also the home helps. The Welfare Officer, while having no responsibility for the aged as such, is concerned with the person in need of care and attention (not medical or nursing care and attention) which he cannot provide himself or is not receiving from others. Such people are admitted to the welfare homes. Many elderly people develop abnormal mental states and the Mental Welfare Officer may need to help. Then in this area, as in many others, the local hospital has established a Geriatric Department with its own Geriatric Officer and Welfare Officer, whose concern is the elderly. This service which the hospital provides is something over and above that available to the elderly as ordinary members of the public. The elderly too, of course, may make especially heavy demands on the time of their own doctors. Then there are the various forms of help provided by different organisations. These are linked through the Old People's Welfare Committee. In addition, are the services such as the home visiting provided by volunteers, the whole service being administered by the Committee. While the person of pensionable age is recognised, there is no definition of the elderly. Of the so many people of pensionable age, only a small proportion need to avail themselves of any of the various forms of help which are provided. What determines whether any one falls into this group is not age as such as much as some complicating factor or factors. As long as people remain outside this group, they do not need help. On the other hand, it is so very necessary to be able to discover those who fall into the group of those needing help at the earliest stage, and it would seem that this can be done only by having under supervision of some sort the more elderly people even though at any particular time they are not suffering from any such complication. But many of those who need help of some sort are not needing medical help. It may be that they are suffering merely because they are lonely, and if they are not housebound the solution could be that they join one of the excellent clubs which are run by many churches, the British Red Cross Society, and the Womens Voluntary Service. There are many other ways in which these people can be adequately helped which do not entail the services of a doctor or nurse. On the other hand, to deal with some of the more difficult problems the medical and nursing services are necessary, and it 33 could well be that the assessment of the problem and the discovery of the solution can be dealt with only by someone such as the Medical Officer of Health. This problem was debated in the House of Lords towards the end of the year. It was submitted by one that—"The great and glaring need was for one authority or person in each area to be responsible for the old people and he believed that person should be the Medical Officer of Health." Against that view it was submitted that as it was important not to associate the care of the aged too much with ill-health, it should be put under the social-care department rather than the Medical Officer of Health. This is the view of a doctor who said—"What is essentially a social problem has been looked at through the haze of the ordinary mental and physical disabilities of old age and wrongly labelled a medical one. We have tried to cope with it by providing beds and places without realising that a negative policy of this kind has no chance of keeping pace with the rising tide If we could persuade others to look after the welfare side, we could best contribute by understanding that far from being an illness, old age is largely an attitude in mind." The present position about the responsibility for the arrangements for meeting the needs of the elderly is strange. Of all officers engaged by local authorities, the Welfare Officer would seem to be the one whose duties are most closely allied to those of whoever should be responsible for the administration of the services for the aged. Some elderly are his responsibility; not though because of their age but because of some disability. In the same way he has responsibilities for others who are aged; but again not because they are old but because they are in need of care and attention. His responsibilities for those in this class though are limited to those who need to go and are prepared to go to a welfare home. If they do not need to go to such a home or alternatively, if admission to a home is what is wanted but they refuse to go there, then these people pass out of his hands. The work of the Welfare Department is closely associated with that of the Health Department. So much is this the case that some authorities have appointed the Medical Officer of Health as the Welfare Officer. Where this has been done, it would seem that the natural step would be for the Medical Officer of Health to be made responsible for the overall supervision of the arrangements for the aged. What does not seem right is that authorities, while bearing the financial burden of the cost of much of the service, should not be responsible or directly control its running. There is room and there will continue to be room for the help of volunteers, either as individuals, or as members of voluntary organisations. It ought to be possible for their help to be made available in just as unfettered a manner if the general consideration of the various forms of helP are the responsibility of a committee of the local authority as if they were that of an ad hoc committee. Many very different kinds of service are made available in different districs for the elderly. In so far as many depend for their running on the help of volunteers, and in so far too as for some of them accommodation needed, with extensions of these services the time will come when a 34 decision will have to be taken as to which are the most valuable of these various kinds of help because there will not be the volunteers or the accommodation available for continued expansion on all fronts. The factors of overall cost, manpower and general effort will have to be weighed. Workshops have been opened, which have proved of great help to those who attend. Would that same expenditure of time and money be more profitably used if it were applied to the extension of clubs which could help many times the number of people attending the workshops. These points can be decided only when it is quite clear what is being aimed at. To avoid people passing into the stage of needing care and attention or to catch them when they look like moving into that stage, it is essential that those at risk should be in touch with some body or organisation. Might not an extension of the clubs be the best way of bringing this about ? If so, should this not always be at the top of any programme of extension of services for those who are mobile, coupled with an efficient home visiting service for those who are not! Experiments are being made into the value of medical supervision of the elderly. Without these practical trials an answer can never be reached as to the best way of achieving this if it is considered to be necessary. But these essentially medical aspects are something quite apart from the arrangements for dealing with the large general body of the elderly. LABORATORY SERVICE Before the war, the laboratory work for the examination of clinical materail of public health significance was carried out at private laboratories. Specimens were usually sent by post, a not very satisfactory arrangement. In time a few local authorities developed their own service, at least for the examination of specimens where an early result was necessary. During the war, in anticipation of the disruption of communications and because of the possibility of outbreaks of infection, a laboratory service was set-up throughout the country. Although it was not really needed for the reasons for which it was established, gradually increasing use was made of it. After the war a national service was set up by the Medical Research Council. By the Public Health Laboratory Service Act, I960 which came into force in August 1961, the association with the Medical Research Council was severed and the service is now administered by the new Public Health Laboratory Service Board. The services of the laboratory are available for the examination of all clinical material of public health significance. The laboratory serving this area is the Central Public Health Laboratory, Colindale Avenue, London, N.W.9. (Telephone No. Colindale 7041.) The material is collected each day by a van sent by the laboratory which calls about mid-day at the Harrow Hospital and at Kynaston Court. The service is free of charge to the patient and to the doctor. 35 The following is a summary of the examinations of material from this district carried out during the year Nose and Throat swabs, 107; Faeces, 299; Sputum, 21; Miscellaneous, 10. AMBULANCE SERVICE The following is an extract from a report of the Clerk of the County Council of March 1961, about the revised proposals for the Ambulance Service :— Chain of Responsibility. In accordance with the proposals approved by the Minister of Health on the 17th August, 1959, the Ambulance Service is being separated from the Fire Service. The County Council will continue to administer the Ambulance Service through the Health Committee. The Health Committee in turn will refer matters relating to the service either to an ad hoc sub-committee or to a sub-committee dealing with other aspects of the health services. The County Medical Officer of Health will be responsible to the Health Committee for the service, assisted by a County Ambulance Officer who will advise him on operational matters. The County Ambulance Officer is assisted by a number of operational officers. Adminstrative matters relating to the Ambulance Service will be integrated so far as possible with other services of the Health Department. Integration of the Accident and Sick Removal Branches of the Service. Under the proposals approved in 1950, the Ambulance Service has been divided into two branches—the accident branch based mainly on fire stations and using the fire service system of communication, and the sick removal branch based on ten depots. Of these, No. 6 is at Imperial Drive, Rayners Lane and No. 5 at The Mall, Kenton, (Telephone No. Dryden 0251), the latter becoming the County headquarters for the Ambulance Service. It is proposed to integrate the two branches of the service and all vehicles and operational personnel will be based primarily at the depots, each of which will have a small number of "satellite" stations at which some of the ambulances and crews reserved for accidents and emergencies will be located. Communications. A communications system is to be provided for the ambulance service which will be quite separate from that of the fire service, and the movement of all ambulances will be governed by an ambulance control system operated by personnel specially appointed to the ambulance service. Communications will be based on the G.P.O. telephone system and a large number of private telephone lines will be rented. Anyone requiring an ambulance for an accident or emergency will use the "999" or other appropriate emergency telephone system and will be connected immediately to a control which will direct the nearest available ambulance to attend. 36 Establishment of Vehicles. The Ambulance Service fleet will comprise a maximum number of 250 vehicles (including ambulances, onestretcher dual purpose and sitting-case vehicles) of which a minimum of 120 ambulances capable of carrying two or more stretchers will be required to provide an adequate service. Driver/Attendants. The County Council will ensure that, as far as possible all ambulance drivers and attendants shall hold one of the first-aid certificates approved from time to time by the National Joint Council for Local Authorities Services (Manual Workers) for the purpose of first-aid qualifications pay. Mutual Assistance. The following arrangements for mutual assistance have been made with Local Health Authorities of areas adjoining the County and will be continued under the present proposals:— (a) With regard to accident and emergency calls, the Authority receiving the call deals with it irrespective of County boundaries, unless it is clear that there is an ambulance on the other side of the boundary which is nearer and can reach the case sooner. (b) Calls for the removal of non-urgent sick cases are referred to the County from whose area the call comes. Hospital Car Service. The County Council will continue the arrangements with the Hospital Car Service organised by the voluntary aid societies whereby a number of cases are transported by the Hospital Car Service on payment by the Council Hire of Ambulances. The County Council proposes to continue the arrangements whereby ambulances are hired from the local branches of the British Red Cross Society and the St. John Ambulance Brigade for the transport of suitable cases as and when necessary. Hire of Vehicles. The County Council will continue to hire coaches and cars from private firms when necessary for the transport of sitting cases. Railway Transport. In accordance with the original proposals, the County Council has made arrangements with the railway authorities for the transport of patients where very long journeys are involved. The County Council proposes to continue these arrangements and also those with the British Red Cross Society for the provision of escorts when required. These arrangements provide, inter alia, for the reimbursement of the out-of-pocket expenses of the escorts. 37 LEGISLATION Some new legislation affecting public health came into force during the year. The Public Health Act, 1961 gives added powers to deal with sewers, drains and sanitary conveniences; storage accommodation in new houses and in existing houses; provision of bathrooms in new houses and in conversions; the removal of accumulations of rubbish on vacant sites; further powers to control the spread of infection; the power to reduce the numbers of pigeons and the making of bye-laws as to hairdressers and barbers. The Home Safety Act, 1961 empowers a local authority to promote home safety by publishing information and giving advice, and to make grants to any non-profit making body whose activities aim at promoting home safety. In the Middlesex County Council Act, 1961 the powers of chief interest are those relating to streams, and the prohibition of the emission of dark smoke from any industrial premises. The Factory Act, 1961 which contains provisions imposing duties on local authorities, relating to minimum requirements for health in factories, does not come into force until the 1st April, 1962. 38 SANITARY CIRCUMSTANCES OF THE AREA WATER Supply The area is supplied by water by the Colne Valley Water Company from wells supplied by gathering grounds in the Chilterns. Before distribution the water is chlorinated and partly dechlorinated; part of the supply is filtered and most of it is subjected to softening. The supply has been satisfactory in quantity and quality. Safety Responsibility for the wholesomeness of the water supply rests with the Water Company. In addition, district councils have under Section 111 of the Public Health Act, 1936, responsibility for ascertaining the wholesomeness of the water supplies of their districts. To this end samples are submitted periodically for full chemical and bacteriological analysis. In addition, samples are submitted for analysis of water collected from houses in which there are persons suffering from complaints which might have been contracted by consuming water. Particulars of these cases are passed by the Public Health Department to the Water Company. The Company carry out regular bacteriological and chemical examinations of the raw water and of the water going into supply from the Company's pumping stations, service reservoirs and at the houses of the consumers. While the results of the chemical and bacteriological analyses of raw waters were variable, those of water going into supply were satisfactory. The following is a copy of the result of the chemical analysis of a sample of water submitted for examination in February :— Appearance Clear and bright Colour 5 pH 7.4 Electric Conductivity 610 Chlorine Present as Chloride 42 Hardness: Total 260 Nitrate Nitrogen 6.2 Ammoniacal Nitrogen 0 013 Albuminoid Nitrogen 0 020 Metals-Iron, Zinc, Copper and Lead: —Absent Turbidity Nil Odour Nil Free Carbon Dioxide 15 Dissolved Solids dried at 180°C 420 Alkalinity as Calcium Carbonate 180 Carbonate 180 non-carbonate 80 Nitrite Nitrogen Approx. 0.01 Oxygen absorbed 0.60 Residual Chlorine Absent "This sample is clear and bright in appearance, just on the alkaline side of neutrality and free from iron and other metals. The water is hard in character but not to an excessive degree, contains no excess of mineral constituents and it is of very satisfactory organic quality. 39 From the aspect of the chemical analysis, these results are indicative of a pure and wholesome water suitable for drinking and domestic purposes." The following which is a summary of the bacteriological examination of a sample submitted for analysis in August, is typical of other reports:— "No coliform bacilli present in 100 ml in MacConkey incubated for two days at 37°C; no faecal coli per 100 ml." There is no evidence that the water is plumbo-solvent. There are no houses in the district supplied by stand pipe only. Fluoridation of Water Supplies. All trials carried out into the effect of the fluoridation of water on the incidence of caries of the teeth point quite definitely to this treetment bringing about a saving of one half of dental decay, with no harm to anyone. The report of the Ministry of Health trials in this country expected shortly will almost certainly be on the same lines as the results of the trials in other parts of the world; just as certainly its publication will be followed by intense activity of those who oppose the practice on various grounds. This opposition doubtless will be sufficiently strong in some localities as to deter those responsible for supplying water in those areas from adopting the practice of adding fluorides to the water. Elsewhere where opposition is less intense the water will be treated and the consumers benefit markedly. The fluoride content of each sample of water from this district was found to be less than 0.1 p.p.m. Water Supplies and Fall-out. Concern has been expressed at the various effects of fall-out from the nuclear tests, including the risk of contamination of water supplies, especially where large surfaces of fresh water are exposed. In replying to a question in the House as to what steps were taken to maintain a monitoring service of the exposed water, the Parliamentary Secretary for Science said that a representative selection of public sources had been monitored for several years for radio-active strontium and caesium. In addition, following the resumption of nuclear tests, special arrangements were made to test water supplies for iodine 131. The results had not shown any appreciable amount of this isotope in water supplies from large areas of fresh water. 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. 40 Legislation The Public Health Act, 1961 amended the law about certain aspects of drainage : s.16 Examination and testing of drains. s.17 Summary power to remedy stopped-up drain. s.18 Power to repair drains and private sewers. s.19 Disconnection of drains. s.20 Fine for improper construction and repair of water closets. s.21 Closet accommodation for separate dwellings. s.22 Power to cleanse or repair drains. s.23 Loan of temporary sanitary conveniences. The principle effect of the Rivers (Prevention of Pollution) Act, 1961 which came into operation in September, is to require the River Board's consent for all discharges existing before the commencement of the 1951 Act as is already required under that Act for discharges which have begun since then. Drainage The Wealdstone sewage system had become seriously overloaded. The first step to relieve this was the construction of a sewer for the Cullington Close development. The next stage was the construction of a sewer from the head of the existing sewer in the allotments at the Council's Elmgrove Road Depot, along the eastern end of Masons Avenue, Byron Road, Oxford Road and Palmerston Road, then 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 Works, would go to the new sewer. The existing sewer at Headstone Drive would continue to serve domestic properties and discharge into the relief sewer at the High Street. In 1957 the Minister of Housing and Local Government was prepared to consider a scheme for this new relief sewer. This work was completed in the summer. This should result in some houses which periodically had suffered from sewage backing on to their gardens being no longer subjected to this nuisance. Most of the work on phase II of the Pinner relief soil sewer had been completed by the end of the year. The construction of a relief culvert in Hillside Road and Hillview Close to relieve flooding in the Hatch End Broadway was agreed on. Pollution of water courses. In July 1960 complaints were received about the pollution which was noticed in the half-mile of the open section of the Wealdstone Brook in Kenton. This water-course rises in Harrow Weald. It receives the surface water drainage from a large area in the Borough. It is liable to pollution 41 from the road surfaces and from any surface water gulleys that are misused. In parts of the Wealdstone area the surface water drains flow through the same inspection chambers as the soil drains, with the result that obstruction in one can result in the effluent flowing into the other. Investigation of possible sources of pollution were carried out. A number were discovered and dealt with; not all were discovered though because the source of admission of some coloured effluent was not traced. The brook is very difficult to clean so that the annoyance from faecal pollution is more marked than it would be if the offensive matter could easily be removed. The Public Health Committee at their meeting in September then recommended that the Highways and Cleansing Committee be asked to consider the question of concreting the bed of the open section of the brook and providing along both banks of these open sections concrete walling which would prevent debris from the banks being washed into the watercourse and so enable the stream to be more easily cleansed. With the onset of wet weather no further complaints were received in that year. This, of course, reduced the possibility of tracing the sources of pollution. The dry and warm weather in March 1961 led to complaints being received from a number of persons living in houses adjacent to different parts of the open part of the water course. The Public Health Inspectors followed every hint which might lead to the detection of sources of pollution. While it ought to be possible to check the grosser manifestations, some degree of pollution will continue to occur. This will always be the concern of the Public Health Inspectors. The extent to which those living near the brook are inconvenienced though depends on the extent to which any solid pollution is held up, in time to decompose and become obnoxious. The Public Health Committee then are interested in any proposals the Highways and Cleansing Committee have about the exposed part of the brook. The powers of the Council to carry out work are limited unless they are riparian owners. The brook emerges as an open water course on the south side of Becmead Avenue. From this point down stream the Middlesex County Council as the river authority are responsible for all maintenance and works of improvement. Above this point they act under the Rivers (Prevention of Pollution) Act to prevent pollution. The Borough Council, if they wish the water courses improved, except where they are riparian owners, can only ask the Middlesex County Council to agree to exercising their powers on the Borough Council's behalf. The Highways and Cleansing Committee accepted that culverting the water course should be treated as a definite Programme and the open sections of the stream culverted a length at a time. PUBLIC CLEANSING Much the arrangement for the collection of refuse, its disposal and for street cleansing were continued last year as were described in the Annual Report for 1954. 42 Collection of Refuse The number of bins collected is now over 81,000. The contents are deposited in vehicles which travel an average distance of twelve miles to the tip at Harefield. The refuse from business and shop premises is collected on the normal weekly refuse collection round. A charge is made for the emptying of any bins more than the one for each property. In addition special collections are made at a charge from those premises where there is more to be removed than can be dealt with by the normal services. In addition to the waste paper collected on the normal weekly refuse collection, a free waste paper and cardboard collection service is provided by the fortnightly collection made to 3,339 shops and business premises. For years the Public Health Committee has been concerned about the deposits of waste material, accumulations which lead to conditions bordering on sanitary nuisances. These accumulations often enough would start because of the difficulty a householder had in getting rid of a disused bedstead or perambulator. The Highways and Cleansing Committee were all the time unable to agree to the request of the Public Health Committee that the term "house refuse" might be construed beyond that matter which ordinarily finds its way into the household bin and is emptied each week. The time arrived though when such deposits caused a different sort of trouble because some of them interfered with the flow of water courses. In the middle of 1959 then the Council agreed to arrangements being made for the collection free of charge of household refuse comprising typical domestic articles such as old mattresses, linoleum and carpets, old fenders, domestic cooking utensils, etc. In addition, the Council proposed to continue the existing practice of removing at a nominal charge by special collection such items as old water tanks, rubble, garden rubbish, etc. The Highways Committee agreed at their meeting in October to give suitable publicity on the Council's refuse collection vehicles to these facilities, and the Public Relations Committee were asked to publicise them in the Civic Bulletin or Civic News. Use of disposable sacks. In some districts the refuse bin has been replaced by a disposable sack. A metal stand is provided at the house, either fixed to the wall or the house or free-standing. A paper sack is attached to this stand and is used in place of the dustbin. On collection, the sack is removed and replaced with a fresh sack. The collection of refuse in these sacks causes less dust, it is less noisy and saves time by avoiding the return trip to replace the empty bin. On the other hand, the saving of time is to some exten offset by the time taken to take off the used sack and replace it by another There are other disadvantages in that it is necessary to carry large number of sacks with each vehicle. The sacks too are liable to damage by hot 43 ashes, and cannot stand up to rain. The Highways and Cleansing Committee favoured further investigation and possibly the introduction of a pilot scheme. Refuse Disposal Each of the three constituent districts which combined to form the Urban District of Harrow had its own method of disposal of house refuse. In Harrow-on-the-Hill it was dealt with by incineration in a destructor. Wealdstone had a separation plant. In this the dust was first extracted; the refuse then passed on to a picking belt where reclaimable articles such as paper or glass were removed and tins. The remaining material passed to a furnance. In the Hendon Rural area the refuse was disposed of by controlled tipping. When the two plants were no longer servicable, for a while all refuse was disposed of by controlled tipping in the district. When all available sites were used up, arrangements were made for all refuse to be conveyed to a tip at Harefield. While disposal of the rubbish by incinerators would seem to be the most hygienic method, in point of fact the amount of grit thrown into the air by the high draught causes a real nuisance. Those in the adjoining isolation hospital in South Harrow were only too conscious of this nuisance from the destructor. Disposal by a separation plant causes much less nuisance. Because of the materials which are extracted, much less draught in the chimney stack is needed and little or no nuisance is caused from grit or smoke. Although the practice met with considerable opposition when introduced, controlled tipping carried out efficiently causes surprisingly little inconvenience or nuisance to those in the neighbourhood. The method of disposal by controlled tipping, particularly when the tip is out of the district, results indirectly in the creation of nuisances. It was the practice of the Harrow Council when they had the local facilities to agree to those who had material they wished to dispose of having this done at these plants. With the loss of these facilities, tradespeople are more prone to accumulate collections of disposable articles, and then to dispose of them periodically by burning. The accumulations in themselves are unsightly and might provide harbourage for vermin, and certainly militate against the endeavours of the Council to improve standards of food hygiene. There is too the question of the disposal of condemned meat, fortunately for this district the Borough of Wembley disposes of refuse in a destructor and have agreed to get rid of the local condemned meat in this way. Some other solution would have to be found if Wembley turned to some other method of disposing of their refuse. The Council in 1948 agreed that the accepted arrangements for the disposal of refuse for the district should be by separation and incineration, and two sites were agreed. 44 The present agreement with the Uxbridge Corporation runs to 31st March, 1964. There is a limit to the sites available there, and the Uxbridge Corporation invited Harrow and Ruislip and Northwood to consider the possibility of setting-up a joint committee to explore the question of providing a refuse destructor to serve the three districts. No site suitable for a destructor of this size is available. The Engineers and Surveyors of the three districts submitted a report on possible methods of disposal. Of four of these, disposal in wet pits or by composting were ruled out. That left the alternatives of disposal by destructors or by bulk handling. The Highways and Cleansing (General) Sub-Committee considered these alternatives at their meeting in September and recommended that the main Committee approve the principle of the provision in the Borough of two refuse destructor plants. The main Committee at their meeting in October however, decided on the principle of the disposal of refuse by bulk handling. SWIMMING BATHS There are two open-air swimming baths in the district, one at Charles Crescent, Honeybun Estate, Harrow, and the other at Christchurch Avenue, Wealdstone. The former, constructed in 1923, measures 165 feet by seventy-five feet, with a depth of seven feet to three feet six inches. The water, after being filtered, is treated by chlorination. Dressing accommodation, shower and foot baths and sanitary conveniences are provided. The Wealdstone bath, constructed in 1934, measures 165 feet by seventyfive feet, with a depth of eight feet six inches to two feet six inches; in addition, there is a shallow semi-circular beginners' pool. Suitable dressing accommodation, with shower and foot baths, and sanitary conveniences, are provided. The water is treated by passing through filters and is then chlorinated by the break-point method. The duration of the turn-over period varies according to the extent the baths are used, but it is at least once a day, and at busy times is every eight hours. Daily tests are carried out for the presence of free chlorine and to determine the pH value. PUBLIC CONVENIENCES Work was started in 1960 on conveniences at Rayners Lane and at Belmont Circle. By the end of the year, consent had been received for the erection of a convenience in the grounds of what was at one time the Honeypot Lane Isolation Hospital and tenders had been accepted. Negotiations were proceeding about conveniences to be put up at Woodridings Close, Hatch End and about the one in Kenton Road. In the early part of 1961 the convenience at Rayners Lane was opened and in 45 November that at Qucensbury. In June it was decided a convenience should be provided near Brockhurst corner. In November tenders were accepted for the construction of the convenience at Woodridings Close, Hatch End. At the end of the year, negotiations were still proceeding about the convenience at Kenton Road. Two features of public conveniences have been discussed much during the year. In November the Minister of Housing and Local Government advised authorities that he had come to the conclusion that turnstiles are unsatisfactory as a means of access of public conveniences. He asked all local authorities not to instal any more and to remove existing ones as soon as possible. None of the public conveniences in this district has turnstiles, and the Open Spaces Committee decided to remove the turnstiles from the conveniences under their control. The other question was that of charges. The Council decided to abolish charges for the use of public conveniences and those in the open spaces, except that a charge be retained for one W.C. in each building for the use of those members of the public who would prefer to pay the charge. 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. Crematorium The Council at their December meeting accepted the recommendation of the Open Spaces Committee "that the Council do concur with the Council of the Borough of Uxbridge and the Ruislip/Northwood Urban District Council that the Breakspear Crematorium Joint Committee shall be deemed to take effect as from the 18th October, 1961." The question of the erection of a crematorium behind Valencia Road, Stanmore was still being considered at the end of the year. Harrow invited Hendon and Wembley to provide a crematorium jointly. In reply, Wembley suggested Harrow should consider part of the rpenders Park site for this purpose. At present though Harrow do not contemplate building a crematorium there. Hendon offered Harrow the use of facilities at their crematorium at Holders Hill Road, N.W.7. Harrow declined though as this crematorium would not serve the part of Harrow most in need of such facilities. 46 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. The Council arranged with the local undertaker to carry out these burials. In no year has it been necessary to make these arrangements for many. It can be expected that the number will diminish rather than increase. There were only three this last year. 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, telephone number Harrow 3871. Advantage was taken of the decision to erect a new disinfecting station to replace the one at the Stanmore Honeypot Lane Isolation Hospital near to the mortuary to improve the facilities there. Work was completed just before the end of the year. The main change has been that the viewing room has been transferred so that it now joins the main room, and adequate waiting accommodation for visitors has been provided. For some weeks while certain work was being done the mortuary could not be used, bodies for this period being admitted to the Wembley mortuary. During the year, 216 bodies were admitted; post mortem examinations were carried out on 214, and inquests were held on 26. In addition, 57 bodies were admitted to the Wembley mortuary during the time that the work was being done on the Harrow mortuary. 47 SANITARY INSPECTION OF THE DISTRICT AND THE INSPECTION AND SUPERVISION OF FOOD The activities of the public health 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 (j) On complaint of dampness or other housing defects 1,014 (ii) On complaint of other nuisances 435 (iii) Routine inspections 981 (iv) Revisits arising from defects found 3,018 (v) Surveys under S.157 Housing Act, 1936 90 Conditions Found (i) Number of dwellings or other premises where defects were found 1,425 (ii) Number of cases of overcrowding revealed 10 PUBLIC HEALTH Visits (i) On complaint or request 157 (ii) Routine inspection of premises 833 (iii) Revisits arising from defects found 823 (iv) (v) Surveys arising from Rats or Mice complaints 1,635 Inspection of Factories 221 (vi) Inspection of Workplaces 88 (vii) Inspection of Outworkers' Premises 142 (viii) Inspection of Cinemas and Places of Entertainment 58 (ix) Inspection of Licensed Premises 85 to Visits under Shops Act 1,255 (xi) Evening observations under Shops Acts 17 (xii) Sunday observations—Shops Acts 13 (xiii) Observations made for Smoke Nuisances 96 (xiv) Surveys under Clean Air Act 5,614 48 Conditions Found (i) Premises visited as a result of (i) and (ii) where defects or unsatisfactory conditions were found 925 (ii) Number of premises where action was taken by Rodent Operatives to deal with rats or mice 1,359 (iii) Number of Factories, Workplaces and/or Outworkers' Premises where defects or contraventions were found 45 (iv) Number of Cinemas and/or Licensed Premises where defects were found 8 (v) Contraventions of Shops Acts— (a) Failure to observe closing hours 12 (b) Other contraventions (failure to exhibit notices, etc.) 127 FOOD HYGIENE Visits (i) Slaughterhouses 432 (ii) Butchers' shops 206 (iii) Cowsheds 7 (iv) Dairies 34 (v) Fish Shops 50 (vi) Bakehouses 57 (vii) Cafes and Restaurants 189 (vlll) Ice Cream Premises 91 (ix) Provision Merchants 262 (x) Greengrocers 193 (xi) Other Food Premises 352 COMPLAINTS RECEIVED Summary Accumulations of Refuse 81 Animals causing a nuisance 26 Dampness and Housing defects 226 Drains and sewers—choked 72 —defective 64 Dustbins defective 21 Flooding—Gardens 11 Vermin 14 Insect infestations 59 Overcrowding, alleged 18 Smoke nuisances 18 Watercourse 19 Other complaints (wasps'nests, defective fences) 169 Food unfit (excluding requests received from shops to visit and inspect food) 31 49 NOTICES SERVED Under Housing Act, 1957 Statutory Notices served under S. 9 requiring execution of repair work - Dwellings reported under SS. 16/17 as being unfit for human habitation 16 Dwellings reported under S. 18 (closing orders) 2 Informal notices served under S. 9 — Under Public Health Act, 1936 Statutory Notices under— (i) S.24—work to a public sewer 107 (ii) S.39—repair or renewal of drains 2 (iii) S.45—repair or renewal of defective water closets — (iv) S.56—Undrained or badly drained yard area — (v) S.75—renewal of a dustbin 1 (vi) S.93—abatement of a nuisance 22 (vii) Informal notices served 1,270 ACTION TAKEN Following Housing Act Notices (i) S.9 Housing Act, 1957—dwelling rendered fit— (a) By owners — (b) By local authority in default of owners — (ii) S. 16/17 Housing Act, 1957, Demolition order made 12 (iii) S.18 Housing Act, 1957, Closing order made 2 (vi) Dwellings rendered fit by owners after receipt of informal notice 6 (v) S.28 Housing Act, Closing order converted to Demolition Order - Following Public Health Act Notices (i) S.24—Public sewers repaired 18 (ii) S.39— (a) By owners 2 (b) By local authority in default of owners — (iii) S.45- (a) By owners — (b) By local authority in default of owners — (iv) S.5- (a) By owners — (b) By local authority in default of owners — (v) S.75— (a) By owners — (b) By local authority in default of owners 1 (c) By occupier — (vi) S.93—Nuisances abated 20 (vii) Nuisances abated and/or other work carried out by owners on receipt of informal notice .. 1,183 50 Following action under Factory Act 1957—S.7 Number of Notices 3 Number complied with by owners 1 Following action under Clean Air Act—S.12(2) Number of notices 21 Complied with by Owners 2 HOUSING Inspection of Houses Although the Housing Act required local authorities to carry out the systematic inspection of houses, this routine work has not been started since the war. Most inspections are carried out on receipt of a complaint, and to obtain the carrying out of the necessary work, reliance is placed more on the provisions of the Public Health Acts than on those of the Housing Acts. Repair of Houses Improvement Grants. The Housing Act, 1949 authorised local authorities to give assistance in respect of the provision of dwellings by means of the conversion of houses or other buildings and of the improvement of dwellings. Later legislation amended these provisions. In this district Little use has been made of the powers granted in the original Act or in the amending Acts. What has been done has been mostly in respect of owner-occupied houses. The 1959 Act introduced the standard grant which relates to the provision of specific items of improvement to be carried out on houses built before 1944. During the year twenty-two applications for standard grants were received. All the eighteen of those approved were in respect of owneroccupied houses. Eighty-seven enquiries were received about obtaining a discretionary grant; eleven were approved in principle. Of the seventeen discretionary grants approved in detail during the year, all were in respect of owner-occupied houses. 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 house included twenty-nine which were already the subject of confirmed Clearance Orders, thirty-nine the subject of confirmed Demolition Orders 51 and 115 about which action had already been started. This 115 included the ninety-one houses in the Northolt Road areas, 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. By the end of 1960 of the 577 houses, 106 had been demolished and twenty-one had been reconditioned. During 1961 nineteen were demolished and seven reconditioned, making by the end of 1961 a total of 125 demolished and twenty-eight reconditioned. Some 200 houses were the subject of Clearance, Demolition or Closing Orders or were being dealt with with one of these in mind. Of these eighty-two were vacant. It is expected that many of those 577 houses included in the return but not up to this dealt with will be reconditioned and so be removed at least for a time from the list of these to be demolished. The fate of these cannot be determined though until the Council is in a position to rehouse within a short time the occupants from houses which are made the subject of Clearance Orders or Demolition Orders. Demolition of Houses Once more little progress could be made in dealing with houses which are considered to be unfit for human habitation. During the year only nineteen houses were demolished. The position is more satisfactory than these small numbers would suggest, because the occupants of many houses deemed unfit have been rehoused by the Council but for one reason or another the houses have not been demolished. Most often this has been because the continued occupancy of one or two houses has delayed the demolition of a whole terrace. Of the houses covered by Clearance Orders, excluding those that have been demolished, there were thirteen vacant and another fifty-seven had been purchased by the Council in the Northolt Road clearance scheme. The nine houses in the group 44-60 Greenford Road had been purchased and vacated. In the houses 34-42 Palmerston Road which had been purchased were seven families. Nos. 15, 17 and 19 Crown Street and No. 1 Albert Cottage and 8 and 9 Albert Place were all purchased but were occupied by six families. There is still a pre-war Clearance Order on Nos. 1-5 Brewery Cottages which are still occupied. The following houses which are the subject of Demolition Orders or Closing Orders made before 1961 were still occupied at the end of the year 1 and 3 Crown Street (1957), 14 Camden Row, Cuckoo Hill (1959). 1, 5, 6 Kirby Cottages (1959), 12 Wordsworth Road (1955), Golf Cottage, Pinner Hill (1959). Behind these figures of such very slow progress are all the families doomed these many years to living in houses which have been officially condemned as being unfit for human habitation and which would have been in the long enough before that date. Even considering only those houses dealt with since the war, it is as far back as 1954 since the 52 houses in the Northolt Road scheme were represented and it is only now that some of these families are being rehoused. Particularly in these days of rising standards in so much for most people, it is tragic that these families who can look only to the Council for help should have to continue for so long in these unsatisfactory conditions. Many of these houses have been acquired by the Council well before they could be demolished so that for a long time the Council are the owners of slum dwellings. New Demolition or Closing Orders. During the year, Demolition or Closing Orders were made in respect of the following thirteen properties:— 4 Grove Hill Road, 41 Nelson Road, 6 Canons Cottages, Whitchurch Lane, 16 Crown Street, 67 West Street, 23 Bridge Street, 300 Everton Court (flat), Chestnuts, Cornwall Road (flat), 21, 23 Headstone Drive, 1 and 2 Belgrano Cottages, 27 Mead Road. Demolition. The following nineteen properties were demolished during the year:— 33, 35, 37 Crown Street (officially represented 1954), Gothic Cottage, Waldron Road, 1, 3, 5, 7, 9, Waldron Road, 115-131 (odd nos.) Northolt Road, 82 High Street, Stanmore. Reconditioning of Houses. The following seven houses were reconditioned:— 1 and 2 Camden Row, 1 and 2 Sunny Cottages, 56 Francis Road, 22 Little Common, 9 Trafalgar Terrace. Proposals for reconditioning were received in respect of four other houses. Some provisions of the Public Health Act, 1961, deal with improvements to houses. S.31 deals with food storage accommodation in new houses, S.32 with it in existing houses. S.33 deals with the provision of bath-rooms in new houses or in conversions. Underground Rooms. The Council adopted new model regulations relating to the closing of any unhealthy underground rooms. These were confirmed by the Ministry and came into force on the 1st November. Legislation Provisions of the 1961 Housing Act altered the procedure for dealing with condemned houses. Section 24 enables a local authority to exclude from a clearance area a house which has been or will be made fit for human habitation and am other houses which were only included in the area because of the inclusion of a house which is so excluded. Section 25 enables a local authority to receive proposals from persons who are not owners, but who may be in a position to make a house subject to a Demolition Order fit for habitation. 53 Section 26 enables a local authority when proposals are made for using a house the subject of a Demolition Order for a purpose other than for human habitation to determine the Demolition Order and substitute a Closing Order. 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 21 Number of applications not granted 1 Number of Undertakings accepted from owners 18 Number of Certificates cancelled upon application 12 Number of applications for a Certificate as to the remedying of defect 14 Number of applications by owners for Cancellation of Certificates not granted 5 Overcrowding The annual return of the state of overcrowding in the district showed that once more there is an improvement. The number of cases known on the 31st December, 1960 was thirty-eight; the number on the 31st December, 1961 was thirty-one. The net reduction of seven is the difference between seventeen cases in which the overcrowding was abated and ten new cases which were added during the year. In three instances the overcrowding was abated by families being rehoused by the Council. Of the ten new cases, four were the result of an increase in the size of the family, or of the ageing of the children and three the marriage of one of the children. Three were caused by lodgers; in one instance this was a relative. Of the thirty-one cases which were overcrowded on the 31st December, 1961, seven were overcrowded by half a unit, twenty by one unit, three by one and a half units and one by two units. New Housing The total number of new dwellings provided in this district from the end of the war to the 31st December, 1961, was 6,866. Of these, 2,873 were new Permanent Council dwellings and 200 were new temporary dwellings. Of these 200, sixty-seven have been removed. 3,182 permanent dwellings have been provided by private enterprise. 338 dwellings destroyed by enemy action were rebuilt and 340 existing houses coverted. At the end 54 of the previous year the number of permanent Council dwellings provided was 2,731 and the number of buildings provided by private enterprise 3,182. Further use was made during the year of the arrangements for the removal of Harrow families to the New or Expanded Towns, 210 Harrow families being housed. By the end of the year, the total number of families who had been housed under these arrangements was 2,338, of which 736 were from the normal housing list. Most of these removals were to the New towns of Hemel Hempstead, Stevenage, Harlow, Welwyn and Hatfield and the Expanded Towns of Swindon and Bletchley. Smaller numbers went to Basildon, Bracknell, Crawley, Aylesbury and Thetford. New Housing Programme By the end of the year the erection of ninety-seven dwellings, fortyeight flats and eight old people's flats had been completed. There were five dwellings in Pinner Hill Road, twenty-four in Stage 2 and twenty-four in Stage 3 of Phase II of the Rayners Lane development and fourteen in Northolt Road. Forty-eight flats were completed at Rayners Lane, Twenty-four of Phase I of the programme, twenty-four in Stage 1 of Phase II. In addition there were eight old people's flats at Bessborough Road. Work on forty-four flats was started during the year but not completed by the end. Twelve of these were in Pinner Road, twenty in the Brookside Estate, and twelve in the Marsh Road/Rayners Lane development. Common Lodging Houses There are no common lodging houses in the district. SUPERVISION OF OTHER PREMISES Routine visits are paid by the public health inspectors to such premises as factories, licensed premises, cinemas, schools, church ha and dance halls to see the conditions were sanitary. Factories There are 529 factories in the district. To these 348 visits were Seventy-one contraventions were found. Of these sixteen were due to want of cleanliness, and twenty-two to defective or unsuitable sanitary accommodation. The remaining offences were mostly in regard to compliance with the requirements about the exhibition of notices. 55 Information about matters about which he is concerned are passed to the Inspector of Factories. He in his turn draws the attention of the department to those matters which he has discovered and which concern them. The building of different premises, blocks of offices, private houses, shops, etc. has necessitated special attention being given to the provision of sanitary conveniences for the use of the building employees. Forty-nine visits were paid for this purpose. In some instances the use of an Elsan chemical closet was the only solution. Local authorities are required to keep a register of outworkers with a view to action being taken where work is being done in unwholesome premises or where there is risk of spread of infection. At the end of the year, there were 149 outworkers on the register. 142 visits were paid. The premises in all cases were satisfactory. The Ministry require the inclusion of prescribed particulars about the administration of the Factories Acts to be set out in a set form. Part 1 of the Act 1. Inspections for purpose of provisions as to health (including inspections made by the Public Health Inspectors). Premises (1) Number on Register (2) Number of Inspections (3) Written Notices (4) Occupiers (5) (i) Factories in which Ss. 1, 2 3, 4, and 6 are to be enforced by Local Authorities 54 36 - - (ii) Factories not included in (i) in which S.7 is enforced by the Local Authority 408 274 7 - 0") Other premises in which S.7 is enforced by the Local Authority (excluding outworkers' premises). 67 38 - - Total 529 348 7 - 56 2. Cases in which defects were found. Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Referred Found Remedied To H.M. Inspector By H.M. Inspector Want of cleanliness (S. 1) 16 12 — 1 — Overcrowding (S.2) — — — — — Unreasonable temperature (S.3) — — — — — Inadequate ventilation (S.4) — — — — — Ineffective drainage of floors (S.6) — — — — — Sanitary Conv'es (S7): (a) Insufficient 4 2 — 1 — (b) Unsuitable or defective 6 6 - 2 - (c) Not separate for sexes 1 — — — — Other offences against the Act (not including offences relating to outwork) 19 12 - 1 - Total 45 32 — 5 — The return in Part VIII of the Act (Sections 110 and 111) relating to out-workers is that of the 143 out-workers on the August list as required by S.110(1) (c), 119 were engaged on the making etc., cleaning and washing of wearing apparel, one on curtains and furniture, three on artificial flowers, four on the making of boxes, eight on brush making, one on stuffed toys, six on Christmas stockings and one on lamp shades. There were no cases of defect in sending lists to the Council under S.110 and no prosecutions for failure to supply lists. Under S.111 there were no instances of work in unwholesome premises, so that no notices were served and there were no prosecutions. 57 Shops There are 2,348 shops on the register, a decrease of thirteen on the previous year. During the year 1,255 visits were made for the purpose of administering the Shops Act. The following is a summary of the contraventions noted Shops in need of decorating 4 Heating, insufficient or absent 17 Watercloset accommodation insufficient for sexes 1 Watercloset choked, dirty or defective 32 Assistants employed on their weekly half-holidays 10 Shops open on the half-holiday without displaying prescribed notices 24 Shops with no weekly half-holiday closing 2 Shops failing to close on the weekly half-holiday 3 Serving customers with non-exempted articles after closing hour or half-day holiday 7 Serving customers after evening Closing Hour 3 Absence of seating for female assistants 3 Shops open for selling non-exempted articles 5 Failing to keep records of assistants' employment 8 Failing to allow compensatory holiday for Sunday employment or working excessive number of Sundays 8 Keeping the shop open without prescribed notices 18 Shops failing to close and assistants employed 4 Three hundred and twenty-six warnings were sent in respect of the above items and in one instance authority given to take legal proceedings. During the routine inspections of shops the following defects were noted:— six defective water heaters; eight defective waterclosets; ten watercloset compartments requiring re-decoration and four shops requiring re-decoration. As contrasted with the position in 1938 there were increases of onethird in the number of radio, television and electrician shops; in furnishers and in motor and cycle supplies and accessories shops; and of about 20% in ladies outfitters. The greatest increase was more than a doubling of the number of shops selling wallpapers and paints. There were decreases of about 10% in the numbers of confectioners/cafes, in grocery shops and on newsagents, and a rather greater decrease in the number of boot repairers, dairies and fish shops. After a ballot had been taken, an order was made entitling motor traders to sell motor vehicles on the weekly half-holiday but not on Sundays. 58 Places of Entertainment At the end of the year there were seventy-eight premises in the district licensed for public entertainment. These include ten cinemas; fourteen public houses; fifteen church halls; three local authority assembly halls; twenty-one schools and fourteen dance and other assembly halls, clubs, etc. These premises received the usual attention during the year. All were found to be satisfactory, except that in three instances minor defects were found; these were soon remedied. Licensed Premises There are fifty-eight licensed premises in the district. To these seventyfive visits were paid. In most cases the premises are modern and were found to be satisfactory. In the few cases where minor defects or poor decoration needed attention, the faults were soon dealt with. During the year the new Queens Arms in High Street, Wealdstone, was completed and opened and the Iowa closed down. At the Case Is Altered, Harrow Weald, and the Seven Balls, Kenton Lane, the drainage of the cellars and sanitary arrangements are not satisfactory. These matters have been discussed. A report about the state of these licensed premises is sent to the Clerk of the Justices each year just before the Brewster Sessions. Keeping of Pet Animals One new business started during the year so that the number of licensed Pet Shops in the district was fourteen. They were all inspected during the year and found to be satisfactory. Rag Flock New regulations under the Rag Flock Act of 1951 came into force on the 1st August. They deal, in the main, with the sampling of rag flock and other filling materials used in bedding and upholstery, furniture etc.. with the type and method to be used in sampling and testing, and with the increased fees to be paid to Analysts. Four of these premises are registered. At each place the fibre, kapok or other filling material used is supplied under warranty for cleanliness. All the premises were visited during the year and no nuisance was found. There are no premises in the Borough licensed for the manufacture of rag flock. Marine Stores The three premises registered with the Authority under the old Metal Dealers Act 1861 to deal in old metal were visited during the year, nuisance was found. 59 Hairdressers' and Barbers' Premises At the end of the year there were 139 hairdressers and barbers premises. To these thirty-four visits were paid to see that the bye-laws made under Section 282 of the Middlesex County Council Act to secure the cleanliness of the premises, instruments, towels, equipment and materials used in the premises and all the requirements of the Shops Act were being complied with. Except in four instances, the premises were found to be satisfactory. S.77 of the Public Health Act, 1961, empowers a Local Authority to make byelaws for securing the cleanliness of premises, instruments and equipment used, and also the cleanliness of the hairdressers and barbers in regard both to themselves and their clothing. CONTROL OF NUISANCES Atmospheric Pollution Smoke Complaints. Eighteen complaints were received during the year about smoke nuisances. Five of these concerned the emission of smoke from dwellings in the area affected by the Council's No. 1 Smoke Control Order. Enquiries showed the householders had failed to appreciate what was expected of them; they took immediate steps to deal with the situation. Of the other complaints most were about the chimneys of incinerators where stoking lapses led to smoke emissions. These, however, were not serious. Smoke Control During the year, the first smoke control order came into operation, the second order had been confirmed and much work had been done in relation to the third order. Area No. 1. On November 22nd, 1960 the Minister of Housing and Local Government confirmed the Borough of Harrow Smoke Control (No. 1) Order to come into operation on September 1st, 1961. This deals with some 2,179 dwellings and other premises in an area of 225 acres. The estimated cost of adapting and replacing the fireplaces was about £40,000. This sum was reduced by £1,000 because of the decision of the Minister that only where firebricks were defective or had to be renewed should their replacement qualify for a grant. This original estimate was prepared on the assumption that all who were eligible to take advantage of the grant would do so. The experience of other authorities was that only about onethird would in fact do so. By the end of August, out of the 1981 private dwellings, applications had been received in respect of only 775. Of these, 60 300 were received in the last nine months before August 31st. As to the actual work done, it seems the owners are spending on adaptations nearly double the amount of grant received by them under the Act. Order No. 2. At their meeting on the 3rd January, the Public Health Committee agreed that the area between Eastcote Lane and the Metropolitan and Piccadilly railway line at Rayners Lane on the one hand and Alexandra Avenue and the Borough boundary with Ruislip/Northwood on the other, should be declared as the Borough's (No. 2) Smoke Control Area. This was an area of some 440 acres with some 3,600 dwellings and other premises. At their meeting in September, the Committee agreed to this area being divided into three, each to have its own Smoke Control Order. This would enable the part covered by the first of these three Orders to come into operation at an earlier date than if the area were to be covered by the one Order, while at the same time, not delaying by many weeks the coming into force of the third of the Orders. The decision about the area to be covered by the No. 2 Order was therefore revoked and instead No. 2 Order now relates to the smaller area bounded on the south by Eastcote Lane but on the north by Malvern Avenue. This area is some 105 acres with 1,119 dwellings and twenty-five commercial and three other premises. Of these 1,119 dwellings, 744 are private dwellings built before the Act and forty-six are private dwellings built after the Act, 272 are Council dwellings built before the Act of which 254 have already been converted to use smokeless appliances and fifty-seven are Council dwellings built after the Act. The estimated cost of adapting and replacing the fireplaces was about £8,000. The proposed date for coming into operation of the Order was 1st July, 1962. The Minister fixed 1st September, 1962. Order No. 3. By November, the survey of the No. 3 area was complete. This area of approximately 132 acres with 1,071 hereditaments, is bounded to the east by Alexandra Avenue, to the south by Malvern Avenue, on the west by the Borough boundary with Ruislip and Northwood and on the north by Widdicombe Way, Newquay Crescent and Drake Road. Of the hereditaments, 1,069 are private dwellings. These include sixty Council flats in Alexandra Avenue which are fitted with coal burning appliances. The other two buildings are the Middlesex County Council clinic in Alexandra Avenue and a school sports pavilion in Malvern Avenue. There are no industrial or commercial properties in the area. The estimated cost of the work of coversion is about £10,000. The Council at its meeting on the 15th December made the No. 3 Order, to come into operation not before September, 1st, 1962. Programme. In January, the Minister of Housing and Local Government asked the Council to submit a programme for extending smoke control in the Borough. It was felt it should be possible to deal with some 3,000 dwellings and premises or about 500 acres each year. With the appointment of additional staff at the end of the year, it is confidently expected there will be a marked speeding-up in the programme. 61 Up to this, it has not been felt that the atmospheric pollution of this district was sufficiently serious to warrant the Inspectors' being taken off more urgent duties to free them to do the work necessary before additional Smoke Control Orders could be met. The district was classified as a black area not because of the extent to which the atmosphere is polluted, but because much, though not all of it, was affected by the fog of December 1952. Nevertheless, it is hoped that the additional staff will not only enable the arrears to be overtaken but more speedy progress to be made so that Harrow can feel it is playing its part in improving the condition of the atmosphere. Estimates from Warren Springs towards the end of the year indicated that real progress is being made. The emission of smoke over the country decreased from an estimated figure of 2.3 million tons in 1952 to 1.9 in 1959. Progress in London was even more striking; between 1953 and 1959 the emission of smoke was reduced from 152 thousand tons to eighty-two thousand tons. Finance. From 1st June, the British Ironfounders Association recommended their members should increase the cost of domestic solid fuel appliances by 5%. The Council approved the increase, making the approved sum £4 17s. 0d. Problems arose because of the impossibility of comparing one set of costs with another when very different types of work were being done, or where the applicant was doing the work himself and so was not providing for any labour charge. It was decided as a general principle, that grants should be assessed on (a) the Council's total estimated cost of the work considered to be reasonably necessary or (b) the total of the applicant's approved estimate (no figure being included for the applicant's own labour), the applicant being granted the lesser of these amounts. Hazards of Radiation Fall-out. The explosion of a series of bombs in Russia in the Autumn again raised the question of the risk from fall-out. The danger comes from the various radio-active isotopes which are created by the disintegration of uranium used in the fission bomb. Of these isotopes some are short-lived, some have very long lives. All contribute to the external radiation of the whole body; some are absorbed and can be particularly dangerous. The most dangerous of the shortlived is iodine 131 which becomes concentrated in the thyroid gland. It is taken into the body predominately through milk. The short-lived zirconium 95 contributes to the external radiation only. Of the longer lived isotopes the most serious is strontium 90. This makes for the bones where it can cause cancer of the bone or leukaemia (cancer of the bone marrow). Because of this and because of its long half-life it is regarded as the most important single indication of the possible total hazards to the individual. Carbon 14 and caesium 137 are important because they give use to general irradiation of the body, including the gonads. 62 From the bombs released in North Russia a cloud of fall-out rose, passing in an easterly direction to reach this country some days later. At this stage radio-active iodine is the most important component. In the Spring of 1962 there will be further danger. By this time the radio-active iodine which has a half-life of only eight days will have disintegrated and the dangerous components will be the strontium 90 which has a half-life of many years. The contamination in the Spring will come about because the radio-active cloud which has risen into the stratosphere will descend in the troposphere gap. Although the largest amounts of radio-active dust from this series of bombs will be expected to fall in the Spring of 1962, there will be further, though smaller falls, each Spring for at least ten more years. The degree to which this country is exposed to contamination from this series of bombs set off in the locality they were, depends partly on the height at which they were released and partly on the composition of the bombs. Deposition from large explosions is most rapid when debris is released into the lower stratosphere in high altitudes during the autumn and on such factors as latitude and the time of the year. The largest are of the fission-fusion-fission type. The first fission element is to set-off the rest of the bomb. The dirtiness of an individual bomb depends on the extent to which it is made up of the dirty fission element as compared with the cleaner fusion part. When it became apparent that the new series of explosions might lead to appreciable amounts of radio-active elements in the air, the Agricultural Research Council Radiobiological Laboratory started examining milk from eight depots or farms located in different parts of England and Wales, Scotland and Northern Ireland. This was later expanded to collections from twenty sites. Most of the samples were examined daily for iodine 131, and were also examined for strontium 90. The results of the earlier examinations suggested that if larger bombs were released, the amounts of radio-active iodine in the milk might reach dangerous levels and be a danger to infants under one year of age consuming such milk. Those of about six months of age would be at greatest risk because they would be the greatest consumers of the milk. The Government therefore made arrangements for supplies of dried milk, sufficient to be able to provide 1½ pints of reconstituted milk daily for each child under one year of age, to be available. In point of fact at no stage did the amount of radio-active iodine in milk reach a sufficiently high level as to be at all dangerous. The highest level reached was sufficiently low that it would have been necessary for milk containing that contamination to be consumed for six months before it became dangerous. This could come about of course only if the bombs were released continously over this period. That the later larger bombs did not present the danger apprehended from the consideration of the fall-out from the earlier smaller ones, might have been due to the larger ones being release at greater heights, but also probably because they were cleaner bombs. 63 There still remains the possibility of contamination in the Spring by strontium 90. It is not expected though that this will reach dangerous levels. In considering the question of the danger of this contaminated milk, it must not be forgotten that all milk is naturally radio-active to some extent. There is no way of obtaining a wholly non-radio-active milk. Contamination from fall-out temporarily raises the level of certain radio-active substances. What risk there was, was to children under one year of age who might have consumed radio-active milk. Children over one year of age, expectant mothers and nursing mothers were not especially at risk, nor the babies who were being breast fed. Rats and Mice The rodent operatives found rats or mice at 1,359 of the 1,635 premises they visited. Each of the infestations was small and localised. Most complaints were from private dwelling houses, 1,346 of these being in respect of rats, seventy-five of mice. Thirty-nine infestations of rats and four of mice were at Corporation properties, 145 and twenty-six at other premises. The number of visits made by the rodent operatives to these properties was 1,635; in 1960 it was 1,690. 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 this encouraging rodents. The small number of sewers known to be infested with rats were treated twice during the year. The results of the treatments 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 in different years and so in the requests for help to destroy their nests. These numbered 345 in 1957; 213 and 265 in the next two years; only 111 in 1958; the largest number ever recorded was 818 in 1959; there was a reduction to 647 in 1960 and a further fall to 450 this last year. In spite of the smaller numbers because of reduced staff, only 398 cases could be dealt with—the other fifty-two being treated in other ways. 64 Pigeons These birds again became a nuisance particularly in South Harrow, the sites affected being, as before, the Railway Arches, the Gas Works Yard and the shopping arcade. This year there were numbers of birds in the shopping centres in Station Road and College Road, Harrow, of North Harrow and Pinner; of Wealdstone and Stanmore. The treatment which had been carried out at the Railway Arches and the Gas Works in 1958 had resulted in a marked reduction in numbers. It was appreciated that similar treatment would be needed periodically, as long as these places are unguarded and so provide facilities for the pigeons to roost. Difficulties are increased because so many people make a practice of feeding the birds. Section 74 of the Public Health Act 1961 gives Local Authorities greater powers than they had before to "take steps for the purpose of abating or mitigating any nuisance, annoyance or damage caused by the congregation in any built-up area of housedoves or pigeons or of starlings or of sparrows. The Local Authority may take reasonable steps to cease or destroy or sell or otherwise dispose of housedoves or pigeons which, in their belief, have no owner." The question of what action under these added powers might be taken was being considered at the end of the year. Noise The provision of the Noise Abatement Act, 1960 making noise or vibration a statutory nuisance were much the same as the powers contained in Section 313 of the Middlesex County Council Act 1944 which has been in force in this district all these years. Probably because these added powers were better known, on the introduction of the new Act, more complaints were received about noise. One related to that from the machinery in a workshop near houses, and another about the noise from the dance band employed at an hotel. Caravan Site Although for all these years the Public Health Committee has been concerned about the unsatisfactory state of the caravan site at North Lodge, no real progress has been made to improve matters. Admittedly things are better in that there is now a limit to the number of caravans on the site, a number far smaller than those that were at one time there. Although the Middlesex County Council Act gives powers to enforce satisfactory conditions about sanitation, water supply, hard standing, footpaths, etc. nothing has been done to see that this work is carried out because of the various suggestions which have been made about the alternative use of the site. All the time that it seemed possible that the use of the land as a caravan site would soon come to an end, there was little point in insisting on this work being done. The County Council at 65 one time proposed to acquire the site, and to facilitate matters the Corporation agreed to rehousing of the occupants of five of the caravans. This was in fact done. Later the County Council changed its mind and no longer wished to acquire the site. The position was discussed by the Planning Committee at its meeting in July. At that meeting the Committee agreed to accept a late application under the Caravan Site Control of Development Act, 1960 for a site licence for the use of the land at North Lodge as a caravan site. The Middlesex County Council had approved under Part III of the Town and Country Planning Act, 1947 of the use of the land as a caravan site for a limited period expiring 31st March, 1964 and to the discontinuance of the land for a caravan site, such order to operate as from the expiration of planning permission. Certain standards of work which could be enforced under the Middlesex County Council Act had already been decided upon. As the new proposals contemplated the use of these structures for something under three years, in some instances lower standards entailing the use of less durable materials were agreed on. The Committee then agreed to grant a licence for the use of the land at North Lodge as a caravan site for a period up to the 31st March, 1964, subject to certain conditions. Amongst these were the provision of hard standings, suitable carriageways and footpaths, adequate sanitary fittings, a proper water supply, suitable arrangements for refuse disposal and adequate fire-fighting appliances. Each of the conditions was to be complied with within a period of three months from the date of the site licence. 66 INSPECTION AND SUPERVISION OF FOOD (A) MILK Production There are five farms in the district producing milk. Store cattle art kept at two farms. Four out of the five farms produce tuberculin-tested milk; the milk from the other farm is sent to a wholesaler for processing. Distribution and Licensing Milk is pasteurised at two dairies in the district; the plants are licensed by the Middlesex County Council. The responsibility for the licensing of premises from which milk is retailed up till recently lay with the Borough Council. The County Council now issues these licences. Supervision During the year forty-one visits were made by the Public Health Inspectors to dairies and cow sheds in the district. Sampling Twenty-four samples of milk were taken and submitted to the Colindale Laboratory for analysis. Ten were pasteurised, nine T.T. pasteurised, three T.T. farm bottled, and two sterilised; all were satisfactory. This sampling is independent of that carried out by the County Council. Complaints During the year twenty-five complaints were received about milk bottles. Twelve were about the dirty or damaged state of the bottles, the other thirteen about the presence of other foreign matter. Milk and Infection With the virtual elimination of the tubercle bacillus from milk, the Ministry of Agriculture, Food and Fisheries has now turned its attention to brucellosis, another very common infection of milk, which can cause trouble in man. Towards the end of 1960 they started a survey into the incidence of this infection in dairy herds. It is likely a free scheme of vaccination of calves will be introduced. 67 (B) MEAT Slaughtering facilities The Slaughterhouses Act 1958 required the Council to review and, after consultation with such organisations as appeared to them to represent the interests concerned, to report to the Ministry of Agriculture, Fisheries and Food on (a) the existing and probable future requirements of the Borough for slaughterhouse facilities and (b) the slaughterhouse facilities which are, or are likely to become, available to meet these requirements. Both the Planning and Public Health Committees favoured the construction in the district of a single suitably-sited slaughter house which would enable the existing slaughterhouses, which are not well sited, to be closed. The Minister appointed January 1962 as the date upon which the construction regulations for the bringing up to today's standards, should apply to the slaughterhouses in the district. The licences for the slaughterhouses at 7 Northolt Road, 46 High Street Wealdstone and 87 Stanmore Hill were renewed. No application was received for the renewal of the licence of the slaughterhouse in Dennis Lane. Inspection of Meat The total number of animals slaughtered last year at the slaughterhouses was 7,411. The figure for 1960 was 6,094. The number of cattle killed rose from the previous year's figure of 917 to 1,109; this is not a satisfactory feature as these are the animals with which the local slaughterhouses are least equipped to deal in large numbers. The number of sheep killed rose from 3,202 to 4,303. The number of pigs 1,558 and calves 438 were much the same as the figures for the previous year. The incidence of tuberculosis in cattle has continued to fall. This trouble was, in fact, found in only one of the 1,109 beasts killed. None was found in the cows or calves and only twelve in the 1,558 pigs killed, an incidence of 0.8% contrasted with the figure of 2.35 in 1960. Fifteen cases of cysticercus bovis in cattle which cause a tape worm in man, were found, a percentage of 1.35, a figure slightly below that of the previous year. In six the carcases were submitted to treatment by freezing. The incidence of other diseases in cattle, other than cows, fell from a figure of 33.5% in 1959 to 20% in I960. There was a further fall this last year to 17%. The percentage figure in cows was the same at 33.3%; in pigs 23.0, a rise on the previous year's eighteen; and in sheep the figure was the same as in the previous year, 4%. All condemned meat was destroyed by incinerator at the Wembley Destructor. The following is a summary of the return, to the Minister, of the findings of the post-mortem examination of animals in slaughterhouses:— 68 Cattle Excluding Cows Cows Calves Sheep and Lambs Pigs Horses Number Killed 1,109 3 438 4,303 1,558 — Number inspected 1,109 3 438 4,303 1,558 - All diseases except Tuberculosis and Cysticeri— Whole carcases condemned - - - - - - Carcases of which some part or organ was condemned 188 1 3 165 359 Percentage of the number inspected affected with disease other than tuberculosis and cysticerci 17 33 0-75 4 23 Tuberculosis only Whole carcases condemned - - - - - - Carcases of which some part or organ was condemned 1 - - - 12 - Percentage of the number inspected affected with tuberculosis 01 - - - 0.8 — Cysticercosis Carcases of which some part or organ was condemned 15 - - - - - Carcases submitted to treatment by refrigeration 6 - - - - — Generalised and totally condemned — — — — — - (C) OTHER FOODS Food Premises There were at the end of the year in the district 211 grocers shops, 137 greengrocers and fruiterers', 131 butchers', 53 fishmongers', 29 dairies and 158 confectioners/cafes. Food Condemned During the year 6,024 lbs. of food were found to be unfit and had to be destroyed. Fresh meat and offals accounted for 3,770 lbs; fresh fish, 69 fifty-six lbs.; canned fruit, twenty-five lbs; fresh fruits, 765 lbs; canned fish 122 lbs; canned meats 686 lbs; canned vegetables 133 lbs; and canned groceries 467 lbs. 1,117 packets of frozen food and thirty-three pints of condensed and evaporated milks were also condemned. Complaints Sixty-eight complaints were received about the unsoundness of or presence of foreign matter in foodstuffs. Of these, twenty-five related to bread; nine to cakes and confectionery; twelve to meat or meat pies; three to sausages; two to fish; one to vegetables; one to ice cream; one to fresh cream; three to minerals; and eleven to tinned or packed foods. Summary Proceedings: Court action was taken against two firms. In the one where a cigarette end had been found in a loaf, a fine of £15 was inflicted and £5 costs; in the other, where a needle had been found in a loaf, the fine was £50 and £21 costs. Ice Cream At the end of the year 424 premises were registered for the retailing of ice cream, an increase of seven on the number at the end of 1960. Of these only two manufacture ice cream. Sixty samples were taken, fourteen being of loose ice cream, and one pre-packed from the manufacturers in the district; forty-five from retailers of pre-packed or loose ice cream. Grades 1 and 2 are considered satisfactory, grades 3 and 4 are not and if repeated indicate faults in manufacture. Of the fifteen samples from local manufacturers, three were grade 3 and one grade 4, and therefore not satisfactory. Of the remaining forty-five, three samples of loose ice cream were in grade 3 and two in grade 4, the remaining forty being either grades 1 or 2. In those cases classified as grades 3 and 4, suggestions as to better sterilization of equipment and other improvements were adopted. Later samples were found to be satisfactory. All thirty samples of lollies examined were satisfactory. Preserved and Pickled Foods Those premises where sausages or preserved or pickled foods are prepared or manufactured have to be registered under the Food and Drugs Act 1938, by this Authority. There were 145 such premises at the end of the year, an increase of five on the previous year. All these premises are regularly inspected. Where unsatisfactory conditions or other irregularities were found, the occupiers' attention was called to them and were promptly attended to. Registration of Hawkers It is a requirement of the Middlesex County Council Act 1950, that any person not being a shopkeeper who retails from a cart, barrow, basket or other receptacle, shall be registered with the local authority and that 70 storage premises used by him shall also be registered. The number registered as trading in the district at the end of the year was seventy-one, an increase of five during the year. Of these, twenty-eight were trading from storage premises in Harrow and forty-three from premises outside the district. Before registering those premises where storage is outside this district, enquiries of the local authority concerned are made. (D) ADULTERATION OF FOOD The steps to protect the public against various forms of adulteration of food are carried out by the staff of the Public Control Department of the County Council. The Borough for some years has had a population of sufficient size to enable it to have been made the Food and Drugs Authority. However, the applications of a number of Middlesex District Councils to be made the authorities for this purpose were refused because what would be left for the County Council to administer if the powers were granted to all the authorities in the county who were eligible to receive them would be inconvenient and difficult to administer. The control of the adulteration of food is only one of the responsibilities of the Public Control Department. They have other duties under the Weights and Measures Acts, the Merchandise Marks Acts, the Pharmacy and Poisons Act, the Road Traffic Act (limiting loads of heavy motor vehicles and motor cycle protection helmets regulations), Explosives Acts. Nurses Agencies Acts, Theatrical Employers' Registration Acts and the control of the activities of employment agencies. The following particulars have been taken from the Annual Report of the Chief Officer of the Public Control Department of the Middlesex County Council for the year 1960/61: During the year, 1,652 samples were submitted to the Public Analyst. Of these, only ninety-two were not up to standard. There was only one offence this year of the sale at a cafe of hot milk containing added water. One farmer was cautioned for selling milk with slightly added water. The incidence of foreign bodies in food was not so high. Only some of the sufferers complained, and of these only some complained to the Public Control Department of the County Council rather than to the Public Health Department of the County Districts. There were eight cases of the addition of preservatives to meat, a practice which has been forbidden for over thirty years. This was just half the number found in the previous year. There were only ten infringements arising from samples submitted to the Public Analyst in respect of misdescription of food, the commonest fault being confectionery being described as chocolate which was in effect chocolate substitute. 71 During the year, a special investigation was made of contamination of fruit and vegetables by metals. Sixty samples were submitted for analysis for the presence of copper, lead and arsenic. All the samples tested were well within the accepted limits for each of these metals. Samples are examined not only by the Public Analyst but by members of the staff of the Department. Of the 1,201 samples examined in this way, 205 were not up to standard. This examination is primarily aimed at checking the passing-off one kind of food for another. There were fiftyfive such offences; ten were the passing-off of one fish for another; seven the passing-off of one kind of liver for another, and eleven were the passing-off of other plums as Victorias. The greatest number of such offences though was the passing-off of one variety of apple for another. In addition to these examinations were the 6,433 made by the officers of the Department as part of the system of selective sampling for articles to be sent to the Public Analyst. In only one of the 332 samples of milk submitted to test for the presence of the tubercle bacillus was the organism discovered. In spite of examinations of the herds, no animals were found to be infected. Five hundred and nineteen visits of inspection were paid to the twenty-four premises licensed for the pasteurisation of milk and three for the sterilising of milk to ensure that the premises, plants and records were all satisfactory. The Milk (Special Designations) Regulations, 1960 came into operation on the 1st January, 1961. These require retailers selling designated milk in the county to be licensed by the County Council instead of by the District Councils, and require them to use the designations "pasteurised," "sterilised" or "tuberculin-tested" in relation to milk sold in the county. Only three of the 1,128 samples of milk submitted for tests for keeping quality and for the adequacy of heat treatment did not come up to standard. The Labelling of Food Order 1953 requires that pre-packed food with certain exceptions must be marked with the correct name of the food, a statement of the ingredients and either the name and address or registered trade mark of the packer or labeller. 3,314 premises were visited, and 1,615 packets examined to see that these provisions were being observed. Only minor infringements were detected. Radioactivity in Diet. Although the radioactive isotopes of iodine and strontium form only a small part of the total radioactivity produced by atomic fusion, from the Point of view of contamination of human diet, they are the most important because those that fall on agricultural land pass much more rapidly than other radioactive substances in to human food. Moreover, they accumate and are retained in the thyroid gland and in bone respectively. The isotopes of iodine all decay relatively rapidly. The half life of iodine 131, the most persistent, is eight days. Because of the large amount 72 of it in relatively fresh fission products, it is the chief concern when fission products are rapidly deposited on agricultural land as, for example, after a reactor accident. Being volatile, it is particularly likely to escape in many types of accident. Milk will be the most contaminated food if the accident occurs when dairy cattle are grazing in open pastures because cows derive their food from wide areas of grass and iodine is rapidly transferred to milk. Iodine 131 is however, very easily detected even in doses small enough not to be dangerous, and the time elapsing between the deposition of iodine 131 on grass and its appearance in high quantity in milk, is enough to allow emergency plans to be put into operation. The isotopes of strontium are less abundant than those of iodine in fresh fission products, but they are much more persistent. The half life of strontium 90 is twenty-eight years; with the passage of time then it becomes the chief cause of concern. It is for this reason that the effects of fall-out from nuclear weapons have been largely concerned with strontium 90; the short-lived iodine has largely disappeared before the fall-out reaches the earth's surface. The extent to which strontium 90 enters diet is examined on an extensive scale in the United Kingdom as well as in other countries, special attention being given to milk which contains half the total strontium 90 in Western diets. Special studies are also made in areas where local conditions cause the quantity of strontium 90 in diet to be above average. The results published at intervals by the Agricultural Research Council show that they are everywhere below that judged safe on medical grounds. Strontium 90 in diet largely consists of the recently deposited fall-out trapped directly on plants. With few weapon trials, the rate of fall-out is decreasing. Radioactivity can enter human food by means other than by the contamination of agricultural land. Diluted radioactive effluent may be discharged into rivers or into the sea from nuclear plants, and so enter fish or marine plants. These releases can be strictly supervised and controlled. New sensitive detection procedures now make it possible to measure the small quantities of naturally occurring radioactive substances that have always been present in human diet. In total this natural radioactivity greatly exceeds the artificially produced radioactive substances that are now present in food. (E) HYGIENE OF FOOD Some ten years ago, the Council embarked on a food hygiene campaign. With the removal of the shortcomings at those premises which did not reach desirable standards and later with the introduction of the Food Hygiene Regulations which gave the force of law to those standards which, up to then, had been reached by agreement, the conditions improved 73 sufficiently that there was no longer the need for a campaign as such, any work of this nature falling into place as part of the routine work of the Public Health Inspectors. There still remains though, and will continue to remain, the educative side of the work. These concern those who actually handle food at any stage and in any way, and aim at teaching them why the various recommendations whether to do something or to refrain from doing something else are important; because without an appreciation of these the food handler is only too liable to serious lapses. In the same way, the education of the consumer has to be continued; not only that she might know why she has to carry out certain precautions in her kitchen, but to invoke her help in discouraging these lapses on the part of those handling food, whether in shops, canteens or in restaurants. It is out of this educative side of the Clean Food Campaign that the Department's activities in health education has grown. Many talks on different subjects about health education and about the health services of the district are given each year to various audiences in the district. Advantage too is taken for arranging exhibits such as those shown at the time of the Delegate Conference. The Inspectors work in collaboration with the Health Visitors in their educational work at the Maternity and Child Welfare Centres, and arrange special publicity in the appropriate localities when an area is being defined for the introduction of an Order under the Clean Air Act. 74 PREVALENCE OF AND CONTROL OVER INFECTIOUS AND OTHER DIEASES PREVALENCE OF INFECTIOUS DISEASES (other than Tuberculosis) Disease Under 1 yr. 1-4 yrs. 5-9 yrs. 10-14 yrs. 15-19 yrs. 20-24 yrs. 25-34 yrs. 35-44 yrs. 45-54 yrs. 55-64 yrs. 65+ yrs. , Unknown Total Scarlet fever - 24 63 4 4 2 2 - - - - 1 100 Pneumonia, primary 3 9 5 2 1 — 1 3 6 11 10 1 52 Pneumonia, influenzal — 2 2 — 1 — 2 2 4 3 8 — 24 Diphtheria - - - - - - - - - - - - - Dysentery — 1 1 — — — — — 2 1 — — 5 Erysipelas — 1 — — 2 — 1 — 4 1 2 — 11 Meningococcal infection 1 - - - - - - - - - - 1 Puerperal pyrexia — — — — 1 1 2 - - - - - 4 Ophthalmia neonatorum 1 - - - - - - - - - - - 1 Poliomyelitis, paralytic - - - - - - - 1 - - - - 1 Poliomyelitis, non-paralytic - - - - - - - - - - - - - Encephalitis, infective - - - - - - - - - - - - - Measles 89 1,436 1,462 53 18 — 5 4 3 1 1 19 3.091 Whooping Cough 5 22 19 9 1 2 - 1 — — — — 59 Paratyphoid fever - - - - - - - - - - - - 1 Typhoid Fever - - - - - - - - - - - - - Food poisoning 2 4 4 1 — 1 5 2 — 1 — — 20 Malaria - - - - - - - - - - - - - CONTROL OF INFECTIOUS DISEASES The benefits of the improved 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; and 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 then of these infections which even in the 75 early days of the century were so damaging, has so declined that they no longer loom as public health dangers. Others at times take their place. From 1947 when poliomyelitis first attacked this country on a national scale this infection has been feared each summer. By active immunisation it is now being controlled. In the winter months there is always the fear of an outbreak of influenza. Even when the fatality rate is not high, so little can be done to control its spread and its attack rate is so high that it can cause severe disruption to the life of the community. Although there are hopes that the vaccines now available could help to control the infection, as yet there is nothing to stem its march. Smallpox too is an ever-present fear. Apart from such incidents though, the infections do not now occupy the important position they used to and it may be that in some cases they are being treated too lightly; certainly scarlet fever is in that position. It is not being treated sufficiently seriously even by some of the doctors. 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 infectious diseases notifiable under the Public Health Act, 1936 are—smallpox, cholera, diphtheria, membranous croup, erysipelas, scarlet fever, typhus, typhoid, enteric and relapsing fevers. A local authority can, with the sanction of the Minister, add to the list of diseases which are notifiable. In this way, pemphigus of the newborn has been made notifiable in this district. The Minister of Health is empowered to take steps to control the spread of various infections. Under these he has made regulations which call for the notification of the following conditions:—plague, acute poliomyelitis, acute encephalitis, meningococcal infection, tuberculosis, Puerperal pyrexia, ophthalmia neonatorum, malaria, dysentery, acute pnmary pneumonia, acute influenzal pneumonia, measles and whooping cough. Puerperal pyrexia is any febrile condition occurring in a woman when a temperature of 100.4°F. or more has occurred within fourteen days after childbirth or miscarriage. Ophthalmia neonatorum is defined as Purulent discharge from the eye of an infant commencing within twenty- 76 one days of birth. By the Public Health Infectious Diseases Amendment Regulations 1960, anthrax was added to those conditions listed in the Public Health Infectious Diseases Regulations, 1953. Food poisoning is notifiable to the Medical Officer of Health under the provisions of the Food and Drugs Act, 1938. Under the Leprosy Regulations, 1951, a medical practitioner must notify the Chief Medical Officer of the Ministry of Health of any case of leprosy he is attending. Enquiries. Following the receipt of a notification a visit is made to the home. For most of the infections these visits are made by the health visitor; she is the most suitable person to advise about isolation and concurrent disinfection. In certain conditions though such as food poisoning or the enteric or the dysenteric infections or smallpox, the Public Health Inspector visits. Enquiries are directed to two ends. The first is to determine if possible the source of the infection with the object of taking whatever steps might be practicable to avoid others being infected from that source. It is for this reason that enquiries are made as to the source of water or milk or about the school or other places the sufferer has been at. The second line of enquiry is to enable such steps to be taken as will minimise the spread of infection by the infected person. It is for this reason that enquiries about his place of occupation are made and lists obtained of the contacts and their places of work. Aid to Diagnosis. The earlier the diagnosis, the greater the likelihood that preventive measures will limit the spread of infection. In some diseases, the laboratory is of help. (See Laboratory Service, page 34). Where a patient is suffering from some clinical condition which is suspected as being infectious, and in which the help of the laboratory is sought, it is usually advisable, pending the confirmatory diagnosis, for the same precautionary steps to be taken as if the patient were known to be suffering from the infectious condition. The other assistance a practitioner can obtain in the making of a diagnosis is having a second opinion. Because of his training and because too, he was so often associated with an isolation hospital, the Medical Officer of Health usually had more experience in infectious diseases than his colleagues in general practice. It was quite usual then for him to see cases about which the general practitioner was in doubt. Since 1948, the Medical Officer of Health has not been any more closely associated with infectious cases than the medical practitioners, who now obtain the second opinion from the medical superintendent of the isolation hospital. To obtain a consultant's opinion in doubtful cases of smallpox or typhus fever, advantage is taken of the arrangements made by the Ministry of Health. Section 38 of the Public Health Act, 1961 provides for the medica examination of a person who is suspected to be or to have been suffering from a notifiable disease. 77 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. Cases of smallpox from all parts of Middlesex are admitted to the Joyce Green Hospital, Dartford, Kent. Although the removal of these patients is made by the ambulances of the London County Council, the approach for the removal is made to the Middlesex County Council ambulance service. The schoolchild who has suffered from scarlet fever is usually excluded from school for seven days after his discharge from hospital or from home isolation. This period is extended should he develop a cold in the head, a discharge from the nose or ear, a sore throat or septic spots. The period of exclusion of those who have suffered from diphtheria is determined usually by the Child's clinical condition; after recovery, it is usual to obtain negative nose and throat swabs. A sufferer from measles is excluded for fourteen days from the appearance of the rash; from german measles for seven days from the appearance of the rash; from whooping cough for twenty-eight days from the beginning of the characteristic cough; from mumps for fourteen days from the onset of the disease, or seven days from the subsidence of the swelling; and from chickenpox for fourteen days from the date of the appearance of the rash. Exclusion of Contacts Today it is very rarely felt necessary to prohibit persons carrying on employment with a view to limiting the spread of infection. The practice as regards children attending day schools follows the recommendations set out in the Memorandum on the Closure of Schools and Exclusion from School on account of Infectious Illness issued jointly by the Ministry of Education and the Ministry of Health. School contacts of those suffering from scarlet fever, german measles, mumps and chicken pox are not excluded. The apparently well contacts of cases of measles can continue to attend school, though contacts under five years of age or contacts 78 who are suffering from coughs, cold, chills or red eyes are excluded, but not if they are know for certain to have had the disease. A child under seven years of age who is a contact of whooping cough should be excluded for twenty-one days from the date of the occurrence of the last case in the house unless he is known with certainty to have had the disease. These recommendations apply to children attending day schools. More stringent standards are advisable about the return to school of children at boarding schools who have been in contact with a case of infection during the school holidays. It is now only exceptionally that adult contacts are excluded from their work. There are two main classes of workers who may be required to abstain from their ordinary work. The one is of those persons whose work brings them into close contact with those such as young children who are especially susceptible to attack, or hospital nurses who might cause infection in a ward. The other group is of those whose work brings them into contact with such foods as milk which, if infected, might result in widespread infection. Even in the case of persons so employed, it is not always necessary that they should stay away from work, but only from that work at which there is the risk of spread. Many employers are able to put the contact employees temporarily on to some alternative work where there is no greater risk of the spread of infection than in the case of ordinary members of the public. If a person has to remain away from work with a view to reducing the risk of spread of infection, he is entitled to draw sickness benefit at the rate he would receive were he ill. This payment can be made, however, only if the Medical Officer of Health for the district can issue a certificate that the exclusion of the contact is necessary with a view to reducing the risk of spread of infection. The Ministry of Health Circular 115/48 reads:— "As Medical Officers of Health are aware, it is only exceptionally that it is necessary to require a contact or carrier of infectious disease to stay away from work, and then only as regards the more serious infections. But a Medical Officer of Health, in his responsibility for preventive action, may on occasion consider it necessary, where there is special risk, that such a person should absent himself from his employment for a time; and it is in such circumstances that the right to draw sickness benefit will arise. Benefit will only be paid on the strength of a certificate by a Medical Officer of Health that the person concerned is under medical observation by reason of being a carrier of infectious disease, or of having been in contact with a case of infectious disease (as the case may be), in circumstances which make it advisable to exclude him from work. The Medical Officer of Health should accordingly be prepared to issue such a certificate where he thinks it proper to do so in order that the person concerned may send it to the local office of the Ministry of National Insurance in support of his claim for sickness benefit. The certificate should be given in writing, preferably on official notepaper." Because of the special features in the spread of poliomyelitis, more stringent precautions are advised for the contacts of those suffering from this complaint than from others. 79 By the Public Health Infectious Diseases Regulations, 1927 a person suffering from enteric fever or dysentery may be required to discontinue any occupation in connection with the preparation or handling of food or drink for human consumption. Where any such person sustains damage, the local authority shall pay full compensation. Section 41(2) of the Public Health Act, 1961 empowers a Medical Officer of Health with a view to preventing the spread of a notifiable disease or a disease to which Section 23(1) of the Food and Drugs Act, 1955 applies to require any person to discontinue his work. The local authority shall compensate a person who has suffered any loss in complying with the request under this Section. By Section 39 of the Public Health Act, 1961 the occupier might be required to provide information about a case of notifiable disease or food poisoning. Section 40 gives powers to call for the exclusion of children from places of public entertainment or assembly with a view to preventing the spread of notifiable disease. Disinfection The Council decided that except in cases of smallpox and typhoid fever, and in any exceptional cases approved by the Medical Officer of Health, where disinfection cannot be carried out in the home, terminal fumigation and removal of bedding and other articles for stoving after the commoner notifiable infections shall be abandoned, the householder being instructed as to the precautionary measures to be taken, Where householders still requested that fumigation or stoving be carried out, a charge was to be made. It was later decided that terminal fumigation and stoving of articles should be carried out free of cost in the case of open tuberculosis and scabies. In regard to the treatment of premises which have been occupied by those suffering from open tuberculosis, it is felt that in this even more than in the other infections, it is essential that the premises should be thoroughly cleansed beforehand, otherwise the organisms are too likely to be protected against the action of the disinfectant. The practice has been adopted, then, through the kindness of the staff of the chest clinics, of a report being obtained from them that the other steps have been taken and the premises cleansed. On receipt of this report, but not until then, arrangements are made for the treatment of the rooms and their contents. In 1954 the Council agreed to the following charges: Articles from households where disinfection is not considered necessary by the Public Health Department, but where the householder wishes this to be done—20s. for the first load. 10s. for each subsequent load. Fumigation of rooms in these circumstances—10s. 6d. per room. Stoving of articles for despatch to certain other countries—2s. 6d. per parcel. 80 Cleansing Section 42 of the Middlesex County Council Act 1956 lays down that when it appears to the Medical Officer of Health or a Public Health Inspector of a local authority that the cleansing, purifying or destruction of any articles under Section 84 of the Public Health Act, 1936 (cleansing or destruction of filthy or verminous articles) is urgently required, he may, subject to any direction of the local authority, himself cause such articles to be cleansed, purified, disinfected or destroyed at the expense of the local authority and, if necessary, be removed from the premises. It is also necessary for the local authority to take such steps as are necessary to free from vermin any person who makes application to them that he is in need of cleansing. If this is found to be necessary the cleansing must be undertaken at the expense of the local authority. In 1951 arrangements were made with the Royal Borough of Kensington by which they would deal at their Cleansing Station with any persons found in Harrow to be in need of cleansing. Whenever it is necessary to use the facilities at Kensington, the person requiring treatment is taken to the Cleansing Station in Corporation transport where he and his clothing are dealt with. ACTIVE IMMUNISATION IN CHILDHOOD For long the only disease against which active immunisation in childhood was offered was smallpox. Between the two wars inoculation against diphtheria became practicable. It was not accepted on any great scale until the early days of the last war. Since then it has been very well accepted. Then came the trials of the vaccine against whooping cough. When these proved the vaccine was effective, even though on nothing like the same scale as the protection against diphtheria, authorities offered it to children. Then came the discovery of the fortunate chance that diphtheria and pertussis antigens boosted each other in effect when given together. This led to the manufacture and use of combined vaccines. After a temporary unpopularity because of the incidence of provocation poliomyelitis, this combined vaccine again found favour. Then it was found that tetanus antigen could be incorporated with this combined vaccine without any substantial loss in efficacy. This led to the manufacture of the triple vaccine which is now so generally used. In the meantime, vaccination against poliomyelitis became practicable. As yet, it has not been possible to incorporate this with the combined or the triple vaccine. This means then that these days children can be protected against five infections by the one vaccination against smallpox, by injection of three or four doses of triple vaccine and of three doses of vaccine against poliomyelitis. The most desirable time for any inoculations to be given depends on a number of factors. One is that the child must have reached the age at which the body tissues will react to the antigen. Account too must be taken of the age of attack; for instance whooping cough is so very damaging to the very young child. 81 The Ministry of Health in September, issued a memorandum based on advice received from the Standing Medical Advisory Committee. Unfortunately, alternative programmes are offered. In the one, three doses of triple vaccine are given within the first six months, followed by three doses of vaccine against poliomyelitis, then a fourth dose of triple vaccine. This programme entails seven inoculations apart from vaccination against smallpox. In addition, in later years booster doses are advised. In the alternative schedule, designed to reduce the risk of provocation poliomyelitis two doses of poliomyelitis vaccine are given between six and eight months, then two doses of triple vaccine, followed by the last dose of poliomyelitis and then the last dose of triple vaccine; in all six inoculations. In addition, in this schedule there is the vaccination against smallpox and booster doses have to be given later. It is unfortunate that the Standing Committee could not have reached a decision to recommend one schedule which would then have been adopted throughout the country. Further changes will soon be introduced if only because work is being done of the manufacture of a vaccine which will protect against four infections—diphtheria, pertussis, tetanus and poliomyelitis. On the other hand, inoculation against poliomyelitis might soon be replaced by the giving of the vaccine by mouth. DIPHTHERIA In none of the patients admitted to the isolation hospital suspected to be suffering from diphtheria was the diagnosis confirmed. The district has been free from this infection since 1950, a period of eleven years. The last fatal case here was in 1946. This freedom from diphtheria is today accepted as common-place. In this last year, a number of towns had limited outbreaks but all totalled to only a small number of cases. This satisfactory position is almost certainly the result of the production of immunity in the susceptible population by inoculation. Where the general level of immunity is low, either because many of the people have not been immunised or having been treated, with a passage of time their immunity has waned, diphtheria is liable to strike, and where it does the case mortality is just as high as ever. Over a long stretch of years in the country as a whole there would be as many as 50,000 cases of diphtheria each year of which 3,000 might prove fatal. Although the means to bring about immunity were available in the late 1920's, they were not used to any great extent. It took with the war, with the risk of transmission of infection in communal air raid shelters, to get the practice adopted. When a high proportion of the population were protected, then the fall in incidence started, a fall which was to continue each year so that the position was reached when throughout the country in one year less than 100 cases were notified. This district was never attacked on the same scale as the rest of the country, the 82 highest number of cases in any one year being the ninety-five of 1937. The highest number of deaths was nine in 1939. For this, as for many parts of the country, this once dangerous complaint with its high case mortality is just a memory; but can remain so only if parents will have their children inoculated not only in infancy but later, receiving booster doses. If they see to their children being protected in this way, then children lying in bed flat on their backs perhaps for weeks, children on whom tracheotomy has been performed and children with bull necks in whom the prognosis was so black too will remain a memory. Immunisation. Antigen given to stimulate resistance to the disease may be given by itself, in combination with pertussis antigen, or as a component of triple antigen which aims at protecting against diphtheria, whooping cough and tetanus. During the year, 3,254 were treated for the first time, 2,142 be general practitioners and 1,112 at the infant welfare clinics. The corresponding figures for 1960 were 3,055, 1,541 and 1,514. It is estimated that at the end of the year, 69% of children under five years of age were protected and 97% of those aged five to fifteen years. These figures are probably sufficiently high to ensure freedom from the risk of any serious outbreak of this infection in this district. While the larger proportion of immunes helps to protect those not immunised, there is, of course, no guarantee that those unprotected children shall not be exposed to infection, and on such exposure, as they are not immune, they are liable to contract the infection. The protection of any individual child can be assured only by the development of immunity in that child, and this for ordinary purposes means that that child must be inoculated against the disease, and later inoculated again. Particularly these days when children are not exposed to the organism and therefore do not receive the subliminal infection necessary to maintain their state of immunity for them to remain protected, it is necessary they have booster doses of antigen. These are given at about five years of age when the child is going to school and so is subject to a greater risk of exposure than he has met up to then, and again at ten years of age. Booster doses were given to 2,456 children, 1,861 by general practitioners, and 595 at the clinics. SCARLET FEVER In this last year the district escaped heavy infection by scarlet fever. 102 cases were notified. In two the diagnosis was withdrawn. The net figure of 100 is a rate per hundred thousand population of 0.47, compared with the national figure of 1.1. Scarlet fever today continues to remain s mild disease causing very few deaths. The last case contracted in this district which proved fatal was in 1937. Although mild, scarlet fever is still communicable. Its mildness is due to the relative innocuousness of the causative organism and is not due a all to human agencies. Just as for some reason it has become more innocuous, so it can revert and become more toxic. There is no reason at 83 all that it should not revert in this way, and become again one of the killing diseases which at one time filled the cemeteries with so many children from the one family as it did towards the end of the last century. Even as recently as in the first year of the newly created district of Harrow, there were nine deaths from this disease. Today there are means both of prevention and of treatment of the declared case, means which were not available when the infection was last virulent, and means which in ordinary circumstances are hardly worth using when dealing with today's mild complaint. When such a reversion does occur, it is to be hoped that there will be sufficient hospital beds and sufficient staff trained in the nursing of communicable diseases to enable the sufferers to be treated. As contrasted with the position of only a few years ago, when most of those suffering from scarlet fever were removed to an isolation hospital, today very few are admitted. Last year there were only four. There were four households in which secondary cases occurred, one case in each of three, two in the fourth. The interval between the onsets of the illness of the primary and of the secondary cases was long enough in each instance for the secondary infection to have been prevented had the primary case been diagnosed sufficiently early and been adequately isolated. In one of the cases the interval separating the onsets was as long as fourteen days and in another twenty-six days. There was only one instance where the grouping of cases amongst pupils of the same department of a school suggested that school attendance might have played a part in the communication of the disease. The number of pupils of this school, who fell ill in consecutive weeks in the summer termwere:- 1, 0, 1, 3, 0, 1, 1, 0, 1. SMALLPOX On most days throughout the year there are no cases of smallpox in this country. Most of the few cases that do occur are in persons who have contracted the infection abroad. If the disease in that person is not recognised in time, he might pass on his infection to others who might have become so advanced in the incubation of the infection that vaccination carried out at that time is powerless to prevent the development of the disease. There might then develop from the first person a small ring of secondary patients. However, by the time the infection in the first person has declared itself and has been recognised, while it may be too late to prevent the development of illness in the secondaries, vaccination of those who have been in contact with them will usually prevent the development of the disease in those contacts of the secondaries. While then a patient coming from abroad might cause the infection of a small number of persons, there is little risk of a widespread outbreak. Circumstances might be different when the disease in the first patient is atypical, either because of the variety of smallpox or because the rash has been modified by previous vaccination carried out sufficiently long ago for some but not all of the immunity to have been lost. There is a mild variant of smallpox 84 which is quite distinct from the classical attack. It goes by different names in various parts of the world. Here it is called variola minor as constrasted with the ordinary variety variola major. About 1930 this country was attacked by this type of smallpox. Because of the mildness of the illness and in many cases the paucity of the lesions on the skin, many people did not realise they were suffering from this infection. For this reason it spread throughout the whole country and was not controlled. Some of the more serious of recent outbreaks in this country of the ordinary variety have been due to the atypical nature of the attack in the original patient, almost invariably due to its having been modified by previous vaccination. Recent vaccination is a certain preventive. In many people this protection lasts for many years. There is no assurance though that it is effective for more than about two years. Some protection remains even in those where the effect wanes. This results in the person becoming susceptible and liable to develop the attack; but there may be sufficient protection to modify considerably the attack which might be then so atypical that diagnosis is difficult. In such cases it is only the development of classical smallpox in others that leads to the recognition of this atypical illness in the first patient. When a patient who had contracted the infection say in India, comes by boat, the disease will be manifest and all precautions could be taken on the boat before it landed in this country. Air travel has complicated matters because the time of travel is so much shorter than the incubation period of the disease. A person who has been infected then might have landed in this country and go about his business for some ten days after landing before he falls ill. This adds immensely to the difficulties in tracing contacts. The usual procedure is for those who might be contacts to be kept under surveillance for some two days longer than the usual incubation period of the infection. If they have not recently been vaccinated, this is advised. These contacts are not excluded from carrying on their ordinary work. There were only two occasions this last year when this procedure had to be put into operation. The first was in September when a person on a cross-channel steamer was thought to be suffering from smallpox. A number of local residents were on the boat. Later the diagnosis was not confirmed. The other case was a Pakistani who arrived in this country on 25th December. His rash came out on 27th December and he was removed to hospital on 28th December. There was one local contact, a nurse at the hospital he first attended. Vaccination. During the year, 2,391 persons living in the district were vaccinated against smallpox for the first time. Of these, 1,553 were under one year of age and 397 were over one but under two years of age 620 persons were re-vaccinated. 3,085 babies were born during the year. The number of vaccinations of those under one year of age was therefore 50% of the births. Of those under one year of age who were vaccinated 630 were treated at the infant welfare centres. 85 ENTERIC FEVER When the fever hospitals were opened in the last quarter of the last century, those admitted were persons suffering from scarlet fever, diphtheria and enteric fever. In those days the enteric fever was the water-borne typhoid fever. With the improvements in water supplies, this infection has become steadily less and these days most of those in this country who suffer from typhoid fever have contracted their infection from abroad. Apart from them, most of those notified as suffering from enteric fever are suffering from one of the forms of paratyphoid fever. Although this can be conveyed by water, it is more especially a food-borne infection. Up to a few years ago. it could be expected that a few persons living in this district would be notified as suffering from enteric fever. There were none though in 1958 or in 1959. In 1960 there were two notifications, both relating to boys who had probably contracted their infection while at holiday resorts in this country. In this last year, there were two cases. The first was a girl of ten who had paratyphoid fever. The organism was one which had been found in part of the country to be associated with coconut. Coconut had been used in this girl's house but samples examined did not disclose the organism. The other patient was a girl of thirteen in whom the diagnosis was made because of an altered blood titre, the organisms not being recovered. Typhoid fever is one of the infections in which the sufferers might develop a carrier state, either urinary or foecal. In March a lady was notified as being a carrier of paratyphoid fever. It was learned she was an assistant cook at a restaurant in the district. Pending further enquiries she was asked to absent herself from work. It seems that when living in another district she had an attack of paratyphoid fever early in 1960. She was discharged after some weeks in hospital. In November she had a gastro-intestinal attack. This led to the bacteriological examination of faeces and to the discovery of the organism. At their meeting on the 28th March, the Public Health Committee decided that she should not be engaged in any trade or business concerned with the preparation or handling of food or drink for human consumption and it was agreed she be compensated under the provisions of the Public Health (Infectious Diseases) Regulations 1927 and S.308 of the Public Health Act, 1875. Intensive treatment at home failed to free her. She was then admitted to hospital for further medical treatment. Although specimens of faeces were yielded which were free from organisms, on further sampling they were found again. She was discharged home and agreed to be admitted to another hospital for surgical treatment. The position at the end of the year was that she was to be admitted for this early in the new year. In the meantime, she had been receiving each week the same payment as she had been having from her employers when she was engaged as a cook. 86 DYSENTERY Although dysentery can be caused by a variety of organisms, most of the cases of this now quite prevalent complaint in this country are caused by Shigella Sonnei. At one time the means of infection was food or drink. Some cases are still occasionally contracted by these means, but the commoner pattern of spread today is by direct or indirect contact. Many cases seem to have been contracted at school, infection often then being handed on at home to other members of the family. Most cases occur in the first half of the year. In general, it is a relatively mild complaint. The result is, that a doctor is not called in, and even where he is, often enough the case is not notified. The notification figures then do not indicate the prevalence of this infection. The department gets to know from the schools of quite heavy infections. Enquiries about the suffering pupils leads to further information about attacks amongst home contacts; and yet perhaps none of the cases have been notified. On the other hand, notifications are received of persons suffering from this disease based on clinical symptons and not on bacteriological findings. This overweighting by numbers of cases which might not really be dysentery might lead to the notification figures being above the true incidence of infection if there have been no school outbreaks during the year. Where however, as is often the case, there are one or more of these school outbreaks where many of the sufferers are not notified, the numbers of cases notified fall very short of representing the actual incidence. For these reasons no conclusions can be drawn about trends, nor can the figures be usefully compared with those of other years for the same district, or with those of other areas. Very few cases were notified, in all only five. Of these, one, an adult, almost certainly contracted the infection while on holiiday abroad; another a child, was suffering from the early symptons of the illness when his family came to live here from another district. Two adults were notified on clinical grounds. The organism was recovered in only one patient, a school child. A number of other children thought to be suffering from dysentery were found on bacteriological examination to be suffering from food poisoning. FOOD POISONING The number of cases of food poisoning notified each year since the war have been far greater than the numbers before the war. Part of the rise is no doubt real; part though is due to the recognition as instances of food poisoning of cases which before would have been missed. One reason for this is the Laboratory Service which the war gave the country. This provided greatly improved facilities for the bacteriological examination of food stuffs and excreta. Another reason is the greater interest in the subject. This too is largely the outcome of the activities of those in the Laboratory Service. Part of the increase though is real, and to a very large 87 extent can be accounted for by the very much greater extent to which people these days, as contrasted with the position before the war, have meals away from their homes, whether in works' canteens or in school canteens. The same faults in technique which might have caused a family outbreak before, under today's conditions can result in a large-scale occurence. in common with those in many other districts, the Council planned a clean food campaign. It was directed on three fronts. The first was to ensure that the premises in which food was prepared or stored or handled was of satisfactory hygienic standard. While food stuffs prepared in dirty insanitary conditions will not necessarily give rise to trouble to those who consume them, there is much more risk of this happening than when the standards of hygiene are high. Clean premises and equipment easy to cleanse and nothing to encourage the breeding of flies are minimal acceptable standards. Trouble might follow even when the best equipment is used if the workers are ignorant of the importance of the elementary standards of hygiene. The second front then was the education of those engaged with foodstuffs at any stage. The third approach was the education of the housewives who it was hoped would insist on the highest standards in the shops where they bought their foodstuffs or the cafes or restaurants where they had their meals out, and would themselves practice these in their own kitchens. Most of what was stressed was only indirectly related to food poisoning. Probably little enough real trouble follows the consumption of bread which has fallen on the roadway, or of foodstuffs which have been put in a paper bag which has been blown on to open it. These acts are more important as being indications of a low standard of hygiene. The person who did such things would be more likely than one who did not, to carry on his occupation without washing his hands after having been to the lavatory and he could then be a very real danger. Cases of food poisoning still occur because of faults on the part of those handling foodstuffs. Explosive outbreaks of staphylococcal infection still result from the contamination of food stuffs and multiplication of the organisms which obtain admission from an uncovered sore on the finger of a handler or from a nasal discharge. Ft is still necessary and will continue to be necessary for the inspectors to pay their periodic visits to premises dealing with foodstuffs to see that the premises are satisfactory, that the technique of those handling the food is sound, and that there are no practices such as the reheating of meat which in certain circumstances might give rise to such trouble. There has been a change though in the manner in which the food is being infected. Today, so very much of the food poisoning in which the cause has been identified has been found to be Salmonellae. It is now appreciated that to control the trouble it is necessary to discover how the or ganisms found their way into the food stuff. Sometimes it will be because one animal has been infected by another; sometimes the animal will have 88 been infected by some of its feeding stuff. Many of these organisms have been introduced to this country from abroad in foodstuffs of different kinds, including the dried eggs so very welcome during the war, Chinese eggs used so much in the bakery industry, and coconuts. Whatever improvements are brought about in the way food is handled, food poisoning will continue to occur until the answer is found to the control of the importation of these organisms from abroad. The Public Health Laboratory Service publishes each year a report about food poisoning in England and Wales based on information obtained from reports of pathologists in the Public Health and the Hospital Laboratories and reports made by Medical Officers of Health to the Ministry of Health. For some years now the outstanding problem has been the control of the spread of salmonellae. To this end studies of eggs and egg products, meat and meat products, food stuffs and fertilizers, were being made in the hope that food could be protected from contamination, or that any contaminated could be adequately treated. The report for 1960 has just been published. There was a reduction o: eighteen per cent in the incidents (general outbreaks, family outbreaks and sporadic cases) compared with the previous year. The decrease was specially noticeable in incidents caused by salmonellae other than salmonella typhimurium which were down as much as forty-three per cent. This reduction is mainly accounted for by decreases due to those types which in recent years have been isolated from egg and meat products. Whether this pressages a permanent fall in incidents from these products will not be demonstrated for some years, but it is hoped that it is an indication that egg products and meat products such as boneless beef, boneless veal and sausages are being produced with greater regard to the risks of infection. The reduction in incidents due to staphylococci is all the more gratifying as there were many outbreaks associated with canned meats from abroad in which the meat was contaminated before the cans were opened. It ought not to be difficult to prevent this type of trouble. Had it not been for these, there would have been a substantial fall m staphylococcal outbreaks. A small reduction in the number of incidents due to C1. Welchii was recorded. Of the outbreaks in which the vehicle of infection was noted, all but one were associated with meat, gravy and stock. Reheated meat, particularly stews, stocks and Shepherd's pie and cold meats were most frequently contaminated. Locally there was a further fall in the number of cases of food poisoning notified. The twenty notifications related to thirteen incidents, there being four occasions when more than one person was involved an nine single cases. Where any organism was recovered, it was almost invariably salmonella typhimurium. The first cases were two children of a family who fell ill at the same time while the rest of the family remained free. The next were two children 89 of the same family, a child of five and then his brother of seventeen months falling ill a week later; S. typhimurium was recovered from both. In April there was one single case and in May two single cases, all infected by S. typhimurium. Towards the end of May, in the course of four days, an illness due to S. typhimurium which started in a child of four, spread to two other children and to his parents. In July there were two single cases from neither of which were food poisoning organisms recovered. Then followed another family outbreak due to S. typhimurium which started in a child of four months and spread in three weeks to his mother and then in three days to his brother. In August and in September there were single cases from whom no organisms were recovered. In September, a child of seven months in a local residential children's nursery free from symptoms, was found to have S. Brandenberg in his stools. This is an organism commonly found associated with sausage, not a usual article of diet of an infant of this age. In October there was a single case in which no organisms were recovered. Of the four family outbreaks then, S. typhimurium was responsible for three. Of the nine single cases, S. typhimurium was recovered from three. The organisms were examined at the Colindale Laboratory and were typed. Type 12a was recovered most commonly. Five of the notifications were received in the first quarter of the year, eight in the second, five in the third and two in the fourth. Meat as a Cause of Food Poisoning. The Annual Report of the Chief Medical Officer of the Ministry of Health for the year 1960 referred to the fact that in spite of the raised standards of food hygiene, the predominance of meat and meat products as the vehicle in food poisoning shows no signs of decreasing. Over 80% of outbreaks and family outbreaks (950 incidents) during the period 1955 to 1959 were associated with meat. In 280 of these incidents, the cause of organism was not identified. Of the remaining 670 incidents, 74 (11%) were due to salmonellae, 209 (32%) to staphylococci and 348 (54%) to C1. Welchii. C1. Welchii incidents are almost always associated with partial cooking of meat dishes (stews, pies, joints) the day before consumption. Slow cooling and insufficient cooking prior to service allow multiplication of the organisms. A staphylococcus food poisoning incident is usually due to human contamination of the food vehicle. Hand-washing is of paramount importance in preventing such contamination. ERYSIPELAS This disease, once such a scourge especially in hospital wards and one which caused so many deaths, has long since ceased to be one of public health importance. As one of the diseases notifiable under the original Notification of Infectious Diseases Act, it remains notifiable. Today, it is of importance only in such circumstances as there being a patient in a house in which an expectant mother is due to be confined. The causative organism, a streptococcus, which is related to that which causes scarlet fever, can also cause severe puerperal infection. 90 Only eleven cases were notified here in this last year, six women, four men and one child. In all cases the face was affected. The lesion spread from the eye in the case of the child and from the nose in another of the patients. Two sufferers were removed to hospital. There were no deaths. MENINGOCOCCAL INFECTION For many years menigoccal meningitis (cerebrospinal fever) was notifiable. Because the same organism could cause reactions in other parts of the body, the more general condition of meningococcal infection became notifiable. While it is many years since there were any large numbers of cases in the district in any one year, it is usual to have a few. Many patients are admitted to hospital suspected to be suffering from this condition but later, as a result of laboratory findings, are found to be suffering from aseptic menigitis or some other condition not due to the meningococcus. The corrected number of notifications this last year was one. This was a boy of two who fell ill in March. Post mortem examination of a child of nine months who died in April showed she had suffered from meningoocccal septicaemia. ACUTE ANTERIOR POLIOMYELITIS 1961 proved to be a year of much higher incidence of infection throughout the country than the previous year. This higher rate though was primarily due to the occurrence of a number of cases in a number of large towns rather than to the diffuse distribution throughout the country. The town most heavily involved was Hull in October. In 1960 in not a single week had there been as many as twenty cases. By contrast the weekly average even as early as May, was nineteen and the figure remained the same throughout June and July. It rose to twenty-two in August and to twenty-six in September. There was a sharp rise in October with a weekly average of sixty-nine. The peak incidence was in the week ending October 21st when there were ninety-four cases. After that there was a sharp fall to a weekly average of forty-five in November and sixteen in December. There were only seven cases in the week ending December 23rd and in the week ending December 30th. The corrected figure of notifications for the whole year was 946. Locally the district remained free from infection, the only patient who suffered having contracted his illness while abroad on holiday. Immunisation. Active immunisation against a number of diseases can be brought about by the injection of the organisms causing those diseases or, in some cases, of something from those organisms. In most instances where the organisms have been used, these have been killed before injection. In others, the living organisms are used, but these have usually been attenuated. 91 Vaccines of both types are available to produce active immunisation against poliomyelitis. When the Government decided to offer facilities for certain sections of the population to be protected, they deciced on the Salk vaccine. In the manufacture of this, the three types of virus which cause poliomyelitis are incorporated. Although it seemed that this vaccine could bring about an eighty per cent reduction in the incidence of paralytic poliomyelitis, there had in fact been no definite statistical evidence of its efficacy. Little was known either about the most efficient course of treatment, nor how long the effect would last. This meant that nothing was definitely known about whether further injections would be required. Nevertheless, this vaccine was decided on, and where it was used on a large scale it almost certainly contributed to a fall in the incidence of this infection. It was found that not long after the second of the injections of the course of two which was first recommended, the level of antibodies fell. Accordingly, another injection was recommended, the course now becoming one of three injections. Later, facilities were made available to the especially susceptible group of children between the ages of five and eleven to have a fourth injection. The most dangerous of the three types of virus is type I. Unfortunately, the antibody against this falls the most readily. It is hoped and can confidently be expected that vaccine can be manufactured which will result in a high level of antibody protection against type I and that this can be maintained, even without repeated booster doses. In the meantime, vaccines using the living organism were being used. The best known of these was the Sabin vaccine. This, or a similar preparation, has been given to some 100 million people throughout the world. Again, there has been no strict statistical evidence of its efficacy. Its use on a large scale though does seem to have been followed by a fall in the number of cases, especially when used while an outbreak was prevalent. Its use has been followed by antibody production and it has been proved to be safe. A trial was carried out in this country on babies to determine the antibody response. In this trial different vaccines were used, and the doses were given at different intervals of time. The result of this trial appeared as a report of the Public Health Laboratory Service to the Poliomyelitis Vaccine Committee of the Medical Reasearch Council in October. The recommendations of this Committee were that Sabin's vaccine should be given in three doses of the trivalent mixture at four to six weekly intervals. The Committee reached the conclusion "that in order to ensure immunity of the herd as well as of the individual to poliomyelitis, the Sabin vaccine is preferable to the Salk vaccine. Not only does it stimulate the protection of antibody equally well, but if affords the additional safeguard of rendering the gut resistant to the implantation of the so-called wild polio virus. The Government has accepted the recommendation of the Joint Committee on Poliomyelitis Vaccine that the new oral Sabin vaccine may now be used for the routine vaccination of persons in the priority groups, 92 broadly speaking those up to forty years of age. The Committee's advice is:— 1. Sabin vaccine may be used both safely and effectively for primary vaccination. 2. Pending further study, Sabin vaccine should not be used to complete a course of vaccination started with Salk vaccine. 3. So long as Salk vaccine is available, it should also be provided for primary vaccination if the doctor prefers it. 4. The trivalent vaccine will be used for routine immunisation. The course will comprise three doses at intervals of four to eight weeks. The vaccine is likely to be given as drops on a lump of sugar or in syrup in the case of babies. That is the position of the use of Sabin's vaccine as a recommended procedure for general immunisation. There is another use for it, and that is to stem an outbreak. To be successful, it has to be used in the early days of an outbreak and must be given to the entire population within a very short space of time. The Ministry had advised local authorities that they were holding a supply of this vaccine to be used to halt an outbreak which had started. The responsibility for deciding whether the vaccine should be used remained with the Ministry who would consult with the major health authorities, not with the district councils. The first instance of the use of this vaccine in this way in this country was in Hull. The strain used was type II on the principle of blocking colonisation of the gut by the epidemic type I strain. The first case was notified in Hull on the 4th October; by October 17th there were forty-six cases. Arrangements for the administration of the vaccine were started on Monday, October 23rd. By the end of the week ninety-six per cent of the City's population had received it. Further cases continued to occur but in very much smaller numbers. By October 30th the case total was seventy-five. There were eight in the next week and seven in the following. Arrangements were then made to offer to people under forty years of age who had not previously had Salk vaccine two more doses of oral vaccine made from viruses type I and type III if they had had a dose of type II vaccine. The arrangements for inoculating sections of the population with killed vaccine continued to run smoothly, most of the work carried out being the routine inoculation of babies. The following is a summary of the work done during the year:- 3,692 children born in the years 1943-61 received two injections only, 3,364 three. Of the young persons born in the years 1933-42, the corresponding numbers were 1,448 and 1,607; of those born before 1933 but who had not passed their fortieth birthdays there were 3,973 and 3,966. and of other persons 514 and 139. In all 9,627 persons received two injections during the year and 9,076 three injections. 228 persons had received only the one injection by the end of the year. MEASLES This is a complaint from which virtually everyone suffers from once in his life time, but rarely more than once. Because in an outbreak nearly all those who are susceptible are attacked, thereby becoming immune, it 93 takes some two years to build-up a susceptible population, with the result that typically in established urban areas measles attacks every other year. The pattern is that late in the year which had up to then been free from measles there would be some cases starting perhaps in November, rising slowly in December, then more quickly in January to reach a peak in February. The period of high incidence would be sustained for perhaps two or three weeks and then be followed by a rapid decline to virtual extinction by mid-summer. This district has never reached the stage of this marked biennial beat. 1960 was a year of relative freedom, there being only 180 cases. Of these, forty-seven were in the last week of the year. This was the start of the outbreak of 1961 and came without the usual warning. In January there was a weekly average of thirty-nine notifications. This rose to 128 in February and to 242 in March. There were 300 notifications in the week ending March 25th, the largest number ever received in this district. The weekly notification figure fell to 174 in April, to seventy-five in May, to forty-three in June, to seven in July and to two in August. Some pupils at virtually all the maintained schools were attacked in the spring term and some, about half of them, in the summer term. In general, the attacks were mild. The difference between today's measles and the killing and crippling illness of only a few years ago, is partly due to the causative organism being less virulent, partly to the ability now to control with antibiotics the secondary invaders which caused so much harm. Of the 3,091 cases notified none was removed to hospital There were no deaths. Vaccination. Up to recently, there was nothing which could be given to induce active immunity to measles. All that was available was a serum prepared in different ways which when injected would give passive immunity. This, however, would last only a few weeks. Its use then was limited to those whom it was especially necessary to protect against an attack. These mostly would be very young children or children suffering from some illness. Measles today is not the dread disease it was only a few years ago. Not only are attacks in general less severe, but the various measures to protect against or control the secondary invaders have reduced its malignancy. Deaths from measles have declined from a figure of 307 in 1949 to ninety-eight in 1959. Nevertheless, it can still be a serious complaint, and it will be a great benefit when it becomes possible to protect young children against the risk of contracting it, even though they lose their immunity and succumb to attacks when they are older. It has been especially prevalent in this country this last year when there were more cases than in any year since the disease first became generally notifiable in 1940. There were hopes of its being possible to prepare a vaccine when in 1954 a measles virus was first grown in tissue culture. Vaccines have recently been made. All children inoculated with them developed neutralising antibody, and when later exposed to natural measles did not develop 94 the disease. Unfortunately though the incidence of reactions associated with the inoculation was high. Most recovered in a few days; some though developed serious complications, mostly infections of the middle ear and respiratory tract. It would seem that the present vaccine is effective, though the duration of the immunity conferred is not known. The complications which it might cause though make it doubtful whether extensive trials are justified, and research towards further attenuation of the vaccine virus is desirable. WHOOPING COUGH The district was almost entirely free from whooping cough throughout 1961, only fifty-nine cases being notified. These were spread throughout the year, but the incidence was rather more common in the first half. Whooping cough is an infection with no set pattern of periodicity. The relative freedom might be wholly due to changes in the infectiousness of the organism. On the other hand, so many children are now being inoculated against whooping cough that this must have quite a substantial effect on its prevalence. If any child who develops pertussis is surrounded by those who are immune, passage to others is barred. In the earlier days of inoculation against whooping cough the preparation was a long way from being fully effective. The result was that some of those incoculated on exposure might contract the infection, but as they were partially protected the attack would be atypical and so very often the characteristic whoop would not develop. The attack then might not be recognised for what it was, so that infection would be passed on to others, possibly more than would have been the case if the child had not been inoculated and had developed a frank and recognisable attack. This is less likely to occur today with the more potent vaccine. Whooping cough is still a killing disease in young children, especially those under one year of age and more especially those under six months. This emphasizes the need for those who are to be protected to have their inoculations in infancy. On the other hand, the infant is introduced to the infection generally by the development of the disease in an older child of the family. If all these older children are adequately protected, there is that much less risk of the infant being exposed to infection while at an age when the attack is most damaging. Were inoculations against pertussis generally practiced amongst all children, there would be the less need for the infant to be protected while very young. It would too reduce the disadvantages following on the development of an atypical attack in a child whose inoculation had afforded only partial protection. No persons suffering from whooping cough were removed to hospital and this infection caused no fatal cases in this district in 1961. Inoculation. During the year, 3,111 children were inoculated against whooping cough, 2,034 by general medical practitioners, and 1,077 at the clinics. 95 PUERPERAL PYREXIA Because the term puerperal fever developed unfortunate associations, many cases were not notified. So much was this the case that for some years the death returns would be more than the number of cases notified. The condition of puerperal pyrexia then became notifiable. For a period both conditions called for notification, but later on only puerperal pyrexia. What is now notifiable is the occurrence of a rise of temperature to a certain height or for a certain length of time in a woman who has recently been confined or has had an abortion. This rise in temperature could be due in some way to the confinement or abortion, or might be quite unrelated to it, as for instance an attack of influenza or a common cold in a woman recently confined. Even where due to the confinement it would not necessarily be due to a uterine infection. It could be the result of an inflammation of the breasts, a thrombosis of the veins or a urinary infection, all conditions which can readily occur after a confinement. Where this rise of temperature takes place in a woman confined in hospital, the notification is sent to the Medical Officer of Health of the district in which the hospital is. Where, as is the case in this district where there are no such hospitals, all notifications relate to mothers confined in their own homes or in the one nursing home which still accepts expectant mothers. During the year, four notifications were received. In two of these the raised temperature was due to a breast abscess; in the others the cause was probably not due to the confinement. OPHTHALMIA NEONATORUM At one time much blindness was due to infection of the eyes of infants. A steady improvement followed the practice of the instillation into the eyes of newborn infants of a silver preparation. The condition has now become relatively uncommon even though the practice of instillation of prophylactic preparations has largely been abandoned. Although many infants might develop sticky eyes soon after birth; the development of the full condition of ophthalmia neonatorum is now rare. While then occasionally a notification is received that an infant is suffering from ophthalmia neonatorum, recovery is usually rapid and complete. One such notification was received this last year. NON-NOTIFIABLE INFECTIONS Knowledge of the prevalance of some of the infections which are not notifiable in the district is obtained from intimations received from the Head Teachers about the absence of children from school. Where there is an outbreak of an infection, these figures are a useful guide. On the other hand, they are based on information provided by the parents about the illness of a child when often enough no doctor has been summoned and no corrections are made later. This can result in returns being sent 96 in when the parents' diagnosis is at fault. This would account for the absence of children being reported allegedly because of some infectious condition when the fact that no other case is reported from the school about the same time suggests that the child was really not suffering from that illness. Chicken Pox Only 149 intimations were received of children being absent from school because of chicken pox. A few schools were affected in the summer term. About half the cases though were the pupils of three schools affected in the autumn term, particularly in the second half of it. Mumps The district was very heavily attacked with mumps in the first half of 1960. In that year in all there were 1,295 intimations. In the whole of 1961 there were only fifty-six. There were groupings of cases of twelve, seven, six and five at some schools; but nearly all schools were virtually free. German Measles This infection often occurs when the usual variety of measles is prevalent; but it sometimes occurs when the other is absent. At many of the schools which are affected by measles in the spring term there would be some cases of german measles; but in many of these german measles became more prevalent in the summer term, by which time the school was free from the usual variety of measles. On the other hand, the school most heavily affected with in all 130 cases, was attacked in the spring term when it was almost free from the ordinary measles. Intimations were received of 586 cases. Apart from the 133 cases at one school there were twenty-seven in another and twenty-one at a third, all in the spring term, after which the schools were virtually free. On the other hand, five schools which had been almost free in the spring term had sixty-seven, fifty-eight, fifty, thirty and twenty-seven cases in the summer term. The district was almost entirely free from this infection in the second half of the year. These cases of german measles are not important in themselves, but they are disturbing because of the risk of transmission of infection to the expectant mother. Again, it is not the mother herself who is the special concern but her unborn baby, especially during the first twelve weeks ot pregnancy. Of such complicated pregnancies there were, in an investigation carried out in this country, twice as many abortions and almost twice as many stillbirths, four times as many infants weighing less than 5½ lbs at birth and eight times as many infants who had major congenital defects. These were mostly of hearing, the proportion defective being about twenty per cent and to a less extent defects of the heart and eye. The infant mortality rate of infants following rubella in the first twelve weeks of 97 pregnancy was almost three times that of the control infants. In the event of exposure to this infection early in pregnancy, the expectant mother, if susceptible, should be given gamma globulin. Glandular Fever Of the three clinical manifestations of infectious mononucleosis, the glandular fever variety is common in children. In this the lymphatic glands and the spleen are enlarged, but there is no throat involvement. The illness might last two to several weeks. The causative agent is unknown. It is not known how the infection is spread, though probably the source is man, transmission being by the respiratory tract. In early March attention was drawn to the occurrence of a number of cases in the junior department of a maintained school. In the week ending January 23rd, two children in one class fell ill; this class remained free subsequently. The following week a child in another class fell ill. In the next week there were three cases amongst the pupils of another class, which subsequently remained free. A fortnight later another child in the same class as the child who fell ill in the week ending 28th January succumbed and then a fortnight later, the week ending March 4th, a third pupil in this class fell ill. Influenza Towards the end of 1960 there was no indication of any undue prevalence of the influenza virus anywhere in the world so that it was hoped that the country might once more escape the outbreak in the winter months. In the last two weeks of the year there was the usual rise in deaths from respiratory complaints. About the middle of December, an influenzal type of illness affected many of those in the Midland region. Influenza virus A was isolated from several cases, this virus being similar to or possibly identical with the Asian influenzal virus. The outbreak then spread to the North-Western region and then to the Eastern region. Respiratory diseases due to other causes became prevalent in many parts of the country. Some indication of prevalence in the London region is obtained from the Emergency Bed Service which, in the event of heavy demands on hospital beds, issues first a yellow warning and then a red warning. The red warning came into operation on January 23rd. In the last weeks of the month the sickness benefit claims in this district rose to figure of 250 per cent. above the usual weekly average. Most of the deaths from influenza, pneumonia and bronchitis which had risen steeply, were in the Midlands and North West region. The number of deaths attributed to the disease reached a peak of 1,400 in the week ending February 11th. Most of these deaths were amongst those over fifty-five. The outbreak had largely subsided by the middle of March. When it reached this part of the country, the infection was apparently milder and less damaging than the outbreak that had occurred in the Midlands and the North Western 98 regions. By February 11th the Emergency Bed Service red warning was replaced by the yellow warning, and was itself cancelled on March 10th. In May there occurred a number of localised outbreaks in residential schools and institutions in Yorkshire. These were due to virus B. In the last days of the year, a forty-eight hour influenza attacked many people, more especially school children. This, and the prevailing harsh weather, resulted in a large number of deaths, especially of the elderly. Twenty-four notifications were received of people suffering from influenzal pneumonia; influenza caused eighteen deaths. Vaccination. Influenza is caused not only by different types of virus but these types have different strains. It can be assumed that a vaccine specific to the prevalent strain is more likely to be effective than others. As yet, vaccine to produce immunity against prevalent influenza has not attained the level of efficacy of those against some other infections. The highest degree of protection in the most favourable circumstances has been seventy-five per cent. In ordinary use the vaccine containing the right strains and given at the right times should protect forty to sixty per cent of the recipients. In general, antibody resulting from inoculation lasts only a few months. While the question of whether an individual should be inoculated against influenza is a matter for him and his doctor to decide, the Chief Medical Officer of the Ministry of Health in September drew attention to the advice given by the Joint Committee on Poliomyelitis Vaccine about vaccination against influenza. The vaccine recommended is a combined influenza A and B vaccine, the most important component being A strain. The main points of the Committee's advice are:—1. The routine immunisation of all sections of the population is not recommended. 2. Routine vaccination should, at the doctors' discretion, be advised only for patients suffering from certain chronic diseases where an attack of influenza might be dangerous. Instances are patients with chronic pulmonary, heart or renal disease or diabetes or other endocrine disorders and expectant mothers, particularly those suffering from chronic lung or heart disease. 3. In the event of a threat of a large epidemic, prionty should be given to the vaccination of special groups, including nurses, hospital staff, general medical practitioners, public safety, transport and utility services and workers in essential trades and industry where a break in continuity or production might result in severe economic loss. But the routine annual immunisation of these groups is not recommended since it could not be expected to make a significant contribution to the contro of outbreaks. Venereal Diseases The following is an extract from the Annual Report of the Chief Medical Officer of the Ministry of Health for I960—"The spread of veneral diseases is promoted by two allies—promiscuity and prostitutionand so long as these continue to be practised to the present extent it is unlikely there will be any improvement in the general situation. Part 99 perhaps half, of the increase is due to infection and re-infection of immigrants. The venereal diseases clinics again report increases in all the veneeral diseases." TUBERCULOSIS Notifications. From 1955 the numbers of cases of tuberculosis notified in this district fell each year from a figure of 183 new cases to 102 in 1959. There was a slight rise to 107 in 1960 but the figure for last year was eighty-nine; eighty-four of these were in respect of pulmonary and five to non-pulmonary disease. In addition to the new cases notified for the first time, most of whom have contracted their infection while living here, intimations are received of the disease in persons who suffered from it before moving into the district. These figures too have continued to fall. The combined figure of 287 in 1955 fell to 152 last year. The local notification rate per thousand population was 0.44; the corresponding figure for the country as a whole in 1960 was 0.51. The following table gives the age and sex distribution both of persons who were resident in the district when it was recognised they were suffering from tuberculosis, and of those who moved into the district already suffering from the disease:— Primary Notification Brought to notice other than on Form "A" Pulmonary Nonpulmonary Pulmonary Nonpulmonary M F M F M F M F Under 1 . - - - - - - - - 1-4 1 1 - - - - - - 5-9 1 3 - - - 1 - 1 10-14 - 2 - 2 1 1 - — 15-19 3 2 - - 2 1 - — 20-24 3 4 - - 1 9 - - 25-34 8 8 1 - 12 10 - — 35-44 4 6 - - 4 6 — — 45-54 14 3 - - 7 2 - — 55-64 13 2 - 1 - 1 — — 65 and over 5 1 1 — 2 2 — — Totals 52 32 2 3 29 33 — 1 Some people are for various reasons more prone than others to contract tuberculosis. This may be because they are exposed to infection cither at their home or at their place of work. A family history of contact was obtained in twenty-two per cent of the males notified and in thirtyseven per cent of the females, a combined average of twenty-seven. There were three instances of people engaged in occupations which carry an 100 increased risk. In addition, notifications were received of two persons who were in the armed forces. There was no history of any of those illnesses or other states which predispose to the onset of tuberculosis. The position this year then was the same as in previous years in which in the vast majority of cases of this infection no reason could be discovered to account for the breakdown in resistance which allowed the organism to gain the upper hand. Register. The tuberculosis register is a compilation of the names of those persons in the district who are suffering from the disease or have recently suffered from it. The names of those newly notified are added to it, and entries are made of those persons who have moved into the district suffering from tuberculosis. Names are deleted on the removal of persons from the district or on death or recovery, an accepted standard of recovery being a lapse of five years in the pulmonary cases and three years in nonpulmonary cases from the date the disease was arrested. The following 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, 1961 1,263 1,000 124 146 No. of new cases added 52 32 2 3 No. of new cases other than on a Form "A" 29 33 — 1 No. of cases restored to register 4 3 — — No. of cases removed 135 95 5 5 No. on register, 31st December, 1961 1,213 973 121 145 Of the 242 deductions, ninety-three (ninety-two pulmonary) were of persons who had left the district, thirty-four (thirty-one pulmonary) were of persons who had died, eighty-eight (eighty-two pulmonary) were of persons who had recovered and seventeen (sixteen pulmonary) were of persons who had been lost sight of. The net decrease in the number of cases on the register is eighty-one, there being seventy-seven fewer pulmonary cases and four fewer nonpulmonary cases. This is the fifth consecutive year it has been possible to record a fall in the number of cases on the register. In 1960 there was an increase of two in non-pulmonary cases. Apart from this, each of these years has seen a diminution in the number of cases for each sex and for each type of disease. Deaths. This infection caused the deaths of eleven local residents last year, nine (three men and six women) from pulmonary disease, and two (one of each sex) from a non-pulmonary lesion. There were twe 101 deaths from this cause in 1960. This infection was responsible for the deaths of ninety-seven persons in this district in 1944 and even of fiftyseven in 1949. Preventive Measures. Perhaps the chief of these is the early recognition of infection in a person, preferably even before his lesion has broken down and he has become infectious. The routine examination and re-examination of contacts, especially family contacts of declared cases carried out at the Chest Clinics results in the discovery of many cases, some in the earliest stages. Then again the very ready facilities for the examination of patients referred to the Chest Clinics by their own doctors leads to the detection of disease in those who had not developed signs or symptoms. This aspect of the work of the Chest Clinic is of the highest importance. The Mass X-ray Unit plays its part in prevention in the same way. In the country as a whole, about twenty-five per cent of new cases are diagnosed by this means. The school medical and nursing staff continue to play their part in controlling this infection:— 1. Tuberculin testing of the school entrants is carried out at some of the schools. The object is to pick out those who react positively and to encourage the home contacts of these reactors to attend the Chest Clinic for examination, it being assumed that the child who reacts positively has most probably come across the infection in his own home. On 280 children on whom the jelly test was used, two were positive; the x-ray examination of the chests of these children was clear. 538 were tested by the Heaf gun. Of the seven who reacted positively, six had had B.C.G; x-ray examination of the chest of the other was clear. 2. Examination of Contacts. Whenever a pupil or anyone engaged at a school is found to be suffering from pulmonary tuberculosis, the question arises as to whether or not any investigations should be carried out at the school. These will be possibly for two reasons : One is to discover whether the infection might have been contracted from anyone in the school. Nothing need be done on these lines if the source of infection is known. This might be the case when there is a strong family history of close contact with an infectious person at home. Similarly, if the child has already contracted the infection before coming to live in this district, or befors attending that school. But while investigations at the school in such cases might not be necessary for this reason, they might still be required for the other reason, which is to discover any pupils at the school to whom the infection might have been passed on. This action will be necessary only if the patient is considered to be infective. While then in every case of this sort the question of whether or not investigation should be made is gone into, not in all cases is it felt necessary that any- thing should be done. 102 To start with, in these cases where investigations were carried out all the children in the school were examined. Experience showed that this was not necessary and anything beyond the examination of the pupils in the class or sometimes classes affected is now carried out only if the more limited enquiry shows this to be advisable. The procedure then is to tuberculin test the immediate contacts. Those who react negatively have not been exposed to the tubercle bacillus. They then could not have caused the infection in the notified case, nor will they have had the infection passed on to them. Nothing further then need be done about them. Positive reactions means that those children have been exposed to infection sometime or other. These children are therefore invited to the Chest Clinic where they are x-rayed and where if necessary, further examinations are carried out. Although this procedure has now been followed for some years, it is not felt that it has on any occasion led to the recognition of the source of infection of the notified case, nor is it felt that the practice has led to the discovery of infection amongst the contacts which had been contracted from the notified case. Many of these contacts have been found to give positive reactions. A number of them had to be kept under observation for a while. There was in fact one instance in which one of the contacts was found to be suffering from pulmonary tuberculosis, but it was not felt that she had contracted the infection from the notified patient. There were during the year, five instances of either pupils or staff at maintained schools being found to be suffering from pulmonary tuberculosis, so that the question of whether or not investigations were necessary had to be considered. The first was a teacher who had been at his school for a short time only. Nevertheless, because he was infectious it was considered advisable that all the pupils in the classes he took should be tested. Out of the 255 pupils tuberculin tested, seventeen were found to be positive. Of these, two were kept under observation for a while. The next was a child of six. As he had almost certainly contracted his infection from his mother and as he was himself not infective, no investigations were necessary. The third case was a pupil who gave a history of illness before coming to the district and so before attending school here. As she was not thought to be infectious, no investigations were necessary. The fourth case was a boy of six notified in November. He had probably contracted his infection from his grandfather. As he was not infective there was no reason to examine the school contacts. In December a girl of six was notified; she was not infective but because there was no history of contact with infection at home, it was felt desirable her class contacts at the school should be examined. 3. B.C.G. Inoculation. Another contribution made by the school health staff is by B.C.G. inoculation. The object of this is to raise the child's resistance to infection so that he is less likely to succumb when on leaving school he is more exposed than he has hitherto been, and in many cases is subject to greater stresses which have a bearing on the lowering of 103 immunity. The age group selected for treatment was thirteen. B.C.G. is of no benefit to a child which has been exposed to and has reacted to the tubercle bacillus. The procedure then is first to tuberculin test the children to pick out those positive reactors who are not inoculated. The following is a summary of the work carried out in 1961:— Type of School No. of Pupils Eligible No. of Acceptances Negative Reactors Positive Reactors Secondary Modern 1,547 1,202 1,016 91 Secondary Grammar 822 651 562 52 Special 16 13 11 1 Independent 720 545 474 40 3,105 2,411 2,063 184 Of the negative reactors. 2,053 were given B.C.G. The acceptance rate was seventy-eight per cent. The percentage of positive reactors was 8.2, a figure well below the national rate of 15.4. In his report for the year 1960, the Physician in Charge of the Harrow Chest Clinic said it has been a routine during the past year for all the domiciliary contacts of children who arefound to be tuberculin positive during the school leaving scheme for B.C.G. vaccination to have an x-ray examination. This scheme has not found many new unknown cases of tuberculosis. This arrangement of inoculating children of these ages started in this district in 1957. Each year some seventy per cent of those eligible for treatment are tested. Up to fifteen per cent react positively so are not inoculated. A proportion of those tested, for one reason or another do not attend for reading. This means that some sixty per cent of the school children of these ages receive B.C.G. Inoculation. The Medical Research Council trials showed that over a period of some years inoculation might bring about a reduction of eighty per cent in the incidence of infection of treated children. The net result is that what is being done in the schools, bearing in mind that not all parents agree to their children being treated, and other considerations, should result in a reduction of one-half of the tubercular infection of children for some years after they have reached the age of thirteen. To what extent the fall in incidence in this group in this district can in fact be attributed to this practice is difficult to assess because, of course, children of these ages have enjoyed the fall in recent years which people of all ages have experienced. Ten persons between the ages of fourteen and twenty-four were notified during the year as suffering from pulmonary tuberculosis which they presumably contracted while living in this district. Five of them gave a family history of infection. To these B.C.G. would not have been given. One had contracted his infection in the services. The other four (or four-fifths of them) might have been saved from infection had they had 104 B.C.G. They were two boys of fifteen and twenty-one and two girls of fourteen and twenty-two. The corresponding figure in the previous year was eleven. The Council has always been generous in the allocation of Council houses to families in which there is a member suffering from pulmonary tuberculosis. The object, of course, is to do what is possible to prevent the spread of infection. The factors taken into account in selecting families for such favourable treatment are those which favour the spread of infection, these are the infectiousness of the patients and the degree of overcrowding. Over the years large numbers of families have been rehoused for this reason and the Council at one time were allocating as much as one-tenth of its new houses for this purpose. In the earlier days it was difficult to select from the many being considered, the families whose needs were greatest because the circumstances in which so many were living were so very bad. Gradually most of the cases were housed and the time came when there was only a small list of such families and in their cases, the needs were nothing like as urgent as those of the families in the earlier days. Conditions have improved still further and at the end of the year there was no family on the list of those being recommended for re-housing on the grounds that a member of the family was suffering from tuberculosis. This, of course, does not mean that there are no families with a member suffering from tuberculosis who would not be helped by being given better housing, but in the case of these families, the advantage of their being re-housed would not be to reduce the risk of spreading the infection but to improve the surroundings of the sufferer. In that re-housing such families would do nothing to prevent spreading the infection, the patient would be in the same situation as those people suffering from one of a number of non-communicable diseases who would benefit by better housing. The circumstances of these families are considered by the Special Housing Sub-Committee. Arthur Gaunt & Sons (Printers) Ltd., Market Place . Heanor . Derbyshire