WIL 35 AC 439(1) WILLESDEN Borough of Willesden. 1939. THE 64th ANNUAL HEALTH REPORT. GEORGE F. BUCHAN, M.D., F.R.C.P., D.P.H., Medical Officer of Health ~Xon6oit: JAS. TRUSCOTT & SON, LTD., Suffolk Lane, Cannon Street, London, E.C.4. BOROUGH OF WILLESDEN. Health Department, 54, Winchester Avenue, Kilburn, London, N.W. 6. August, 1940. To the Willesden Borough Council— The Local Sanitary Authority, and the Local Education Authority. I beg to submit herewith the Annual Health Report for Willesden for the year 1939, in accordance with instructions received from the Ministry of Health and Board of Education that it should be a short report. 3 VITAL STATISTICS. The estimated population of Willesden at Midsummer, 1939, was 209,230.* *This population has been calculated on the assumption that the average number of persons per inhabited house at Midsummer, 1939, was the same as estimated for November, 1935. It is not improbable that the population is too high, but it was thought desirable to make the records for the inter-censal years on the same basis as to population. The number of persons registered for food rationing at August, 1940, was approximately 159,000. This does not include Willesden residents who have become evacuees, or have joined the Services, and certain others, but these are included for the purposes of this report. In all the circumstances, it is probable that the population of Willesden is approximately 200,000. 2,738 live births were registered during 1939, giving a birth rate of 13.09 per 1,000 of the population as against 14.57 in 1938. 78 still births were registered, giving a still birth rate of 27.70 per 1,000 total live and still births. 1,831 deaths were registered in 1939, giving a death rate of 8.75 per 1,000 of the population. These figures compare with a total number of deaths of 1,841 and a death rate of 9.04 in 1938. The infantile mortality rate for the year 1939 was 54.42 per 1,000 births. 149 children under one year of age died in 1939. CANCER. There were 299 deaths of Willesden residents from Cancer in 1939 as compared with 332 in 1938. The two Municipal Cancer Clinics were continued throughout the year but after September the sessions were held in the morning instead of in the evening on account of the difficulties of the black-out. 28 new patients attended these Clinics and the total attendances were 64. INFECTIOUS DISEASES. During the year 1939 1,936 cases of infectious disease were notified as compared with 1,867 in the previous year. The following table gives the number of notifications of certain diseases included in the above total of 1,936 together with the corresponding figures for 1938 :— Table No. 1. Number of Cases notified. 1938 1939 Diphtheria 415 331 Scarlet Fever 371 245 Pneumonia 284 269 Whooping Cough 277 672 Erysipelas 72 48 The most striking phenomenon during the year was the dramatic fall in Scarlet Fever and Diphtheria which occurred in the autumn with the outbreak of war and which has continued up to the time of writing. During the last 17 weeks of the year 22 cases of Scarlet Fever and 32 cases of Diphtheria were notified as against 223 cases of Scarlet Fever and 299 of Diphtheria in the previous 35 weeks. For four consecutive weeks in September not a single case of Scarlet Fever was notified, an event unique in my knowledge of Willesden. This is remarkable since at least half the school children and the majority of children under 5 years of age remained in Willesden. Not only Scarlet Fever and Diphtheria but all infectious disease was notably low during the last four months of 1939. Enteric Fever.—Three cases were notified as Typhoid or Para-typhoid Fever during 1939. All 3 cases were removed to hospital. One was removed to the Willesden Municipal Hospital where it was diagnosed as Para-typhoid Fever B and recovered, 1 was removed to the London Hospital and recovered, 1 was removed to St. Andrew's Hospital and was still there at the end of the year. No deaths from Typhoid or Para-typhoid Fever were recorded during the year. Infectious Diseases of the Central Nervous System.—Poliomyelitis and Polioencephalitis, Cerebro-Spinal Fever and Encephalitis Lethargica.—18 of these diseases were notified in 1939 as against 24 in 1938. Four of these notified cases proved fatal, giving a fatality rate of 22 per cent. of notified cases. All 4 deaths were certified as due to Cerebro-Spinal Fever. One occurred in a non-Willesden resident and was therefore not allocated to Willesden. In addition there were 4 further deaths from these diseases in Willesden residents. Whooping Cough was already a notifiable disease in Willesden before the Measles and Whooping Cough Regulations, 1939, came into force. 672 cases were notified during the year but a total of 1,293 cases coming to their knowledge were visited by the Health Visitors. There were 5 deaths from Whooping Cough, all in children under one year of age. Measles became notifiable in Willesden on 23rd October, 1939, under the Measles and Whooping Cough Regulations, 1939. Four cases were notified between 23rd October and the end of the year but 80 cases were visited during the year by the Health Visitors. There were no deaths from Measles. 4 MOTHERS AND CHILDREN UNDER FIVE YEARS. Municipal Centres.—On the outbreak of war one of the Council's three Municipal Health Centres—Health Centre (3)—was closed as a Health Centre and brought into use as a First Aid Post. The Maternity and Child Welfare Work for the whole of Willesden then had to be carried out at the two remaining Health Centres. For a number of years overcrowding at the Health Centres has been considerable. In the Ante-Natal Clinics these conditions reached their worst. For many years plans for a new Health Centre (2) and the extension of Health Centre (3) were under consideration by the Council and in August, 1938, plans approved by the Willesden Council for new Health Centre (2) were submitted to the Ministry of Health and Board of Education for their approval. These Government Departments still had the plans under consideration on the outbreak of war when the matter was postponed. Maternity and child welfare attendances are more conducive to overcrowding than school attendances and as the bulk of attendances are now maternity and child welfare attendances the conditions at the Health Centres are even worse than formerly, notwithstanding the fact that the sessions at the two Health Centres now open have been increased to the maximum possible. The Health Centres have also had to cope with large attendances in connection with the distribution of babies' anti-gas helmets. At the Municipal Centres, expectant mothers attended the medical consultations and treatment Clinics on 14,383 occasions; nursing mothers 30,182 and children under five 57,296, making a total of 101,861 attendances. Out of the total number of 2,738 children registered as born alive during the year, 1,919 or 70 per cent. subsequently attended the Municipal Welfare Centres. Altogether, however, 2,004 children under 1 year of age attended the Municipal Centres for the first time during the year, excluding transfers from other districts. This represents 73 per cent. of the 2,738 registered live births belonging to Willesden. 309 children between the ages of 1 and 5 years attended the Municipal Centres for the first time during the year, excluding transfers from other districts. The number of live births occurring amongst expectant mothers who attended the Ante-Natal Clinics was 1,652; 73 per cent. of these mothers with their babies subsequently attended the Welfare Centres. Government Evacuation Scheme—Expectant Mothers.—The registration of expectant mothers under the Government's Evacuation Scheme was carried out at the Health Centres in accordance with the Government plan. On the 1st September, 1939, 101 mothers within a month of confinement and 288 within more than a month of confinement had registered. Actually 77 mothers within a month of confinement were despatched from the three Municipal Health Centres on 2nd September, 1939. The expectant mothers within more than a month of confinement were evacuated with non-school parties by the Willesden Education Department. By the end of the year the majority of these mothers had returned to Willesden. Maternity Hospital— Bookings.—1,113 patients were booked during 1939 for confinement in the Willesden Maternity Hospital. This is the largest number yet booked in any year. The fees at which these 1,113 cases were booked varied from 3 at £15 to 402 free. The average fee per case was approximately £1 17s. 9d. During 1939, 379 applicants for confinement in the Willesden Maternity Hospital were unable to be booked for the reasons set out below :— Table No. 2.—Applications for Booking Refused. No beds available 338 Not resident in Willesden 33 Will not have had 3 months' residence in Willesden prior to expected date of confinement 8 379 Hospital Confinements.—During 1939, 913 women were confined in the Willesden Maternity Hospital. In addition to these, a number of Willesden mothers were confined in Institutions outside Willesden, 426 births of Willesden residents being notified from such outside Institutions—104 from Queen Charlotte's Hospital, 55 from St. Mary's Hospital, 22 from Queen Mary's Maternity Home, Hampstead, 22 from University College Hospital, 21 from Paddington Hospital, 14 from Middlesex Hospital and smaller numbers from other Hospitals; 51 from a Nursing Home and smaller numbers from other Nursing Homes. These, together with some 389 in the Central Middlesex County Hospital, are approximately 62 per cent. of the births belonging to Willesden and show the desire of the present-day mother for institutional confinement. 5 The following table shows the demand for institutional confinement :— Table No. 3. Years. Domiciliary Births attended by Midwives. Domiciliary Births attended by Doctors. Births in hospitals and nursing homes. Total Births notified. (Note—Notified not registered.) 1931 515 1,174 1,110 2,799 1932 457 997 1,220 2,674 1933 532 776 1,357 2,665 1934 610 680 1,436 2,726 1935 589 568 1,706 2,863 1936 646 516 1,745 2,907 1937 760 465 1,906 3,131 1938 710 394 1,974 3,078 1939 703 257 1,789 2,749 A report on the Willesden Maternity Hospital by Mr. Arnold Walker, F.R.C.S., the Council's Consultant Obstetrician, appears later in this report. Ante-Natal Work for Institutions not under the Council.—Requests are received from the Middlesex County Council and from various London Hospitals for home visits to expectant mothers, and for special reports by the Council's Health Visitors in connection with women who are to be confined in these Hospitals. 122 such reports were supplied to London Hospitals and 318 to the Middlesex County Council during the year. 305 Expectant Mothers booked for confinement in the Central Middlesex County Hospital were referred to the Willesden Health Centres for Ante-natal care. Puerperal Pyrexia.—40 cases were notified during the year. All recovered. Maternal Mortality.—During 1939 there were 7 deaths classed to pregnancy and childbearing—2 to Puerperal Sepsis, and 5 to other puerperal causes. The puerperal mortality rate from Sepsis was, therefore, 0.70 per 1,000 registered total births. The total puerperal mortality rate was 2.49 per 1,000 registered total births. During 1939 there was, in addition, 1 maternal death from non-puerperal causes. There was no maternal death from criminal abortion. The total maternal mortality from all causes excluding criminal abortion, was thus 2.84 per 1,000 registered total births. The total maternal mortality from all causes including criminal abortion was 2.84 per 1,000 registered total births. Sterilised Accouchment Sets.—These sets are supplied in accordance with the arrangements stated in my Annual Report for 1930, p. 10. During 1939, 579 were supplied free, 3 at full cost and 132 at part cost. Specialist Help.—The Council accept responsibility for the payment of the fee of one of their specialists called in by a medical practitioner to assist him in connection with a difficult case of labour occurring in a Willesden resident. Seven such consultations were paid for in 1939. The services of the Council's Consultant Obstetrician are also available in cases of Puerperal Fever and Puerperal Pyrexia when desired by the practitioner in attendance. Provision of Anœsthetist.—The Council further accept responsibility for the payment of a fee to an anaesthetist called in by a medical practitioner in connection with confinement cases. No such fee was paid in 1939. Home Helps.—The Council provided the services of home helps in connection with 326 confinement cases. Convalescence.—Two mothers were sent away by the Council for a period of convalescence after confinement. Maternal Mortality Investigations.—The Council has continued to take part in the investigation of deaths of mothers in childbirth for the Maternal Mortality Committee of the Ministry of Health. The investigations are carried out by the Council's Consultant Obstetrician. Nine cases were inquired into during 1939. Hospital Treatment of Children under 5 Years of Age. Treatment for children suffering from Marasmus continued to be available at the Willesden Municipal Hospital throughout the year. The operative treatment of enlarged tonsils and adenoids was discontinued on the outbreak of war in September but was resumed in January, 1940, when the Council's Surgeon was free again to undertake this work. 45 children were under treatment for Marasmus during the year and 62 for enlarged tonsils and adenoids, Mastoid Disease and Otitis Media. Five of the children suffering from Marasmus died. The majority of children in hospital for orthopaedic conditions were discharged on the outbreak of war but children have subsequently been admitted to a limited extent. 6 Health Visiting and Medical Inspection of Children between the ages of 1 and 5 years. The proportion of the Health Visiting Staff allocated to Maternity and Child Welfare pursued the normal duties with, in addition, certain Civil Defence duties such as the distribution of babies' gas helmets. A certain number of Health Visitors were for a period after the outbreak of war required to work at the First Aid Posts. The number of children under 5 years who were able to be given a full routine medical inspection during the year was only a small percentage of the 10,000 or so children who should be so dealt with, were the staff and accommodation available. With the transfer of one of the three Municipal Health Centres for use as a First Aid Post and the postponement of the plans for the rebuilding of Health Centre (2) on the outbreak of war, the outlook for this important branch of the work is uncertain. Ophthalmia Neonatorum.—The number of cases of this disease notified during the year was 18, as against 26 last year. This gives a case rate of 6.6 per 1,000 registered live births. A district midwife attended at the confinement in 5 cases, 8 cases were born in hospital and 5 were attended by private doctors. One of the 18 cases was notified in error and had no eye defect. In the remaining 17 cases treatment was obtained at a hospital in 7 cases, at the Municipal Centres in 6 cases, and by a private doctor at home in 4 cases. The result of treatment in 1 case which left the district is unknown, but complete recovery with unimpaired vision occurred in all the other cases. Cases of inflammation of or discharge from the eyes of infants or of cases of ophthalmia neonatorum entering Willesden after notification elsewhere are also visited by the Health Nurses. Teaching of Mothercraft at the Centres. This important part of the work of each Health Centre had to be suspended on the outbreak of war. CHILD LIFE PROTECTION. At the outbreak of war a number of foster-children were evacuated under the Government Scheme or privately with their Foster Mothers. At the end of the year there were 69 Foster Mothers and 101 Foster Children still in Willesden and Foster Mothers and Foster Children were steadily returning from the reception areas. Two foster children died during the year. One of these was drowned accidentally whilst on holiday with his Foster Mother. The other died, aged 19 days, from Spastic Diplegia in the nursing home where it was born and which it had never left. In addition 3 children died after removal to hospital from their foster homes. NURSING HOMES. One new home, providing accommodation for 4 patients other than maternity patients, was registered in 1939. The total number of homes on the register at the end of the year was 8, providing accommodation for 13 maternity patients and 27 other patients. THE SCHOOL MEDICAL SERVICE. In view of the letter received from the Lord Privy Seal asking the Council to reduce their routine work so that air raid precautions should have first call on their time, the Council determined to discontinue School Medical Inspection as from 19th May, 1939. From the outbreak of war on 3rd September, 1939, there was still further dislocation of the School Medical Service. All schools were closed and some 9,000 of the 18,000 school children were evacuated to reception areas. The School Nursing Staff was commandeered for the First Aid Posts. One of the Council's three Municipal Health Centres—Health Centre (3)—was closed as a Health Centre and brought into use as a First Aid Post. Medical, dental and cleanliness inspections in the schools were of necessity inoperative until certain schools reopened in January, 1940, when some dental inspection in school was recommenced on 15th February, 1940, and cleanliness inspections were recommenced early in April, 1940, after the release of the School Nursing Staff from the First Aid Posts. Minor ailment treatment, cleansing and dental treatment continued to be available at Health Centres (1) and (2) without interruption. The Specialist Clinics were closed for a time but were subsequently reopened with limited sessions. The Artificial Sunlight Clinic has remained closed. A new clinic in the charge of a Consultant Pediatrician was opened on 22nd February, 1940, to deal with mental health problems occurring in children. SCHOOL MEDICAL SERVICE FOR CHILDREN SENT TO RECEPTION AREAS. Seven of the School Nursing Staff were transferred to Reception Areas where they still are. Two others were transferred to assist in reception areas for shorter periods. The complete equipment of one dental surgery was transferred to a reception area. One Dental Surgeon was also transferred until he was called up for war service. 7 According to the Government's arrangements, evacuated children are entitled to receive the same school medical services as are provided by the reception area for its own children. In the experience of Willesden, the parents and teachers of the evacuated children clamour for the services to which they have been accustomed in their own area, and the past months have been marked by a succession of letters, visits by parents and telephone calls to the Health Department requesting that the children should be so treated. A number have been brought back to Willesden for treatment including the treatment of such simple conditions as cleansing and scabies. UNCLEANLINESS IN EVACUATED CHILDREN. The normal incidence of nits and vermin amongst public elementary school children in Willesden is approximately 4 per cent. It must be recognised that not yet has the time arrived when every mother can be depended on of her own free will to keep her children free from nits and vermin but it is a fact that the defaulting families are mostly known to the Health Department and by unremitting supervision the condition of these families and the harm they do can be kept within limits. After the lapse of supervision during the summer holidays it has invariably been found that the incidence of nits and vermin is considerably higher. Evacuation came at the end of the long summer holiday and it is therefore likely that a proportion of the children entered the reception area with their hair in a more or less nitty condition. Normally their mothers would have kept this condition within bounds and after the first cleanliness inspections of the autumn term usually held promptly after the reopening of the Schools the children would have been restored quickly to their wonted condition of cleanliness. The hostesses in the reception areas were, however, probably unaware of the urgent need for inspection and cleansing of their charges' hair. Some may have been unfamiliar with such procedure, others unwilling or unable to shoulder forthwith all the extra tasks thrust upon them. In such circumstances it would only be a matter of days or at most a week or two for conditions to become such as to cause the outcry of last autumn with which we are all familiar and which caused grossly unfair and incorrect reflections to be cast on the School Health Service. The results of cleanliness inspections made by the Willesden Council's Health Visitors in reception areas from 28th September, 1939, to 20th April, 1940, were as follows :— Table No. 4. Number inspected. Number Nitty or Verminous. Percentage Nitty or Verminous. Willesden Evacuees 3,798 345 9.1% Other Evacuees, mainly London 5,293 498 9.4% Natives 2,834 265 9.3% Findings of Cleanliness Inspections in Willesden.—Cleanliness inspections were carried out in the schools on 408 occasions during the year 1939, the average number of visits paid to each school by the Health Visitor being 12. The total number of examinations and re-examinations made during the year was 36,787. It should be noted that the routine cleanliness inspections were discontinued as from the end of the summer term 1939. This is highly important work. In 1914, when it was first begun, the percentage of nitty or verminous children in the schools was as high as 20. In those days a child was not called nitty or verminous except there were many nits on the hair. In 1931, when a child with only a few nits was placed in this category, the percentage of nitty or verminous children in the schools had dropped to 3.6. It will therefore be noted that enormous improvement had been effected, far greater actually than the figures show. In 1939, the percentage was 3.8. The first reverse in the steady decline which had been maintained since 1920 was in 1933. when the percentage rose to 4.1 after having fallen to 3.6 in 1931 and 1932. Table No. 5. Percentage of Nitty and Verminous individual children recorded upon routine cleanliness inspection at the Schools from year to year since 1914:— 1914 20% 1915 23% 1916-19 Results not recorded owing to war. 1920 11.9% 1921-25 7.9% 1926-30 4.6% 1931-35 3.8% 1936 4.0% 1937 4.2% 1938 3.8% 1939 3.8% Note.—Routine cleanliness inspections were discontinued from the end of the summer term, 1939. 8 Medical Treatment in Willesden.—During the year 1939, school children were followed up by the Health Department on account of 11,869 medical defects and 4,132 dental defects. Of those defects found to require treatment, medical or dental treatment was obtained for 10,796 and domestic treatment was obtained for 1,688. 90 per cent. of the medical defects were treated, 74 per cent. receiving medical treatment and 16 per cent. domestic treatment, 73 per cent. of the dental defects followed up were treated. No record is available of defects requiring treatment which were not followed up. 95 per cent. of the total medical defects treated and 99 per cent. of the total dental defects treated were dealt with by the Education Committee. The remainder, or 5 per cent. of the medical defects and 1 per cent. of the dental defects treated, were dealt with by private practitioners, voluntary hospitals or other charitable institutions. or Public Assistance. In connection with defects treated, the children concerned made 60,967 attendances at the Health Centres in 1939. HEALTH CENTRES. ATTENDANCES. Table No. 6. Medical and Dental Treatment—Attendances at Health Centres, 1939. Condition. (1) Mothers, and Children under Five. School Children. (8) Grand Total (Cols. 7 and 8). (9) Expectant Mothers. (2) Nursing Mothers. (3) Children under Five. Total (Cols. 2—5). (7) 0—1. (4) 1—5. (5) Total (Cols. 4 and 5). (6) 1. Cleansing - 6 4 4 10 276 286 2. Throat, Nose and Ear Diseases — — 57 1,131 1,188 1,188 6,597 7,785 3. Minor Ailments 46 179 1,299 3,741 5,040 5,265 26,120 31,385 4. Eye Diseases 7 12 280 485 765 784 3,284 4,068 5. Skin Diseases 24 37 282 258 540 601 711 1,312 6. Artificial Sunlight Treatment — — 524 2,567 3,091 3,091 3,922 7,013 7. Orthopaedics 1 41 419 1,814 2,233 2,275 3,387 5,662 8. Medical Consultations 14,305 29,907 30,331 14,104 44,435 88,647 88,647 9. Diphtheria Immunisation — — — 364 364 364 386 750 10. Total (1—9) 14,383 30,182 33,192 24,468 57,660 102,225 44,683 146,908 11. Dental Consultations 2,889 1,606 997 997 5,492 7,485 12,977 12. Total (10—11) 17,272 31,788 33,192 25,465 58,657 107,717 52,168 159,885 13. School for Mothers — — — — — 3,067 — 3,067 14. Nursery — — — — — 2,943 — 2,943 15. Miscellaneous — — — — — 40,083 9,185 49,268 16. Grand Total (12—15) 17,272 31,788 33,192 25,465 58,657 153,810 61,353 215,163* (1) Health Centre (1). Health Centre (2). Health Centre (3). Grand Total. (11) Mothers and Children under Five. (2) School Children (3) Total. (4) Mothers and Children under Five. (5) School Children (6) Total. (7) Mothers and Children under Five. (8) School Children (9) Total. (10) 17. Medical Attendances 20,827 10,865 31,692 48,033 13,359 61,392 33,365 20,459 53,824 146,908 18. Dental Attendances 1,684 1,381 3,065 1,941 2,637 4,578 1,867 3,467 5,334 12,977 19. School for Mothers 1,213 — 1,213 800 — 800 1,054 — 1,054 3,067 20. Nursery Attendances 1,556 — 1,556 481 — 481 906 — 906 2,943 21. Miscellaneous 17,102 2,737 19,839 17,658 4,509 22,167 5,323 1,939 7,262 49,268 22. Total 42,382 14,983 57,365 68,913 20,505 89,418 42,515 25,865 68,380 215,163* *In addition 1968 attendances were made by secondary and technical school children and the following attendances by adults:—Cleansing 150, Skin Diseases 69, Diphtheria Immunisation 3, Varicose Ulcers 604, Eye Diseases 4, and Orthopaedics under Section 181 of the Public Health Act, 1936, 81, making a total of 2,879, which, together with the 215,163 above, makes a grand total of 218,042. 9 Table No. 7. Showing attendances at the Municipal Centres each year since 1913. Year. Mothers and Children under 5 years. School Children. Total. School for Mothers. Nursery. Miscellaneous. Grand Total. Medical. Dental. Total. Medical. Dental. Total. 1913 0 0 0 299 0 299 299 0 0 299 1914 0 0 0 2,517 0 2,517 2,517 0 0 2,517 1915 0 0 0 5,674 0 5,674 5,674 0 0 5,674 1916 389 0 389 9,593 0 9,593 9,982 0 0 9,982 1917 8,641 0 8,641 9,448 0 9,448 18,089 0 0 18,089 1918 32,169 1,165 33,334 15,811 2,403 18,214 51,548 44 220 51,812 1919 32,870 878 33,748 46,179 11,024 57,203 90,951 1,089 2,814 94,854 1920 51,468 1,823 53,291 64,588 10,670 75,258 128,549 2,354 3,452 134,355 1921 41,562 1,667 43,229 57,032 7,718 64,750 107,979 1,716 2,356 112,051 1922 27,505 894 28,399 39,989 7,025 47,014 75,413 1,616 2,190 79,219 1923 23,271 533 23,804 40,381 3,599 43,980 67,784 2,761 3,270 73,815 1924 17,082 520 17,602 34,845 2,460 37,305 54,907 2,896 2,808 60,611 1925 26,119 936 27,055 41,695 5,123 46,818 73,873 4,074 3,812 81,759 1926 39,084 1,491 40,575 47,786 5,909 53,695 94,270 4,126 3,645 102,041 1927 40,958 1,593 42,551 47,199 6,583 53,782 96,333 3,847 3,291 103,471 1928 40,787 1,733 42,520 43,956 6,484 50,440 92,960 4,485 3,355 100,800 1929 43,419 1,598 45,017 39,698 6,307 46,005 91,022 4,523 3,446 98,991 1930 59,372 2,341 61,713 49,610 10,537 60,147 121,860 5,958 5,371 133,189 1931 76,395 3,473 79,868 65,942 15,180 81,122 160,990 6,928 6,985 21,884 196,787 1932 84,342 4,385 88,727 67,964 16,094 84,058 172,785 6,536 6,227 28,817 214,365 1933 84,782 4,791 89,573 71,587 15,652 87,239 176,812 5,297 5,268 27,256 214,633 1934 88,472 5,036 93,508 62,212 13,095 75,307 168,815 5,337 4,726 30,139 209,017 1935 92,666 5,596 98,262 63,666 12,447 76,113 174,375 5,343 5,299 32,553 217,570 1936 96,728 5,752 102,480 67,736 12,325 80,061 182,541 5,198 4,985 38,440 231,164 1937 108,715 5,143 113,858 71,621 11,250 82,871 196,729 4,257 4,092 42,169 247,247 1938 114,769 5,265 120,034 67,811 11,541 79,352 199,386 4,877 4,387 47,312 255,962 1939 102,225 5,492 107,717 44,683 7,485 52,168 159,885 3,067 2,943 52,147* 218,042 * This includes the 1,968 attendances made by Secondary and Technical School children and the 911 by adults and others under Section 181 of the Public Health Act, 1936, which are shown in the footnote to Table No. 6. 1 School Child and 1 Child under 5 years of age were treated under the Council's Scheme by X-rays for Ringworm of the Scalp. 7,474 Individual Public Elementary School Children attended the Municipal Centres during 1939. 6,640 ,, Children under 5 years of age attended the Municipal Centres during 1939. 2,915 „ Expectant Mothers ,, ,, ,, ,, „ „ 3,515 „ Nursing Mothers ,, „ ,, ,, „ SECONDARY AND JUNIOR TECHNICAL, ETC., SCHOOLS. The arrangement by which the Medical Staff of the Willesden Council carry out the inspection of pupils attending the Secondary and Technical Schools in Willesden, on behalf of the Middlesex County Council has been continued. The total number of pupils on the rolls of the Secondary and Technical Schools in Willesden now included in this arrangement is approximately 3,000. School Medical Inspection was discontinued as from 19th May, 1939, as stated on page 6. 349 medical examinations and 250 re-examinations of Secondary and Technical School pupils were carried out during the year 1939. 93 medical defects were found amongst the scholars examined. Parents and Head Teachers are notified of defects and are advised as to the action to be taken. The Middlesex County Council's scheme of treatment of scholars suffering from defective vision at the Willesden Council's Health Centres, and also that of dental inspection and treatment by the Council's dental staff, have also been continued. 1,841 pupils were dentally inspected during the year, 1,265 were found to require treatment and 432 were treated at the Willesden Council's Dental Clinics. 1,968 attendances were made at the Clinics during the year for Medical and Dental Treatment. 10 PROVISION OF MEALS. Meals have been provided at the Council's Feeding Centres throughout the year. On 17th April, 1939, the Council opened a fifth feeding centre with seating accommodation for 250 in Percy Road, Kilburn. This Centre provides both breakfasts and dinners on seven days a week. The Voluntary Feeding Centre in South Kilburn was closed when the Percy Road Centre opened. After approximately half the Willesden School Children were sent to reception areas at the end of August and the Schools closed, the one-third of a pint of milk previously given in School to all children receiving free meals was thereafter served in the feeding centres with the midday meal. 273,630 meals were supplied in 1939, as compared with 320,148 in 1938, 283,367 in 1937, 260,822 in 1936 and 249,509 in 1935. The recipients of these meals are mainly children of the unemployed, widows and deserted wives. HOME NURSING SERVICE. The Home Nurse employed by the Council nursed 361 cases during the year, and in connection with such cases paid 3,524 visits. 1,296 of these visits were paid in the Carlton Ward, 815 in the Kilburn Ward, 305 in the Roundwood Ward, 293 in the Willesden Green Ward, 259 in the Mapesbury Ward and smaller numbers in the other wards of Willesden. Of the 361 cases nursed during the year, 349 were new cases. 305 of these 349 new cases were referred by the Health Department for nursing, 12 by private doctors and 32 by Hospitals, Associations and private persons. Ophthalmia neonatorum received 151 visits and other ophthalmia cases 737 visits. OUTBREAK OF WAR—REPORT ON SANITARY STAFF. Prior to September, 1939, two members of the Sanitary Staff were used for Civil Defence duties and on the outbreak of war most of the remaining Sanitary Staff were seconded for duties at Control Room, Mortuaries, Lecturing on Anti-gas measures and Billeting. All billets used in connection with A.R.P. and A.F.S. Posts, Military Billets and Billets for Nursing and Medical Staffs were periodically inspected and, where necessary, action was taken to render such billets clean and wholesome. The following inspections were made from September to the end of the year:— Table No. 8. Primary Inspections. Re-Inspections. Inspection of A.R.P. Billets.. 3 10 „ Civilian Billets 226 37 „ Military Billets 6 20 „ Auxiliary Fire Service Quarters 9 49 244 116 Disinfection of bedding for above: 897 articles—13 rooms. Total number of visits in respect of the above—1,247. With reference to Sanitary work, routine house-to-house inspections by the Sanitary Inspectors were discontinued on the outbreak of war and inspections of offices, factories, food premises, etc., were much curtailed, only matters of an urgent nature receiving daily attention. Meat Depot No. 14 was opened in Willesden Lane in September, 1939, inspections being made twice daily of all meat received prior to distribution to traders in Willesden, Hampstead and Paddington. PUBLIC MORTUARY. 124 bodies were deposited at the Mortuary during the year ending 31st December, 1939, as follows:—3 Accommodations, 70 Post-Mortems, 13 Post-Mortems and Inquests, and 38 Inquests only. AMBULANCE SERVICE. During the year 6,906 calls were made for the Council's ambulances and 164,084 miles were run. Approximately 250 defective children were on the lists for daily conveyance by the Council's school ambulances to and from the special schools up to the outbreak of war when the Schools were closed. MUNICIPAL HOSPITAL. The 48th Annual Report on the Municipal Hospital, written by Dr. Troup, appears later in this Report. Your obedient Servant, GEORGE F. BUCHAN, Medical Officer of Health. 11 THE FORTY-EIGHTH ANNUAL ' REPORT on the MUNICIPAL HOSPITAL For the year 1939 By ARTHUR G. TROUP, M.D., D.P.H., Medical Superintendent. Table No. 9. Cases in the Municipal Hospital during the Year 1939. Diseases. No. in Hospital on 1-1-39. Admitted. Total under treatment. Discharged recovered. Died. Mortality per cent. Remaining on 31-12-39. Cerebro-Spinal Fever —• 4 4 2 1 25 1 Diphtheria 62 251 313 300 4 1.2 9 Diphtheria (Bacteriological) — 6 6 6 — — — Enteric Fever — 3 3 3 — — — Erysipelas 1 34 35 32 1 2.8 2 Measles — 3 3 2 — — 1 Mixed Infections — 2 2 2 — — — Puerperal Infections 2 10 12 12 — — — Scarlet Fever 30 184 214 200 1 .46 13 Whooping Cough 3 119 122 116 5 4.1 1 Other Diseases 4 160 164 158 5 — 1 Marasmus 7 38 45 33 7 15.5 5 Tonsil & Adenoid Cases 1 360 361 361 — — — Civilian Sick — 78 78 59 2 — 17 Totals 110 1,252 1,362 1,286 26 — 50 12 12 Laboratory. The Bacteriological Laboratory was opened for work on 1st January, 1932. It undertakes the examination of the routine bacteriological specimens from the District, the Municipal Hospital and other local Institutions. Table No. 11. Sources of Specimens examined 1939. Willesden Municipal Hospital 3,108 Private Practitioners 1,792 Heath Centres and Health Visitors 1,306 Middlesex County Council Tuberculosis Dispensary 5 Other Hospitals 81 Engineer's Department 236 Total 6,528 Annual Number of Specimens. 1932 4,526 1933 5,908 1934 6,693 1935 7,774 1936 7,075 1937 6,305 1938 8,604 1939 6,528 13 Emergency Medical Service. The Hospital has been classified as an A1 Casualty Receiving Hospital under the Emergency Medical Services Scheme. For this purpose it has been upgraded so as to be in a position to deal with acute surgical and medical cases, the Government supplying the necessary extra equipment. It is situated in Sector 5, the parent Hospital of which is the Middlesex Hospital, Mortimer Street, W. The number of beds has been increased from 200 to 310, and the hospital divided into two sections, one for casualties and the other for infectious diseases. One pavilion has been reorganised and contains a reception room for casualties, an immediate treatment room, a resuscitation room and two operating theatres. It proved impracticable to provide adequate protection for the existing operating theatres, and two new ones are being constructed in the basement of a two-storied ward, the floors of which are constructed of concrete. These theatres will be used if and when the circumstances demand it. The following staff were originally allocated to the Hospital:—-2 Surgeons, 1 Physician, 1 Anaesthetist, 3 House Officers, 22 Medical Students and 60 Nurses. One Surgeon and the Medical Students have since been withdrawn, but would have to be replaced should casualties in any number be admitted for treatment. Apart from 1 Surgeon and the House Officers, all the extra staff have been accommodated in billets. The Government have agreed to accept financial responsibility for the treatment of transferred civilian sick patients, that is, patients who ordinarily would have been admitted to the Middlesex Hospital, but could not be sent there owing to a proportion of the beds being reserved for casualties. Seventy-eight such patients have been treated in the Willesden Municipal Hospital, and they may be classified as follows :— Appendicitis 11 Haemorrhoids 5 Carcinoma . 9 Thyrotoxicosis 4 Hernia 7 Miscellaneous 37 Tonsils and Adenoids 5 — Total 78 14 THE NINTH ANNUAL REPORT on the WILLESDEN MATERNITY HOSPITAL. Report on the work from 1st January, 1939, to 31st December, 1939. By ARNOLD WALKER, M.A., M.B., B.Ch., F.R.C.S., F.R.C.O.G. During 1939 there has been a fall of over a hundred cases compared with the previous year. This is accounted for in two ways. Firstly, bookings were restricted for a period during the summer for re-painting, and secondly, a number of expectant mothers were evacuated during the early part of the war. In September little more than half the cases booked presented themselves, and it was not until December that the hospital was working normally again. In view of the uncertainty of the future, the number of cases which have been booked for the early part of 1940 is higher than normal, and, at the time of writing this report, it looks as though January, 1940, will be a record month. As it is possible that further evacuation will be necessary as the war progresses, the policy of booking a number of cases greater than normal seems to be the right one and best calculated to make full use of the facilities available. At the present moment the lying-in wards for the mothers who have been delivered are full, and patients whose progress has been normal are sent home early and are being cared for by the municipal midwives until the fourteenth day, as laid down by the Midwives Act, 1936. This is a more desirable procedure than over-crowding the lying-in wards. The labour ward accommodation is adequate for the increased work. This policy of treating a larger number of cases for a shorter period throws an increased strain upon the nursing staff, but it is satisfactory to record that this has not resulted in any lowering of the high standard of the nursing in peace-time. One maternal death occurred during the year. The patient developed appendicitis immediately before labour, and the cause of death was general peritonitis from the rupture during labour of an appendix abscess. This is classified as an "incidental death," and is not included by the Ministry of Health as a true maternal death. Statistical details of the 913 Cases dealt with during 1939. Cases completed 913 A. Booked at the Health Centres 887 Discharged well 869 Delivered elsewhere 14 Transferred 3 Died 1 B. Admitted as Emergencies 26 Discharged well 26 Of the 887 booked cases, 444 were primiparae and 443 were multiparae. Of the 26 emergency cases, 12 were primiparae and 14 were multiparae. 15 Statistical Details—(continued'). Presentations— Occipito Anterior 734 Occipito Posterior 86 Normal Breech 28 Complicated Breech 5 Twins 16 Face 1 Complicated 1 Miscarriages 19 Ante-Partum Haemorrhage— Placenta Praevia 2 Accidental Haemorrhage 2 Prolapse of Cord 4 Organic Heart Disease 8 Toxaemia of Pregnancy admitted for treatment 33 Eclampsia 1 Puerperal Pyrexia 34 Uterine Infection 8 Breast Infection 3 Urinary Infection 13 Pulmonary Tuberculosis 1 Thrombo-phlebitis 1 No cause found 8 Operations performed— Forceps Delivery 26 The forceps rate was therefore 3 per cent. Caesarean Section 8 Disproportion 5 Heart Disease 1 Placenta Praevia 1 Breech (Elderly primipara) 1 Manual Removal of Placenta 10 Hysterotomy and Sterilisation.1 Chronic Nephritis. 1 Induction of Premature Labour 18 Blood Transfusion 4 From relative 1 Stored blood 1 Not stated 2 895 viable children were born to 879 mothers. Of these, 27 were stillborn and 12 died. 16 THE TENTH ANNUAL REPORT on the SUPERVISION OF MIDWIVES for the Year ending 31st December, 1939. 66 Midwives gave notice of their intention to practise in Willesden in 1939, 34 of these being in the Central Middlesex County Hospital. Midwives practising and living in Willesden attended 1,846 cases as midwives or maternity nurses in 1939 as against 1,891 in 1938. 136 of these were outside Willesden. In addition, 22 midwifery or maternity cases were attended in Willesden by midwives living outside Willesden. The 6 Municipal Midwives attended 514 midwifery cases as against 447 in 1938. Midwives attached to Queen Charlotte's Hospital District Home, Kilburn, attended 267 midwifery and 2 maternity cases. 143 of these were Willesden residents attended on behalf of the Willesden Council as against 166 in 1938. 126 were cases attended outside Willesden. Midwives attached to the Willesden District Nursing Association attended 222 maternity cases on behalf of the Council as against 280 in 1938. During the year 222 notifications were received from Midwives practising in Willesden in accordance with the rules of the Central Midwives Board and of these 187 notifications were in respect of medical aid, 148 in respect of the mother and 39 in respect of the child. The second year's working of the Domiciliary Midwifery Scheme has been satisfactory. The number of whole-time Municipal Midwives remains at 6 and the qualifications and off-duty time are as given in the report for 1938. With regard to the 5 Midwives allotted to the Willesden District Nursing Association, to deal with the Maternity Nursing in Willesden, arrangements have now been made for the Association to receive payment in respect of each booked Maternity Nursing Case and emergency or miscarriage case nursed, so that the number of midwives will vary, from time to time, according to the amount of work to be done. Two and a half midwives are still allotted for the area served by Queen Charlotte's Hospital District Home. Owing to the war, the approved compulsory four weeks' residential courses for midwives have been suspended. The Watling and Willesden Training School for second-period Pupil Midwives.— The first pupil midwife came to the Willesden District on 1st June. From this date to the end of the year 10 pupil midwives worked in Willesden on the district, 8 of the 10 subsequently going to the Watling District Nursing Association. Of the 514 Municipal Midwifery cases shown above, the pupil midwives attended 115. They took responsibility for the ante-natal care, attended and took responsibility for the labours and nursed the mothers and their babies during the 14 days immediately following labour. In addition to the work shown above in respect of the Municipal Midwives cases, in Willesden the pupil midwives attended :— Ante-Natal Clinics 44 Post-Natal Clinics 32 Infant Welfare Clinics 35 The Cullingworth lecture courses. A discussion class, each week, taken by the Supervisor of Midwives at the Health Department. Of the 10 pupil midwives, 6 entered for their final examination, 5 passed, 1 failed but passed at the subsequent examination. Four do not complete their training until 1940. 17 THE TWENTY-SECOND ANNUAL REPORT for the YEAR 1939, on DENTAL WORK in connection with SCHOOL CHILDREN, EXPECTANT and NURSING MOTHERS and CHILDREN under 5 years. By E. A. JENNINGS, L.D.S., R.C.S.Eng. CURTAILMENTS. Civil Population. The Dental Service continued on normal lines until the Midsummer vacation. At the commencement of hostilities compulsory education ceased, schools closed, children left the district for the reception areas and routine dental work could no longer be in operation. Health Centres. Health Centre (3) at Stonebridge was closed as a health centre and adapted as a First Aid Post. Dental equipment sufficient for one surgery was dispatched to the reception area for the use of Willesden children. Health Centre (1) at Kilburn and Health Centre (2) at High Road, Willesden, have since carried on the Authority's work between them. Staff. One Dental Surgeon resigned his appointment in September. He had completed twelve years' service with the Council. A second Dental Surgeon is on the Active Army List, and will, in due course, be called for service as a dental officer in the Army Dental Corps. He has, in the meantime, been temporarily transferred to the country, where the majority of Willesden children are accommodated. Two Dental Nurses have also been taken out of the service. Thus a skeleton staff of 2 Dental Surgeons and 2 Dental Nurses alone remain on duty for dental work in the Borough. Reaction. The public anxiety and disorganisation of the first few weeks of war brought the work of the Clinics to a standstill. This period of inactivity soon passed, and the requests for treatment regained considerable proportions. The Year's Work. The number of working sessions amounted to 1,594, which were utilised as follows:— Treatment sessions at the Centre 1,371 Routine inspection sessions 181 Administration (including Civil Defence) 42 1,594 39 sessions were lost on account of sickness and 9 sessions included in the above figure (1,594) were worked by locum tenens. The Anaesthetist attended on 146 sessions and administered 2,794 general anaesthetics. An average of 19 per session. 13,730 mothers, infants, elementary and secondary school children were inspected. 10,689 or 77 per cent. were found defective and 4,034 or 36 per cent. were treated at the Centres. 11,350 teeth were extracted, 6,770 fillings done and 3,265 other operations performed, making a total of 21,385 treatments. The average work done per session is set out in the table below:— Total Operations Attendances. Fillings. Extractions. Sundries. per Session. 10 4-9 8 2 14-9 Maternity and Child Welfare. A marked feature of the year's work is the continued growth of this service. 1,874 mothers and infants have been inspected at the Centres, an increase of no fewer than 859 over last year's total of 1,015. 76 of the number inspected were passed as not requiring treatment, and of the remaining 1,798 patients, 1,059 were treated at the Centres. Treatment for mothers tends to become more and more conservative, and fewer teeth were extracted although 198 more patients were treated this year than last. The method of gum treatment also conserved many teeth, and 76 cases of gum packs and gingivectomy have been undertaken as against 53 for 1938. There is every reason to extend this form of treatment, as it not only improves oral health, but is also of considerable educational value. 18 APPENDICES. APPENDIX A. 10th January, 1939. PROVISION OF HOUSES FOR TUBERCULOUS PERSONS. Memorandum by the Medical Officer of Health on the letter of the Middlesex County Council dated 24th November, 1938. Tuberculosis in Willesden. The following table shows the number of cases of tuberculosis notified in Willesden during the past 10 years and the death rate per thousand of the population in each of these years from respiratory tuberculosis:— Year. Cases Notified. Death Rate of Respiratory Tuberculosis per 1,000 Population. Respiratory. Non-Respiratory. 1928 200 50 .58 1929 254 53 .89 1930 258 73 .69 1931 262 72 .75 1932 249 62 .67 1933 247 47 .65 1934 253 64 .66 1935 247 49 .57 1936 240 53 .58 1937 246 62 .55 Fatality of Tuberculosis. Pulmonary tuberculosis is an extremely infectious and deadly disease. In Lancashire, the Central Tuberculosis Officer for the County conducted an enquiry into what became of such cases over a period of 5 years from notification. His results showed that of the net number (1,097) of definite pulmonary cases (removals from area excluded), 63.1 per cent. died from tuberculosis within the 5 years (39.7 per cent. dying in the first year, 10.1 per cent. in the second year, 5.8 per cent. in the third, 3.6 per cent. in the fourth and 3.9 per cent. in the fifth). In the Annual Report of the Medical Officer of Health for Middlesex it is stated that 49.9 per cent. of cases of pulmonary tuberculosis were dead at the expiry of eleven years. In a study of mortality among individuals with tuberculosis in New York State, published by the Milbank Memorial Fund in July, 1938, it is stated that active pulmonary tuberculosis has an exceedingly high fatality rate and that 4 per cent. to 5 per cent. per annum of arrested cases of pulmonary tuberculosis break down. Tuberculosis Authorities in Willesden. The Willesden Borough Council is primarily the authority in Willesden for the prevention of tuberculosis. The Middlesex County Council is primarily the authority in Willesden for the treatment of tuberculosis. Proposals of the Middlesex County Council. The first proposal of the Middlesex County Council is:— (a) To acquire land in the County and to erect thereon houses for persons suffering from tuberculosis. It is not quite clear whether this means that the houses to be erected will merely be a group of houses for tuberculous people who will have to find work in the neighbourhood, or a village settlement where suitable work is provided for arrested cases. 19 The descriptive report of the Papworth Village Settlement states:— " If the consumptive working man is to maintain the progress he has made during his sanatorium treatment, he must be assured of employment which is not too strenuous, of hours which are not too long, and of a wage sufficient to provide a plentiful food supply for himself and his family, and to free him from all financial worries. " The same applies, of course, to the tuberculous woman who is dependent upon her own efforts for a livelihood. " The Papworth Village Settlement exists for the sole benefit of tuberculous men and women and provides " (1) Treatment for their physical condition. " (2) Training in a variety of trades. " (3) Permanent employment under ideal conditions. " (4) Living accommodation in model cottages and hostels. " (5) Constant medical supervision." The second proposal of the Middlesex County Council is:— (b) To reimburse any local authority any additional expenditure in excess of that incurred in the provision of houses for the working classes under the Housing Acts, e.g., providing additional accommodation for tuberculous persons. The establishment of such houses for arrested tuberculous cases in the ordinary housing estates of local authorities is open to objection for the following reasons:— (i) Tuberculous persons living with others on an ordinary housing estate are a potential danger to all with whom they come into contact directly and a further potential danger in respect of indirect contact by way of articles which may be used by others, e.g., public telephones. The most important consideration is the prevention of the spread of the disease. It will be noted that the crude death rate per thousand of the population for pulmonary tuberculosis for England and Wales has fallen from .755 in 1928 to .584 in 1937 but this is not because patients have been cured but because the disease has been prevented, the notification rate for the same period having fallen from 1.5 per 1,000 population in 1928 to 1.1 per 1,000 population in 1937. The following table illustrates this fact:— Population of England and Wales. Respiratory tuberculosis— No. of notifications. New cases. Notification rate per 1,000 population. No. of deaths. Crude death rate per 1,000. Percentage of deaths to New notifications. 1928— 39,482,000 57,682 1.5 29,799 .755 52 1937— 41,031,000 44,996 1.1 23,971 .584 53 While the fall in the number of notifications of the disease cannot be dissociated from the removal to Hospital of active cases, I think that Local Sanitary Authorities may nevertheless claim considerable credit for this fall on account of their efforts to improve housing conditions and sanitary circumstances generally. The problem of the prevention of tuberculosis is a complex one—prevention cannot be separated from treatment entirely nor can either be separated from measures designed for the improvement of the public health. I recently reported to the Health Committee on two families with housing difficulties arising from tuberculosis and I beg to set out this information about these two families in this report. Family S. In this case the family consists of:— The mother aged 27 years who is suffering from tuberculosis of the lungs and has been in Clare Hall Sanatorium since the week ending 18-6-38. A daughter aged 6 years who has been in Victoria Home, Margate, since the week ending 14-5-38, suffering from tuberculosis of the mediastinal glands. A son aged 8 years who was in Victoria Home, Margate, suffering from tuberculosis of the mediastinal glands for some 3 months and was discharged to his maternal grandmother's home during the week ending 9-7-38. 20 The father—not known to be tuberculous—aged 28 years, who is now staying with his mother-in-law. It should be noted that another son aged 1¼ years was notified as suffering from tuberculosis of the lungs on 11-2-38, and died in Paddington Green Hospital on 9-5-38 from toxaemia due to pulmonary tuberculosis. This family have no home of their own but live with the wife's parents who occupy 3 rooms and whose family consists of father, mother, son aged 18 years and male friend aged 54 years. With them are now staying the son-in-law and the grandson, aged 8 years, above referred to and if their daughter and their granddaughter are discharged from Clare Hall and Victoria Home, this is the only place to which they will have to come. Family M. This family consists of husband and wife. The wife is aged 22 years, has been in Clare Hall Sanatorium for the past 10 months and the Medical Superintendent informs me should go out soon. They have no home of their own but live with the patient's mother, father, sister and brother, who have 3 bedrooms and 1 small sitting room. The wife in this case was notified as a case of pulmonary tuberculosis before she was married. In a letter from the Medical Superintendent of Clare Hall he enquires if anything can be done to help her in the housing difficulty. You will remember that I did not care to forward the letter to the Housing Committee without the express direction of the Health Committee in view of the above circumstances. This express direction the Health Committee did not give. I think it will be obvious that such families as " S " and " M " above require special housing provision away from the general community, such as is provided at Village Settlements. (ii) The second important point is that houses set apart for tuberculous persons on a housing estate would be regarded by others on the estate as " leper " houses and social difficulties in such circumstances would not unlikely arise. Village Settlements. I have indicated in the early part of the report the purpose of Village Settlements. The Chief Medical Officer for the Ministry of Health in his Annual Report for 1935 states that " the first two years after leaving a sanatorium are very critical years. From this it follows that the patient at first should only work under sheltered circumstances in occupations suitable for his condition. He must live in as healthy an environment as practicable and his labour may need to be subsidised in order that he may maintain his dependents and himself. Usually these requirements can only be entirely satisfied by life in a village settlement." Again, the Chief Medical Officer in his Annual Report for the year 1937 refers to the fact that the Sherwood Village Settlement was established by the Nottinghamshire County Council during the year 1937 adjacent to the Sanatorium Hospital near Mansfield. He goes on to say—"The importance of the village settlement in a complete scheme for dealing with tuberculosis has frequently been emphasised in previous annual reports. It is therefore sincerely hoped that the efforts of the Nottinghamshire Council, the first County Council to undertake the provision of a village settlement, will prove completely successful." In a village settlement it is possible for the tuberculous case, if a worker, to be given work suitable to his condition, whereas employers in the ordinary way cannot cater for a person who is unable to do the full work. It should further be observed that in a village settlement a tuberculous patient, even if living with his family, is under constant supervision and compelled to abide by the rules of the settlement for his own care and for the prevention of the spread of the disease. Such supervision cannot be applied in a private dwelling house. In selecting land for a village settlement for tuberculous cases the County Council can secure a suitable site where the atmosphere is not deleterious to the patient and where accordingly he can have the best possible chance. This does not apply to a house, however suitably constructed, in the more or less built-up areas of the County of Middlesex. It should also be observed that the economic circumstances of tuberculous families, especially in cases where the father suffers, are necessarily poor and it is doubtful if such families can live without special subsidy having regard to the inability of the head of the family to do full-time work or to the casual nature of his employment. Having regard to these various circumstances it would appear undesirable to support either of the Middlesex County Council's proposals, if they do not include a proposal to establish houses on the lines of a village settlement. GEORGE F. BUCHAN, Medical Officer of Health. 21 APPENDIX B. 14th March, 1939. PROGRESS IN MATERNITY WORK. The total number of births of Willesden residents notified in 1938 was 3,078 ; the total number of confinements, of which there is a record, was 2,995. N.B.—These two figures differ because occasionally twins are born and a few confinements have to be added to the total of 2,995 to include cases which were confined in their own homes, and for whom the Council did not provide maternitv nurses. The 2,995 confinements were provided for as follows:- By the Borough Council. Willesden Maternity Hospital 1,045 Municipal Midwives 447 Queen Charlotte's Midwives 166 Maternity Nurses 280 Total 1,938 Provided for otherwise. Kilburn and West Hampstead Midwives 15 Independent Practising Midwives 75 Central Middlesex County Hospital 448 Institutions outside Willesden 519 Total 1,057 It will accordingly be observed that the Willesden Borough Council are more or less directly responsible for approximately 65 per cent. of the confinements in Willesden. Ante-Natal Care. 2,747 expectant mothers attended the Council's Health Centres during 1938 ; these included the following:— Cases confined in the Willesden Maternity Hospital 1,045 Cases confined by Municipal Midwives 447 Cases referred from the Central Middlesex County Hospital 298 Total 1,790 In addition a certain proportion of cases booked by the Kilburn and West Hampstead Midwives, Independent Practising Midwives and Institutions outside Willesden attended during some period of their pregancy for ante-natal care. The difference between the figure 1,790 and 2,747 is further accounted for because the number of expectant mothers who came to the Clinic, namely, 2,747, include the 1,790 confinements referred to above, plus expectant mothers who were not confined in 1938. As 3,078 births were notified in Willesden in 1938, the percentage of mothers attending for ante-natal care relative to the notified births is approximately 90 per cent. Nursing Mothers. 3,543 nursing mothers attended the Council's Health Centres during 1938. Accouchement Sets. The Council provided accouchement sets for women who were confined at home in 667 cases. Home Helps. The Council provided home helps in connection with the confinement in 321 cases. Consultant. The Council provided the services of a consultant in three cases of difficult labour. Maternal Mortality. The following table gives the puerperal mortality per 1,000 live and still births for England and Wales and Willesden resnertivelv since 1928:— England and Wales. Willesden. 1928 4.25 2.90 1929 4.16 3.95 1930 4.22 3.71 1931 3.95 3.06 1932 4.04 3.86 1933 4.32 5.07 1934 4.41 2.82 1935 3.94 2.73 1936 3.65 1.71 1937 313 3.17 1938 — 1.63* * The returns for the December, 1938, quarter have not yet reached the department, but as we almost invariably get early information of a maternal death through the health visiting staff this figure is not likely to require alteration. 22 It will be observed that in 1938 in Willesden this rate fell to 1.63 per 1,000. I am of opinion that the puerperal mortality rate can be reduced to 1.0 per 1,000 and that this should be regarded as the normal puerperal mortality rate. It will be observed that the efforts of the Council have reduced the rate very nearly to this figure, but there are still some gaps in the maternity organisation which require to be filled. I referred to four of these in my memorandum to the Committee on Motherhood in Willesden, dated November, 1936, namely:— (1) The need for increased hospital accommodation. (2) The need for adequate feeding to improve the fitness of the mother for childbirth and the nursing of the baby. (3) Better hospital provision for the care of the premature infant. (4) The appointment of a physician skilled in the care of infants during the early days of life. Effect has been given to the last of these recommendations, namely, the appointment of a physician skilled in the care of infants, but the others still require attention. Particularly is the demand for hospital accommodation increasing as may be seen from the following table:— Year. Domiciliary Cases attended by Midwives. Domiciliary Cases attended by Doctors. Births in hospitals and nursing homes. Total Births notified. 1931 515 1,174 1,110 2,799 1932 457 997 1,220 2,674 1933 532 776 1,357 2,665 1934 610 680 1,436 2,726 1935 589 568 1,706 2,863 1936 646 516 1,745 2,907 1937 760 465 1,906 3,131 1938 710 394 1,974 3,078 Ante-natal care remains the most important factor in maternity and this will not be available for the pregnant woman to the extent required until increased clinic accommodation and increased hospital accommodation has been provided. Only then shall we be in a position to attain the irreducible minimum of deaths of mothers in childbirth. GEORGE F. BUCHAN Medical Officer of Health. APPENDIX C. 11th April, 1939. MEMORANDUM ON THE CARE OF FOSTER CHILDREN. {Report approved by the Council and forwarded to the Association of Municipal Corporations.) The law relating to Child Life Protection is now contained in Part VII. of the Public Health Act, 1936, which came into operation on 1st October, 1937. This Act is a consolidating Act and although it contains certain amendments it was not devised to alter the existing law. In administering the Child Life Protection provisions of the Act the point which has impressed us most and with which this memorandum deals is the frequent changes of home to which a foster child is subject so that it finds no security in life at all. Frequent Changes of Home. The Willesden records show that of the 449 individual foster children under observation during the year 1937, 248 changed hands during 1937. 206 made one change, 31 made two changes, 8 made three changes and 3 made four changes. These changes do not include the first reception of the child. Of the 203 foster children under observation at the end of 1937, 66 had been in the foster mothers' care less than six months, 47 between six months and one year, 38 between one and two years, 32 between two and three years, 8 between three and four years, 4 between four and five years, 2 between five and six years, 5 between six and seven years, and 1 seven years. Lack of Recognition of Responsibility of Parent. There is no restriction on the frequency with which a mother may change her child's foster home. Indeed, in the law relating to Child Life Protection, the responsibility of the parent receives very little recognition. 23 A foster mother must notify that she receives a foster child but there is no obligation on the mother to notify that she has placed her child with a foster mother. A foster mother must notify where a child goes when it leaves her care but if it is to its mother that it returns the welfare authority has no further responsibility. The mother may be suitable or unsuitable, it may be impossible for her even to take the child in, she may pass it on anywhere and there is no obligation on her to notify what she has done with it. The law does not even arrange that the mother must necessarily know of change of address or change of foster mother or death of child. There is no obligation placed on her to keep the foster mother informed of her own address. The foster mother has responsibilities under the law to the welfare authority but the mother of the child has no such responsibility and is under no control. Cause of Change of Foster Home. The most general cause of change of foster home is the failure of the mother to pay or keep up her payments or some such financial reason. It may, however, be due to the fact that the foster child's character or health is such that no foster mother will keep him. It may also be due to the fact that the child's mother becomes a burden to the foster mother because she interferes with the foster mother's regime for the child or because she uses her child's foster home as a place of resort in her off duty time, expecting the foster mother to give her meals and generally to be regarded as one of the family. Example 1.—Four changes in a fortnight. 4-1-38—Miss E. applied to the Child Life Protection Visitor for a foster mother for her son J.E. born 30-11-37. The address of Mrs. G. was given to her. 7-1-38—Mrs. G. received the child with promise of payment. 16-1-38—Having received no payment Mrs. G. took the child back to the mother at 10 a.m. The mother refused to accept him and went into her room and shut the door leaving Mrs. G. and the child in the passage. Mrs. G. put the child on the mat, knocked at the door and called out " I have left your baby on the mat." The door was then opened by a man who picked the child up and took him into the room. 17-1-38—A notification was received by the Child Life Protection Visitor from a Mrs. X. stating that she had taken in a baby, J.E. When visited she said she had taken the child in at 6.30 p.m. on 16-1-38 out of pity. The mother had taken him to her in a taxi and stated that she had applied to an adoption society's hostel and had been referred to headquarters and advised meanwhile to see if Mrs. X. would take the child for the night. The child was screaming and his mother said he had had nothing to drink all day because she had no bottle. She left him with Mrs. X. with a promise of payment. 20-1-38—Mrs. X. returned the child to his mother because she had not received any payment. 21-1-38—The mother was heard of from the Health Department of another district where she went to enquire for a foster mother. This child changed hands four times in a fortnight and may be still changing hands in various districts. His mother told the Child Life Protection Visitor that she was employed as a mannequin and earned £5 a week. Example 2.-—Two changes in a week. M.K. was an illegitimate child born in the neighbourhood of Blackheath and fostered out there. Her mother went into service in Willesden. She found she could not afford the fares to and from Blackheath to see her child and pay the foster mother and so arranged with Mrs. S., a daily worker at the house where she was in service, to take the child temporarily. 10-1-37—M.K. was received by Mrs. S. in Willesden from a foster mother in Blackheath. 13-1-37—Mrs. S. reported the reception of this child and stated that she did not wish to become a registered foster mother but had taken the child for a few days until the mother could find a foster mother in Willesden. 14-1-37—The Child Protection Visitor visited the foster home. Her report as to the health of the child is as follows:— " Digestion poor, bowels very constipated, suffers a good deal with flatulence." Mrs. S. said that she could not keep the child any longer as it cried all night. The child was therefore transferred to Mrs. W. also in Willesden the same day 14-1-37. 15-1-37—Mrs. W. telephoned to the Child Protection Visitor to report that M.K. was very ill and unconscious and a private doctor had been sent for. Arrangements were made for the child's admission to the Willesden Municipal Hospital. 24 16-1-37—M.K. died in the Willesden Municipal Hospital, the cause of death being certified as gastro-enteritis. In this case there was difficulty in finding a suitable foster mother within reach of the child's mother and the child of four months' old was looked after by three different foster mothers within a week, one of whom did not want a foster child and only took it temporarily to oblige the mother. Example 3.—Four changes in six months. P.Q., born 22-4—38, was received by Mrs. M. 29-5-38. The child remained with her for two months. The Council refused to grant Mrs. M. a licence and the child was then received by Mrs. D. He remained there for one week only. Mrs. D. did not want the care of a young baby and also she had the chance of taking another foster child whose mother could pay more money. The child was then received by Mrs. H. who kept the child for four months. During that period the payments were few and very irregular. The child had scarcely any clothes. Mr. H. lost his work and was on unemployment insurance. Mrs. H. tried to get the foster child removed. She sent letters to the mother but these were returned address unknown. Mrs. H. applied to the Public Assistance Officer for the removal of the child as being deserted. She had to keep the child another week before he was removed to the Central Middlesex County Hospital. This baby had five different homes in six months. Example 4.—Four changes in four months. P.G. was born 30-12-37 in the Central Middlesex County Hospital. Mother and child had to remain in the Central Middlesex County Hospital for two months because the mother had nowhere to go. Eventually she persuaded a friend to give her a room and to fetch her from the hospital. The baby was taken to Mrs. R. She was a small, delicate child. The first 12s. 6d. was paid in advance but the mother could not produce the second payment so the baby was handed back to her. The mother was working and could not look after the child. She applied to the Child Protection Visitor for the address of another foster mother and she was given Mrs. W. The Child Protection Visitor also advised her to apply to the Crusade of Rescue for help. This was the girl's second child. The Crusade of Rescue had taken the first child. Mrs. W. took the child on a promise of payment but only kept her for one week. The child was then taken to Mrs. C. The Crusade of Rescue had taken the case over and paid Mrs. C. The child remained with Mrs. C. for two months and was then taken into one of the Crusade of Rescue Homes. This child had five different homes in four months. Example 5.—Nine changes in four years. M.W., born 8-2-35, a pale, nervous child with dirty habits, was moved on nine different occasions because the mother did not keep up her payments. The child had scarcely any clothes and what he did have had been given by the various foster mothers. On two occasions the foster mother had been unable to trace the mother and had taken the child back to his aunt. The aunt is poor and has several children of her own. The mother was found and made to remove her child, by the husband of the aunt. The Rescue Worker has had a great deal of trouble with the mother. She is said to have been living with various men. The last that was heard of the child was that he was with his mother in the King's Cross area. Example 6.—Mother a nuisance to foster mother. L.G., born 29-7-30, had seven different homes in a year. The mother paid regularly but when she went to see her child once a week she gave him sweets and cakes and kept him out late at night with the result that the child was sick and ill practically every time he went out with his mother. The boy was rude and difficult to manage. The foster mothers would not be bothered with him. He has been with the present foster mother for two years and appears to be happy and has made good progress in general health and at school. The present foster mother believes in discipline and is capable of exacting it. If the mother kept the boy out late one week she refused to allow her into the house the next week. The mother now co-operates with the foster mother. Fees. The Child Life Protection law takes no notice of fees. They are a matter of arrangement between the mother and the foster mother and no responsibility of the welfare authority. The fees paid for foster children in Willesden are generally 12s. or 12s. 6d. a week. They are sometimes as low as 5s. a week and only very occasionally as much as £1 a week. Frequently the payments are irregular and not infrequently they lapse altogether. Sometimes they never materialise at all. There is nothing the foster mother can do in such cases but (1) Give the child back to its mother ; (2) Get the child taken by the Public Assistance Department; (3) Keep the child for nothing. (1) Give the child back to its mother. This is not always easy and seldom satisfactory for the child. 25 Example 7.—Returning child to mother. The mother of K.C., reported to be earning 38s. 6d. a week, failed to keep up her payments. The foster mother, finding it impossible to keep the child without money and being unable to find the mother, applied to the Public Assistance Officer to take the child into the Institution. This was not done but the mother's address was traced and as a result of instructions received the foster mother eventually left the child at its mother's address with the result that the child was subsequently found abandoned in a church porch. Example 8.—Returning child to mother. Miss J. on a wet and foggy day knocked at various houses and enquired if anyone would take her three weeks' old child as a foster child. At last she found a Mrs. H., who agreed to keep the child for two weeks only as she was expecting a baby of her own in three weeks. Miss J. gave her address and promised to return with 10s. the next day. Miss J. was not seen again and had never been heard of at the address given. Mrs. H. took the child to the Public Assistance Officer but admission to the institution was not arranged until after Mrs. H. had been removed to hospital for confinement and the foster child left with a neighbour to leave with the Public Assistance Officer. This child died in the Institution. (2) Get the child taken by the Public Assistance Department. The Public Assistance Department will only accept responsibility where it is satisfied that the fullest enquiry has already been made by the foster mother as to the whereabouts of the parents. Meanwhile the foster mother has to go on keeping and feeding the child as best she can without money. See the two examples, Nos. 7 and 8, given immediately above. (3) Keep the child for nothing. Surprising as it may seem this is not infrequently done. Example 9.—Child retained for nothing. Miss H. knocked at Mrs. R.'s door and asked her if she would take her two months' old child in because she had failed to pay the foster mother who would not now keep the child. It was raining fast and Mrs. R. took the child in. The mother threatened " to do away with him " if she didn't. Miss H. promised to pay regularly but has failed to pay anything at all. Mrs. R. proposes legally to adopt the child. Example 10.—Child retained for nothing. Foster mother, Mrs. G.,has two boys for whom the payments have lapsed for years and whom she has continued to keep. One boy is now working. The other is 7 years old. Mrs. G. received him when he was two months old. His mother kept up the payments for one year and then disappeared. Example 11.—Child retained for nothing. Foster mother, Mrs. H., has a coloured child in her care aged 8 years. She has had her since six months of age and received no payments after the first few months. The foster parents would adopt this child but cannot trace the mother. The father was a native of West Africa. Standard of Living for Foster Children and Provision of Medical Attention. The law states that it is the duty of child protection visitors to satisfy themselves as to the health and well-being of foster children and to give any necessary advice or directions as to the care of their health and their maintenance but the law does not enable any particular standard of living to be insisted on. As indicated previously the fees paid to foster mothers are usually low. 15s. a week is nothing more than a reasonable sum on which to maintain a child in Willesden. But the 15s. a week child life protection foster child is in the minority and the initial outfit with which it goes to its foster mother usually the scantiest. In the cases dealt with in child life protection work the child's mother often has very little or no money and must find a foster home to suit her purse. It is not possible, therefore, for the welfare authority who are making no payments to exact any great standard of living and to say, for instance, that all foster children must have a pint of milk a day. A further matter which causes considerable concern is the provision of medical attention for foster children. We are informed that only persons who are destitute and unable otherwise to obtain medical attention are entitled to the services of the public assistance district medical officer and that a foster mother who takes a child for reward should look to the parent to pay the cost of any medical attention—a vain hope in most cases. This being so, it seems to us only human nature that a foster mother, especially if payments are irregular or in arrears, will hesitate before calling in a doctor for a foster child. Further, we understand that the procedure to obtain the services of a district medical officer is by application to the nearest relieving officer, a procedure which in emergency is likely to involve delay which a mother would not risk in the case of her own child. 26 Example 12.—Medical attention. R.C.S., aged 2 years, the illegitimate child of a married woman, was placed in the care of a foster mother, Mrs. P. The mother got into arrears with her payments. This child had an accident when in the care of the foster mother. He was left in the bathroom with the foster mother's own child for a few minutes. During the period the foster child climbed up the side of the bath and fell into half a bathful of water. When the foster mother returned she found the child in the bath with his head under the water. The child was unconscious, the foster mother partially revived him and although the child appeared to be still very ill she did not send for a doctor. The child appeared to be worse at night and the foster mother had said to her husband : " If this child isn't better I shall have to call a doctor in the morning." The child was found dead in bed next morning. The post-mortem revealed that the child's death was due to meningeal haemorrhage which could have been caused through falling into the bath. The foster mother's reason for not sending for a doctor was that she did not want to have a doctor's bill if it could be avoided because the mother was already in arrears with her payments and she herself would have to pay the doctor. The woman did not think that the foster child's fall was serious. This case would suggest that it is desirable that a foster mother should be able in an emergency to call in the Public Assistance doctor without the procedure of having to go to the Public Assistance Officer. The Mother's Difficulties. The majority of foster children are illegitimate. Their mothers are frequently in employment and may work up to a month before confinement. During this last month when they are not employed they must keep themselves and make some provision for the child. They are generally confined in hospital. At the end of ten days or a fortnight they are discharged. They have no money left. They have nowhere to go. They are handicapped by the child. It is important that they get work at once. What often happens seems to be that such a mother finds some woman who perhaps out of kindness or perhaps in hope of money later on, takes the child whilst the mother searches for work. The child may be well cared for or not, but in any case the mother probably in the circumstances does not enquire too closely. She is glad to get anybody to take the child. If she gets work and pays the woman it may be that the child stays on for a time but if the payments are small and irregular the child may be passed from one woman to another, finding no stability in life at all. Mothers do not know how to find foster mothers for their children. Further, for the most part they have not the knowledge or experience or the incentive to judge as to the suitability of possible foster mothers. The law does not help mothers out of their difficulties. The law does not make it the duty of a welfare authority to find or recommend foster mothers. Example 13.—The mother's difficulties. On 17th February, 1937, Miss H. called at the Municipal Health Centre to ask for the names and addresses of foster mothers with vacancies. Miss H. said her child was born in Kingston and was now three weeks old. She came to Willesden to be near a sister who was in service and took a room in Hampstead whilst looking for a situation. She placed her child with a foster mother in Paddington. She had not been able to pay 12s. 6d. in advance as required because she was without money but had promised to pay with her first week's earnings. She had obtained a situation to go to on 18th February, 1937, but on 16th February, 1937, the foster mother brought the child back to her, stating that the Paddington Authorities would not allow her to keep it. Miss H. said she owed a week's rent for her room, she was now penniless and had no money to buy food for the child and had only had a cup of tea that day. She could not go to work unless she could find a foster mother. There was no foster mothers in Willesden with vacancies. Miss H. was therefore urged to go at once to the Hampstead Relieving Officer. It was subsequently ascertained that she did this and that the Hampstead Relieving Officer telephoned to a Rescue Worker who found a temporary foster mother and later a permanent one in Wembley. The mother was thus enabled to go into her situation on 18th February, 1937. 27 Observations. This case illustrates a mother's difficulties when she comes out of hospital with her child. It shows the difficulty she has in placing her child suitably before she has money to pay for its care and until she has placed her child she cannot go to work to earn the money. It also shows the need for suitable foster mothers to be readily available. It further illustrates the hazardous life of the child from the time it leaves hospital at least until its mother gets work and shows the frequent changes of home and mothering to which it is subject. This child of three weeks old passed from the care of its mother to foster mother A, from foster mother A back to its mother, from its mother to foster mother B and from foster mother B to foster mother C, all in the space of a few days. Defects in the Child Life Protection Law. (1) Insufficient control by the Welfare Authority over the Foster Mother, the Foster Child and the Child's Mother. (2) Shortage of Foster Mothers. Requests are being constantly received from parents, rescue workers, hospital almoners and others for addresses of possible foster mothers and only a small percentage of these can be met. It is not unusual for applicants to state when they ring up Willesden that they have already tried London and neighbouring districts in vain. Suitable women are chary of becoming foster mothers on account of:— (1) The small payments. (2) The irregularity of the payments. (3) The possible or even probable lapse of payments altogether. (4) The difficulty and delay in getting help from Public Assistance Departments when foster children are left on their hands. (5) The knowledge that at any time a child whom they have become fond of may have to be parted with. (3) Impairment of health and well-being of Foster Children. (1) The children are suffering on account of their hazardous lives from the time they leave hospital until their mothers get work. (2) The children are suffering both physically and mentally on account of the frequent changes of home and the different mothers under whose care they come. Suggested Remedies. (1) The amendment of the law to give Welfare Authorities better control over Foster Mothers, Foster Children and Foster Children's Mothers. This would require a careful and thorough examination of the present position and consideration of the best means for improvement. (2) The payment of foster mothers directly by Welfare Authorities—part or all of the fees to be recovered by the Welfare Authorities from the parents. This should be a duty placed by law on all welfare authorities alike. Payments to foster mothers could thus be made secure and sufficient. (3) Applications for placing children with foster mothers to be made by the mothers to the Welfare Authority. (4) The establishment by the Welfare Authority of a Home or Clearing House in which when necessary children could be received straight from hospital or in other emergency until placed with a suitable foster mother. (5) Mothers' pensions. It hardly seems that these would solve this particular problem but they might be desirable in some cases. Although illegitimacy is not the severe social handicap it was years ago the majority of these girls still desire to keep the knowledge from their friends and usually do not want to be hampered with a baby. They prefer to work and be free. 28 APPENDIX D. 11th July, 1939. NEED FOR DAY NURSERY. Mothers make use of a day nursery in the following circumstances:— 1. Because they go out to work either from necessity or from a desire for a higher standard of living or from inclination. (This is the main reason for the use of a day nursery.) 2. Because they are ill. 3. Because they have to be away from home temporarily, e.g., to attend hospital; to look after a sick relative ; to do shopping. Mothers' needs may be met in several ways:— 1. By the establishment of Day Nurseries (children up to 5 years). 2. By the establishment of Nursery Schools (children 2 to 5 years). 3. By the establishment of Nursery Classes attached to Public Elementary Schools (children 3 to 5 years). 4. By the establishment of a system of day foster mothers (children up to 5 years). 5. By assisting the mother to stay at home to attend to the child (children up to 5 years). Nos. 2 and 3 come within the province of the Education Committee of the Council and this branch of work is developing in Willesden. The establishment of Nursery Schools and Classes lessens the need for Day Nurseries, particularly as they are cheaper for the mothers than Day Nurseries, but does not entirely do away with the need, as the hours during which Day Nurseries are open more nearly correspond with the mothers' working hours than do the hours of Nursery Schools and Classes, and children under 3 years of age are not admitted to Nursery Schools and Classes to any extent. Nos. 1, 4 and 5 can be undertaken by the Council under the Public Health Act, 1936, Section 204 and Circular M. & C. W. 4, paragraphs 31 and 33. No. 5 would seem to be the natural solution of the difficulty and the one which would be in the best interests of the mother and the child and the family generally from a public health point of view. Nevertheless, it is doubtful if this would in all cases meet the mothers' views. It has to be recognised that in not a few cases the mother finds going out to work more attractive than home life, and even if there is no actual necessity for her to go out to work she may desire the extra money for a higher standard of living. It should be observed that if method No. 5 were adopted it would be very difficult to say who should or should not be going out to work. No. 4 most nearly approximates No. 5 when No. 5 is not possible. In view of the increasing number of Nursery Schools and Classes, it is likely that Nos. 4 and 5 would meet the remaining cases, the majority of which would be under 2 years of age and these are certainly better in their mothers' care. Applications received by the Health Department during 1938 for daily care of children. Health Centre (1) 6 Health Centre (2) 10 Health Centre (3) 6 54 Winchester Avenue 8 30 PRINCESS DAY NURSERY, 47 AND 49, CHICHESTER ROAD, N.W.6. Attendances. The number of places for children under 5 years of age is 52. The Nursery is open on Mondays to Fridays, both days inclusive, from 8 a.m. to 6 p.m. The children pay 10d. a day which includes two meals. The attendances during the past 5 years have been as follows Year. Attendances. Daily Average. 1934-35 8,099 37 1935-36 8,894 42 1936-37 7,552 38* 1937-38 7,508 36 1938-39 7,639 37 * Note by Dr. Shattock in Annual Report as follows:—" The number of children attending the Nursery is below that of the previous year, the diminution being mainly among the older children. The fall in numbers is probably temporary and due to the opening of nursery classes for children over three in a school in the neighbourhood. The proportionate increase in toddlers and infants at the Day Nursery has thrown more work on the staff in charge of these children and may necessitate some rearrangement in the routine of the Nursery." In 1931 the Nursery was arranged for:— 8 children under the age of 1 year. 20 children between 1 and 2½ years. 24 children between 2½ and 5 years. 52 29 At the present time they have to refuse children because although there are vacancies in the older group there are more applicants than there is accommodation for in the infants' group. The children are not limited to Willesden residents. In 1938-39 6,722 of the 7,639 attendances were made by Willesden residents and 917 by Hampstead and Paddington residents. At June, 1939, the numbers in attendance were as follows:— Willesden residents 41 Non-Willesden residents 12 Total 53 The ages of the Willesden residents were:— Under 1 year 5 1-2 years 19 2-3 years 14 3-4 years 0 4-5 years 3 Total 41 Refusals. Babies under 1 year are often refused admission owing to lack of accommodation. Staffing. The staff at the Princess Day Nursery is as follows:— 1 Matron. 1 Sister. 1 Staff Nurse. 1 Junior Staff Nurse. 3 Probationers. Voluntary workers. Some time of a Medical Officer. Domestic staff. Maintenance. The expenditure for the year ended 31st March, 1939, was as follows:— £ s. d. By Medical Officer 19 12 0 Salaries 508 11 9 Furniture and Equipment 20 10 5 Repairs 70 19 0 Rent, Rates and Taxes 70 8 2 Heating, Lighting and Cleaning including Laundry 160 14 8 Printing and Postage 9 18 11 Telephones 15 2 1 Food and Provisions 263 0 1 Drugs 9 5 3 Sundries 5 8 0 Bank Interest 5 3 0 Interest on Loan 5 0 0 £1,163 13 4 The income for the year ended 31st March, 1939, was as follows:— £ s. d. To Grants from Willesden Council for year ended 31st March, 1938 365 3 0 Payments by mothers 311 14 3† Subscriptions and Donations 404 1 2†† Sales and Entertainments 164 16 9†† Students' fees 10 6†† £1,246 5 8 † It is doubtful if as large a sum as this would be forthcoming under the Council's regime. †† It should be noted that these sums would not be forthcoming under the Council's regime. There is an overdraft in connection with the Day Nursery of £66 0s. 4d. There is an impending expense of some £200 in respect of a defective wall. 30 Premises. The Day Nursery premises at 47 and 49, Chichester Road are leasehold with about 18 years unexpired at a ground rent of £1 10s. per annum each, and both houses are held direct from the Ecclesiastical Commissioners. They were valued for the Princess Day Nursery Committee at the end of June at £400 each. The Princess Day Nursery Committee desire to hand over the Nursery to the Council as a going concern. They must sell the houses but propose to present the Council with the furniture and equipment. PRINCESS ROAD WELFARE CENTRE. Mrs. Figgis states in her letter:—"We mean to continue to work at Princess Road," i.e., the Welfare Centre. This work includes:— 3 Infant Consultation Sessions a week. 1 Ante-Natal and Nursing Mother Session a fortnight. 2 Light and Massage Sessions a week. 1 Margaret Morris Exercises for Toddlers session a week. Minor Ailments daily 9.30 to 10.30 a.m. There appear to be no sessions held at the Centre on Monday afternoons, Wednesday afternoons, Thursday mornings (except 9.30 to 10.30 a.m.), Friday afternoons or Saturdays. The work undertaken appears to be:— Infant Welfare Consultations. Ante-Natal and Nursing Mother Clinic. Treatment of Minor Ailments. Light Treatment. Massage Treatment. Margaret Morris Exercises for Toddlers. Health Talks. Sewing Class—discontinued July, 1938, on account of poor attendance. Some Mothers and Children sent away during the summer. A few Children sent to Convalescent Homes through the Invalid Children's Aid Association. Garden Parties for the Mothers. Christmas Social. Christmas Parcels. Christmas Tree Party. Home Visits by Health Visitors. Supply of Dried Milk and Nutritive Foods. (Supplied free to the Voluntary Centre by the Council for cases below the Council's Economic Circumstances. Scale.) Attendances. The attendances for the year 1938-39 have been as follows:— Infant Welfare Consultations 5,861 Ante-Natal and Nursing Mother Clinic 279 Minor Ailment Treatment 185 Light Treatment 1,136 Massage Treatment 489 Margaret Morris Exercises for Toddlers ? Health Talks 283 Sewing Class 132 (Discontinued July, 1938.) Mothers and Children sent away during the summer 14 Mothers. 19 Children. Home Visits by Nurses— to Children under 5 years 3,979 to Expectant Mothers 500 31 Staffing. The staffing at the Princess Road Voluntary Centre is as follows:— 1 Medical Officer, part time. 1 Superintendent. 1 Assistant. 1 Masseuse, part time. Voluntary workers. Domestic staff. Maintenance. The expenditure for the year ended 31st March, 1939, was as follows:— £ s. d. By Medical Officer 263 11 0 Salaries 670 4 7 Furniture and Equipment 15 4 10 Repairs 3 15 6 Rent, Rates and Taxes 72 14 7 Heating, Lighting and Cleaning, including Laundry 53 13 0 Printing and Postage 14 8 2 Telephones 12 14 8 Milk 159 7 7 Drugs 17 17 11 Sundries 4 0 6 Bank Interest 5 2 6 Interest on Loan 5 0 0 £1,297 14 10 The income for the year ended 31st March, 1939, was as follows:— £ s. d. To Grants from Willesden Council for year ended 31st March, 1938 597 5 6 Payments by Mothers 17 16 6 Payments by Mothers for Light Treatment 10 1 6 Subscriptions and Donations 418 4 6 Sales and Entertainments 145 3 4 Sale of Milk 170 0 11 Sale of Drugs 20 6 2 Sale of Flannel 1 4 0 £1,380 2 5 There is an overdraft in connection with the Welfare Centre of £160 7s. 1d. In connection with Princess Road Welfare Centre, it should be borne in mind that patients who attend there still have to attend Municipal Health Centre (1) for dental treatment, for examination by Obstetrician, for booking for confinement, for ear, nose and throat conditions, eye conditions, skin diseases, cleansing and Municipal Health Centre (3) for orthopaedics, and that dried milk and nutritive foods are supplied free to the Voluntary Centre for necessitous cases by the Council. Pending the establishment of the Council's proposed Health Centre (4), if the Council desire to take over the Voluntary Centre the most satisfactory arrangement for the public and from the administrative and economical points of view would be to transfer the Princess Road Welfare Centre work to Health Centre (1), transferring also the Princess Road two Nurses and appointing a wholetime Medical Officer. GEORGE F. BUCHAN, Medical Officer of Health. 32 APPENDIX E. 19th July, 1939. HOUSES FOR MIDWIVES. It is suggested that two houses be obtained for Midwives, one in the neighbourhood of Nicoll Road area and one in the neighbourhood of Dyne Road. If possible, garage accommodation or space for garages should be associated with each of these houses. Each house would accommodate two Municipal Midwives and two Pupil Midwives. The annual cost of upkeep of each house is estimated as follows :— 1. House. £2,000 at 4% for 30 years 115 2. Furniture and equipment, £500 at 4% for 10 years 61 3. Repairs to house 40 4. Rates and taxes 80 5. Telephone 24 6. Replacement of furniture, linen, utensils, brushes, etc., at 15s. per week 39 7. Domestic laundry and personal laundry of Midwives and Pupil Midwives to be undertaken at the Municipal Hospital at 15s. per week 39 8. Heat and light at £1 per week 52 9. Cleaning materials at 5s. per week 13 10. Food for 5 at 15s. per week each 195 11. Domestic Help at 35s. per week 91 £749 The provision made for domestic help is small because it is anticipated that the Midwives and Pupil Midwives would help with the keeping of their own rooms in order. Present Cost to Council and Midwives. If a house were established as above, the following present costs would be saved:— £ Council—Telephones at £12 per annum per Midwife 24 Laundry for 2 Midwives at £10 per annum per Midwife 20 Laundry for 2 Pupil Midwives at £10 per annum per Pupil Midwife 20 Maintenance of Pupil Midwives at £2 per week 208 £272 Midwives—Charges for board residence— 2 Midwives at £2 5s. per week 234 Total £506 Additional Cost. It will be observed that the additional cost per annum is estimated at £243 per house. It is suggested that this additional cost be met as follows:— (1) that the two Midwives assume responsibility for the running of the house, the provision of food and the provision of domestic help at an estimated cost of £286, being an increase on their present payments of £52 per annum or 10s. per week each ; (2) that the Council assume responsibility for all other payments estimated at £463, being an increase on their present payments of £191 per annum. These suggestions have been placed before the Midwives concerned, and I am unable to say that they entirely approve of the suggestion of an additional payment by them of 10s. per week each. GEORGE F. BUCHAN.