Lcc 52. LONDON COUNTY COUNCIL REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1946 Published by the London County Council, and may be purchased, either directly or through any bookseller, from Staples Piess Limited (incorporating P. S. King & Staples, Limited), 14, Great Smith Street, Victoria Street, Westminster, S.W.I, Agents for the sale of the publications of the London County Council. No. 3610. Price 2s. Od. Post free 2s. 3d. 1947 London County Council V REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1946 By Sir Allen Daley, M.D., F.R.C.P., K.H.P., County Medical Officer of Health and School Medical Officer INTRODUCTION The difficulties through which the country passed in 1946 were, to a large extent, reflected in the public health work of the Council. Not only did the shortage of housing accommodation result in the number of applications for rehousing on grounds of ill-health being increased to more than ten times that for 1945 (p. 28), but the priority given to the building of housing accommodation retarded the work of reinstating the accommodation in hospitals, schools, etc., which had been reduced by enemy action during the war. Many public health activities had to be carried on in buildings, such as school treatment centres, which were still war damaged. The shortage of manpower in the country generally has also been reflected in the Council's public health work, q,nd, in spite of strenuous efforts to recruit the necessary staff, especially nursing and domestic, the shortage has been so acute that some thousands of equipped beds are closed because of lack of nursing staff. Large numbers of Londoners returned to the metropolis during the year and the population, which had dropped from the pre-war figure of 4,000,000 to 2,500,000 at the end of the war, rose again above 3,000,000 (p. 2). By the end of the year it was estimated to be 3,277,100. The birth-rate (20.0 per 1,000 of the total population) was in the region of 50 to 60 per cent, above the pre-war level, and was higher still during the first half of 1947. General mortality (death-rate 12.6 per 1,000 of the civil population) showed a return to pre-war level, especially was there a reduction in the number of deaths from heart disease, cancer, tuberculosis (in which the ground lost during the war has been recovered), and respiratory diseases. The fatality from infectious diseases has also continued to fall, while in infant and maternal mortality low records have been attained. The rate of infantile mortality was 38 per 1,000 live births, compared with an average of 63 during the ten pre-war years. The neo-natal and maternal mortalities were 22 and 1.26 per 1,000 live births, compared with the averages for ten years prior to the war of 25 and 2.9. Although much remains to be done to secure more extensive immunisation against diphtheria, there are evident signs of the success of diphtheria prophylaxis (p. 11). The number of cases of venereal disease is greater than before the war, and, probably owing to the enlightenment of the public as to the dangers of the disease, the number of persons attending the clinics and found not to be suffering from venereal disease was almost double that for 1938 (p. 29). On the other hand, there has been a sharp decline in the number of notifications under Regulation 33B. This is probably due to extensive demobilisation during the year, as the majority of the notifications came from the Services (p. 30). As less bed accommodation was available for the treatment of tuberculosis, more patients were treated at home, and the waiting list for residential treatment 700 (M.C. 521155-6) 1-12-47. 3735. (1) A 2 has increased substantially (p. 33). Mass miniature radiography has been continued. The number of patients needing sanatorium treatment discovered by this means during the year was 90, compared with 77 in 1945 (p. 36). The domiciliary midwifery service continued to expand, and, in spite of the reduction in the population of London, the number of domiciliary confinements was considerably higher than before the war. The number of institutional confinements has increased also, but not to the same extent (p. 39). A feature of the work of the Council's hospitals has been the extension of the various forms of association with the voluntary hospitals (p. 50). Thanks to the co-operation of the British Red Cross Society, it was possible to develop considerably the work of the hospital libraries and to inaugurate a picture library scheme (p. 54). During the year a number of posts were established for demobilised Service doctors. Post-graduate refresher courses were held for ex-Service doctors and panel practitioners (p. 54), and a pharmacists' advisory committee was formed to advise on matters affecting the pharmaceutical service (p. 53). Another feature of the year has been the restoration of most of the functions allocated to the hospital committees before the war (p. 52). The return of large numbers of children to London during the year involved a considerable increase in the work of the School Health Service. Despite the difficulties and shortages, the school children of London appeared to be as healthy as they were before the war. There was a higher percentage of children whose nutrition was recorded as excellent, and a lower proportion of children were assessed by the school doctors to have subnormal nutrition (p. 69). This is a tribute to the arrangements by which they received special consideration in the rationing schemes. There was a lower incidence of children with pathological conditions of the ear, nose and throat, and a smaller proportion of children with dental defects in 1946 than in 1938 (p. 69). There was a higher proportion of children with normal eyesight in 1946 than in 1938 (p. 69). The incidence of heart defects was less than half that recorded in 1938, and there appeared to be a decrease in the incidence of juvenile rheumatism (p. 70). The overall incidence of verminous conditions and of scabies was lower in 1946 than in 1938 (p. 71). The percentage of children referred for treatment who obtained it was higher than in 1938 (p. 72). At the request of the Ministry of Health a unit has been established at Sutton Emergency Hospital for the in-patient treatment of industrial workers suffering from neuroses (p. 80). During the year, Miss J. M. Calder was appointed a principal matron, and Dr. G. Chaikin, divisional medical officer, who had been in charge of school health work in the east end of London for many years, retired after 37 years' service with the Council. It is a pleasure to record that, during the year, the O.B.E. was conferred on Mr. A. G. Hellman, officer-in-charge, London Ambulance Service; and that the B.E.M. was awarded to the following members of the staff: Miss P. McCarthy, ambulance driver, L.A.A.S.; Mrs. M. E. Pegg, auxiliary station officer; Miss A. E. Cook, domestic assistant, St. Alfege's Hospital; Miss F. Merritt, domestic assistant, Mile End Hospital. Population VITAL STATISTICS The Registrar-General estimates the civilian population of the county in the middle of 1946 to have been 3,109,240, compared with 2,601,370 a year earlier. The corresponding estimates for metropolitan boroughs are shown in table 3 on page 18, and the rates given in this annual report are calculated upon these figures. 3 Table 1 shows the size and age distribution of the population at the middle of each year from 1921, as estimated by the Registrar-General. The effect of the falling birth-rate between the two wars is indicated by the last column of the table, in which the average age of the population is shown. Despite a fall in the total population, the number of people over the age of 65 increased between 1921 and 1938 by over 30 per cent. This ageing of the population, apart from the long-term tendency to depress the standard of living owing to the contraction in the productive section of the community, has a more immediate effect on the mortality trend. Any increase in the proportion of the population in the advanced age groups must tend to increase the crude rates of mortality from those diseases such as degeneration or neoplasm which operate mainly in these age groups. Mortality is discussed later, but it is pertinent to point out that the increase in the average age of the population does not arise only from the fall in the birth-rate. The reduction in mortality at young ages, though now less dramatic than at the end of the 19th century, still continues, and more people reach a ripe old age. Migration loward the end ot the third decade of this century, there began an accelerated movement of population from the centre of London, i.e., the administrative county, to the growing urban areas in the outer ring of greater London. This was partly due to a desire of the population for a dormitory in less industrial surroundings though they continued to work in the central area, partly due to the drift of industry to new factory sites on the fringe of the London area, and partly due to the active steps taken by the Council to decant population from overcrowded slum areas to new housing estates wherever these could be provided, in most instances outside the county. The net loss to the county in each year up to 1938 is shown in table 2. This migration was selective in so far as the people who moved were younger and, speaking generally, better in circumstances and health than the average. Some evidence of this selection is given in the fourth column of table 2, where it is shown that, about 1926, coincident with the acceleration of this outward movement, the death-rate in the outer ring improved in comparison with the administrative county, i.e. the ratio of outer ring to county mortalitv began to fall. Fertility lhe total births allocated to London for 1946 were:— Live 65,883 Still 1,598 Total 67,481 This corresponds to a crude live birth rate (see remarks below) of 21.2 per 1,000 civilians. The provisional figure for marriages is 36,224, or 23.3 persons married per 1,000 of the civil population. Prior to the war, the birth-rate in London followed the same trend as for the country as a whole but running at a lower level. Immediate pre-war values per 1,000 living were:— 1931-35 13-8 average 1936 13-6 1937 13-4 1938 13-4 During the war years and since, rates have had to be based upon the civil population though the births included those registered in respect of non-civilians. In view of the artificial character of these rates, it is not proposed to reproduce them here, though for comparability it is necessary to quote them in tables 3 and 4. The Registrar-General agrees that it would be justifiable to correct these "civilian" rates by multiplying them by the ratio of the civilian to the total population of England and Wales as a whole for each year (i.e., assuming that the recruitment to the forces affected London to the same degree as the whole country), and he has kindly supplied these ratios. The approximate values thus obtained for the true birth-rates are:— 4 1939 13.4 1940 14.3 1941 13.5 1942 15.4 1943 16.1 1944 16.2 1945 15.7 1946 20.0 Thus it is evident that, partly as a natural consequence of the return of men from service overseas, and partly as a result of the war-time disturbance of the normal marriage rate associated with Service movements, the current birth-rate in London, as elsewhere in the country, is in the region of 50-60 per cent, above the pre-war level, but the history of the period following the 1914-18 war shows that substantial changes can occur in a comparatively short time, and it remains to be seen whether this rise is merely an expression of postponed reproduction or whether any political or economic measures already taken, or likely to be taken, will succeed in sustaining this rise. Illegitimacy There were 5,283 illegitimate births (8-0 per cent, of the total live births). Percentages in recent years are:— London England and Wales 1938 6.3 4.3 1939 5.9 4.2 1940 6.1 4.3 1941 7.4 5.3 1942 7.4 5.5 1943 8.2 6.3 1944 9.3 7.2 1945 11.4 9.4 1946 8.0 6.7 It appears that the peak of the inevitable war-time rise occurred last year and that the trend may now be downward. Deaths under one year among illegitimate infants amounted to 61 per 1,000 live births, compared with a rate of 36 for legitimate births. The corresponding rates in 1945 were 63 and 42, respectively. A detailed comparison of deaths in the legitimate and illegitimate groups is given in table 8, page 23. Stillbirths There were 1,598 stillbirths in 1946, or 2-37 per cent, of all births (legitimate 2-33, illegitimate 2-81). The number of stillbirths and the rate per 1,000 total births in each year since 1928 is shown in table 7, from which it will be clear that since 1942 there has been a considerable fall in the frequency of stillbirth. As to the reasons for this fall no precise answer can be given. In examining the decline of 27 per cent, in the national stillbirth rate over the period 1938-1944, Sutherland (Lancet—1946, 2, 955) suggests that better economic conditions, together with the greater nutritional opportunity resulting from the controlled distribution and priorities, have improved the ante-natal care of the pregnant woman and lowered the stillbirth rate. Nutrition in pregnancy has an important effect upon both mother and infant. Nutrition studies for example in the Rhondda and Toronto and, in particular, the careful experiments conducted in London from 1938 by the People's League of Health have shown that dietary supplementation, where deficiencies have previously existed, produce striking reductions in the frequency of miscarriages, stillbirths and premature births. As the war progressed, the expectant mother became a nutritional priority, and there is little doubt that, especially in the lower income groups, the attention given to food and well-being was of great benefit to the mother and to the child. The importance of this improved wellbeing of the mother is emphasised by the fact that the stillbirth rate declined, while the proportion of "first maternities" (where the risk of stillbirth is greatest) was rising and the average parity was falling. This is illustrated by the following figures for England and Wales, taken from the RegistrarGeneral's Statistical Review for 1942, Part II:— 5 Year Total legitimate maternities First maternities as a per cent, of total maternities Average number of previous maternities (live or still) Stillbirth rate 1939 606,203 42.0 1.42 37.8 1940 592,634 43.1 1.39 36.1 1941 558,205 44.3 1.38 34.4 1942 625,985 45.4 1.27 33.0 On the other hand, the average age of females at marriage fell gradually from 26.05 in 1939 to 25.66 in 1942; but, while this would mean younger maternities with a lower stillbirth risk, the change is relatively small. Unfortunately, the figures stop short at 1942, and tell nothing about 1943 when the stillbirth rate fell from 33 to 30, a larger drop than ever previously recorded, and the rate in London fell from 29.3 to 24.6, a sharper fall still. Since 1943, the London (and the national) stillbirth rate has declined very gradually, so that the fall in 1943 can only be explained by reference to some sudden and permanent change in ante-natal conditions or in the average calibre of mothers in late 1942 or early 1943. With regard to nutrition, the egg priority to expectant mothers began in the winter of 1941-42, but no information is available as to the timing of the full effect of this scheme, nor is there any measure of the extra number of eggs coming into the family where there was an expectant mother. The distribution of vitamin preparations was extended to expectant mothers later in 1942, but there is doubt as to the effect owing to the fact that the take-up of the vitamin supplements was disappointing—for fruit juices it has not exceeded 46 per cent, of the potential issue, while for cod-liver oil the corresponding figure is 21 per cent. No clues can be sought in the causes of stillbirths because these are not officially recorded in this country. Causes of stillbirth are recorded in Scotland, but the pattern of movement of the stillbirth rate in that country has been different from that experienced in England and Wales. The following figures for Scotland do suggest, however, that the major factor in the decline of the stillbirth rate has been an improvement in the health of the mother, i.e., the risk attributable to disease of mother has declined to a relatively greater extent than the other risks:— Stillbirths in Scotland Year Stillbirth rate Disease of mother Causes of stillbirth (rates per 1,000 live births) efined Anomalies of foetus, placenta or cord Death of foetus by injury or other cause 1939 42.2 1940 42.1 — — — — 1941 39.6 — — — — 1942 38.2 11.2 9.4 11.3 6.3 1943 35.6 9.4 8.7 10.6 6.9 1944 32.5 8.2 8.6 10.3 5.4 lhe total civilian deaths in 1946 amounted to 39,103, or 12-6 per 1,000 of the Mortality civil population. Detailed figures are given in tables 3, 4 and 5, on pages 18.21. Mortality from infectious disease is discussed below under that heading, and tuberculosis is dealt with separately. For the latter and other principal causes of death the trend is indicated by the diagrams on page 7. The discontinuity between 1939 and 1940 is attributable to two causes. In the first place, the Registrar-General abandoned the rules of selection which had hitherto operated in multiple causes of death, and, as from 1940, accepted the principal cause of death as shown on the medical certificate. In addition, the International List of Causes of Death, which was revised in 1938. was applied in 1940 in accordance with international agreement. The chief movements resulting from these alterations are estimated to be:— B 6 Cause Approximate change as a percentage of those formerly assigned to this cause* Influenza — 11 per cent. Cancer - 3,, Diabetes - 30,, Heart disease - 10,, Other circulatory diseases - 6,, Bronchitis + 100,, Pneumonia + 5 ,, Other respiratory diseases + 50,, Nephritis + 12,, Diseases of pregnancy, etc. + 10,, * Based on the dual classification of deaths for England and Wales, 1939. The second cause anecting the statistics was the outbreak 01 war. A young ana healthy section of the population was, from September, 1939, excluded from the mortality statistics, which henceforth related only to civilians. This selective factor was bound to inflate the death-rates, since the population in respect of which they were calculated was now on the average older and less healthy. To mark the discontinuity in the diagram, the curves have been broken at 1939. In so far as the slopes of the curves before and after 1940 are more important than absolute figures, it is possible to take the two parts of the diagram together and to observe continuity in trend. To reduce the confusing effect of the large-scale reclassification of deaths, heart disease and bronchitis have been combined. The death-rate from all causes, which, with the increasing age of the population, had been slowly rising before the war rose sharply in 1940. This rise was partly a feature of the war-time statistical basis as explained above, but the heavy toll of air-raids (2.59 per 1,000 in 1940) was an important contributory factor. Even in 1945 the fatality from V-bombs was 0.34 per 1,000. The rate for 1946, at 12.6, represents a close approach to the pre-war level. Tuberculosis Another cause of the rise in the death-rate, notably in 1941, was the increase in deaths from tuberculosis. This rise was only temporary and measured the effect of war conditions in hastening the death of those with advanced tuberculosis. The war-time experience in both mortality and morbidity is more fully discussed in a later paragraph. Bronchitis and heart disease The death-rate for the bronchitis and heart disease group has followed a similar trend to that of the rate for "all causes" of which it forms a large part. Figures for the component diseases are shown in table 4 (page 19). Mortality from heart disease and bronchitis, after reaching a higher level in the early years of the war, subsided, and for the last two years has declined. Pneumonia and other respiratory diseases Mortality trom pneumonia rose sharply in ia-lU and remained higher than formerly until 1943, when it began to fall, reaching in 1945 and maintaining in 1946 a level lower than the average of the immediate pre-war years. The rate for "other respiratory diseases" was distorted in 1940 by the statistical revision but has since declined fairly steadily. Diabetes Diabetes mortality tell steadily throughout the war. rood rationing has presumably been a contributory factor. Cancer Despite the ageing of the population, the cancer death-rate has declined in the last two years. A disturbing feature of the cancer statistics has been the persistent rise in recorded deaths from cancer of the lung. The mortality from cancer of the respiratory system as a whole in London has between 1931 and 1946 almost doubled for men, and increased by a third for women. The Registrar-General, in commenting on the national figures in the Text of the Statistical Reviews, 1938 and 1939, remarks on the fact that the standardised death rate from cancer of the lung in males rose 78 per cent, between 1931-35 and 1939 and he is not yet prepared to say whether this 7 8 increase " is entirely or only partially due to radiological diagnosis." In New York, where in the period between 1931 and 1945 the mortality from cancer of the lung increased from 7.6 to 20.2 per 100,000 for men and from 3.6 to 5.7 for women, a greater rise than experienced in London, the authorities consider the rise to be greater than can be accounted for by mere improvement of diagnosis and sufficiently extensive to suggest the operation of environmental hazards.* Road accidents Deaths from road accidents are analysed by age in table 6, page 21. The re-issue of a basic petrol ration during 1945 and the corresponding increase in motor traffic was reflected in a rise in fatal road accidents, but there was no further advance in 1946. Infant mortality The iniant mortality rate in 1946, 38 per 1,000 live hirtns, constitutes a new low record, an improvement on the rate of 44 per 1,000 live births in 1945. The movements of the death-rates from the principal diseases at ages below one year since 1911 are shown in table 9, page 23. The following diagram illustrates the contraction in the fatality of infants since the years 1911-14:— * Tuberculosis Reference Year Book—New York, 1945. 9 The increase in deaths assigned to congenital malformations is partly attributable to changes in classification following the adoption of the 5th revision of the International List of Causes of Death which added about 12 per cent, to the deaths which would formerly have been assigned to this group. For most diseases there has been a dramatic reduction in mortality over the last forty years, and, even since 1927, the improvement is substantial. Since evacuation disturbed the normal biennial sequence of epidemic outbreaks, the incidence of measles in London up to the end of 1946 has been comparatively light and this partly explains the low mortality, but there has also been a striking reduction in case mortality in recent years. The equally pronounced fall in the case-mortality of whooping-cough has also helped to bring down the infant mortality rate. Diarrhoea and respiratory infections too are now less frequently contracted, as a result of the efforts of health authorities in improving the nursing and nutrition of infants. In particular, increasing attention has been paid to the care of the premature infant, and there are signs that these efforts are having a salutarv effect on the mortality risk. Neonatal mortality Deaths in various periods of the first year of life are shown in detail in table 8, page 23. Deaths under 4 weeks numbered 1,463, or 22.2 per 1,000 live births, compared with a rate of 23.0 in 1945. Comparative rates lor London and England and Wales in recent years are:— London England and Walts 1931-35 25.1 31.4 1936-40 22.9 29.0 1941 28.4 28.5 1942 24.7 27.0 1943 23.4 25.3 1944 23.1 24.5 1945 23.0 24.7 1946 22.2 24.2 The more intense degree of adversity in London during the war is reflected by the steep rise in the London rate in 1941, and the narrowing of the margin between London and the country as a whole. In the later years of the war, however, despite the manifold difficulties, the mortality in London was gradually brought down to pre-war level, and it continued to fall. Puerperal fever and pyrexia ; maternal mortality The basic figures in respect of the hazards of childbirth are as given below. Detailed figures for the metropolitan boroughs are shown in tables 3 and 11 and comparative figures for England and Wales in recent years are shown in table 10, page 24. Year Live births Deaths Notifications Puerperal sepsis Other childbirth Puerperal fever Puerperal pyrexia No. 1 Rate No. Rate No. Rate No. Rate 1946 65,883 22 0.33 61 0.93 137 2.09 519 7.90 1945 45,532 32 0.70 56 1.23 188 4.13 472 10.37 Rates per 1,000 live births. The maternal mortality rate (1.26) in 1946 was much lower than in 1945 (1.93) and constitutes a new low record. The trend of maternal death-rate in the administrative county of London from 1891 is shown by the figures in table 4. It will be observed from the table that maternal mortality fell very slowly until the introduction of the sulphonamides, in the middle thirties, resulted in a substantial decline in the mortality from puerperal infection. Indeed, but for the war-time increase in abortions with their relatively higher risk of infection, the sepsis mortality would be an even smaller proportion of the total than is indicated by the table. In recent years puerperal sepsis has lost 10 its position as the most serious mortality risk of pregnancy and has been displaced by toxaemia, haemorrhage and other accidents (trauma of pelvic organs, etc.) which now contribute the greater part of the total mortality. The effect of war conditions in temporarily arresting the decline in maternal mortality in London is shown by the following diagram, which indicates the movement of the rates in both London and over the country as a whole. The sharp rise in London in 1941 was not shared by the country as a whole, and can be attributed to the effect of the bombardment, which reached its peak intensity in that year and the consequent evacuation. These factors rendered it difficult to maintain the normal high standards of maternal care. Infectious diseases The attack-rates and death-rates of the principal infectious diseases in London during 1946 and earlier years, and for the constituent metropolitan boroughs in 1946, are shown in tables 3, 4 and 13. A comparison of the death-rates in London and England and Wales is given in table 12, page 25. Anthrax No case of anthrax was notified during the year. London has now been free from this disease since 1943. Cerebrospinal fever Prior to the war, the attack-rate had fluctuated, rarely falling below 0.020 per 1,000 and rarely exceeding 0-050 per 1,000. Not unexpectedly, the rate rose during 1940-41 to 0.3 per 1,000, reflecting the poor conditions of ventilation then obtaining. Subsequently, the rate fell, and in 1946 was only 0.081 per 1,000. In 1921, 80 per cent, of notified cases were fatal. In 1946 the case-mortality had been reduced to 24 per cent. Dysentery The dysentery notifications are not at present an indication of the trend of incidence of the disease. In the March, 1947, issue of the Bulletin of the Ministry of Health and the Public Health Laboratory Service, Dr. J. A. Glover points out that the notification figures show capricious movement from year to year. In England and Wales as a whole, the ratio of notifications to death has risen from 4-6 in 1919 to 98-6 in 1945. Dr. Glover says "a partial explanation of this outstanding change is, of course, to be found in the influence of bacteriology on medical terminology, and the real answer to the enigma of notified dysentery lies in the recognition of the 11 fact that many cases of comparatively mild disease without any of the classical signs and symptoms are due to the same infection as bacillary dysentery. Any enteritis or diarrhoea, however slight, which is found to be due to Shigella is now reported by that same dread term "dysentery" which used to designate "one of the four great epidemic diseases of the world" (Osier). "The scourge of armies" has become the bane of residential nuseries. By gradual steps in 20 years the term dysentery has been expanded, and now includes not only the fatal cases and those cases severe enough to be notified on clinical grounds (usually the presence of blood in the stools and tenesmus) but also all those cases of diarrhoea in which Shigella has been bacteriologically identified, cases often so mild, except in infants and young children, that only 1 per cent, of those notified died." There is no doubt that the extension and improvement of laboratory services has led to earlier examination of stools, i.e., in the acute stage of disease, so that the organism is more often identified and every year more cases of milder enteritis are notified as dysentery. In the circumstances it is necessary to fall back upon the death certificates for a guide to the trend of incidence. In London, the death-rates from dysentery since the beginning of the century have been as follows:— Mean annual rate per 1,000 1901-1910 0.0052 1911-1920 0.0321 1921-1930 0.0054 1931-1940 0.0036 1941-1945 0.0096 1946 0.0035 It would appear that apart from increased incidence during the two wars, the real incidence of dysentery has remained fairly stationary. Diphtheria A satisfactory antigen tor aipntneria propnyiaxis naa Deen iouna long oeiore the war, and had encouraged the long term view that diphtheria would be stamped out. When war came the need for preventing epidemic outbreaks of this damaging disease became even more insistent. A national campaign for immunisation of children was launched by the Ministry of Health at the end of 1940. Staffing difficulties and the emergency movement of children during the war made abortive any attempt to record precisely the proportion of children immunised at any point of time during the campaign, which is still proceeding, but from various sample surveys and such other records as are available, the following estimates have been made and are thought to be correct within a small margin:- Mid-year Percentage of London children 0-14 immunised 1938 Less than 5 1941 24 1942 37 1943 53 1944 64 1945 70 1946 74 Before assessing the result of the campaign, attention must be drawn to the apparent cyclical nature of diphtheria epidemics. While there is no sharply defined periodicity, the following notification rates in London administrative county illustrate the rise and fall in incidence since 1891 Years Notifications per 1,000 living 1891-95 2.4 1896-1900 2.9 1901-05 1.9 1906-10 1.6 1911-15 1.8 1916-20 2.3 1921-25 2.9 1926-30 2.8 1931-35 2.2 1936-40 1.4 12 Thus over 50 years the attack-rate has varied over an approximate range 1.5-3.0 and a decline in the rate could not be regarded as significant of a major change of experience, unless it proceeded at least below 1.0 per 1,000. What has been the wartime experience? A sharp fall in the rate occurred in 1939. This was probably due not to immunisation, but to reduced facility of transmission of the disease owing to the evacuation of large numbers of children from the metropolis and the consequent "thinning out" of the remainder. There was a further fall in 1940, when the full effect of the initial evacuation was manifest, followed by a rise in 1941. Thereafter the attack-rate has steadily fallen and since 1944 has been less than 0.5, well below any previous trough, pointing to a new influence and leading to the suggestion that the immunisation campaign is yielding tangible results. This inference is supported by the subjoined diagram, on which the continuous lines indicate the trend of the notification rates in the three age groups 0-4, 5-14, 15+, and the broken line indicates the percentage not artificially immunised. Two features evoke comment— (1) since 1941 the attack-rates among children have declined more rapidly than among adults who have not been affected by the campaign for immunisation ; and (ii) there is suggestive parallelism between the "unimmunised" percentage and the juvenile attack-rates. (The word "unimmunised" is only broadly correct because though these include all children who have not received inoculations some of them will have recovered from actual attacks, i.e., active immunisation). 13 As a corollary of (i) the proportion of adults in the total cases of diphtheria notified in anv period is now increasing as is evident from the following figures Years Average percentage of diphtheria cases over 15 years to the total number of cases at all ages 1936-38 15.6 1944-46 27.5 T he association of these effects with diphtheria immunisation is, of course, inferential. Much more definite and even more important is the solid achievement that, in persons attacked by diphtheria, those who have previously received inoculations experience a very much reduced mortality risk. Records kept by the Ministry of Health have shown that the death-rate among the unimmunised is thirty times as great as among the immunised. Diarrhoea and enteritis The mortality from diarrhoea and enteritis under two years of age (269 deaths) 1 amounted to 4.08 per thousand live births, compared with 6.98 in the previous year. This represents an improvement on the low level of mortality attained in 1940-41. The following diagram shows the trend of mortality in London and England and Wales in recent years. Ten years ago the London rate was twice as great as the national rate. It now appears that the difference between the London rate and the average for the country as a whole is negligible. Notifications of fevers of the enteric group (61) were not significantly more Enteric numerous than in 1945 (45). There were only 5 deaths, representing a mortality-rate fevers of 0-0016 per thousand—one hundredth of the rate experienced fifty years ago. There were 371 deaths (0-12 per thousand) from influenza during the year, influent During recent years the deaths have been:— Year Influenza deaths 1940 569 1941 397 1942 198 1043 720 1944 206 1945 171 1946 371 There has so far been no major outbreak of influenza since 1937. Measles became notifiable in London in 1938. For control purposes the results Measles were immediate, but , before any records of epidemiological value could be accumulated, the normal biennial rhythm of attack was disturbed by the evacuation movements of 1939 and subsequent war years. It will be seen from table 13 that periodical o 14 epidemic outbreaks have occurred, but there is not yet any evidence that conditions have been stable sufficiently long to restore the biennial wave. An important feature is the reduction in the case-mortality in measles. Prior to 1938, knowledge of the incidence of measles was confined to reports from schools. Not all cases came to light by this means, but the records are so consistent that there was clearly a fixed relationship between the school reports and the number of cases which would have been notified if the notification regulation had been in force. This relationship has been estimated by reference to the periods during the 1914-18 war and recent years, when school reports and notifications overlapped (allowing for the fact that from 1916-19 " first cases " in a family only were notifiable and rubella was included), and it has therefore been possible to estimate the total cases (notifications) and to assess the trend of the case-mortality. The figures are as follows Years Estimated cases* Deaths Crude case-mortality per cent. 1921-25 271,500 3,868 1.43 1926-30 321,000 3,885 1.21 1931-35 223,500 1,912 0.86† 1936-40 175,500 876 0.50† 1941-45 84,925 170 0.20 * Actual notifications from 1939. † These rates differ slightly from those suggested in the Annual Report for 1945. In some of the earlier years the separation of rubella cases in the school reports was difficult, and evidence on this point which came to hand later suggested that the above estimates would be more accurate. Most measles deaths are due to respiratory complications, and the dramatic reduction in mortality can largely be attributed to the discovery of the antibiotic drugs such as penicillin or the sulphonamides, which either by prophylactic administration usually prevent the onset of respiratory complications or improve the treatment of these complications when they do occur. Ophthalmia neonatorum The incidence ot ophthalmia neonatorum which, since lyzi, remained iairiy constant at between 8 and 10 new cases per 1,000 live births, began to fall slightly toward the end of the 1931-1940 decade and in recent years has fallen to below 5 new cases per 1,000 live births. Rheumatic fever Deaths in London trom rheumatic lever in ly4b numbered 28, ot which 12 were among children under fifteen years of age. Corresponding figures in 1945 were 28 and 13, respectively. Scabies Scabies became notifiable in London in August, 1943. Notifications in 1946 numbered 11,892, compared with 14,753 in 1945, and 16,450 in 1944. The effect of improved control resulting from notification is evident from the persistent decline in incidence. Scarlet fever The incidence of scarlet fever was lower than in 1945 — 4,595 cases (1.48 per thousand), compared with 4,252 (1.64 per thousand). There was again only one fatal case in 1946. Fifty years ago the annual death roll in London amounted to over 1 000. Smallpox Typhus There were two notifications of smallpox, both were confirmed. No case of typhus was notified to the metropolitan borough medical officers of health during 1946. Whoopingcough There were b,olo notifications ot whooping-cough during the year, compared with 3,307 in 1945. The death-rate was 0-017 per thousand (crude case-mortality 0.78 per cent.). Corresponding rates for 1945 were 0-018 per thousand and 1.4 per cent. It will be seen from table 4 that the fatality for this disease is now less than a twentieth part of what it was fifty years ago. Tuberculosis Detailed figures of new cases of tuberculosis notified in 1946 are shown in tables 15 and 16, pages 26 and 27, and the trend of mortality and morbidity is indicated by the rates shown in table 14 (p. 26). The experience of the war years may be briefly summarised in retrospect. 15 In contrast to the steady pre-war decline there was a sharp rise in mortality in 1940 and 1941, mainly due to the impact of the hard conditions of war on existing advanced cases. For this reason the rise soon exhausted itself: it reached a peak in 1941 at a level of about 70 per cent, above that of 1938 (72 per cent, for pulmonary and 67 per cent, for non-pulmonary disease). Subsequently the mortality has fallen at a gradually increasing pace, and in 1946 the death-rates for both pulmonary and non-pulmonary tuberculosis were just below the corresponding rates for 1938. The rate of occurrence of new cases of pulmonary tuberculosis (including noncivilians) rose by nearly 50 per cent, between 1938 and 1941, and remained at that level until the end of the war when it began to fall. The 1946 rate, 1-57 primary notifications per 1,000 total population is still 23 per cent, above the rate for 1938, and corresponds roughly to the level to which it had been reduced in the late "twenties." The war-time increase in non-pulmonary tuberculosis, 25 per cent. between 1938 and 1942, was not so extensive as for pulmonary tuberculosis, and the 1946 rate is the lowest hitherto attained. A detailed review of the causes of the increased war-time incidence has already been published*. Consideration of space prevents complete recapitulation here, but the main conclusions were:— (1) At ages over 25, males were more affected than females in the initial war-time rise. Below 25, it appeared that there was no conclusive evidence that one sex had been more affected than the other, though there was a suggestion that at very young ages the increase was greater in boys than girls. (2) The increase in non-pulmonary tuberculosis occurred almost equally in all the principal sites, except in abdominal tuberculosis, in which the increase was significantly lower. (3) New cases of pulmonary tuberculosis increased more in adults than new cases of the non-pulmonary disease. This fact, coupled with the evidence of site distribution for non-pulmonary forms in children, suggested that contact and droplet infection had been an important feature in London. (4) There was evidence both that pasteurization of milk had held back the spread of bovine infections, and that the principal infecting source was human. (5) Factors influencing the incidence of tuberculosis included changes in the age and sex distribution of the population as a result of evacuation and of recruitment to the Forces, the strain and overcrowding resulting from bombing, fatigue and lack of rest, restriction of diet, and, on the other hand, increased employment and financial resources for those formerly on the verse of do vert v. Civilian death-rates per 1,000 living in 1946 in London and for the whole country were:— Pulmonary Non-pulmonary London 0.624 0.078 England and Wales 0.466 0.083 Food poisoning The following information has been supplied by the Ministry of Health. In 1946, 14 outbreaks of food poisoning in the county of London were reported to the Ministry of Health by the medical officers of the metropolitan boroughs. The number of persons suffering from illness as a result of poisoning was 376 in twelve of the outbreaks, in the remaining two outbreaks the number of persons affected was not specified. No fatal cases were reported. • B.M.J. 1942. ii. 417 and 1943. ii. 712. 16 Infection of food was confirmed in five of the fourteen outbreaks which originated as follows 6 in private canteens. 5 in the homes of families. 3 in the school meals and Londoners' Meals Service. The most serious occurrence was in the nature of a triple outbreak, in May (80 persons), June (29 persons) and December (104 persons), at the private canteen of a printing firm in Southwark. Food infection was confirmed on the first occasion when the lay-out of the canteen was considered unsatisfactory. Metallic dust from the factory was found to have penetrated the canteen, and it is thought not unlikely that all three outbreaks may have been due to mild metallic posioning. The last outbreak in December occurred before improvements recommended as a result of the first occurrence had been effected. Table 1—Population of the administrative County of London, 1921-1946 Year Mid-year estimate of population Average age Total 0-4 5-14 15-24 25-44 46-64 65+ 1921 4,484,523 376,055 809,212 796,590 1,365,546 877,145 259,975 31 .2 1922 4,523,800 393,500 797,000 799,600 1,368,700 898,500 266,500 31.3 1923 4,554,600 421,400 768,600 808,500 1,368,800 914,900 272,400 31.4 1924 4,576,500 440,700 739,900 821,700 1,370,600 928,900 274,700 31.4 1925 4,601,900 419,200 746,400 824,200 1,379,900 951,400 280,800 31.7 1926 4,605,400 404,800 746,900 826,300 1,380,400 961,300 285,700 31.9 1927 4,541,000 386,200 738,300 811.800 1,360,900 958,900 284,900 32.1 1928 4,458,200 362,100 717,500 794,700 1,341,900 954,500 287,500 32.4 1929 4,417,900 347,800 702,300 787,700 1,338,500 954,900 286,700 32.5 1930 4,388,000 336,400 687,500 777,400 1,337,500 956,700 292,500 32.8 1931 4,374,300 297,700 646,700 827,940 1,330,200 951,000 320,760 33.4 1932 4,357,800 290,470 640,450 809,240 1,333,820 956,410 327,410 33.6 1933 4,298,600 281,800 636,200 772,600 1,328,000 951,000 329,000 33.8 1934 4,230,200 271,000 629,200 736,300 1,317,100 944,600 332,000 34.0 1935 4,185,200 281,300 596,600 734,600 1,304,000 935,600 333,100 34.1 1936 4,141,100 254,400 576,600 729,500 1,306,100 935,700 338,800 34.5 1937 4,094,500 249,300 555,000 721,800 1,296,800 930,000 341,600 34.7 1938 4,062,800 249,300 538,600 709,700 1,291,200 927,300 346,700 34.8 1939 3,780,700 211,900 457,500 3,111,300 1940 3,084,100 141,300 232,500 2,710,300 1941 2,327,300 79,200 142,100 2,106,000 1942 2,405,000 137,700 234,500 2,032,800 1943 2,500,600 179,500 282,000 2,039,100 1944 2,462,500 172,000 302,300 1,988,200 1945 2,601,370 189,720 311,440 2,100,210 1946 3,109,240 227,470 353,050 2,528,720 17 Table 2—Migration from the County Year Estimated net loss to county by migration Estimated net gain to outer ring Ratio of outer ring to county mortality (all ages, all causes) Triennial mean ratios 1921 20,000 7,000 0.824 1922 9,000 -4,000* 0.807 0.823 1923 13,000 -1,500* 0.838 1924 6,000 9 000 0.854 1925 13,000 28,000 0.861 0.853 1926 56,000 47,000 0.844 1927 92,000 86,000 0.862 1928 80,000 95,000 0.826 0.831 1929 42,000 122,000 0.805 1930 40,000 140,000 0.813 1931 26,000 110,000 0.815 0.809 1932 46,000 96,000 0.800 1933 67,000 97,000 0.792 1934 62,000 95,000 0.796 0.799 1935 52,000 109,000 0.809 1936 50,000 113,000 0.785 1937 43,000 79,000 0.790 0.792 1938 49,000 50,000 0.801 Note.—Both the loss to the county and the gain to the outer ring are given as total figures, including in first case some persons who went elsewhere than to the outer ring and in the second case some persons who came from sources other than the county, i.e., persons from other industrial areas who followed the movement of industry to the London area. * In 1922 and 1923 there were small movements away from the outer ring. 18 Table 3—Vital statistics for the metropolitan boroughs and the County of London in the year 1946 (Rates per 1,000 of civil population) Metropolitan boroughs arranged in topographical order Estimated civilian population, 1946 Live births Deaths Infant mortality (per 1,000 lire births) Measles Scarlet fever Diphtheria Whooping cough Typhoid fever Diarrhoea and enteritis age 0.2 (per 1,000 live births) Pulmonary tuberculosis Pneumonia Other resp. dis. Cancer Maternal mortality (per 1,000 live births) Notifications of infectious disease (52 weeks) Scarlet fever Diphtheria Cerebro spinal fever Acute pneu mon Measles Wboopinp. cough Western Paddington 117,670 20.3 13.0 47 0.01 — 0.02 — — 5.5 0.81 1.03 0.98 2.14 1.68 1.94 0.31 — 0.20 0.03 1 .03 5.84 1 .33 Kensington 147,870 18.2 12.3 49 0.01 — 0.01 0.02 — 6.7 0.47 0.70 0.79 1.96 1.11 1.35 0.29 0.04 0.25 0.06 0.77 1.74 1.42 Hammersmith 111,860 20.7 11.9 45 ' — 0.01 002 — 7.4 0.69 0.65 111 2 02 3.03 1.46 0.44 — 0.21 0.07 0.66 4.88 2.25 Fulham 116,870 21.5 13.0 40 — 0.03 0.01 — 3.6 0.68 0.82 0.98 2.22 1.20 1 .41 0.46 001 0.25 0.11 0.47 6.65 2.02 Chelsea 45,740 17.8 12.0 44 — — 0.02 9.8 0.42 1.07 0.61 2.08 1.23 1.89 0.44 0.04 0.18 013 0.18 4.32 2.63 Westminster, 90,110 15.1 11.3 40 0.01 — — — 0.01 3.7 0.67 0.77 0.87 2.01 — 1.14 0.57 0.02 0.10 0.03 0.09 2.92 1.18 City of Northern St. Marvlebone 70,920 13.1 11.5 37 — — 0.01 — 4.3 0.58 0.69 0.85 2.27 3.23 0.99 0.14 — 0.31 0.03 0.78 2.06 119 Hampstead 89,720 17.4 11.8 36 0.01 — — — — 2.6 0.33 0.58 0.77 1.98 0.64 1 .33 0.25 0.03 0.20 0.01 0.89 3.61 101 St. Pancras 129,410 19.3 13.3 38 0.02 — 0.02 0.01 0.02 5.6 0.71 0.90 1.42 2.13 1.20 1.88 0.71 0.04 0.41 0.09 0.95 8.59 3.94 Islington 227,160 23.3 13.0 39 0.01 — 0 04 — 3.8 0.64 0.74 1.36 2.14 1.52 1.74 0.60 0 02 0.38 0.04 0.51 8.26 2.55 Stoke Newington 43,790 21.9 11.5 37 0.02 — — 0 02 — 1.0 0.39 0.96 1.03 1.85 2.09 1.65 0.18 0.02 0.21 0.07 0.41 11.43 1.47 Hackney 166,560 20.6 11.9 31 0.01 — — 0.01 — 6.4 0.55 0.68 0.86 2.10 0.58 1.60 0.36 0.02 0.31 0.02 0.34 8.90 3.32 Central Holborn 21,190 14.0 13.8 40 — 3.4 0.61 1.32 1.46 1.84 — 1.28 0.62 0.09 019 0.24 0.66 5.25 2.13 Finsbury 33,400 20.6 15.6 54 0.03 0.06 — 5.8 0.84 1.47 1.50 2.43 1.45 2.34 0.39 0.03 0.42 0.15 1.02 10.06 1.17 City of Lndn. (a) 5,080 6.5 13.8 30 — — — — — — 118 1.18 0.59 1.57 — 0.59 0.20 0.20 0.20 — — 1.78 0.39 Eastern Shoreditch 42,600 23.4 14.4 32 — — — 5.0 0.92 0.82 1.53 2.28 2.01 2.24 1.20 0.02 0.38 0.35 0.64 13.65 4.19 Bethnal Green 57,800 22.6 13.4 41 0 .02 — 0.02 0.02 — 2.3 0.61 0.78 1.18 1.90 1.54 2.41 1.09 0.02 0.14 0.09 0.64 10.81 2.32 Stepney 94,800 22.7 14.8 51 0.01 — 0.01 — 001 7.0 0.75 0.84 1.14 2.09 1.87 1.50 0.51 0.02 0.31 0.07 0.86 7.75 0.96 Poplar 69,010 25.7 13.1 30 — — 0.01 0.03 — 3.4 0.88 0.55 1.59 1.93 — 2.32 0.33 0.01 0.33 0.09 1.73 12.76 2.63 Southern South wark 86,280 24.3 15.8 46 0.01 — — 0.03 — 4.8 0.72 0.99 1.65 2.29 1.91 1.92 0.73 0.01 0.33 0.14 0.79 9.10 2.72 Bermondsey 56,320 24.0 13.9 39 — — — — — 3.7 0.55 0.75 1.44 2.50 2.22 1.46 0.39 — 0.27 0.09 0.94 9.24 4.11 Lambeth 209,910 22.9 12.4 36 0. 00 — 0.00 0.02 — 4.4 0.70 0.64 0.99 1.80 0.63 1.11 0.16 0.01 0.27 0 03 0.39 7.81 1.91 Battersea 108,610 23.4 13.5 42 0.01 — 0.02 — — 3.9 0.76 0.69 1.07 2.06 1.57 2.23 0.41 0.02 0.38 0.16 0.99 1013 3.21 Wandsworth 314,030 20.2 12.1 33 0. 00 — — 0.03 — 3.0 0.53 0.55 0.97 2.09 1.27 1.17 0.40 0.02 0.29 0.10 0.80 6.42 2.09 Camberwell 164,380 23.4 13.5 38 0. 02 001 0.01 0.04 — 3.1 0.54 0.77 1.20 2.21 1.30 0.96 0.37 0.01 0.29 0.11 0.95 7.40 2.62 Deptford 69,480 26.0 13.1 38 — — 0.01 . — 6.1 0.58 0.71 1.12 2.25 0.55 1.08 0.27 0.01 0.25 0.09 0.97 8.21 1.26 Greenwich 76,840 22.6 11.4 35 — — 0.03 0.03 — 1.2 0.83 0.47 0.92 1.68 1.73 1.38 0.54 0.04 0.23 0.08 0.97 11.76 2.75 Lewisham 207,410 21 .7 10.7 33 — — 0.01 0.01 — 0.9 0.53 0.47 0.73 1.67 1.11 0.80 0.15 0.03 0.16 0.08 0.56 6.40 1.43 Woolwich 134,420 21.6 11.4 31 — — 0.01 0 .01 — 2.1 0.57 0.45 0.74 1.77 0.34 1.88 0.23 — 0.42 0.14 0.51 7.86 2.28 London, 1946 3,109,240 21 .2 12.6 38 0.01 0. 00 0.01 0.02 0. 00 4 .1 0.62 0.71 1.05 2.04 1.26 1.48 0.41 0.02 0.28 0.08 0.75 7.26 2.20 [.onion, 1945 2,601,370 17.5 14.1 44 001 0 00 0.01 0.02 0.00 7. 0 0.78 0.71 1.22 2.33 1.93 1.64 0.49 0.02 0.33 0.07 0.77 9.07 1.27 (a) Including Inner and Middle Temple. 19 Table 4—County of London—Principal vital statistics, 1891.1946 Period Annual rate per 1,000 living Annual mortality per 1,000 living Annual mortality per 1,000 live births Live births Marriages Deaths (all causes) Cerebrospinal fever Diphtheria Enteric fever Tuberculosis Diarrhoea and enteritis 0—2 Puerperal fever Other acc. of ch. birth Scarlet fever Smallpox Whooping. cough Measles Influenza Pulmonary Non.pulmonary Pneumonia (all forms) Bronchitis Other resp. diseases Heart disease Cancer Diabetes Infants 0—1 1891-95 30.8 17.3 19.8 (a) 0.53 0.13 0.24 0.02 0.52 0.59 0.41 1 .83 0.80 1.45 2.45 0.48 (a) 0.80 0.07 156 23.8 215 2.22 1896-1900 29.7 18.4 18.5 (a) 0.45 0.14 0.14 0.00 0.47 0.57 0.27 1.75 0.69 1 .32 1.80 0.35 (a) 0.92 0.07 162 41.3 1.70 1.74 1901-05 28.6 17.7 16.4 (a) 0.20 0.08 0.11 0.07 0.36 0.45 0.17 1.58 0.57 1.46 1.41 0.26 1.31 1 .01 0.08 139 30.4 1.64 1.52 1906-10 26.5 17.4 14.9 (a) 014 0.04 0.10 0.00 0.29 0.42 0.22 1.39 0.48 1.49 1.22 0.22 1.26 1.11 0.10 114 23.8 1.46 1.47 1911-15 24.0 20.0 14.8 0.02 0.13 0.03 0.05 0.00 0.22 0.43 0.16 1.39 0.39 1.33 1.29 0.21 1.54 1.16 0.11 108 28.0 1.40 1.57 1916-20 20.0 20.1 15.1 00.4 0.17 0.02 0.03 0.00 0.20 0.28 1 .01 1.43 0.34 1.38 1.30 0.19 1.71 1.28 0.09 92 15.4 1.64 1 .72 1921-25 19.9 17.9 12 3 0.01 0.17 0.01 0.04 0.00 0.15 017 0.32 1 .01 0.19 1.14 0.97 0.16 1.66 1.38 0.10 71 11.7 1.36 1.63 1926-30 16.2 18.6 12.3 0.02 0.10 0.01 0.02 0.00 0.11 0.16 0.30 0.90 0.14 1.00 0.72 0.16 2.29 1.52 0.12 64 10.2 1.66 1.69 1931-35 13.8 19.5 121 0 03 0.08 0.00 0.02 0.00 0.07 0.09 0.26 0.79 0.11 0.85 0.47 0.14 2.99 1.66 014 63 11.6 1.50 1.66 1936-40 13.7 25.4 13.4 0.02 0.04 0. 00 0.01 — 0.04 0.04 0.19 0.72 0.09 0.83 0.67 0.13 3.67 1.87 0.16 56 10.9 0.80 1.22 1941 14.6 30.2 18.7 0.05 0.04 0.01 0.00 — 0.05 0.02 0.17 1.10 0.15 1.08 1.37 0.18 4.46 2.38 0.13 57 6.3 1.47 1.58 1942 16.9 27.6 15.0 0.02 0. 02 0.00 0.00 — 0.04 0.01 0 08 0.90 0.12 0.86 1.03 0.16 3.86 2.40 0.11 50 8.0 1.13 1.38 1943 18.0 21.7 15.7 0.02 0.02 0.00 0.00 — 0.03 0.02 0.29 0.88 0.10 1.04 1.18 0.18 4.02 2.46 0.11 51 9.9 0.95 1.18 1944 181 21.5 16.7 0.02 0.02 0. 00 0.00 — 0.05 0.00 0.08 0.84 0.10 0.87 1.03 0.16 4 .05 2.35 0.10 51 9.6 0.76 0. 94 1945 17.5 28.0 14.1 0.02 0.01 0.00 0.00 — 0.02 0.01 0.07 0.78 0 09 0.71 1.08 0.14 3.63 2.33 0.08 44 7.0 0.70 1 .23 1946 21.2 23.3 12.6 0.02 0.01 0.00 0.00 — 0.02 0.01 0.12 0.62 0.08 0.71 0.92 0.13 3.36 2.04 0.08 38 4.1 0.33 0.93 (a) Comparable figures are not available for this period. 20 Table 5—Administrative County of London—Civilian deaths in 1946 by cause Cause Sex 0— 1— 5— 15— 45— 65 + Total 1946 1945 1. Typhoid and paratyphoid M - 1 1 1 - 3 F - - - - 1 1 2 3 2. Cerebro-spinal fever M 13 11 1 2 2 1 30 20 F 10 9 1 5 4 1 30 25 3. Scarlet fever M - - - - - — — 1 F — 1 — — — 1 — 4. Whooping-cough M 14 7 — — — — 21 18 F 20 9 3 — — — 32 29 5. Diphtheria M — 4 — 1 — 1 6 7 F 1 11 2 3 1 — 18 17 6. Tuberculosis—respiratory M 6 10 7 484 540 191 1,238 1,338 F 1 8 5 498 139 51 702 695 7. Tuberculosis—other forms M 7 24 25 38 14 8 116 118 F 10 23 20 44 22 8 127 106 8. Syphilitic disease M 6 — — 26 115 116 263 216 F 3 12 62 53 130 114 9. lufluenza M 12 6 2 19 63 81 183 90 F 6 2 1 18 50 111 188 81 10. Measles M 4 4 1 — — — 9 19 F 4 5 3 — — — 12 12 11. Acute poliomyelitis and polioencephalitis M — — 1 1 2 — 4 2 F 1 1 — 2 2 — 6 4 12. Acute infectious encephalitis M — — 1 5 8 1 15 11 F — 6 4 — 10 16 Cancer of— 13. Mouth and oesophagus M 1 — — 4 99 229 333 314 14. Uterus F — 30 164 116 310 326 15. Stomach and duodenum M 30 211 291 532 567 F 21 127 301 449 420 16. Breast M — — 3 4 7 7 F 70 283 244 597 571 17. All other sites M 1 4 10 124 1,018 1,241 2,398 2,314 F 6 6 100 608 985 1,705 1,536 18. Diabetes M 2 9 23 45 79 65 F 9 55 95 159 156 19. Intra-cranial vase, lesions M 23 347 1,021 1,391 1,266 F __ 20 422 1,452 1,894 1,667 20. Heart disease M 1 7 182 1,263 3,691 5,144 4,542 F 3 194 711 4,407 5,315 4,902 21. Other circulatory diseases M 2 3 31 212 544 792 732 F - - 17 145 654 816 701 22. Bronchitis M 50 5 2 59 606 1,098 1,820 1,758 F 21 3 2 29 147 854 1,056 1,051 23. Pneumonia M 208 31 7 59 292 564 1,161 1,030 F 161 25 4 56 176 628 1,050 817 24. Other respiratory diseases M 3 4 — 23 99 123 252 228 F 2 1 17 49 76 145 140 25. Ulcer of stomach or duodenum M - 52 216 170 438 424 F 11 45 68 124 106 26. Diarrhoea under 2 years M 158 6 — — — — 164 188 F 103 2 — — - - 105 130 21 1 able 5 Administrative County of London—Civilian deaths in 1946 by cause—continuec Cause Sex 0— 1— 5— 16 — 45— 65 + Total 1946 1945 27. Appendicitis M 1 6 9 11 14 25 66 68 F 1 3 6 12 16 18 56 52 28. Other digestive diseases M 23 9 5 48 127 218 430 347 F 17 7 8 37 112 281 462 424 29. Nephritis M 1 — 4 47 152 210 414 379 F — 1 5 46 110 212 374 356 30. Maternal sepsis F - - 21 1 - 22 32 31. Other maternal F _ 60 1 - 61 56 32. Premature birth M 371 - - - - - 371 239 F 232 - - - - - 232 184 33. Congenital malformation, birth M 493 12 5 22 19 10 561 427 jury, other infant diseases. F 332 5 5 21 29 11 403 309 34. Suicide M — — — 83 82 55 220 164 F — — — 60 58 28 146 128 35. Road traffic accidents M — 10 34 50 43 60 197 225 F — 8 11 17 29 54 119 92 36. Other violent causes M 65 26 28 105 104 196 524 889 F 76 17 8 51 49 358 559 1,000 37. All other causes M 52 24 21 192 283 773 1,345 1,290 F 37 15 25 174 277 631 1,159 1,187 All causes M 1,489 206 176 1,731 5,958 10,967 20,527 19,303 F 1,038 161 119 1,661 3,899 11,698 18,576 17,445 Table 6—Road deaths by age 1940-46 Year 0—4 5—14 15—44 45—64 65 All ages 1940 24 32 144 144 199 543 1941 11 28 77 116 141 373 1942 14 32 66 75 99 286 1943 9 28 47 66 79 229 1944 13 41 49 62 103 268 1945 24 51 51 69 122 317 1946 18 45 67 72 114 316 d 22 Table 7—Stillbirths—Administrative County of London Year Stillbirths Rate per 1,000 live and stillbirths 1928 2,417 32.3 1929 2,335 32.2 1930 2,448 34. 0 1931 2,205 32.5 1932 1,987 30.9 1933 1,934 33. 0 1934 1,844 31.4 1935 1,854 32.2 1936 1,857 31.9 1937 1 864 32.8 1938 1,711 30.4 1939 1,579 29.3 1940 1,405 29.5 1941 1,046 29.9 1942 1,225 29.3 1943 1,137 24.6 1944 1,138 24.9 1945 1,095 23.5 1946 1,598 23.7 23 Table 8—County of London—Infant mortality, 1946 Age at death Total Kates per 1,000 live births Under 1 day 1 to 7 days 1 to 4 wks. 4 weeks to 1 year No. Males Fe. males Total Male Female Measles ... ... Leg. Illeg. Whooping.cough Leg. Illeg. Influenza ... Leg. Illeg. Tuberculosis ... Leg. Illeg. Bronchitis ... Leg. Illeg. Pneumonia ... Leg. Illeg. Diarrhoea ... Leg. Illeg. Premature birth Leg. Illeg. Congenital malformation, birth injury and other diseases of early infancy. Leg. Illeg. Other causes ... Leg. Illeg. 2 242 27 215 33 10 28 I 27 7 6 204 20 275 21 7 1^ 1* 1^ 4' 2j 461 5j 161 5j 801 12 j 119^ 15 25 6, • 7 34 15 24 65 282 234 18 147 238 8 34 18 24 71 369 261 603 825 314 4 14 12 13 50 208 158 371 493 166 4 20 6 11 21 161 103 232 332 148 012 0.52 0.27 0.36 108 5.60 3.96 915 12.52 4.77 0.12 0.41 0.35 0.38 1.47 6.12 4.65 10.91 14.50 4.88 0.13 0.63 0.19 0.35 0.66 5.05 3.23 7.28 10.41 4.64 All causes Leg. M. F. Illeg. M. F. 278 191 49 39 321 198 30 19 174 117 26 21 5321 394 J 791 59 J 2,205 322 1,305 184 900 138 36.39 60.95 41.75 67.06 30.68 54.35 Total 1946 557 568 338 1,064 2,527 1,489 1,038 38.36 43.79 32.56 Total 1945 434 401 212 964 2,011 1,173 838 44.17 50.26 37.76 1945 Leg. M. F. Illeg. M. F. 196 148 43 47 220 128 30 23 96 75 22 19 4791 341 j 871 57 j • 1,683 328 991 182 692 146 41.71 63.34 48.03 67.33 35.09 58.99 Table 9—Infant mortality in London by cause 1911—1946 (Rates per 1,000 live births) Cause of death 1911 to 1914 1915 to 1918 1919 to 1922 1923 to 1926 1927 to 1930 1931 to 1934 1935 to 1938 1939 to 1942 1942 1943 1944 1945 ###] Measles 3.40 3.84 1.64 2.02 2.07 1.44 0.95 0.22 0.20 0.51 0.09 0.18 0.12 Whooping.cough 3.63 4.45 2.50 2.60 3.14 2.27 2.01 1.43 1.48 115 2.13 0.77 0.52 Influenza 0.27 1.10 0.81 0.38 0.48 0.40 0.24 0.39 0.30 0.44 0.27 0.18 0.27 Tuberculosis 3.40 3.20 1.52 1.26 0.89 0.77 0.56 0.63 0.52 0.53 0.22 0.33 0.36 Bronchitis 6.41 6.72 4.42 2.91 2.30 2.16 1.97 1.81 2.19 1.67 1.39 1.45 1.08 Pneumonia 12.28 14.96 12.60 11.51 12.10 11.45 10.39 7.64 7.43 8.04 7.45 6.39 5.60 Diarrhoea 24.28 16.10 12.16 9.36 8.87 10.86 12.10 6.96 7.67 9.44 9.02 6.68 3.96 Premature birth 18.16 17.42 17.00 14.74 14.17 14.91 13.41 12.51 13.50 11.66 12.03 9.29 9.15 Congenital mal., etc. 14.69 14.66 11.26 8.39 7.38 7.22 6.35 10.08 11.54 11.44 10.10 13.49 12.52 Other causes 21.48 20.55 15 09 11.83 12.60 13.52 12.30 8.14 5.24 5.84 7.79 5.42 4.77 All causes 108 103 79 65 64 65 60 50 50 51 51 44 38 24 Table 10—Maternal mortality—London and England and Wales 1937-46 (Rates per 1,000 live births) 1937 1938 19u9 1940 1941 1942 1943 1944 1945 1946 Puerperal fever:— London 0.84 0.79 0.65 0.98 1.47 11.3 0.95 0.76 0.70 0.33 England and Wales 0.98 0.89 0.77 0.82 0.85 0.80 0.75 0.62 0.50 0.32 Other causes:— London 1.45 1.12 1.32 1.00 1.58 1.38 1.18 0.94 1.23 0.93 England and Wales 2.28 2.19 2.16 1.88 2.01 1.76 1.60 1.38 1.34 11.5 Table 11—Maternal mortality in London 1931-46 Metropolitan boroughs arranged in topographical order Childbirth deaths (a) per 1,000 live-births Number of deaths (b) in childbirth 1946 1931-40 1941-46 Puerperal fever Other causes Total Puerperal fever Other causes Total Puerperal fever Other causes  Western Paddington 1.9 2.2 4.1 1.3 1.1 2.4 2 2 4 Kensington 1.5 1.6 3.1 0.8 1.0 1.8 — 3 3 Hammersmith 1.0 1.2 2.2 0.7 1.1 1.8 2 5 7 Fulham 1.1 1.6 2.7 0.7 1.2 1.9 — 3 3 Chelsea 1.5 1.8 3.3 11 2.1 3.2 — 1 1 Westminster, City of 2.0 1.4 3.4 1.8 1.2 3 0 — — — Northern St. Marylebone 1.5 2.1 3.6 1.7 1.7 3.4 3 — 3 Hampstead 0.8 1.4 2.2 0.3 1.5 1.8 — 1 1 St. Pancras 1.4 1.7 3.1 1.2 1.2 2.4 2 1 3 Islington 1.2 1.5 2.7 0.8 1.1 1.0 4 4 8 Stoke Newington 0.6 2.9 3.5 0.7 1.7 2.4 — 2 2 Hackney 0.9 1.4 2.3 0.4 0.9 1.3 1 1 2 Central Holborn 2.1 1.4 3.5 2.2 — 2.2 — — — Finsbury 0.8 0.7 1.5 1.7 1.0 2.7 1 — 1 City of London 3.3 — 3.3 — — — — — — Eastern Shoreditch 0.8 1.4 2.2 1.2 1.2 2.4 — 2 2 Bethnal Green 1.1 1.0 2.1 0.7 0.7 1.4 1 1 2 Stepney 0.9 1.7 2.6 0.7 1.6 2.3 1 3 4 Poplar 1.4 1.1 2.5 1.2 0.9 21 — — — Southern Southwark 0.9 1.7 2.6 0.6 11 1.7 — 4 4 Bermondsey 1.3 1.5 2.8 1.1 21 3.2 — 3 3 Lambeth 1.0 1.1 2.1 0.9 10 1.9 1 2 3 Battersea 1.2 1.5 2.7 0.5 0.7 1.2 — 4 4 Wandsworth 1.5 1.4 2.9 0.9 1.2 21 2 6 8 Camberwell 1.2 1.5 2.7 1.0 1.3 2.3 2 3 5 Deptford 1.1 1.3 2.4 0.7 0.7 1.4 — 1 1 Greenwich 1.2 1.5 2.7 0.3 0.8 11 — 3 3 Lewisham 11 1.6 2.7 0.6 1.5 21 — 5 5 Woolwich 0.8 1.1 1.9 0.3 1.1 1.4 — 1 1 London 1.2 1.5 2.7 0.8 1.2 2.0 22 61 83 (a) Including deaths due to abortion except that those legally determined to have resulted from criminal interference have been included only from 1940. (b) The deaths in childbirth in 1946 are shown in the above table but not the death.rates, as, owing to the smallness of the figures, the rates for a single year in any metropolitan borough may be misleading. The maternal mortality.rates for each metropolitan borough in 1946 and for London as a whole are, however, set out in table 3. Table 13—County of London—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—1931.1946 Year Anthrax Cerebrospinal fever Continued fever Diphtheria Dysentery Encephalitis lethargica Enteric fever Erysipelas Malaria Measles Ophthalmia neonatorum Pneumonia Polioencephalitis Poliomyelitis Puerperal fever Puerperal pyrexia Scabies Scarlet fever Smallpox Typhus Whoopingcough Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rat e Cases ###] 1931 2 0.001 175 0.040 3 0.001 8,384 1.90 58 0.013 40 0.009 186 0.042 2,294 0.521 32 0.007 (b) (b) 629 (a) 9.60 6,880 1.562 5 0.001 51 0.012 291 (a) 4.44 828 (a) 12.64 (b) (b) 12,025 2.73 1,452 0.330 — — (b) (b) 1932 3 0.001 247 0.057 4 0.001 8,087 1.87 79 0.018 47 0.011 195 0.045 2,230 0.515 41 0.009 (b) (b) 687 11.10 5,673 1.309 10 0.002 79 0.018 218 3.52 741 11.97 (b) (b) 14,119 3.26 1,131 0.261 — — (b) (b) 1933 3 0.001 216 0.050 5 0.001 9,557 2.23 31 0.007 22 0.005 164 0.038 2,766 0.645 21 0.005 (b) (b) 527 9.31 6,299 1.469 6 0.001 60 0.014 255 4.51 838 14.81 (b) (b) 21,911 5.11 531 0.124 — — (b) (b) 1934 3 0.001 137 0.032 4 0.001 11,782 2.79 58 0.014 29 0.007 109 0.026 2,586 0.613 30 0.007 (b) (b) 467 8.24 5,569 1.320 8 0.002 66 0.016 254 4.48 758 13.37 (b) (b) 18,238 4.32 144 0.034 — — (b) (b) 1935 2 0.0005 105 0.025 3 0.001 9,294 2.23 199 0.048 15 0.004 187 0.045 1,868 0.448 37 0.009 (b) (b) 382 6.87 3,707 0.888 4 0.001 81 0.019 241 4.33 652 11.72 (b) (b) 10,954 2.63 — — — — (b) (b) 1936 — 113 0.027 4 0.001 7,030 1.68 304 0.072 12 0.003 255 0.061 1,815 0.432 35 0.008 (b) (b) 462 8.10 4,141 0.986 2 0.0005 36 0.009 175 3.07 635 11.13 (b) (b) 10,705 2.55 — — — — (b) (b) 1937 3 0.001 175 0.043 6 0.001 7,810 1.91 916 0.224 8 0.002 216 0.053 1,764 0.432 42 0.010 ('b) (b) 453 8.26 4,798 1.175 13 0.003 95 0.023 228 4.16 793 14.16 (b) (b) 8,455 2.07 — — — — (b) (b) 1938 4 0.001 182 0.045 1 0.0002 7,611 1.88 1,049 0.259 5 0.001 191 0.047 1,829 0.451 16 0.004 282(c) 0.28 489 9.00 3,962 0.978 12 0.003 122 0.030 199 3.66 853 15.70 (b) (b) 8.093 2.00 — — — — 1,891 (c) 1.87 1939 3 0.001 169 0.045 3 0 001 3,671 0.974 268 0.071 11 0.003 98 0.026 1,388 0.368 17 0.005 1,303 0.35 408 8.07 3,733 0.990 3 0.001 95 0.025 163 3.22 704 13.92 (b) (b) 5,677 1.51 — — — — 10,537 2.80 1940 3 0.001 839 0.274 6 0.002 1,844 0.601 161 0.052 8 0.003 158 0.052 1,076 0.351 16 0.005 5,447 1.78 303 7.10 2,688 0.876 3 0.001 17 0.006 155 3.63 472 11.05 (b) (b) 2,498 0.81 — — — — 669 0.218 1941 1 0.0004 706 0.298 2 0.001 2,179 0.921 610 0.258 10 0.004 210 0.089 1,171 0.495 13 0.005 11,039 4.67 185 6.67 2,518 1.064 5 0.002 36 0.015 94 3.39 340 12.26 (b) (b) 2,372 1.00 — — — — 7,944 3.36 1942 1 0.0004 341 0.142 1 0 0004 1,813 0.756 749 0.312 3 0.001 67 0.028 1,034 0.431 16 0.007 19,987 8.33 210 5.18 2,246 0.936 1 0.0004 24 0.010 110 2.71 505 12.46 (b) (b) 4.416 1.84 2 0.001 — — 6,234 2.60 1943 4 0.002 231 0.093 1 0.0004 1,862 0.747 1,103 0.442 4 0.002 47 0.019 1,054 0.423 35 0.014 22,882 9.18 233 5.19 3,159 1.267 3 0.001 40 0.016 147 3.27 471 10.49 9,689 (d) 9.18 9,477 3.80 — — — — 6,661 2.67 1044 — — 195 0.079 2 0.001 1,126 0.459 1,558 0.634 4 0.002 38 0.015 924 0.376 78 0.032 7,499 3.05 211 4.76 2,252 0.917 2 0.001 18 0.007 172 3.88 387 8.73 16,450 6.70 4,153 1.69 2 0.001 — — 7,144 2.91 1945 — — 185 0.071 2 0.001 1,273 0.491 2,082 0.803 7 0.003 45 0.017 846 0.326 93 0.036 23,518 9.07 224 4.93 1,992 0.768 — — 70 0.027 188 4.14 472 10.40 14,753 5.69 4,252 1.64 4 0.002 4 0.002 3,307 1.28 1946 — — 252 0.081 1 0.0003 1,264 0.408 899 0.290 11 0.004 61 0.020 864 0.279 168 0.054 22.517 7.26 267 4.06 2.313 0.746 3 0.001 36 0.012 137 2.09 519 7.90 11.892 3.84 4,595 1.48 2 0.001 — — 6,818 2.20 (a) Rate per 1,000 live births. (b) Comparable figures not available for this period. (c) Cases relate to last quarter only — Rates are adjusted on an annual basis. (d) Cases relate to last 22 weeks only — Rates are adjusted on an annual basis. Table 12—Death rates from certain infectious diseases—London and England and Wales—1931-46 Rates are per 1,000 living except for diarrhoea and enteritis where it is expressed per 1,000 live births Year Measles Whooping-cough Scarlet fever Diphtheria Diarrhoea & enteritis under 2 London E. & W. London E. & W. London E. & W. London E. & W. London E. & W. 1931 0.026 0.082 0.069 0.063 0.016 0.014 0.059 0.067 9.71 5.90 1932 0.189 0.085 0.080 0.074 0.020 0.013 0.072 0.058 12.55 6.60 1933 0.023 0.048 0.077 0.056 0.020 0.018 0.084 0 060 11.74 6.98 1934 0.202 0.093 0.069 0.051 0.016 0.024 0.114 0.101 12.80 5.36 1935 0.005 0.033 0.040 0.039 0.006 0.014 0.065 0.086 11.31 5.56 1936 0.141 0.067 0.067 0.051 0.010 0.012 0.055 0.075 14.47 5.75 1937 0.006 0.026 0.060 0.043 0.008 0.009 0.053 0.072 12.29 5.54 1938 0.058 0.040 0.025 0.027 0.007 0.009 0.050 0.071 13.23 5.30 1939 0.001 0.007 0.035 0.031 0.002 0.005 0.026 0.053 8.36 4.67 1940 0.009 0.021 0.003 0.017 0.002 0.004 0.022 0.052 6.13 4.76 1941 0.022 0.029 0.048 0.062 0.001 0.003 0.035 0.068 6.30 5.08 1942 0.013 0.012 0.042 0.021 0.0004 0.003 0.021 0.047 7.97 5.22 1943 0.020 0.020 0.034 0.029 0.004 0.003 0.023 0.036 9.86 5.15 1944 0.003 0.006 0.047 0.028 0.003 0.003 0.015 0.024 9.58 4.97 1945 0.012 0.019 0.018 0.018 0.0004 0.002 0.009 0.018 6.98 5.50 1946 0.007 0.005 0.017 0.020 0.0003 0.001 0.008 0.011 4.08 4.24 25 26 Table 14—Primary notifications (a) of and deaths from tuberculosis in the Administrative County of London Year Pulmonary tuberculosis Non-pulmonary tuberculosis Formal primary notifications Deaths Formal p notifica rimary tions Deaths No. Annual rate per 1,000 living No. Annual rate per 1,000 living No. Annual rate per 1,000 living No. Annual rate per 1.000 living 1913 (b) 19,218 4.25 5,863 1.30 (b) 6,436 1.42 1,611 0.36 1914 (b) 16,467 3.64 6,331 1.40 (b) 3,862 0.85 1,666 0.37 1915 (b) 14,712 3.26 6,715 1.49 (b) 3,949 0.88 1,841 0.41 1916 (b) 13,547 3.01 6,364 1.41 (b) 4,084 0.91 1,641 0.36 1917 (b) 14,870 3.31 6,768 1.51 (b) 3,864 0.86 1,715 0.38 1918 (b) 15,670 3.50 6,920 1.55 (b) 3,517 0.79 1,526 0.34 1919 (b) 12,356 2.76 5,197 1.16 (b) 3,231 0.72 1,127 0.25 1920 9,202 2 06 4,675 1.04 2,461 0.55 1,070 0.24 1921-25 38,807 1.71 22,980 1.01 10,881 0.48 4,383 0.19 1926-30 34,353 1.53 20,247 0.90 8,971 0.40 3,080 0.14 1931-35 29,569 1.38 17,075 0.79 6,322 0.29 2,354 0.11 1936 5,176 1.25 2,849 0.69 1,056 0.26 363 0.09 1937 5,455 1.33 2,888 0.71 1,014 0.25 351 0.09 1938 5,200 1.28 2,590 0.64 982 0.24 347 0.09 1939 4,691 1.24 2,650 (c) 0.70 805 0.21 302 (c) 0.08 1940 4,326 1.34 2,687 (c) 0.87 653 0.20 318 (o) 0.10 1941 4,577 1.83 2,552 (c) 1.10 675 0.27 343 (c) 0.15 1942 4,734 1.80 2,164 (c) 0.90 796 0.30 283 (c) 0.12 1943 5,066 1.82 2,204 (c) 0.88 782 0.28 256 (c) 0.10 1944 5,056 1.84 2,073 (c) 0.84 673 0.24 237 (c) 0.10 1945 4,893 1.68 2,033 (o) 0.78 614 0.21 224 (c) 0. 09 1946 5,137 1.57 1,940 (o) 0.62 611 0.19 243 (c) 0.08 (a) Excluding posthumous cases. (b) Not checked for duplicates, (c) Excluding non.civilians from 3 Sept., 1939. Rates based on civil population. Table 15—Tuberculosis—-Primary notifications in London during the year 1946 Form of tuberculosis notified Sex Number of formal primary notifications of new cases of tuberculosis Total all ages Total notifica tions 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65+ Pulmonary tuberculosis M. 13 92 99 76 271 377 690 449 380 314 155 2,916 3,487 F. 5 76 98 79 331 493 615 243 137 84 60 2,221 2,670 Other forms of tuberculosis M. 5 38 47 42 35 26 61 21 9 7 8 299 340 F. 6 38 53 43 44 24 54 22 14 8 6 312 357 All forms of tuberculosis M. 18 130 146 118 306 403 751 470 389 321 163 3,215 3,827 F. 11 114 151 122 375 517 669 265 151 92 66 2,533 3,027 27 Table 16—New cases of tuberculosis in London found by other means than notification Form of tuberculosis Sex New cases of tuberculosis coming to knowledge otherwise than by formal notification 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total Pulmonary tuberculosis M. 3 18 21 10 31 113 213 135 88 81 70 783 F. 2 14 13 9 42 127 256 84 37 32 21 637 Other forms of tuberculosis M. 1 16 12 10 10 10 14 4 7 4 4 92 F. 5 15 12 12 14 21 18 8 2 5 6 118 All forms of tuberculosis M. 4 34 33 20 41 123 227 139 95 85 74 875 F. 7 29 25 21 56 148 274 92 39 37 27 755 The sources of information as to the unnotified cases shown above were as follows:— Source of information Number of cases Pulmonary Non-pulmonary Death returns from local registrars 142 35 transferable deaths from Registrar-General 129 39 Posthumous notifications 64 18 "Transfers" from other areas 1,036 116 Other sources 49 2 Table 17—Numbers on the tuberculosis registers, for the whole county, 1941-1946 1941 1942 1943 1944 1945 1946 Cases on the register at the end of the year— Pulmonary— Males 12,677 12,894 13,608 14,340 15,018 15,695 Females 9,119 9,441 10,232 10,990 11,496 12,262 Other forms— Males 2,916 2,785 2,847 2,866 2,813 2,821 Females 3,044 2,963 3,074 3,185 3,123 3,099 Total 27,756 28,083 29,761 31,381 32,450 33,877 No. per 1,000 of population 11.9 11.7 11.9 12.7 12.5 10.9 GENERAL PUBLIC HEALTH Housing In view of the present concentration on building new houses and repairing old properties, it was not to be expected that there would yet be any considerable revival of activity on the Council's pre-war clearance schemes. The Director of Housing requested, however, information concerning two areas which were being considered for development and in which " clearance " powers might be applicable. Surveys were undertaken and full particulars of the sanitary conditions of the properties within the areas were supplied. It is anticipated that similar surveys of other areas will be required in the near future, and, in the meantime, steps are being taken, as far as possible, to bring up to date earlier surveys of areas which still remain in the programme of clearance operations drawn up by the Council before the war. 28 As in previous years much detailed information has been provided in response to enquiries concerned with local land charges, and regarding properties scheduled as "dangerous structures." There has been a very great increase in the number of applications for preferential consideration for rehousing on grounds of ill-health received through the Director of Housing and direct from individual applicants. In all, 4,624 applications, more than ten times the number (450) for 1945, were considered. In view of the serious difficulties in rehousing, special care was exercised, by detailed enquiry and consideration, td select only the most needful cases for recommendation for preference. The number so recommended was 2,126, of which 1,053 were classified as most urgent. These figures do not include applications concerning persons receiving treatment under the Council's tuberculosis scheme, which are referred by the Director of Housing to the medical officers of health of the metropolitan boroughs for advice. In this connection I have to acknowledge the valuable help given by the medical officers of the metropolitan boroughs and numerous out-county authorities in providing reports and giving their opinions on many premises occupied by applicants. Tuberculous milk The sampling for biological examination of milk coming into London in churns by road and rail and of milk produced at the Council's farms has been continued. Efforts have been made to secure at least one sample from each known consignor and in many cases two samples were taken. A total of 1,155 samples was obtained, including a small number taken after pasteurisation from plants at the London depots. In no case was a positive result obtained from pasteurised milk or from milk produced at the Council's establishments. Details of the milk samples and results of examination follow:— Source of sample Designation Samples Percentage positive of completed samples Total Positive Incomplete Negative 1946 1945 (a) Supplied to London by road and rail in churns Ordinary 989 19 145 825 2.3 4.2 Accredited 65 3 9 53 5.4 — Tuberculin tested 56 — 5 51 — 10 (b) Plant at London depots Pasteurised. 21 — 3 18 — — Total 1,131 22 162 947 2-3 31 (c) Council's farms Ordinary and tuberculin tested 24 — 1 23 — — Total 1,155 22 163 970 Venereal diseases Work The work of the clinics included in the London and Home Counties Scheme ^"clinics' at ^or the free diagnosis and treatment of venereal diseases has been continued throughout the year, and increased facilities have been provided. The following is a summary of work done at the London clinics for all areas during the undermentioned years :— 111 29 Year New cases Total venereal cases Total non-venereal cases Syphilis S. Chancre Gonorrhoea M. F. M. F. M. F. M. F. M. F. 1918 3,764 3,002 116 13 4,844 1,940 8,724 4,955 1,345 1,348 1928 3,433 1,837 229 6 8,249 2,647 11,911 4,490 6,369 3,226 1938 1,799 1,065 235 9 7,120 2,151 9,154 3,225 8,249 5,269 1939 1,573 904 164 5 5,982 1,652 7,719 2,561 7,468 5,008 1940 1,493 709 146 9 4,591 1,319 6,230 2,037 5,383 3,515 1941 1,381 773 205 12 3,862 1,425 5,448 2,210 4,675 3,709 1942 1,369 917 148 9 3,082 1,444 4,599 2,370 4,960 5,177 1943 1,362 1,107 104 15 2,839 1,442 4,305 2,564 7,627 8,867 1944 1.176 967 89 13 2,929 1,363 4,194 2,343 6,568 8,234 1945 1,417 1,176 102 3 3,962 1,738 5,481 2,917 9,517 9,849 1946 2,371 1,354 154 11 7,718 1,785 10,243 3,150 17,153 8,654 Year Total attendances In-patient days Pathological examinations for M. F. M. F. Clinic Practitioners 1918 169,485 66,095 25,973 6,380 1928 544,969 218,566 23,821 41,285 107,410 29,785 1938 588,815 263,908 20,608 32,303 263,710 48,763 1939 412,067 189,355 13,030 22,715 223,696 40,176 1940 305,693 131,375 9,907 11,236 153,695 35,554 1941 224,954 122,492 13,708 10,459 135,152 34,981 1942 222,864 155,559 16,991 13,787 164,459 61,897 1943 219,014 177,859 6,828 9,725 182,558 76,533 1944 188,450 155,332 6,605 7,861 170,861 73,784 1945 196,074 160,697 6,408 7,635 209,199 88,971 1946 284,108 161,839 6,472 9,384 279,414 88,531 It will be observed from the foregoing table that there has been a marked increase in the number of new cases and pathological examinations during 1946 compared with the war years. The rise is chiefly due to an increase in male cases, particularly male early syphilis cases, which have risen from 851 in 1945 to 1,817 in 1946, an increase of 113-5 per cent. As mentioned in my report last year, the increase in work at the civilian clinics is due to demobilisation from the Forces, but it will be noted that despite the rapid rise during the last two years, the number of new V.D. cases is at the present time only slightly higher than before the war, when, in 1938, there were 12,379 compared with 13,393 in 1946. The number of non-V.D. cases has, however, increased considerably from 13,518 in 1938 to 25,807 in 1946. This is probably due to propaganda campaigns during the war years and to enlightenment of the public as to the dangers of the diseases. To meet the sharp rise in work, extra sessions have been held at many of the treatment centres, most of which have reverted to a pre-war basis in order to cope with the additional work. In some cases the clinics have been improved and reorganised. During the year, there has been a great extension in the use of penicillin, and 11,362 patients (compared with 2,305 in 1945) were treated by this method. Of these, 2,954 (240 in 1945) were suffering from syphilis, 7,962 (2,026 in 1945) from gonorrhoea, and 446 (39 in 1945) from other venereal or non-venereal diseases. During the year, the Ministry of Health intimated that the free supply of penicillin had ceased as from 31st May and that hospitals would, from that date, have to purchase supplies through commercial channels. As a result the cost of the V.D. scheme to the participating authorities has been considerably increased. A note regarding certain limitations in the use of this drug for treatment of venereal diseases was included in my report for 1945. E 30 Service patients A reduced, though still considerable, number of Service patients attended the clinics in the Scheme, totalling 1,181. Service attendances, numbering 3,756, were made at the clinics and 6,322 Service pathological tests were carried out in the approved laboratories. These figures are included in the above tables. Most of these patients were referred by the Service medical authorities in special circumstances to the civilian clinics for continuation treatment, and they represent only a very small proportion of the total number treated at the centres, viz., 3 per cent, of new cases, 0-8 per cent, of attendances and 1-7 per cent, of pathological tests. Additional in-patient treatment In addition to the in-patient treatment provided in direct association with the clinics, the Council's Sheffield Street Hospital (50 beds) continued to admit pregnant women suffering from venereal disease, and Queen Mary's Hospital for Children, Carshalton, continued to provide the unit (26 beds) for children suffering from congenital syphilis and vulvo-vaginitis. Propaganda Propaganda by means of posters and advertisements in the daily press has been continued throughout the year, and full use has been made of the services provided by the Central Council for Health Education, to which body the Council pays an annual grant. Hostels The accommodation provided by the two hostels, viz., Highbury (Quadrant and the Salvation Army Hostel, 122/124, Lower Clapton Road, remaining in the Scheme at the end of 1945, has proved to be sufficient for present needs. Defence Regulation 33b In contrast to conditions during and immediately following the war, the number of notifications, under Defence Regulation 33B, of alleged contacts has, in 1946, shown a sharp decline. This is no doubt largely due to the withdrawal from London of the majority of allied Service men and the extensive demobilisation of our own forces. Service conditions were apparently very favourable for securing from patients information of the alleged source of infection and there is probably far more reticence among civilians concerning their private lives. The number of alleged contacts reported in 1946 was 667, compared with 2,030 in 1945. The following statement summarises the work of the past four years :— 1943 1944 1945 1946 M. F. M. F. M. F. M. F. (1) (a) Total number of contacts in respect of whom form 1 was received 34 620 11 1,333 21 2,009 28 639 (b) Number in (a) transferred from other areas - - - - - 6 - 9 (2) Number of cases in (1) in which attempts were made outside the scope of the Regulation to persuade the contact to be examined before the latter had been named on a second form 1 20 190 7 528 15 856 20 338 Contacts found 10 94 7 328 13 473 15 167 Contacts examined or already under treatment 9 70 6 199 12 343 10 122 (3) Number of those in (1) in respect of whom two or more forms 1 were received - 60 - 172 3 292 - 83 (4) Number of those in (3) who were:— - - (a) found - 37 - 123 2 202 - 58 (b) examined after persuasion or already under treatment - - - - 7 - 5 (c) served with form 2 - 32 - 123 — 195 - 53 (d) examined after service of form 2 - 29 - 103 2 170 - 49 (e) prosecuted for failure— (i) to fittend for, and submit to, medical examination - 3 - 10 - 15 - 11 (ii) to submit to and continue treatment - - - 4 - 25 - 26 (/) transferred to other areas - - - - - 24 - 8 31 A summary of the results of the 37 prosecutions in 1946 is given below. Result of prosecution for failure to attend for examination— Imprisonment 6 Probation 2 Bound over 3 Result of prosecution for failure to continue treatment— Imprisonment 12 Probation 5 Bound over 7 Fined 2 I have again gratefully to acknowledge the continued co-operation of the Commissioner of Police for the Metropolis in making available the services of police officers to assist in tracing alleged contacts named more than once. The arrangements, outlined in my report for 1945, for co-operation with the Service authorities to ensure continued attendance at clinics of men who, on discharge from the Services, were under treatment or surveillance for V.D., have been continued. Due to the progress of demobilisation, this work increased rapidly during the year. The total number of notifications received from the commencement of the arrangement to the end of 1946 was 1,393. In that period, 745 of the men concerned had been interviewed with a view to attendance at civilian clinics if they had not already completed treatment and been discharged. Of these ex-Service men, 594 were interviewed, by written invitation, at County Hall, while 151 visits and 20 re-visits were paid to home addresses. The difficulties inherent in this type of work are obvious but they have been satisfactorily overcome. Sanitary inspection Possibly owing to a wider appreciation of the advice and facilities available for the extermination of vermin and other pests, there has been an increase in the number of reports of infestation. Apart from the County Hall and adjacent premises, 400 reports were dealt with, the majority being from Meals Service establishments (173), schools (96) and hospitals and institutions (80). By the end of the year, the nuisance had been abated in 301 instances, the remainder being incomplete. Some 1,350 visits were made in this connection, apart from visits of inspection to hospitals at which routine disinfestation work is carried out by members of the staff. Disinfestation Arrangements were made to conduct experiments to determine the toxicity of various insecticides, with particular reference to the much-publicised D.D.T., and the co-operation and advice of Mr. A. W. McKenney Hughes of the British Museum (Natural History) were secured and proved of great value. During the year, loo primary and 117 secondary visits were paid tor the purpose of sanitary inspection to the restaurants under the control of the Meals Service and, where necessary, reports of defects have been forwarded to the Chief Officer, Meals Service. The examination of foodstuffs for fitness for human consumption was undertaken at 46 restaurants. Meals Service Reports were received ot a number 01 cases ot suspected tood poisoning in connection with the Meals Service and in each instance a thorough investigation into the possible cause was made in conjunction with officers of the local sanitary authority. In one instance a consignment of gelatin was suspected to be the cause, and was demonstrated by bacteriological examination to be unfit for human consumption. Supplies to the Council's establishments of this particular lot were withdrawn, the contractor undertaking to convert it to glue. As a further precaution instructions were issued as to heat treatment of all gelatin used in the preparation of food dishes, and a standard bacteriological and chemical specification for gelatin was nreacribed for inclusion in contracts for supply. Rest centres and homes were visited in connection with sanitary arrangements as well as for the control of infestation. Arrangements have been made for some 30 institutions and homes to receive regular inspection to guard against pest and vermin Social welfare establishments 32 nuisance and for a monthly inspection to check general sanitary conditions at 10 hostels and rest homes. British Standards Instititution During the year the chief inspector attended nine meetings of committees of the British Standards Institution, convened to consider specifications of sanitary fitments, etc. The meetings also provide opportunity for the exchange of ideas and for keeping the Council's officers informed of progress made in this field. The Chief Inspector has been elected Chairman of one of the committees dealing with some of the subjects under consideration. Cancer Act, 1939 Investigation was made into an alleged infringement of the Cancer Act, 1939, by the publication of a brochure detailing cures, with an invitation to write to an advertised person. A conviction was obtained with a fine of £5 5s. Od. and £2 2s. Od. costs. By-laws Representations to the Council for revision of its Drainage and Seamen's Lodging House By-laws have been under consideration, as also has the making of by-laws giving power to require an owner of a block of dwellings to keep in repair and adequately light a common staircase. These matters were still under consideration at the end of the vear. Co-operation with other authorities and departments Interchange of information with other departments is frequent and is often of mutual advantage. Special mention may be made of co-operation with the "Housing and Valuation Department in connection with the application of the " one pipe system" of plumbing to block dwellings. As a result, improved plumbing lay-outs have been designed which are greatly in advance, both in efficiency and cost, of the system previously used. The Chief Inspector has, at the request of the housing architect, interviewed a number of borough engineers to explain the proposals. Blind persons Particulars of examinations under the provisions of the Blind Persons Acts 1920 and 1938, during the year are set out below:— Examinations by the Council's ophthalmologists— Classification Certified blind Not blind Grand total Male Female Total Male Female Total New cases 214 355 569 49 72 121 690 Prev. blind, still blind 27 39 66 — — — 66 Prev. not blind, now certified 13 15 28 — — — 28 Prey, not blind, still not blind — — — 21 38 59 59 Prev. blind, now not blind — — — 5 8 13 13 Total 254 409 663 75 118 193 856 Persons examined as to suitability for training— Suitable Not suitable Grand total Male Female Total Male Female Total 22 8 30 2 3 5 35 In addition 135 certificates (67 male and 68 female/ submitted by voluntary hospitals, outside authorities or private ophthalmologists were accepted as evidence of blindness. 33 Treatment of tuberculosis The number of definite cases of tuberculosis on the dispensary registers at the end of the year was 26,374, compared with 24,879 at the end of 1945, and 21,740 at the end of 1938. Dispensary service. The work of the dispensary service has functioned satisfactorily throughout the year. Evening sessions were held for the convenience of patients unable to attend normal sessions. The X-ray examination of patients has shown a steady increase during the past three years and it is anticipated that the increase will be maintained. The number of recommendations for residential treatment with the corresponding figures for the war years and 1938 were:— Year For the first period of treatment For further treatment Total/###] ExService Service sick† Civilian adults Children ExService Service sick† Civilian adults Children Male Female Male Female *1946 249 163 1,740 1,761 853 213 1 927 983 105 6,995 *1945 286 193 1,699 1,763 707 209 1 1,034 915 104 6,911 1944 583 — 1,774 1,874 712 183 — 1,159 945 80 7,310 1943 376 — 1,947 2,015 749 116 — 1,216 912 56 7,387 1942 330 — 1,944 1,830 694 77 — 1,043 764 60 6,742 1941 262 — 1,943 1,562 578 53 — 1,098 748 52 6,296 1940 68 — 2,160 1,584 389 44 — 1,503 1,097 90 6,935 1939 4 — 2,473 1,667 609 35 — 1,695 1,206 163 7,852 1938 2 2,610 1,960 796 52 — 1,671 1,160 199 8,450 Residential treatment *The revised procedure authorised in Ministry of Health circulars 127/45, 177/45 and 68/46, under which the discharge of patients from the Services is deferred for a period up to 30 months while they are undergoing treatment, continued to reflect in the number of recommendations received for ex-Service men and women accepted by the Ministry of Pensions under Ministry of Health Memo. 146 T (Revised). †Prior to 1945 " Service sick " patients were dealt with by the Emergency Medical Service. Patients recommended for treatment during the year were dealt with as follows (the corresponding figures for 1945 to 1943 and 1938 are also shown, but those for the years 1942 to 1939, inclusive, are not available):— Adults Children 1946 1945 1944 1943 1938 1946 1945 1944 1943 1938 (o) Admitted to "observation" beds to determine diagnosis or suitability for treatment at sanatoria 945 838 713 692 1,338 202 235 227 90 202 (b) Admitted to Pleural Effusion Unit 260 278 271 202 — 22 14 20 55 — (c) Passed for admission direct to sanatoria or hospitals 4,609 4,841 5,317 5,532 5,963 619 517 503 636 749 (d) Not accepted for residential treatment ... 42 26 56 11 106 31 — — 13 23 (e) Withdrawn after application but before decision was reached 181 117 161 145 48 84 24 16 11 21 Total 6,037 6,100 6,518 6,582 7,455 958 811 792 805 995 The availability of suitable bed accommodation showed further deterioration compared with 1945, and it was necessary to continue the special selection of cases suitable for treatment at home under the supervision of the local tuberculosis officer. This is reflected in the reduced number of patients recommended for in-patient treatment as well as the numbers actually admitted. This reduction in numbers of patients is also related to the slightly lower incidence of tuberculosis and the reduced London population. 34 The number of beds occupied by patients under the tuberculosis scheme on 31st December, 1946 (with corresponding figures for the years 1938 to 1945, inclusive) were as follows ; the figures in brackets represent the number of ex-Service men and women (included in the figures) whose tuberculous condition has been accepted by the Ministry of Pensions as connected with war service:— Year Council's special hospitals and sanatoria Council's general hospitals Voluntary institutions Total ADULTS 1946 1,134(109) 615(49) 1,246(120) 2,995(269) 1945 1,233(160) 596(23) 1,316(145) 3,145(328) 1944 1,419(242) 490(30) 1,399(157) 3,308(429) 1943 1,249(184) 713(33) 1,323(120) 3,285(337) 1942 1,296(129) 654(18) 1,170(106) 3,120(253) 1941 1,102(65) 577(15) 1,195(78) 2,874(158) 1940 983(6) 579(5) 1,303(17) 2,865(28) 1939 853(3) 787(2) 1,128(8) 2,768(13) 1938 1,299(1) 1,010(6) 1,134(16) 3,443(23) CHILDREN 1946 422 21 167 610 1945 437 13 127 577 1944 416 12 55 483 1943 519 9 43 571 1942 580 10 57 647 1941 494 15 56 565 1940 400 4 68 472 1939 496 8 55 559 1938 658 6 60 724 *Including 237 Service patients (201 in the Council's special and general hospitals and 36 in voluntary institutions). †Including 176 Service patients (165 in the Council's special hospitals and 11 in voluntary institutions). The decrease in the number of beds occupied, both in the Council's special hospitals and sanatoria and in voluntary institutions, is due to staffing difficulties prevalent throughout the country. Domiciliary treatment by collapse therapy During the year, many beds at suitable hospitals and sanatoria remained unoccupied, due to the shortage of nursing and other staff; and, in consequence, the number of patients on the waiting list for residential treatment tended to increase, With a view to alleviating anxiety arising through failure to commence treatment in the early stages of the disease, active treatment, limited to artificial pneumothorax therapy, was started as an experiment in two metropolitan boroughs for suitable patients still at home. The Council authorised free conveyance by its ambulances of such patients between their homes and the local tuberculosis dispensaries, foi purposes of radiological control. The experiment proved satisfactory in carefully selected cases as, apart from the cancellation of a number of recommendations foi residential treatment, the patients received active treatment earlier than would have been the case had this been delayed until their admission to sanatoria. Dental treatment and provision of spectacles Dental treatment, (including the provision of dentures where necessary), and spectacles, were provided for patients undergoing residential treatment for tuberculosis where such provision was considered a necessary aid to treatment. No charge is made to patients for dental treatment except that any grants received from approved societies under the National Health Insurance Acts are taken into consideration. Provision of clothing and boots (and repairs) Where it was certified to be essential to enable patients to benefit from residential treatment, clothing and boots (and repairs) were provided free in cases where the patients could not make such provision. Verification of the patients' circumstances 35 was made by the tuberculosis care committees. The patients were allowed to retain the articles on discharge from residential treatment. Children were boarded out under the tuberculosis contact scheme in cases where they were in danger of being infected with tuberculosis at home or where their parent or parents were recommended for or were receiving residential treatment for tuberculosis and for whose care other adequate arrangements were not possible. The arrangements for boarding out are made to the extent possible by the Invalid Children's Aid Association on behalf of the Council. Boardingout of child contacts Uwing to the lack of suitable foster homes the majority of the children under five years of age were however boarded out in the Council's nurseries, and the majority of older children were placed in the Council's residential schools and homes. The number of children boarded out under the scheme has shown a marked increase during the year, the average numbers for 1944, 1945, and 1946 being 152, 155 and 180, respectively. The number of children boarded out at any one time was greatest in November, when the figure rose to 214, against 170 and 179 in 1945 and 1944 respectively. lhe distinction between type T open-air schools (for children with a tuberculous background) and type 0 (open-air schools for delicate children) has been abolished. The children are admitted to the schools regardless of whether they are type T oi type 0, but no child with "open" or infectious tuberculosis is admitted to eithei type of school. Residential open-air schools I he schools in use at the beginning of 1946 were : Burrow Hill Colony, Frimley; Balls Park open-air school, Hertford; Kathleen Schlesinger Home, near Henley; George Rainey residential open-air school, St. Leonards-on-Sea; Wanstead House residential open-air school, Cliftonville; and the Horsleys Green Camp, Stokenchurch, Bucks. During the year Balls Park open-air school and Horsleys Green Camp were closed, and new schools were opened at Swanley Residential School, White Oak Hospital, Swanley, and the Downs Hospital for Children, Sutton. At the end of 1946 the number of children with a tuberculous background accommodated at these schools was 145. The arrangements for surgical after-care described in last year's report continue. Surgical after-care There has been no special development in rehabilitation of the tuberculous during the year. Rehabilitation Mass miniature X-ray examination of sections of the general public continued throughout the year at static centres. It was hoped that an additional apparatus would become available for the Council's use during the year, but supply and staff difficulties continued, and expectations did not materialise. In December, 1946, a specially equipped motor van, officially described as a mobile laboratory, was handed over to the Council by the Ministry of Health. The laboratory incorporates a dark room with up-to-date equipment and generator, and there is provision for transporting the X-ray set in the van. In future, therefore, it will be possible to carry out X-ray examinations at offices, factories and workshops where there are sufficient numbers of employees volunteering for examination. Miniature mass radiography Examinations were carried out at the following centres : South-Western Hospital, Stockwell, S.W.9 (covering Lambeth and part of Wandsworth) ; South-Eastern Hospital, New Cross, S.E.14 (covering Bermondsey, Camberwell, Deptford, Greenwich, part of Lewisham and Southwark); Old Vestry Hall, Maxey Road, Woolwich, S.E.18; Lewisham Town Hall, S.E.6 ; St. Pancras Hospital, N.W.I (covering Hampstead, Holborn, Islington, St. Marylebone and St. Pancras). At each of the centres, factory, shop and office employees, and children (fifteen years of age and over) attending secondary schools and technical colleges, were examined. 36 Since the inception of the unit in 1943 until the end of the year 1946, 164,147 persons have been X-rayed. The following is a summary of the work done during the year, with corresponding figures for 1945 shown in brackets:— Number Per cent. of miniatures Miniature films take 40,691 (47,223) — — Large films taken 1,182 (1,594) 2.90 (3.37) (1) Details of conditions revealed by labqe films (i) Persons requiring further investigation— (a) For lesions probably tuberculous 306 (437) .75 (.92) (b) For lesions probably non-tuberculous 39 (50) .10 (.11 (c) For cardio-vascular lesions 51 (79) .13 (.17) (d) Previously known tuberculous cases 25 (45) .06 (.09) (e) Referred for a further X-ray examination in 3-6 months 49 (24) .12 (.05) 470 (635) 1.16 (1.34) (ii) Radiologically inactive lesion* 428 (507) 1.05 (1.07) (iii) No abnormality 284 (452) .69 (.96) Total 1,182 (1,594) 2.90 (3.37) (2) Analysis of lesions probably tuberculous Diagnosis confirmed 282 (402) .69 (.85) Doubtful cases 6 (5) .02 (.01) Awaiting report 5 (12) .01 (.02) Refused investigation 13 (18) .03 (.04) Total 306 (437) .75 (.92) (8) Summary of reports from tuberculosis officers or other doctors of advice given (lesions probably tuberculous) Requiring no further medical action 10 (9) .03 (.02) Requiringafurtherexamination later as a precaution 13 (31) .03 (.07) Requiring continued dispensary observation 170 (274) .41 (.58) Should cease work and remain under observation at home 5 (16) .01 (.03) Requiring sanatorium treatment 90 (77) .22 (.16) Information so far not available or refused investigation 18 (30) .04 (.06) Total 306 (437) .75 (.92) (4) Results of sputum examinations (i) Patients with lesions probably tuberculous (306) Positive Negative None Unknown (a) Unilateral lesions (212) 32 59 109 12 (b) Bilateral lesions (94) 18 32 38 6 Total 50 91 147 18 (ii) Patients requiring sanatorium treatment (90) (a) Unilateral lesions (55) 28 14 13 — (b) Bilateral lesions (35) 13 10 12 — Total 41 24 25 — 37 (5) Numbers, in age groups, of significant lesions probably tuberculous (306) and persons advised sanatorium treatment (90). Age groups Miniature films taken Significant lesions probably tuberculous Advised sanatorium treatment Number Percentage of miniatures Number Percentage of miniatures 14 1,014 4 .39 2 .20 15-19 10,840 70 .65 22 .20 20-24 5,634 67 1.19 25 .44 25-34 7,739 74 .96 20 .26 35-44 8,336 42 .50 13 .16 45-59 6,172 40 .65 6 .10 60+ 956 9 .94 2 .21 Total 40,691 306 .75 90 .22 (6) Statistics of children or students attending secondary schools and technical colleges (15 years of age or over) included in foregoing tables dumber Per cent. of miniature Miniature films taken 5,854 - Large films taken 103 1.76 A nalysis of large films— No significant abnormality 67 1.14 Probably non-tuberculous 4 .07 Lesions probably tuberculous— (a) Admitted to sanatorium 3 22 .05 .38 (6) Under dispensary or G.P. supervision 19 .33 Curdio-vascular lesions— (a) Congenital abnormality 4 10 .07 .17 (6) Acquired abnormality 6 .10 Total 103 1.76 Out of a total of 1,215 recalled for full sized film examinations, 33 examinees (2.72 per cent.) failed to attend. A review of the miniature films for these 33 persons showed 7 with definite lesions probably tuberculous in origin, 18 with a doubtful shadow in the lung, and 4 with some suspicion of a cardiac abnormality; the remaining 4 persons were known cases of pulmonary tuberculosis and had previously undergone sanatorium treatment. Persons in whom there was evidence of a significant radiological abnormality, as disclosed by full sized film examinations, were followed up. With the consent of the individuals the X-ray films and reports were forwarded to their private doctors, who were asked to furnish information as to the subsequent diagnosis and the steps taken to obtain treatment. It was suggested that patients with lesions probably tuberculous, should be referred to their local tuberculosis officer for further investigation. The results of the survey since the inception of the scheme have remained fairly consistent. There have been slight variations at the different centres, but statistically these cannot be regarded as of any significance. For the year 1946, 0-75 per cent. (0-92 per cent. 1945) showed significant lesions, probably tuberculous in origin, and 0-22 per cent. (0-16 per cent. 1945) were recommended institutional treatment on the clinical findings at the initial investigation, that is a period up to three months from the date of the first examination. In the course of the year under review, six confirmed cases and one probable case of unsuspected carcinoma of the lungs were discovered. p 38 Of the 306 persons found to have lesions which were probably tuberculous, 56 (18.3 per cent.) resided outside the administrative county of London, and any treatment considered necessary was the responsibility of the appropriate tuberculosis authority. During the year, a survey was carried out by request of the Prison Governor at Holloway Gaol, where 313 prisoners were examined, of whom ten were advised further investigation. Further surveys (mental patients and staff) were also carried out at Banstead Hospital, Sutton, Surrey, and St. Lawrence's Hospital, Caterham, Surrey, where the total number of patients examined was 4,115. Of these, at Banstead Hospital 2-54 per cent, male and 0-62 per cent, female showed significant previously unsuspected lesions, probably tuberculous in origin, and at St. Lawrence's Hospital the comparative findings were 4-0 per cent, male and 0-29 per cent, female. In addition, 240 members of the staff of these hospitals were examined, of whom three were referred for further investigation. These examinations are not included in the foregoing tables as they deal with a specially selected group. Maintenance allowances (Memo. 966T) Payment of maintenance allowances and grants under the Government's scheme, set out in memorandum 266T of the Ministry of Health, to patients undergoing prescribed treatment either in a hospital or sanatorium or at home under the tuberculosis officer's direction, continued throughout the year. The machinery of the dispensary service was utilised in connection with enquiries for the purpose of determining the amounts payable, and, where practicable, for the actual payment of the allowances. The tuberculosis officers are responsible for determining eligibility on medical grounds for any allowances authorised, and the Social Welfare Department is responsible for determining payment of allowances. During the year approximately £137,000 was paid in allowances by the metropolitan boroughs compared with £123,000 in 1945. Midwivcs Acts, 1902 to 1936, nursing homes registration and contributions to voluntary organisations for maternity and child welfare In 1946, 865 midwives notified their intention to practise, compared with 683 in 1945, and the distribution of those midwives at 31st December among the main branches of midwifery was as follows:— L.C.C. hospitals (intern) 181 Voluntary hospitals (intern) 272 L.C.C. domiciliary midwives 147 Voluntary organisation domiciliary midwives 137 Independent midwives 27 Others, including part-time midwives 101 Twenty-five mid wives who had surrendered their certificates under Section 5(1) of the 1936 Act were permitted to resume midwifery for stipulated periods by order made by the Council under Defence Regulation No. 33(1) of 1939. All cases of raised temperature and skin affection are investigated by supervisors of midwives and dealt with individually, and on fifty occasions midwives were suspended to prevent the spread of infection. All eye affections in the new-born are also visited by supervisors regularly until cured or admitted to hospital. Number of confinements The subjoined statement shows the number of confinements which occurred in London in each of the years 1938-1946, classified under the various forms of attendance. The figures have been arrived at as a result of an examination of statistics furnished from various sources. 39 1938 1939 1940 1941 1942 1943 1944 1945 1946 Institutional confinements L.C.C. hospitals 21,037 19,243 13.975 6,885 12,230 13,645 12,739 12,375 21,375 Borough Council maternity homes 2,556 1,544 659 369 528 733 526 617 810 Voluntary hospitals 17,260 15,109 8,562 5,721 5,733 9,963 10,957 15,161 20,599 Nursing homes 1,447 1,556 866 497 1,594 2,585 1,910 2,447 3,140 Total 42,300 37,452 24,062 13,472 20,085 26,926 26,132 30,600 45,924 Domiciliary confinements L.C.C. midwives 3,373 5,381 6,924 3,570 6,137 6,747 5,924 6,867 11,639 Borough Council midwives 340 71 105 51 100 98 100 88 160 Voluntary hospitals and voluntary organisations 7,708 7,656 7,259 2,998 5,223 5,640 4,623 5,478 10,069 Independent midwives 4,517 2,230 614 230 407 357 218 179 277 Total 15,938 15,338 14,902 6,849 11,867 12,842 10,865 12,612 22,145 Total number of confinements 58,238 52,790 38,964 20,321 31,952 39,768 40,596 36,997 37,905 43,212 41,975 68,069 Births (RegistrarGeneral's figures) 66,406 58,049 43,758 21,482 34,877 68,017 The substantial difference between the number of births used by the RegistrarGeneral in calculating the birth-rate of London, and the number of confinements is accounted for by the fact that no figures are available for the number of confinements attended by doctors, and also for the large number of women whose normal place of residence is outside London who come to London for their confinement. Multiple births also cause some difference. There was a substantial increase compared with 1945 in the total number of confinements undertaken by the Council's domiciliary midwives. Domiciliary midwifery service— London County Council midwives The following are the figures for 1938, which was the first year of the Council's domiciliary midwifery service, and for the years 1945 and 1946:— Maternity nursing cases Midwifery cases Total 1938 449 2,924 3,373 1945 440 6,427 6,867 1946 805 10,834 11,639 The number of midwives employed at 31st December, 1946, was 148, compared with 122 at the end of 1945. The average number of midwives employed throughout the year (permanent and temporary) was 134, compared with 120 in 1945. In addition, six part-time midwives were employed for periods ranging from 8 to 30 days. The average number of confinements undertaken by each midwife, including sick and holiday reliefs, was approximately 87. This figure is considerably higher than that mentioned (66) in the Report of the Midwives Salaries Committee (Rushcliffe). The weekly number of confinements rose throughout the year, and, at th<> end of 1946, midwives were working at extreme pressure, the average for the last three months being at the rate of 93 a year. Holidays and off-duty time equivalent to those recommended by the Midwives Salaries Committee have, however, been given without interruption to all midwives. Ambulance cars for the transport of the midwives were supplied in emergency, particularly for night work, and 19,624 miles were run on this service. 40 During 1946, 10,834 patients were delivered in their own homes by the Council's domiciliary midwives. There were 2,478 primigravidse and 8,356 multigravidse. A number of women booked by the Council's domiciliary midwives are admitted to hospital suffering from toxaemia, antepartum haemorrhage, etc., and are not, therefore, included in the foregoing number of confinements. There were 9 maternal deaths, of which 1 died at home from pulmonary embolism, and 8, who had booked Council domiciliary midwives, died in hospital. There were 68 neo-natal deaths, 52 at three days or under (14 of them under four hours) and 16 over three days; 22 were full-term and 46 premature infants; 32 were males and 36 females. In only one case was there maternal toxaemia. The number of stillbirths was 155, including 44 premature infants. These figures do not include women transferred to hospital who were subsequently delivered of stillbirths. The following is an analysis of stillbirths:— No. Sex Full time Prem. Maternal toxaemia Condition of infant Method of delivery Presentation Macerated Not macerated Normal Forceps Breech Others Vertex Breech Others M. F. (1) Primiparae 34 17 17 23 11 5 12 22 19 7 3 5* 27 3 4 * 2 B.B.A., 1 hand and foot, 1 face, 1 failed forceps. MCLTTPAK/E No. Sex No. where previous Maternal toxaemia Full time Prem. Condition of infant Method of delivery M. F. Prem. Neo-natal deaths Still births Abortion Macer| a ted Not macerated Normal Forceps Breech Others (2) Parity, 5 and under 99 50 49 6 5 10 10 12 73 26 45 54 72 2 16 9* (3) Over parity 5 22 11 11 4 3 6 5 2 15 7 10 12 15 — 3 4† * 2 face, 2 footling, 5 B.B.A. †B.B.A., 1 footling. The cause of stillbirth was ascertained in 111 cases, as follows:— In 26 out of 34 primiparae—prematurity (11), abnormality of cord (6), prolonged second stage (5), following external version (4). In 64 out of 99 parity 5 and under—prematurity (26), abnormalities (18), antepartum haemorrhage (11), abnormality of cord (6), abnormal presentation (2), influenza (1). In 21 out of 22 over parity 5—prematurity (7), abnormalities (3), abnormality of cord (3), following external version (2), impacted shoulders, weights of infants llf and 11 lbs. (2), infants born before arrival of midwife (2), abnormal presentation (1), ante-partum haemorrhage (1). The incidence in primiparae of prolonged second stage and in multiparae of ante-partum haemorrhage in relation to stillbirths is noticeable. 41 There were 402 premature infants not admitted to hospitals, of whom 25 died. The following is an analysis of these premature infants:— Parity Total Weight 3 lbs. and under Weight over 3 lbs. No. Died Stillborn No. Died Stillborn (1) Primiparae 115 7 — 6 108 4 5 (2) Parity 5 and under 257 19 8 10 238 10 16 (3) Over parity 5 30 3 1 2 27 2 5 The number of district confinements undertaken by the voluntary organisations included in the Council's domiciliary midwifery scheme showed a correspondingly substantial increase compared with confinements for 1945. These numbers, together with those for 1938, were as follows:— Maternity nursing cases Midwifery cases Total Grand total 1938 Voluntary hospitals domiciliary service 251 5,484 5,735 District nursing associations 606 1,158 1,764 - 7,499 1945 Voluntary hospitals domiciliary service 53 3,502 3,555 District nursing associations 327 1,584 1,911 - 5,466 1946 Voluntary hospitals domiciliary service 129 6,120 6,249 District nursing associations 501 3,225 3,726 - 9,975 Domiciliary midwifery service— voluntary organisations Relief midwives for the Council's midwives were supplied by the voluntary hospitals and district nursing associations at a cost of £196 15s. and £656, respectively, during 1946. Gas and air analgesia is administered on the district by those of the Council's midwives who hold the analgesia certificate, approved by the Central Midwives Board. The Minnitt's apparatus is kept at ambulance stations in different parts of London. The midwife telephones for the apparatus, when required, and it is delivered to her at the patient's house by ambulance. The scheme for the administration of analgesia commenced on 1st June, 1946, and the number of administrations up to 31st December, 1946, was 206. At the time, 50 midwives were qualified to give it. Others are now being trained. Gas and air analgesia Fourteen hospitals and 9 district nursing associations included in the Council's domiciliary midwifery scheme offered gas and air analgesia to women, and 838 administrations were given by the former and 162 by the latter. These are for a full year. Training in analgesia is provided for the Council's midwives in accordance with the rules of the Central Midwives Board, and the 15 cases to be administered during training are taken either in hospital or on the district. The Midwives Salaries (Rushcliffe) Committee recommended that local authorities should provide accommodation for domiciliary midwives with a view to (i) eliminating the difficulty experienced by new midwives in making satisfactory living arrangements ; (ii) removing differences in rent and rates as between midwives ; and (iii) having the premises available for her successor, whenever a midwife leaves the service. The Council has adopted this policy, and premises have been provided from the Council's own property, on lease from private owners or through the Borough Councils. During 1946, 39 midwives were so accommodated in 33 premises, of which 25 were provided by the Council and 8 were taken on lease, Housing of midwives 42 either from the Borough Councils or direct from the owners. The total number of these "Rushcliffe premises" under the Council's control at 31st December, 1946, was 38, and the number of midwives accommodated in them 48. Lectures, etc., for midwives Iwo courses of five post-certificate lectures each and five courses of four antenatal and post-natal demonstrations were arranged in conjunction with the Middlesex County Council and Surrey County Council during the year. The number of tickets issued to midwives for attendance at the lectures was 377, and 60 for attendance at the demonstrations. Five of the Council's domiciliary midwives attended the summer schools arranged by the College of Midwives, and 70 pupil midwives were accepted for district Part II training with the Council's domiciliary midwives. Payment of medical fees Fees paid under the Midwives Act, 1918, to medical practitioners called in by midwives in emergency amounted to £13,303 12s., and claims for fees paid were 8,351 in 1946, compared with £6,824 10s. and 4,530, respectively, for 1945. During 1946 medical aid was summoned for either mother or child by the Council's midwives in 22-13 per cent, of their cases, which compares with 20-05 per cent, in the case of the voluntary hospital district midwives, and 32"63 per cent, in the case of the district nursing association midwives. Registration of nursing homes There were 101 nursing homes on the register at the end of the year, compared with 108 at the end of 1945. Of the nursing homes registered at the end of the year, 38 were temporarily closed, compared with 40 at the end of 1945. There were 6 new registrations during the year. There were 72 exemptions granted from the operation of Part XI of the Public Health (London) Act, 1936. Nursing homes are experiencing the prevalent difficulty in replacing linen and equipment, but otherwise the general standard is reasonably maintained. Maternity and child welfare work of voluntary associations Grants paid to voluntary maternity and child welfare associations during the year 1946, under section 101 (6) of the Local Government Act, 1929, amounted to £24,793, compared with £20,967 in 1945. Increased grants were made to some associations to meet higher costs. Thirty-five associations were grant-aided during the year, of which 6 were maternity hospitals, 16 mother and baby homes, 5 babj homes and 7 district midwifery practices. During the year one mother and baby home re-opened, and negotiations were begun regarding the opening of three other mother and baby homes or baby homes. Government grant In circular 32/44, dated 13th March, 1944, the Ministry of Health asked the Council to make payments on account of the government grant to district nursing associations, to certain mother and baby homes and to certain baby homes, towards the cost of applying the recommendations of the Midwives and Nurses Salaries Committees (Rushcliffe). This request was implemented, with the assistance of the Central Council for District Nursing in London in the case of the associations ; and, £15,829 12s. 3d. was authorised to be paid to associations for the year ended 31st March, 1947, compared with £6,336 10s. in 1945-46. The amount paid to mother and baby homes and to baby homes for the year ended 31st March, 1946, was £436 lis. 3d., compared with £553 Is. for the years 1943-44 and 1944-45, part of which was on account of Government grant and part direct assistance from the Council. Care of illegitimate children In accordance with Ministry of Health circular 2866/43, dated 16th November, 1943, on the care of illegitimate children, a joint advisory body was set up under the chairmanship of the Chief Officer of Social Welfare, consisting of officers of the Council and the Metropolitan Borough Councils, and of representatives of the voluntary organisations concerned. The advisory body has dealt with (i) a scheme of guaranteed payments to foster-mothers ; (ii) increased financial assistance to voluntary organisations ; (iii) residential nursery places for illegitimate children, and (iv) homes for mothers in the late stages of pregnancy and immediately after confinement. A large proportion of the accommodation for the children has been provided in the Council's hospital nurseries in and outsid London, where nursing 43 mothers are also accommodated. In addition, unmarried mothers are accommodated in voluntary homes, some of which are grant-aided, and all of which are inspected by the Council. Medical examination of staff The number of references made to the department for medical examination or advice concerning the health of staff and suitability of applicants for appointment was 15,134, compared with 14,900 in 1945. In addition 2,381 candidates for appointment as teachers were examined at the request of the Ministry of Education, and 3,235 examinations were made on behalf of the Chief Regional Fire Officer (No. 5 Region) in connection with the recruitment of permanent firemen for the National Fire Service. The Council's staff medical examiners have made 80 home visits for the ascertainment of the fitness of staff unable to travel for examination. During the year, under the war-time scheme whereby London personnel staying in the provinces and provincial personnel temporarily domiciled in London are examined locally, the provincial medical officers have examined 18 London staff and London County Council medical officers have examined 11 persons at the request of the provincial medical officers. This scheme still serves a useful purpose and the help given to London by provincial medical officers of health is much appreciated. Chemical branch The work of the chemical branch was carried on during the year at the three laboratories, and Mr. C. J. Regan, the Chemist-in-Chief, has submitted the following rp/nort:— The number of samples examined in 1946 was 18,938, their classification being:— Air, tunnels, etc 281 Milk : liquid, condensed, dried 317 Air, sulphur in 1,522 Miscellaneous 219 Building materials 114 Oils, lubricating, fuel, etc. 63 Clays and subsoils 145 Paints 99 Coal and coke 28 Petroleum and allied statutory acts 217 Compost (manurial use), etc. 36 Rain water (atmospheric pollution) 83 Detergents 34 Sewage and effluent 3,819 Disinfectants 51 Sludge, primary and digested 1,854 Drugs and medical stores 279 Sludge, activated 714 Fertilisers and feeding stuffs 105 Water, steam raising plants 1,655 Floor oils and polishes 36 Water, drinking, chemical, bacteriological, etc. 1,608 Foods, groceries, etc. 357 Gases, dry cleaners, flue, etc. 134 Water, river, chemical, bacteriological, etc 3,372 Gases, sludge digestion plant 305 Gas liquor 169 Water, swimming bath, chemical, bacteriological, etc. 594 Insecticides 16 Lamps, gas detector 387 Total 18,938 Meals and vitamin assays 305 Metals 20 Examination of sa mples A general indication of the origin of these samples and also of the consultative and advisory work of the branch for the various executive services of the Council follows. The subject of nutrition was studied by the analysis of meals as to their fat, protein, carbohydrate and mineral contents, and the determination of their calorific value. On the vitamin side special assays were made of the vitamin C content and the standards for and means of conserving it were considered and reported upon. In view of the shortage of soap the subject of detergency was investigated, and the use of a new type of synthetic detergent for washing-up introduced. The possibilities of the " Lye " (caustic soda) process for peeling potatoes were also investigated. Meals Service Of the wide range of work undertaken for the housing service, that on the examination of paints is particularly important on account of the difficulties in Housing 44 the supply of raw materials. For example, on the "vehicle" side, linseed oil has had to be replaced by materials such as plastics or chlorinated rubber. A failure of concrete was investigated and attributed to the nature of the aggregate and its lack of grading. Much attention was paid to the sulphate content of the subsoils and underground waters of new estates in view of the potential deleterious effect on ordinary portland cement concrete. Public Health Regular chemical analyses and bacteriological examinations were made of the drinking waters derived from private wells supplying hospitals and institutions ; all these are chlorinated before use. Assays were made by various methods of the polluting matter (total deposit, tarry matter, sulphur gases, etc.) in the air in various parts of London and also, for comparison, at premises outside the county. This work was done in conjunction with a scheme sponsored by the Department of Scientific and Industrial Research. This subject (atmospheric pollution) assumed importance in view of the proposals for erecting new electricity generating stations which would involve the consumption of large quantities of coal; the question, therefore arose as to the desirability of flue gas washing to prevent access of sulphur gases to the air. The air in the Council's vehicular tunnels was examined in order to ensure safe conditions from the health aspect as regards the carbon monoxide and lead contents derived from motor exhaust fumes (the lead coming from leaded petrol). Main Drainage The laboratories at the two outfall works are wholly concerned with work for the main drainage service, and some is also done at the central laboratory. The sewage of London north of the River Thames is treated at the Northern Outfall Works by sedimentation, and a portion of it subsequently by the activated sludge process. That from south London is submitted at the Southern Outfall Works to sedimentation only. In both cases the sedimented matter (sludge) is taken out to the estuary in ships and dumped ; the effluent is discharged into the river at the outfalls. After being out of operation during the war years the activated sludge plant was re-started in 1946, and a stock of activated sludge having been conserved, smooth building-up of treatment was effected. The effluents from the outfall works are discharged into the River Thames, and natural oxidation by the dissolved oxygen in the water is the final process in their purification. A careful watch was therefore kept on the condition of the water of the river by regular sampling and analysis at many points between Teddington weir and the estuary. The sludge digestion plant at the Northern Outfall Works functioned satisfactorily, the temperature of operation being 85° F. ; the sludge gas produced (containing about 70 per cent, methane) was used for power production. Work on the composting of sewage products was continued and large quantities of compost for use on Council farms were made from household refuse and sludge screenings. Advice was given as required as to the nature of industrial discharges into sewers, particularly in regard to their compliance with the requirements of the Public Health (London) Act, 1936, and batches of safety lamps for use in the sewers were tested. Public Control The work of the chemical branch for the public control service is mainly to comply with various Acts of Parliament. The Fertilisers and Feeding Stuffs Act, (1926), under which the Chemist-in-Chief is the official agricultural analyst for the county, was designed to prevent fraud in connection with the sale of these materials, and statutory statements of essential ingredients have to be made; samples are examined to ascertain compliance with these statements. The Petroleum Consolidation Act (1928), London County Council (Celluloid) Act, and the London Building Act (1930) regulate the storage and use of inflammable materials samples of which were tested as to compliance with the various requirements. Firms operating certain dry-cleaning processes work under licence ; plants were examined and samples of the atmosphere in them analysed to ascertain whether the conditions of the licence were being fulfilled. 45 The chief work for the Parks Department is the chemical analysis and bacteriological examination of the water in swimming baths (all of which are fitted with filtration and chlorination plants), and advising as to procedure in connection therewith. The water of natural ponds was also tested and soil and other samples analysed as required. Parks Work for the Supplies Department covers a very wide field, dealing with all types of material purchased by the Council. Not only are samples examined, but advice is given as to the compilation of specifications. Baking powder, gelatine, mustard, and other articles of food or ingredients thereof are supplied to specification, and tendered samples are examined in order that the contract may be allocated to the most economically satisfactory offer. Some rejections occur : for example, a tendered batch of tinned guavas was rejected in 1946 as containing an excess of tin. Drugs and medical supplies were analysed as to compliance with the British Pharmacopeia or British Pharmaceutical Codex requirements, and some were found to be unsatisfactory. Oils of many classes (lubricating, fuel and fatty) were also tested. Modern developments in the insecticides field have been kept under review, and the use of modern synthetics (D.D.T. and Gammexane) adopted in specifications in place of older and less effective types. Supplie» lhe main connection with the education service is in regard to the feeding of school children (referred to under Meals Service). Additionally the whole-day food intake at residential schools was examined; and the testing of water supplies and swimming baths at these schools might also be mentioned. Another item was the examination of modelling clays for the absence of lead and other poisonous metals and dyes. Parties of senior students from secondary schools made educational visits to the central laboratory. Education Steam raising, heating, etc., plants come under two departments (Chief Engineer and Architect), and the scientific control thereof has developed considerably in recent years. The chemical branch advises and does analyses in connection with plants at hospitals, schools, etc. At many premises where water-softening plants are not available, the "internal treatment" of the boiler water by soda ash and quebracho is operated ; in other instances phosphate conditioning has been adopted. To minimise the deposition of calcium carbonate in calorifiers, feed lines, etc., a preparation of sodium hexameta-phosphate has been used with success. Corrosion problems have been investigated (e.g. of calorifier tubes), and supervision of the chemical de-sealing of boilers has been undertaken. Steam raising, heating, etc., plants Many other problems were investigated as required ; examples are the death ,of cows (lead poisoning from paint flakes), and the marking of linen by transfers instead of marking ink. During 1946, two papers were published in scientific journals : " The Air of London," by the Chemist-in-Chief, and " The Chemical De-scaling of Boilers," by Mr. R. H. Burns. Miscellaneous HOSPITALS AND ANCILLARY SERVICES General and special (other than mental) hospitals Throughout the year, ten hospitals remained closed for the reception of patients, viz., Downs Hospital for Children, Sutton, Surrey ; Millfield Convalescent Home, Littlehampton ; Norwood Hospital for Children ; Orchard Hospital, Dartford; Princess Mary's Convalescent Hospital, Margate; St. Clement's Hospital, E.3 ; St. Luke's Hospital. Lowestoft; St. Margaret's Hospital, Kentish Town ; St. Peter's Hospital, Whitechapel; and the South-Eastern Hospital, New Cross. Some of the buildings were used for other purposes. At the beginning of the year 8.216 patients were under treatment. The number rose to 8,739 on 23rd January, 1946, and then fell to 7,607 on 11th September, 1946. The number remaining at the end of the vear was 8,373. Acute general hospitals 46 Maternity The maternity units have had a most difficult year, as is evident from the following figures:— (1) Ihe number 01 confinements in 1946 (21,385) rose to the 19.59 level, but the number of available beds, even at the end of the year, was 168 less than in 1939, i.e. 886 against 1,054. (2) The over-pressure on the units was even worse than these figures indicate, for the rate of admission rose sharply in the second half of the year and was not evenly distributed throughout the year. Moreover, the number of beds available was much reduced for substantial periods by closure on account of infection among patients or illness or shortage of staff. (3) The main problem in all units has been shortage of staff. There have been grave deficiences in all grades of midwives and domestic workers. (4) Irregular movements of the population made the resumption of early and continuous ante-natal care almost impossible and the proportion of emergency admissions had grown from the pre-war figure of under 10 per cent, to 20 per cent, and even 40 per cent, in some areas. (5) To cover the shortage of accommodation, a complicated system of bed allocations has to be worked. Normal cases are required to have their babies at home with a domiciliary midwife in attendance, or, if the home conditions are impossible, to be evacuated three to four weeks before the confinement to a provincial maternity establishment conducted by a local authority at the instigation of the Ministry of Health. Hospital beds in London are reserved as far as possible for abnormal cases, women living under bad home conditions who cannot be found a bed under the evacuation scheme, and acute emergencies. Unfortunately it is impossible in practice to make clear-cut divisions into these categories, and considerable inconvenience is caused to all concerned, especially to mothers who find that they are still left in uncertainty about their plans within a few weeks of their confinement. But for the helpful co-operation of the officers of the London boroughs and of the London Voluntary Hospitals Joint Committee, the situation would have been far worse. In the circumstances, it is not surprising that the maternal death-rate for 1946 is not as satisfactory as in past years. Experience has shown that a minimum maternal death-rate can only be achieved by adequate staffs working in adequately equipped maternity units and that the system of ante-natal care must be simple, smooth-running and complete for every emergency. The high incidence of deaths from causes which are included in the theoretically "preventible" category (e.g. eclampsia 7, and sepsis 5) shows that London is still paying the penalty of war disorganisation. Most of the women who died from eclampsia were admitted moribund or almost so. One of the patients with sepsis and two with placenta praevia were admitted in a hopeless condition. A woman died from anaphylaxis after an injection of sucrose, and two women died (probably, though not certainly) from results of blood transfusion administered for an obstetrical emergency. The Rhesus factor is now estimated in every case attending the Council's ante-natal clinics and very valuable work has been done in the saving of infant lives. Interesting and important experiments are being made in the use of trilene for maternal analgesia in normal labour. Maternal mortality statistics, 1946 Number of confinements in London County Council hospitals 21,385 Births, Live 21,147 „ Still 679 (3 11 per 1,000 total births) Total 21,820 47 Maternal deaths— Deaths due to pregnancy or confinement 31 Deaths associated with pregnancy, etc. 10 Total maternal deaths 41 Maternal mortality per 1,000 total births 1.88 Other deaths— Confined before admission 4 From abortion 12 „ ectopic gestation 3 Emergency obstetric service Considerable use has been made during the year of the emergency obstetric service which is now operated from the majority of the Council's hospitals with maternity units. The object of the service is to provide in a patient's home in an acute obstetrical emergency not covered by the service of consultants maintained by the Borough Councils, nor by the medical aid which a midwife is required by the Central Midwives Board to summon in emergency, a hospital unit equipped to provide all necessary treatment and staffed by doctors and nurses experienced in obstetrics. The unit is summoned by a district midwife or a doctor in charge of the confinement telephoning to the London Ambulance Service headquarters, the unit being brought to the patient's home by ambulance. The service was originally started in 1938, but considerably increased in use during the latter years of the war. During 1946, a total of 61 calls was made, covering 17 metropolitan boroughs, and being answered from 10 of the Council's hospitals. Eleven calls came from the borough of Wandsworth, and 10 from Lewisham. Eighteen of the total calls were answered by St. James's Hospital, and 11 by Lewisham Hospital, Hammersmith, Hospital, with 9, being the next highest. Parts of the county north of the River Thames, comprising the City and the boroughs of Finsbury, Shoreditch, Holborn, St. Pancras and Islington, are not included in the Council's scheme, their emergency needs being covered by University College Hospital and St. Bartholomew's Hospital. Of the 61 calls, 46 were made by the Council's own midwives, by midwives employed by district nursing associations and similar bodies, or by independent midwives; eight calls were made by doctors, and four were from nursing homes. In the remaining three it is not clear from the information available who made the call. In 45 the patient was subsequently admitted to hospital. The majority of the calls were to patients where post-partum haemorrhage had occurred (43 cases), the next most frequent cause being retained placenta. In 39 cases a blood transfusion was given to the patient. Out of the 46 calls made by midwives, medical aid had been summoned prior to the calling of the emergency service in 31 instances. It will thus be seen that in a majority of the cases a blood transfusion was required for a patient who had had a severe haemorrhage, but the service has also dealt with other serious obstetrical emergencies, and it is, doubtless, true to say that a considerable number of patients owe their lives to the skill and promptness with which the emergency service was provided. During the year 1946, it became apparent that, especially in those parts of London remote from the centre, and where it was formerly not easy to obtain the best obstetrical aid in a sudden emergency, the knowledge that the emergency service was available was being widely spread among general practitioners, with a resulting considerable increase in the service which the emergency units were able to render. Chronic sick hospitals The number of patients in the chronic sick hospitals at the beginning of the year was 2,243. This rose to 2,455 on 27th November, 1946, and the number remaining at the end of the year was 2,448. 48 Acute infectious hospitals Grave difficulties were experienced throughout the year, owing to the shortage of nursing and female domestic staff, in providing hospital accommodation for the treatment of patients suffering from infectious diseases. At the period of greatest pressure on the accommodation, only 1,450 beds (less than one quarter of the pre-war provision) were available for patients suffering from infectious diseases. But, fortunately, the demand for beds is substantially less than it was before the war. The restrictions on the admissions of cases of infectious diseases, e.g., scarlet fever, measles, chickenpox, German measles and mumps, were continued throughout the year. The number of infectious patients admitted during the year was 13,695. The number of patients under treatment at the beginning of the year was 1,315. This rose to 1,416 on 3rd April, 1946, and fell to 1,060 on 30th September, 1946. The number remaining at the end of the year was 1,123. Smallpox Nine cases of suspected smallpox were admitted during the year to Clandon Isolation Hospital, where, by agreement with the Surrey County Council, London smallpox patients as well as those from other areas are received. Two of these patients were finally found to be suffering from smallpox. Typhus Tuberculosis hospitals No case of typhus occurred during the year. St. Luke's Hospital, Lowestoft, remained closed throughout the year. All available beds in the remaining hospitals for tuberculosis were occupied, except a number at Grove Park Hospital and St. George's Home, which could not be opened owing to the lack of staff. Children's hospitals The Downs Hospital, Millfield Convalescent Hospital, and Norwood Hospital for Children remained closed throughout the year. Queen Mary's Hospital for Children, Goldie Leigh Hospital and White Oak Hospital continued to provide accommodation for children. St. Anne's Home, Heme Bay, was re-opened on 6th November, 1946, for the reception of convalescent children. Because of shortage of staff, however, accommodation was available for only 35 children. Hospitals for epileptics The two hospitals for epileptics (St. David's Hospital, Edmonton, and St. Faith's Hospital, Brentwood) continued to provide treatment for male and female epileptic patients. The number of patients undergoing treatment remained fairly constant throughout the year. Convalescent hospitals Princess Mary's Convalescent Hospital, Margate, remained closed throughout the year. A few convalescent adult patients were sent to Queen Mary's Hospital, Sidcup, and large numbers of male and female adult convalescent patients were sent to voluntary convalescent homes. Convalescent children The arrangement made with the Invalid Children's Aid Association under which children for whose medical care the Council is responsible were referred to the Association, by whom they were sent to convalescent homes, was continued throughout the year. During 1946. 897 children were dealt with in this way. In addition to the foregoing arrangement, the long-standing practice was continued of accepting financial liability for the convalescent treatment of children brought to the Council's notice by the Invalid Children's Aid Association themselves. During the year these children numbered 927, compared with 820 in the previous year. Other hospitals The Northern Hospital, Winchmore Hill, Queen Mary's Hospital, Sidcup, and Southern and Joyce Green Hospitals, Dartford, continued to serve a useful purpose by receiving numbers of patients transferred from the other hospitals. Venereal diseases Beds for patients suffering from venereal diseases were provided at Sheffield Street, Bethnal Green and St. Charles' Hospitals. 49 Admissions to Public health hospitals The numbers of patients admitted during 1946, compared with 1938 and 1945, are shown below:— 1938 1945 1946§ Acute general hospitals 173,796 126,157* 133,638* Chronic sick hospitals 10,014‡ 6,982 7,022 Convalescent hospitals (adults) 4,698 — — „ „ (children) 4,257 — 47 Convalescent fever hospitals 2,942 14,813† 10,530† Acute fever hospitals 33,159 20,825††ø 14,558ø Tuberculosis hospitals 4,163 1,873ø 1,5180ø Children's hospitals 5,489 2,814 3,172 Post-encephalitis lethargica unit 49 23 23 Venereal diseases hospitals 801 438 525 Nursery units — 713 1,332 Epileptic hospitals 237 180 158 Total 239,605 174,818 172,523 * Includes Queen Mary's Hospital Sidcup. † Hospitals devoted wholly to non-fever patients. ‡ Includes 802 patients in social welfare establishments. ø Includes general medical patients. § The figures for 1946 are provisional only. †† Includes 3,000 patients passing through the Western Hospital in transit from evacuation to the provinces. Evacuated hospital patients Owing to the continued shortage of staff it was not possible to complete during the year the return to London of the remaining evacuated hospital patients. During the year 196 patients were returned to their homes or social welfare establishments. At the end of the year there remained about 700 such patients in hospitals in various parts of the country. Residential nuseries At the end of 1945, there were 773 cots in the Council's nurseries for children up to two years of age, and 583 children were in residence. Two more country establishments to which the children had been evacuated during the war have closed, and had to be given up early in January, the children returning to nurseries in or near London. Two further country nurseries (Basted House, Wrotham, Kent, and The Elms, Bourne End, Bucks.) were closed in February. To meet the ever-growing need for more accommodation, the nursery at the Downs Hospital, Sutton (157 cots), which was partially opened in December, 1945, was brought into full use by the end of January. A nursery unit (40 cots) was opened at the South-Western Hospital, Stockwell, S.W.9, at the end of March. The need for accommodation continued to grow during the year owing to the increased number of children coming into the Council's care, and in December, 1946, authority was given for the extension of the nursery unit at the South-Western Hospital by 24 cots as soon as staff could be obtained. By the end of the year, however, it had not been found possible to bring this additional accommodation into use. The following statement shows the position as regards nursery accommodation on 31st December, 1946:— Total accommodation Number of children in residence 7 public health nurseries (4 in country, 279 cots ; 3 in London, 164 cots) 443 cots 404 4 social welfare nurseries (in London) 337 cots 302 780 cots 706 Of the seven public health nurseries, all but two (Easneye and Widbury House) are in hospital buildings. Two of the remainder (South-Western Hospital and Queen Mary's Hospital for Children, Carshalton) are in hospitals where patients are under 50 treatment, although the nurseries are in separate blocks. The other three are in hospital premises which are not at present used to accommodate the sick. The policy of establishing nurseries in hospital buildings, although open to objection, was forced upon the Council for two reasons, viz.:— (1) The pressing need for nursery accommodation could only be met by establishing units at premises which were immediately available and where little or no structural alteration was required. (2) The shortage of suitable staff made difficult the opening of nurseries at short notice and it was most economical for this reason to establish units at hospitals where the services of some of the hospital staff could be utilised. Linkage with voluntary hospitals The various forms of association between the Council's hospitals and voluntary hospitals have been continued and extended. There are a number of wards in the Council's hospitals which, owing to the acute shortage of staff, cannot be used, but which can be opened if voluntary hospitals provide the domestic or more particularly nursing staff, who are either seconded or are appointed to the Council's service. The subordinate medical staff of these units are appointed by the Council, the senior medical staff of the voluntary hospital being associated with the selection committee. Payment for the services of the senior medical staff from the voluntary hospital is by way of a block grant which is distributed by the Council to the staff concerned on the advice of the medical committee of the voluntary hospital. The Council also reimburses the salaries and the employers' share of any superannuation contributions of the seconded nursing and domestic staff. The overall administrative responsibility of the Council's medical superintendent is preserved, but clinical responsibility is with the senior staff from the voluntary hospital. Applications for bed accommodation in Council's hospitals are received mainly from voluntary hospitals wishing to replace beds destroyed or seriously damaged by enemy action, and from teaching hospitals desiring to extend their facilities for instruction. The association between the Council's hospitals and the voluntary hospitals has proved to be mutually beneficial. The following associations between the Council's and voluntary hospitals were established during the year:— Council's hospital Voluntary hospital Particulars of association St. Charles' Hospital ... West End Hospital for Nervous Diseases. Establishment of neurological unit to replace beds in the voluntary hospital destroyed by enemy action. *North-Western Hospital St. Peter's Hospital for Genito-Urinary Diseases. Establishment of unit for genitourinary diseases, to replace beds in the voluntary hospital damaged by enemy action. Lambeth Hospital St. Thomas's Hospital Medical staff of St. Thomas's hospital assumed responsibility for the maternity unit at Lambeth Hospital. Two staff midwives from St. Thomas's Hospital are seconded to Lambeth Hospital for teaching purposes and a quarterly interchange of pupil midwives is made between the twohospitals. Medical students are instructed in the unit. * This association ceased in December, 1946. 51 Council's hospital Voluntary hospital Particulars of association Brook Hospital Hospital for Sick Children, Great Ormond Street. (a) Secondment of student nurses from Great Ormond Street Hospital for a period of two months at a time for training in nursing of infectious diseases. (b) Accommodation of the preliminary training school of Great Ormond Street Hospital at Brook Hospital owing to lack of accommodation at Great Ormond Street. Archway Group of Hospitals. Royal Free Hospital "Post" of six medical students from Royal Free Hospital attached to the medical wards at Archway Hospital for three months at a time. Queen Mary's Hospital for Children, Carshalton. South-Eastern Hospital for Children, Sydenham. Secondment of student nurses from Queen Mary's Hospital for Children. Carshalton, to staff a ward at SouthEastern Hospital for Children, Sydenham, to give more experience in acute medical and surgical work. Fulham Hospital West London Hospital Dean of West London Hospital Medical School assumed clinical control of 32 beds (16 male and 16 female) on the medical side of Fulham Hospital. Students from West London Hospital attend Fulham Hospital to receive medical teaching Besides the foregoing associations, mention should be made of the ophthalmic department which has functioned at Lambeth Hospital since 1943 in the clinical charge of medical staff from the Royal Eye Hospital, and of the arrangements made for accommodating 39 nurses from Guy's Hospital at Lambeth Hospital and for seconding six senior nurses from Guy's Hospital for duty at St. Olave's Hospital. The possibility of extending the co-operation between the Council's hospitals and voluntary hospitals is under active consideration and many schemes are being discussed. Works of improvement The reports for the years 1944 and 1945 indicated that, with certain exceptions, rebuilding of destroyed or damaged hospitals and the overtaking of six years' arrears of works of improvement had had to be deferred in conformity with the policy to give priority to housing. While this need remained of paramount importance, it was decided that the more urgent requirements of the hospital service should be met, so as to prevent the marked lowering of hospital standards. With this aim, attention was drawn, during the year, to the most pressing needs for repairs, etc., and certain urgent works were approved. A request (circular 185/45) from the Ministry of Health for particulars of estimated capital expenditure for the three years 1946/49 necessitated the preparation of a programme of major building works at hospitals, group laboratories, etc. A priority list of works has been prepared and authority obtained for the preparation of sketch plans in respect of 35 major building works at 28 hospitals. During the year re-instatement of air-raid damage at a number of hospitals was continued. In addition, certain works were carried out under arrangements made by the Ministry of Works. The works necessary for re-opening Princess Mary's Hospital, Margate (closed during the war period), as a convalescent home for women, were completed. 52 Acquisition of property On 30th July, 1946, the Council authorised steps to be taken to acquire certain sites, including bomb-damaged properties adjacent to ten hospitals, for the future development of the hospitals service. The Council also sanctioned the acquisition of premises in Cromwell Road with a view to their adaptation as a nurses' home for St. Mary Abbots Hospital to replace destroyed accommodation. Hospital committees In July, 1946, the Council restored most of their pre-war functions to hospital committees and gave them authority to sanction within the votes expenditure not exceeding certain specified annual amounts ranging from £50 to £200 on works of minor improvement and on items of additional equipment for the benefit of patients and staff. This addition was part of the Council's policy of strengthening the individuality of each hospital without prejudice to its efficient administration as an integral part of a large service. It was also decided that hospital committees should meet more frequently than was possible during and immediately after the war. It may not be out of place to refer in some detail to the large amount of administrative work which was performed last year by hospital committees and which enhanced the position of the Council's hospitals as factors in local communal life. Each of the Council's hospitals, or in a few instances groups of hospitals, has as its local governing body a hospital committee appointed by the Hospitals and Medical Services Committee. As many as 373 members served on these local committees last year; more than 200 meetings were held and some 1,500 "interim visits" made. Among the more important of the duties of hospital committees are the regular visiting of the wards and inspection of the diets; appointing ladies' visiting committees; fixing the detailed arrangements for the visiting of patients by their relatives and friends; examination of the hospital's books; considering the reports of the medical superintendent and other senior officers of the hospital; approving requisitions for supplies; the appointment and promotion of certain grades of staff; deciding the disposal of small gifts of money to the hospital and considering works for inclusion in the annual maintenance estimates. These administrative functions of hospital committees are perforce conditioned to some extent by the fact that each hospital is only a part of a very large service. Although there is express provision for hospital committees to submit for consideration any proposals they may desire to make on matters affecting the hospital, decisions on matters of major policy are necessarily reserved for the Hospitals and Medical Services Committee. District medical service In 1946, the district medical service was continued as in previous years, and the number of persons receiving attention showed a slight increase. Several district medical officers retired on reaching the age limit, and others who were on national service returned to civilian life. All but two of the temporary war-time appointments have now been terminated and the resulting vacancies filled, following public advertisement. Although as a result of the National Insurance Act, 1946, supplementary pensions were, from October, 1946, absorbed in increased old age pensions, former supplementary pensioners and their dependants were retained on the permanent medical relief lists and so continued to be entitled to call on a district medical officer at any time. A large part of the work of district medical officers was with old people, and difficulties of obtaining hospital admissions for chronic sick patients led to increased domiciliary visiting. During the year emergency calls on district medical officers at night, due to applicants' inability to obtain a doctor, decreased because of the larger number of doctors normally available. All statistics for the year showed slight increases over comparable figures, except for hospital admissions. 53 Statistical information about the service in 1946 can be summarised conveniently as follows, figures in brackets referring to the work done in 1945:— Medical relief districts served Doctors Attendances at relief stations or surgeries Domiciliary visits Persons seen Persons admitted to hospital Attending at relief stations Attending at surgeries Part-time general practitioners 78 41 32 98,648 34,962 26,757 1,694 (86,840) (27,968) (23,236) (1,866) Hospital doctors 11 11 — 18,098 4,422 5,210 594 (14,812) (3,644) (4,411) (611) Total 89 52 32 116,746 39,384 31,967 2,288 (101,652) (31,612) (27,647) (2,477) There are 30 medical relief stations, at 11 of which are pharmacies. In other cases, and where patients attend at doctors' surgeries, medicines are obtained from local chemists. District nursing service During 1946, the arrangements for the nursing of patients in their homes on behalf of the Council by nurses employed by district nursing associations was continued. Grant was paid by the Council to the Central Council for District Nursing in London for distribution on a visit basis to the associations concerned. The amount of grant was reviewed, and increased to meet the cost of higher remuneration paid to individual nurses. The numbers of visits made on the Council's behalf, both for general nursing and for the administration of insulin, showed an increase on the comparable figures for 1945 (193,261 and 163,993 general nursing visits ; and 129,137 and 105,252 insulin visits). Hospital pharmaceutical service A pharmacists' advisory committee, under the chairmanship of a senior medical officer on the central office staff, and composed of six pharmacists from general, special and mental hospitals, annually elected by the pharmacists themselves, has been formed to advise the medical officer on matters affecting the pharmaceutical service in the hospitals. This committee has done much useful work, and the administrative advantages resulting from this form of co-operation between central office and the hospitals has been marked. A pharmaceutical bulletin edited by one of the pharmacists and containing instructions and information relating to the pharmaceutical service, as well as extracts from professional and technical journals relating to the use of drugs, research and forms of preparation, etc., is circulated to pharmacists once every two months. Artificial limbs The arrangements with Queen Mary's (Roehampton) Hospital for the supply and repair of artificial limb continued during the year. The scheme first came into operation in 1932, and was originally formed for the provision and repair of artificial limbs for persons in receipt of public assistance. It has proved a great success and dow, in addition to elderly social welfare patients, arrangements are made for school children, and for tuberculous, blind and mental health service patients, to be provided, if required, with artificial limbs under the scheme. School children are examined at school at six-monthly intervals and referred for the repair or adjustment of their limbs if necessary. Each patient referred to the hospital for the provision of a limb is seen by a limb fitting surgeon, who decides on the type of limb to be provided. He also sees the patient after completion of the limb, and instruction is given in the use of it. This necessitates admission of some of the patients to the hospital for a short period, for example, those with a double amputation, or school children fitted with artificial arms. 54 During 1946, seventy new patients were referred under the scheme, and the total number seen was 261, compared with 210 in 1945. Hospital libraries The great value of libraries to patients in the Council s hospitals has long been recognised, and this service has been mainly developed through the co-operation of the Hospital Library of the British Red Cross Society, to which the Council makes grants. Through this service thousands of books, many of them valuable, have been distributed to the hospital libraries; the Society have also procured the services of a number of voluntary librarians. At the Southern Hospital, which has a very large library, three full-time librarians are employed by the Council, and paid librarians have also been appointed at Joyce Green Hospital and Queen Mary's Hospital, Sidcup. The Council also makes a grant to the British Red Cross Society in payment of the salaries of two full-time librarians, who visit those hospitals which have difficulty in obtaining an adequate supply of voluntary workers. In addition to the libraries in the general hospitals, the British Red Cross Society have organised an excellent circulating library for patients in the tuberculosis wards. Under this scheme books are exchanged at regular intervals. Picture library scheme In May, 1946, a picture library scheme, inaugurated by the British Red Cross Society, was introduced into certain hospitals and sanatoria catering for long-term patients. The object of the scheme is to bring to patients who have to spend a long time in hospitals interest that transcends the limitations of their surroundings. The pictures, which consist of a number of reproductions and prints, are distributed by the society's representatives and are changed periodically, usually once a month. Arrangements are also made by the society for the occasional services of a lecturer who talks in simple language about art and artists, some talks being illustrated by reproductions. Artists' materials are provided for patients who express a desire to draw or paint. The arrangements are much appreciated by the patients. St. John's Hospital, Battersea: clinic for epileptics An out-patient clinic was opened at St. John s Hospital on 23rd October, 1946, to provide for epileptic persons who are not under regular treatment, and were unable to retain employment for lack of suitable arrangements for their supervision and after-care. Some of these persons had at one time or another been patients at St. David's or St. Faith's Hospital or in voluntary establishments. Under the Disabled Persons (Employment) Act, 1944, new opportunities of industrial employment became available to such people, but the Council considered that some further provision was required. The function of the clinic is to give advice and treatment to epileptics referred from any of the Council's establishments or by general practitioners. Guidance is also given on working capacity and suitability for employment. Persons considered fit to take and hold employment are referred to the appropriate employment exchange. The clinic staff work in close co-operation with the local disablement rehabilitation officers of the Ministry of Labour. Medical education An important feature of the year was the series of post-graduate refresher courses for medical officers released from H.M. Forces and panel practitioners under the National Health Insurance scheme. By arrangement with the Ministry of Health, through the agencies of the British Post-Graduate Medical Federation and the Local Medical and Panel Committee for the County of London, courses of lecture-demonstrations were organised at general and fever hospitals grouped for administrative reasons in the north-west, north-east, south-west and south-east areas of London, in addition to post-graduate instruction at the British Post-Graduate Medical School located at Hammersmith Hospital. Financial assistance is afforded by the Ministry of Health to officers released from H.M. Forces, provided such doctors enrol and complete a course within 12 months of demobilization. Panel practit ioners are also assisted. 55 The numbers of medical officers released from H.M. Forces must, in due course, diminish, but those enrolled for refresher courses under the National Health Insurance scheme, together with general practitioners willing to pay their own fees, will no doubt sustain the demand for some time to come. Resident and non-resident courses of instruction in the diagnosis and treatment of fevers have been continued and extended as circumstances permitted. No fewer than 641 undergraduate students were enrolled for the fever courses at 6 hospitals, and of these 126 were women. In addition, 3 months' post-graduate courses of instruction in fever hospital administration suitable for candidates for the Diploma in Public Health were conducted at North-Eastern Hospital. At the request of the Fellowship of Post-Graduate Medicine, revision courses have also been held at St. Stephen's Hospital in rheumatism and general medicine suitable for M.R.C.P. candidates. Arrangements have been in operation for many years for medical students from the London Hospital to visit Whitechapel Clinic, and these have been continued. Facilities have also been provided at that Clinic and at Endell Street Clinic for medical officers to gain some experience of the work on veneral diseases, and for others to undergo courses to enable them to fulfil the qualifications prescribed for venereal disease officers. Visits, etc., by students and others Medical officers of various nationalities, mostly from the Dominons, the Crown Colonies and India, worked in a voluntary capacity at various hospitals in order to widen their professional experience and to become acquainted with modern methods of treatment. Visits were paid to a number of hospitals by parties of students from the London School of Economics, the Battersea Polytechnic, and other educational establishments ; lectures and demonstrations were given to many of them by members of the hospital's medical and nursing staff. Facilities were afforded to cookery students, sponsored by the Ministry of Labour and National Service, to enable them to obtain experience of large-scale institutional cookery by working for a few weeks in hospital kitchens. Legacies and donations During the year five legacies were received for the benefit of four of the Council's hospitals, viz., Bethnal Green (£85), Fulham (£126 and £10), Lambeth (£10) and St. Mary Abbots, Kensington (£500). These sums have been, or will be, used for the benefit of the patients and staff of the hospitals concerned. The total balance at 30th September, 1946, of the forty-seven bequests, etc., held by the Council in respect of its general and special hospitals was nearly £19,000. Many small gifts of money were received at hospitals during 1946 in recognition of "kindly treatment" given to patients and the total of these local funds at the end of last year was approximately £5,500. Donations were also received for Samaritan purposes, i.e., to assist necessitous patients on discharge from hospital, and the total balance in the central and local Samaritan funds on 1st November, 1946, was a little over £2,000. These donations, together with the income from the capital investment of legacies, were expended on the authority of the hospital committees in the manner indicated by the donors. During the war, there was little call for disbursement from these funds, partly because of the limited number of objects on which the money could be spent and partly because of the Government's desire that all expenditure should be minimised. There was a tendency last year for expenditure under this heading to increase and for many extra comforts to be provided for patients and staff alike. Canteen for out-patients At sixteen hospitals, mostly long-stay, canteens are in operation at which cups of tea, cakes, toilet requisites, etc., are sold to staff and patients. The profits from these canteens are devoted to providing additional amenities for patients and staff The balance in hand in respect of these canteens stood on 30th September, 1946, at £11,966. 56 During the year small canteens to supply light refreshments for out-patients have been opened at Mile End and Dulwich Hospitals. It is intended when the necessary facilities are available to open similar canteens at other hospitals where the number of out-patients is considerable. Research on diseases of old age At the request of Dr. Trevor H. Howell, who has been awarded a grant by the Nuffield Foundation for the purpose of conducting research into the diseases of old people, facilities have been granted to enable him to do this work in one of the Council's hospitals. Hospitals exhibition An exhibition of the hospital services of the Council was held at the County Hall from 21st to 26th January, 1946. As many aspects as possible of the wide variety of work in the hospitals and allied services were shown by means of trained demonstrators, pictures, posters, models and actual equipment. The main purpose of the exhibition was to stimulate recruitment to the nursing and domestic staff of the hospitals, and visits to the hospitals by persons interested were arranged to enable them to see the actual working of the service. The Ministries of Health, Labour, Information and Food, helped with advice and information, the Ministry of Food supplying an exhibit. Films of public health interest were shown, and the valuable co-operation of the B.B.C., the press and of many cinemas, which showed a slide announcing the exhibition, was obtained. The exhibition was opened by the Minister of Health and subsequently the Minister of Labour performed the opening ceremony for a particular day. A number of leading personalities of the stage and screen attended on various days. To ensure the attendance of the right type of potential recruits, arrangements were made for parties of schoolgirls to visit the exhibition, and women's youth organisations, the British Red Cross Society, etc., also organised parties. Matrons from various of the Council's hospitals were in attendance to interview prospective candidates for the hospital service, and an information bureau was provided. Nearly 11,500 people attended the exhibition and over 2,000 enquiries about employment in the hospitals were received. It is impossible to assess with any accuracy the value of such an exhibition as it is mostly " long-term, " but the immediate results were the recruitment of a certain number of staff. Clinical Research Committee The Clinical Research Committee met on six occasions during 1946. Among the matters considered were:— (1) Research work carried out at Council hospitals by the medical staff— Level of vitamin A in the blood in cases of acute rheumatism. Treatment of diabetes insipidus. Iron compounds in the treatment of anaemia. (2) Drugs or forms of treatment tried at hospitals— Chemical test for the diagnosis of cancer. U.F.I. (urea formic iodide) for treatment of infective wounds, burns, etc. Anethaine. Para-aminosalicylic acid in the treatment of tuberculosis. (3) The effect of various dosages of penicillin in the treatment of syphilis in its relationship to relapse (including an arrangement with the Ministry of Pensions regarding the use of service medical cards of patients in the Council's hospitals reported to have had treatment for syphilis whilst in the services). The Committee also considered the arrangements regarding the trials, sponsored by the Medical Research Council, to be made of streptomycin at certain of the Council's hospitals when supplies of the drug become available. The sub-committees of the Clinical Research Committee continued to meet for the purpose of carrying out special investigations. I mentioned in my report for 1945 that the medical officer of an eminent research laboratory had informed the Council that initial tests of a whooping-cough serum had given promising results 57 but that clinical trials were desired, and that the Clinical Research Committee had set up a sub-committee to consider the matter and to arrange for trials. The subcommittee reported that the trials had not demonstrated any high therapeutic value of the serum and that large-scale trials were not indicated. The use of the serum for prophylaxis was considered by the sub-committee as it was thought that, in a disease like whooping-cough with its ill-defined onset, there would be more scope for prophylaxis than treatment. Medical Society The Medical Society, whose inauguration was mentioned in my report of 1945, started the year with 320 members and ended the year with 315. During the year, three discussion meetings were held at County Hall, one on "Surgery of the hand," the second on "Dental disease in its relation to ill-health" and the third on "Penicillin." Clinical meetings have been held at four general and three special hospitals; the society also visited Roffey Park Rehabilitation Centre in the summer. The average attendance at discussion meetings was GO, the largest attendance being at the penicillin meeting, when 97 members were present. The attendance at clinical meetings has averaged 95, the largest attendance being 120 at the Maudsley Hospital. Staff on war service Staff Shortly before the outbreak of war in 1939, hospital staff who were members of the Territorial Army and the Royal Naval Reserve commenced to be called up for duty with H.M. Forces, and by the end of 1945 a total of 1,203 permanent hospital staff in the following grades were with the Forces: medical, 51; nursing (male) 170; nursing (female) 79; male domestic, 514; clerical, 207; other staff, 182. In addition, 40 members of the permanent staff of all grades left to undertake some form of national service, while 366 temporary staff joined the Forces or took up war industry—a comprehensive total of 1,609. Appointments during the war During the war a simplified procedure was adopted for the appointment and promotion of hospital staff. Apart from a few special exceptions, all appointments and promotions were made only on a temporary basis but with the conditions of service for permanent staff. This practice continued until the latter part of 1946, by which time the majority of the staff who had been called up had returned. The war-time powers delegated to medical superintendents, matrons and stewards were then withdrawn, and the hospital committees resumed their former functions. A review of all the temporary appointments and promotions that had been made was then commenced and the pre-war procedure re-instated. Shortage of staff The call-up of men from hospital staffs for H.M. Forces combined with the heavy demand on man and woman power for war work led to considerable and gradually increasing shortage in certain grades, notably nursing and male and female domestic staff. These shortages did not, however, become acute until 1943-44, principally because redundant staff from hospitals which had suffered severe damage from bombing were distributed among other hospitals. The position then began to deteriorate seriously as replacements became inadequate in quality and number, and it was with the utmost difficulty that a reasonable standard of efficiency was maintained. When the flying-bomb attack developed in 1944-45, the hospitals sustained further damage. Child-patients and chronic sick patients, together with nursing staff, were evacuated from London to hospitals administered by other authorities, and four hospitals were opened by the Council in the provinces with staff of all grades, mostly transferred from London. This increased the difficulties and it became necessary to resort to the recruitment of persons not normally eligible for employment, e.g., aliens and staff beyond the normal age of retirement; to extend the fields of employment of married women and part-time workers; and to employ women on work hitherto done by men. Return of staff from war service With the conclusion of the war, 322 members of the permanent staff returned by the end of 1945, and a further 706 by the end of 1946; 72 members of the staff were 58 killed in action or died on war service, apart from those killed in London by bombs. Except for a few who have not yet been demobilised, the remainder resigned their positions to take up other forms of work. Staffing position after the war The acute position with regard to medical and laboratory services began to be relieved by September, 1945. The supply of male domestic staff improved, and by the end of 1946 practically all vacancies had been filled. There was, however, no corresponding improvement in the recruitment of nursing staff and female domestic staff. The shortage has continued to be acute. The war-time practice of employing women in place of men began to be reversed, and a number of male domestic assistants and male assistant cooks were engaged in the place of women. The war-time pressure on dispensary, X-ray and massage staffs also continued. Although the number of available beds in hospitals had through bombing fallen considerably below the pre-war level, the increased rate of turnover of in-patients, combined with substantial increases in the number of out-patients, brought about a general increase of work in these special departments. The widespread use of new drugs, e.g. sulphonamides and penicillin, added considerably to the duties of pharmacists, while modern medical practice made new demands on radiographers and physiotherapists. To augment the number of these medical auxiliaries by locum tenens staff, it was necessary to offer enhanced rates of pay, and the staff thus secured were utilised not only as sick and annual leave reliefs, but also for the temporary filling of vacancies which could not be filled in the normal way. To ameliorate the situation in the larger X-ray departments, clerks were allocated for duty so as to enable radiographers to spend their whole time on technical duties. Training of radiographers During 1943, a scheme for training State-registered nurses who desired to qualify as radiographers was introduced at Hammersmith and Lambeth Hospitals. Practical and theoretical training for the Diploma of Membership of the Society of Radiographers was provided for fifteen pupils for two years. The scheme proved successful and the arrangements were extended in 1946 to include students, other than qualified nurses, eight of whom were accepted for a two-year course of training. In addition, a short course of training in radiotherapy was provided during 1946 for ex-service radiographers. Postgraduate training of doctors In 1945 a scheme developed by the Ministry ot Health tor the post-graduate training of doctors released from H.M. Forces was adopted by the Council, and about 250 medical officers were allocated to hospitals in a supernumerary capacity as assistant medical officer (post-graduate), class I, and trainee specialist, class III, covering all branches of medicine. Clinical responsibility for patients Under the original organisation of the general hospitals, the medical superntendents had responsibility not only for the administration of the hospitals but also, at least nominally, for the clinical care of the patients. Some years before the war there had been several breaches of the latter principle and obstetricians, surgeons and a physician had been appointed with full charge of beds. During the war there were several extensions of this method of staffing, which placed clinical responsibility on the specialists, and left the medical superintendent in the large hospitals concerned, more free for his administrative work. Further extensions of this method of organisation are contemplated and, also, in those smaller hospitals, where the medical superintendent is a specialist, combining in him full clinical responsibility for a section of the work of the hospital and administrative responsibility for the whole hospital. Training of nurses Several measures designed to stimulate the flow of candidates for the nursing profession were adopted in 1946. Among these was the modification of the curriculum of student nurses to enable the period of training in general nursing to be reduced from four to three years, plus a short period in the preliminary training school. In addition, approval was given to the inauguration of a pre-professional course, to bridge the gap between school leaving age and the age at which girls can commence nursing training in hospital. Under this scheme, girls—to be known as nursing 59 cadets—will attend part-time at a polytechnic institute, for theoretical instruction, and part-time at a nursery for practical training. Representative councils and committees Nurses representative councils and domestic staff committees, the setting-up of which was advocated by the Minister of Health and Minister of Labour and National Service in the booklet "Staffing the Hospitals," issued at the end of 1945, are now functioning at the majority of the Council's general and special hospitals. Rehabilitation Rehabilitation facilities were provided at certain hospitals, and in this connection two new grades of staff were introduced—occupational therapist and remedial gymnast. Hospital libraries Until 1945 the work of cataloguing and distributing reading material to patients in the Council's hospitals had been undertaken by voluntary workers : but the work at certain hospitals had increased beyond the capacity of these workers, and two full-time librarians were experimentally appointed. During the following year, this number was increased to five. Catering During the year, the Council appointed catering officers at four of its hospitals. These officers, who are experienced in large scale catering, have immediate charge at the hospitals at which they are employed of the whole of the catering managements, which have thus been placed in specialist hands. Disabled persons Under the Disabled Persons (Employment) Act, 1944, an obligation was placed on employers to employ a proportion of registered disabled persons. The quota was originally fixed at 2 per cent, but was increased eighteen months later to 3 per cent. Naturally, a large proportion of hospital staffs consists of nurses, and the nature of their duties renders it essential that they should be physically fit. It was not therefore without some difficulty that the prescribed quota was attained, the male domestic staff providing a large proportion thereof. Rates of pay and conditions of service During the period covered by this report, the extension of nationally agreed rates of pay and conditions of service to cover many grades of hospital staff resulted in the adoption by the Council of many new scales of salary and systems of grading. In 1943, the recommendations of the Nurses' Salaries Committee and the Midwives' Salaries Committee (the " Rushcliffe " Reports) for improved scales of salary for nursing and midwifery staff were adopted and applied to the staff concerned in the Council's hospitals, as were the various revisions and further recommendations subsequently put forward from time to time by these committees. In 1946, a similar step was taken on behalf of domestic staff at hospitals, when the Council adopted the recommendation of the National Joint Council for Staff of Hospitals and Allied Institutions (The "Mowbray" Report). The recommendations included certain innovations for hospital domestic staff, for example, additional payments for Sunday and bank holiday duty and for shift work and night work. During the same year, most grades of medical auxiliary staff were brought on to national scales of pay, agreed by the Joint Negotiating Committee (Hospital Staffs). Grades included were pharmacists, physiotherapists, radiographers, psychiatric social workers and speech and occupational therapists. In July, 1946, the Council increased the salary scales of all its whole time medical staff, in the light of the interim revision of the Askwith agreement agreed at a conference at the Ministry of Health in March, 1946. Towards the end of 1946, the Council reviewed the recruitment, grading and scales of salary of stewards and clerical staff in the hospitals and adopted improved salary scales. The former system of having a separate hospital clerical service not integrated with the general clerical service was reintroduced, and at the same time a general widening of the field for recruitment to the grade of hospital clerk was agreed upon, including provision for the admission into the grade of women up to 40 years of age for work directly connected with patients, e.g., in medical superintendents' offices, receiving wards, etc. For hospital clerks employed in the steward's offices the 60 passing of the Examinations of the Institute of Hospital Administrators has now been made necessary for advancement to the higher positions of assistant steward, deputy steward and steward. The policy of allocating clerks to relieve the professional and nursing staff of the clerical work associated with many of the departments in hospitals was also expanded. Group laboratories Pathological laboratory service The number of examinations (including post-mortem examinations) completed in the group laboratories during the year ended 31st December, 1946, compared with the year 1945, is given below:— Oroup laboratory 1946 1945 Archway, Highgate 47,620 45,889 Lambeth 60,465 40,028 Lewisham 68,786 48,968 Joyce Green (subsidiary to Lewisham) 11,299 11,668 Mile End 47,186 35,334 North-Western, Hampstead 42,850 44,509 St. Mary Abbots, Kensington 46,230 31,584 Southern, Hither Green 18,491 16,676 Total 342,927 274,656 The number of post-mortem examinations carried out by the Central Histological Laboratory staff during the year was 1,490 (1,216 in 1945) and the number of histological examinations in the laboratory was 30,626 (27,858 in 1945). These are the highest totals ever reached since the establishment of the laboratory in 1931. In addition to the bacteriological work at the Southern Group Laboratory, this laboratory manufactures and provides culture media and other laboratory requisites for all the Council's hospitals. During the war, the Council's organisation was utilised to cater for the War Office, the Ministry of Health emergency pathological laboratories and other authorities. This arrangement was continued after the war, upon request, and although the requirements of the War Office diminished, the total quantities supplied during 1946 were still considerable, as will be seen from the following list:— 1940 1945 Culture media 30,291 37,351 litres Stains and chemical solutions 10,975 6,952 „ Vaccines 23,209 52,284 c.c.s. Grouping sera for blood transfusion 65,762 26,296 tubes Sterile sulphonamides 18,504 16,496 bottles Tuberculin for Mantoux test 11,165 7,309 c.c.s. Intravenous solutions 50,696 46,729 litres Measles serum, Adult 17,320 24,560 c.c.s. „ „ Convalescent 1,770 2,450 „ Kahn and Wassermann antigen 62,765 81,305 „ Hospital laboratories The total number of specimens examined in the hospital laboratories, as distinct from the group laboratories, during the year was 355,944 (296,345 in 1945), and 1,334 post-mortem examinations (1,696 in 1945) were carried out in addition to those by the pathologists. General During the year, 21 students of the London School of Medicine for Women attended the group laboratory at Archway Hospital for a two months' course of practical pathology, and facilities were given for them to attend post-mortem examinations and to make use of the museum of specimens at the Central Histological Laboratory. The group laboratory at the North-Western Hospital co-operated with the British Pædiatric Association in a survey of cross-infection in children's hospitals. The work 61 is to be continued in 1947 when a report will be made to the Association. Further work has been done in conjunction with the British Launderers' Research Association on the effect on cross-infection of the oiling of bed linen. Research work has, however, had to be limited owing to the very heavy demands on the staff for the routine work of the laboratories. The question of the adequate staffing and accommodation for the whole of the laboratory service has received very close attention during the year. As a result it is hoped that the proposals will culminate in the addition of sufficient staff of all grades to the group and hospital laboratories to enable time to be devoted by the pathologists to the more complex problems of research. Serum Institute and Belmont Laboratories As stated in the annual report for 1943, the Serum Institute and Belmont Laboratories were leased to the Wellcome Foundation Ltd., for the period of the war to meet the national emergency. In October, 1946, arrangements were made for the termination of the lease of both premises on 10th April, 1947. The agreement made in 1943 provided for the supply by the company of all antitoxins, etc., necessary to meet the needs of the Council's hospitals. These supplies were maintained throughout the year. LONDON AMBULANCE SERVICE As the first complete year under peaceful, if not peacetime, conditions, 1946 was a year of consolidation and steady progress rather than a period of far-reaching changes. The increased demands on the accident section resulted in the total emergency calls for the year, 56,971, being the highest yet recorded, surpassing the previous record of 1938, by some 600 calls. These figures included the removal to hospitals of booked maternity cases. The Council decided that on and after 1st April, 1946, no charge would be made to either patient or hospital for patients removed by the London Ambulance Service from an address in the County of London to a voluntary hospital in the County, except for those admitted to "pay" wards in which cases the existing charges would continue. Previously all removals of patients to voluntary hospitals had been on a pay basis. Transfer of patients from one voluntary hospital to another for admission is included in the free service; but, owing to pressure on the existing resources of the ambulance service, it has not yet been possible to extend the free facilities for discharged patients in need of an ambulance on medical grounds, to out-patients requiring treatment or removals to or from places outside London. From 1st April, 1946, to 31st December, 1946, 6,352 free removals were carried out under this extension of free facilities. At the same time as the above arrangements were approved, the Council agreed that the practice of including a charge for the ambulance journey when assessing the contribution to be paid by patients in the Council's own hospitals should be discontinued. This provision became effective from 1st April, 1946. The Council agreed that as from 1st June, 1946, certain of the Council's domiciliary midwives should be provided with facilities for the administration of nitrous-oxide and air analgesia to their patients. Two sets of apparatus are kept at each of sixteen accident ambulance stations, and the London Ambulance Service is responsible for conveying the apparatus to the address of the patient on application by a Council midwife authorised to use the apparatus. A request for the apparatus is treated as an emergency call, and 289 such calls were answered from 1st June to 31st December, 1946. On and from 24th June, 1946, arrangements for smallpox removals, previously provided only by the Eastern general ambulance station, were extended to the North-Western general ambulance station. The Council agreed to the transport of tuberculous persons in the boroughs of Bermondsey and Southwark free of charge between their homes and the local 62 tuberculosis dispensaries for the purposes of radiological control in connection with artificial pneumothorax treatment. The demand made on the London Ambulance Service for the provision of transport on behalf of the Ministry of Pensions of seriously disabled war patients, both ex-Service and others resident in London requiring hospital and other forms of treatment, was small, and 27 journeys only were made during the year. The Council agreed to the continued use of 30 ambulance motor cars for the conveyance of "walking" patients and certain medical staff and domiciliary midwives. During 1946,11,199 journeys, involving a mileage of 140,939, were undertaken by the motor cars. Of these total figures, 3,616 journeys with a mileage of 40,304 were accounted for by conveyance of patients and the balance by other authorised users. The operation of transport for the Emergency Medical Service (Ministry of Health) has continued throughout the year. On the average, 19 of the Council's ambulances were engaged solely on this work, while 16 ambulance motor cars belonging to the Ministry of Health were maintained and staffed by the London Ambulance Service for E.M.S. purposes. The mechanical deterioration of vehicles of the regular ambulance fleet, many of which are sixteen years old, has been a source of constant anxiety; and, although the greater part of the converted 123 Bedford ambulances (formerly auxiliary vehicles for war purposes—now 7 years old) have been brought into service, they cannot be regarded as an adequate substitute for a properly designed ambulance. Energetic efforts have been made throughout the year in conjunction with the Chief Officer of Supplies in the exploration of the possibilities of obtaining suitable new vehicles but without success. The Council approved the acquisition of the Carlyle Garage, 350, King's Road, Chelsea, S.W.3, for joint use as an ambulance station and supplies department vehicle maintenance depot, and this will enable temporary accommodation to be given up at Allen Mansions, Allen Street, Kensington. The partial reinstatement works (approved July, 1945) at the original premises of the Brook Ambulance Station in Shooters Hill Road, S.E.10, which were severely damaged by enemy action, had made good progress at the end of the year. The Council approved the provision of rubber hot water bottles and covers as part of the normal equipment of the general section ambulances. Arrangements were also made for a simple first-aid outfit to be carried on these vehicles which are not equipped for "accident" work so that the general section crews may, if called upon while on normal operational duties, be in a position to deal with a casualty pending the arrival, if required, of an accident ambulance. By the end of 1946, the return of members of the operative staff from war service was practically complete. At that time, the staff consisted of 269 permanent and 203 temporary drivers and attendants. Of the latter figure, 42 were women. The number of former members of the staff returning to the Council's service was approximately equal to the wastage, and there was, therefore, practically no recruitment during the year. In the last few months of the year, however, the rate of return diminished sharply, while the wastage continued and the recommencement of recruitment will be necessary. Now that the staffing situation is more stable, it will be possible to deal with the question of granting permanent status to a number of the temporary staff, many of whom have rendered valuable service to the Council during the war years. 63 Special arrangements were made to strengthen the accident section in anticipation of increased demands being made on the service on the occasion of the Victory Day celebrations on 8th June, 1946. Council ambulances and crews were in operation on special duty at the St. John Ambulance Brigade and British Red Cross Society dressing stations along the route of the procession from 6 a.m. and during the morning and again at special points during the aquatic display in the evening. Former members of the London Auxiliary Ambulance Service, both men and women, represented that service in the civilian contingents of the Mechanised and Marching Columns. On Victory Day there were 250 calls to accidents and emergencies; on the following day, Whit Sunday, there were 173 and on Whit Monday, 10th June, 1946, there were 148 calls. These compare with a daily average of emergency calls of 141 for the first five months of 1946. By comparison the figures for Coronation Day, V.E. Days and V.J. Days were:— Coronation Day 12th May, 1937 457 V.E. Day 8th May. 1945 241 9th May, 1945 205 V.J. Day 15th August, 1945 226 16th August, 1945 172 An ambulance and crew participated in the Motor Industry's Jubilee London Cavalcade on 27th July, 1946. After an inspection by H.M. The King in Regent's Park, the vehicles formed a procession which was routed through the west end of London, and later were on show to the public in Regent's Park. Ambulances were provided for short periods to Wandsworth and Battersea Borough Councils in connection with their Road Safety Campaigns in June and September, 1946, respectively. Seven ambulances were despatched to the scene of an accident at Catford Bridge on 20th September, 1946, when the 2.10 p.m. train from Victoria to Ramsgate became derailed. Considering the size and nature of the accident, casualties were remarkably light. They were: 1 killed, 16 injured taken to hospital. A letter of appreciation of the efficient services rendered by the London Ambulance Service was received from the Southern Railway Company. The Council agreed revised reciprocal arrangements in respect of accident section ambulances with Penge Urban District Council and the Borough of Beckenham on the operation of a combined ambulance service by these two authorities. Comparative statistics for the years 1938 to 1946 are as follows:— Accident Section No. of calls No. of cases Mileage 1938 56,318 58,196 293,166 1939 55,268 54,323 269,947 *1940 44,700 45,600 211,000 1941 37,344 38,545 182,252 1942 37,788 38,659 193,975 1943 41,405 42,217 207,950 1944 43,798 44,878 224,958 1945 52,136 53,452 286,281 1946 56,971 58,551 321,951 * Actual figures are available for the period 5th February to 31st December, 1940, only. A proportionate estimate has been included in the figures shown to cover the period 1st January to 4th February, 1940. 64 Subjoined are details of work carried out in 1946:— The county average time to reach an emergency case (all kinds) was 8.4 minutes, varying from 7.2 minutes at Westminster accident station to 9.4 minutes at Lee and South-Western stations. The average time taken to reach a street accident was 7.5 minutes. The number of calls per station ranged from 6,336 at Bloomsbury to 2,280 at Woolwich accident station. The greatest number of calls (3,132) was received during the hours of 3 to 4 p.m., and the lowest (1,259) between 5 and 6 a.m. December was the month with the highest number of calls—5,424, and February had the lowest—4,190. Street accident cases by ages were:— Age (in years) Number of cases Percentage —10 1,029 11.8 10—20 1,156 13.3 20—30 1,060 12.2 30—40 1,261 14.5 40—50 1,172 13.4 50—60 1,062 12.2 60—70 1,065 12.2 70—80 711 8.2 80—90 186 2.1 90— 10 0.1 Not stated 155 — Total 8,867 100.0 GENERAL SECTION Year Miles run Persons conveyed Patients Relatives and friends of patients, staff, etc. Total 1938 1,930,172 217,908 102,520 320,428 1939 1,707,620 138,150 62,030 200,180 1940 1,352,029 135,745 72,329 208,074 1941 1,034,966 104,372 53,033 157,405 1942 933,866 86,245 35,307 121,552 1943 1,017,646 101,362 53,642 155,004 1944* 832,063 89,778 53,392 143,170 1945 1,348,342 131,788 97,805† 229,593 1946 1,633,813 160,074 127,706† 287,780 * Returns from Brook ambulance station from March 31st to November 11th, destroyed by enemy action. † Icludes conveyance of nurses between hospitals and outlying nurses' homes as former staff quarters were destroyed by enemy action ; domiciliary midwives; district medical officers and other medical staff. 65 Particulars of work for the years 1938, 1939, 1945, and 1946 1938 1939 1945 1946 (i) Admissions to Council's establishments: Infectious hospitals 35,580 20,002 14,922 13,506 General hospitals 82,636 49,820 55,065 70,037 Hospitals for tuberculosis 3,877 3,003 2,984 2,779 Hospitals for sick children 10,235 7,395 1,387 1,644 Mental hospitals 3,452 3,469 2,510 3,116 Others 310 317 186 259 136,090 84,006 77,054 91,341 (ii) Transfers 26,971 17,063 13,647 14,718 (iii) Discharges 23,171 13,114 16,994 28,110 (iv) Returned—mistaken diagnosis 9 28 15 7 (v) Removals—for accident section 169 214 288 490 (vi) Removals—Education service 14,235 8,823 5,014 6,862 (vii) Removals—Social Welfare service 5,181 4,798 2,050 3,272 (viii) Sick staff 401 220 164 270 (ix) Visitors to patients 30 37 1 8 (x) Staff (not sick staff) 7,446 3,723 30,663 42,778 (xi) Other journeys 663 629 6,413* 339 (xii) Upon payment for hire 11,018 9,255 10,215 8,327 (xiii) Friends accompanying patients, etc. 95,044 58,270 67,056 84,906 (xiv) Refugees (1945): Free removals— voluntary hospitals (1946) — — 19 6,352 320,428 200,180 229,593 287,780 * Includes nearly 6,000 persons conveyed under the mass radiography scheme. LONDON AUXILIARY AMBULANCE SERVICE Air-raid casualties conveyed Year London regional groups Disposal of cases Men Women Children Total 1 II III IV V Hospital F.A.P. L.C.C. Vol. 1940* 3,228 2,919 4,806 3,471 5,527 6,910 6,893 6,148 9,848 9,046 1,057 19,951 1941 1,159 1,328 2,182 1,339 2,155 2,242 3,901 2,020 4,471 3,381 311 8,163 1942 — — — — 73 14 32 27 29 33 11 73 1943 46 66 101 259 272 360 250 134 346 331 67 744 1944† 3,488 — 4,314 3,611 5,487 5,409 8,648 2,843 6,847 8,909 1,144 16,900 1945‡ 362 — 914 1,086 516 737 1,525 616 1,003 1,535 340 2,878 Total 8,283 4,313 12,317 9,766 14,030 15,672 21,249 11,788 22,544 23,235 2,930 48,709 * Air-raid casualties first conveyed on l8/8/40. † Group II ceased to operate. ‡ Air-raid casualties last conveyed on 27/3/45 SCHOOL HEALTH SERVICE Organisation The school health work, under the supervision of the School Medical Officer, comes within the public health department under a principal medical officer. It is organised in two main divisions each under a senior medical officer, one dealing with medical inspection, treatment and cleansing of pupils, and the other dealing with the medical work in special and approved schools. The Council's dental service is under a full-time consulting dental surgeon with a full-time deputy, and deals, in addition to the school dental work, with the dental service in hospitals and institutions. 66 The duties of the matron-in-chief of the public health department include superintendence of the school nursing staff which is in charge of a principal matron. At the end of 1946, there were three part-time consultants, for ophthalmology, for diseases of the ear, nose and throat and for orthopaedics, respectively. In addition to the two senior medical officers, there are at County Hall one principal assistant medical officer, 4 divisional medical officers (one acting) and one assistant medical officer. Working in the 5 divisions, there are 5 divisional medical officers, and 15 full-time assistant medical officers. In addition to the full-time medical officers, part-time assistant medical officers worked 14,079 sessions during the year. Full-time and part-time dental surgeons worked 1,315 half-day sessions on inspections, and 16,512 sessions for treatment; two part-time orthodontists together worked 13 sessions a week during the year. There were 43 dental attendants working full time. There were, in addition to the principal matron in charge, 6 superintendent school nurses, 5 deputy superintendent school nurses, and 381 school nurses. The treatment side of the children's care organisation is under a principal organiser, and, at the end of the year, there were in addition 6 divisional organisers, 17 senior organisers and 36 assistant organisers. School buildings During the war approximately 290 schools were either demolished or seriously damaged, 310 were less seriously damaged, and 550 slightly damaged. Rehabilitation was limited to minor works, and following an intensive programme of cleaning and modified decoration introduced during 1946, work was completed in 86 schools, and minor repairs, including renewal of window sashes and frames, had been carried out in 153 schools. Pupils on school rolls The re-organisation under the Education Act, 1944, into primary and secondary schools continued during 1946, and, at the end of the year, there were 942 county schools and 406 voluntary or assisted schools (a department or combined department under one head is regarded as one school). There were 246,921 children of primary and secondary school age in county schools, and 87,863 children in voluntary or assisted schools, making a grand total of 334,784 pupils. The average attendance in November, 1946, was 85.9 per cent. for all former elementary schools. Medical inspection Medical examination of the normal four routine age groups was carried out, viz., on first entrance to school, in the eighth year of age, in the twelfth year of age, and in the term before leaving school. There were also other examinations carried out which did not fall into the foregoing age groups. These are classified as the " other age " group. Summary of School Medical Inspections—1946 (a) Routine Inspections Age group Boys Girls Total[/$$$] Nursery schools and classes 2,217 2,001 4,218 Other entrants 19,488 18,729 38,217 Age 7 years 13,663 13,219 26,882 Age 11 years 13,079 13,095 26,174 Leavers 11,184 10,457 21,641 Other ages 14,001 13,367 27,368 Tota 73,632 70,868 144,500 Special schools 749 665 1,414 Total 74,381 71,533 145,914 67 Brought forward 145,914 (b) Other inspections Special inspections 80,178 Re-inspections 65,205 Rheumatism supervisory centres (attendances) 8,117 Special ear inspection centres (attendances) 3,344 Nutrition centres (attendances) 5,250 162,094 Grand total 308,008 In addition 27,140 new cases were examined at vision centres. (c) Higher education institutions Medical inspections of students in higher education institutions 34,487 Medical examinations of candidates for major county awards 764 Total 35,251 (d) Diphtheria immunisation Immunisation carried out by school health service : Initial immunisations 10,493 Boosting doses 2,788 Total 13,281 The results of the examinations of entrants to nursery schools and classes were tabulated separately for the first time, and are available for comparison, but space forbids the printing of details of the defects found. The numbers and percentages of children seen at routine medical inspections who were referred for, or were under treatment for, defects other than cleanliness, teeth or nutrition are shown in the following table:— Age group Number examined Number of children referred for or under treatment for any defect* Number Percentage Nursery:— Boys 2,217 382 17.2 Girls 2,001 295 14.7 Entrants:— Boys 19,488 3,395 17.4 Girls 18,729 2,900 15.5 7 years old:— Boys 13,663 2,664 19.5 Girls 13,219 2,505 18.9 11 years old:— Boys 13,079 2,405 18.4 Girls 13,095 2,770 21.2 Leavers:— Boys 11,184 1,914 17.1 Girls 10,457 2,095 20.0 Other ages:— Boys 14,001 2,961 21.1 Girls 13,367 2,952 22.1 Total (all ages) 144,500 27,238 18.8 Special schools 1,414 275 19.4 * Other than cleanliness, teeth, or nutrition. 68 It will be seen that the nursery children compare favourably with the entrants. The following table gives an analysis of the defects found in the examination of 73,632 boys and 70,868 girls of all ages in 1946:— Defect Boys Girls No. Percentage No. Percentage Skin diseases (a) 1,058 1.4 1,017 1.4 (b) 879 1.2 864 1.2 Tonsils (a) 3,420 4.6 3,376 4.8 (b) 1,458 2.0 1,466 2.1 Adenoids (a) 534 0.7 402 0.6 (b) 335 0.5 250 0.4 Tonsils and adenoids (a) 2,279 3.1 2,090 2.9 (b) 1,638 2.2 1,506 2.1 Other nose, throat (a) 459 0.6 391 0.6 (b) 343 0.5 307 0.4 Cervical glands (a) 1,069 1.5 740 1.0 (b) 240 0.3 183 0.3 Eye disease (a) 1,501 2.0 1,459 2.1 (b) 1,115 1.5 1,057 1.5 Otorrhœa, otitis media (a) 399 0.5 384 0.5 (b) 276 0.4 260 0.4 Other ear (a) 281 0.4 301 0.4 (b) 221 0.3 245 0.3 Hearing (a) 253 0.3 195 0.3 (b) 149 0.2 128 0.2 Speech (a) 285 0.4 146 0.2 (b) 131 0.2 73 0.1 Heart (a) 495 0.7 481 0.7 (b) 95 0.1 115 0.2 Anaemia (a) 282 0.4 268 0.4 (b) 190 0.3 203 0.3 Lungs (not T.B.) (a) 1,273 1.7 976 1.4 (b) 564 0.8 374 0.5 Epilepsy (a) 59 0.1 40 0.1 (b) 25 0.0 16 0.0 Chorea (a) 33 0.0 39 0.1 (b) 21 0.0 22 0.0 Paralysis (a) 19 0.0 12 0.0 (b) 6 0.0 4 0.0 Other nervous (a) 707 1.0 568 0.8 (b) 425 0.6 317 0.4 Spinal deformity (a) 203 0.3 262 0.4 (b) 132 0.2 188 0.3 Other deformities (a) 2,252 3.1 2,270 3.2 (b) 1,404 1.9 1,330 1.9 Rheumatism (a) 308 0.4 525 0.7 (b) 202 0.3 346 0.5 Other defects (excluding malnutrition, teeth or cleanliness) (a) 836 1.1 710 1.0 (b) 599 0.8 494 0.7 (a) Total number found. (b) Number included in (a) requiring treatment. Parents' attendance Parents' interest in their children and the value they place on school medical inspection is evidenced by the fact that they were present at 72.9 per cent. of all age group inspections. Care Committee attendance clothing and footgear A care committee representative was present at 89.6 per cent. of all routine medical inspections. The nurses note the condition of the children's clothing and footgear when they are undressing them, and there was a smaller percentage of clothing and footgear marked ' bad ' by the school nurses in 1946 (0.2) than in 1938 (0.4). Vaccination Of the children in the four age groups, 46.74 per cent. were found by the school doctors to have been vaccinated. The corresponding percentage for 1938 was 46.5. These figures are much lower than is desirable. 69 Diphtheria immunisation According to the parents' statements, 81.0 per cent. of the children had been immunised. This is probably an over-statement, and, as no complete records are available, particularly for those evacuated from London during the war, it is impossible to check it. The following table shows the percentage of children with normal eyesight in Vision 1946, compared with 1938:— Age group 1938 1946 7 years old 63.64 78.19 11 years old 69.30 78.65 Leavers 70.13 77.83 In each age group there was a higher proportion of children with normal eyesight in 1946 than in 1938. The reason for this improvement which began during the war and has persisted is not known. Nutrition The subjoined table shows the doctors' assessment of nutrition in percentages as found in the normal four age groups in 1946, with 1938 for comparison. The classification is as follows: (1) Excellent, (2) normal, (3) subnormal. (4) bad. Age groups 1038 1946 No. examined 1 2 3 4 No. examined 1 2 3 4 Entrants 47,301 15.28 78.26 6.39 0.07 38,217 16.30 78.24 5.42 0.04 7 years old 39,044 13.55 77.70 8.65 0.10 26,882 15.76 77.48 6.71 0.05 11 years old 41,576 15.54 77.71 6.72 0.03 26,174 18.31 75.74 5.90 0 05 Leavers 42,074 20.50 75.03 4.44 0.03 21,641 23.22 72.67 4.07 0.04 Total 169,995 16.24 77.20 6.50 0.06 112,914 17.96 76.42 5.58 0.04 There is a higher percentage in each age group classed as of excellent nutrition in 1946 than in 1938, and a lower percentage of the children classed as subnormal in 1946 than in 1938. Only 49 children out of 112,914 were classed as malnourished in 1946, compared with 100 out of 169,995 children so classed in 1938. Dental conditions The following table shows the doctors' findings in 1946, at medical inspections of children in the four age groups—grouped into (a) sound and (b) caries, and for comparison the 1938 percentage figures are also shown:— Age groups 1938 1946 Sound Caries Sound Caries Entrants 59.7 40.3 69.11 30.89 7 years old 69.6 30.4 67.73 32.27 11 years old 77.4 22.6 79.14 20.86 Leavers 75.1 24.9 80.79 19.21 In every age group except 7 years old there is a higher percentage of children, as found by the doctors, with sound teeth in 1946 than in 1938, but the doctors' assessments are naturally not so reliable as the findings of the dental surgeons with probe and mirror. The dental surgeons inspect children of all ages, and the following table summarises the dental surgeons findings in 1946, with corresponding data for 1938:— Year Number examined Number requiring treatment Percentage requiring treatment 1938 292,971 204,205 69.7 1946 138,290 91,441 66.1 The total percentage reported by the doctors to require treatment was 26.07, compared with the findings of the dental surgeons, viz., 66.1 per cent. in 1946. The doctors only record gross and obvious caries, the dentists include incipient decay. 70 The following extract is taken from the report submitted by the Council's consulting dental surgeon The figures show the work undertaken during the year. The children treated include a number referred by medical officers during the course of their inspections at the schools, in addition to those obtained from dental surgeons' inspections in school:— 1946 1945 Ordinary treatment sessions 15,017 8,522 General anaesthetic sessions 1,495 941 New cases treated 91,601 55,986 Total cases treated 121,434 74,874 Attendances 171,554 100,641 Temp. teeth extracted 110,177 65,591 Perm. teeth extracted 18,999 12,341 Temp. teeth restored by filling 31,117 (33,262 f.) 14,216 (14,953 f.) Perm. teeth restored by filling 72,303 (79,866 f.) 44,988 (49,423 f.) Scalings 6,619 2,568 Temporary dressings, etc 32,234 17,593 Local anæsthetics for extraction 22,807 11,622 Local anaesthetics for conservative treatment 4,003 3,630 General anaesthetics 4,664 21,867 Cases completed 3,006 43,795 A gratifying result is the increase in the rate of conservative dental treatment in permanent teeth to permanent teeth extracted as compared with pre-war years. The figures are:— 1935 2.05 to 1 1936 2.06 „ „ 1937 2.31 „ „ 1938 2.54 „ „ 1945 4.04 „ „ 1946 4.20 „ „ Other defects In the four age groups, the percentages of children inspected during 1946 found to have defects, were as follows, those for the years 1938, 1944 and 1945 being included for comparison:— Nature of defect 1946 1945 1944 1938 Adenoids and enlarged tonsils 8.5 7.3 6.5 9.2 Skin diseases 1.4 1.6 1.5 1.0 Enlarged glands 1.2 1.2 1.0 1.5 Exteral eye disease 2.1 1.3 1.7 1.7 Otorrhœa 0.5 0.3 0.5 0.6 Defective hearing 0.3 0.3 0.3 0.2 Heart disease 0.6 0.7 0.7 1.4 Anœmia 0.4 0.3 0.3 0.4 Lung disease (not T.B.) 1.5 1.3 1.2 1.5 The incidence of adenoids and tonsils is increasing but is still below the pre-war level. There is no adequate explanation of these variations in incidence. The incidence of skin disease is still above that of 1938, as is that of external eye disease. Apart from the marked fall in the incidence of heart disease, the remaining defects are proportionately much the same as in 1938. Vermin The table below gives the percentages of children in each of the four prescribed age groups found to have nits or vermin in the hair at routine inspections during 71 1946, with corresponding figures for the years 1938, 1944 and 1945 included for comparison:— Age group 1946 1945 1944 1938 Entrants Boys 0.74 0.74 1.05 1.58 Girls 1.85 1.72 2.24 2.31 7 years old Boys 0.75 1.20 1.17 1.88 Girls 2.08 2.30 2.95 3.17 11 years old Boys 0.51 0.52 0.64 1.74 Girls 2.46 1.99 3 05 3.55 Leavers Boys 0.44 0.55 0.53 1.43 Girls 2.15 1.95 2.70 2.85 This table shows an improvement in the verminous conditions as found by the school doctors in every category during 1946, compared with 1938, but the parents are warned beforehand of the doctors' examinations and so the children are often specially cleaned. The most reliable index of the incidence of verminous conditions is found at the school nurses' personal hygiene inspections, when the parents are not previously warned. During 1946, the school nurses made 1,532,848 examinations, and the number of cases in which children were noted as verminous was 87,668, giving an all-round incidence of 5.72 per cent., the corresponding percentage for 1938 being 7.3. The subdivision between boys, girls and infants is as follows:— Total no. examined No. found verminous Percentage Boys 507,114 14,255 2.8 Girls 496,245 42,639 8.6 Infants 529,489 30,774 5.8 Total 1,532,848 87,668 5.72 Scabies Scabies is a notifiable disease in London and all cases are notified to the local borough medical officer of health. The rising incidence of scabies in school children had given cause for concern for some years before the war: in 1936 the figure was 8,389, in 1937 it was 10,962 and in 1938 it had risen to 14,292. The incidence soared during the early years of the war, and reached the peak of 23,119 cases in 1942, when the number of school children in London was less than half that in 1938. In 1945, the number of children treated for scabies was 14,196, while in 1946 the number treated was 12,894, with a third greater school population in 1946 than that in 1945. Choice of employment A note is made of any defect, on the leaver's "choice of employment" slip, which might contra-indicate certain types of employment. The following table summarises the contra-indications (excluding special schools):— Contra-indication for jobs involving or needing Boys Girls Number Percentage of inspected children Number Percentage of inspected children Heavy manual work 484 4.33 392 3.75 Sedentary confined work 99 0.89 91 0.87 Exposure to bad weather 194 1.73 207 1.98 Dusty atmosphere 146 1.31 119 1.14 Climbing 84 0.75 64 0.61 Proximity to moving machinery 54 0.48 38 0.36 Prolonged standing 323 2.89 411 3.93 Eye strain 960 8.58 1,034 9.89 Acute distant vision 850 7.60 907 8.67 Acute hearing 89 0.80 52 0.50 Handling of confectionery 77 0.69 100 0.96 Food preparation 78 0.70 98 0.94 No. of children with contra.indications 1,988 17.78 2,000 19.13 72 The following table shows the percentages of both sexes with defects limiting their choice of employment in 1946, the corresponding figures for 1943, 1944 and 1945 being given for comparison :— 1946 1945 1944 1943 Boys 17.78 17.26 16.50 15.77 Girls 19.13 18.33 17.81 16.96 It appears that the upward trend in the recording of contra-indications noted in previous years continues. The absence of any other evidence of deterioration of the children's health suggests that stricter criteria of fitness are being used. The following-up of children referred by the school doctors for observation or treatment is an essential part of the School Health Service, and is carried out by members of the children's care organisation. Each referred child is re-inspected by the school doctor a few months after the medical examination to allow time for treatment to be carried out. During 1946, 65,205 re-inspections were carried out for defects previously noted by the doctors. Excluding those requiring dental treatment, the combined results of the first and second re-inspection gave a total of 88.8 per cent. under treatment or further treatment no longer required. This is a higher percentage than that recorded in 1938, which was 83.1. Medical treatment The Council has arranged comprehensive free treatment in the Council's hospitals and school treatment centres and, for the treatment of specified defects, at certain voluntary hospitals. The scheme also includes the free supply and repair of surgical appliances, including artificial limbs, spectacles and insulin prescribed at voluntary hospitals for pupils for whose education the Council is responsible. The Council also pays for in-patient and out-patient treatment, at hospitals outside London, of its pupils who are temporarily absent from their homes in London. Payment of the cost of emergency dental treatment by private practitioners (for the relief of pain) during the evenings, week-ends and other times when clinics are not open, is also authorised. Sanction was given during the year for payment of travelling expenses for pupils from Council schools and their parents or escorts, when the clinic is more than 2 miles from the home of a senior pupil, or 1½ miles in the case of a junior pupil, or for any shorter distance when the school medical officer considers this is necessary, e.g. in the case of certain handicapped pupils. During the year arrangements were made for an experimental period of one year with Westminster Hospital (All Saints genito-urinary department) for reference of pupils from Council schools suffering from enuresis. At the end of 1946 there were 83 school treatment centres, and in addition 24 voluntary hospitals were co-operating with the Council in providing treatment for defects of school children (medical and dental). Following-up and reinspection The following table shows the number of new cases treated at the school treatment centres and at the co-operating voluntary hospitals in 1946 and in 1938 Ailment 1946 1938 Eye (refraction and squint) 27,140* 37,359 Ear, nose and throat 2,361t 12,726 Minor ailments 106,938 128,819 Teeth 91,601 138,639 Special ear defects 770 1,830 Rheumatism supervisory centres 1,417 1,885 Nutrition defects 808 641 Ringworm 311 103 * During the year spectacles were prescribed and supplied to 19,351 children at 5 voluntary hospitals; trained orthoptists assist the ophthalmic surgeons to obtain proper muscular balance of the eyes. † Most of these operations were carried out in the Council's hospitals, and the number of school treatment centres used for this purpose was much smaller than in 1938. 73 At the end of 1946, there were 12 special classes for speech defects conducted by part-time speech therapists under the supervision of a principal assistant medical officer. During the year, 456 individual children attended the classes ; 56 were discharged as cured or greatly improved, 71 left for various reasons, many of whom were improved, and the remainder were still under treatment at the end of the year. The number of artificial limbs provided for school children at Queen Mary's Hospital, Roehampton, was 18, in addition to 3 supplied through voluntary hospitals. Speech therapy Artificial limbs In patients. The following summarises the school pupils treated as in-patients in the Council's and E.M.S. hospitals in the year 1945-46 :— Hospitals No. of children treated Total days Average no. under treatment Average stay (days) Long stay (over 8 weeks) L.C.C. acute general hospitals 10,805 144,750 396.5 13.3 338 L.C.C. convalescent fever hospitals 955 15,207 41.6 15.9 40 L.C.C. children's hospital schools 1,867 178,082 487.9 95.4 1,086 E.M.S. hospitals 539 14,919 40.8 41.5 130 Total 14,049 354,373 970.0 25.0 1,602 Ascertainment of pupils needing special education Children numbering 4,806 were examined as to their being in need of special education. Of this number it was found that 4,012 were in need of it. The division between the various categories of handicapped children was:— Blind 5 Partially sighted 84 Deaf 63 Partially deaf 45 Physically handicapped 724 Educationally subnormal 1,381 Epileptic 30 Diabetic 10 Maladjusted 129 Delicate 1,131 Speech defects 410 In addition, 218 children were reported to the mental health authority as being ineducable. Of the children attending and examined in special schools, 77 physically handicapped and 8 educationally sub-normal were found to be no longer in need of special education and were able to return to ordinary schools. During the year, 1 deaf child. 58 physically handicapped, and 7 educationally subnormal children at or over 14 years of age were released from further attendance at schools as being no longer in need of special educational treatment. Accommodation for handicapped children In addition to 58 day special schools in London the Council has the following residential special school accommodation (the blind and deaf residential schools have also accommodation for day pupils):— Defect No. of schools Accommodation Residential Day Boys Girls Blind 1 40 40 80 * Deaf 3 1 60 30 90 1 38 38 76 1 plus other defects 69 — 35 34 Physically handicapped 2 1 72 — 72 — 1 45 — — 45 Delicate 6 497 — 277 192† Epileptic 1 28 — 14 14 Diabetic 1 50 25 25 * Girls at present sent to non-Council schools. † Plus 28 infants. 74 In addition to the children in the Council's own residential special schools, there were some 626 handicapped children of all categories in non-Council residential schools. The hospitals division of the Public Health Department arranges for children recovering from illness, operation, etc., to be sent to convalescent homes for periods up to 8 weeks, and also administers the Council's 6 hospitals for children requiring medical treatment and who receive education when declared fit for it by the medical staff. At the end of 1946 there were 962 children on the school rolls in these hospitals. There are eight residential schools for children committed to the care of the Council under the Poor Law Acts, with accommodation for about 3,000 children. A visiting medical officer attends each day and when necessary, and examines all children on entry, before discharge and at such other times as are prescribed by the Council. A dental surgeon is appointed to visit and undertake all dental treatment of the children resident in the schools, and at each school there are at least two resident school nurses. Periodical visits are made by senior medical and nursing officers from the County Hall. During the year under review, an invitation was received from two Swiss organisations, the Don Suisse and the Secours Suisse aux Enfants, for about 200 delicate children to spend six months in a children's home at Adelboden. The children were selected from those attending the Council's schools for the delicate or on the waiting lists for admission to those schools. Residential schools Visit of delicate children to Switzerland Provision of meals The following table, supplied by the Education Officer, shows the result of a census of the total numbers of school pupils provided with school meals and/or milk on a typical day in the month of October, 1946:— Number in attendance on selected day Number who had dinner Number who had milk— one-third pint free Free Paying Primary 198,960 8,030 77,927 191,706 Secondary 97,576 2,620 52,929 84,516 10,650 130,856 Total 296,536 141,506 276,222 The percentage of children in attendance (primary and secondary) who received meals was 47.72 compared with 45.09 in June, 1946, when the last return was made. Since 6th August, 1946, milk in schools has been free, but, by order of the Minister of Education, it is restricted at present to one-third of a pint each child a day except in the case of the children ascertained to be "delicate" each of whom gets 2/3 of a pint of milk each day. The return shows that the vast majority of the children in primary and secondary schools are having this one-third pint of milk every day. The exact percentage is 93.14 compared with only 65.5 per cent. in June, 1946, when the milk had to be paid for. 75 Day schools Infectious diseases in schools The numbers of infectious cases reported from the day schools during the year are shown in the following table, the figures for the preceding eight years being given for comparison:— Year Diphtheria Scarlet fever Measles and German measles Whoopingcough Chickenpox Mumps Conjunctivitis 1938 3,676 3,988 34,235 4,067 11,018 4,805 342 1939* 1,279 2,298 2,067 7,726 7,402 4,147 262 1940 59 82 390 9 124 24 1 1941 221 322 2,564 1,656 738 358 16 1942 472 1,617 9,601 1,928 4,232 8,092 81 1943 562 3,990 12,560 2,518 8,398 5,986 332 1944 293 1,430 12,266 2,353 5,899 971 314 1945 288 1,419 7,585 938 2,227 3,219 93 1946 290 1,654 8,640 2,421 5,602 5,296 251 * 7 months only. The numbers of schools kept under observation during 1946 by school nursing sisters on account of the principal infectious diseases are shown in the following table:— Division Diphtheria Scarlet fever Measles and German measles Whoopingcough Chickenpox Mumps Total S.W. 3 12 62 4 26 17 124 S.E. 1 8 84 15 32 23 163 N.E. — 2 34 2 13 5 56 N.W. 7 9 33 3 14 16 82 N. 3 5 48 7 24 9 96 Total 14 36 261 31 109 70 521 No case of smallpox was notified from schools in London during the year ; the last confirmed case occurred in June, 1934. The arrangements made with Guy's Hospital and St. Mary's Hospital, Paddington, for the treatment of diphtheria "carriers" at special out-patient clinics were continued during 1946, but no cases were referred to them. The year 1946 is the first full year of normal work since the coming into effect of the immunisation arrangements which were introduced in 1940 in response to the appeal by the Ministry of Health for more intense efforts on the part of local authorities. The arrangements outlined in my report for 1940 have been continued since that date, and it is significant that the number of cases of diphtheria reported from schools has fallen from 3,576 in 1938 to 290 in the year under review. Immunisation is carried out by school doctors in 24 boroughs. The number of children who received the full course of prophylactic injections in the schools during the year was 6,635. The total number of children immunised in school by the school medical staff since the issue of the Ministry of Health circular in 1940 is 78,990, and 3,436 "boosting" doses have been given. Diphtheria "carrier" clinics Immunisation Ringworm During the year there has again been an increase in the number of cases of scalp ringworm as indicated in the following table, which gives details of cases reported in 1938, 1945 and 1946 Year New cases Cured cases Cases outstanding at end of year Percentage of cures effected by X-ray treatment 1938 194 206 44 83 1945 200 152 55 78 1946 311 266 100 82 76 During the year, 430 specimens of hair from school children were microscopically examined in the Council's laboratories, 176 showed the presence of ringworm. The number of cases of scabies and impetigo treated at bathing centres during the year are mentioned on page 71. There were 7 cases of scalp ringworm and 11 of body ringworm among children in residential schools and children's homes. The outbreaks were isolated and were investigated as they arose. Surveys with a Wood's lamp were made of contacts and spread prevented. Of the seven cases of scalp ringworm, one was at Ongar Residential School and occurred at the beginning of the year, being the last case of an outbreak which was already under control. Two cases were at Hutton Residential School, occurring among children in an out-county nursery temporarily housed in the premises. No fresh infections arose therefrom. The remaining four were at Banstead Residential School, three being discovered as a result of inspection on receipt of report of the first case. Residential accommodation for the treatment of ringworm is provided at the Council's Goldie Leigh Hospital. During the year 30 cases were discharged cured, and there were 7 cases in the hospital at the end of 1946. The school nurse examines all entrants to the residential schools with a Wood's lamp (where electricity is available). Active immunisation against diphtheria was continued at the Council's residential establishments for children. At the end of the year 67.5 per cent. of the children in residence had been immunised and 11.9 per cent. were in process of being immunised. Of the remainder, the majority were too young to be immunised. Rheumatism scheme A condensed account of the work of the Council's rheumatic scheme, presented by Dr. C. E. Thornton, is given below. The mass movements of children out of and into London during the war may well have led to failure in early recognition of subacute rheumatism and/or of early cardiac involvement, so that caution should be observed in comparing 1946 data with those of pre-war years. Year Number of children cm school rolls Number of children accepted for treatment in rheumatic units Percentage of school population 1938 482,096 2,009 0.42 1946 314,000* 591 0.19 * This is the figure for January. The number increased very considerably towards the end of the year. This indicates an apparent decrease in the incidence of juvenile rheumatism (including chorea). The percentage incidence of permanent and severe cardiac damage is a fair indication of the severity of rheumatic infection in any particular series of cases. For the reasons stated above, the conditions during the war were not strictly comparable with those of pre-war years, and it is impossible to say what influence selection had in producing differences in the severity of cardiac involvement in the cases admitted to the rheumatic units. Dr. Thornton's view is that there was a more virulent type of infection; that the attacks were characterised by more prolonged carditis ; and that the occurrence of nodules and of pericardiac involvement was more prevalent during the war years than in 1938. Scabies and impetigo Residential establishments for children: Ringworm Diphtheria immunisation 77 The following table gives a statistical summary of the work of the Council's juvenile rheumatic scheme from 1938 to 1946:— 1946 1945 1944 1943 1942 1941 1940 1939‡ 1938 No. of rheumatism units 1 1 2 2 2 2 3 5 5 No. of beds available 2501 250† 200† 310† 170† 220 220 900 900 Average no. of beds occupied 240† * * * * * * 800 794 No. of admissions to units 545 335 418 555 358 248 302 1,542 2,030 Percentage with cardiac involvement 62.4 60.3 68.4 66.7 67.3 40.7 321 35.4 36.7 No. of supervisory centres 22 21 18 16 14 11 13 21 20 No. of sessions 702 471 469 409 272 148 222 598 1,090 No. of children under supervision, 31st December 2,440 1,821 1,600 1,483 1,080 620 1,066 4,384 5,160 Total no. of attendances 8,117 5,197 4,407 4,366 3,156 1,446 1,678 5,173 5,306 No. under supervision of school doctors, 31st December 187 161 187 * * * * 2,104 2,632 † Approximate figure. * No records. X All figures relate to the period ending 31st August. Investigation was carried out during the autumn and winter months of 1945-46 at certain of the rheumatism supervisory centres into the method of preventing rheumatic recurrences by small doses of sulphanilamide, which had been reported on favourably in America. The results were disappointing, and the good results reported in America were not obtained in London. An investigation into the blood concentration levels of vitamin A in rheumatic children in Queen Mary's Hospital, Carshalton, was begun in 1945 in co-operation with a wader research under Dr. Leitner at other of the Council's hospitals. Although the number of children concerned was not large, certain conclusions seemed to be j ustified:— (i) A low vitamin A blood concentration occurs in the presence of active rheumatic infection and a raised blood sedimentation rate (E.S.R.). (ii) Large doses of vitamin A favour a drop in the blood sedimentation rate, indicating the probability of a subsidence of rheumatic infection. (iii) In certain instances, the vitamin A blood concentration level seemed to be a more reliable indication of activity than the blood sedimentation rate. It appeared that with a high vitamin A blood concentration a raised sedimentation rate might be safely ignored. If further work confirms this, the curtailment of the period of treatment in such cases will render vitamin A investigation well worth while. Tuberculosis Mass miniature X-ray examinations were carried out at various centres where arrangements were made for the voluntary attendance of pupils (of 15 years of age and over) attending secondary schools, technical colleges, etc. Investigation into sulphanilamide prophylaxis Vitamin A Mass miniature radiography The numbers and results of the examinations of school children were as follows:— Number Percentage of miniatures Miniature films taken 5,854 — Large films taken 103 1.76 Analysis of large films No significant abnormality 67 1.14 Probably non-tuberculous 4 .07 Lesions probably tuberculous:— (a) Admitted to sanatorium 3 22 .05 .38 (6) Under dispensary or G.P. supervision 19 .33 Cardio-vascular lesions:— (a) Congenital abnormality 4 10 .07 .17 (6) Acquired abnormality 6 .10 103 1.76 78 Audiometry Arrangements were being made at the end of 1946 to re-establish systematic audiometric testing of the children in the schools in one division. This work had been interrupted during the war. Classes for foot defects Special classes to correct foot defects before they develop into permanent disabilities were commenced during the year under the supervision of a part-time specialist in physical medicine, who made a selection of suitable children, and trained teachers selected by the Council's organisers of physical training. There were 30 classes in action at the end of the year, at which the selected children attended for 8 weeks under instruction of the specially trained teachers. Diabetic unit The diabetic unit, established under the evacuation scheme to meet the need for special care of diabetic children, has been continued, and the Council has thus become the first authority to provide residential care for diabetic pupils under the Education Act, 1944. The unit is housed within the curtilage of the residential school at Hutton (Essex). The day to day care of the pupils is undertaken by the visiting medical officer and nursing staff with special experience. A consultant visits fortnightly, and at such other times as are necessary. The laboratory work necessary to ensure control is undertaken by the staff. The pupils take part in all school activities, including a visit to a holiday camp, and attend educational establishments according to their age and ability. During their stay they are taught the principles of the control of their disease, the importance of dietary, and to give themselves injections of insulin. About half the number of children at the school are sent and maintained by education authorities other than London. The only restriction placed on selection of pupils for admission is that they should be suffering from diabetes mellitus and be of such intelligence as to profit by their stay. Teaching of mothercraft The classes taken by school nursing sisters with special experience in mothercraft were extended during the year. The course comprises 12 lectures, each of 40 minutes, with added time for practical demonstrations. At the end of 1946, there were 29 secondary schools providing special mothercraft courses. Children under the age of 5 years The number of under 5-year-old children on the school rolls increased rapidly during 1946, and each primary school with 30 or more children under 5 years was visited by a divisional medical officer and an inspector from the Education Officer's department, with a view to introducing some approximation to nursery class conditions. Much of the accommodation was unsuitable for more than a few children approaching 5 years of age, and, in practically all places visited, recommendations were made for some adaptations which, owing to lack of staff and materials, were necessarily limited to minor works. By the end of 1946, there were 14 day nursery schools maintained by the Council, with accommodation for 861 children, and 6 aided nursery schools with about 245 places for children between 2 and 5 years of age. There were also over 70 nursery classes, with accommodation approaching 3,000 places, for 3 to 5 year olds. 79 In all, there was a total of 12,441 children under 5 years of age on the school rolls, 9,270 being in Council schools, and 3,171 in voluntary or aided schools. There were 10 residential nursery schools, with accommodation for 504 children between 2 and 5 years of age. All the children attending nursery schools are provided with 3 meals daily (two light meals in the case of nursery classes) in addition to mid-morning milk, cod-liver oil and orange juice. Each child is examined every 3 months by the doctor, and a school nurse visits each day. Remand homes Dr. C. W. J. Ingham reports as follows on the work of the Stamford House and Marlesford Lodge Remand Homes:— From 1st January up to 10th August, 1946, the medical services of the remand homes were in the charge of Dr. J. D. W. Pearce, as part-time medico-psychologist. The number of special psychiatric reports asked for and submitted were : Male, 433 ; female, 68 ; total, 501. From 10th August to 31st December, 1946, changes of medical personnel resulted in a variation of the arrangements in the remand homes:— (1) Routine physical examinations and treatment of casual sick cases were undertaken by a medical officer of the School Health Service. (2) Psychiatric investigation and preparation of all psychiatric special reports were undertaken by psychiatrists from the Maudsley Hospital except in cases where states of educational subnormalitv, within the meaning of Section 34 of the Education Acts 1944-46, or feeble-mindedness within the meaning of Section 1 of the Mental Deficiency Acts, 1913 27, were suspected. (3) All statutory examinations and reports under Education or Mental Deficiency Acts, including attendance at Courts were undertaken by specialist medical officers of the Public Health Department. During this period 613 cases were admitted. Detailed physical examinations were carried out in every case admitted irrespective of any special request from the Courts. The number of routine mental and psychometric reports were: Male, 58; female, 7 ; total, 65. Thirty-one special 'conduct' reports were requested by the magistrates and supplied by the superintendents of the remand homes. The number of special psychiatric reports asked for and supplied were : Male, 180 ; female, 42 ; total, 222. Problem children The Council's scheme, established in 1944, to co-ordinate the special children's care work by the reference of the particulars of all school children presenting difficulties in behaviour or of educability to a case conference of senior officers of the Education Officer's and School Medical Officer's departments, in each of the 9 divisions into which London is divided for educational purposes, was continued during 1946. A full dossier of the child's home, family and social background, his medical and educational history, and his conduct and educational progress in and out of school and at home, is available for consideration of the case conference. Interviews with parents, teachers and others interested, can be arranged, and the views of the head teacher and school medical officer are taken into account by the conference. Visits were made by a psychiatrist of the Council's Mental Health Services to ensure consistency in appreciating the types of cases for which child guidance is suitable, the underlying consideration being that the child would be directed into the channel best suited to his age, aptitude and ability. 80 All cases officially referred by the conference for specialist medical examination or for child guidance are submitted to the school medical officer. Cases officially referred by the school medical officer to approved child guidance clinics are paid for at the rate of 15s. for the first visit, and 5s. for each subsequent visit, and progress reports are called for at the end of each term. (Revision of these rates was under consideration at the end of the year.). During 1945-46,822 cases were referred to the case conferences. These cases were disposed of as follows: 448 were referred for child guidance, 18 for attendance enforcement, 36 for medical treatment, 41 to special schools, 35 to special classes, 49 for boarding education, 165 for other forms of treatment, and 30 for ascertainment as maladjusted. During the year additional special classes were opened for educationally backward and maladjusted children. The number of sessions at the Maudsley's children's department were increased from 16 to 27 a week, and by the end of the year, in addition to the Maudsley Hospital, there were 9 voluntary child guidance clinics approved by the Council for the official reference of its pupils. Mental Health Services During the year Claybury Hospital was withdrawn from the emergency medical services scheme, leaving only Horton and Sutton Hospitals still in the scheme at the end of the year. At the request of the Ministry of Health, arrangements have been made for the establishment at Sutton Emergency Hospital of a special unit for providing in-patient treatment for persons referred from employment exchanges and other sources, who appear to be suffering from neurotic disorders. Hitherto such cases have been referred in the first instance to psychiatric out-patient clinics, but, in the view of the Minister, experience has indicated the need for a residential diagnostic and observation centre, where more difficult cases can be assessed and tried out in industrial processes over a period of about 6 to 8 weeks with a view to later treatment, training or employment according to the ascertained need in each case. In the first instance, 100 beds (50 for each sex) have been allocated for the purposes of the new unit. The year under review has seen the 21st anniversary of the establishment at Horton Hospital of a malarial therapy unit. The unit was established in May, 1925, by the Ministry of Health with the approval of the Board of Control and the cooperation of the Council. The laboratory has supplied infective material for malarial therapy to hospitals throughout the country, and at Horton Hospital alone a series of over 2,000 cases has been treated for general paralysis of the insane, tabes and latent neuro-syphilis. In addition, valuable research work has been done in connection with malaria itself. In 1931, early researches on atebrin (now known as mepacrine) were initiated and the foundations were laid for the prophylactic work which proved so beneficial to H.M. Forces operating in malarial endemic areas during the recent war. The erection of the children's block at the Maudsley Hospital was completed just before the outbreak of war, but had not been brought into use when the hospital was evacuated. The block, when fully equipped, will provide accommodation for 30 patients. The first patients were admitted during 1946. Volume XV of " The Archives of Neurology and Psychiatry " for the year 1946 is in course of publication. The facilities provided at the Maudsley Hospital for post-graduate medical education have been extended to include a scheme for the post-graduate training as psychiatric specialists of medical practitioners demobilised from H.M. Forces. It is impossible to say exactly how many persons joined the Council's service as a direct result of the Hospitals Exhibition held from 21st to 26th January, 1946 Emergency medical services scheme Industrial neurosis unit Malarial therapy unit Maudsley Hospital: re-opening of childrens' block Archives of neurology Postgraduate training Hospitals exhibition 81 (see p. 56), but, so far as the Mental Health Services are concerned, 417 nurses (119 male and 298 female) joined between 1st February and 31st May, 1946, compared with 261 (40 male and 221 female) during the preceding four months. The Council agreed to continue for a further period of one year the work carried out on behalf of the Minister of Labour and National Service of placing in employment and providing industrial after-care for children leaving the Council's special schools for the educationally subnormal (see footnote to table 5). The Ministry made a grant of £1,500 to cover the cost of this work. Statistics The following table gives the numbers of London's mental cases of all types for whom the Mental Hospitals Committee and, up to 1930, the Metropolitan Asylums Board were responsible to provide institutional accommodation since the year 1890* and the increase or decrease in total numbers since then:— After-care of special school leavers Table 1 Year 1st Jan. Mentally disordered patients under reception orders Voluntary and temporary patients Chronic harmless patients in ex-M.A.b. institutions under sec. 24or 25 of Lunacy Act, 1890 Uncertified patients Mentally defective patients dealt with under the Mental Deficiency Acts Total Increase Decrease Cases of senile dementia over 70 years of age Feebleminded persons 1890 10,104 5,566 15,670 1895 12,118 — 5,908 — — — 18,026 2,356 1900 15,185 — 5,770 — — — 20,955 2,929 1905 18,168 — 6,450 — — — 24,618 3,668 1910 19,914 — 6,676 — — — 26,590 1,972 1915 21,539 — 7,258 — 641 35 29,473 2,883 1920 17,296 — 5,291 — 720 687 23,994 — 5,479 1925 19,060 136 4,976 — 889 1,881 26,942 2,948 1930 21,034 161 4,370 942 944 3,189 30,640 3,698 1935 21,580 607 3,931 1,073 83 6,347 33,621 2,981 1936 21,445 856 3,942 1,123 54 6,600 34,020 399 1937 21,366 1,076 3,959 1,042 14 6,845 34,302 282 1938 21,153 1,255 3,955 942 9 7,017 34,331 29 1939 20,824 1,511 3,940 896 9 7,117 34,297 34 1940 20,555 1,454 3,867 991 9 7,381 34,257 — 40 1941 20,364 1,516 3,653 997 9 7,369 33,908 — 349 1942 19,340 1,514 3,399 944 9 7,340 32,546 — 1,362 1943 18,578 1,480 3,155 1,018 9 7,380 31,620 — 926 1944 18,071 1,593 2,965 1,005 — 7,403 31,037 — 583 1945 17,687 1,576 2,874 1,087 — 7,404 30,628 — 409 1946 17,379 1,629 2,598 1,126 — 7,405 30,137 491 1947 17,221 1,816 2,447 1,239 — 7,430 30,153 16 — * The figures for each year up to 1935 will be found in the Annual Report of the Council for 1937 (Vol. VL., p. 4.) 82 The following table shows the number of mental patients of all classes undergoing treatment in London County mental hospitals and ex-M.A.B. institutions during 1946:— Table 2 Lunacy and Mental Treatment Acts Uncertified senile patients Total of all classes Certified Voluntary Temporary Lunacy Act Sections 24 & 25 M. F. Total M. F. Total M. F. Total M. F. Total M. F. Total M. F. Total Patients at 1st Jan., 1946 6,980 10,293 17,273 736 706 1,442 2 6 8 1,072 1,526 2,598 311 815 1,126 9,101 13,346 22,447 Admissions in 1946— Direct 735 1,151 1,886 598 721 1,319 13 34 47 43 41 84 264 475 739 1,453 2,422 4,075 Indirect 257 294 551 41 53 94 1 — 1 34 3 37 — 333 350 683 Exits in 1946— Discharged recovered 206 407 613 102 258 360 1 4 5 — — — — — — 309 669 978 *Discharged otherwise 490 541 1,031 437 438 875 9 19 28 9 9 18 41 50 91 986 1,057 2,043 Deaths 374 570 944 68 38 106 4 2 6 123 131 254 211 324 535 780 1,065 1,845 Total patients 31st Dec., 1946 6,902 10,220 17,122 768 746 1,514 2 15 17 1,017 1,430 2,447 323 916 1,239 9,012 13,327 22,339 * Includes patients transferred to other mental hospitals and to other classes. 83 The following table shows the admissions at each of the London County mental hospitals during 1946, including voluntary and temporary patients received under the provisions of the Mental Treatment Act, 1930:— Table 3 Hospital Total number on register, 1st January, 1946 Admissions, 1946 Total number under treatment, 1946 Direct Indirect, t.e.f by transfer from other mental hospitals Total London County Other County Male Female Total Male Female Total Male F. Total Male F. Total Male Female Total Male Female Total Banstead 897 1,601 2,498 130 259 389 1 1 1 2 3 131 262 393 1,028 1,863 2,891 Bexley 965 1,294 2,259 152 224 376 3 3 2 4 6 154 231 385 1,119 1,525 2,644 Cane Hill 710 1,527 2,237 106 323 429 2 2 1 1 2 107 326 433 817 1,853 2,670 Claybury 894 1,286 2,180 165 201 366 2 3 5 4 5 9 171 209 380 1,065 1,495 2,560 Frien 978 1,078 2,056 64 154 218 9 62 71 7 3 10 80 219 299 1,058 1,297 2,355 Long Grove 1,182 1,226 2,408 188 130 318 1 2 3 2 2 191 132 323 1,373 1,358 2,731 St. Bernard's 680 1,183 1,863 133 234 367 206 175 381 6 4 10 345 413 758 1,025 1,596 2,621 St. Ebba's 312 319 631 315 239 554 315 239 554 627 558 1,185 West Park 1,042 1,250 2,292 93 142 235 1 1 1 3 4 95 145 240 1,137 1,395 2,532 * The Manor 58 76 134 — — — — — 58 76 134 *St. Lawrence's — 165 165 – – – – – – – – – – – – – 166 165 Total 7,718 11,005 18,723 1,346 1,906 3,252 219 248 467 24 22 46 1,589 2,176 3,765 9,307 13,181 22,488 * The Manor and St. Lawrence's Hospital are not county mental hospitals, the Manor being a certified institution and St. Lawrence's Hospital an institution approved under section 37 of the Mental Deficiency Act, 1913, but each provided accommodation for some of the mental patients evacuated from Horton Hospital in 1939. 84 The numbers of patients on the registers at the London County mental hospitals on 1st January, 1947, were:— Table 4 Hospital Under reception orders Voluntary patients Temporary patients Total M. F. Total M. F. Total M. F. Total M. F. Total Banstead 805 1,448 2,253 26 35 61 — — — 831 1,483 2,314 Bexley 873 1,112 1,985 72 125 197 — 2 2 945 1,239 2,184 Cane Hill 676 1.457 2,133 48 92 140 — 5 5 724 1,554 2,278 Claybury 823 1,209 2,032 83 72 155 — 1 1 906 1,282 2,188 Friern 894 1,118 2,012 11 26 37 — — — 905 1,144 2,049 Long Grove 1,010 1,087 2,097 84 54 138 — 2 2 1,094 1,143 2,237 St. Bernard's 835 1,293 2,128 61 70 131 — — – 896 1,363 2,259 St. Ebba's 79 141 220 259 183 442 2 4 6 340 328 668 West Park 857 1,124 1,981 120 89 209 — 1 1 977 1,214 2,191 The Manor 50 75 125 4 — 4 — — — 54 75 129 St. Lawrence's — 156 156 – – – – – – – 156 156 Total 6,902 10,220 17,122 768 746 1,514 2 15 17 7,672 10,981 18,653 Note.—These figures include patients chargeable to out-county authorities and patients absent on prolonged leave on trial under Section 55 of the Lunacy Act, 1890. The following table gives a summary of action taken under the Mental Deficiency Acts:— Table 5 Source of information From 1st April, 1914, to 31st December, 1946 1946 only Supervision section 1,508 3 Local education authority 12,986 434 Police authority (Sec. 8) 1,789 45 Transfers from prison (Sec. 9) 222 7 Transfers from approved schools (Sect. 9) 550 7 Miscellaneous 9,499 130 Total cases with which the Council has been called upon to deal 26,554 626 Action taken on the above cases Position as at 31st December, 1946, with regard to the 26,554 cases referred to in the first column of the preceding table:— Detained:— In institutions provided by the Council— The Manor, Epsom, Surrey 1,379 Farmfield, Horley, Surrey 228 St. Lawrence's Hospital, Caterham, Surrey 1,673 Darenth Park, Dartford, Kent 1,654 Fountain Hospital, Tooting, S.W.17 696 Leavesden Hospital, Kings Langley, Herts. 1,202 Leytonstone House, Leytonstone, Essex 252 Bethnal Green Hospital, E.2 1 In institutions under contract 323 Under guardianship 330 In places of safety awaiting the presentation of a petition for an order 22 7,760* Under statutory supervision 3,800† In institutions awaiting presentation of a petition for an order 22 Still under consideration 69 Total remaining on the active list 11,651 85 Removed from active list:— Discharged from institutional care 2,119 Removed to mental hospitals under Lunacy Acts 452 Removed to a State institution 142 Ascertained not subject to action 8,429 Died 3,761 14,903 26,554 Summary of movements during 1946 Placed in institutions provided by the Council— The Manor 53 Farmfield 11 St. Lawrence's 81 Darenth Park 41 Fountain 79 Leavesden 34 Leytonstone House 8 Bethnal Green Hospital 3 Placed in institutions under contract 12 Placed under guardianship 15 Placed in places of safety pending presentation of a petition for an order 76 Placed under supervision 363 Discharged from institutional care 181 Removed to mental hospitals 14 Removed to a State institution 9 Ascertained not subject for action 266 Died 190 — 1,436 * The figure includes 638 patients on licence with a view to discharge. In addition, 291 patients were absent in local daily employment on 31st December, 1946. The number of patients on leave is almost14 per cent. of the total number on the registers of the institutions. † In addition to the 3,800 cases under statutory supervision, 976 cases of defective persons known to the local authority to bo mentally defective but not subject to be dealt with under the M.D. Acts are visited on a voluntary basis at infrequent intervals. The Council acts as the paid agent of the Ministry of Labour in placing in employment mentally defective children who leave special schools, and in supervising these cases up to 18 years of age. On 31st December, 1946, 430 defectives were being afforded the benefits of this scheme. Land under cultivation Farming operations During the year 1946, the area of land farmed by the Mental Health Services decreased by 205 acres, some of this having been surrendered for housing purposes. The following table shows the total areas of land under cultivation since the outbreak of war:— Acreage at outbreak of war Arable Grass Total 1,041 1,748 2,789 ,, 30-9-41 2,239 2,905 5,144 ,, 30-9-42 3,169 2,814 5,983 ,, 30-9-43 3,574 2,750 6,324 ,, 30-9-44 3,793 2,766 6,559 ,, 30-9-45 3,777 2,766 6,543 ,, 30-9-46 3,428 2,910 6,338 Produce Particulars of the main items of produce derived from these farms during the year ended 31st March, 1946, are given below with comparative figures for preceding years:— Eggs No. 1938-39 1939-40 1940-41 1941-42 1942-43 1943-44 1944-45 1945-46 556,902 518,228 359,310 210,844 201,123 176,618 178,981 222,014 Milk Gals. 650,262 664,072 543,997 456,807 434,238 439,684i 464,220 515,954 Meat Tons 403 374 351 294 263 245 227 240 Potatoes 1,026 1,531 1,772 2,290 3,104 2,809 3,068 2,721 Other vegetables „ 1,201 1,477 1,668 1,792 2,456 2,299 2,120 2,324 Fruit ,, 78 80 81 94 119 149 147 157 Animal foodstuffs „ 1,433 1,309 3,353 4,959 6,213 7,623 9,082 8,984 Total value for year £106,589 £110,240 £125,513 £139,000 £156,721 £l 62,631 £172,294 £189,994 86 In addition, at a few institutions at which food production is on a small scale, about 35 tons of vegetables and 1 ½ tons of fruit, valued in total at about £792, were produced during the year. Stock The approximate numbers of pigs and poultry on the farms in the Mental Health Services at 31st March, 1946, and at the same date in each of the preceding three years (figures as at 31st March in earlier years not being available) were:— Pigs Poultry 1943 3,011 3,387 1944 2,712 3,840 1945 1,938 3,437 1946 1,807 4,423 The numbers of cattle at 31st March in each of the years 1939-46, inclusive, were:— Cows (i.e., cattle other than bulls, heifers and calves, and including dry cows as well as those in milk) Other cattle (i.e., bulls, heifers and calves) Total 1939 1,091 505 1,596 1940 1,064 618 1,682 1941 948 636 1,584 1942 872 682 1,554 1943 938 782 1,720 1944 1,008 921 1,929 1945 974 976 1,950 1946 1,025 907 1,932 During the year steps were taken to replace the herd of non-attested cattle at Bexley Hospital farm by a tuberculin tested herd. When this replacement is completed, the Council's long term policy of establishing attested herds at all the Council's farms will have been achieved. In addition to the areas of land shown above, which are farmed directly by the Mental Health Services, there are approximately 290 acres of land attached to general and special hospitals, which are under the general supervision of the Mental Hospitals (Farming Operations Sub-) Committee. INDEX page Admissions to hospitals 49 After-care of mental patients 81 Analgesia 41 Anthrax 10 Artificial limbs 53, 73 Audiometry 78 Births 3 Blind persons 32 British Standards Institution 32 Bronchitis 6 By-laws 32 Cancer 6 Canteens at hospitals 55 Catering 59 Cerebro-spinal fever 10 Chemical branch 43 Child guidance 80 Children under 5 years 78 Children's hospitals 48 Choice of employment 71 Chronic sick hospitals 47 Cleanliness of school children 70 Clinical Research Committee 56 Convalescence 48 Delicate children 74 Dental condition of school children 69 Diabetes 6, 78 Diarrhoea 13 Diphtheria 11, 75, 76 Disinfestation 31 District medical service 52 District nursing service 53 Domiciliary midwifery service ... 39 Dysentery 10 Enteric fevers 13 Enteritis 13 Epilepsy 48, 54 Evacuation 49 Farming 85 Fertility 3 Food poisoning 15 Foot defects 78 General hospitals 45 Handicapped children 73 Heart disease 6, 70 Hospital committees 52 Hospital pharmaceutical service 53 Hospitals and ancillary services 45 Hospitals exhibition 56, 80 Housing 27 Illegitimacy 4, 42 Immunisation against diphtheria 11, 75, 76 Industrial neurosis unit 80 Infant mortality 8 Infectious diseases 10, 75 Infectious hospitals 48 Influenza 13 Laboratories 60 Legacies to hospitals 55 Libraries at hospitals 54, 59 London Ambulance Service 61 Malarial therapy unit 80 page Maternal mortality 9, 46 Maternity and child welfare 42 Maternity patients 46 Maudsley Hospital 80 Meals for school children 74 Measles 13 Medical education 54 Medical examination of staff 43 Medical inspection of school children 66 Medical Society 57 Medical treatment of school children 72 Mental Health Services 80 Mental health statistics ... ... 81 Midwives Acts 38 Migration 3 Miniature mass radiography 35, 77 Mortality 5 Mothercraft in schools 78 Neonatal mortality 9 Nurses, Training of 58 Nursing homes 42 Nutrition of school children 69 Obstetric service, Emergency 47 Open-air schools 35 Ophthalmia neonatorum 14 Pathological Laboratory Service 60 Picture library scheme 54 Pneumonia 6 Population 2 Post-graduate training of doctors 58, 80 Problem children 79 Puerperal fever and pyrexia 9 Pupils on school rolls 66 Radiographers, Training of 58 Rehabilitation 35,59 Remand homes 79 Research 56, 61 Residential nurseries 49 Residential schools 74 Respiratory diseases 6 Rheumatic fever 14 Rheumatism 76 Ringworm 75,76 Road accidents 8 Sanitary inspection 31 Scabies 14, 71, 76 Scarlet fever 14 School buildings 66 School Health Service 65 Sewage disposal 44 Smallpox 14,48 Speech therapy 73 Staff 57, 62, 65 Steam raising plants 45 Stillbirths4, 40 Tuberculosis 6,14, 33,48, 77 Tuberculous milk 28 Typhus 14, 48 Venereal diseases 28, 48 Visits to hospitals 55 Vital statistics 2 Voluntary hospitals 50 Whooping-cough 14 Works at hospitals 51