AC 493(1) SOUTH CATE BOROUGH OF SOUTHGATE. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1947. WM. CLUNIE HARVEY, M.D.. D.P.H., Medical Officer of Health and School Medical Officer. Crusha & Son, Ltd., Tottenham, Enfield and Wood Green. SOUG 32 BOROUGH OF SOUTHGATE. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH FOR THE YEAR 1947. WM. CLUNIE HARVEY, M.D., D.P.H., Medical Officer of Health and School Medical Officer To the MAYOR, ALDERMEN AND COUNCILLORS OF THE BOROUGH OF SOUTHGATE Mr. Mayor, Mrs. Winston and Gentlemen, I beg to present the Annual Report of the Medical Officer of Health for the year 1947. The present Annual Report is unique in as much as it covers the last full year during which the Borough Council remained the Statutory Authority for Maternity and Child Welfare and the personal Health Services. There will be no need to expatiate on the fact that the coming into operation of the National Health Service Act in July 1948 places the responsibility for those services on the County Council as Local Health Authority; nor would any useful purpose be served by discussing the pros and cons of the new regime. I am of opinion, however, that opportunity should be taken in this, the last Annual Report in its present form, to review the situation as it stood at the end of 1947, to attempt to assess some of the results achieved, and at least to suggest the manner in which the Borough Council can co-operate in the new Health Services. The present Report will therefore include brief historical reviews of past work, and various paragraphs designed to place on permanent record the situation which closed a long and very illustrious chapter in local government. As the pattern of the Annual Report of the Medical Officer of Health for 1948 is still in doubt, opportunity will also be taken in the present Report to deal with changes in administration and extensions to Public Health Services scheduled for the first six months of 1948. Apart from the topical significance of 1947, the year was noteworthy for the fact that the staff of the Public Health Department 3 became responsible for the local School Health Service in September. The taking over of the School Health Service necessitated a regrouping of the staff, and additions to its numbers. It also necessitated a re-distribution of duties, and placed considerable additional responsibility on the Department as a whole. The work of the School Health Service does not properly belong to this report, but opportunity will be taken to refer to it from time to time as occasion arises. 1947 was a satisfactory year from the point of view of vital statistics. The birth rate rose slightly over the rate for the previous year and is one of the highest yet recorded; the death rate showed no material alteration. The infantile mortality rate was low for the second year in succession; indeed, the rates for 1946 and 1947 are the lowest for any two consecutive years yet recorded. The Infectious Sickness Rate showed a slight rise, although it was lower than the average for the past five years. In this field, the most noteworthy feature was the part which Southgate played in the widespread epidemic of infantile paralysis during the summer and autumn months. The fact that only seven cases were recorded, and that all made a satisfactory recovery, is pleasing. The arrangements made whereby cases of infectious diseases are removed to the Finchley, Hornsey, Wood Green and Friern Barnet Isolation Hospital, proved entirely adequate. The most cordial relations exist between the Hospital staff and the Public Health Department, no difficulties having arisen during the year. The various changes in the staff, most of them due to the merging of the Maternity and Child Welfare and School Health Services, will be found set out on page 7 of the Report. It is impossible in a factual report of this character to deal adequately with the changes envisaged by the National Health Service Act. One might, however, be permitted to express the personal regret, not only of the senior officials of the Public Health Department, but also of the staff as a whole, that the Borough Council has had to relinquish its controlling interest in matters which intimately affect the welfare of the inhabitants. It need scarcely be said that the staff will continue to devote the same interest to their work, no matter what authority may be responsible. We none the less feel the break, and can only hope that the years which lie ahead will mark the same progress as those during which local knowledge and experience remained the most important governing factors. 4 I would take this opportunity of expressing my thanks to the Borough Council and to the Chairman and Members of the Public Health and Maternity and Child Welfare Committees, for their support and consideration not only during the year under review, but during the 17 years since I first took up my duties as Medical Officer of Health of Southgate. This support and consideration has been of inestimable service to me; without it no Medical Officer could ever hope to achieve his professional object. I should also like to thank the members of my Department for the admirable manner in which they have carried out their many and difficult duties. I am, Mr. Mayor, Mrs. Winston and Gentlemen, Your obedient Servant, W. C. HARVEY, Medical Officer of Health. Southgate Town Hall, N. 13. 5 PUBLIC HEALTH COMMITTEE at December 31st, 1947. Alderman 6. Peverett (Chairman). Councillor H. S. Beardow. Councillor R. V. Faithfull. Councillor S. C. Jenner. Councillor W. A. MacGregor. Councillor R. Prior. Councillor W. Saxon (Vice-Chairman). MATERNITY AND CHILD WELFARE COMMITTEE at December 31st, 1947. Councillor Mrs. R. Winston (Chairman). Alderman G. Peverett. Councillor H. S. Beardow. Councillor R. C. Evans. Councillor R. V. Faithfull. Councillor E. H. Lake, J. P. Councillor A. F. Pullinger. Councillor W. H. Warren. CO-OPTED MEMBERS. Mrs. E. Forward. Mrs. E. Miatt. Mrs. J. Skinner. Dr. L. Westlake (Vice-Chairman). 6 PUBLIC HEALTH STAFF. **Medical Officer of Health and School Medical Officer: W. C. Harvey, M.D., Ch.B., D.P.H. **Assistant Medical Officer of Health: Marjorie K. Hall, M.B., B.S. (Lond.), D.P.H.(Lond.), (full-time). (Resigned 25th November, 1947). **Assistant Medical Officer of Health: Nora T. U. O'Callaghan, M.B., Ch.B., B.A.0., D.P.H. (full-time). Commenced 23rd June, 1947. **Assistant Medical Officer of Health: Christina M. Small, M.B., B.S., D.P.H., (full-time). Commenced 17th December, 1947. *Senior Sanitary Inspector (No. 1 District): A. E. Gooday, Cert. R. San.I., M.S.I.A., Cert.R.San.I. Meat Inspection. *Sanitary Inspector (No. 2 District): J. D. Dant, Cert.R.San.I., M.S.I.A., Cert.R.San.I. Meat Inspection. *Sanitary Inspector (No. 3 District): R. L. Burkill, A.R.San.I. M.S.I.A., Cert.R.San.I. Meat Inspection. *Sanitary Inspector (No. 4 District): E. T. Jephcott, M.S.I.A., Cert.R.San.I., Cert.R.San.I. Meat Inspection. (Appointed 1st August, 1947). Chief Clerk: P. E. Barber. Clerk: Miss M. Munch. Clerk: Miss K. Stoten. Junior Clerks: Miss C. Everest (Resigned 16th May, 1947). Miss M. Baylis (Appointed 16th June, 1947). Mr. J. Swinchatt (Commenced, 12th May, 1947— Resigned 2nd August, 1947). Miss E. Anderson (Commenced 28th August, 1947). Health Visitors (Maternity and Child Welfare): **Miss M. Maddock, S.R.N., S.C.M., H.V. Cert. **Miss A. Joy, S.R.N., R.F.N., S.C.M., H.V. Cert. (Resigned 3rd April, 1947). **Miss B. M. Finnegan, S.R.N., S.C.M., H.V. Cert. 7 **Miss P. Carter, S.R.N., S.C.M., H.V. Cert. **Miss G. J. Franklin, S.R.N., S.C.M., H.V. Cert. (commenced 8th April, 1947). **Miss E. Thurgood, S.R.N., S.C.M., H.V. Cert. (commenced 8th April, 1947). **Miss M. N. Hilton, S.R.N., H.V. Cert. (commenced 8th April, 1947.) **Miss J. McNamee, S.R.N., S.C.M., H.V. Cert. (commenced 21st April, 1947). Health Visitor (Public Health): Supt. Health Visitor as from November 1st, Miss B. E. Wellman, S.R.N., S.C.M., H.V. Cert. R.San. I. Home Help and Domestic Help Organiser: Mrs. W. Goodman (commenced 28th October, 1947). Full-time Assistant (Maternity Centres): Miss N. Freeman. Part-time Assistant (Maternity Centres): Mrs. M. Edwards. Disinfector: A. G. Bates. Assistant Di&infector: B. Latter. Rodent Operator: W. Dowsett. * These Officers' salaries are repaid to the Council, in part, by the Ministry of Health or the County Council. **As from 1st April, 1947 these officers carried out part-time duties in connection with the School Health Service. 8 Statistics and Social Conditions of the Area. Area (in acres) 3,764 Registrar General's estimate of Resident Civilian Population, 1947 74,320 Number of inhabited houses (end of 1947) according to Rate Books 21,413 Rateable Value (1947) £933,877 Sum represented by a penny rate (1947) £3,874 The social conditions of Southgate are substantially the same as those set out in last year's Annual Report. Overcrowding and the use of dwelling houses by more families than was ever intended, has continued and shows little sign of abatement. Distribution of the population still shows a weighting towards the older age groups, although the recent rise in the birth rate, if continued, will inevitably increase the younger age groups at the expense of the old. This trend is already being shown in the large waiting lists for most of our schools, and represents a serious problem which will have to be faced. It is still true to say that Southgate is a dormitory, and that industrial development has not and probably never will be an important factor in the life of the community. Now that environmental hygiene is being partly divorced from the personal Health Services, the part which the Borough Council can and should play in maintaining and, where possible, improving living conditions and amenities within the Borough, assumes an ever greater importance. The significance of environmental hygiene, more especially housing and its allied problems, is apt to be forgotten, either wholly or partially, in the welter of talk and literature centring round the Personal Health Services. Environmental hygiene is never spectacular; the advantages which follow close attention to the sanitary services are seldom apparent to the casual observer, although the disadvantages are very quickly realised and disliked. It is equally true that errors in environmental hygiene are very difficult to remedy; once the harm has been done the results are all too often permanent. For those very cogent reasons the importance of this branch of preventive medicine, for it is medicine in 9 its widest sense, must never be forgotten. The years ahead are critical, fraught with unlimited potentiality for good or ill. No one can say that the position to-day is as satisfactory as it was in 1939. A great effort is required to make up the leeway, to ensure that the vicious circle will finally be closed. But it is an effort which must be made, since the future of Southgate may well depend upon its successful application. A great deal has recenty been made of the part which local authorities such as Southgate can play in the reconstituted field of public health. Much of this is interesting, a lesser amount is of practical importance. While no one would deny that sanitary authorities have a very significant, if restricted, role to play, their activities must of necessity be covered by the number of staff available. If some of the suggestions put forward are to be implemented, there is no doubt that additional staff will have to be obtained. I personally hope that concentration on environmental hygiene will allow us to devote more time to such problems as field epidemiology, housing, and food hygiene. I intend to submit a detailed report along these lines to the Public Health Committee when the situation has clarified itself, and when we can better assess our opportunities for more intensive work in the fields which I have mentioned. • We must at all costs avoid the impression that the diminished Public Health Department is concerned only with drains, sewers, and the extermination of rats; that the Sanitary Inspector has been relegated to his original role of Inspector of Nuisances. Our horizon remains as wide as before, our task as important. If this fact is remembered, and if we are allowed fully to explore the avenues which lie immediately before us, definite advantage may lie in the fact that the remaining staff of the Public Health Department is now more or less relieved of the necessity to consider the individual as a health entity rather than the environment which produces or aggravates his problems. EXTRACTS FROM VITAL STATISTICS OF THE YEAR. Male. female :. Total. Live Births Legitimate 616 601 1,217 Illegitimate 17 12 29 Totals 633 613 1,246 - Birth rate per 1,000 of the estimated population 16.76 10  Male. Female. Total. Still Births Legitimate 21 10 31 Rate per 1,000 total (live and still) births 24.27 Illegitimate 0 0 0 Deaths from all causes and at all ages 397 439 836 Death Rate per 1,000 of the estimated population 11.25 Deaths from puerperal causes:— Deaths. Rate per 1,000 total (live and still) births. From puerperal sepsis 0 0.00 From other puerperal causes 0 0.00 Total 0 0.00 Deaths of Infants under 1 year of age:— Male. Female. Total. Legitimate 23 16 39 Illegitimate 2 0 2 Totals 25 16 41 Infant Death Rate:— All infants per 1,000 live births 32.90 Legitimate—per 1,000 legitimate live births 32.05 Illegitimate—per 1,000 illegitimate live births 68.96 Deaths from Measles (all ages) 1 Deaths from Whooping Cough (all ages) 0 Deaths from Diarrhoea (under 2 years of age) 2 POPULATION. The Registrar-General estimated the civilian population of the Borough at the middle of 1947 to be 74,320, an increase of 2,610 as compared with 1946. BIRTHS—BIRTH RATE. The nett total of births accredited to the district was 1,246, an increase of 33 on the preceding year. Of these, 633 were males and 613 females (21 males and 10 females being illegitimate). The birth-rate for the year was 16.76 per 1,000 of the population. 11 The birth-rate for England and Wales for 1947 was 20.5 and for the administrative County of London, 22.7. The births and birth-rates for the past 5 years were as follows:— No. of Births. Birth Rates. England Southgate. & Wales London. 1943 1,088 16.55 16.5 15.8 1944 1,096 17.07 17.6 15.0 1945 976 15.02 16.1 15.7 1946 1,213 16.68 19.1 21.5 1947 1,246 16.76 20.5 22.7 During 1947, the number of births recorded was 410 greater than the number of deaths, as compared with 330 in 1946. The total number of births actually registered in the district during the year amounted to 1,328, of which 18 were unnotified. The percentage of births notified was therefore 98.6 as compared with 98.4 in 1946. MORTALITY. General Mortality and Death Rate.—The nett number of deaths accredited to this district was 836, 47 fewer than in 1946. This gives a death-rate of 11.25 per 1,000 of the population, a decrease of 0.89 on the rate for the previous year, which was 12.14. The rate for England and Wales (1947) was 12.0 and for London 12.8. The deaths and death-rates for the past 5 years were as follows:— No. of Deaths. Death Rates. England Southgate. & Wales. London. 1943 802 12.20 12.1 15.0 1944 803 12.51 11.6 15.7 1945 781 12.02 11.4 13.8 1946 883 12.14 11.5 12.7 1947 836 11.35 12.0 12.8 As usual the rates applicable to 1947 are based on the Registrar General's estimate of population at mid-year, which was 74,320. I am still of opinion that this estimate is slightly on the low side, an opinion which is substantiated by information received from the Food Office. None the less we must accept the population figure supplied and base our calculations upon it. 12 Infant Mortality.— There were 41 (2 illegitimate) deaths of infants under 1 year of age, which give an infantile death-rate of 32.90 per 1,000 births, as compared with 36 deaths and a rate of 29.68 in the preceding year. The corresponding rates for England and Wales and London were 41 and 37 respectively. The infant deaths and rates for the past 5 years were as follows:— No. of Deaths. Infantile Death Rates. England Southgate. & Wales. London 1943 36 33.08 49 58 1944 42 38.32 46 61 1945 38 38.93 46 53 1946 36 29.68 43 41 1947 41 32.90 41 37 Of the 41 infant deaths during 1947, 20 or 48.8 per cent. occurred within the first week of life, while the total under 1 month numbered 21 or 51.2 per cent. Eight of these deaths were due to prematurity, 8 to pneumonia, 3 to gastro-enteritis and 4 to congenital abnormalities. It is pleasing to record that, for the second year in succession, a low infantile mortality rate has been recorded in the Borough. This is a source of satisfaction, but must not allow us to shut our eyes to the fact that there is still room for improvement. As I said in my Annual Report for last year, every infant death represents a tragedy. There will always be unavoidable tragedies during the first twelve months of life, as there are during later years. But even if we accept this fact, there are still the avoidable deaths, for which a remedy can and should be found. We have by no means reached the irreducible minimum. Until we can categorically state that we have done so our efforts must be continued with unabated vigour. So far as Southgate is concerned, the addition of one extra ante-natal session during the year had added to our available facilities. The addition of this one session allows the Health Visitors and Medical Officer concerned to devote more time to individual cases, and to try by all possible means to ensure that untoward circumstances which might jeopardise the life and well-being of the expected infant are removed. All women attending our ante-natal clinic 13 have a blood specimen taken. This specimen is examined for determination of the Rhesus factor, while a Kahn test is also performed. These represent additional safeguards which may well prevent a tragedy. Every infant death is fully investigated, in the hope that preventable circumstances, should they have occurred, can be eliminated. Such investigations are extremely useful, as they enable us to form a detailed, over-all picture of the causes and background of infant deaths within the Borough. We have also arranged to participate in a national survey connected with Maternity and Child Welfare, designed to assess the factors which influence the health of mother and infant. It is only by the accumulation of such knowledge and the application of the knowledge so acquired that we can hope to reduce still further the infantile mortality rate. Later in this report I will emphasize the need for more home visiting. Maternity and Child Welfare is essentially a service which should be centred in the home. Until we can be absolutely certain that our Health Visitors have adequate time to devote to home visiting, we cannot truthfully say that the steps which we are taking to protect infant life are as good and as comprehensive as we would wish them to be. Stillbirths.—Thirty-one stillbirths, (0 illegitimate) were accredited to the district for 1947. This is equal to a death rate of 24.27 per 1,000 (live and still) births, the corresponding figures for 1946 being 31 stillbirths, with a rate of 24.92. The rate per 1,000 of the population was 0.417, the rates for England and Wales and London being 0.50 and 0.49 respectively. The stillbirth rate is still unsatisfactory. The associated factors are inextricably bound up with the causes of infantile mortality and, in my opinion, should be considered as a single entity. Antenatal supervision (with which is included investigation of the Rhesus factor) remains the foundation upon which our preventive work should be laid. The future of this preventive work when the Regional Hospital Boards assume at least partial responsibility in July, 1948, is at the moment somewhat nebulous. It is to be hoped that the closest possible liaison will be maintained with the local Health Department; there is no reason to believe that this will not be the case. For the time being we must continue our work along the lines which have produced so much improvement during past years. Maternal Mortality.—The maternal mortality rate, i.e., the number of mothers dying as the result of childbirth per 1,000 total 14 (live and still) births was nil, there being no deaths in this category during 1947. In 1946 there were 6 deaths with a corresponding rate of 4.82. It is pleasing to record that no maternal deaths occurred during the year. Although this is satisfactory, the fall has very little significance, bearing in mind the very few cases involved. None the less, the saving of the lives of six women following childbirth is very pleasing to record. All maternal deaths are carefully investigated. Where any preventable cause is ascertained, the matter is immediately followed up. Mortality of "Toddlers".—Eight deaths occurred amongst children of the age group 1—5 years during 1947. This represents a death-rate of 0.11 per 1,000 of the population, and 0.95 per cent. of the total deaths for the year at all ages. In 1946 there were 5 deaths giving a death-rate of 0.07 and a percentage of 0.56. Mortality of Persons over the Age of 65.—560 or 66.98 percent, of the total deaths during the year were persons over the age of 65. Of these, 157 died between the ages of 80 and 90, while a further 31 were over the latter age (12 males, the eldest being 98, and 19 females, the eldest being 100). Once again diseases of the heart and circulatory system were responsible for the majority of deaths of elderly persons in the district. This is not in itself a bad sign, as it at least means that many people are living to the age when such degenerative conditions are a natural sequal to advancing years. Medical science can still offer a limited service in the direction of eliminating these degenerative processes; but much is being and will continue to be done to delay their final effect for as long as possible. Zymotic Mortality (including deaths from the seven principal zymotic diseases, viz. : smallpox, scarlet fever, diphtheria, typhoid fever, measles, whooping cough and diarrhoea (in children under 2 years of age)).—There were 3 deaths in this category, 1 from measles and 2 from infantile diarrhoea. The zymotic death-rate for the year was therefore 0.040 per 1,000 of the population, as compared with 3 deaths and a rate of 0.041 in 1946. Once again diptheria does not appear as a cause of death during the year. Only one death occurred from measles, while pertussis was also absent from the list, revealing the change in virulence of those diseases. Altogether, the zymotic death rate is very satisfactory, and is an index of the high standard of resistance towards the common infectious diseases. 15 Table I. Causes of Death During the Year 1947. Causes of Death. Male. Female. Total. Rates per 1,000 of Population All Causes (Civilians only) 397 439 836 11.25 1 Typhoid and Paratyphoid Fevers — — — — 2 Cerebro-spinal Fever 1 — 1 0.01 3 Scarlet Fever — — — — 4 Whooping Cough — — — — 5 Diphtheria — — 16 0.22 6 Tuberculosis, Respiratory System 9 7 7 Tuberculosis, Other forms 1 3 4 0.05 8 Syphilitic Diseases 4 5 9 12 0.12 9 Influenza 8 4 0.16 10 Measles — 1 1 0.01 11 Acute Poliomyelitis and Polioencephalitis — — — — 12 Acute Infectious Encephalitis — 1 1 0.01 13 Cancer, Oesoph. (M) Uterus (F) 1 5 6 0.08 14 Cancer, Stomach and Duodenum 16 13 29 0.39 15 Cancer, breast — 18 18 0.24 16 Cancer, other sites 57 39 96 1.29 17 Diabetes 2 2 4 0.05 18 Intra-cranial vascular lesions 37 72 109 1.47 19 Heart Disease 118 146 264 3.55 20 Other Circulatory Diseases 10 10 20 0.27 21 Bronchitis 18 23 41 0.55 22 Pneumonia 20 23 43 0.58 23 Other Respiratory Diseases 4 2 6 0.08 24 Ulcer, Stomach or Duodenum 7 2 9 0.12 25 Diarrhoea under 2 years 1 1 2 0.03 26 Appendicitis 1 — 1 0.01 27 Other Digestive Diseases 13 8 21 0.28 28 Nephritis 17 12 29 0.39 29 Puerperal Sepsis — — — — 30 Other Maternal causes — — — — 31 Premature Birth 4 4 8 0.11 32 Congenital Malformations, Birth Injuries, etc. 10 5 15 0.20 33 Suicide 3 4 7 0.09 34 Road Traffic Accidents 3 2 5 0.07 35 Other violent causes 7 6 13 0.17 36 All other causes 25 21 46 0.62 16 TABLE II. Deaths from all causes, divided as to sex and certain age groups, and showing a percentage of total deaths and death-rate per 1,000 of population for each group. 1947. Age. MALES. FEMALES. TOTALS. No. % of Total Deaths. Rate per 1,000. No. %of Total Deaths. Rate per 1,000. No. %of Total Deaths. Rate per 1,000. 0— 1 year 25 2.99 0.34 16 1.91 0.21 41 4.90 0.55 1— 5 years 2 0.24 0.03 6 0.72 0.08 8 0.96 0.11 5—15 ,, 2 0.24 0.03 2 0.24 0.03 4 0.47 0.06 15—25 ,, 5 0.60 0.07 3 0.36 0.04 8 0.96 0.11 25—45 ,, 18 2.15 0.24 14 1.67 0.19 32 3.83 0.43 45—65 ,, 98 11.72 1.32 85 10.17 1.14 183 21.89 2.46 65 and over 247 29.55 3.32 313 37.44 4.21 560 66.98 7.53 Totals 397 47.49 5.34 439 52.51 5.91 836 100.0 11.25 17 Table III. Infantile Mortality. 1947. Nett Deaths from stated causes at various periods under 1 Year of Age. Causes of Death. Under 1 Week. 1—2 Weeks. 2—3 Weeks. | 3—4 Weeks. Total under 1 Month. | 1—3 Months | 3—6 Months. | 6—9 Months. | 9—12 Months. Total Deaths under 1 Year. 1 Smallpox 2 Chickenpox 3 Measles 4 Scarlet Fever 5 Whooping Cough 6 Diphtheria and Croup 7 Erysipelas 8 Tuberculous Meningitis 9 Abdominal Tuberculosis 10 Other Tuberculous Diseases .. .. .. .. .. .. 2 .. .. 2 11 Meningitis (Not Tuberculous) .. .. .. .. .. 1 .. 1 1 3 12 Convulsions 13 Laryngitis 14 Bronchitis .. .. .. .. .. .. 1 1 .. 2 15 Pneumonia 1 .. .. .. 1 3 1 l 1 7 16 Diarrhoea l 17 Enteritis .. .. .. .. .. 2 .. 3 18 Gastritis 19 Syphilis 20 Rickets 21 Suffocation 22 Want of Attention and Injury at Birth 1 .. .. .. 1 .. .. .. .. 1 23 Atelectasis 2 .. .. .. 2 .. .. .. .. 2 24 Congenital Malformations 2 .. 1 .. 3 1 .. .. .. 4 25 Premature Birth 8 .. .. .. 8 .. .. .. .. 8 26 Atrophy, Debility and Marasmus .. .. .. .. .. .. .. .. .. .. 27 Other Causes 6.. .. .. .. 6 1 .. 1 1 9 Totals .. 20 .. 1 .. 21 6 6 5 3 41 18 Table IV. Vital Statistics of Whole District during 1947 and Eight Previous Years. Year. Population estimated at Middle of each Year. Nett Births belonging to District. Nett Deaths belonging to the District. At all Ages. Under 1 Year of Age. Number. Rate per 1,000 Population. Number. Rate per 1,000 Population. Number. Rate per 1,000 Nett Births. 1 2 3 4 5 6 7 8 1939 67,770 780 11.24 693 10.16 21 26.92 1940 66,570 707 10.62 769 10.97 23 32.81 1941 64,890 647 9.97 771 11.28 25 40.91 1942 65,790 925 14.06 702 10.67 34 36.75 1943 65,720 1,088 16.55 802 12.20 36 33.08 1944 64,190 1.096 17.07 803 12.51 42 38.32 1945 64,970 976 15.02 781 12.02 38 38.93 1946 72,710 1,213 16.68 883 12.14 36 29.68 1947 74,320 1,246 16.76 836 11.25 41 32.90 Comparison of the Rates of Southgate with those of England and Wales, and London, for the Year 1947. Rate per 1.000 Total Population. Annual Death Rate per 1,000 Population. Rate per 1,000 Live Births. Live Births. Still Births. All Causes. Typhoid Fever. Smallpox. Measles. Scarlet Fever. Whooping Cough. Diphtheria. Influenza. Diarrhoea and Enteritis (under two years). Total Deaths under one year. England and Wales 20.5 0.50 12.0 0.00 0.00 0.01 0.00 0.02 0.01 0.09 5.8 41 126 County Boroughs and Great Towns, including London 23.3 0.62 13.0 0.00 0.00 0.02 0.00 0.03 0.01 0.09 8.0 47 148 Smaller Towns (1931 Census Populations 25,000—50,000). 22.2 0.54 11.9 0.00 0.00 0.02 0.00 0.02 0.01 0.08 3.7 36 London 22.7 0.49 12.8 0.00 — 0.01 0.00 0.02 0.01 0.08 4.8 37 Southgate 16.76 0.41 11.25 — — 0.01 — — — 0.16 1.60 32.90 A dash (—) indicates that there were no deaths. 19 GENERAL PROVISION OF HEALTH SERVICES. Hospitals.—The remarks set out under this heading in the Annual Report for 1946 still hold good. Hospital beds are still in short supply, partly owing to lack of sufficient accommodation, even more to lack of adequate staff. This particularly applies to beds for the chronic sick and infirm, for whom the waiting list is distressingly long. The practice of supplying domestic helps to families in which illness has occurred and in which removal to hospital of the patient has not been possible, is merely an expedient, and not a very good one at that. In the same way, the provision of a part-time nursing service fails to solve the problem. With a population such as Southgate's, heavily weighted towards the end of the scale, the problem is really acute. Requests for admission to hospitals and institutions received by the Public Health Department have shown a considerable increase over the past few years, and it is quite obvious that many families are now having to endure hardship and unhappiness which should never be their lot in a well-organised community. The solution does not lie with us, but we must none the less be keenly interested in its application. We await the setting-up of the new Regional Hospital Boards with interest, in the hope that the needs of the population who require hospital accommodation will be more adequately met. It is pleasing to report that the urgent demand for maternity beds was met in a more satisfactory manner in 1947 than during previous years, although it still cannot be said that this problem has been adequately solved. As previously noted, the arrangements whereby cases of infectious disease from Southgate are admitted to the Finchley, Hornsey, Wood Green and Friern Barnet Isolation Hospital, Coppetts Road, have worked very satisfactorily during the year. Requests for admission were met in practically every case, the few exceptions being adequately dealt with by admission to other Isolation Hospitals. The facilities provided at the Finchley, Hornsey, Wood Green and Friern Barnet Joint Isolation Hospital are excellent, and I would like to take this opportunity of thanking the Medical Superintendent, Dr. Montgomery, for his unfailing courtesy and skill in dealing with Southgate patients. 20 Ambulance Facilities.—The following table sets out the total number of journeys carried out by our Ambulance Service during the past four years:— 1947. 1946. 1945. 1944. General removals to or from hospitals, etc. 2,704 1,930 1,577 1,112 Maternity cases 320 318 352 394 Traffic accidents 80 71 57 29 Other accidents 418 390 505 436 3,522 2,709 2,491 1,971 From the table set out above it will be seen that the Service continues to expand. Arrangements have now been completed whereby the Ambulance Service will be transferred to the County Council in July, 1948. Fortunately, the Ambulances will be retained at or near their present site, which means that the Borough should be adequately covered. It will be common knowledge that removal to hospital under the new service will be undertaken free of charge. During 1947, the personnel attached to the Ambulance Service was considerably increased. A three-shift system was adopted in place of the previous 24-hour shift, and has worked satisfactorily. Early in 1947 it became apparent that the transport of cases of infectious disease to Coppetts Road by means of the London County Council Ambulance Service was not sufficiently speedy to cover all emergencies. Arrangements were therefore made to use our spare ambulance for this purpose, the ambulance being manned by the regular ambulance staff. This arrangement very quickly proved its worth, and represents a considerable improvement on the previous system. During the year, 88 journeys were made to Coppetts Road and other Isolation Hospitals. Mortuary.—The position with regard to the Council Mortuary at the rear of the Town Hall is as set out in the report for 1946. The Mortuary is still being maintained, and is available for use as and when required. No post-mortem examinations were carried out in the Mortuary during the year. 21 Laboratory Facilities.—The arrangement whereby the Central Public Health Laboratory, Colindale, carries out bacteriological examinations from cases within the Borough has worked very well indeed throughout the year. A daily collection of specimens is made from the Town Hall. Urgent specimens received after the collection has been made are taken either to the Central Public Health Laboratory, or to the Laboratory at Coppetts Road Isolation Hospital. Use is still made of the Council's Laboratory in Wolves Lane for the examination of urgent throat swabs received late in the afternoon, at week-ends, or after office hours. The Central Public Health Laboratory staff has been most helpful in the investigation of outbreaks of measles at our day nurseries. A Medical Officer was sent from the Laboratory on 16 occasions, and carried out detailed investigation of cases and contacts. Contacts were supplied with various types of ' 'measles modifiers'', with very satisfactory results. The services of the Laboratory are also available for consultative purposes at all times. Opportunity was taken on more than one occasion during the year to remind General Practitioners of the facilities available, and to invite a fuller use of the Laboratory services. Particular emphasis was laid on the assistance which could be obtained from post-pharyngeal swabs in the diagnosis of pertussis. Many General Practitioners acted upon my letter, and sent an increased number of such swabs for examination. The Laboratory arranged several short courses on food hygiene on similar lines to those held during 1946. Seven Canteen Supervisors and members of the various school canteen staffs attended these courses, which were of very great practical value. The Director of the Laboratory Service states that further courses will be held in the near future. It has not yet been possible to arrange for the setting up of branch laboratories in this part of Middlesex, as was suggested in the Annual Report for 1946. So far as Southgate is concerned, the need is not urgent, as we are adequately covered by the present service. 22 Summary of work carried out at Central Public Health Laboratories, Colindale:— Borough Positive. Specimens. Negative. Swabs for Diphtheria Bacilli 7 304 Swabs for Pertussis — 64 Cough Plates for Pertussis — 7 Sputa for Tubercle Bacilli 8 117 The following specimens were also examined:- Urine 7 Faeces 59 Cerebro-spinal fluid 1 Blood 14 Blood for Rhesus Factor 261 Pus 5 Foodstuffs 45 Scabies and Lice.—The arrangements set out in the Annual Report for 1945 for the treatment of patients suffering from scabies and vermin infestation remain unaltered, except that the appointment of two Health Assistants in the School Health Service has allowed us to cope much more adequately with infestation among school children. Generally speaking, disinfestation and treatment of scabies occurring among school children is dealt with at the appropriate minor ailment clinic. Severe and recurring cases, of which not many are reported, are sent to the Hornsey Disinfestation Centre for treatment. Adults suffering from scabies are mostly treated in their own homes; cases of infestation among adults are sent to the Hornsey Disinfestation Centre. Twenty-five patients were so treated during the year. The problems of lice infestation and scabies are not acute in Southgate. Figures showing the percentage infestation of adults are not available, but the number of children infested either with live lice or with nits is extremely low. Two schools only (DeBohun and Oakwood) show a percentage infestation higher than 5%. Even in these cases individual infestation was almost invariably mild and, except in a very few instances, yielded rapidly to treatment. A few families in which infestation among the children occurred —not more than 12 in number—were found to be completely uncooperative. As all these families are residents on the Council Housing Estate, steps have been taken to report their non-co-operation to the Housing Management Committee with a view to action being taken in cases where lack of co-operation continues. 23 Nursing in the Home.—(a) The Southgate Queen's Nursing Association continued to provide nursing facilities in the home during 1947. Year after year it has been my privilege to record my personal appreciation and that of the Public Health Department for the excellent services rendered by the Nursing Association. It is particularly fitting that this appreciation should be repeated now, in view of the fact that the work of the Association will be taken over by the Middlesex County Council on July 5th, 1948. It is difficult to estimate the value of these nursing services to Southgate. Our lot has been fortunate compared with many Boroughs which have not enjoyed the benefits of a progressive, enterprising and well-staffed organisation such as the Southgate Queen's Nursing Association. The quality of the work has always been high, and quite out of proportion to the small cost borne by the recipients. Like all organisations of a similar nature, the Southgate Queen's Nursing Association has found difficulty in obtaining sufficient nurses; but there can be no doubt that the excellent reputation of the Association, together with the admirable manner in which the staff is housed and cared for, has resulted in more nurses being available than would have otherwise been the case. All in all, the inhabitants of Southgate owe a very deep debt of gratitude to the Nursing Association. As many are perhaps not fully aware of the services which this body has rendered, it gives me particular pleasure to put on record my personal and very high opinion of the Association and all its officers. The Southgate Queen's Nursing Association also undertakes the midwifery service in the Borough, acting on behalf of the Middlesex County Council. As in the case of the home nursing services, the quality of the work is excellent. Co-operation between the Queen's Nurses and the staff of the Maternity and Child Welfare Department has always been cordial and intimate, and there is no reason to believe that this co-operation will not be continued when the National Health Service Act comes into operation and the Middlesex County Council becomes directly responsible for the midwifery services within the County. (6) As indicated in previous Annual Reports, home nursing of certain infectious diseases is undertaken by the Southgate Queen's Nursing Association at the request of the Borough Council, where such home nursing is considered necessary or desirable. Little use has been made of these services within the past few years, mainly owing to the fact that the limited number of nurses available were required for more urgent work. 24 Details of the work carried out by the Southgate Queen's Nursing Association are as follows: 1946. 1947. Domiciliary Nursing Visits 16,315 15,561 Midwifery, Maternity and Ante-natal Visits 5,277 5,359 Patients attending Physiotherapeutic Clinics 3,337 2,948 Treatments given 15,534 14,418 In addition to the above, 389 children under five years of age were sent from the Maternity and Child Welfare Centres for treatment in the Physiotherapy Department of the Nursing Association during 1947. CLINICS AND CENTRES. The following lists set out the various clinics and treatment centres in operation within the Borough at 31st December, 1947 : Infant Welfare: The Grange, The Bourne, Southgate Monday and Wednesday 2—3.45 Methodist Church, Palmerston Road, Bowes Park Tuesday and Thursday 2—3.45 Combined Clinic, Bowes Road, N. 11. Wednesday 2— 3.45 Methodist Church, Green Lanes, N.21. Tuesday and Thursday 2—3.45 DeBohn School Clinic, Green Road, Southgate Friday 2—3.45. Pre-natal: Combined Clinic, Bowes Road, N. 11. Tuesday 10—12. The Grange, The Bourne, Southgate Wednesday 10—12 Methodist Church, Palmerston Road, Bowes Park Thursday and Friday 10—12 Post-natal: Combined Clinic, Bowes Road, N.11. First Tuesday in each month. 10— 12 Immunisation: Against Diphtheria or against Whooping Cough and Diphtheria—Town Hall, N.13. Thursday 2—3.45 Against Whooping Cough alone—Town Hall, N.13. Tuesday 2.30— 3.30 25 Tuberculosis: (Middlesex County Council).—The Dispensary serving the area is situate at:— 980, High Road, Whetstone, N.20. Venereal Disease Clinic: (Middlesex County Council).—Prince of Wales's Hospital, Tottenham. All London General Hospitals are included in the London and Home Counties Joint Scheme for the treatment of Venereal Diseases. Day Nurseries.—Alderman House, Aldermans Hill, Palmers Green; Tottenhall Sports Ground, Tottenhall Road, Palmers Green; Hoppers Road, Palmers Green. It will be appreciated that those among the above services which were not already the direct responsibility of the County Council will become so on and after July 5th, 1948. It is not anticipated that any material alteration will immediately take place, although adjustments will doubtless be made in the light of the new arrangements envisaged by the National Health Service. A comparison with the list of clinics and treatment centres set out in the Annual Report for 1946 will show that extensions were made during the year, particularly in regard to infant welfare. It can, I think, be stated that the district is now adequately covered, and that no resident can complain either of the number of clinics or of their distribution. DOMESTIC HELPS. The year under review saw a considerable increase in the scope of our Domestic Help Scheme. During 1946, the number assisted under this scheme was 80; in 1947 it has risen to 180. The increase in the work is also shown by the fact that the number of full-time and part-time domestic helps engaged has risen from 5 full-time and 3 part-time helps in 1946 to 8 and 15 at the end of 1947. In view of the increasing urgency of the home help and domestic help problem the Borough Council decided to appoint a full-time organiser for both services. In October 1947 Mrs. W. Goodman commenced her duties as Domestic Help Organiser, and very quickly justified her appointment. The new appointment has allowed us to devote more time to these very important aspects of social medicine and has resulted not only in more staff being employed, but in many more families being assisted. 26 As indicated in my Annual Report for 1946 it is quite obvious that the domestic help scheme has come to stay. It is indeed difficult to exaggerate the relief which the provision of a domestic help gives to aged persons. In addition, the assistance which the scheme affords to families enduring a time of temporary crisis is almost equally important. This service is one which gives great pleasure to those engaged upon it, and it is to be hoped that the coming years will see its consolidation and extension to an even greater extent than have previously been possible. Reference might here be made to the very welcome efforts begun during the year to deal with the welfare of the aged. The setting-up of a special committee for this purpose was a particularly happy step, as was the inauguration of several clubs in various parts of the district. In addition, the anticipated provision of a ' 'meals-on-wheels'' service by the Women's Voluntary Service has added still another amenity in a field where amenities have been distressingly few. The Public Health Department has been privileged to assist in this work, in which team-work and co-operation have shown themselves to a very marked degree. The solutions to the various problems of old age are difficult to find: at present some are well-nigh impossible. But at least we can say that efforts are now being made to brighten the last stages of life, and to make those added years a pleasure instead of a burden. As has been truly said, it must be our aim not only to add years to life, but to add life to years, since one without the other is like a slice of dry, stale bread with neither jam nor butter. Preventive medicine has done a great deal to fulfil the first object; the social medicine of the future should vigorously tackle the second. Maternity and Child Welfare. In view of the changes envisaged by the National Health Service Act. I took the opportunity of preparing a brief historical survey of Maternity and Child Welfare in Southgate from its inception until the services were handed over to the County Council in July 1948. This survey was printed in the Council Minutes of July 1948, and there is therefore no need to repeat the information here. It will suffice to say that the thirty-two years during which Southgate was responsible for its own Maternity and Child Welfare services produced results which had and will continue to have far-reaching effects upon the health not only of the child but also of the adult population. 27 The development of the Maternity and Child Welfare services illustrates the importance of forward planning; this type of social service must never be regarded as static, it must move with the times, indeed, ahead of the times. There is every reason to believe that the policy adopted by Southgate will be maintained in thefuture, and that the years which lie ahead will see an even greater development of Maternity and Child Welfare in its fullest sense, than was previously possible. A glance at the number of attendances and the work carried out at our Welfare Centres during 1947 will show that the level of attendances has been maintained. Attendances at the various Welfare Centres in Southgate necessitated a review of the facilities available, and was the subject of a special report submitted to the Maternity and Child Welfare Committee in September, 1947. This resulted in the establishment of one additional child welfare session and one additional ante-natal session. When the change was made, it was also known that the Centre previously in use at Broomfield House would become available early in 1948. This excellent Centre has since been opened, and is serving a very useful purpose. It is also pleasing to record that the taking over of the School Health Service in September, 1947, made practicable a much closer liaison between Maternity and Child Welfare and the school child than was previously possible. Our Health Visitors, with an addition of three to the existing total, were then made responsible for work in the schools in addition to their previous duties. The same Medical Officers are now in charge of Maternity and Child Welfare and the work of the School Health Service, and are thus able, with their staffs, to secure a continuity of records and information which will undoubtedly prove of value as time passes. There can be no doubt that this combination of duties holds out greater prospects of success than did the separation of the staff into watertight compartments. It is too soon yet, of course, to assess the ultimate results of the fusion, but I am fully convinced that time will prove the wisdom of the step. There is one aspect of our Maternity and Child Welfare Work which is not so pleasing. This relates to the number of home visits which are paid by our Health Visitors in the course of their work. This unsatisfactory factor is not confined to Southgate. It is more or less nation-wide, and has been the subject of comment at one time or another by almost every Medical Officer of Health. 28 In 1937 our Health Visitors paid a total of 6,251 visits to homes during the year. In 1946 this number had fallen to 4,241, and although in 1947 the number had again risen to 6,922—the highest total recorded in Southgate—it must be remembered that, during this year, additions were made to our Health Visiting staff. The inadequate number of home visits is not the result of any falling off of enthusiasm, lack of concentration, or carelessness. It merely illustrates the inadequate proportion of time which the modern Health Visitor has at her disposal for this very important aspect of her work. This is all the more unfortunate when it is remembered that Maternity and Child Welfare must always be regarded as essentially a home service. We must never allow ourselves to confine our activities within the walls of a Clinic or Day Nursery. Advice in the home, particularly in the very early days and weeks of a child's life, is vitally important. It is within the narrow confines of a child's home that the groundwork upon which the future depends must be laid; it is here that advice is most needed and bears the greatest fruit. If we do not give this problem adequate attention, we cannot truthfully say that our work is adequately performed. The solution to the problem lies, of course, in additional staff. Bearing in mind the magnificent results so far achieved, it is surely logical to proceed one step further, and to ensure that the staff employed is adequate to cope with all the calls made upon their training and experience. I should personally have liked to see this obstacle overcome before the Borough Council handed over its responsibilities to the County Council. That it remains is no reflection on the Borough Council; it merely means that one significant problem still awaits solution. In this my last Annual Report in its present form, I should like to pay a most sincere tribute to the work of the Voluntary Helpers. As I indicated in my survey of Maternity and Child Welfare, to which reference has already been made, these ladies began their work in 1917, and have continued to give unselfish service since that date. Our Borough owes them the deepest debt of gratitude, not only for their work during those early years, but for the admirable way in which they responded with unfailing zest and loyalty to the increasing demands made upon their services. To say that they kept abreast of all new developments and extensions to the service is to indicate in a word what they have meant to the mothers and children of Southgate. It is sincerely to be hoped that their work will continue, and that it will be fully recognised as a truly valuable adjunct to the statutory services provided. 29 STATISTICS OF ATTENDANCES AND WORK DONE AT THE WELFARE CENTRES DURING 1947. Number on Registers. Under 1 year. Over 1 year. Totals 1947. 1946. January 1st, 1947 722 1,030 1,752 1,622 December 31st, 1947 1,963 1,444 3,407 3,408 New cases during 1947 1,241 414 1,655 1,786 Twenty-one of the new cases under 1 year were "removals" into the district. The remaining 1,220 represent 97.91 per cent. of the total births credited to the district. Attendances at Centres, 1947:— Under 1 year. Over 1 year. Totals. Sessions. The Grange 3,655 1,649 5,304 100 Bowes Park 4,948 1,983 6,931 102 Combined Clinic 3,815 1,487 5,302 62 Winchmore Hill 4,888 2,266 7,154 102 De Bohun 2,528 1,018 3,546 50 Totals—1947 19,834 8,403 28,237 416 1946 17,841 8,934 26,775 400 Average—1947 47.68 20.19 67.87 1946 44.60 22.33 66.93 STATISTICS OF ATTENDANCES AT PRE-NATAL CENTRES. Number on Registers:— 1946. 1947 January 1st 178 201 December 31st 201 146 New cases during the year 555 428 Number of sessions held 142 159 Total attendances 3,707 3,547 Average per session 26.1 22.3 POST-NATAL CLINIC. The Post-Natal Clinic was continued throughout the year, the following being the details of attendances:— Attendances, 212; Sessions, 12; Average attendance, 17.7. 30 TABLE OF VISITS MADE BY THE HEALTH VISITORS UNDER THE NOTIFICATION OF BIRTHS, MATERNITY AND CHILD WELFARE, AND PUBLIC HEALTH ACTS. Children:— 1947. 1946. First visits 932 738 Under 1 year of age 1,245 In addition to first visits. 793 Over 1 year of age 4,148 2.043 Visitsre:— Deaths under 5 years of age 15 3 Stillbirths' 2 3 Pre-natal visits 510 541 Clinics attended 1,210 1.036 Special visits (test feeds, following up special cases seen by M. O. at Clinics, failing lactation, etc.) 70 120 8,132 5,277 Child Life Protection.—The following is a summary of the work carried out in this connection during 1947 :— Number of registered Foster Mothers 18 Number of Foster Children on register during the year 21 Number of Foster Children at end of year 17 Number of visits paid by Health Visitors 121 No unsatisfactory conditions were met with throughout the year. Maternity Outfits.—Sterilized maternity outfits were supplied to expectant mothers during 1947, as follows:— 13 were supplied free of charge. 13 were supplied at one-sixth full charge. 20 were supplied at one-third full charge. 22 were supplied at one-half full charge. 12 were supplied at two-thirds full charge. 8 were supplied at five-sixths full charge. 49 were supplied at cost price. Totals: 1947, 137; 1946, 145. 31 Care of Premature Infants.—Opportunity was taken during 1947 to purchase two additional draught-proof cots for the use of premature infants. Our four cots are loaned to nursing homes, and to mothers in their own home, mainly through the Queen's Nursing Association. They have proved of very great value and, although statistical evidence cannot be adduced, were probably the means of saving actual life. During the year, 55 premature infants were notified, of whom 48 survived at the end of one month, as compared with 46 and 43 respectively in 1946. Care of Illegitimate Children (Circular 2866).—The Council continues to participate in the scheme operated by the Middlesex County Council in conjunction with the British Red Cross Society for the care of unmarried mothers and their babies at the Society's hostels at "Maryland" and 16, The Park, Hendon. Two cases were dealt with during 1947. Home Help Scheme. The following are the details of the work carried out under the above scheme during 1947 : Home Helps were provided for 76 patients confined at home during the year, as compared with 74 in 1946. 3 were provided free of charge. 9 were provided at one-sixth full charge. 15 were provided at one-third full charge. 15 were provided at one-half full charge. 11 were provided at two-thirds full charge. 6 were provided at five-sixths full charge. 17 were provided at full charge. From the table set out above it will be noted that demands on the home help service continued to increase during the year. The number of home helps available also rose from 4 at the end of 1946 to 9 at the end of 1947. For the first time since the scheme was instituted, we were able to meet all demands made upon us, in spite of the very high birth rate and the early discharge of maternity cases from hospital. This has been a source of great satisfaction, as there can be no doubt that the provision of a home help immediately or shortly after confinement supplies a valuable safeguard. 32 The scale of charges applicable to the home,help service was made the subject of a special report to the Maternity and Child Welfare Committee in November. The Committee very carefully considered these charges, but decided to make no alteration in view of the impending change-over in July, 1948. As has already been stated, a full-time organiser for the home help and domestic help service was appointed in October. Day Nurseries.—The day nursery facilities available in the Borough remain as set out in the Annual Report for 1944. In this connection, I can find little to add to the comments which I made in last year's Annual Report regarding the part which day nurseries can and should play in the scheme of social medicine. I am still of the opinion that the continued need for day nurseries is an indication of a serious flaw in our social system. Unfortunately, it is not within our power to deal with this flaw, the problem having national rather than local significance. We must accept the fact that day nurseries are required, and will presumably continue to be required for many years to come. Having accepted this fact, we must ensure that adequate provision is made, and that the nurseries are maintained and run in the best possible manner, having due regard to special local requirements. Investigations carried out by several large authorities have shown that the maintenance of Day Nurseries makes a very slender contribution to the availability of women in industry. When the staffs which have to be maintained at Day Nurseries are set against the number of women whom the provision of Day Nursery facilities allows to go to work, the final result is little more than negligible. When one also sets the physical and mental advantages to the children against the quite substantial disruption of the family unit, the permanent value of the Day Nursery as a social factor in the life of a community is more than ever doubtful. Although these quite serious considerations must not be allowed to detract from the value of Day Nurseries as temporary expedients or as a means of assisting with special problems, it is hoped that the vital importance of proper home environment will still be recognised as the only basis of a sound social system. The waiting lists for admission to our three day nurseries are invariably long, and point to the fact that the need for day nurseries exists at present in an acute form in Southgate. It has only been 33 possible to admit the children of parents whose needs are really urgent, more specifically the children of widows, unmarried mothers and mothers who are required to find employment in order that the needs of the family can be adequately met. Strict priorities in admission are maintained, every effort being made to ensure that the most deserving cases receive preference. In September I suggested to the Maternity and Child Welfare Committee that the time had arrived for the appointment of a Superintendent Health Visitor. The duties of such an office, I stated, should include correlation of the work of the Health Visitors, the arrangement of talks and demonstrations at our various Centres, closer supervision of the day nurseries, and also the home help and domestic help schemes, and general administrative duties centred in the department. The Committee agreed to this proposal, following which Miss B. E. Wellman was appointed to the post on October 1st. Miss Wellman has performed her many and difficult duties in an entirely satisfactory manner and has done a great deal to ensure continued efficiency and to effect improvements where such were indicated. 1947 also saw one other important change in the staff of the Maternity and Child Welfare Department. Dr. M. K. Hall, who had been Assistant Medical Officer of Health since 1939, resigned in November to return to clinical medicine. It will be remembered that Dr. Hall took up her duties in Southgate at an extremely critical period; few words of mine will be required to indicate the value of her service. It is difficult to imagine a more loyal, competent and conscientious colleague, and there can be no doubt that Dr. Hall's work in Southgate will be evident for many years to come in the health and well-being of countless families. Following the resignation of Dr. Hall, the work of supervising our three day nurseries was allocated to the newly-appointed Superintendent Health Visitor, to whom reference is made above. Steps were taken to tighten up control, to institute a more detailed system of accounting and keeping stores, and to check over various points which required attention. This resulted in more efficiency, not only in the running of the nurseries themselves, but in the matter of examination of the children, the keeping of records, and the system of admissions. I should also like to record the assistance given by the Borough Surveyor's Department in the matter of repairs, which are constantly required. 34 It can, I think, be stated that we will hand over to the County Council three well-equipped nurseries, whose staffs are enthusiastic and efficient in the performance of their duties. It will be interesting to watch the future of these nurseries. I am of opinion that their disappearance, in part or in whole, will coincide with a return to conditions which allow of a re-establishment of normal family life. In spite of the excellent work carried out in day nurseries throughout the country I am also of opinion that the sooner this comes about the better will it be for the nation as a whole. The following table supplies details of attendances at each of the Nurseries during 1947 :— Aldermans Hill. Tottenhall Road. Hoppers Road. Total attendances. Daily average attendance. Total attendances. Daily average attendance. Total attendances. Daily average attendance. Jan. 790 34 818 35 973 42 Feb. 641 32 672 33 782 39 Mar. 632 30 650 31 738 35 April 670 33 570 28 446 22 May 810 38 759 36 795 38 June 905 43 820 39 642 30 July 962 42 861 37 995 43 Aug. 747 37 693 34 767 38 Sept. 737 33 889 40 1,077 49 Oct. 871 38 1,057 46 1,183 51 Nov. 859 43 826 41 1,018 51 Dec. 827 39 779 37 1,000 48 1947 9,451 37.06 9,394 36.84 10,416 40.85 1946 9,563 37.79 9,361 36.85 11,690 46.02 35 Sanitary Services Sanitary Inspections, 1947:— Housing inspections and re-inspections 2,790 Registered premises, including factories, workshops, bakehouses, milk shops and other food shops, visits and inspections 1,297 Infectious Desease, visits and inspections 1,790 Miscellaneous visits and inspections, including various complaints, rats and mice infestations, ditches and ponds, non-notifiable diseases, etc. 8,183 Visits re verminous premises 78 Other Visits 4,062 18,200 Service of Notices:— Total informal sanitary notices served 949 Total informal dustbin notices served 384 Total informal notices served 1,333 Total informal notices complied with 1,222 Total statutory notices served 119 Total statutory notices complied with 118 The work of the sanitary staff continues to be heavy, and shows no sign of immediate or even future abatement. As I indicated earlier in this report, environmental hygiene is all too often set aside as uninteresting, unproductive and inviting little comment. That is far from being the case. The work of the sanitary inspectors is playing and will continue to play a vital part in the future welfare of the Borough. It is a tragic corollary to our present difficulties that so much of what should be done cannot even be attempted. There is, however, much which can and must be tackled if the position in which we find ourselves to-day is not to deteriorate still further. Our responsibilities in this field have not been altered by the passing of the National Health Service Act; we still maintain our rights, our privileges, and our duties. So far as Southgate is concerned I am quite sure that the spate of publicity given to the present Health Service will not allow us to blind ourselves to the importance of the less spectacular work of environmental hygiene. Boroughs such as Southgate have won an enviable reputation for their achievements in the care of the individual; we must now concentrate our efforts on another field, a field which, although 36 admittedly restricted, none the less affords us very great opportunities. Co-operation with the County Council as local health authority is assured and will have the advantage of allowing the Borough Council's staff to devote their time and energies to work within the sphere which has been allocated to them. As noted elsewhere in this report, special efforts are being made to arouse more interest in food hygiene, and to effect practical imprints in this quite important branch of public health. Arrangements have also been made for a thorough inspection of all school premises within the Borough. This will be the subject of a special report to the Development Sub-Committee of the Education Committee. During 1947 a request for additional staff was met by the appointment of a fourth sanitary inspector. The wisdom of this appointment has already made itself felt. Housing.—The Public Health Department continues to cooperate with the Housing Department in the investigation of cases of overcrowding reported in the district. This co-operation has always been cordial, the work having been willingly undertaken by the sanitary inspectors. It would appear that 1948 will see the end of an accumulation of inspections, and that thereafter it will be possible for the inspectors to devote more time to their normal duties. It should, however, be stated that the investigation of these housing cases has been a useful exercise, bringing to light conditions which might otherwise have escaped notice. Inspection and Supervision of Food. It became increasingly obvious during 1947 that more attention should be paid to the various cafes and canteens in the Borough. Our school canteens are of course, very adequately supervised, while the few canteens in large factories in the district are in most respects satisfactory. The same cannot be said for all the small cafes and eating houses scattered throughout the district. Several schemes were considered, with a view to stimulating interest among the staffs of cafes and canteens in the vital subject of food hygiene. The time did not appear opportune to embark upon any ambitious project, but it was felt that something should be done if only on a modified scale. Arrangements were therefore made to hold an inaugural meeting and demonstration, to which canteen workers and cafe proprietors and staffs would be invited. This meeting is being held during 1948, and will be followed by similar meetings, should this course appear advisable. 37 The occurrence of the food poisoning outbreak at Garfield Road School in September 1947, and the investigation carried out in Southgate, to which reference is made later in this report (see page 51), clearly show the importance of food hygiene. I am convinced that more work in this field is called for. and that it would fully justify the time and expense incurred. Milk Supply.— No registration of retailers or producers has had to be refused under the provisions of the Milk and Dairies (Amendment) Act, 1922 (Milk and Dairies Order, 1926), as continued by the Food and Drugs Act, 1938. No additional retailers were registered during the year. Under the Milk (Special Designations) Orders, 1936 and 1938 30 Dealers' Licences, 1 Pasteuriser's Licence and 17 Supplementary Licences were granted. Bacteriological examinations of milk are no longer carried out by the Borough Council. This work is undertaken by the County Council, but we continue to co-operate very closely with the County in checking up on local milk supplies. Meat and Other Foods.—Butchers' shops, restaurants, bakehouses, grocers' shops, fruit stores and fish shops have been inspected frequently. A considerable quantity of food of all kinds was condemned during the year as unfit for human consumption. This was disposed of, whenever possible, as salvage. 38 FACTORIES ACT, 1937 Details of Work Carried out During the Year 1947. 1.—INSPECTIONS for purposes of provisions as to health (including inspections made by Sanitary Inspectors). Premises Number on Register Number of Inspections Written notices Occupiers prosecuted (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities .. 98 98 10 — (ii) Factories not included in (i) to which Section 7 applies (a) Subject to the Local Authorities (Transfer of Enforcement) Order, 1938 — — — — (b) Others 135 135 35 (iii) Other Premises under the Act (excluding out-workers' premises) — — — — Total 233 233 45 — 2.—Cases in which DEFECTS were Found. Particulars No. of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspector By H.M. Inspector Want of cleanliness (S. 1) 44 44 1 3 — Overcrowding (S. 2) — — — — — Unreasonable temperature (S.3) — — — — — Inadequate ventilation (S.4) — — — — — Ineffective drainage of floors (S.6) .. — — — — — Sanitary Conveniences (S.7) (a) insufficient — — — — — (b) Unsuitable or defective 21 21 — — — (c) Not separate for sexes — — — — — Other offences (not including offences relating to Homework) — — — — — Total 65 65 1 3 — 39 40 OUTWORK.—(Sections 110 and 111). Nature of Work Section 110 Section 111 No. of out-workers in August list required by Sect. 110(1) (c) No. of cases of default in sending lists to the Council No. of prosecutions for failure to supply lists No. of instances of work in unwholesome premises Notices served Prosecutions Wearing apparel Making, etc. 25 — — — — — Cleaning and washing The making of boxes or other receptacles or parts thereof made wholly or partially of paper 10 Textile weaving 6 — — — — — Establishments for Massage or Special Treatment.— Under the bye-laws governing this class of establishment, 11 existing licences were renewed. No new licences were granted. Swimming Bath.—The figures of the attendances at the Barrowell Green Open-Air Swimming Bath for the last two years were as follows: 1947. 1946. Mixed Bathers 63,574 42,137 From Schools 17,023 6,872 Season Ticket Holders 16,505 9,288 97,102 58,297 Spectators 5,440 3,736 Costumes, etc., hired 836 767 In spite of the infantile paralysis epidemic which swept the country during 1947 attendances at our swimming bath showed a very welcome increase. Opportunity was taken during the height of the epidemic to inform the general public that the risk of attending the bath was negligible, and that they would be duly warned if and when the danger increased. Happily, most parents viewed the matter in a common-sense light, and allowed their children to continue to take advantage of this very valuable adjunct to health. There can be no doubt that Barrowell Green Swimming Bath pays very handsome dividends in the matter of health, and plays a most important part in our scheme of disease prevention. The staff at the bath, very ably controlled by the bath superintendent, are enthusiastic in their task, and fully appreciate the fact that they are contributing to the public health safeguards of the Borough. Rivers and Streams.—Very few complaints were received during the year concerning the above. Rats and Mice Destruction Act.—The Public Health Committee gave very careful consideration during the year to the question of treatment of our sewers. After full discussion it was decided to carry out a test survey of manholes in the Borough. This was done during November and showed 31 per cent. infestation. A decision has since been taken to carry out treatment on all the sewers within the Borough. This complies with the wishes of the Ministry of Food. 41 Various discussions also took place relating to the charges made to residents for the destruction of rats and mice on their premises. The Public Health Committee decided to adhere to their previous policy, i. e. to fix the charge at a sufficiently low level which would not discourage residents from notifying the presence of rats and mice. This is obviously a sound policy, and has led to more information regarding infestation being received than would otherwise have been the case. The charge for dealing with business premises infested with rats and mice is made on a work and time basis. Public Conveniences.—Seventeen public conveniences are available in the Borough, situated as follows: Broomfield Park (2). Arnos Park. Bramley Sports Ground. Oakwood Park. Grovelands Park. Tottenhall Sports.Ground. North Circular Road, Palmers Green. Triangle, Palmers Green. Fords Grove, Winchmore Hill. Southgate Tube Station, N. 14. Cherry Tree Hotel, The Green, N. 14. Crown, Chase Side, N.14. White Hart, Chase Road, N. 14. King's Head, Wades Hill, N.21. Orange Tree, Highfield Road, N.21. Fox Hotel, Green Lanes, N.13. Conveniences provided by the London Passenger Transport Board at Southgate and Oakwood Underground Stations are also available to the public. The question of an additional public convenience in the neighbourhood of The Green, Southgate, was considered during 1947. All public conveniences in the district are inspected by members of the Public Health Department staff. This inspection includes conveniences in our parks and open spaces, and conveniences provided for the use of the public in public houses and hotels. Defects are brought to the notice either of the Borough Surveyor's Department or of the proprietors of the premises in which the public conveniences in question are situated. 42 Ponds and Rubbish Dumps.—There are now very few ponds or rubbish dumps left in the Borough, although the number of the latter has increased since the war. Ponds and rubbish dumps are kept under as strict observation as is possible in the circumstances, and the existence of any nuisance is brought to the attention of those responsible for the upkeep of the ground on which the nuisance has occurred. Ponds and rubbish dumps are sprayed regularly throughout the summer season, in order to minimise the breeding of insects. Water Supply.—The water of the district, which is almost entirely supplied by the Metropolitan Water Board, remains satisfactory in quality and quantity. The supply is from high pressure mains. All houses in the district are provided with a direct pipe supply, the few remaining wells which previously existed having now been discontinued. It was not necessary to carry out any bacteriological or chemical examinations of the drinking water during the year. There is no evidence of any plumbo-solvent action in the water. Collection and Disposal of Refuse.—The Borough Engineer and Surveyor, who is responsible for this service, reports that the fleet of vehicles used in this connection consists of eight Scammell Self-Loaders, one S. D. Freighter and one Lorry. A weekly collection from all dwelling-houses in the Borough is now being carried out. Minor complaints continue to be received and are dealt with by the Borough Engineer and Surveyor's Department. Fly nuisance, particularly around the Destructor, of which complaints were received in previous years, has not assumed serious proportions owing to the continual exercise of preventive measures. The total tonnage of refuse collected and dealt with at the Destructor during the year 1947-48 was 15,152 tons. An important factor in connection with house refuse collection is salvage of various materials. The following is the tonnage sold during the year: Mixed paper, books, etc. 704 Broken glass . 56 Non-ferrous metal 5 Rags '25 Baled tins 590 Bottles 85 Carpets 13 Sundries 14 Mixed Scrap . 65 Total 1,557 tons. 43 The value of this material amounted to £8,497. Residents are requested to bundle their paper and keep it separate, as special compartments are provided in the vehicles for this material. The machinery at the Destructor is provided with Picking Tables over which all material passes. Such items as tins, rags, etc., are removed therefrom. During the year, 871 tons of kitchen waste were collected. This material is collected once weekly from every house in the Borough on Monday mornings. 44 Prevalence and Control over Infectious Diseases From the table of notifications set out on page 53 it will be seen that 887 cases of infectious disease were notified during the year, as against 797 in 1946 and 1,006 in 1945. The Infectious Sickness Rate for the district was thus 11.93, as compared with 10.96 during 1946 and 15.48 in 1945. The rise in the infectious sickness rate for the year was entirely due to an increase in measles and pertussis notifications. The rate for the year is altogether lower than the average for the past five years. Diphtheria.—For the second year in succession only two cases of diphtheria were notified. These occurred in adults, both in the same family. The absence of diphtheria from among our child population will be referred to in more detail in the section on immunisation, but it would appear reasonable to state that, provided the present level of immunisation is maintained, this disease need hold no future terrors. Scarlet Fever.—Scarlet fever notifications rose by 13 during the year, although the total for 1947 is no more than the average for the past 10 years. The type of disease met with has been mild, admission to hospital only being necessary in 51 cases. I am more than ever convinced that the admission of mild cases of scarlet fever to hospital is undesirable unless the home conditions are such that home nursing is not a practicable proposition. It is our practice to investigate all such requests for admission to hospital, and to withhold permission for a case to be removed unless we can be satisfied that removal to hospital is in the best interests of the patient. Exceptions are made in the case of patients who cannot remain at home because of family circumstances, or who cannot be isolated and nursed in a separate room. It must always be remembered, of course, that the present mild variety of scarlet fever may only represent a passing phase and that the severe type, common before the war, may at any time return. Should such be the case, the disease known as scarlet fever—the term is largely a misnomer and possesses little real significance nowadays—may have to be regarded in a different light. Until that time arrives, however, we should continue to regard scarlet fever as a clinical syndrome which can be produced by a substantial variety of streptoccoci and which is best treated outside hospital, if complications and relapses are to be avoided. 45 Puerperal Pyrexia.—The remarks which I made regarding this disease in my last year's Annual Report hold with equal significance to-day. The advent of the sulphanilamides and penicillin have very radically altered the prognosis and treatment of this disease, and have removed many of its previous terrors. No serious case was reported during 1947, all the patients recovering without incident. Acute Anterior Poliomyelitis.—As noted in the introduction to this Report, seven cases of acute anterior poliomyelitis (infantile paralysis) were reported during the year. Two of these cases occurred in July, two in August, one in November, and two in December. Three of the cases were over fifteen years of age (eldest 30 years), the ages of the remaining four cases being three, seven, nine and fifteen years respectively. Two of the cases were males, and five females. Three of the cases occurred in the South Ward, one in the Middle Ward, two in the North-East Ward, and one in the North-West Ward. It will be appreciated that, with such a small total, very little information of epidemiological significance can be elicited. There was no evidence of case-to-case spread, or of the existence of any physical barrier to infection. It can be assumed, of course, that a number of mild, sporadic and therefore undetected cases occurred. This number was probably not high, as general practitioners reported many doubtful cases, which were all seen and admitted to hospital for observation when this course appeared desirable. Measles.—The number of cases of measles reported during the year fell slightly from 411 in 1946 to 392 in 1947. The type of disease was again mild, admission to hospital being necessary in only a very small percentage of cases, and then almost invariably for domestic reasons. As with scarlet fever, there is always the danger that the virus of measles will increase in virulence and that the severe type formerly responsible for so many unfortunate sequelae and even death may return. Present evidence leads one to believe that the comparatively large number of cases reported tends to reduce the risk of increased virulence, and serves as a useful means of maintaining the threshold of immunity at an adequate level, while confining severity within reasonable limits. The use of "measles modifiers" in one or other of the various forms has provided us with a means of protecting contacts at a critical time. Used properly, these modifying agents will adequately protect young infants, delicate children, and hospital patients in whom an attack of measles might be a serious event. Apart from such specialised sections of the community it is now realised that the exclusion of measles contacts from school or their segregation from other members 46 of the same family is neither necessary nor desirable. We have still very much to learn about this disease, more perhaps than relates to any of the other common infectious illnesses. But we have at least the satisfaction of knowing that, although the incidence of measles has not altered materially within the past few decades, the death and complication rates have fallen appreciably. This may be only a passing phase, but it has resulted in the saving of many young lives which would previously have been either lost or seriously impaired. Pertussis.—Notifications of pertussis rose during the year 1947, from 136 in 1946 to 208 in 1947. The type of the disease was comparatively mild, a particularly pleasing feature being the absence of broncho-pneumonia as a serious complication. The scheme whereby immunisation against pertussis either alone or combined with diphtheria, is being offered to Southgate parents is referred to later in this Report. Tuberculosis.—Tuberculosis notifications rose from 71 in 1946 to 82 in 1947. Here I have little to add to the comments made in last year's Annual Report. I would again point out that our responsibilities in regard to this disease are more or less confined to the efforts which we exert in the field of environmental hygiene. These efforts must not, of course, be deprecated, as on the success or failure of our national drive for improved living and working conditions, the future course of a chronic disease such as pulmonary tuberculosis must ultimately depend. It is tragic to know that the problem exists and that there is little which we can do to arrive at an adequate solution. So long as a large section of our population continues to live in overcrowded conditions, so long as our rations continue to be no more than adequate, and so long as the strain of modern life is allowed to bear so heavily upon us, the fight against tuberculosis will be long and hard. Anything which we can do to improve living conditions in our area will help to reduce the risk. Once the disease has shown itself, the responsibility passes to the County Council, whose task is equally difficult. The County Council has at least one advantage over the Borough Council, inasmuch as it can see the results of its work in diagnosis, treatment and after-care. No statistics will show the result of ours. But we know what can and should be done, and no degree of difficulty should allow us to be sidetracked from our obvious and urgent responsibilities. I have already stated that environmental hygiene plays a most significant part in shaping the course of a disease such as pulmonary tuberculosis. This, of course, is only part of the story. There still remains the bovine type of infection, affecting glands, joints, the 47 abdomen and other parts of the body. Bovine tuberculosis is almost entirely spread by infected milk, and poses a different type of problem. The immediate solution to the problem is almost universally held to lie in the pasteurisation of milk supplies, particularly the milk supplies of towns and cities. Until we can be quite certain that the bacillus tuberculosis, which still finds its way into certain milk supplies, has been rendered harmless, the danger of bovine tuberculosis will remain. It is a particularly tragic corollary to present-day conditions that the availability of pasteurising plant is wholly unsatisfactory, and that the essential pasteurisation of milk is being held up by lack of such plant. This is surely a problem of sufficient magnitude to demand the attention of those responsible for ensuring a clean, safe milk supply for our child population, particularly when the increase in the consumption of milk, brought about very largely by the milk-in-the-schools scheme, is taken into consideration. We know beyond all reasonable doubt that the provision of a safe milk supply for children will have a very definite and beneficial effect on the incidence of bovine tuberculosis. This knowledge should be used to the fullest possible extent, since the problem is one amongst few which holds out every prospect of adequate solution. Immunisation.—1947 saw a great stride forward in our campaign of immunisation, not only against diphtheria but against pertussis, a disease which still holds many terrors for the anxious parent. In January, 1947, we invited parents to have their children immunised against pertussis alone or against diphtheria and pertussis combined, additions to the facilities previously available for immunisation against diphtheria. This step was not taken without careful consideration and a detailed survey of available information, both in this country and in the United States. We had to be sure that the antigen was satisfactory, that there were no undue risks of untoward effects, and that the fact that full protection could not be guaranteed against pertussis would not prejudice the more important scheme for immunisation against diphtheria. Having satisfied ourselves on these points we embarked upon the scheme, not as an experiment but as a means of providing practical protection against two serious diseases. The results have so far been very satisfactory. During the year, 994 children were immunised against diphtheria, either alone or in conjunction with pertussis; while 1,207 children were immunised against pertussis, either alone or in conjunction with diphtheria. The total number of visits paid to local immunisation clinics during the period under review was 6,368 one of the highest figures yet recorded for any year. In addition to the above, 1,379 reinforcing injections against diphtheria were given, mainly 48 in our schools. We adopted a system of regular visitation of schools, parents being invited to bring the children for reinforcing doses after 4 to 5 year intervals or to have them inoculated for the first time. It can now be claimed that regular 4 to 5 yearly reinforcing doses are available to all school-children in Southgate, and that protection is continued from school entry until the pupil is ready to leave. So far as I am aware, our system is one of the most complete in any area. In addition to visiting maintained schools, arrangements were made during 1947 to extend an invitation to parents of children attending selected private schools in the Borough, for the purpose of carrying out reinforcing doses and immunisation generally. The response to this invitation has been very gratifying. Up to the time of writing this report four private schools have been visited. During these visits 370 children received reinforcing doses, while 20 were immunised for the first time. A particularly gratifying feature of the combined method of immunising against diphtheria and pertussis is the fact that the number of schick-positive reactions met with after three months is very small and definitely less than was the case when protection against diphtheria alone was provided. While it must be admitted that reactions following the combined method are more frequent than in the single type of protection, they are not such as to militate against the method or to affect adversely the attitude of parents. Since the first immunisation clinic was set up in Southgate in 1933, 12,732 children have been immunised against diphtheria. The effect of this campaign can now be clearly seen. If one takes the seven-year periods from 1927 to 1947, a steady decline in the number of cases and deaths is observed. The actual figures are as follows:— The fall in the case rate and the death rate is even better illustrated if the averages for the three seven year periods are examined. These were as follows:— No. of cases. No. of deaths. 1927-1933 1934-1940 1941-1947 234 143 52 11 9 1 Average No. of Average No. of cases per year. Deaths ver year 1927-1933 1934-1940 1941-1947 33.4 20.4 7.4 1.6 1.3 0.14 49 There can be little doubt that immunisation has been the prime factor in this marked improvement. One would normally have expected the hardships produced by the war and continued during the post war years to have increased the diphtheria case and death rates. The fact that this is not the case is surely a potent argument in favour of immunisation. It is also pleasing to record that no deaths from diphtheria have occurred in Southgate since 1943, and that the last case of diphtheria reported in a Southgate child took place in October, 1945. If the present level of immunisation is maintained, and if we continue our existing practice of immunising first at the age of 9—12 months, reinforcing the protection between the ages of 5—6 years, and thereafter at 4—5 yearly intervals, diphtheria as a major killing or even incapacitating factor should very largely disappear from our midst. This is not to say that the older methods of hygienic control such as isolation, supervision and exclusion of contacts and ' 'carriers," alleviation of overcrowding and disinfection should not be continued. These play there separate parts, and must always form the foundation upon which any preventive structure should be laid. We can justly claim that Southgate was among the earliest pioneers in the field of organised immunisation against diphtheria. Bearing in mind the high cost of maintaining diphtheria cases in hospital, the work has been fully justified on the score of economy alone. With regard to immunisation against pertussis, it is too soon yet to assess the results of our work. The available information on the year's working of the special immunisation clinic against pertussis and of the combined inoculations against pertussis and diphtheria was made the subject of a special report which was submitted to the Public Health Committee in January 1948. This report was also sent to the Chief Medical Officer to the Ministry of Health, and was the subject of a reply which congratulated Southgate upon its work and gave us authority to continue. The conclusions set out in the above-mentioned report may, with advantage, be restated. They were as follows: (a) The evidence available encourages one to the belief that immunisation against pertussis either alone or combined with diphtheria, does tend to modify an attack of pertussis, should this occur. (b) There is as yet no evidence that the incidence of pertussis is less among the immunised than among the nonrmmunised. 50 (c) Many more children in Southgate would have to be immunised against pertussis before, the campaign could have any effect on the pertussis rate among the child population as a a whole. (d) I am of the opinion that the results of the work carried out during 1947 justify us in continuing our present policy and procedure. It now appears that the Southgate policy of immunisation against diphtheria and/or pertussis will show little or no alteration after July 5th, 1948. Our present system of organised immunisation clinics will continue under the aegis of the Area Health Committee, at least for the present. In addition, general practitioners who agree to participate in the scheme of immunisation, will undertake this work as part of their general duties, and will be supplied with the necessary materials free of charge to allow them to do so. This is all to the good, as it will still further inorease the facilities available to parents in the Borough, and should make it easier for them to take advantage of the protection afforded by immunisation. It can, I believe, be claimed that the method of immunisation carried out at our immunisation clinics and in our schools is as fool-proof and safe as care and thought can achieve. The results which we have obtained, and the very trivial incidence of unpleasant after-effects, substantiates this belief and encourages us to continue along similar lines. Food Poisoning.—Although food poisoning is not strictly speaking an infectious disease, cases are notifiable. That does not mean to say that they are always notified. There can be no doubt that many more cases of food poisoning occur than are ever brought to the notice of the Public Health Department. Most of them are fortunately mild, and recover with simple forms of treatment. We are told that food poisoning is on the increase, and although it is difficult to obtain statistical evidence to support this contention, it is probably a true statement of fact. During the summer of 1947 a fatal case of food poisoning was reported from a road in Southgate. A full investigation was immediately carried out, in an endeavour to trace the source. Part of the investigation included a visit to each family in the road, where enquiries were made as to the existence of any signs or symptoms of 51 food poisoning in each household during the previous month. Out of approximately 90 families visited, no less than 15 families produced evidence to show that such signs or symptoms had occurred in one or more members of the family during the period in question. There was no reason to believe that the inhabitants of this particular road were more affected than those of any other road in Southgate. If, therefore, the information produced by this short survey can be regarded as typical, it would certainly appear that there is much more gastro-intestinal infection than ever shows itself in recorded returns. An interesting outbreak of food poisoning occurred in Garfield Road School during the autumn of 1947. This involved 45 children, and was the subject of several reports to the Ministry of Health. The presumptive cause of the outbreak was tinned salmon, although this was never definitely proved. The Central Public Health Laboratory, which was most helpful in investigating the outbreak, isolated an unusual type of organism from the stools of several of the individuals affected. All the patients made a satisfactory recovery, without incident. The final report on the outbreak appears as Appendix 3 to this report. The steps which are being taken to promote a better standard of hygiene among canteen workers and cafe staffs have already been mentioned (see page 37). Although no statistical evidence is available, I am coming more and more to the opinion that the use of small cafes in which the method of food preparation, cooking and washing up leaves much to be desired, is a fruitful source of food poisoning. We have therefore decided to inaugurate a special drive to improve existing conditions, and to promote a better knowledge of a subject which very intimately affects the welfare of every member of the community. 52 NOTIFICATIONS OF INFECTIOUS DISEASE, 1947 Jan.— March. April— June. July— Sept. Oct.— Dec. Totals. Diphtheria 2 - - - 2 Scarlet fever 23 20 14 48 105 Paratyphoid fever — — 1 — 1 Dysentery — — — — — Malaria — — — — — Puerperal Pyrexia 2 4 2 5 13 Erysipelas 4 3 2 5 14 Ophthalmia Neonatorum 1 3 5 4 13 Measles 238 67 15 72 392 Whooping Cough 46 81 72 9 208 Pneumonia 21 12 3 10 46 Cerebro-spinal fever 1 1 — 2 4 Acute Poliomyelitis — — 3 4 7 Tuberculosis— Pulmonary 22 21 25 8 76 Non-Pulmonary — 2 1 3 6 Totals 360 214 143 170 887 REGISTER OF TUBERCULOSIS CASES. Pulmonary. NonPulmonary. Totals." M. F. M. F. Cases on Register, 1/1/47 192 171 41 38 442 Cases Notified for first time, 1947 49 27 1 5 82 Cases Restored to Register 1 4 — — 5 Other cases added 9 12 — 4 25 Cases Removed from Register 33 21 2 7 63 Remaining on Register, 31.12.47 218 193 40 40 491 53 Periods. *New Cases. Deaths. Pulmonary. NonPulmonary. Pulmonary. NonPulmonary. M. F. M. F. M. F. M. F. Under 1 year 2 — — — 1 — — - 1-5 years 3 1 — 4 — — — 3 5-10 ,, 4 1 - - - - - — 10-15 ,, - 1 — 1 — — • — 15-20 ,, 2 5 — 1 1 1 — 20-25 ,, 9 9 — 1 — — — — 25-35 ,, 16 15 — 2 1 3 1 — 35-45 ,, 6 3 1 - - - - - 45-55 „ 4 4 ' — — 3 1 — — 55-65 ,, 7 3 — — 1 — — — 65 and over 6 1 - — 2 2 — — Totals 59 43 1 9 9 7 1 3 These figures include all cases previously notified elsewhere and noted by the Tuberculosis Officer and others as having removed into the district. Appendix 1. HEALTH EDUCATION. As the Council will be aware, Health Education has for many years taken a prominent place in the Public Health programme of the Borough. Many of the aspects of our work regarding which health education is required will no longer be the concern of the Borough Council, but there will still be room for health education in the field of environmental hygiene. I am hopeful that our work can be continued, and that a link-up will be possible between the activities of the Borough Council and those of the County Council. This would appear to be the logical method of approach, as health education is not a subject which can be sub-divided into watertight compartments. The Public Health Committee has already considered this problem, and authorised me to inform the County Council that they would favourably consider the use by the County Council of our film projector, for health education purposes within the Borough. This should be of great assistance, and will enable us to carry through a comprehensive programme on the lines which have proved so successful in past years. This would appear to be an opportune moment to place on record the general principles on which our Health Education programme has been based, together with suggestions for the future. The information must of necessity be summarised, but will give some idea of the ground which has been and should be covered: (a) Film Shows and Talks. Organisations in the Borough are approached in the early summer asking whether they will be prepared to accept a Health Talk and/or Film Show for inclusion in their winter programme. The organisations usually approached include Ratepayers' Associations, Women's Organisations, Youth Clubs, Church Guilds, ParentTeachers' Associations, Senior Schools and similar bodies. Most organisations prefer a film show with an accompanying talk, and it can, I think, be stated that past offers have been appreciated. The Bell & Howell Sound Film Projector owned by the Borough Council was purchased in 1938, and has already been used on more than 1,000 occasions. It was completely overhauled during 1947 at a cost of £17 14s. 5d., and now is in very good repair. 55 (6) ' Better Health." Eight hundred copies of the magazine "Better Health" are circulated each month through Maternity and Child Welfare Centres, libraries and schools. A copy is sent to all general practitioners, councillors, and other interested individuals and bodies. The magazine contains a foreword by the Medical Officer of Health on a topical health subject, while for 1948 at least, the Medical Officer of Health of Southgate is responsible for supplying material for the centre pages of the magazine. (c) Articles in the Local Press. Opportunity is taken to insert material in the local press relating to health subjects of current interest, including reproduction of the foreword to "Better Health". The local press is most cooperative, and has been very generous in affording space. This co-operation is very greatly appreciated, and has been the means of supplying many thousands of residents with information relating to matters which intimately affect their welfare. Apart from reports on talks and film shows, comments on discussions at Council Meetings and the insertion of material taken from annual and special reports, 29 articles on health subjects of topical interest supplied by the Medical Officer of Health appeared in the local press during 1947. It would appear correct to say that the public appreciate and has come to expect the appearance of regular information and articles in the local press. (d) Talks, Demonstrations and Film Shows at Maternity and Child Welfare Centres. Talks, Demonstrations and Film Shows are arranged from time to time at Maternity and Child Welfare Centres. In this connection the Ministry of Food presented food demonstrations at all our Maternity and Child Welfare Centres during 1947, and has arranged to repeat these demonstrations during 1948. In addition, a short course of lectures was arranged for ante-natal mothers, in. conjunction with the Central Council for Health Education on the subject of ' 'How Life is Passed On''. Short film shows were arranged at several ante-natal clinics, but were not entirely successful owing to lack of space and administrative difficulties. It is hoped that this aspect of Health Education work can be considerably extended. It presents a fruitful field for endeavour, at a time, when information is particularly valuable. Lack of adequate premises has been a handicap in the past, but this difficulty can and should be overcome. 56 (e) Literature. Health literature is available and is distributed through Maternity and Child Welfare Centres and the Public Health Department. A special display stand is used for this purpose in the general office of the Public Health Department. (/) Public Health Handbook. Messrs. Ed. J. Burrow & Co., Ltd. have issued three editions of the Southgate Public Health Handbook, setting out the health services available to the inhabitants of the Borough. The firm has recently written intimating that they are prepared to consider the preparation of a fourth edition. A reply was sent accepting this offer, but pointing out that it would appear wise to wait until after July 5th, 1948, or at least until the present situation is more fully clarified. The new edition of the Public Health Handbook, while issued by the Public Health Department of the Southgate Borough Council, will list the health facilities available to the burgesses and will give due consideration to the part played by the Area Health Committee, the Middlesex County Council and other responsible bodies. The appearance of such a handbook as soon after July 5th as possible should serve a particularly useful purpose in acquainting the general public with the new regime and the extended facilities which have been made available. (g) Information Room. I should very much like to see the establishment of an Information Room within the Borough. The setting up of such an Information Room could either be the responsibility of the Borough Council, of the Area Health Committee, or of both working in conjunction. It would be used for the purpose of displaying Health Literature, supplying information relating to local health services, and staging exhibits dealing with one particular aspect of preventive medicine. This latter exhibit would be changed at regular intervals. Lack of accommodation in the Public Health Department or in any centrally situated premises has so far prevented the setting up of an Information Room, but the situation is still being explored, in the hope that suitable accommodation can be obtained. There is no doubt that an attractive Information Room could be put to excellent use, and I am of opinion that this method of health education has not yet been fully exploited. 57 (h) Civic Week. A feature of the Health Education Programme during 1947 was the part which the Public Health Department played in Civic Week, held during September. A very successful Health Exhibit was staged, comprising sections of Maternity and Child Welfare (including vitamin therapy), immunisation against diphtheria and pertussis, food hygiene, insect pests, mass X-ray, rodent control, housing defects, health education and Queens Nursing. It is estimated that the exhibit was visited by between 15,000 and 20,000 persons. The Public Health Department's effort also included the arranging of three film shows daily during Civic Week, an extended visit from the Middlesex County Council Mass X-ray Unit, during which 1,991 persons attended for X-ray, and the visits to Maternity and Child Welfare Centres and Day Nurseries. It may be too soon yet to consider repeating such a feature, but the success obtained during 1947 encourages the belief that a similar scheme should be considered in the relatively near future on the same or on a modified scale. (i) Food Hygiene. As noted elsewhere in this report, arrangements have been made to extend the scope of our work by holding a meeting of canteen supervisors and workers and cafe proprietors and their staffs, at which the important question of food hygiene will be discussed. It is hoped that this meeting will be followed by other meetings of a similar character. The meeting will form part of a larger scheme to encourage a more comprehensive knowledge of food hygiene among food handlers. All our Sanitary Inspectors, together with seven canteen supervisors and workers, have attended short courses on food hygiene in order that they may be in a position to pass on the information gained to those who require enlightenment. Southgate has every reason to be proud of the part which the Borough has played in health education during the past decade. There can be little if any doubt that the efforts have been effective in the fight against ill-health and disease, and that the results will continue to be felt for many years to come. 53 Appendix 2. LETTERS TO DOCTORS. The system of sending circular letters to doctors from time to time on matters of current interest was continued during the year. The following letters were sent during 1947 and the first half of 1948: 1947 10th Jan. Central Public Health Laboratory—facilities available. 28th Jan. Immunisation—requesting information for 1946 returns. 21st Feb. Damage to swabs during present fuel crisis. 3rd Mar. Notification of short absence of Medical Officer, and advice concerning persons to be contacted in his absence. 3rd April Availability of gamma globulin for modification of measles in contacts. 22nd April Admission to Coppett's Road Isolation Hospital; method of procedure. 11th June Whooping cough; use of gamma globulin, post-pharyngeal swabs, etc. 3rd July Suspected botulism. 10th July Home Help and Domestic Help Schemes. 17th July Home Help Scheme; use by nursing mothers. 21st July Acute anterior poliomyelitis. 28th July Acute anterior poliomyelitis; additional information. 1st Aug. Special swabs for pertussis diagnosis. 29th Oct. "Flying Squad" Obstetric Service; to function in northern and north-western portion of the Borough, from Chase Farm Hospital. 24th Nov. Prevalence of scarlet fever. 1st Dec. Admission of cases of infectious disease to hospital; notification of Dr. Hall's resignation and Dr. O'Callaghan's telephone number, etc. 16th Dec. Collection of laboratory specimens—Christmas holiday period. 1948. 2nd Jan. Immunisation against diphtheria and whooping cough. 12th Jan. Food poisoning—recent increase. 19th Jan. Admission of cases to isolation hospital, etc. 19th Jan. Admission of urgent cases of infectious disease to Hospital; revised procedure. 19th Mar. Notification of infectious disease; information regarding immunisation against diphtheria and pertussis. 18th Mar. Collection of laboratory specimens—Easter week-end. 59 Appendix 3. FINAL REPORT ON OUTBREAK OF FOOD POISONING— GARFIELD ROAD SCHOOL. Submitted to the County Medical Officer on 7th October, 1947. The Central Public Health Laboratory which investigated this outbreak, reported as follows: "None of the usual pathogenic organisms were isolated from specimens of food and faeces from the Southgate outbreak but a particular strain of paracolon bacillus which was isolated from 17 of the 28 (60%) faeces specimens examined from patients and 1 of 8 specimens from members of the kitchen staff are being further investigated with regard to pathogenicity and serology". The bacteriologist who carried out the investigation goes on to remark that, as paracolons have not been too seriously considered in this country in relation to food poisoning outbreaks, the laboratory considers that the case against this particular organism should be clarified as soon as is possible by further laboratory work, before any more definite statement is made. It will be noted that the number of faeces examined by the laboratory is higher than was stated in the Preliminary Report. This is due to the fact that second specimens were taken from a nutnber of selected cases and sent for examination. Specimens of blood were also collected from six selected children and one member of the kitchen staff. These bloods will be used to investigate the serology of the suspected paracolon. It should also be recorded that six members of the laboratory staff inoculated themselves with a culture of the paracolon to which reference has been made. One of the individuals so inoculated developed signs and symptoms typical of those exhibited by most of the children affected during, the outbreak. The attack lasted for approximately 48 hours, followed by speedy recovery. So far as we know, the total number of children definitely known to have been associated with the outbreak, which was first reported on 12th September 1947, remains as set out in my Preliminary Report (45). Recovery has been complete in all instances, no aftereffects having been reported or discovered. The available evidence would make it appear that the paracolon bacillus referred to in the laboratory report was responsible for the outbreak. It is unfortunate that this bacillus was not recovered from any of the food-stuffs 60