LIBRARY LCC 54 LONDON COUNTY COUNCIL REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1948 Published by the London County Council, and may be purchased, either directly or through any bookseller, from Staples Press Limited, 14, Great Smith Street, Victoria Street, Westminster, S.W.I, Agents for the sale of the publications of the London County Council. 1949 No. 3674. Price 2s. 6d. By post 2s. 10d. London County Council REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1948 By Sir Allen Daley, M.D., F.R.C.P., K.H.P., County Medical Officer of Health and School Medical Officer INTRODUCTION During the year 1948 there were vast changes in the functions and administrative structure of the Department. They were a consequence of the coming into operation on July 5th, of the National Health Service Act, 1946. The Council said "Farewell" to the great municipal hospital service which it had built up particularly since 1930. It comprised 98 hospitals with a pre-war bed complement of 70,120 and a staff, all told and including head office hospital staff, of about 32,000. It was a complete hospital service in that it catered for all types of illness—mental and physical. The Council expressed its warm appreciation of the devoted work done by all those who had served on committees responsible for the hospital service, and by the staff who were transferred to the new national service. The Chairman of the Council invited the Hospital Committee members and representatives of all grades of the staff to receptions at County Hall. The Council's best wishes for a happy and successful future in the new administration were given. It is a tribute to both the old and the new administration that the change-over was effected without a hitch and, except that a patient who had formerly been assessed under the then Statute, to pay in whole or in part for his treatment, received it without charge, the sick person in a hospital bed was not aware that overnight there had been a change in the administrative body responsible for his welfare. This was accounted for, partly, by the fact that the Council provided on an agency basis, for some months after the " appointed day " the supply, engineering and finance services for the hospitals. Further, from the beginning of the year the Regional Boards had been building up their staffs and Council officers were gradually absorbed by them and by Hospital Management Committees. The new hospital authorities also took over the Tuberculosis Dispensaries and Venereal Diseases treatment clinics and the clinical staffs. The Council's hospitals were transferred to one or other of the four Metropolitan Regional Hospital Boards, except that the Hammersmith Hospital was transferred to the Board of Governors of the Hammersmith, West, London and St. Mark's group of hospitals, the Maudsley Hospital to the Bethlem Royal and Maudsley Board of Governors, the St. Pancras Hospital to the University College Hospital and the North Western Hospital to the Royal Free Hospital. These are all Teaching Hospitals. To the first is attached the Postgraduate Medical School of London and to the second the Institute of Psychiatry. The last two are undergraduate medical schools. Though the hospitals are no longer the direct responsibility of the Council, preventive and curative medicine are so interwoven that extremely close contact has to be maintained between the Local Health Authority and the Hospital Authorities. Each of the four Regional Hospital Boards and each of the twenty-six Boards of Governors of Teaching Hospitals contains members appointed by the Minister after consultation with the County Council. The day by day administration of the non-teaching hospitals is entrusted to Hospital Management Committees, each Management Committee being responsible, except in the case of very large 756. (m°C. 53400-6) 12.13 49 4956 a 2 mental hospitals, for a group of hospitals. The membership of most of these Committees includes a member or officer of the Council. Apart from these links frequent consultations between officers of the Council and of the hospitals are necessary in order to effect satisfactory liaison. While all these arrangements for a smooth transfer of the hospital service were going on, an equally complex administrative change had to be prepared for, as a result of the transfer to the Council from the City of London and the 28 Metropolitan Boroughs, of the maternity and child welfare services, the vaccination and immunisation services and of the officers employed in the care and after-care of the tuberculous. This involved the transfer to the Council of 4,843 staff, including 50 whole-time and 152 part-time medical officers, 2 full-time and 35 part-time dental surgeons, and 350 health visitors. These officers were welcomed to the Council's service at a reception given by the Chairman of the Council. There was also a transfer of 70 premises owned by borough councils and of 252 tenancy arrangements for buildings. In some cases, the County Council, a Borough Council and a Regional Hospital Board were all concerned in the future use of a building. The National Health Service Act also placed on the Council responsibility for certain services wholly or mainly new both to it and to the Boroughs, for example, the Home Nursing service and the provision of health centres. Further, there was need to expand the ambulance service and to take over from the Social Welfare Department the arrangements for placing mentally disordered persons under care. The Council decided that there should be decentralisation of the services to the greatest extent possible, and that London should be divided into nine divisions each containing between two and five Boroughs. For each Division there is a Divisional Health Committee, some two-thirds of the members of which are appointed after consultation with the constituent boroughs. A divisional medical officer, a nursing officer and an administrative officer were appointed for each division, together with the necessary staff: and divisional offices had to be found and equipped. Much thought was also given to the best method of utilising the services of the Borough Medical Officers in the new scheme, and discussions were still proceeding at the end of the year. The transfer of these borough services was effected with the same smoothness as occurred in the hospital service, and the mother attending a clinic or taking her baby to a day nursery, was unaware of the administrative change. Tribute for this must be paid to the Divisional staffs and to the Borough Medical Officers of Health, who did not spare themselves in their efforts to facilitate a transfer which was naturally distasteful to them. Brief reports of the divisional medical officers will be found on pages 95 to 106. Despite all this " general post " and detailed planning for the despatch of the old and the arrival of the new services, the very considerable volume of the Council's public health work which was outside these changes had to be continued. A description of its main features will be found in the body of this report. A summary of the vital statistics for the year, shows a small increase in the population from 3,326,000 at the beginning +0 3,374,000 at the end of the year and still substantially below the pre-war population of 4,062,800 which again was much less than the peak figure of 4,605,400 in 1926. The birth-rate (17.9 per 1,000 of the total population) has declined considerably from the peak post-war rate of 1947 (20.9). Generally mortality (death-rate 11.1 per 1,000 of the civil population) was substantially lower than in 1947, mainly due to the very low mortality rates experienced for influenza, pneumonia and bronchitis, and for heart disease. For respiratory diseases, the mortality rate was about one-half of the immediate pre-war figure and for heart disease the rate was about 10 per cent. below the pre-war level. There were further substantial falls in infant and maternal mortality and new low records have again been attained. 3 The rate of infantile mortality was 31 per 1,000 live births, compared with an average of 63 during the ten pre-war years. The neo-natal and maternal mortalities were 17.5 and 0.77 per 1,000 live and total births respectively, compared with the average for the ten years prior to the war of 25 and 2.8. The tuberculosis statistics underline the urgent need to improve the segregation of infectious patients by reducing the present far too long waiting lists for sanatoria. Mortality shows a slight decline but the notification rate shows a small upward tendency. It must, however, be borne in mind that the detection of early cases is now more efficient and in consequence the recorded new cases are more numerous than they would otherwise be, but there should be no underestimation of the very real challenge which the figures represent. Signs of the success of diphtheria prophylaxis continue but they are dependent on the maintenance of a high level of immunisation, and it is vitally important to ensure that as many infants as possible are immunised. The number of new cases of venereal disease remains greater than before the war, but shows a reduction on the figures for 1947. The number of calls on the accident ambulance service again increased by 13 per cent. over the figure for 1947, while the demand on the general section increased by 18 per cent. One of the most discussed sections of the National Health Service Act has been that dealing with the provision of health centres. The Council's problems in this connection are dealt with on page 28. The home help service is expanding rapidly. It provides assistance at the rate of 2,000,000 hours per year in homes where there is sickness or a maternity case (p. 41). The dental scheme for school-children and, since the "appointed day," other priority classes has caused concern. The difficulties under which this service has laboured are discussed by the Chief Dental Surgeon (p. 83). Changes had to be made in the Mental Health Service as a result of the National Health Service Act and some difficulty was experienced in obtaining admission of patients to "observation wards" (p. 57). The provision of occupation centres for mentally deficient patients became the responsibility of the department in July, 1948, and continuous progress has been made in the provision of centres and in the handicrafts taught (p. 60). The full impact of the National Health Service on that of the School Health Service still remains to be seen. The most difficult problems arose in connection with child guidance and with the school ophthalmic service. Every endeavour is being made to ensure that the children requiring treatment obtain it with at least the ease and facility with which they did so before the change (p. 62). It is proposed each year to devote special attention to one aspect of the Council's work. This year domiciliary midwifery has been selected and a description of the service will be found on pages 106 to 114. Appointments.—The reorganisation of the department necessitated several promotions and appointments, of which the most senior were : Dr. J. A. Scott as Deputy Medical Officer of Health and Deputy School Medical Officer; Dr. M. MacGregor as Principal Medical Officer ; Dr. Margaret Hogarth as a Senior Medical Officer ; Mr. W. Ritchie Young as Chief Dental Surgeon ; and Messrs. D. J. B. Cooper and W. H. Joyce as Principal Clerks. The appointments of Divisional Medical Officers for the nine new health divisions were all new appointments and the names of the officers will be found on pages 95 to 106. Retirements.—The department lost by retirement during the year the services of six members of the senior staff, all of whom had given many years of devoted service to the work of the Council: Dr. A. M. Hewat, Principal Medical Officer, retired on 30th April, 1948, and Mr. R. Coleman, Principal Clerk of the Hospitals Division on 3rd July, 1948 ; Major-General Helliwell, Consulting Dental Surgeon, who had been 4 in ill-health for many months retired on 7th July, 1948, but died, I regret to record, four months later ; Dr. Letitia Fairfield and Dr. J. N. Dobbie, both Senior Medical Officers, retired on 3rd September and 16th December, respectively; Dr. R. C. Harkness, who for some years had been Principal Medical Officer of the Hospitals Division and Acting Deputy Medical Officer of Health, was transferred on 5th July to the service of the new Hospital Authority ; he was appointed jointly by the four Metropolitan Regional Hospital Boards as Liaison Officer with the Council, and retains his office at County Hall—this is a very happy and satisfactory arrangement. The hospital services of the Council will carry on, but under new management; July 5th, 1948, however, marked the passing of one service which disappears. That is the provision under the Poor Law Acts of a medical service for the destitute. From at least the reform of the Poor Law over a hundred years ago, any person destitute of medical care could apply to the Relieving Officer of his district, who would refer him to the District Medical Officer. If need be, he could also issue an order for the patient to be admitted to hospital—but that is a different question. Now that everyone is entitled to a free medical service, the District Medical Officers have become redundant, and I should like to pay a very warm tribute to their work. They were always available. At some periods of the war, in some districts, they were the only doctors whose services could be readily obtained at night, and the gallantry with which, without hesitation, they set off to visit during air raids an urgent case of sickness is beyond all praise. Foreign Visitors.—The flow of visitors coming to County Hall in quest of information about the health services continues. During 1948, four delegations consisting of 107 persons (6 from Argentine ; 26 from Austria; 20 from Canada ; 20 from Italy; 15 from the United States and a group of 20 who were attending the International Congress of Industrial Medicine) visited County Hall. They were addressed on matters relating to public health and arrangements were made for them to pay visits to hospitals, clinics, etc. Individual visitors, numbering over 50, from many countries, including North and South America, India, Pakistan, Australia, New Zealand, China, Sweden, Denmark, Holland and France, had the work of the department explained to them and were given facilities to investigate the field work of the department. Population VITAL STATISTICS The Registrar-General estimates the civilian population of the county in the middle of 1948 to have been 3,339,100, compared with 3,309,700 a year earlier. The corresponding estimates for metropolitan boroughs are shown in Table 2 on page 115, and the rates given in this annual report are calculated upon these figures. Table 1 shows the sex and age distribution of the population at the middle of each year from 1921, as estimated by the Registrar-General. Though exact figures are unavailable, it is clear that the number of the aged in the population of London is increasing substantially. Migration Toward the end of 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 built-up 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. Reference was made in the Report for 1946 to the possibility that this migration has been selective in so far as the people who moved were younger and healthier than the average and that the effect may be to increase the divergence in mortality between the administrative county and the outer ring. 5 The total births allocated to London for 1948 were:— Live 60,934 Still 1,191 Total 62,125 The live birth rate was 17.9 per 1,000 total population. The births allocated to London, i.e., those of mothers residing within the county are less than those actually registered as occurring in the county owing to the fact that a number of mothers come to be confined in London hospitals and nursing homes each year. This excess of registered over allocated births amounts to about 9 per cent., i.e., some 5,500 births in 1948. The number of marriages registered was 38,527, or 22.7 persons married per 1,000 of the total population. Prior to the war, the birth-rate in London followed the same trend as for the country as a whole, but ran 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 The birth-rates in war and post-war years have been:— 1939 13.4 1944 16.2 1940 14.3 1945 15.7 1941 13.5 1946 200 1942 15.4 1947 20.9 1943 16.1 1948 17.9 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 birth-rate in London, as elsewhere in the country, reached a very high level in 1946 and 1947, greatly exceeding the pre-war level, but the history of the period following the 1914-18 war had indicated that substantial changes could occur in a comparatively short time, and it is not surprising that a decline has taken place. The point of interest lies in how far the decline may proceed. The Royal Commission on Population have affirmed that the statistical evidence laid before them indicated that the high birth-rates of recent years were mainly due to the postponement or anticipation of births which would under normal conditions have been more evenly spread. As yet there has been no appreciable increase in the average size of family nor is there any convincing sign that the lowered average age of marriage in recent years will bring any increase in size of family. The present average size of family is a little below replacement level. Fertility There were 4,240 illegitimate births (7.0 per cent. of the total live births). Percentages in recent years are :— London England, and Wales 1938-42 6.6 4.7 1943 8.2 6.3 1944 9.3 7.2 1945 11.4 9.4 1946 8.0 6.7 1947 6.7 5.3 1948 7.0 5.4 The peak of the war-time rise occurred in 1945, and the trend has since been downward. The percentage for 1948 though slightly higher than in 1947 is not Illegitimacy 6 regarded, as yet, as more than an upward fluctuation but does appear to mark the end of the recovery period. Deaths under one year among illegitimate infants amounted to 39 per 1,000 illegitimate live births, compared with a rate of 30 for legitimate births. The corresponding rates in 1947 were 47 and 34 respectively. A detailed comparison of deaths in the legitimate and illegitimate groups is given in Table 6, page 119. Stillbirths There were 1,191 stillbirths in 1948, or 1.92 per cent. of all births (legitimate 1.85, illegitimate 2.84). The number of stillbirths and the rate per 1,000 total births in each year since 1928 is shown in table 5, from which it will be clear that since 1942 there has been a considerable fall in the frequency of stillbirth. Possible reasons were reviewed in the report for 1946, where it was suggested that an improvement in the health of the mother as a result both of increased emphasis upon dietary supplementation, of more effective ante-natal care generally, and more skilled obstetric service had led to a sharp fall in the stillbirth rate. Mortality The total civilian deaths in 1948 amounted to 36,928, or 11.1 per 1,000 of the civil population. Detailed figures are given in Tables 2, 3 and 4, on pages 115 to 117. 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 9. 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:— Approximate change as a percentage Cause of those formerly assigned to this cause* Influenza -11 percent. 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 affecting the statistics was the outbreak of war. A young and 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 7 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 1948, at 11.1, represents a substantial improvement on the pre-war mortality. 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 disease. Recent experience in both mortality and morbidity is more fully discussed in a later paragraph. Tuberculosis 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 3 (page 116). Mortality from heart disease and bronchitis, after reaching a higher level in the early years of the war, subsequently declined. The 1947 figure is an upward fluctuation in this general trend and reflects the severe winter. The 1948 figure is very much lower and marks a return to the trend which was being followed immediately prior to 1947. After allowing for the changes in classification outlined above, it can be said that the 1948 death-rate from heart disease is 10 per cent. below the level of 1936-40, and the 1948 death-rate for bronchitis is about one-half of the rate experienced in the period 1936-40. These two reductions are the chief elements in the fall in the general death-rate. Bronchitis and heart disease Mortality from pneumonia rose sharply in 1940 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 thereafter declined fairly steadily. In 1947, however, there was an increase in respiratory mortality, associated with the severe weather conditions of February and March. In contrast, 1948 was a year of very light mortality for respiratory disease. The death-rate for pneumonia fell to 0.54 per 1,000, well below the previous low record of 0.67 of 1935. Pneumonia and other respiratory diseases Diabetes mortality has been falling steadily since 1939, partly as a result of more effective treatment and partly as a result of the dietary stringency of the was and post-war years. In 1948 the number of deaths at ages under 55 was 27—a record low figure which compares with an average of 31 in 1945-7. Diabetes The cancer death-rate for all ages for 1948, was 2.11 per 1,000, a little higher than in 1947, and this is the second successive year in which a slight rise has been recorded. Cancer is a disease of advanced age and mortality is sensitive to changes in the average age of the population which has not only been rising naturally consequent upon the falling birth-rate during the pre-war years (see Table 3), but, so far as mortality statistics are concerned, has also been artificially increased by the removal of young persons from the civilian population, to which such statistics relate, by evacuation and mobilisation movements of the war years. Any analysis of cancer mortality should therefore either have specific reference to advanced age groups or to rates which have been "standardised" for age, i.e., rates which are still averages over the whole population but averages in which the representation follows not the actual pattern, disturbed as it is by temporary factors, but a standard pattern which is kept invariant over the period under consideration. The importance of this adjustment can be seen from the following figures for England and Wales, for which estimates of the population in age groups are available. The difference between the two sets of figures here measures only the effect of mobilisation since, for the country as a whole, the evacuation movements would cancel out. Canoer 8 England and Wales—Civilian Mortality from Cancer, 1940 to 1947 Crude death rate per 1,000, all ages combined expressed as per cent. of 1938 rates Comparative Mortality Index* (Base year 1938) Males Females Males Females 1940 112.7 101.6 101.0 98.5 1941 120-6 101.9 101.3 96.9 1942 125.6 104.1 101.2 96.4 1943 132.8 106.0 102.2 96.1 1944 133.7 105.3 100.6 94.1 1945 137.0 106.5 102.4 93.7 1946 123.7 107.6 101.8 94.9 1947 122.6 108.3 104.7 94.9 * The C.M.I, expresses the mortality of each year as a percentage of that of 1938 after adjustment for age difference in the population's exposure to risk and for changes in cause assignment from 1940 onwards. It will be noticed that crude figures for the country as a whole would have suggested a war-time rise in cancer mortality of 37 per cent. for males and 7 per cent. for females, though the risk, measured by a more exact method, was in comparison almost stationary—a very small rise in males and a small fall in females. The difference between the crude and standardised rates for London, which lost a large proportion of its population (more young than old) by evacuation would doubtless be larger but " standardisation " in London cannot be carried out until age-group population estimates are once more available. With regard to the long term trend, this is summarised for England and Wales as a whole, in the last published Statistical Review (1940-45) by the RegistrarGeneral as follows :— "The combined effect of the various trends in different groups summed up in the C.M.I, for both sexes, was that the index rose from 0.853 in 1901-10 to 0.983 in 1921-30 and 0.999 in 1931-35 and then decreased to 0.998 in 1936-40 and 0-988 in 1941-45. On the whole, therefore, cancer mortality has now turned downwards, but amongst children, and males between 35 and 55, it appears to be still increasing." Up to 1948 the comparative mortality index for females has fallen to 0.911 (1938 = 1.000) while the male index has risen to 1.057. For both sexes combined the long-term trend of cancer mortality in London can be seen from Table 3 (p. 116). The increase there shown between 1891 and 1940 is partly due to the increasing age of the population, partly due to improved diagnosis. Mortality from cancer is higher in London than in England and Wales as a whole particularly for men, as the following specimen figures show:— Cancer Death-rate (all ages) per 1,000 Year Males Females London England and Wales London per cent. of E. and W. London England and Wales London per cent. of E. and w. 1931 1/69 1.41 120 1.59 1.47 109 1938 1.91 1.61 119 1.69 1.62 104 1948 2.31 1.96 118 1.94 1.76 110 The important changes in mortality in London between 1931-33 and 1946-48 in relation to certain specific sites are summarised on page 10:— 9 10 London : Changes in Mortality Rates between 1931-33 and 1946-48 (all ages). Bite Males Females Mean deathrate 1946-48 per 1,000 Change between 1931-33 and 1946-48 Mean deathrate 1946-48 per 1,000 Change between 1931-33 and 1946-48 Buccal cavity 0.111 decrease 33 per cent. 0.021 decrease 13 per cent. Respiratory system 0.709 increase 200 per cent. 0.123 increase 124 per cent. Digestive system 1.088 increase 16 per cent. 0.829 increase 19 per cent. Breast 0.363 increase 19 per cent. Genito-urinary organs 0.304 increase 44 per cent. 0.390 increase 3 per cent. All sites 2.36 increase 41 per cent. 1.84 increase 21 per cent. There has been a considerable improvement in the mortality from cancer of the buccal cavity especially in males. It is evident that the increase in respiratory cancer, however it may be exaggerated by improved diagnosis, overshadows all other changes for both sexes. The increase since 1931 in male mortality from cancer of the digestive system has been substantial, but in the last three years the death-rates for males per 1,000 have been 1.144, 1.063, 1.057; and the increase now appears to be halted. For females the death-rates have been 0.802, 0.818 and 0.868 and the increase is at present progressive. The increase in cancer of the genito-urinary organs in males has been large and can hardly be attributed to diagnostic advances. Deaths in the last four years have been 372, 441, 433 and 456. Road accidents Deaths from road accidents in 1948 amounted to 248. In the two previous years the numbers were 316 and 319. Road accidents regrettably still require mention as an important cause of death, to say nothing of the permanent invalidism resulting from a proportion of the non-fatal accidents, but the reduction in 1948 is encouraging. Infant mortality The infant mortality rate in 1948, 31 per 1,000 live births, constitutes a new low record, an improvement on the rate of 34 per 1,000 live births in 1947. The movements of the death-rates from the principal diseases at ages below one year since 1911 are shown in Table 7, page 119. The diagram on the next page illustrates the contraction in the fatality of infants since the years 1911-14. The increase in deaths assigned to congenital malformations and birth injury 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 and partly also to a tendency for post-mortem examination to be done more frequently resulting in increased precision in certification. For most diseases there has been a dramatic reduction in mortality over the last forty years, and, even since 1927, the improvement is substantial. The pronounced fall in the case-mortality of whooping-cough and measles has helped to bring down the infant mortality rate. Diarrhoea and respiratory infections too are now less frequently contracted, and methods of treatment are more effective. Increasing attention has been paid to the care of the premature infant, and there are signs that these efforts are having a salutary effect on the mortality risk. Deaths in various periods of the first year of life are shown in detail in Table 6, page 119. Deaths under 4 weeks numbered 1,067, or 17.5 per 1,000 live births, 11 INFANT MORTALITY MORTALITY PER 1,000 LIVE BIRTHS compared with a rate of 18.1 in 1947. Comparative rates for London and England and Wales in recent years are:— London England and Wales 1931-35 251 31.4 1936-40 22.9 29.0 1941 28.4 28.5 1942 24.7 27.0 1943 23.4 25.3 1944 231 24.5 1945 230 24.7 1946 22.2 24.2 1947 18.1 22.7 1948 17.5 19.8 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 12 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 has continued to fall. It is important, however, to remember that the reduction in infant mortality in the past fifty years as a result both of rising social standards and the energetic intervention of public health authorities has mainly been effective against the causes of death (principally infectious) which do not operate until after the first few weeks of life and that deaths within the first four weeks of life have not been reduced to the some extent. The following figures for London illustrate this point:— London : Deaths of Infants per 1,000 Live Births Under 4 weeks Between 4 weeks and one year 1906-10 37 77 1948 18 13 Percentage reduction 51 83 The reason for this is that while in the first weeks of life mortality from infection has been much reduced (as at later ages) there has remained an apparently intractable core of mortality from prematurity, congenital malformations and birth injury, i.e., conditions which represent a fatal handicap to the infant on entry into the world. The distribution of causes of death in the first four weeks of life in 1948 was as follows:— Cause No. of deaths % Total Prematurity 401 38 Birth injury 130 12 Congenita] malformations 153 14 Other diseases of early infancy 273 25 Broncho-pneumonia 50 5 Diarrhœa and Enteritis 7 1 All other causes 53 5 Total 1,067 100 Thus deaths from prematurity, birth injury and congenital malformation account for 64 per cent. of all neonatal deaths. Many prematurities could, no doubt, be prevented by greater attention to the general health of the mother and by improved ante-partum medical care; and where prevention fails and premature births do occur, many of the subsequent deaths are preventable by specialised treatment of the infant. In London, deaths in the first four weeks from prematurity per 1,000 live births fell from 16.1 in 1911 to 11.6 in 1938, a comparatively slow rate of progress but after a temporary rise due to war-time difficulties, the rate has been further reduced from 11.6 in 1944 to 6.6 in 1948, and this comparatively large advance is doubtless associated with the contemporary emphasis on the care of premature infants. Many birth injuries would not occur if specialised obstetrical assistance were more general. The average neonatal rate from this cause over the period 1936-40 was 2.20 per 1,000 live births and was still 2.13 in 1948. The average neonatal death rate from congenital malformation was 2.84 per 1,000 live births over the period 1936.40 and in 1948 the rate was 2.51. 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 2 and 9 and comparative figures for England and Wales in recent years are shown in Table 8, page 120 13 London: Year Live and still births Deaths Notifications Puerperal sepsis Other childbirth Puerperal pyrexia No. Rate No. Rate No. Rate 1947 72,877 23 0.32 47 0.64 441 6.05 1948 62,125 22 0.35 26 0.42 460 7.40 Rates per 1,000 total births. The maternal mortality rate (0.77) in 1948 was much lower than in 1947 (0.96) and constitutes a new low record. Neither the increase of 0.03 in the sepsis mortality nor the decrease of 0.22 in that from other childbirth since 1947 is statistically significant. In this connection it should be noted that owing to the small number of deaths compared with confinements the laws of chance applicable to small numbers operate. The analysis of maternal deaths for the two years into (i) post-abortion (ii) other, is as follows:— Cause of Death 1948 1947 Postabortion Other Total Postabortion Other Total No. Rate No. Rate No. Rale No. Rate No. Rate No. Rate Puerperal sepsis 14 0.22 8 0.13 22 0.35 14 0.20 9 0.12 23 0.32 " Other childbirth " 4 0.06 22 0.36 26 0.42 9 0.12 38 0.52 47 0.64 Total maternal deaths 18 0.28 30 0.49 48 0.77 23 0.32 47 0.64 70 0.96 It will be observed that while the mortality from septic abortion and other sepsis has slightly risen since the previous year that from other causes following abortion and childbirth has fallen by 50 per cent. and 30 per cent. respectively. This improvement in the non-sepsis rates can be ascribed to better midwifery and better co-operation from the patient. Puerperal fever is now no longer notifiable as such in the county of London as the term is covered by Puerperal pyrexia, thus bringing the county into line with the rest of the country. The trend of maternal death-rate in the administrative county of London from 1891 is shown by the figures in Table 3. It will be observed from the table that maternal mortality fell very slowly until the introduction of the sulphonamides, in 14 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 in 1941-45 would be an even smaller proportion of the total than is indicated by the table. In recent years puerperal sepsis has lost 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, though the risk of death from these causes has also been falling rapidly. The effect of war conditions in temporarily arresting the decline in maternal mortality in London is shown by the above 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 1948 and earlier years, and for the constituent metropolitan boroughs in 1948, are shown in Tables 2, 3 and 11. A comparison of the death-rates in London and England and Wales is given in Table 10, page 121. In order to preserve uniformity with national statistics the notification figures used in this section of the report have been corrected as far as possible to take account of changes of diagnosis made after the original notifications had been received. See footnote to Table 11. Anthrax One case of anthrax was notified during the year and it was confirmed bactenologically. The disease was contracted by a fur dresser and the infection was traced to two bales of hides from South Africa which were immediately destroyed. Cerebrospinalfever Prior to the war, the attack-rate tor cerebro -spinal lever had fluctuated, rarely falling below 0.02 per 1,000 and rarely exceeding 0.05 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 1948 was only 0.03 per 1,000 (110 cases). In 1948 the case-mortality was 33 per cent. Two-thirds of the cases are in infants under the age of five. Dysentery The dysentery notifications are not at present an indication of the trend of incidence of the disease. The notification figures show capricious movement from year to year. The 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 has become increasingly recognised. In London, the death-rates from dysentery since the beginning of the century have been as follow:— Mean annual death-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 1947 0.0033 1948 0.0009 Diphtheria It would appear that apart from increased incidence during the two wars, the real incidence of dysentery remained fairly stationary up to 1947. In 1948 there were however only three deaths compared with 11 in 1947. The campaign to encourage immunisation against diphtheria began in 1941 and the results have been very encouraging. The fall in the incidence of diphtheria since then has been far in excess of any downward fluctuation observed in the previous 50 years. In 1948 there were only 335 cases or 0.100 per 1,000 living, compared with a rate of 0.136 in 1947. The effects of the immunisation campaign are illustrated by 15 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. During 1948 the rates have continued their rapid decline although the degree of artificial immunisation at school ages having reached 75 per cent. has tended to become stabilised. There were 19 deaths from diphtheria in London in 1948. Detailed reports are available in 15 of these fatalities and in all cases they show that the victims had not been previously immunised. It cannot be too strongly emphasised that the maintenance of this good progress depends upon the co-operation of the public in increasing still further the rate of immunisation; great efforts must be made not only to ensure that there is no falling off in the existing proportion immunised but also to convince those parents who have not yet decided to come within the scheme that to leave their children unprotected is to invite the return of those tragedies which, only ten years ago, occurred with such appalling and needless frequency. The mortality from diarrhoea and enteritis under two years of age (164 deaths) amounted to 2.69 per thousand live births, compared with 4.47 in the previous year. 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 small but favourable to London, and that both rates are declining. Diarrhœa and enteritis b 16 DIARRHœA AND ENTERITIS 'MORTALITY PER 1,000 LIVE BIRTHS Enteric fevers Notification of fevers of the enteric group numbered 48, exactly the same as in 1947. There was only one death. Fifty years ago the mortality rate was 0.14 per 1,000 (600 deaths per annum, approximately). A large part of this reduction in the incidence of typhoid and the now too often forgotten conquest of the once-dreaded cholera is due to the improvement in water supplies. Prior to 1904 the water supply within the area of the London County Council was in the hands of eight water companies, the oldest of them dating from 1619. The first effective method of water purification by sand filtration (as opposed to the old ineffective method of settling in reservoirs) was applied by one company (Chelsea Company) in 1829. This lead was followed by all except three companies until 1852, when the Metropolis Water Act was passed making such filtration compulsory and also making it obligatory to cover all reservoirs within five miles of St. Paul's Cathedral (the approximate City centre). The studies of Dr. John Snow during the eighteen-fifties which demonstrated that cholera was spread by water and that its incidence varied directly with the degree of faecal contamination of the water, had a powerful effect upon informed opinion, and contributed to subsequent legislation. (See " Snow on Cholera a reprint of two papers by Dr. John Snow, M.D.—New York. Commonwealth Fund, 1936.) By 1856 all companies had moved their intakes from the influence of the tide (another provision of the Act) and were delivering filtered water. From 1856 onwards the story is of gradual but steadily progressive improvement. In 1871 the Board of Trade were given powers for water examination in London. These powers were transferred to the Local Government Board (predecessors of the Ministry of Health) in 1872. Routine bacteriological examination of the Metropolitan supply commenced in 1885. In 1904 the Metropolitan Water Board (a public authority) took over the supply of water from the private companies. The work of Sir Alexander Houston demonstrated that pre-filtration storage assisted the reduction in disease producing organisms. In 1923 more rapid filters were introduced to remove particulate matter before secondary filtration, but this increase in speed made it necessary to introduce chlorination. Chlorination was first employed in a well-supply in 1910, for river water before filtration in 1916, and for river-derived filtered water in 1921. In the last case taste difficulties were encountered, but these were overcome by the introduction of chloramine treatment at Kempton Park in 1929, and by 1936 all water passing into supply was treated by the ammonia-chlorine process. In 1921 water examination powers of the Ministry of Health were abolished and replaced by those of a Water Examination Department of the Water Board. To sum up, real progress began with the introduction of the slow sand filter and the removal of the intakes to points above Teddington Weir, and has proceeded steadily until, in 1948, 99.8 per cent. of all samples representing the water pumped into supply complied with the highest standard of bacterial purity. What was the parallel effect upon the incidence of disease ? In the early part of the 19th century outbreaks of cholera occurred in London at intervals of a few 17 years. In 1849 there were 14,137 deaths (cholera and diarrhoea together accounted for 26 per cent. of deaths from all causes in that year). In 1854 there were 10,738 cholera deaths. There is no evidence that the cases of cholera which occurred after the termination of the 1866 epidemic were attributable to the public water supply. The last case was notified in 1911 and the cases which occurred between 1866 and that date were probably due to minor outbreaks from ship-borne cases conveyed by means other than the public water supply. Enteric fever was conquered less rapidly but the reduction in incidence has been no less dramatic. In 1869 the Registrar-General distinguished enteric fever as a cause of death, although the distinction was, of course, on clinical grounds, since the specific organism was not discovered bacteriologically until 1880. The death rate for enteric fever in London in 1870 was 0.62 per 1,000. By 1889 when the London County Council was instituted, the rate had fallen to 0.12 per 1,000. Later figures are:— 1891-95 0.13 1926-30 0.008 1896-1900 0.14 1931-35 0.005 1901-05 0.084 1936.40 0.004 1906-10 0.045 1941-45 0.003 1911-15 0.028 1946 0.002 1916-20 0.016 1947 3 deaths 1921-25 0.011 1948 1 death A rising standard of personal cleanliness has also played an important part in this saving of lives. But for continual vigilance enteric fever might easily return as an important cause of death, and as has been illustrated by minor outbreaks in recent years, the public cannot afford to relax their efforts to maintain high standards of personal hygiene, and of care in the production and handling of food. I am indebted to the Water Examiner, Colonel E. F. W. Mackenzie, for much of the above information. There were 719 cases of erysipelas in 1948, giving an attack-rate of 0.215 per 1,000 compared with 0.224 in 1947. The incidence of this disease has been declining continuously since 1941. There were 3 deaths in 1948 (0.0009 per 1,000 living). Erysipelas There were 78 deaths (0.023 per thousand) from influenza during the year ; 1948 was an exceptionally light year for respiratory mortality generally. During recent years the deaths have been:— Year Influenza deaths 1940 569 1941 397 1942 198 1943 726 1944 206 1945 171 1946 371 1947 284 194.8 78 Influenza There has so far been no major outbreak of influenza since 1937. Measles became notifiable in London in 1938. For control purposes the results 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 11 that periodical epidemic outbreaks have occurred, but there is not yet any evidence that conditions have been stable sufficiently long to restore the biennial wave. Cases have been less frequent in recent years than before the war. This is partly a consequence of the reduction in the child population but there is evidence also of a significant fall in the overall incidence of the disease. A special study* has reached the conclusion that whereas before the war about 80 per cent, of children had a * Breen, G. E. and Benjamin, B.—• (Lancet, 1949 ii. 620). Measles 18 notifiable attack of measles before attaining age 15, the risk of attack before age 15 has now fallen to 60 per cent. An important feature is the reduction in the case-mortality in measles. The figures are:— 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 1931-35 208,000 1,912 0.92 1936-40 170,750 876 0.51 1941-45 84,925 170 0.20 1946 22,846 21 0.09 1947 17,486 23 0.13 1948 30,608 26 0.08 *Actual notifications from 1939. Most measles deaths are due partly to respiratory complications, and the more recent 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. A steady decrease in mortality was however in progress long before the more recent accelerated fall, but there is insufficient evidence as to whether this was due to increased resistance, or to reduced virulence of the disease. Ophthalmia neonatorum The incidence of ophthalmia neonatorum which, since 1921, remained fairly constant at between 8 and 10 new cases per 1,000 live births, began to fall slightly towards the end of the 1931-1940 decade and in recent years has fallen to below 5 new cases per 1,000 live births. There were 224 cases in 1948 (3.7 per 1,000 live births). The introduction of penicillin has had dramatic results in the treatment of this disease. Duration of treatment has been reduced from weeks to days and resulting blindness is almost unknown. There was no case of blindness resulting from ophthalmia neonatorum in 1948. Pneumonia Notified cases of pneumonia in 1948 numbered 1,891, or 0.566 per 1,000, compared with 0.638 per 1,000 in 1947. It will be seen from Table 11 that these rates are lower than either wartime or pre-war rates. There is no doubt that the development of many infections is now inhibited by the early administration of sulpha drugs or antibiotics. Poliomyelitis and polioencephalitis In 1948 the incidence ot poliomyelitis tell almost to the level experienced in the endemic conditions which preceded the epidemic of 1947. During the year, 141 cases occurred (corrected notifications). Research into the causation and behaviour of this iisease has been intensified and respites such as that of 1948 are to be welcomed as placing time on the side of the investigators. Puerperal pyrexia During 1948, 460 cases of puerperal pyrexia were reported, or 7.40 per 1,000 total births, compared with 6.05 in 1947. Rheumatic fever Deaths in London from rheumatic fever in 1948 numbered 30, of which 15 were among children under fifteen years of age. Corresponding figures in 1947 were 34 and 17 respectively. But to complete the picture it is necessary to consider also the deaths under 45 years assigned to heart disease, since apart from deaths due to congenital heart disease the vast majority of these deaths are rheumatic in origin. The following table shows the distribution of heart disease deaths under 45 according to age:— London Deaths from Heart Disease under 45 years 1948 1947 Age . 0-l 1-4 5-14 15-44 Total Age .0-1 1-4 5-14 15-44 Total M. - 1 4 195 200 M. - - 7 220 227 F. - - 5 143 148 F. 1 - 4 178 183 P. - 1 9 338 348 P. 1 - 11 398 410 19 It will be seen that there has been a slight reduction of juvenile deaths from heart disease ; there were 10 in 1948 compared with 12 in 1947. Scabies became notifiable in London in August, 1943. Notifications in 1948 numbered 2,484, compared with 5,304 in 1947. The effect of improved control resulting from notification is evident from the persistent decline in incidence shown by the figures in Table 11, facing page 122. Scabies The incidence of scarlet fever was slightly higher than in 1947—4,568 cases (1.37 per thousand), compared with 4,331 (1-31 per thousand). There were only two fatal cases in 1948. Fifty years ago the annual death roll in London amounted to over 1,000. Soarlet fever There was no notification of smallpox. No case of typhus fever occurred. In the immediate post-war years, a few infections were imported to this country from liberated concentration camps and war-wrecked areas of Europe. Four of these cases occurred in London. It is to be hoped that under more normal conditions London will again be free of this disease as it was for many years prior to 1945. Smallpox Typhus fever There were 10,450 notifications of whooping-cough during the year, compared with 9,267 in 1947. The death-rate was 0.016 per thousand (crude case-mortality 0.53 per cent.). Corresponding rates for 1947 were 0.025 per thousand and 0.89 per cent. It will be seen from Table 3 that the fatality from this disease is now less than a thirtieth of what it was fifty years ago. Whoopingcough The number of cases of infectious disease reported from schools in 1948 and other years are shown in Table 17, page 126. 1948 was a light year for German measles and ringworm. The downward trend of scabies is reflected in the school figures. There was also a fall in the incidence of impetigo. The incidence of scarlet fever, whooping-cough and chickenpox was not significantly different from that of 1947 but there were more cases of measles. Cases of mumps were numerous and the incidence greatly exceeded that of any recent year. Infectious disease in schools Detailed figures of new cases of tuberculosis notified in 1948 are shown in ' Tables 12 to 16, pages 122 to 125. Non-civilians are included in the statistics and total populations are used except where otherwise stated. The general trend of morbidity and mortality since 1921 is indicated by Table 12, p. 122, and is also illustrated by diagram, p. 20. The persistent decline in deaths and notifications during the inter-war years was substantial. New cases of pulmonary disease were reported at the rate of 2.1 per 1,000 living in 1920 and at only 1.3 per 1,000 in 1938, a fall of about 40 per cent. in just less than twenty years. In 1938 the death-rate from pulmonary disease was 0.64 per 1,000, i.e., about 40 per cent. lower than the 1920 rate of 1.04; a saving of some 1,600 deaths annually at the 1938 population level. In the early years of the war the upsetting of the balance between input and output of energy, the general deterioration in living conditions, the strain placed upon the population by bombardment and the increased opportunities for the spread of infection, all combined to reverse the trend of both morbidity and mortality and by 1941 the ground gained in the inter-war years had been lost. Mortality rates rose to a peak of 1.10 per 1,000 for pulmonary disease and 0.15 per 1,000 for non-pulmonary disease in 1941, but in so far as this rise was mainly due to the impact of the hard conditions of war upon existing advanced cases, it was shortlived, and the mortality quickly began to decline again as the war progressed. By 1946 the mortality rates had fallen below the pre-war levels and for the present at least they may be regarded as having reached the level to which they might have declined if the pre-war trend had not been interrupted. Tuberculosis Civilian death-rates per 1,000 living in 1948 in London and for the whole country were:— Pulmonary Non-pulmonary London 0.569 0.061 England and Wales 0.440 0.067 20 With regard to morbidity the rate of occurrence of new cases of pulmonary tuberculosis rose by nearly 50 per cent. between 1938 and 1941 and remained at the higher level until the end of the war, when it began to decline, at first quite rapidly However, the rate has since 1946 risen very slightly and it appears that the decline has ceased. The morbidity level for pulmonary cases is at present still more than 20 per cent. higher than it was immediately before the war. It must, however, be remembered that morbidity rates are related to the zeal with which new cases are sought and new methods such as mass miniature radiography now discover early cases which formerly would have recovered without notification or would not have been notified until the disease was more advanced. The war-time increase in morbidity from non-pulmonary tuberculosis was less severe than for the pulmonary form and the rates have fallen below the pre-war level; here also, however, the 1947 rate was not lower than that for 1946, and though the 1948 figure indicates a slight fall there is a hesitancy about the decline. Evidently the immediate benefit of the return to peace conditions has ceased to operate and further improvement will not be easily attained. Dr. Stallybrass has surveyed the problem (British Medical Journal, 1949, i. 207) and has stressed the fact that the standard of living which is a major factor can only be expected to rise slowly, that sanatoria waiting lists are far too high and segregation correspondingly insufficient, and that the control of contacts needs to be improved. 21 The age distribution of new cases of tuberculosis is shown in Tables 13 (a) and (b). Unfortunately the available population estimates permit the calculation of rates only for the two broad groups, under age 15 and above that age. For pulmonary disease the adult rate which had been stable, has risen by 4 per cent., but the rise in the juvenile rate experienced in 1947 has not progressed. The rates per 1,000 for the 0-14 group in recent years have been as follow (numbers of cases in brackets):— 1943 0.85 (392) 1944 0.85 (401) 1945 0.83 (415) 1946 0.94 (548) 1947 1.04 (607) 1948 1.01 (633) Both relatively and absolutely the incidence of pulmonary tuberculosis in children which took a disturbing upward turn in 1946-47 is still much higher than in 1943-45. The non-pulmonary cases have been analysed according to the site of the lesion in Table 15. The following information has been supplied by the Ministry of Health. There were 34 outbreaks of food poisoning within the county of London reported to the Ministry of Health by the medical officers of the metropolitan boroughs, the number of cases being 192. In 19 of the outbreaks infection in food was bacteriologically confirmed. Food poisoning GENERAL PUBLIC HEALTH Housing The following table shows the number of houses and flats erected or brought into commission by repairs during 1948:— In London Outside London Area Total By L.C.C. 4,400 3,868 8,268 By borough councils 3,301 - 3,301 Total 7,701 3,868 11,569 The total number of houses or flats owned by the Council at 31st March, 1948, was 102,060 of which 52,029 are situated in London and 50,031 outside the London area. Overcrowding remains a serious health problem and many of the applicants for rehousing on the Council's estates submit medical evidence of ill-health attributed to or aggravated by unsatisfactory housing conditions. There was again a considerable increase in the number of these applications referred to the public health department for consideration on health grounds which totalled 19,903 in the year compared with 13,662 in 1947. These figures and the percentages shown in the table below are exclusive of the number of recommendations made for priority on the grounds of active pulmonary tuberculosis. A large amount of work is entailed in investigating these claims and it is necessary to consult the medical officers of health of the metropolitan boroughs and out-county authorities regarding the accommodation occupied by many of the applicants. The valuable help given by them is gratefully acknowledged. As a matter of interest an analysis was made on several occasions of 1,000 consecutive applications and note was taken of the various ailments from which the applicants or members of their families were considered to be suffering. The results Rehousing on medical grounds 22 of classification of one such group of 1,000 applications into various headings and the proportional frequency of diseases under these headings is as follows:— Respiratory Tract (other than pulmonary T.B.) 30.5 Organic nervous diseases 2.4 Functional nervous diseases 18.9 Cardiovascular 16.5 Alimentary tract 6.8 Rheumatic manifestations 6.6 Bones and joints 5.5 Pregnancy 3.1 Genito-urinary 2.6 Skins 2.2 Metabolic disorders 2-0 T.B. (non-infectious) 2.0 Special senses 0.9 100.0% In one group of 3,000 applications, 7% were classified as "most urgent" and these, with a further less urgent 34%, were recommended to the Director of Housing for preference in allotting accommodation. It was decided after careful consideration that in the remaining 59% the degree of medical urgency disclosed by the doctors' certificates did not warrant additional preference for housing purposes. These proportions apply, of course, only to the particular group analysed. Clearance areas Representations under the Housing Act, 1936, were submitted by the Medical Officer of Health to the Housing Committee in respect of four areas involving 60 unfit houses. In addition, notifications under Section 33 of the Housing Act, 1936 of intention to deal with certain houses as clearance areas were received from metropolitan borough councils, in respect of four areas comprising 42 houses. Surveys were continued in connection with the classification of houses contained within the Stepney and Poplar Reconstruction Area and 372 investigations were made into the condition of other properties considered for acquisition by the Council. Some 4,530 searches were made in connection with enquiries concerning properties scheduled as " dangerous structures." Tuberculous milk The sampling for biological examination of milk coming into London in churns by road and rail was resumed on 1st April, 1948, after an interval of six months due to failure of the supply of suitable guinea pigs. During the remaining nine months 757 samples were taken including 18 from hospital farms for some of which sampling was continued after their transfer to the regional hospital boards. The following are details of the sampling and the results of examinations :— Source of sample Designation Samples Percentage positive of completed samples Total Positive Incomplete Negative 1948 1947 (a) Supplied to London by road and rail in churns Ordinary 675 28 65 582 4.6 2.8 Accredited 25 2 - 23 - - Tuberculin tested 23 - 2 21 - - (b) Plant at London depots Pasteurised 16 - 2 14 - - (c) Hospital farms Ordinary 2 - - 2 - - Tuberculin tested 16 - 2 14 - - Total 757 30 71 656 4.4 21 * The number of samples (25) is so few that a percentage could not be regarded as reliable. 23 Investigations by officers of the Ministry of Agriculture into the origin of the positive samples disclosed the presence of infection in 22 herds. As a result 21 cows were slaughtered under the provisions of the Tuberculosis Order, 1938, and infection was also traced to five other cows which had been removed from herds subsequent to sampling. Sanitary inspection Reports of 312 instances of infestation were received from various establishments controlled by the Council, e.g., restaurants, schools, rest centres, parks. Infestations by rats, mice, cockroaches, bugs, ants, flies, etc., were dealt with and 280 disinfestations were satisfactorily completed. Disinfestation More than 2,200 visits of inspection were made to Civic restaurants, kitchens and school meals centres. These visits were made to 552 centres in connection with maintenance, sanitary accommodation and food. Restaurants and catering Regular inspections, at least once a quarter, were made of 64 homes, hostels, rest centres and other premises in connection with sanitary conditions. A large number of letters of complaint of and visits about insanitary home conditions were received from the public. These were dealt with by representation to local sanitary inspectors or by reference to borough medical officers of health or by other appropriate means. Welfare establishments Complaints Blind and partially sighted persons The National Assistance Act, 1948, repealed the Blind Persons Acts and imposed duties on the Council regarding the registration and welfare of blind persons which include the certification of blindness for the purposes of the Act. The welfare services which the Council is empowered, under the Act, to provide for blind persons extend also to partially sighted persons who, though not blind within the definition of the Act are, nevertheless, substantially and permanently handicapped by congenially defective vision or who have defective vision of a substantial and permanently handicapping character caused by illness or injury. Such persons are included in an "Observation Register." No modification has been necessary in the Council's arrangements for the examination of persons for certification of blindness and the results of the examinations 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 213 329 542 67 120 187 729 Previously blind, still blind 27 30 57 - - - 57 Previously not blind, now certified 11 19 30 - - - 30 Previously not blind, still not blind - - - 25 36 61 61 Previously blind, now not blind - - - 3 3 6 6 Total 251 378 629 95 159 254 883 Persons examined as to suitability for training Suitable Not suitable Grand total Male Female Total Male Female Total 19 5 24 1 3 4 28 24 In addition, 147 certificates were accepted from other authorities, hospitals and private ophthalmologists as follows:— Blind persons 145 (65 male, 80 female) Not blind persons 2 (male) The number of partially sighted persons, excluding children, recommended for inclusion in the Observation Register was 116 (41 male, 75 female). Registration of nursing homes At the end of the year 62 nursing homes on the register were functioning compared with 63 registered homes open at the end of 1947. Four new registrations of homes took place and 5 homes were closed during the year. Thirty exemptions from the operation of Part XI of the Public Health (London) Act, 1936 were granted. The general standard was reasonably maintained. Chemical branch The work of the branch was carried on during the year at the three laboratories, at County Hall and the Northern and Southern Outfall works, and Mr. C. J. Regan, the Chemist-in-Chief, has submitted the following report The age in which we live has been called the "Scientific Age" and research in every branch of science has advanced in recent years in a kind of geometrical progression. The creative science of chemistry, like the creative arts, calls for the constant cultivation and exercise of the imagination and the increasing need for this in the chemical service of the London County Council has been made evident by the constantly widening range of the problems put to it by many departments. The amount of consultative, advisory and committee duties continued to increase in 1948 as did also the ordinary analytical and testing work. Much of the first type did not entail the actual examination of samples the list of which for 1948 is shown below. The total number examined was 21,400, compared with 20,498 in 1947. Air of tunnels, etc. 288 Metals 41 Bacteriological, miscellaneous 26 Milk, liquid, condensed, dried 290 Building materials 213 Miscellaneous 159 Chemicals, drugs and medical supplies 165 Oils, lubricating, fuel, etc. 80 Paints, varnishes and distempers 1,171 Clays and sub-soils, etc. 220 Petroleum and allied samples 144 Compost (manurial use), etc. 26 Rain water (atmospheric pollution) 84 Detergents 25 Rubber and substitutes 7 Disinfectants 7 Sewage and effluent 3,254 Explosives, fireworks, etc. 36 Sludge, primary and digested 1,968 Fertilisers and Feeding Stuffs 121 Sludge, activated 1,277 Floor oils and polishes 21 Sulphur gases and smoke in air 1,790 Fuel (coal and coke) 40 Water, steam raising plants 1,932 Foods, etc— 478 Water, drinking 2,169 Gases, dry cleaners, flue, etc. 94 Water, river 3,379 Gases, sludge digestion plant 285 Water, swimming bath 656 Insecticides 12 Water, miscellaneous 52 Lamps, gas detector 344 Liquor, effluent from gas works 359 Total 21,400 Meals and vitamin assays 187 The following paragraphs give a general indication of the source of origin of these samples and of the consultative and advisory duties carried out for the various services. The work done has been sectionalised in this way as far as possible but in several instances the same type of work was performed for several departments, so that, for example, the paragraph on steam raising, etc., plants had to be included under this general heading. Housing Another considerable increase occurred in 1948 in the amount of work done for this service, particularly in regard to paints and other protective coatings. The 25 reasons for this are probably three-fold, for in the first place, the supply of these materials has now increased to such an extent that it can meet the demand and competition is again developing; secondly, new and allegedly improved materials are frequently being produced, the claims for which must be investigated; and thirdly, it must be remembered that from the economic aspect, if a paint fails in use, it is not only the cost of the material which is lost but also the cost of the labour of application which may be about five or six times that of the paint itself. Many samples of paint were reported as being unsatisfactory, some of the reasons being, for example, (a) the inclusion of white lead and lithopone in the same pigment, (b) the use of lithopone in a paint supplied for exterior work, (c) the lack of adhesion and/or flexibility of the film produced, (d) gritty nature of the finish produced. In a number of cases of paint failures, the work was inspected and the cause of the failure diagnosed after the subsequent examination of samples in the laboratory. Only a few of the other matters dealt with in connection with housing can be listed shortly, e.g. (a) the decay of wood flooring due to worm attack which started long before the subsequent growth of dry rot fungus; (6) examination of new types of wood preservatives ; (c) devising of an impact test for determining the strength of asbestos composition panels ; (d) investigations as to the failures of plasters; (e) the possible corrosion of Portland cement concretes by sulphates in soil or ground waters, and the alternative use of high alumina cement where necessary. Amongst the other building materials examined may be mentioned Portland and high alumina cements, bricks, mortars, asphalts and asphalt road surfacing, clinkers, synthetic building blocks, tiles, synthetic flooring and roofing materials, putty, waterproofers, etc. The sewage from London north of the River Thames is treated at the Northern Outfall Works, Beckton, by sedimentation, and about one-third of the flow, subsequently, by the activated sludge process. That from London south of the Thames is subjected at the Southern Outfall Works, Crossness, to sedimentation only. In both cases most of the sedimented matter (sludge) is taken out into the estuary in ships and dumped ; the effluent is discharged into the river at the outfalls. Work on the composting of sewage products with pulverised household refuse was continued in 1948 and large quantities of such compost were made from sludge screenings. The sludge digestion plant at the Northern Outfall Works dealt with a small proportion of the sludge, and the sludge gas produced (containing about 70% methane) was used for power production. The final effluents from the Outfall Works are discharged into the River Thames and biochemical oxidation by the dissolved oxygen in the water is the final process in their purification. The condition of the water of the river is therefore of great importance and a careful watch is kept upon it by regular weekly sampling and analysis at many points between Teddington Weir and the sludge dumping area in the estuary. The laboratories at the two outfall works carried out the chemical analyses necessary for the control of the various plants during the year : some research work was also done on several aspects of the sewage disposal problem and as the result of some of this a provisional patent was taken out by the Council at the end of the year for a new process for dewatering sludge. The question of trade discharges into sewers was investigated in a number of cases as to compliance with the appropriate clauses of the Public Health (London) Act, 1936. In view of the decision of the Council in 1947 to construct extensive additions to the existing sewage treatment plants the Chemist-in-Chief, with the Divisional Engineer (Main Drainage), Chief Engineer's Department, visited the United States of America in the early summer of 1948 to study the latest practice in regard to sewage disposal in that country. The visit was facilitated by the generosity of the Rockfeller Foundation which made a travel grant for the purpose, and the United States Public Health Service was also very helpful in making arrangements for the Main drainage 26 itinerary. Many of the largest sewage treatment works were visited as were also research institutions, and much extremely useful information was obtained which will be valuable both from the cost and efficiency aspects in the detailed planning of the new works. The preconceived ideas on the main design were however not fundamentally altered. Public Health Regular chemical analyses and bacteriological examinations were made of the drinking waters derived from private wells at various Council premises and at hospitals both before and, by arrangement with the Committees concerned, after the handing over to the Regional Boards. All these water supplies are chlorinated before use and the dosage was periodically checked. 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 places outside the County. This work was done in conjunction with a scheme sponsored by the Department of Scientific and Industrial Research, and the Chemist-in-Chief continued to be a member of the Atmospheric Pollution Research Committee of this department. The air in the Council's vehicular tunnels was regularly examined in order to ensure that the carbon monoxide content did not exceed the safety limit; in view of the continued use of petrol containing lead compounds the lead content of the air was also checked occasionally and was found to be safe. The cause of onset of cases of dermatitis was examined in some instances and the use of " barrier creams " was considered from the theoretical aspect of their formulae and protective action. In one instance the possible causative agents were narrowed down to typewriter ribbons and ink with which the hands were liable to come into contact. The ink was found to contain arsenic and a doubtful type of dye from the dermatitic aspect. The question of fluorine and teeth was kept under review, for an excessive ingestion of this element causes mottled teeth whereas a deficiency is now considered to assist the onset of dental caries. Water supply is an important source of fluorine and largely on the basis of work done in America, it has been postulated that a supply containing about 1 part per million is the optimum; London water derived from the river Thames and Kent wells contains less than 0.2 parts per million though that from some wells north of London contains about 0.6 parts per million. School and other meals The work done in co-operation with the Restaurants and Catering Department was continued and many meals were analysed as to their nutritional value by the determination of their fat, protein, carbohydrate and mineral contents, and of their calorific value. Attention was also given to the ascorbic acid (Vitamin C) content. Having regard to the continued difficulty in the supply position the results showed a reasonably good approach to the targets aimed at for the nutritional factors for the various age groups concerned. Some "sandwich meals" were also examined, these being a useful occasional alternative to the full meals: these meals were of a reasonably good standard nutritionally. Plastic plates suggested for use in lieu of china ones in short supply were examined and their defects were pointed out. Public Control Samples taken under the Fertilisers and Feeding Stuffs Act, 1926 (under which the Chemist-in-Chief is the Official Agricultural Analyst for the County) were examined as to whether they complied with the statutory statement of ingredients which is required to be given with every sale and also (in the case of feeding stuffs) as to their freedom from deleterious substances. A considerable number were reported upon adversely ; for example, samples of both rice meal and barley meal were adulterated with considerable proportions of chalk. Many samples were also examined under the Petroleum (Consolidation) Act, 1928, the London Building Act, (1930) and the Explosive Acts. Those under the last-mentioned were mainly of indoor fireworks ; they were mostly of the "sparkler" type, and were found to be made of mixtures of barium nitrate, iron filings, aluminium powder and gum and to be scheduled in the list of Authorised Explosives, Class 7, Division 2. In view of the possible imposition of regulations, the atmosphere in many garages was examined to test the ventilation 27 and ascertain the carbon monoxide content. Many samples of bread were analysed under the Bread (Control and Maximum Prices) Order, 1947, to determine whether the short weight supplied was due to the bread being either "fancy bread" or "protein fortified." In cases where this was not so, legal proceedings were attended by an officer of the Chemical Branch to support the certificate given. Premises of firms of dry cleaners working under licence were visited periodically and samples of the atmosphere in the machines were taken for subsequent analysis to ensure that the safety regulations regarding the limitations of inflammable gases, derived from volatile solvents, were being duly observed. Chemical analyses and bacteriological examinations of the water of swimming baths were made and the chlorine dosage being applied for sterilisation purposes was checked, recommendations for any necessary alteration of procedure being made as required. During the bathing season all water used in the Council's public swimming baths is chemically treated, filtered and chlorinated, and, at the majority of the baths, the so-called " breakpoint " system of chlorination is used. This consists of adding a relatively large dose of chlorine which rapidly destroys the polluting nitrogenous compounds : the excess of chlorine above the breakpoint is less likely to cause inconvenience to bathers than smaller doses well below it. Plants capable of such dosage are moreover more flexible and can be adjusted to deal with sudden heavy loading in hot weather. The water of natural ponds used for bathing was also tested and many samples of soil were analysed as to their content of plant nutrient substances. Parks The materials examined for this service cover a very wide field and include a number actually dealt with for some of the other services mentioned above : for example, certain paints, and also foodstuffs used by the Restaurants and Catering Department. Foods of all types, in fact, form a considerable proportion of the work under this heading and they were examined (a) as tendered samples to ascertain which offer gave the best value for money, (b) from bulk supplies to ensure that these were to the standard of the tendered sample and (c) any complaints from consumer services. Generally a high standard of quality was maintained with but few complaints. Some of the materials offered for tender were, however, not satisfactory, certain ice creams for example, being very low in fat content even down to 0.5 per cent. in one case. Particular watch was kept on the question of the use of petroleum in foodstuffs, but in only one case (the material was not accepted for use) was it present in quantity. Canned foods were carefully watched particularly in regard to the corrosion of the containers and the tin (metal salt) content of the food. Many samples of liquid milk were examined and also dried milk, the latter particularly in regard to the acid value and the possibility of curdling dishes in the preparation of which it may be used. Chemicals, drugs and medical supplies of various types were submitted for analysis and report, and also lubricating and other oils, and floor and tile polishes. Many of these were to L.C.C. specifications and the need for keeping these up-to-date, having regard to recent scientific advances and the improvement in the supply position, was constantly borne in mind. In this connection it should be added that the use of the modern insecticides D.D.T. and Gammexane in suitable formulations for the different purposes continued with satisfactory results. The development of synthetic detergents was carefully watched and the use of one type (which previous experimental trials had proved to be the most satisfactory) was continued on a large scale for hand washing up : the newly developed production of these as spray dried powders has some advantages. An investigation was made on anti-freeze solutions for motor car engine radiators with particular reference to the prevention of corrosion : the use of sodium benzoate as an inhibitor was recommended. Disinfectants were examined as to their germicidal value. Supplies Swimming bath waters and drinking water supplies at residential schools were examined and the work on school meals already described was done indirectly for this service. Modelling plastics suggested for use in schools were analysed: one was Education 28 reported against as containing castor oil and another for containing a synthetic dye which might possibly give rise to dermatitis. Instructional visits to the Headquarters laboratories by school and student parties should also be mentioned, and also a demonstration of glass blowing given at a school by an officer of the Chemical Branch. Steam raising, heating, etc., plants Much consultative and advisory work was done involving examinations in situ and subsequent analysis of samples in the laboratory regarding scale formation, scale removal and corrosion problems. The use of sodium hexa-meta-phosphate for scale prevention and of soda ash and quebracho or full phosphate conditioning for boiler water was considerably extended. The dosages were controlled by periodical analysis of the water concerned. Examples of special cases dealt with were:—(a) corrosion found to be due to copper pipes and galvanised pipes being included in the same system with water of high carbon dioxide content: (6) corrosion of a heating boiler on the furnace side of the castings due to the effect of hot gases containing oxygen from the injection air blast, sulphur gases and volatile chlorides from the fuel, and erosion by particles of fuel and ash. Miscellaneous Many other matters were dealt with of which may be mentioned: (a) testing of spiralarm safety lamps for use in sewers, etc.: (6) advice as to the disinfesting agent and apparatus most suitable for use in an installation to be constructed at a museum : (c) examination of a number of pathological samples for arsenic, lead, methyl and isopropyl alcohol, hyoscine: (d) investigation of the cause of a works explosion involving acetylene: (e) devising a chemical method of erasing lines from plans in which areas were to be redrawn: (/) it was alleged that orangeade powder caused children to have dyed and bleeding tongues followed by sickness. The material consisted of sugar, citric acid, dye and flavouring: it was satisfactory if properly used but the children had eaten the power instead of drinking a solution : the sharp crystals had cut the skin, the dye had stained the flesh and the large quantity of acid consumed had deranged the stomach: (g) an "electrode heater" was tested under bench conditions and it was demonstrated that, owing to risk of electric shock, it was not suitable for use in schools. At the ceremonial reception by the Council of the members of the Port of London Authority on 3rd May, 1948, the morning was devoted to a tour of the Headquarters chemical laboratories when a description and demonstration of the work done by the Chemical Branch was given. Attention was paid to the development of new analytical methods and close liaison was maint ained with many Research Associations, branches of the Department of Scientific and Industrial Research, etc. The library of the Chemical branch continued to develop, and is an essential part of its equipment. The Chemist-in-Chief served on three committees of the Ministry of Health, three of the Department of Scientific and Industrial Research and three of the British Standards Institution. The Chemist-in-Chief, and the Deputy Chemist (Dr. S. G. Burgess) were two members of a team of five Council officers which presented a paper to the Royal Sanitary Institute on "Hygiene of the Preparation, Storage and Distribution of Food": a paper by the Deputy Chemist on "Soaps and other detergents" was also published during the year. HEALTH CENTRES As soon as it was known that the Council would become responsible for the maternity and child welfare services under the National Health Service Act, 1946, a detailed survey was commenced of the premises which would be transferred to the Council. Although some metropolitan borough councils had built specially designed maternity and child welfare centres before the war, further developments of this nature had ceased in 1939. It became apparent that one of the major tasks confronting the Council in discharging its duties under the Act would be the provision 29 of adequate premises, even without the added responsibilities of providing the health centres which were intended to be a key feature of the National Health Service. Few of the buildings transferred to the Council on the "appointed day" were freehold premises or even held on long leases, and the premises were mainly improvised. An additional difficulty that had to be faced was that many of the specially designed centres served functions that became the responsibility of the Council on the one hand and the Regional Hospital Boards on the other, while in a few instances the Borough Council still retained a residual interest in the buildings. These buildings became subject to "apportionment" between the various claimants, and negotiations to solve the complex questions involved in their future ownership and administration were still proceeding at the end of the year. The physical basis of the day nursery service proved to be even more insecure than the maternity and child welfare branches of the service. The majority of the day nurseries had been set up in haste during the war in requisitioned buildings or in prefabricated buildings erected on various sites, many of which were earmarked for other services such as housing and education. As programmes for these services gathered momentum the sites on which a number of the day nurseries were situated were required to be released for permanent development. The difficulties involved in continuing the service with the premises which were transferred to the Council are illustrated by the following table in which the high proportion of rented premises (short-term tenancies) and requisitioned premises will be noted: Analysis of the Tenure of Premises Transferred to the Council from the Metropolitan Borough Councils on 5th July, 1948 Maternity and child welfare centres Day nurseries Freehold 34 8 Leasehold 15 13 Rented 103 35 Requisitioned 5 54 In joint use with Regional Hospital Boards and Metropolitan Borough Councils 46 9 An analysis of the distribution of the premises transferred to the Council showed that certain areas would not be adequately served either by maternity and child welfare centres or day nurseries, and the Council expressed in its proposals to the Minister of Health under Section 22 of the Act, the intention to erect within the first few years of the National Health Service fourteen maternity and child welfare centres and thirty-five day nurseries. Of the thirty-five day nurseries proposed, no fewer than twenty-seven were required to replace existing ones which would have to be removed from their nresent sites. Short-term plan Adequate maintenance of buildings had not been possible during the war, some had suffered war damage and arrears of maintenance had not been made good in all cases before the "appointed day." A comprehensive survey was made, which included the Council's school treatment centres which were in a similar state, and schedules of cleaning and painting, repairs and minor improvements were drawn up. Provision has been made in the estimates for 1949/50 for the following expenditure to be incurred to carry out the major portion of this rehabilitation programme:— £ Maternity and child welfare centres 36,060 Day nurseries 45,870 School treatment centres 24,650 £106,580 Repairs and redecorations 30 Long-term plan The above measures were designed as a short-term plan to meet the immediate improvements possible in the circumstances, and to take steps to continue the existing services. In order to place the services on a firm basis in properly designed buildings, it was apparent that a radical replanning both of the location of the centres and the type of building required would be necessary, but that, in view of the magnitude of the task, its implementation would take many years even when limitations on the use of labour and materials were removed. It was decided that the health centres to be provided in London should be comprehensive and should include, and replace where unsatisfactory, both the maternity and child welfare centres and the school treatment centres. The opportunity was also presented of resiting the centres in future in accordance with probable needs and housing developments. A plan was accordingly drawn up in outline to divide the County into 162 health service areas formed by grouping together proposed neighbourhood units in the development plan being prepared under the Town and Country Planning Act, 1947. It is intended that ultimately each health service area should contain a population of approximately 20,000 and be served by a comprehensive health centre and, in some areas, by sub-centres as well. Work on this long-term plan is continuing in more detail, keeping it in step with Town Planning developments. First health centres As the provision of 162 health centres will take many years, they will have to be provided in instalments. Under the "proposals" provision was made for one specially designed health centre at Woodberry Down, Stoke Newington, nine health centres (one in each division) by the acquisition and conversion of existing buildings and, as a transitional stage in the provision of health centres, the acquisition and conversion of a number of premises for group practice by general practitioners. By the end of the year the final plans had been prepared for the comprehensive health centre at Woodberry Down and the approval of the Ministry of Health to the plans was awaited. Work on the centre commenced in March. 1949. Divisional Committees CARE OF MOTHERS AND YOUNG CHILDREN Administration As envisaged in the "proposals" submitted to the Minister of Health, the dayto-day administration of the services for which the Council is responsible under Section 22 of the National Health Service Act, has been delegated to nine Divisional Health Committees. The members of these Committees are appointed partly by the Council's Health Committee and partly by the Councils of the metropolitan boroughs comprising the division. Provision is made for co-option of representatives of local organisations concerned in the preservation of health including a doctor, a dentist, and a nurse or midwife or pharmacist. Periodical reports are submitted to the Health Committee. Medical Staff The Council's divisional health organisation commenced operation on 5th July, 1948, with a medical officer of high standing (designated "divisional medical officer") as the senior administrative officer in charge of each of the nine divisions. Divisional medical officers are responsible for co-ordination of all the personal health services in a division, although not all these services were operated on a local basis as from the appointed day. The transfer of medical staff from the Borough Councils and the recruitment of additional staff has proceeded smoothly, and, as far as possible, there has been specialisation (i.e., ante- and post-natal or infant welfare work). Enquiries of the Boards of Governors of the teaching hospitals showed that for various reasons not all of them were able to co-operate in the initial stages of the plan under which medical staff employed by the Council might obtain experience in the maternity or paediatric departments of the hospitals, and hospital medical staff should similarly 31 obtain experience in the Council's maternity and child welfare centres. It will be realised that this plan is essentially long-term. It has, however, been possible to arrange for teaching hospital staff to conduct certain sessions at centres and to grant facilities for students to attend. Extensions of these arrangements will be made as opportunities arise. No obstetric or paediatric consultants have yet been directly appointed by the Council to work in the maternity and child welfare centres, but, as a preliminary measure, all the Council's ante-natal centres have been linked with suitably placed hospitals willing to provide the services of consultants. Any expectant mother needing specialist advice is thus able to obtain it with the minimum of delay and inconvenience. A similar scheme for obtaining the services of consultant paediatricians is being considered. The Regional Hospital Boards, in conjunction with the Boards of Governors of Teaching Hospitals, are preparing lists of consulting specialists who will visit the home at a doctor's request. Notification of births and deaths of children under five years of age These were new functions for the Council, taken over from the metropolitan borough councils. Particulars are received of all births in the County area both in the home and in institutions. Under Section 255 of the Public Health (London) Act, births are notifiable within thirty-six hours by the father or any other person who was in attendance on the mother at, or within six hours of, the birth. The Council is also under obligation (a) to supply on request a form of notification to all doctors and midwives, and (6) to allow the registrar of births and deaths to have access to notifications received. In practice divisional medical officers and the local registrars exchange particulars of births which they have received. By this mutual check each is able to prepare the most complete and accurate list available for his area. There is no direct notification of deaths of children under five years of age to the divisional medical officer, but he receives from the local registrars details of all such deaths, which have been registered in the division. Under authority which goes back to the Births and Deaths Registration Act, 1874, payment is made by the Council to the registrars for each entry of births or deaths supplied. A comprehensive system for transferring information between divisions and with other health authorities has been established. Transfer of information Expansion of Services All the services provided by the Borough Councils, except those which became the responsibility of Hospital Boards or the Executive Council, have been continued since 5th July, 1948, and in some instances there has been reorganisation with the object of making the best use of available staff without detriment to the public. For example, the increase in the number of domiciliary midwives' booking and antenatal examination sessions (see page 38), has helped to free medical staff and health visitors for duties in other centres or in other spheres of action covered by their enlarged responsibility. This is a matter of considerable importance in view of the shortage of trained staff. Joint arrangements with other local health authorities Negotiations have been opened with the Kent County Council and with the County Borough Councils of East Ham and West Ham for the provision of maternity and child welfare facilities in centres which serve conveniently an area partly under the Council and partly under one of the other authorities concerned. Other neighbouring authorities will be approached if need arises for London residents to attend out-county centres and the Council will continue to co-operate on a basis of mutual assistance with any authority requesting help of this nature. O 32 Providing Maternity and Child Welfare Clinics Voluntary organisations Agreements have been made for the period ending 31st March, 1950, between the Council and twenty voluntary bodies who provide maternity and child welfare services and who were grant-aided by the metropolitan borough councils. The centres continue to function under the management of the voluntary bodies concerned, and the Council makes a substantial grant towards the expenses. The Council is represented on the voluntary committees, and has powers of inspection of the premises. The Council has also made a grant to a similar body which operates in two of its health divisions and which was not grant-aided by any of the metropolitan borough councils. Four voluntary bodies (including the Royal College of St. Katherine by the Tower, which operated three maternity and child welfare centres), intimated to the Council that they did not wish, or were unable, to continue to provide the facilities and the Council assumed responsibility for the administration of the centres and the employment of the staff. The equipment was purchased at an agreed figure. Providing Day Nurseries and Creches Similar agreements have been made with six voluntary bodies who provide day nursery facilities, and were grant-aided by the metropolitan borough councils. St. Vincent's Day Nursery in St. Marylebone, which was formerly grant-aided, is continuing to operate independently of financial support from public funds, as is the Goodwill Centre in Shoreditch. One voluntary body intimated to the Council that it did not wish to continue to provide facilities and the Council assumed responsibility for the administration of the nursery and the employment of the staff. The equipment was purchased at an agreed figure. Under the provisions of the Nurseries and Child Minders Regulation Act, 1948, which came into force as from 30th July, 1948, the Council is required to register all premises (other than those used mainly as private dwellings) where children are received to be cared for during a substantial part of the day, that is, premises used as private day nurseries. Eight of these premises had been registered by 31st December, 1948. Before premises are registered, the Council must be satisfied that they are in every way suitable and that there are satisfactory arrangements for the care of the children. The Council has the right of inspection of registered premises at any time to ensure that there is no departure from the approved standard. Providing In-Patient Treatment Two voluntary organisations provide special in-patient treatment for mothers and babies experiencing breast-feeding difficulties and for babies with dietetic upsets, and arrangements have been made for these facilities to be available to persons recommended for the treatment by the Council's divisional medical officers. The Council assists the organisations financially, and patients are required to pay for board at the rate of £1 Is. a week for adults and 7s. a week for children over the age of six months. Younger children are admitted free of charge. Other Grants Up to 4th July, 1948, grants were paid under the Local Government Act, 1929, to six maternity hospitals, eight district midwifery practices and the Central Council for District Nursing in London. The grants formerly paid to district nursing associations and certain mother and baby homes and baby homes under circular 32/44 of the Ministry of Health towards the cost of applying the " Rushcliffe " salaries for nurses and midwives ceased on 4th July, 1948. The loss of grant under this head will be taken into account by the Council in aiding the associations and homes under the National Health Service Act. Clinics All facilities in existence at 5th July, 1948, have been continued and, where possible, improved. Modification of areas served by various centres will be made as and when found to be necessary, and a beginning has been made in adjustment of areas served by hospital centres. The augmentation of services where they were deficient is dependent on many factors, not least of which is the provision of the 33 necessary staff. Staff shortage has been particularly marked among health visitors. Comments on the provision of suitable premises for these clinics will be found on page 28. Care of premature infants Special attention has been, and is being, given to the care of the premature infant. Doctors and midwives have been asked to record on the notification of birth form the weight of any infant which weighs 5½ lbs. or less at birth, and these infants are dealt with as "premature." Equipment likely to be required when a premature infant is nursed at home has been provided. By the courtesy of the hospital authorities some equipment is being kept at hospitals and is available on request by day or night. In other areas equipment is held at centres scattered over the district, thus facilitating quick delivery to any home where it is needed. Special instructions have been issued to the Council's domiciliary midwives and to the district midwives of hospitals and district nursing associations regarding the care of the premature infant in the home, and, where necessary, the infant is removed to hospital in a warmed cot. Heated ambulances are available for this purpose. All hospitals which do not themselves employ trained visiting staff to follow up premature infants on discharge have established close liaison through their almoners with the Council's health visiting service. Opportunity has been taken to urge on hospital authorities the need for the establishment of more special units for dealing with premature infants on the lines of that established early in 1948 in the Council's Hammersmith Hospital. Dental care Details of the priority service for mothers and babies will be found on page 83 in the Report of the Council's Chief Dental Surgeon. Welfare foods A special departmental committee was set up to advise which welfare foods, nutrients, medical requisites, drugs, etc., should be available at maternity and child welfare centres. A list based on their recommendations has been approved and will be revised periodically. All the voluntary organisations having agreements with the Council for carrying out maternity and child welfare functions have been offered the use of the Council's central purchasing organisation ; the majority have preferred not to take advantage of the offer. Provision of maternity outfits Every woman delivered at home is issued with a free maternity outfit, containing accouchement sheets and dressings required for the confinement. The Council supplies these outfits to its own midwives and to those employed by district nursing associations. The hospitals supply the outfits to their district midwives and the cost is taken into account by the Council in fixing the rate of payment to the hospitals. Day nurseries and creches The facilities available on the "appointed day" have been continued and, where practicable, have been increased. A scheme of priorities for admissions to day nurseries has been drawn up and is applied where the number of applications exceeds the number of places available. Due regard has been paid to the various factors—economic, health, etc.—necessitating the placing of children in day nurseries. A standard charge of Is. a day for each child placed is made to parents availing themselves of these facilities. This is regarded as covering the cost of the midday meal supplied to the child and is not abatable. 34 Comments on accommodation will be found on page 28. The provision of facilities by voluntary organisations is dealt with on page 32. Child minders There has been a marked increase in the number of child minders (formerly known as "daily guardians") voluntarily registered since 5th July, 1948, there being 276 at the end of the year compared with 150 ; most of the increase of over 80 per cent. occurred within the first three months. Each child minder so registered is paid by the Council a registration fee of 6s. a week, payment for services actually rendered being made direct by the parents of the children. The foregoing paragraph does not relate to compulsory registrations under the Nurseries and Child Minders Regulation Act, 1948, but to voluntary registrations by child minders not covered by the provisions of that Act—i.e., those looking after less than three children from different households. Child minders compulsorily registered under the Act are paid no registration fee; 35 persons had been compulsorily registered by the Council by 31st December, 1948. Before being registered, every applicant has to satisfy the Council that she is a suitable person to have the care of young children and that the premises to be used are of an approved standard. The Council has the right of inspection of registered premises at any time to ensure that there is no departure from the approved standard. Residential Nurseries At the end of 1947 there were 859 cots in the Council's nurseries and 733 children were in residence. The position as regards nursery accommodation on 31st December, 1948, was as follows:— Total accommodation Number of children in residence Public Health, Department Nurseries— Five in the country — 289 cots 459 400 Three in London — 164 cots Coram Nursery — 6 cots Welfare Department Nurseries— Five in London 425 368 Total 884 768 At the close of the year 98 cots could not be used owing to quarantine or staff shortages as against a comparable figure of 116 cots at the end of 1947. The pressure on nursery accommodation was as acute as ever during the year and to help the position it was decided to open Oakdale Residential Nursery, South Holmwood, Surrey, a large house which the Council had acquired in January, 1948. By extemporised arrangements as to equipment and children's lavatories and without waiting for more extensive structural alterations, it was possible to bring the nursery into limited use in the first week of May, 1948. At the end of the year there was accommodation for 25 children in the nursery; 42 children will be accommodated when the structural alterations are completed. On 5th July, 1948, the Children Act came into force. This made new provision for the children deprived of a normal home life who were dealt with under the Poor Law until that was brought to an end on 5th July, 1948, by the National Assistance Act, 1948, and put into effect the principal recommendations of the Report of the (Curtis) Committee on the Care of Children. The Act required the appointment of a Children's Committee, who would be responsible, inter alia, for the care of children in residential nurseries, and of a Children's Officer. The Children's Committee was set up by the Council on 30th November, 1948, and a Children's Officer appointed, 35 but he had not been able to take up his duties before the end of the year. Any consequent administrative changes regarding the residential nurseries will be dealt with in my report for 1949. The care of unmarried mothers and their children "The problem of illegitimacy still remains and still needs all the skill, patience and effort which statutory authorities and voluntary organisations can bring to its solution. Constructive help in meeting the responsibility of her child can be given to the unmarried mother and her position eased if her special needs are recognised and are fitted into the structure of the new health and social services." This paragraph concludes the final report of the County of London Advisory Body on the Care of Illegitimate Children, which was set up following the Ministry of Health Circular 2866/43 of 16th November, 1943, to advise on the care of illegitimate children. The Advisory Body ceased its work on 4th July, 1948, when the Council took over responsibility under the National Health Service Act. In undertaking this responsibility regard was had to the advice given by the Minister of Health in circular 2866/43 "that the most promising line of attack would be that the welfare authorities should co-operate with and reinforce the work of existing moral welfare associations." The Minister also commends in this circular the successful work of voluntary agencies and moral welfare workers attached to diocesan and other religious bodies. The care of the unmarried mother and her child is administered by the Council as follows:— (a) Voluntary houses take expectant mothers during the later stages of pregnancy and for several weeks after confinement. With two exceptions, confinements take place in hospital. Formerly grants were paid to the homes on behalf of the Minister of Health under the Local Government Act, 1929, and since 5th July, 1948, the Council has itself continued to pay the grants under Section 22 of the National Health Service Act. Grants are also made to two other homes previously aided under the Council's V.D. Scheme. The homes are visited by medical officers of the department at least twice a year and by sanitary inspectors when any alterations to the premises are necessary. Standards of staffing, space and management which have been approved by the Ministry of Health are carefully applied to the running of the homes. The grants paid are subject to the observance by the voluntary bodies of any improvements suggested by the Council. The two homes which undertake their own confinements are registered under Part XI of the Public Health (London) Act, 1936, and the others are exempted from this Act. Some of the homes are also registered under Section 29 of the Children Act, 1948. The following statement gives certain particulars of the homes:— No. of grant-aided homes 23 Amount of grant (approx.) £19,286 The denominations responsible for these homes are: Church of England, 8; Roman Catholic, 4; Salvation Army, 3; Church Army, 1; Jewish, 1; Methodist, 1; Undenominational. 5. Voluntary Mother and Baby Homes (6) Field work, both pre-natal and post-natal is, in the main, done by moral welfare associations whose workers attach the greatest importance to this part of their work. It includes arrangements for the mother to re-establish her own life with her baby, if possible. Thirty-four moral welfare workers are employed by the five associations which received grants amounting to £4,695 from the Council for the portion of the year from 5th July, 1948. The voluntary committees of the mother and baby homes share in the field work. Field Work (c) The metropolitan boroughs, before 5th July, 1948, required their health visitors to co-operate with the moral welfare workers in the care of unmarried mothers. Participation of Health Visitors 36 This duty was transferred to the Council by the National Health Service Act and is being continued. There is the closest co-operation. Unmarried mothers, including any who need a home and cannot be looked after during this crisis in their lives at their own or their parents' home, are referred to the moral welfare workers. The health visitors see that the maternity and child welfare services are made available to them. Where necessary, financially necessitous cases are referred to the Welfare Department and women considered unsuitable for admission to voluntary homes are cared for in homes maintained by that department. Care of illegitimate children separated from their mothers {d) Under the Children Act, 1948, the duty of ensuring the welfare of " deprived children "will fall to the Children's Officer. Pending the setting up of the Children Department the Public Health Department has continued (i) to administer a scheme of guaranteed payments to foster mothers, and (ii) to obtain residential nursery places for illegitimate children. Grants amounting to about £2,800 a year, have also been paid to three voluntary homes for babies containing seventy-four cots. Holiday homes The demand for recuperative holidays for children has outstripped the accommodation immediately available, but measures are being taken to make good the deficiency. The accommodation used includes a home transferred from the Shoreditch Borough Council under the provisions of the National Health Service Act, 1946. Considerable use has been made of the services of the Invalid Children's Aid Association in placing unaccompanied children in suitable holiday homes, the Council paying the Association £1 for each child placed, over and above the charges made by the homes. Demands for recuperative holidays for expectant and nursing mothers and their children have been met in full. In addition to direct placing by the Council in various approved private holiday homes, it has been possible by arrangement with the Bermondsey Borough Council to send some of these people to a home owned and maintained by that Council. The following is a statement of the persons placed in holiday homes between 5th July and 31st December, 1948:— Unaccompanied Under 5 children School Nursing and expectant mothers and their years children children 637 1,098 Mothers 128 Children 145 Meals Miscellaneous services Provision of meals on medical recommendation for nursing mothers and young children has continued in some divisions and flat rate charges of 1s. for the mother's meal and 6d. for the child's have been fixed. Birth Control The Family Planning Association has been granted facilities for holding birth control clinics in premises transferred to the Council under the provisions of the National Health Service Act, 1946, existing clinics of this nature being continued. Tests Arrangements are nearing completion for pregnancy diagnosis tests to be carried out in cases where confirmation of pregnancy is desired, and for blood samples of all expectant mothers attending the Council's ante-natal centres for the first time to be tested for Rhesus factor and Wassermann reaction (subject to availability of staff and serum at the hospitals undertaking the work). Other Services Other miscellaneous services in existence on 5th July, 1948 (e.g., ante-natal and post-natal exercises, classes in sewing, cookery, mothercraft, etc.), have been continued and are being reviewed from time to time to see what extensions are practicable and desirable. 37 DOMICILIARY MIDWIFERY SERVICE No change has been made in the organisation of this important service which, since its inception in 1938, has been administered from County Hall. The desirability of continuing this centralisation or of transferring the work to the nine divisional offices is kept under constant review. During 1948, there was a drop in the high birth rate that had been the feature of the two previous years. This was reflected in the number of confinements taken by the Council's midwives as shown in the following table:— Year Maternity nursing cases Midwifery cases Total 1945 440 6,427 6,867 1946 805 10,834 11,639 1947 899 12,025 12,924 1948 630 9,533 10,163 Of the confinements during 1948, 1,893 were primigravidæ and 8,270 multigravidæ. Women booked by the Council's midwives but who were admitted to hospital before confinement suffering from toxaemia, ante-partum haemorrhage, etc., are not included in the foregoing figures. The number of midwives employed at the end of the year was 155, compared with 158 at the end of 1947 and 148 at the end of 1946. The average number of midwives employed throughout the year (permanent and temporary) was 158 compared with 160 in 1947. The average number of confinements undertaken by each midwife, including sick and holiday reliefs, was approximately 65, compared with 81 in 1947. The Midwives Salaries Committee (Rushcliffe) recommended that each midwife should attend not more than 66 confinements a year under favourable conditions, and it is a matter of satisfaction that the extreme pressure of work on the midwives relaxed during 1948. Seven part-time midwives were employed during 1948 for periods ranging from 1 to 190 days to assist in the nursing of mothers during periods when the Council's midwives were absent on annual or sick leave. Ambulance cars for the transport of midwives were supplied in emergency, particularly at night, and 15,523 miles were run on this service, compared with 20,360 miles in 1947. London County Council Midwives The number of confinements taken by the district nursing association and hospital district midwives in the domiciliary midwifery scheme showed a similar decline owing to the fall in the birth rate. Year 1947 Maternity nursing cases Midwifery cases Total Grand Total Hospital district service 169 6,525 6,694 District nursing associations 390 3,716 4,106 10,800 1948 Hospital district service 116 5,095 5,211 District nursing associations 2902,940 3,230 8,441 The number of midwives employed on 31st December, 1948 was: Supervisory Midwives Hospital district service 25 68 District nursing associations 24 31 There was also a small number of part-time midwives, and some of the full-time staff of district nursing associations do part-time midwifery and part-time home nursing. Agency Organisations The chief developments in the work of the Council's midwives during the year were the increase in the number of midwives holding ante-natal sessions at maternity and child welfare centres, and the advance made in the use of gas and air analgesia, Developments in 1948 38 Ante-natal sessions at Maternity and child Welfare Centres By arrangement with the metropolitan borough councils, thirty-four midwives held weekly ante-natal sessions at the maternity and child welfare centres at the beginning of the year and on 1st July, 1948, this number had increased to 62. With the transfer of the centres to the Council even more rapid progress was made, and by the end of the year, 111 midwives were regularly attending centres. Wherever possible, the midwife attends a combined session with a doctor to whom she can refer patients, when necessary, with the minimum delay. This has the added advantage that doctor and midwife can hold consultations and exchange reports in regard to each patient. It also suits the expectant mother as her visit to the midwife can be combined with the other visits which she must periodically pay to the centre, e.g., for medical examinations and social services. The other midwives book and examine their patients at home and will be allocated to centres as soon as suitable premises are available. Gas and air analgesia The following tables Set out the number of mothers receiving analgesia during the year and the percentage which they represent of all confinements taken. In addition, there are the mothers on whom the midwives attend as maternity nurses under the direction of doctors who themselves give anaesthesia or analgesia and for whom no figures are available. An indication of the progress made in 1948 is shown by the half-yearly statistics:— January to July to Total for June, 1948 December, 1948 the year London County Council domiciliary midwives 1,345 (25%) 2,102 (44%) 3,447 (34%) Hospital district midwives 787 (27%) 1,051 (44%) 1,838 (35%) District nursing association wives 445 (25%) 458 (30%) 903 (28%) Steady progress was made during the year in the training of midwives to administer gas and air analgesia. Six courses of training were held and the number trained at 31st December, 1948, was 148 out of a total of 155 midwives, as compared with 94 out of 158 midwives at 31st December, 1947. For various reasons, the percentage of mothers confined at home who receive gas and air or similar analgesia will never reach 100 but the aim of the Council is to provide it whenever the mother desires it and there is no medical contra-indication. Housing of midwives The Council has continued to provide accommodation for domiciliary midwives, as recommended by the Midwives Salaries (Rushcliffe) Committee. At 31st December, 1948, 74 midwives were housed in 66 houses, of which 43 were provided by the Council and 23 taken on lease or on licence either from the borough councils or direct from the owners. The Regional Hospital Boards have co-operated in arranging for the temporary accommodation of midwives in hospital staff quarters. Furniture Seventeen midwives were supplied with furniture, valued at approximately £950 during the year, in return for a monthly hire charge. Charges for water heating appliances supplied to midwives occupying premises provided by the Council ceased on 30th June, 1948, as it was decided that the Council would henceforth provide these appliances. Co-operation with Hospitals W hen the Council was a hospital authority, a close system of co-operation was built up between the maternity hospitals and the domiciliary midwifery service, from which the latter service derived much benefit and this co-operation has continued with the Regional Hospital Boards. Its principal features are:— (i) The doctor or, in his absence, the midwife, may apply in any emergency affecting either the mother or child, for a hospital bed through the Emergency Bed Service, and similarly for women who develop puerperal fever or pyrexia, or for infants who are premature or suffering from ophthalmia neonatorum. Direct admission to certain hospitals may also be arranged for infants with rhesus negative condition. 39 (ii) If the patient cannot be moved, the doctor, or in his absence, the midwife may telephone for the emergency obstetric unit consisting of a hospital team of obstetrician and nurse who can give emergency treatment, e.g., blood transfusion, in the home. During the year 62 calls were made on the emergency obstetric units by the Council's midwives. Doctors can also call in an obstetric consultant for specialised advice in the home. (iii) The Council's midwives attend hospitals to take the course of training and examination in the administration of analgesia. (iv) Hospital pupil midwives spend three months of their Part II midwifery training with domiciliary midwives who have been approved by the Central Midwives Board as district midwifery teachers. The pupils reside with their teachers and are instructed in the full duties of the domiciliary midwife before and during labour and the lying-in period. The same training is also provided by certain district nursing associations and the pupil midwives reside for three months at the district homes of the associations. During the year 128 pupils were so trained with the Council's and district nursing associations' midwives. (v) Domiciliary midwives are issued with drugs and dressings from the hospital dispensaries. Before 5th July, 1948, payments were made to district nursing associations and hospitals at the following rates for each domiciliary confinement:— District nursing associations £5 12s. l0d. Hospitals £5 2s. 8d. Payments for relief of the Council's midwives were made in addition at the rate of £1 1s. for twenty-four hours, and 12s. 6d. for twelve hours or less. From 5th July, 1948, the payments to district nursing associations were merged in the deficiency grants made to them for midwifery and home nursing and the rate of payment to the hospital has been increased to £7 13s. 4d. a confinement. Payments to District Nursing Associations and Hospitals Fees paid by patients (£4 for first confinement; £3 for subsequent confinement or maternity nursing) ceased at 4th July, 1948, as required by the National Health Service Act. Fees from patients Midvrives Acts, 1902 to 1936 A large increase in the number of notifications of intention to practise took place in 1948, as a result of the revision of Rules E of the Central Midwives Board. The revised rules contained two new requirements, viz., (i) that midwives must notify their intention to practise as midwives when employed in institutions, and (ii) that midwives practising as maternity nurses must notify their intention to act as such, thus for the first time, so far as the latter are concerned, coming under supervision by the periodical inspection of their statutory records and their appliances. The number of notifications, compared with the previous year, was:— 1947 1948 As midwives 928 1,213 As maternity nurses Nil 289 The supervisors of midwives visit all cases of puerperal pyrexia and all children with skin lesions and inflamed eyes. On twenty-five occasions midwives were suspended from practice for varying periods to prevent the spread of infection. Notifications of intention to practise There were three maternal deaths among women booked for home confinement, two after removal to hospital following delivery and one at home. Of the two cases removed to hospital, one died six days after delivery from haemolytic shock after blood transfusion, and one 37 days after normal delivery of twins from pulmonary embolism and low grade puerperal infection. The third patient died at home from post-partum haemorrhage 24 hours after delivery. Maternal deaths Two courses of six post-certificate lectures each, and five courses of four antenatal and post-natal demonstrations, were arranged in conjunction with the Middlesex Lectures, etc., for midwives 40 and the Surrey County Councils during the year. The number of tickets issued to midwives for attendance at the lectures was 535 and 60 for attendance at the demonstrations. Nine of the Council's domiciliary midwives attended summer schools arranged by the Royal College of Midwives. Payment of medical fees Fees paid under the Midwives Act, 1918, to medical practitioners called in by midwives in emergency amounted to £15,594 and the number of claims was 6,354 in 1948, compared with £12,509 and 7,995, respectively, for 1947. The rise in the amount of fees paid is due to the increased scale of fees introduced from 18th April, 1948, by the Medical Practitioners (Fees) Regulations, 1948. The fall in the number of claims received is attributed mainly to the fall of approximately 13 per cent. in the birth rate for London and also to a lesser degree to the introduction of the general practitioner obstetrician scheme under the National Health Service Act, 1946, as from 5th July, 1948. It is estimated that the full effect of the latter scheme on the number of claims received will not be felt until after March, 1949. Under Part IV of the National Health Service Act, 1946, a pregnant woman can obtain the services of a medical practitioner with obstetrical experience who, for a comprehensive fee paid by the Local Executive Council, will provide her with maternity medical services which include:— (i) examination at time of booking; (ii) examination about the 36th week of pregnancy ; (iii) a post-natal examination about six weeks after confinement; (iv) any medical attention additional to the above, either if he thinks it necessary, or in response to a call from the midwife. The medical practitioner on the medical list is not required to undertake the more frequent routine ante-natal supervision that is essential, nor to attend the labour unless such attendance is considered necessary by himself or by the midwife. The doctor may, of course, provide additional services if he so desires, but his remuneration is not thereby affected. Historical sketches For statement on origin and development of this service see page 106. HEALTH VISITING The day-to-day administration of the health visiting service has been on a divisional basis since the "appointed day" and has followed the lines existing before that date. As anticipated in the proposals submitted to the Minister of Health under the National Health Service Act, it has not been possible to expand the service and the main efforts of the personnel continue to be in the maternity and child welfare field. The over-riding problem has been a shortage of qualified staff. Voluntary organisations Health visitors employed by voluntary bodies have been given the opportunity to transfer to the Council's service in order to provide for that close integration of services which is desirable, but no pressure has been brought to bear on any individual who did not desire so to transfer. The appointment of new health visitors to serve with these organisations should replacements be necessary will be undertaken by the Council, but the voluntary committees will be asked to send one or more representatives to the committee of the Council which is interviewing candidates for appointment. Few of the hospitals have employed health visitors as such, but where these officers have been employed negotiations are proceeding for the integration of their services with those provided by the Council. Child life protection Until 5th July, the authorities for administering the child life protection powers under the Public Health (London) Act, 1936, were the Common Council of the City of London and the metropolitan borough councils. Under these provisions, any person who proposed to undertake for reward the nursing and maintenance of a child under the age of nine years (a "foster child") was required to notify the fact to the Local Authority. It was also the duty of the Local Authority to make enquiries from time to time to ascertain whether there was any person residing in its area 41 who was undertaking such nursing and maintenance of foster children and to appoint one or more child protection visitors, or to authorise individual members of its staff to carry out these duties. The duty of these officers was to visit from time to time all foster children and the premises in which they were living, in order to safeguard the health and well-being of the children and to give any necessary advice or direction to the foster parents on the care of the children. The Local Authority had power to fix the maximum number of children who might be kept in any premises in which a foster child was kept and if it was satisfied that a foster child was being kept by unsuitable people, or in an unsuitable environment, there was the power to apply to a court of summary jurisdiction for an order directing the removal of the child to a place of safety. Under the Children Act, 1948, which came into operation on 5th July, 1948, the child life protection provisions of the Public Health (London) Act, 1936, were extended to apply to foster children while under compulsory school leaving age and in certain circumstances up to eighteen. Under the Children Act the Council became responsible for child life protection work and although this subject stands referred to the Children's Committee, and will eventually be dealt with by the Children's Officer, the supervision of foster children has been delegated, for the present, to the health department. The visiting of foster children and the premises in which they are living have continued to be undertaken by health visitors, designated as child protection visitors, who were transferred to the Council from the metropolitan borough councils. The number of foster children being supervised under child life protection powers at the end of 1947 was 767. Towards the end of this year the number was approximately 700. It is not possible to give an accurate figure, owing to the difficulty in the short time available since the operation of the Act in ensuring that persons caring for foster children for reward between the ages of nine years and compulsory school-leaving age were made aware of the extension of the age range of children requiring to be registered. HOME NURSING Up to 4th July, the arrangement was continued by which district medical officers referred patients to be nursed at home by nurses employed by the district nursing associations, grants being paid by the Council to the Central Council for District Nursing in London for distribution, on a visit basis, to the associations concerned. A majority of the metropolitan borough councils had similar arrangements for the home nursing of patients suffering from certain illnesses. From the " appointed day " the Council arranged with the Central Council for District Nursing in London and the voluntary nursing associations in the county for the provision of home nursing services on its behalf on a grant basis. From 5th July to the end of the year 453,222 visits had been made. Arrangements were also made with the district nursing associations and the British Red Cross Society for the loan of equipment to patients being nursed at home. DOMESTIC HELP SERVICE Prior to the "Appointed Day," all the metropolitan boroughs(with the exception of the City of London) had a scheme for the provision of domestic assistance (home helps) where a mother was unable to carry out her normal duties because of her confinement, and in all but one of the boroughs, there was also a scheme for the provision of similar help for sick or infirm persons. After the "Appointed Day," the demand for the service of home helps increased considerably, and the service was expanded as far as possible to meet this demand. At the end of 1947, the metropolitan boroughs employed 826 home helps (243 whole-time, and 583 part-time) who attended 7,389 cases during that year. By the autumn of 1948, the number of helps had risen to over 1,600, and by the end of the year 1,932 (439 whole-time and Loan of equipment 42 1,493 part-time) were employed. From 5th July to 31st December, 11,302 cases were given home help assistance. At the end of the year, the service was providing about 2,000,000 hours per year, approximately four times the amount in 1946. Welfare oentres IMMUNISATION and VACCINATION Diphtheria immunisation The practice instituted by the metropolitan borough councils of having special diphtheria immunisation sessions at infant welfare centres has been continued and in addition immunisation, when necessary, has been given in the course of normal infant welfare sessions without special appointment. Schools The arrangements outlined in my report for 1940 were continued up to the 4th July, and the significant drop in the number of cases of diphtheria reported from schools has been maintained. Immunisation up to that date was carried out on behalf of the metropolitan borough councils by school doctors in twenty-one boroughs and the number of children who received a course of prophylactic injections in the schools under these arrangements was 2,275. The number of children immunised in schools by the school medical staffs since the issue of the Ministry of Health Circular in 1940 up to the end of June, 1948, was 85,141 and 8,930 "boosting" doses were given. Since the operation of the National Health Service Act, when the Council became the Local Authority for Immunisation, the arrangements for this work at welfare centres and at schools have been merged. The attention of teaching staff was again drawn to the importance of urging the parents of school children to consent to diphtheria immunisation, in order to ensure that everything possible was being done to maintain a high level of immunity among the school population. General practitioners General practitioners are invited to take part in the Council scheme as many parents prefer the family doctor to immunise their children. Under this scheme the family doctor is paid a fee for completing the record of immunisation when this is returned to the Council. The Ministry of Health, through their Public Health Laboratory Service, make available, free of charge, A.P.T. and T.A.F. and the Council supplies these materials to general practitioners taking part in the scheme. Statistics The total number of children immunised at the infant welfare centres, at schools or by General Practitioners from July to the end of the year was 27,024, and in addition 5,078 " boosting " doses were given. Table 18, p. 126, shows the number of infants in London who, at the end of 1948, had received a course of diphtheria immunisation injections. This table also shows the number of cases and deaths occurring in immunised and unimmunised children. Perhaps the most important fact is that, out of the 15 deaths from diphtheria occurring among children, none occurred among the immunised. As to the extent of immunisation, it will be seen that, according to these records the proportions are:— Number Age Population immunised Per cent. 0-4 269,923 138,823 51.4 5-14 359,544 228,346 63.5 Total 629,467 367,169 58.3 There are reasons for believing these figures to be an understatement. In the early years of the campaign the metropolitan borough councils found it difficult to maintain complete records. It is in particular unlikely that they received complete records of children immunised whilst evacuated from London. On the other hand, records obtained at routine medical inspections at schools indicate that 83.1 per cent. of school children claimed to be immunised. This latter figure is equally likely 43 to be an over-statement, because these records are based upon verbal assurances from parents without the production of a certificate of completed immunisation, and there are probably many affirmative answers given when, in fact, immunisation has not been completed. Probably the truth is intermediate between the two limits and it is felt that an estimate that, say, 75 per cent. of school entrants have been immunised is not likely to be greatly in error. In discussing immunisation statistics, the Registrar-General states (Statistical Review, 1940-1945, Text Vol. I (Medical)): "If 47,000 children of those ages (5-15) had returned to London after being immunised in reception areas without their transfer being recorded in the returns, the London percentages (immunised) would be raised to equality with the English County Boroughs." At the end of 1945 the county borough percentage was 72 at school ages. At that time it had been estimated after comparing Borough and School records that the corresponding percentage in London was 70 and it now appears that this was reasonable. The division of cases between immunised and unimmunised children when the relative sizes of the two populations are taken into account indicates that the attack rate in the "protected" population was only about 13 per cent. of that in the "unprotected," and judged from the absence of deaths, the incidence in the "protected" population was restricted to mild cases. Comment on the role of immunisation in accelerating the fall in the incidence of diphtheria in London is given in the Vital Statistics Section of this report (p. 14). In London the notification rate 0-4 has fallen from 5.88 per thousand in 1938 to 0.38 per thousand in 1948. The rate at ages 5-14 has fallen from 4.43 to 0.39. In 1938 there were 205 deaths of all ages, and in 1948 only 19. Active immunisation against diphtheria was continued at the Council's residential establishments for children. At the end of the year, 89 per cent. of the children in residence had been, or were in process of being, immunised. Of the remainder, in the majority of cases, parental consent had not been received. Vaccination The Council assumed responsibility on the 5th July for the vaccination against smallpox of persons in its administrative area, and made arrangements for vaccination sessions to be held at welfare centres, etc., and for vaccination to be carried out by general practitioners in the county who wished to perform this service on its behalf. Where vaccination is carried out by general practitioners, a fee is paid by the Council to the practitioner for completing the record of vaccination, as in the case of immunisation against diphtheria. The lymph is supplied free of charge to the Council by the Ministry of Health through their Public Health Laboratory Service. General practitioners are also able to obtain supplies from the same source. The following tables give particulars of the number of persons who were vaccinated under these two arrangements:— Residential establishments Number of persons vaccinated (or re-vaccinated) during period 5th July to 31st December Age at 31st Dec., 1948 i.e., born in years:- Under 1 1948 1 to 4 1944 to 1947 5 to 14 1934 to 1943 15 or over Before 1934 Total Vaccinated— Division 1 1,272 57 7 5 1,341 2 1,340 51 17 36 1,444 3 729 31 6 8 774 4 764 42 8 17 831 5 276 24 8 10 318 6 646 49 19 16 730 7 796 46 23 16 881 8 990 48 17 10 1,065 9 952 64 30 29 1,075 Totals 7,765 412 135 147 8,459 44 Re-vaccinated Division 1 3 4 4 46 57 2 - 4 9 185 198 3 106 - 3 25 134 4 - - 8 81 89 5 2 - 1 16 19 6 22 1 1 15 39 7 9 2 13 42 66 8 - 1 1 27 29 9 223 9 12 123 367 Totals 365 21 52 560 998 Number of cases specially reported during period (age groups as above):— (a) Generalised Vaccinia Division 1 1 - - - 1 (b) Post-vaccinal Encephalomyelitis - - - - - (c) Death from complications of vaccination other than (a) and (6) - - - - - LONDON AMBULANCE SERVICE This service operates under the immediate supervision of Mr. A. G. Hellman, O.B.E., the officer-in-charge. Effect of the National Health Service Act, 1946 Development of the Service On the introduction of the National Health Service on 5th July, 1948, the responsibility for ensuring that ambulance transport was available, without charge, for all persons for whom the need arose within the Administrative County of London fell upon the Council. Substantial progress had been made during 1947 in planning the organisation to cope with the additional commitments which were to be assumed and a programme for the development of the London Ambulance Service in two stages had been drawn up. Two of the schemes carried out during 1948 were the transfer of the Western Ambulance Station to new and larger premises in Chelsea and the operation of the Headquarters station from new premises in Lambeth. The latter project has not only facilitated the routine maintenance of the whole of the ambulances in the accident section and the operation of additional accident ambulances direct from the Headquarters station but has enabled ambulances to be manned by reserve drivers and sent to assist at general section ambulance stations at times of exceptionaly heavy pressure. The first stage of the development scheme also provided for the extension of the South-Eastern and South-Western General Ambulance Stations and the building of an accident ambulance station in Hampstead, and when these projects have been completed it will be possible to operate an additional 25 ambulances. The second stage envisages the extension of the Brook and Eastern General Ambulance Stations; the provision of an accident ambulance service in the City of London in place of that now operated by the City of London Police and the provision of accident ambulance stations in Mottingham and Putney, permitting the operation of a further 36 ambulances. Agency arrangements Arrangements were made with the following bodies tor the services which they provided prior to the introduction of the National Health Service to be continued on an agency basis on behalf of the Council:— (i) The Home Service Ambulance Department of the Joint Committee of the Order of St. John of Jerusalem and the British Red Cross Society—for the 45 removal of patients by ambulance, primarily those patients travelling long distances. (ii) The County of London Hospital Car Service, administered jointly by the Women's Voluntary Services, the Order of St. John of Jerusalem and the British Red Cross Society—for the conveyance to and from hospitals, etc., by motor car, of patients who are able to sit up. (The voluntary character of these two organisations has been preserved in the arrangements.) (iii) The City of London Corporation—for the continued operation, for one year, of the City of London Police Ambulance Service to deal with persons sustaining injury or suffering from sudden illness in the City. (iv) The West Ham County Borough Council—for the provision of ambulance services in that part of Woolwich which is north of the Thames. (This arrangement ensures the speedy removal of patients from an area not readily accessible to the Council's ambulances by reason of its geographical position.) Consultations took place with other ambulance services, the Port of London 1 Authority and the railway authorities to enable the most efficient service to be t provided with due regard to economy. To reduce as much as possible the period before the arrival of an ambulance, arrangements have been made with all neighbouring local health authorities for emergency calls, e.g., street accidents, near the common boundary to be answered by an ambulance from the nearest ambulance station, irrespective of whether or not the ambulance station is controlled by the authority in whose area the incident has occurred. The special arrangements devised by the London Ambulance Service for the removal of patients suffering from smallpox, and from typhus fever have been made available, within certain limits, to neighbouring authorities. Arrangements have been made with railway authorities for patients who need to travel very long distances to make the major part of the journey by train when the condition of the patient permits and rail transport would be quicker and more comfortable than a long journey by road. Liaison has been established with other ambulance services so that when it is necessary to send an ambulance on a long journey it can, whenever possible, convey another patient on the return journey. Co-operation with other authorities A heavy burden has been borne by the Home Service Ambulance Department of the Joint Committee of the Order of St. John of Jerusalem and the British Red Cross Society and by the County of London Hospital Car Service and tribute is due to the marked success achieved by these two voluntary organisations in meeting the calls made upon them. , Home Ambulance Service and Hospital Car Service The arrangements under which the Council has operated ambulance transport since the war on behalf of the Ministry of Health for the Emergency Medical Service automatically ceased with the inauguration of the National Health Service from which date the provision of this transport, when the need arises in London, became the Council's responsibility. Emergency Medical Service There was an immediate and substantial increase in requests for ambulance transport on the introduction of the National Health Service and demands rose steadily during the remainder of the year. By the end of 1948 the number of patients removed daily was 35% greater than at the beginning of the year. Increase in ambulance calls Special arrangements were introduced and special equipment provided for the removal to hospital of premature babies and babies suffering from haemolytic disease. Premature babies The precautions to safeguard ambulance crews when undertaking the removal of patients suffering from typhus fever and to protect other patients travelling subsequently in the same ambulance were revised. Typhus fever precautions 46 Analgesia apparatus A very marked increase occurred in demands for the delivery of analgesia apparatus to women being confined in their own homes and ambulance journeys for this purpose rose steadily throughout the year from 204 in January to 529 in December. Brook Ambulance Station The Brook General Ambulance Station premises, which had been seriously damaged by a rocket bomb in 1944, were restored sufficiently to enable them to be brought into use again and the station returned from its temporary accommodation to the repaired premises, which were formally re-opened by the Chairman of the Council, on 10th May, 1948. Equipment Vehicles The Council placed an order with the Daimler Company, Ltd., for 120 ambulances conforming to the prototype ambulance produced at the Council's Motor Vehicle Repair Depot and varied accordingly the three-year replacement programme which had been approved during the previous year. The condition of many of the vehicles in the fleet continued to give rise to anxiety and the need for the new ambulances, which will be the first specially designed vehicles to be introduced into the fleet since before the war, has been very pronounced. The only new vehicles brought into use during 1948 were 12 motor cars for the conveyance of sitting patients. Five second-hand motor cars formerly used for transport under the Emergency Medical Service were purchased from the Ministry of Health and added to the London Ambulance Service fleet. The contents of the drugs case and other emergency equipment carried in accident section ambulances was reviewed and certain modifications made, including a variation of the types of disinfectants carried. Arrangements were made, also, for the hypodermic syringes and needles to be kept sterilised in sealed containers ready for instant use by doctors called to assist at accidents. Staff In February, 1948, revised arrangements for staffing the Headquarters Control Room switchboard at night were put into force and the work, which had hitherto been performed by male ambulance clerks attached to the general section ambulance stations, was taken over by the women staff who had until then performed day duties only. This in turn made it possible for the male clerical staff to take over at the general section stations the night duty formerly undertaken by members of the operative staff. The Council authorises the employment of operative staff in excess of the fixed establishment as and when necessary to provide reliefs during periods of sickness and annual leave. In addition to this provision, to meet the increased demands upon the Service and in anticipation of the further demands expected to result from the operation of the National Health Service, the Council, in March, 1948, authorised an increase in the fixed establishment of operative staff from 424 to 535 and recruitment proceeded as the operational work increased. London Ambulance Service Consultative Committee The London Ambulance Service Consultative Committee, established by the Council in 1946 as a medium of discussion on service matters between the management and the operative staff, held nine meetings during the year and considered a variety of matters with a view to the improvement of the efficiency of the service and the well-being of the staff. Strength of the Service At the close of the year the London Ambulance Service consisted of 23 ambulance stations with 260 ambulances, 20 ambulance omnibuses, 33 ambulance motor cars and 2 tenders—operated by a uniformed staff, including temporary staff in excess of establishment, of 570. The specially designed telephone switchboard in the Control Room at the County Hall is kept in continuous commission by supervisory staff and ambulance clerks totalling 29. 42 ambulance clerks are employed at the 47 general section stations and the Headquarters administrative and clerical staff under the Officer-in-Charge numbers 18. Alleviation of Strain Steps taken to ease the strain on the London Ambulance Service include:— A measure of decentralisation was introduced under which certain hospitals requiring ambulances for large numbers of out-patients make their applications direct to the nearest general section ambulance station, instead of centrally to the Control Room. Decentralisation An additional telephone line was installed at each of the general section ambulance stations and ambulance crews are instructed to telephone their stations on arrival at hospitals so that, in suitable cases, they can be sent straight on to other calls. Telephones To reduce pressure on the Control Room telephone system, printed application forms were introduced and issued to the larger hospitals in London to enable orders to be sent by post when time permitted. Ambulance orders Many enquiries regarding the administration of the London Ambulance Service 1 were received during the year from other local health authorities who became res- ^ ponsible for providing ambulance services under the National Health Service and many visits were made by their representatives to study the method of central control and the detailed organisation of the London Ambulance Service. Major Accidents Three major disasters involving calls on the London Ambulance Service occurred during the year. The most serious occurred on 23rd January when six ambulances were sent to London Bridge Station following a collision between two trains, and 18 casualties were taken to hospital. On 18th November, 1948, two trains collided at Woolwich Arsenal Station. Five ambulances were despatched and removed six casualties to hospital. A collision between a private car and a bus in East Dulwich Grove on 21st November, 1948, resulted in the death of five persons and injuries to twelve others. Three ambulances attended at this accident and conveyed the casualties to hospital. Statistics Comparative statistics for 1938 (the last full year before the war) and the years 1945-1948 are:— Accident Section No. of calls No. of cases Mileage 1938 56,318 58,196 293,166 1945 52,136 53,452 286,281 1946 56,971 58,551 321,951 1947 64,560 66,143 362,880 1948 66,373 67,676 367,627 The statistics for 1948 disclose the following details:— A record was again established in the number of calls answered by the accident section; the previous record set up in 1947 being exceeded by nearly 1,800. This increase was mainly due to calls for the delivery of analgesia apparatus to women being confined at home. There was also an increase in the number of cases of sudden illness and accidents in the street and elsewhere. The number of maternity cases D Visits by other authorities 48 taken to hospitals and nursing homes by the accident section fell by over 800. A detailed analysis of cases and comparative figures for the previous year appears in the statistical tables given below. The time taken to reach incidents showed an improvement over the previous year. The average time taken to reach street accidents was reduced from 7.5 minutes in 1947 to 7.1 minutes in 1948 and for emergency cases of all kinds the average time was reduced from 8.3 minutes to 8.1 minutes. The number of emergency calls per station ranged from 6,664 at Bloomsbury to 2,363 at Poplar Ambulance Station. (The second ambulances at the accident stations in the less busy areas are called upon to assist with general section removals.) The hourly record shows that the peak period commenced between 11 a.m. and noon and, with the exception of a slight fall between 2 p.m. and 3 p.m., remained constant until 5 p.m. As in previous years, a sharp rise occurred from 10 p.m. until midnight. Calls were at their lowest between 6 a.m. and 7 a.m. December was once again the month with the highest number of emergency calls (6,394) showing a marked increase over November in which there were 5,397. The nature of the cases dealt with by the accident section was :— 1947 1948 Increase or decrease Street accidents 9,329 9,565 + 236 Other accidents 11,430 11,553 + 123 Assault cases 1,103 1,095 - 8 Attempted suicide 523 612 + 89 Mental 837 684 - 153 Epilepsy 1,222 1,315 + 93 Other sudden illness 10,205 10,915 + 710 Maternity 23,804 22,969 - 835 Analgesia apparatus delivered to women being confined at home 1,132 3,791 +2,659 Special cases (mainly conveying mobile emergency obstetric units to women being confined at home) 178 146 - 32 Transfer of accident cases taken to hospital within previous 24 hours 2,623 1,192 -1,431 Ambulance not required 3,757 3,839 + 82 66,143 67,676 + 1,533 Street accident cases by ages were:— 1947 1948 Age (in years) Males Females Sex not stated Totals Males Females Sex not stated Totals 0— 9 636 342 12 990 795 373 16 1,184 10—19 735 404 4 1,143 819 386 12 1,217 20—29 787 443 8 1,238 755 432 14 1,201 30—39 735 453 8 1,196 705 472 20 1,197 40—49 681 477 6 1,164 633 477 15 1,125 50—59 587 556 10 1,153 598 611 9 1,218 60—69 569 612 1 1,182 577 625 8 1,210 70—79 414 458 3 875 365 448 8 821 80—89 103 131 1 235 107 146 3 256 90 and over 10 8 - 18 11 11 - 22 Not stated 86 48 1 135 66 48 - 114 5,343 3,932 54 9,329 5,431 4,029 105 9,565 49 General Section Year Miles run Persons conveyed Patients Relatives of patients, staff, etc. Total 1938 1,930,172 217,908 102,520 320,428 1945 1,348,342 131,788 97,805* 229,593 1946 1,633,813 160,074 127,706* 287,780 1947 1,768,550 182,206 129,599* 311,805 1948 2,072,545 239,157 130,335* 369,492 *Includes domiciliary midwives and medical officers and nurses conveyed between hospitals and outlying nurses' homes because former staff quarters were destroyed by enemy action. Removals carried out on behalf of the Council under agency arrangements between 5th July, 1948, and 31st December, 1948:— Patients carried Mileage Home Service Ambulance Department of the Joint Committee of the Order of St. John of Jerusalem and the British Red Cross Society 5,454 204,048 County of London Hospital Car Service 30,052 430,121 City of London Police Ambulance Service 907 2,546 West Ham Ambulance Service 37 469 PREVENTION OF ILLNESS, CARE AND AFTER-CARE Treatment of Tuberculosis Responsibility for providing treatment for tuberculous persons in London passed to the four metropolitan regional hospital boards on 5th July, 1948, and most of the statistics which follow refer to the period 1st January to 4th July, 1948. During the first half of the year 3,596 recommendations were made for residential treatment and on 4th July 3,302 adults and 697 children were occupying beds under the tuberculosis scheme compared with 3,047 and 689 respectively on 31st December, 1947. Detailed statistics will be found on page 53. Residential treatment The number of cases of tuberculosis on the notification registers at 31st December, 1948, was 36,809 compared with 35,077 at the end of 1947, and 30,091 at the end of 1938. Dispensary service Before the "appointed day" the tuberculosis dispensaries were staffed by tuberculosis officers, tuberculosis visitors, social workers and clerks appointed by the metropolitan borough councils. Since 5th July, 1948, the tuberculosis officers have been appointed jointly by the metropolitan regional hospital boards and the Council, and they devote 3/11th of their time, as officers of the Council, to prevention, care and after-care. The remainder of their time, as officers of regional hospital boards they devote to the treatment of patients. Other staff, with the exception of the personal clerical assistants to the tuberculosis officers, are full-time officers of the Council. Staffing Extra nourishments are provided for tuberculous persons on the recommendation of the tuberculosis officer, a charge being made in accordance with a scale of assessment approved by the Council. The application of this scale to tuberculous persons receiving national assistance would normally entail their paying the full cost, since the monetary allowances from the National Assistance Board would as a rule exceed the maximum income entitling the recipient to free extra nourishment under the Council's scale. The Council, therefore, decided that it would be in the interest of persons receiving national assistance to obtain their extra nourishments out of the allowances granted to them by the National Assistance Board. Special allowances are given by that Board to Extra nourishment for tuberculous persons 50 the tuberculous. it was appreciated that there was a possibility that in some cases the cash allowance might not be used for this purpose and arrangements were therefore made for the Council's tuberculosis health visitors to give special attention to the matter to ensure as far as practicable that these persons do, in fact, obtain the extra nourishments required. As from the 1st September, 1948, extra nourishments have, therefore, been provided by the Council only for persons not in receipt of national assistance, assessment being made in accordance with the Council's special scale for tuberculous persons, in which the income allowed before any charge is made is 50% higher than for other persons. During 1948 a number of cases occurred in which tuberculous persons receiving extra nourishment would have been financially worse off than they were before 5th July, 1948, if the Council's scale had been strictly applied. The Council, therefore, authorised assessment officers to exercise discretion by taking into consideration unduly high payments for rent and other exceptional circumstances when making the assessment in such cases. 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 was made to patients for dental treatment except that any grants received from approved societies under the National Health Insurance Acts were taken into consideration. The net cost to the Council from 1st January to 4th July, 1948, in respect of dental treatment was £486 and in respect of spectacles £9. 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 from 1st January to 4th July, 1948, free in cases where the patients could not make such provision. Verification of the patients' circumstances was made by the tuberculosis care committees. The patients were allowed to retain the articles on discharge from residential treatment. Boarding out of child contacts As in previous years children were boarded out under the tuberculosis contact scheme when they were in danger of being infected with tuberculosis at home or when their parent or parents were recommended for or were receiving residential treatment for tuberculosis, and for whose care other arrangements were not possible. The arrangements for boarding out were made to the extent possible by the Invalid Children's Aid Association on behalf of the Council. There was a continued shortage of suitable foster homes and accommodation was therefore largely provided by the Council in its nurseries and residential schools and homes. The number of children boarded out under the scheme continued to rise and the average number away at any one time was, in 1945—155, 1946—180, 1947—230, 1948—257. The total number of children accommodated during the year was 585, of whom 362 were new cases and 223 were children whose stay extended from 1947. Residential open-air schools Children with a tuberculous background were accommodated during the year at residential open air schools for delicate children. No child with "open" or infectious tuberculosis was, however, admitted. The schools in use at the beginning of 1948 were:— Burrow Hill Colony School, Frimley; Kathleen Schlesinger Home, near Henley; George Rainey School, St. Leonard's-on-Sea; Wanstead House, Cliftonville; and Swanley Residential School, White Oak Hospital, Swanley. Two additional schools, Bowden House School, near Seaford, and Wainwright Residential School, Broadstairs, were opened during the year. At the end of 1948 the number of children with a tuberculous background accommodated at these schools was 91. 51 The arrangements described in the report for 1945 for the surgical after-care of patients discharged from hospitals continued up to 4th July, 1948, when responsibility was taken over by the appropriate hospital management committees. Surgical after-care 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 period 1st January to 4th July, 1948. Maintenance allowances (Memo. 266T) 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 were responsible for determining eligibility on medical grounds for any allowances authorised, and the Social Welfare Department was responsible for determining payment of allowances. During the period 1st January to 4th July, 1948, approximately £87,000 was paid in allowances compared with £158,000 in 1947. A considerable number of sanatorium beds much needed for the accommodation of patients who require active treatment is at present occupied by ambulant patients who cannot be discharged because they have no homes or the home conditions are unsuitable. Some of these patients can be admitted to village settlements or training colleges for post-hospital rehabilitation, where the Ministry of Labour arrange for training grants to be made. From 5th July, 1948, in necessitous cases the Council accepted responsibility for the cost of maintenance of a number of these patients whilst receiving rehabilitation. Patients are received at the British Legion Village, Maidstone; Papworth Colony, Cambridge, and Barrowmore Colony, near Chester. Up to 31st December, 1948, the Council had accepted responsibility for the maintenance of 31 patients. Workshops, settlements, etc. The Council decided to provide special residential accommodation in the form of "night sanatoria" for patients who, while well enough to be discharged from hospitals to work during the day, need lodging and facilities for rest under medical supervision. It is proposed to arrange with the Disabled Persons Employment Corporation set up under the Disabled Persons (Employment) Act, 1944, for the provision of workshop facilities, preferably on an adjacent site. It is contemplated that each night sanatorium will provide residential accommodation for about fifty persons, and about 150 tuberculous employees be trained in the workshops. Restrictions on building render it difficult to contemplate the erection of new buildings at present, but it is hoped ultimately to provide four such establishments in the county of London in new or adapted buildings. As an interim measure one or two small buildings may be obtained and adapted as residential accommodation for these tuberculous persons who could attend workshops set up by the Disabled Persons Employment Corporation. Night sanatoria Tuberculosis care committees are voluntary bodies for the organisation within the tuberculosis dispensary areas of measures auxiliary to treatment and form an integral part of the measures for fighting tuberculosis. In most London boroughs there were Tuberculosis Care Committees prior to 5th July, 1948, and the Council decided, as an interim measure, that the existing committees should continue to function with the addition, in each case, of a member of the appropriate Divisional Health Committee and the appropriate Divisional Medical Officer. Tuberculosis care committees Responsibility for operating mass miniature radiography units in London passed to the four metropolitan regional hospital boards on 5th July, 1948, and the two X-ray units operated by the Council were transferred, one to the South-East and one to the South-West Board. The Council has co-operated with the boards in arranging for the units to visit areas generally in accordance with past practice. The Borough Medical Officers of Health have assisted in securing volunteers for X-ray examination from factories, business organisations, etc. Mass miniature radiography 52 During the period 1st January to 4th July, 1948, the Council's two mass miniature radiography units carried out X-ray examinations of sections of the general public and children (14 years of age and over) attending secondary schools and technical colleges. Examinations were carried out at the following centres:— Westminster City Council Depot, Monck Street, S.W.1 (conclusion of 1947 centre covering the City of Westminster). Hammersmith Town Hall, W.6 (covering Hammersmith). Western Hospital, S.W.6 (covering Battersea, Chelsea, Fulham, Kensington, Paddington and Wandsworth (part)). South Western Hospital, S.W.9 (covering Lambeth (part) and Wandsworth (part)). The County Hall, S.E.1. Examinations of employees were also carried out by special visits to 22 factories and offices. From the inception of the mass radiography scheme in 1943 until 4th July, 1948, 262,353 persons in the London area had been X-rayed. This figure does not include examinations at mental hospitals. The following is a summary of the work done from 1st January to 4th July, 1948, by the units in operation for the general public with corresponding figures for the period 1st January to 31st December, 1947, in brackets:— Number Per cent. of miniatures Total miniature films taken 47,943 (50,263) — — Total large films taken 1,801 (1,742) 3.76 (3.47) Details of conditions revealed by large films (i) Persons requiring further investigation— (a) For lesions probably tuberculous 467 (474) 0.97 (0.94) (6) For lesions probably non-tuberculous 44 (35) 0.09 (0.07) (c) For cardio-vascular lesions 53 (71) 0.11 (0.14) (d) Referred for a further X-ray examination in 3-6 months 7 (10) 0.01 (0.02) (ii) Radiologically inactive lesions 580 (561) 1.21 (1.12) (iii) No abnormality 650 (591) 1.36 (1.18) The mobile unit visited Friern Hospital in January and Long Grove Hospital in May, 1,868 male mental patients and 2,131 female mental patients being examined. Particulars of the numbers of persons examined from 5th July to 31st December, 1948, are as follow:— Metropolitan Regional Hospital Board Boroughs, etc., covered Number of miniature films taken North-West Hampstead (part), Islington and St. Pancras 8,896 South-East *Lambeth (part), *Wandsworth (part), Bermondsey, Camberwell, Deptford, Greenwich, Lewisham and Southwark 21,544 South-West Visits to factories, business organisations, etc. 14,964 *Completion of work at centre set up before 5th July, 1948. 53 The number of recommendations for residential treatment for the period from 1st January to 4th July, 1948, with the corresponding figures for the last five years and 1938 were:— Year For the first period of treatment For further treatment Total Ex- Service Service sick† Civilian adults Children Ex- Service Service sick† Civilian adults Children Male Female Male Female 1938 2 - 2,610 1,960 796 52 - 1,671 1,160 199 8,450 1943 376 — 1,947 2,015 749 116 — 1,216 912 56 7,387 1944 583 — 1,774 1,874 712 183 — 1,159 945 80 7,310 *1945 286 193 1,699 1,763 707 209 1 1,034 915 104 6,911 *1946 249 163 1,740 1,761 853 213 1 927 983 105 6,995 *1947 386 98 1,789 1,927 854 254 3 868 971 104 7,254 *1948 (to 4th July) 120 52 951 971 414 132 1 404 488 63 3,596 Residential treatment •The revised procedure authorised in Ministry of Health circulars 127/45, 177/45 and 68/40, 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 be reflected 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 period from 1st January to 4th July, 1948, were dealt with as follows (the corresponding figures for the years 1938 and 1945-7 are also shown). Adults Children 1938 1945 1946 1947 1 Jan. to 4 July, 1948 1938 1945 1946 1947 1 Jan. to 4 July, 1948 (a) Admitted to "observation" beds to determine diagnosis or suitability for treatment at sanatoria 1,338 838 945 753 323 202 235 202 181 63 (b) Admitted to Pleural Effusion Unit - 278 260 346 167 - 14 22 27 8 (c) Passed for admission direct to sanatoria or hospitals 5,963 4,841 4,609 4,894 2,566 749 517 619 669 403 (d) Not accepted for residential treatment 106 26 42 88 42 23 21 31 55 3 (e) Withdrawn after application but before decision was reached 48 117 181 215 9 21 24 84 26 — Total 7,455 6,100 6,037 6,296 3,107 995 811 958 958 477 54 The number of beds occupied by patients under the tuberculosis scheme on 4th July, 1948 (with corresponding figures at 31st December for the years 1938 and 1943-47), was 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 1938 1,299(1) 1,010(6) 1,134(16) 3,443(23) 1943 1,249(184) 713(33) 1,323(120) 3,285(337) 1944 1,419(242) 490(30) 1,399(157) 3,308(429) 1945 1,233(160) 596(23) 1,316(145) 3,145(328) 1946 1,134(109) 615(49) 1,246(120) 2,995(278) 1947 1,061(143) 626(49) 1,360(194) 3,047(386) 1948 (on 4th July) 1,246(65) 661(23) 1,395(86) 3,302(174) CHILDREN 1938 658 6 60 724 1943 519 9 43 571 1944 416 12 55 483 1945 437 13 127 577 1946 422 21 167 610 1947 482 50 157 689 1948 (on 4th July) 516 6 175 697 Post hospital rehabilitation Discussions were still taking place at the end of the year with the metropolitan regional hospital boards and the other bodies concerned as to the nature of the arrangements that should be made by the Council in regard to persons requiring after-care following discharge from hospital. Special clinics Certain clinics were provided in the welfare centres by the metropolitan borough councils for the general population. The facilities included clinics for rheumatism; ultra-violet light; physiotherapy and massage; gynaecological and women's ailments; and for general medical and dental treatment. To avoid any break in the continuity of the provision made by these clinics it was decided, in consultation with the metropolitan regional hospital boards, to continue them until alternative arrangements were made. The provision of dental treatment is reported on by the Chief Dental Surgeon (page 83). The other clinics were still in operation at the end of the year. Foot clinics The Minister of Health agreed to the Council continuing to administer the 26 foot clinics which had been established or contemplated by the metropolitan borough councils prior to the "appointed day" but decided that, pending a decision as to whether chiropody was a form of treatment which should be provided by local health authorities, the service should not be extended. Venereal diseases The responsibility for the provision of facilities for the diagnosis and treatment of venereal diseases was transferred from the Council to the regional hospital boards and boards of governors of teaching hospitals on 5th July, 1948. The Public Health (V.D.) Regulations, 1916, were revoked and the London and Home Counties V.D. Scheme terminated on that day. The Council as local health authority continues, however, to be responsible for preventive work, after-care and following-up. A summary of work done at the London clinics for all areas will be found on page 127. 55 These figures and the returns from the clinics show a general decline in the number of V.D. patients in 1948 compared with the previous year. The table below gives the number of patients completing treatment and of defaulters as shown by analysis of the returns from the clinics for the year 1948:— Syphilis Gonorrhœa Male Female Male Female No. of patients discharged after completion of treatment and final tests of cure 972 683 3,375 891 No. of patients who ceased to attend after completion of treatment but before final tests of cure 1,137 551 2,375 372 No. of patients who ceased to attend before completion of treatment 665 395 813 147 No. of patients who died from the disease while still undergoing treatment 8 5 - - The inception of the National Health Service and the revocation of the Public Health (V.D.) Regulations brought to an end the V.D. scheme operated jointly by the Councils of the London and Home Counties for more than thirty years. This scheme arose from the necessity to take steps to combat the increasing menace of venereal disease during the first world war and the years immediately succeeding it. Thereafter, until the late war, a steady decline in the incidence of venereal disease was achieved while at the same time the facilities made available were increasingly used to the benefit of patients suffering from non-specific complaints. Conditions following the outbreak of war in 1939, as might be expected, led to an increase in venereal disease but it seems that the peak has been passed and a growing improvement has taken place in the last two years. 56 Inevitably, the bulk of the burden of treatment has fallen on the Metropolis and the Council, by agreement, arranged with voluntary hospitals to provide free diagnosis and treatment, pathological services and drugs for clinics and general practitioners, teaching facilities and assistance to necessitous patients by payment of fares. Clinics at seventeen voluntary hospitals in London were thus supported by grants from the County Councils and in addition the Council itself maintained two clinics. Aid was also given to hostels for unmarried mothers suffering from the disease. About 80% of the grants were contributed by London and the remainder by the Home Counties. The Council also arranged for extensive health and sex education by lectures, by the free distribution of literature, and by advertisements and notices concerning health and venereal diseases. Throughout the thirty-two years the clinic staffs did work which was beyond praise in combating the spread of these diseases. Most of the hospitals suffered heavy damage by air raids, yet the clinic work went on without a break in face of great difficulties. It is with much regret that this link between the Council and the hospitals is severed but it is hoped that close co-operation may be continued in future in preventive work and persuading patients to accept and complete treatment. As stated in the Annual Report for 1947, Defence Regulation 33B expired on 31st December, 1947, but the Council has continued to undertake the tracing of contacts of patients with a view to persuading them to undergo treatment voluntarily. This forms part of the Council's work under Section 28 of the National Health Service Act, 1946, and male and female welfare officers are available for this purpose and for following-up patients who are defaulting from clinics. An enquiry made into the extent of preventive and social work carried out at sixteen of the clinics in London shows that generally there is among them a similarity in working, the little variation between them being chiefly due to the amount of time which the staff have available to give to patients. The procedure in general use for case holding is for the almoner or director to send a letter which is sometimes followed by reminders if there is no response from the patient. Visiting is resorted to by some clinics but not by all, and it appears that the larger full-time clinics, having more adequate staff, are able to give greater attention to case holding than are the smaller hospitals. Ten clinics were able to do their own case holding and six were not. For tracing contacts the majority of clinics rely on the issue of contact slips which are handed to patients. Almoners at a few clinics have made some attempt to approach contacts direct but generally with negligible results. Only two clinics were able to do all the contact tracing desired and 14 were not. The almoner's work is practically confined to female patients, there being no comparable organisation on the male side. Four clinics have sought the assistance of the Council's welfare officer in persuading male defaulters to return for treatment but these requests were concerned with only twelve patients, several of whom had lodging-house addresses and enquiries met with little success. A few requests were also received for assistance by the Council's officers in tracing female contacts and defaulters. No reliable statistics are available of the results of the issue of contact slips. The V.D. clinics cannot be compared with other departments of a hospital. The relationship between doctor and patient is most important; the patient is often super-sensitive and resents the least interference or inquisitiveness. In no other work is it so essential for staff to have an unbiassed attitude and sympathetic understanding. Tactful handling is the best way to achieve good case holding. In London clinics the medical staff generally try to find time to undertake some propaganda conversation with patients and, in the case of married patients, make special efforts to bring in the spouse. There is, however, probably little time for eliciting information for contact tracing which needs the exercise of much skill and a special line of approach to be successful and yet retain the goodwill of the patient. In female clinics there is 57 generally a trained almoner staff available to advise and assist women but such staff are not available in male clinics, although in some cases experienced male orderlies are able to give individual advice. The use of posters and propaganda literature in the clinics is generally not favoured as it is felt that they may frighten nervous patients and be repugnant to the many patients attending with non-specific complaints. The Council has during the year received from the services a further 180 notifications of demobilised men who were under treatment or surveillance for V.D. Some 220 ex-Service men were interviewed by written invitation and 6 by visits to their homes to ensure as far as possible that they would complete treatment. Health education Posters and leaflets, mainly those published by the Central Council for Health Education and the Royal Society for the Prevention of Accidents, have been distributed through the Council's welfare centres and other establishments. It was found that there were some 80 different documents on the care and up-bringing of children being distributed, some being purchased from organisations dealing with maternity and child welfare, and others having been prepared and printed locally. A departmental committee was set up to examine this literature, and towards the end of the year they recommended that the Council should prepare and publish its own book for distribution to expectant and nursing mothers. Until 31st March, 1948, the Central Council for Health Education acted as agents of the Council in the campaign for the prevention of venereal disease, including the giving of talks and film shows on sex education. Since that date, and up to the end of the year, arrangements were made for speakers who had formerly acted on behalf of the Central Council, to give lectures on sex education to eight youth clubs and five parents' associations. In ten cases, courses of three lectures were given, and in the other three, single talks. In two instances the talks to youth clubs were illustrated by lantern slides. There were 365 attendances at the lectures arranged for parents, and 700 at the youth club courses. Posters giving the facilities available for the treatment of venereal disease continued to be displayed in public conveniences. In the last quarter of the year an intensive campaign on diphtheria immunisation was carried out. In conjunction with the Central Office of Information, newspaper advertisements, giving addresses and times of immunisation sessions, were inserted in the local newspapers. With the co-operation of the cinemas, lantern slides were shown giving similar information, and large quantities of posters and leaflets were distributed. It is impossible to show statistically the success of this campaign but, in the opinion of the divisional staffs, the campaign was so successful that it is being repeated in 1949. The main health education effort is, however, that of the health visitors to individual mothers or to small groups of them. These talks take place both in the welfare centres and in the homes. When space and staff permit, these individual efforts in the centres are supplemented by talks and demonstrations to larger audiences. Unfortunately, it has not yet been possible to expand this side of the work. MENTAL HEALTH SERVICES Mental Health Sub-Committee The appointment of a Mental Health Sub-Committee was approved by the Health Committee on 28th September, 1948. The Sub-Committee consists, apart from the ex-officio members, of eight members of the Council, three drawn from the Common Council of the City of London and the Metropolitan Borough Councils and one co-opted member. The Sub-Committee meets every four weeks, 58 Lunacy and Mental Treatment Acts, 1890-1930 On 4th July, 1948, immediately prior to the transfer of the Council's mental hospitals and institutions to the Regional Hospital Boards, there were on the registers of those hospitals and institutions 21,818 mental patients, of whom 16,989 were certified patients, 2,047 voluntary patients, 13 temporary patients, 1,867 detained under Section 24 of the Lunacy Act. 1890. and 902 uncertified senile Patients. Provision and care and treatment for the mentally ill The duties, previously performed by relieving officers in the Social Welfare Department, of taking the initial steps in providing care and treatment for persons suffering from mental illness have, since 5th July, been carried out by "duly authorised officers," designated mental welfare officers, in the Public Health Department. A senior mental welfare officer, thirteen mental welfare officers and five assistant mental welfare officers have been appointed. Experience in London indicated the desirability, as a general rule, of continuing the previous practice of removing mentally sick persons needing to be placed under care and control in the first instance to an "observation unit" (now properly described as a hospital designated for the purposes of Section 20 of the Lunacy Act, 1890) and the majority of cases have been dealt with in this way since 5th July. The proposals submitted to the Minister provided for the mental welfare officers to be located in the four district offices already established for work under the Mental Deficiency Acts, with a central night and week-end office at the County Hall to meet demands outside normal office hours. It was found necessary, however, owing to anticipated difficulties (which in fact materialised) in connection with the allotment of beds in hospitals designated under Section 20, to centralise the service completely in the first instance at the County Hall. It has not yet been possible to distribute the work among the district offices, but the matter is being kept under review in order that the original proposals may be implemented when favourable circumstances permit. Cars are provided for the use of mental welfare officers in securing the removal of patients in those cases where an ambulance is not necessary. The following table shows the number of cases dealt with by the mental welfare officers during the period 5th July to 31st December, 1948, and the action taken in respect of them:— Male Female Total Number admitted to hospitals designated under Section 20 1,045 1,472 2,517 Number dealt with in their own homes, etc., under Section 14 2 13 15* Number in which no action under the Lunacy Acts was considered necessary 321 42 363 Total 1,368 1,527 2,895 *Of these, 2 men and 7 women were certified and admitted to mental hospitals. Of the 1,045 male and 1,472 female patients admitted to hospitals designated under Section 20, 390 male and 787 female patients subsequently were certified and admitted to mental hospitals. The Council has no precise information as to the action taken in respect of the remaining patients, but it can be stated that some would have been admitted to mental hospitals as voluntary or temporary patients, some transferred to hospitals for the chronic sick, some discharged and some would have died. Care and after-care Since 5th July, 41 patients have been provided with recuperative holidays, usually for four weeks, in Mental After Care Association homes. Of these, 19 had been receiving treatment in general hospitals or at out-patient clinics and 22 were sent from mental hospitals. Of these latter, 10 were discharged from certificate and 12 were voluntary patients. 59 At the end of the year negotiations were in hand with the Mental After Care Association and the National Association for Mental health for those organisations to provide on behalf of the Council an after-care service, as a continuation and extension of the scheme operated since 1943 by the National Association for Mental Health at the request of the Board of Control and the Ministry of Health for persons domiciled in London, including ex-service personnel, suffering from mental illness not requiring, or no longer requiring, in-patient treatment. The Council agreed to contribute 90% of the approved cost of maintaining five psychotherapeutic social clubs in London run by the Institute of Social Psychiatry. The clubs, which are attended by patients referred from psychiatric outpatient clinics or from mental hospitals on discharge, provide in practical form the means by which the patients can secure social re-adjustment and maintain normal social relationships, guided by a psychiatrist and a social therapist. The Council also agreed, in consideration of the care and after-care work conducted at the centre, to contribute 33⅓% of the approved cost of running the social psychotherapy centre at Fellows Road, Hampstead, N.W.3., the management of which has been transferred from the Institute of Social Psychiatry to the North-West Metropolitan Regional Hospital Board. Mental Deficiency Acts, 1913-38 With the transfer of its mental deficiency institutions to the regional hospital boards, the Council was left with the duties, under the Mental Deficiency Acts, of ascertaining what persons in the County are suffering from mental deficiency; providing suitable supervision for mentally deficient persons or taking steps to secure that they are placed under institutional care or guardianship when necessary; and providing training or occupation for those under supervision or guardianship. Engaged in these duties from four district offices are the equivalent of 3¼ fulltime medical officers, five inspectors, four local organisers and twenty-seven assistants. Apart from the medical staff, all these officers are women social workers, most of them possessing a social science certificate or diploma. In placing cases under guardianship, the Council has continued to avail itself of the services of the Guardianship Society, Brighton, and of the National Association for Mental Health. Patients are conveyed to institutions by the Council's officers in private cars specially hired for the purpose, unless an ambulance is necessary. The following table shows the sources from which cases have been brought to notice under the Mental Deficiency Acts and the action taken thereon:— Source of information From 1st April, 1914, to 31st December, 1948 1948 only Supervision section 1,533 15 Local education authority 13,734 389 Police authority (Section 8) 1,843 32 Transfers from prison (Section 9) 227 1 Transfers from approved schools (Section 9) 556 3 From hospitals and institutions (1948 only) 87 87 Miscellaneous 9,788 140 Total 27,768 667 60 Position as at 31st December, 1948 with regard to the cases referred to in the first column of the preceding table:— Detained in institutions 7,530* 23,496 Discharged from institutional care 2,393 Removed to mental hospitals under the Lunacy Acts 495 Removed to a State Institution 141 Ascertained not subject for action 8,818 Died 4,119 Total removed from active list - Under guardianship 330 4,272ø In places of safety awaiting the presentation of a petition for an order 6 Under supervision 3,853† In institutions awaiting the presentation of a petition for an order 21 Still under consideration 62 Total remaining on active list - Total 27,768 Summary of cases dealt with during 1948 Placed in institutions 324 Placed under guardianship 44 Placed in places of safety pending the presentation of a petition 29 Placed under supervision 420 Discharged from institutional care 173 Removed to a mental hospital under the Lunacy Act 17 Removed to a State institution 17 Ascertained not subject for action 262 Died 122 1,408 *This figure includes 353 cases on licence who are visited at regular intervals by officers of the Council on behalf of the Regional Hospital Boards. tIn addition to the 3,853 cases under supervision, 999 persons known to the local authority to be mentally deficient but not subject to be dealt with under the Mental Deficiency 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 children who leave E.S.N. schools and supervising them up to 18 years of age. On 31st December, 1948, 412 children were being afforded the benefits of this scheme. The Ministry of Health made a grant of £1,800 to cover the cost of the work for the year. ø Of these 68 were awaiting the provision of institutional care. Occupation centres On the outbreak of war in 1939, the twelve occupation centres administered by the Mental Hospitals Committee, which catered for a total average roll of 339 mentally deficient children and young persons under supervision, on licence from certified institutions, or under guardianship, were closed. In 1944 it was decided that the Education Committee should undertake responsibility for re-opening, reorganising, and managing the occupation centre service as soon as the general situation permitted. In June, 1947, one small centre was established but was temporarily closed in June, 1948, and the children were transferred to one of three new centres opened on 5th July, 1948. At this date, when the Health Committee assumed responsibility for the centres, negotiations were in various stages of progress for the renting of premises (church halls, etc.) and for the adaptation of two redundant school buildings to establish additional centres. By 31st December, 1948, one centre had been closed owing to the lapse of the tenancy, the small centre (closed in June) had been reopened and three more centres had been established. Plans were also completed for the opening in January, 1949, of three more centres, and arrangements were partially completed for the establishment of four further centres to be opened in March, 1949, making a total of 13 centres (maximum total roll 375). Further provision is to be made for a total maximum roll of approximately 500. 61 Three types of centre are provided, i.e., junior mixed for children under 16 years and separate centres for boys and girls aged 16 years and over. The centres are open from 10 a.m. to 4 p.m. daily from Monday to Friday during primary school terms. The centres established up to 31st December, 1948, were:— Date of opening Address of centre Borough Average No. on roll Average daily attendance Centres for children July, 1948 (closed December, 1948) St. Augustine's Hall, Cadogan Terrace, E.9. Hackney 34 27 July, 1948 London Mission, Methodist Church Hall, Shepherd's Bush Road, W.6 Hammersmith 28 21 Reopened, September, 1948 (closed June-August, 1948) St. Margaret's House, 19, Old Ford Road, E.2 Bethnal Green 15 10 September, 1948 Methodist Church Hall, Albion Way, S.E.13 Lewisham 30 22 September, 1948 Caxton House Community Centre, 19, Andover Road, N.7 Islington 22 14 Centre for elder girls July, 1948 Fellowship Hall, 182, Hammersmith Road, W.6 Centre for elder boys Hammersmith 22 17 September, 1948 St. Michael's Hall, Darley Road, S.W.11 Battersea 17 15 Total 168 126 Note.—Maximum rolls (total 190) were not reached during this period, mainly owing to difficulties in obtaining guides to bring the children to the centres. Note.—Maximum rolls (total 190) were not reached during this period, mainly owing to difficulties in obtaining guides to bring the children to the centres. On terms agreed with the Kent County Council four London children attended a whole-day centre at Bromley, Kent, and approximately 16 (including cases on licence) attended the occupation centre at the Fountain hospital. The Organiser of Occupation Centres appointed by the Education Committee was seconded to the Public Health Department to continue her duties. Except where local circumstances require a variation, centres are staffed by a supervisor, an assistant supervisor and (except at elder boys' centres) a woman attendant. At the end of the year there were sixteen supervisors and assistant supervisors. Guides are employed to bring groups of children to the centres. In necessitous cases the children's fares are paid wholly or partly by the Council. Arrangements have been made for some occupation centre staff to attend courses in physical training, handicrafts and infant subjects, and a short general refresher course for staff was planned to take place during the Easter vacation, 1949, with a view to improving the standards of training in the centres. Mid-day meals provided by the Restaurants and Catering Dept. are deliveerd in heated containers to each centre, for which a charge of 5d. (waived or reduced in necessitous cases) is made to each child. Free milk is supplied to all those under 18 years under the Ministry of Food's Milk in Schools Scheme. At Christmas, 1948, a party at which parents attended was given to the children at each centre and, with the progress of handicraft work, open days and other functions will be arranged. 62 A medical examination and personal hygiene inspection of each child is carried out each term by a medical officer and a nurse on the divisional staff. SCHOOL HEALTH SERVICE Organisation The work of the School Health Service, largely dependent upon the duties imposed upon every local education authority by the provision of the Education Acts, 1944-48, and the Handicapped Pupils and School Health Service Regulations, 1945, made thereunder, was not, up to the end of 1948 greatly affected by the National Health Service Act, 1946. The arrangements for medical inspection and the special educational treatment of handicapped pupils will continue to be unaffected, but those for specialist treatment have to be discussed with the Regional Hospital Boards and the Boards of Governors of Teaching Hospitals. At the end of 1948, there were four part-time consultants, for ophthalmology, for diseases of the ear, nose and throat, for orthopaedics, and for psychiatry. There were also senior medical officers available for consultation in connection with all recommendations for special educational treatment. Examinations under Sections 34 and 57 of the Education Act, 1944, were in the main arranged locally in each Division, for children considered to be educationally subnormal, physically handicapped or delicate, but centrally at County Hall for children considered to be blind, partially sighted, deaf, partially deaf or epileptic. The results of all such "statutory" examinations were considered by senior medical officers at County Hall, and, finally, the School Medical Officer recommended suitable action to the Education Officer. Examinations were also carried out with a view to recommending special educational treatment for children suffering from speech defects, diabetes, and maladjustment. Pupils on school rolls The re-organisation under the Education Act, 1944, into primary and secondary schools continued during 1948, and, at the end of the year, there were 939 county schools and 401 voluntary or assisted schools (a department or combined department under one head is regarded as one school). There were 277,406 children of primary and secondary school age in county schools, and 95,684 children in voluntary or assisted schools, making a grand total of 373,090 pupils at the end of the year. The average attendance during the last term of the year was 88.04 per cent. Medical Inspection The content of the tables for 1948 is unchanged from the previous year and comparison is made with the years 1946 and 1947 and with the year 1938 (to provide a comparison with pre-war conditions). In comparing the years 1938 and 1946 with those of 1947 and 1948 regard must be had to the change that was made in 1947 when the figures for the grammar, technical and former central schools were, for the first time, included in the general tables; formerly the figures for these schools were tabulated separately under the title "Higher Education." This change concerns mainly the "Leaver" age group which now includes all pupils examined prior to leaving school, irrespective of age and the type of school. This means that the "Leaver" age group for 1947 and 1948 covers a group of pupils aged 15 years and upwards from both the former "elementary" and "secondary" schools, whereas for the years 1938 and 1946 the "Leaver" age group refers specifically to pupils of the former "elementary" schools examined in their fourteenth year. 63 The following table gives a summary of the medical inspections made during the year and comparisons with previous years. Routine (detailed) inspections 1938 1946 1947 1948 No. % No. % No. % No. % Nursery (a) — 4,218 2.5 7,074 5.0 8,953 5.7 Entrants 47,301 25.4 38,217 22.8 33,439 23.6 37,793 24.2 7 years old 39,044 21.0 26,882 16.0 26,046 18.3 26,222 16.8 11 years old 41,576 22.3 26,174 15.6 28,556 20.1 32,961 21.1 Leavers 42,074 22.6 21,641 12.9 6,433 4.5 26,817 17.1 Other ages — — 27,368 16.3 40,516 28.5 23,558 15.1 Higher Education 16,208 8.7 23,357 13.9 -(b) — -(b) — 186,203 100.0 167,857 100.0 142,064 100.0 156,304 100.0 Special Schools and Training Colleges 975 — 1,414 — 1,471 — 2,229 — (а) Nursery children recorded separately from 1946, onwards. (b) Now included in the leaver and other ages groups. Other Inspections Reinspections 1938 1946 1947 1948 252,693 130,452 151,443 172,594 132,240 69,912 84,227 8.8,243 384,933 200,364 235,670 260,837 There has been an overall increase in the volume of work carried out by the school health service on medical inspection in 1948 compared with the two previous years; the volume is still less than pre-war but the school population is smaller than in 1938. The proportion of routine inspections in the different age groups approximates to the proportions of 1947 except in the "Leaver" and "other ages" groups. The number in the "Leaver" group in 1947 was low because of the raising of the school leaving age in that year but it has reached more normal proportions in 1948. The "other ages" group covers all those inspections outside the categories listed above and includes pupils who have missed their particular age group inspection, the 12 year old pupils in the secondary schools who were not examined in their last year in a primary school and other inspections from the former grammar, technical and central schools. The significant fall in the proportion of "other age" group inspections may be an indication that the routine of medical inspections is becoming stabilised and that fewer pupils are missing their particular age group inspection. The number of inspections in the nursery group is greater than the number of children in the nursery schools and classes as every child is examined each term. The following table gives a more detailed analysis of the inspections:— Summary of medical inspections, 1948 (a) Routine Inspections Age Group Boys Girls Total Nursery 4,569 4,384 8,953 Entrants 19,199 18,594 37,793 Age 7 years 13,276 12,946 26,222 Age 11 years 16,577 16,384 32,961 Leavers 13,531 13,286 26,817 Other ages 12,622 10,936 23,558 Total 79,774 76,530 156,304 Special Schools 877 704 1,581 Training Colleges 125 523 648 Total 80,776 77,757 158,533 E Pupils referred for treatment Age group and sex Number of pupils examined No. of pupils referred for treatment (a) No. Percentage 1948 1947 Nursery Boys 4,569 743 16.2 16.1 Girls 4,384 630 14.4 14.8 Entrants Boys 19,199 3,666 19.1 18.0 Girls 18,594 3,069 16.5 15.6 7 years old Boys 13,276 2,895 21.8 19.4 Girls 12,946 2,746 21.2 21.2 11 years old Boys 16,577 3,147 19.0 18.5 Girls 16,384 3,508 21.4 20.1 Leavers Boys 13,531 2,007 14.8 14.0 Girls 13,286 2,694 20.3 16.6 Other ages Boys 12,622 2,469 19.6 17.6 Girls 10,936 2,546 23.3 22.4 Total (all ages) Boys & Girls 156,304 30,120 19.3 18.7 Special schools Boys & Girls 1,581 403 25.5 24.8 (a) See note above as to certain defects excluded from this table. The following table shows the percentages of defects in children inspected at routine examinations and referred for treatment or observation, with comparable figures for 1938, 1946 and 1947:— Defects found on medical inspection to require treatment or observation 1938 1946 1947 1948 Numbers examined 169,995 144,500 142,064 156,304 Percentages Skin diseases 0.80 1.3 1.20 1.22 External eye disease 0.53 0.60 0.67 0.61 Defective hearing 0.14 0.28 3.32 0.39 Otitis Media 0.51 0.51 0.47 0.70 Enlarged tonsils and adenoids 7.55 8.17 7.61 8.16 Defective speech 0.16 0.27 0.43 0.53 Enlarged cervical glands 0.63 1.10 0.99 1.01 Heart and circulation 1.00 0.62 0.62 0.73 Lung disease (not T.B.) 1.15 1.37 1.32 1.30 Orthopaedic defects (b) (b) 4.02 4.67 Defects of nervous system (b) (b) 0.33 0.30 Psychological defects (b) (b) 0.42 0.72 Anaemia 0.31 0.35 0.31 0.29 (b) No exact comparison can be given. 64 (6) Other Inspections Special Inspections* 107,844 260,837 Reinspections 88,243 Rheumatism supervisory centres (attendances) 10,505 Special ear inspection centres (attendances) 6,496 Vision centres (new cases) 31,377 Nutrition centres (attendances) 8,452 Medical inspections in residential schools 7,920 Grand total 419,370 *These are non-routine inspections of a miscellaneous nature and include pupils urgently brought to the attention of the school doctor, inspections for employment certificates, for school journeys and holiday camps, admissions to special schools and periodical inspections of handicapped pupils, etc. Number referred for treatment The numbers and percentages of children seen at routine inspections who were referred for treatment (other than for infestation or teeth) in 1948 are shown in the following table and for comparison the percentages for 1947 are also given:— 65 The incidence of skin diseases remains at a comparatively high level compared with pre-war conditions and, as in the previous year, the incidence of skin diseases is highest in the leaver, girls, group. Dealing with the increases in the 1948 figures compared with 1947, the increase in defective hearing occurs amongst the nursery and entrant groups; similarly with otitis media; with tonsils and adenoids there is an all round increase in the age groups, but the increase is particularly noticeable with boys and girls in the entrant and 7 years old and in girls in the leaver, groups. In the heart and circulatory group of defects the increase is mainly in the younger age groups, but the figure for leaver girls is double that of 1947, although the latter may be a "statistical" increase owing to the fact that few leavers were inspected in 1947 and therefore the 1947 percentage is not representative. The increase in orthopaedic defects is evenly distributed between the age groups and between the three defects classified under this heading, namely defect of posture, flat foot and other orthopaedic defects; and the increase in psychological defects is also evenly distributed amongst the age groups. Comparison with pre-war shows an increase in skin diseases, defective hearing, otitis media, tonsils and adenoids, and defective speech. The increases in defects in the past year and on pre-war conditions give no grounds for complacency in the school health service, but it is probable that standards are rising and that more minor illness is noted than in earlier years. Parents are invited to be present at all routine examinations and their presence is of great importance to the welfare of the child. That the parents welcome this opportunity is evidenced by the large proportion who attend—65 per cent. Attendance is highest in the early ages (92 per cent. in the "Entrant" group) and falls off as the children become older (24 per cent. in the "Leavers" group). Parents' attendance Much of the value of school medical inspection in London would be lost without the help of the Children's Care organisation which forms a link between the parents and their homes on the one hand and the school doctors, nurses, teachers and the school on the other. The work of this organisation is performed on a voluntary basis with a nucleus of paid organisers and the assistance rendered by the 1,430 voluntary workers is of great value. The keenness of the voluntary workers is evidenced by the fact that a care committee representative was present at 91.7 per cent. of the routine examinations of the primary school children. Attendance of Care Committee representative Until 1946 the figures for evidence of vaccination were remarkably constant, the overall figure being around the 47 per cent. level. In the past two years there has been a rise in the figure of pupils vaccinated, especially in the nursery and entrant age groups. It is surprising that this should be so, in view of the publicity given to the fact that the law concerning compulsory vaccination was repealed. It may be that the diphtheria campaign has focussed attention on prophylaxis for other diseases. It will be interesting to observe the effect on vaccination since repeal of the compulsion as this becomes evident when the babies of to-day become the school pupils of four or five years' time. The percentage of children found to have been vaccinated was 52.9, 0.2 per cent. more than in the previous year. Vaccination For diphtheria immunisation the percentages of pupils stated to have been immunised follow closely that of 1947. The overall figure for 1948 is 83.1 per cent. against 82.7 in 1947 and 81.0 in 1946. The evidence as to whether or not a pupil has been immunised is taken from parents at routine inspections and school health service staff have instructions that unless there is positive evidence of immunisation "no" should be recorded. Since, however, the parent's statement is in reply to a leading. question, it may be that the parent answers "yes" when the true fact is that the answer should be "no." For this reason it is probable that the figure of 83.1 per cent. immunised is an overstatement. Statistics relating to the immunisation of children of all ages will be found on page 126. Diphtheria Immunisation 66 Vision The table below shows the percentage of children with normal eyesight (with glasses if worn) in 1948 with comparable figures for 1938, 1946 and 1947:— Age Group 1938 1946 1947 1948 7 years old:— Percentages. Boys 63.8 79.0 80.0 79.2 Girls 63.6 77.4 77.4 78.2 11 years old:— Boys 70.8 80.1 80.7 81.7 Girls 67.8 77.2 76.7 78.1 Leavers:— Boys 71.4 79.3 80.7 80.9 Girls 68.9 76.2 77.3 76.7 Other ages:— Boys — 79.3 80.8 81.2 Girls — 77.1 76.8 76.4 There has been a diminution in the number of pupils who, at routine inspections, are found to have defective vision which has not already been adequately corrected. Nutrition The Ministry of Education's new classification of the general condition into (1) good, (2) fair, and (3) poor, was introduced in 1947 and has replaced the previous classification of the doctor's assessment of nutrition into (1) excellent, (2) normal, (3) sub-normal and (4) bad. The interpretation of the new terms has rendered impossible any comparison between the figures for 1947 onwards and those of previous years. Taking the Ministry of Education's ruling of the equivalent value of these two classifications as A—Good 1—Excellent B—Fair 2—Normal C—Poor 3 and 4—Slightly sub-normal and malnutrition the London figures are (in percentage of children examined):— Old classification 1 Excellent 2 Normal 3 and 4 Sub-normal and bad 1938 16.2 77.2 6.6 1946 18.0 76.4 5.6 New classification A—Good B—Fair C—Poor 1947 42.0 54.3 3.7 1948 40.8 56.0 3.2 There were no conditions operating between 1946 and 1948 to account for the great disparity between the percentage classification, the apparent improvement being far in excess of the slight change in the nutritional status which actually occurred. It is, however, satisfactory to note that a smaller percentage of children have been classified by the doctors as of "poor" general condition than in the corresponding group previously assessed as of "sub-normal" and "bad" nutrition. An alternative basis for comparison is to take the percentage of pupils referred for treatment or observation on account of nutrition, and these were for 1938, 1946, 1947 and 1948, respectively, 1.4, 2.0, 1.6 and 1.5. Anything which involves the personal opinion of an examiner is unreliable, but the doctor can, and does, take into account general alertness, flabbiness and poise, etc., in arriving at a correct classification. Height and weight records are facts not opinions, and therefore are subject to closer analysis. It is hoped that full records of height and weight will be available again in 1949. 67 Comment on the Council's dental scheme for school children are included in the report of the Chief Dental Surgeon on page 83. Dental condition The table below gives the percentages of children found to harbour vermin, i.e., nits and/or vermin in their hair at routine inspections during 1948 with corresponding figures for previous years:— Age Group 1938 1946 1947 1948 Entrants Boys 1.6 0.7 0.7 0.3 Girls 2.3 1.9 1.5 0.7 7 years old Boys 1.0 0.7 0.9 0.4 Girls 3.2 2.1 2.1 1.2 11 years old Boys 1.7 0.5 0.9 0.4 Girls 3.5 2.5 2.3 1.0 All ages Boys 1.7 0.7 0.7 0.3 Girls 2.9 2.2 1.8 0.9 Cleanliness There is a progressive improvement on the pre-war year (as is also shown in cleanliness of the body) and also a remarkable improvement during the year as shown by a comparison of the figures for 1947 and 1948. The number of pupils found to have vermin on the body was only 2 out of 156,304 pupils inspected. The parents are, however, warned beforehand of the doctor's inspections so the children are usually specially cleaned for the occasion. The most reliable index of the all-round incidence of head vermin among school children is that found by the school nurses at their monthly inspection of the children at each school, of which the parents are not previously warned. The following table shows the progressive lessening of the incidence of infestation found by the school nurses at these monthly inspections:— Total Number examined Number found to be verminous Percentage found to be verminous 1938 1946 1947 1948 1938 1946 1947 1948 1938 1946 1947 1948 Boys (a) 507,114 533,996 496,586 (a) 14,255 13,299 10,660 (a) 2.8 2.5 2.1 Girls (a) 496,245 548,307 525,730 (a) 42,639 40,829 33,535 (a) 8.6 7.5 6.4 Infants (a) 529,489 562,630 515,871 (a) 30,774 26,652 20,065 (a) 5.8 4.7 3.9 Totals 1,463,634 1,532,848 1,644,933 1,538,187 106,299 87,668 80,780 64,260 7.3 5.7 4.9 4.2 (a) Details not available for 1938. Many children are found to be verminous at more than one inspection which explains the fact that the number of individual children found to be infested in any one year is usually less than 50 per cent. of the total number of cases in which children were noted to be verminous. The number of individual children found during the year to be verminous was 29,970 (37,978 in 1947 and 65,292 in 1938). It is encouraging to note the drop in the all-round incidence of infestation with vermin since the pre-war year, despite the difficulties in housing conditions and of cleansing facilities and materials in the homes of the children. The system of advice cards and follow-up visits outlined in the Report for 1947 was continued. The number of advice cards issued during the year compared with 1947 was 32,677 (52,652). The number of children who attended the cleansing centre after the issue of advice cards was 26,102 (30,090); the number of statutory notices served was 7,626 (9,863); 2,212 (2,983) of the children concerned attended voluntarily and 4,197 (5,651) were compulsorily cleansed. 68 Scabies All cases of scabies are notifiable to the borough medical officers of health. The pre-war rise in the incidence of scabies from 8,389 cases treated in 1936 to 14,292 in 1938 was accentuated dining the early war years till the peak year of 1942, when there were 23,119 cases treated although the school population was less than half that in 1938. Since then the incidence has fallen year by year from 14,196 cases in 1945, 12,894 in 1946 and 6,001 in 1947 until 1948, when the number of cases treated was 3,051. During the year the particulars of the cases treated at the Council's treatment centres were:— Individuals Treatments 1947 1948 1947 1948 For vermin 29,519 28,573 48,467 48,796 For scabies 6,001 3,051 22,890 10,897 For impetigo 533 379 1,814 1,291 Totals 36,053 32,003 73,171 60,984 Choice of employment Owing to the small number of leavers in 1947 (due to the raising of the leaving age) the 1948 figures as to percentages of pupils with defects limiting their choice of employment are more strictly comparable with 1946 than 1947. Comparison of 1948 with 1946 shows a slight reduction in the overall figure and a reduction in practically all the conditions listed as contra-indications. Vision comes at the head of the list for both boys and girls, followed by heavy manual work for boys and prolonged standing for girls. The details are shown in Table 20 in the appendix. Following-up and reinspection 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. If necessary, further re-inspections are made to ensure, as far as possible, that every child gets adequate treatment. The follow-up results calculated from the doctors' inspection findings are the criterion of the effectiveness of the treatment services. The number of defects for which pupils were re-inspected for defects were:— Number of defects (other than dental) Number of dental defects Total defects First re-inspection 26,051 23,853 49,904 Second and subsequent inspections 18,082 13,271 31,353 44,133 37,124 81,257 The percentages of follow-up results showed that treatment was obtained as follows:— 1938 1946 1947 1948 Excluding dental defects 84.5 88.8 90.5 89.4 Including dental defects 82.0 83.5 87.1 87.0 The percentage not receiving treatment is small, but there are always some children who, because of movement to another area or of the neglect of their parents, do not obtain treatment. The neglectful parents are pressed as much as possible, the help of the N.S.P.C.C. being invoked where necessary. Medical treatment The Council arranged comprehensive free treatment at school treatment centres, and until 5th July, 1948, at the Council's hospitals, and at certain voluntary hospitals, for the treatment of specified defects. The scheme also included the free supply and 59 repair of surgical appliances, including artificial limbs, spectacles and insulin for pupils for whose education the Council is responsible. The Council also paid for in-patient and out-patient treatment at hospitals outside London of its pupils who were temporarily absent from their homes in London. Payment of the cost of emergency dental treatment by private practitioners (for the relief of pain) during evenings, weekends and at other times when clinics were not open was also authorised. With the coming into force of the National Health Service Act the Council's hospitals were transferred to the new Hospital Boards and all payments to voluntary hospitals and private dental practitioners for these services ceased. Payment was made of travelling expenses for pupils from Council schools and their parents or escorts, to clinics more than two miles from the home of a senior pupil, or one and a half miles in the case of a junior pupil, or for any shorter distance when the school medical officer considered this necessary, e.g. in the case of certain handicapped pupils. At the end of 1948 there were 84 school treatment centres, and in addition 24 voluntary hospitals had agreed to continue to provide medical and dental treatment for school children. Treatment Centres The following table shows the number of new cases treated at the school treatment centres and at the co-operating hospitals in 1938, 1946, 1947 and 1948:— Ailment 1938 1946 1947 ###] Eye (refraction and squint) 37,359 27,140 29,344 31,377* Ear, nose and throat 12,726 2,361 2,344 3,281 Minor ailments 128,819 106,938 133,731 170,181‡ Teeth 138,639 91,601 104,305 118,439 Special ear defects 1,830 770 1,520 1,691 Rheumatism supervisory centres 1,885 1,417 1,508 1,468 Nutrition defects 641 808 1,065 1,178 Ringworm (scalp) 103 311 245 110 Enuresis — — — 135 *During the year spectacles were prescribed and supplied to 23,034 children. The number of eye cases includes many "covered eye" cases who attend for observation; other children who do not require to have their spectacles changed or do not require them. ‡The total number of attendances at minor ailment clinics was 1,052,081. Until the 5th July, 1948, the Council, under the provisions of the Education Act, 1944, carried out sight tests and supplied and repaired spectacles for school pupils free of charge to parents. The arrangements provided for the services of refractionists at the school treatment centres and attendance at each session of a representative from the firm supplying the spectacles under contract with the Council. Since the operation of the National Health Service Act, spectacles for school pupils prescribed at school treatment centres have been supplied under the provisions of the Supplementary Ophthalmic Services, pending the development of the Hospital Eye Service. The arrangements provide for the continuance of eye sessions at the Council's school treatment centres, the refractionists, whose names must be on the Executive Council's approved Ophthalmic List, are employed and paid by the Council, and the London Executive Council reimburses the Council on a per capita basis. By agreement with the Ophthalmic Services Committee of the London Executive Council, the attendance at each session of an optician is continued, for the convenience of parents, but it is made clear to them that they have freedom of choice of optician for the child. The vast majority of the parents, however, avail themselves of the services of the optician attending the centre. At the end of 1948 there were 16 special classes for speech defects conducted by part-time speech therapists under the supervision of a principal assistant medical officer. Each child attends twice weekly for a period of 50 minutes and the maximum number of children attending a session is nine. Speech therapy 70 The number of new cases admitted during the year was 312 and the total number of individual pupils in attendance was 645. One hundred and four children were discharged as cured and 68, most of whom were improved, left for various reasons. The remainder were still under treatment at the end of the vear. Artificial limbs Artificial limbs were supplied free and were made and fitted at Queen Mary's Hospital, Roehampton, to which children are admitted, if necessary, for training in the use of a limb. During the year five new limbs and six duplicate limbs were supplied and repairs carried out in 25 cases. In addition, voluntary hospitals supplied four artificial limbs and repaired nine. Enuresis The arrangements made with Westminster Hospital (All Saints genito-urinary department) for reference on two sessions per week of pupils from Council schools suffering from enuresis, continued. An average of eight new patients and 32 old patients are seen each week by appointment, plus one or two sporadics. At the end of the year there were 311 current cases attending the clinic and the records show that for cases admitted during the year there was an average increase of 29 out of each possible 100 dry beds. Of the total of 311 children attending the clinic, 69 failed to respond to treatment. In April, a clinic for one session a week was established at Clapham Park School Treatment Centre. There were 121 children on the roll at the end of the year, and of this number four showed approximately 75 per cent. or more increase of dry nights ; 28 showed approximately 40-75 per cent; 32 showed approximately 15-40 per cent.; 53 showed little or no change, and four became worse during attendance. Many of the children attending had been previously treated at other hospitals, by private practitioners, or at child guidance or other clinics. Each child is medically examined in detail, including urinalysis, and is X-rayed or referred for other specialist examination and advice for conditions which may have a bearing on the enuresis. As confidence is established in the parents and the child, improvement takes place, the periods between attendance are lengthened and the parents are advised to bring the child back should there be any recurrence of the trouble. Each child is followed up by the children's care organisation. Classes for foot defects Special classes to correct foot defects before they develop into permanent disabilities, under the supervision of a part-time specialist in physical medicine, who made the selection of suitable children, and trained teachers, selected by the Council's organisers of physical training, were formed in 78 schools during the year. The children taking part in the exercises were drawn from the age group 9—11 years and each class comprised 10-14 children. The Supervising Medical Officer carried out a survey of the work during the year and the following figures show the results obtained:— Of a total of 703 pupils in age group 9-10 years, who took part in classes, 76.3 per cent. have had their deformity corrected, 23.2 per cent. have improved and 0.5 per cent. showed no improvement. In this age group 421, or 59.9 per cent., of the children taking part in the exercises suffered pain before treatment and 95 per cent. of these 421 children lost the pain as a result of the treatment. Of a total of 233 children in the age group 11, who took part in classes, 71.5 per cent. were corrected, 28.1 per cent. improved and one child showed no improvement. Of the total of 233 children, 135, or 57.9 per cent., had pain before treatment and of these 135 children, 95 per cent. lost the pain as a result of the treatment. Shortage of physical training staff necessitated the suspension of classes, either temporarily or permanently, at a few schools, and repair work and decorations in school buildings also prevented some classes functioning to the maximum extent. It is hoped, however, to extend the scheme to further schools as and when opportunity occurs. 71 Handicapped children 5,968 examinations of children were made during the year with a view either to ascertain the need for special educational treatment or to consider the need for continued special educational treatment. From the end of March, 1948, the practice of "ascertaining" what children were in need of special educational treatment was applied to those suffering from a speech defect or a stammer, and the figures given show the number of children dealt with during the remainder of the year. The division between the various categories under which the children were examined is as follows:— Vision 236 Hearing 166 Epilepsy 50 Educational subnormality 1,987 Delicate 2,292 Physical conditions 739 Dual defects 121 Speech defects 321 Various examinations 56 In addition 272 children were considered with regard to maladjustment and nine with regard to diabetes. Tables 21 to 31 in the appendix show the results of the above examinations, divided into ages and sexes and, in the case of the physically handicapped, with details of the morbid conditions found. Cerebral Palsy At the end of 1948, there was a total of 229 children known to be suffering from Cerebral Palsy. These were distributed as under In Day Schools for Physically Handicapped Children 184 In Day Schools for Educationally Sub-normal Children 8 In Residential Schools for Physically Handicapped Children 29 Invalided at home—unfit at present to attend school 8 A. Day Special Schools Defect No. of schools Roll Boys Girls Partially sighted 7 190 185 Deaf 4 147 122 *Partially deaf 4 34 23 Physically handicapped 20 819 732 Delicate 9 621 431 Educationally sub-normal 24 1,497 956 Total 68 3,308 2,449 *Special classes held in normal schools. Accommodation 72 B. Residential Special Schools Defect No. of schools Accommodation Roll Residential Day Boys Girls Blind 2 80 30 54 15 Deaf 3† 155 68 84 75 Physically handicapped 2 104 — 69 31 Delicate 7 439 — 228 136 *Educationally sub-normal 2 238 — 217 — Diabetic 1 63 — 37 26 Maladjusted 1 45 — 44 — Total 18 1,124 98 733 283 †Including "Rayners" which admits children suffering from dual defects. *Girls in "Palingswick House" residential E.S.N, home are included in day E.S.N, rolls. In addition to the handicapped children in the Council's own residential special schools, there were at the end of the year 844 L.C.C. children in non-Council residential special schools catering for the following defects:— Number of children in non-L.C.C. residential schools and hostels Blind 57 Partially sighted 7 Deaf and partially deaf 31 Physically handicapped 61 Delicate 449 Educationally sub-normal 86 Epileptic 58 Diabetic — Maladjusted 92 Speech defect 3 844 C. Hospital schools The Council also maintained the following seven hospitals for children requiring medical treatment, education being given when the children were considered fit for it by the medical staff:— Roll Boys Girls Goldie Leigh 43 36 Heatherwood 42 31 High Wood 111 103 Queen Mary's 272 243 St. Faith's 16 12 White Oak 51 54 St. Anne's, Herne Bay 18 24 Totals 553 503 The Council continued to administer these hospital schools after the end of the year although Goldie Leigh is the only one sited within the County of London. The others will ultimately pass to the local authorities of the areas in which they are situated. Holiday home care School children needing holiday home care, as distinct from convalescence for which provision is made by the Regional Hospital Boards, are sent to holiday homes through the Invalid Children's Aid Association free of any charge. From 5th July to the end of the year 1,098 school children had been placed in holiday homes for an average period of 3 weeks. Prior to 5th July convalescence was arranged by the Hospitals Division of the department and an account of the work is given on page 90. 73 In addition to the residential special schools there are seven residential schools with accommodation for about 2,550 children committed to the care of the Council under the Poor Law and Children's Acts. Residential schools The Children Act, 1948, came into operation on 5th July, 1948, amending or repealing some of the earlier Poor Law and Children's Acts and requiring local authorities to place the care of deprived children under a separate children's committee with its children's officer. The necessary re-organisation could not be completed by the end of the year, and at that date these schools were still administered by the Education Committee and were all full. A visiting medical officer attends each day and is available for emergency calls. He 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 carry out all dental treatment of the children resident in the schools. 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. 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 two typical days in the months of June and October, 1948:— Number in attendance on selected day Number who had dinner Number who had milk—one-third pint free Free Paying Totals June October June October June October June October June October Primary 209,017 208,520 10,503 10,331 89,225 90,144 99,728 100,475 202,528 202,240 Secondary 108,618 122,195 4,629 5,315 55,890 65,602 60,519 70,917 91,940 103,566 Day Special 3,277 4,564 520 668 2,625 3,699 3,145 4,367 3,129 4,497 Total 320,912 335,279 15,652 16,314 147,740 159,445 163,392 175,759 297,597 310,303 Provision of meals The percentage of children in attendance who received dinners was 50.9 in June and 52.4 in October compared with 49.3 and 50.3 in the same months in 1947. The free supply of one-third of a pint of milk to children was continued, 92.7 per cent. and 92.55 per cent. receiving it in June and October, respectively, compared with 92.1 per cent. and 91.8 per cent in 1947. The following information is supplied by the Chief Officer of the Restaurants and Catering Department:— The number of kitchens increased from 519 to 552 and dining centres from 740 to 794 between October, 1947, and October, 1948. Following extensive investigations, including chemical analysis of random samples of meals actually served to school children, it was found impossible to get the London child of any age to consume an average meal of 1,000 calories every school day and the School Meals Service aims at serving meals on the following lines:— Age Group No. of calories Under 7 years 500 7-11 years 650-750 Over 11 years 850-950 The diet of the children taking meals is under the supervision of the Council's nutritional consultant, Dr. T. F. Macrae, O.B.E., D.Sc. Random samples of served meals continue to be analysed by the Council's Chemist to keep a close check on the quantities and qualities aimed at. 74 Infectious diseases in schools Day schools The numbers of infectious cases reported from the day schools during the year are shown on page 126. The numbers of schools kept under observation during 1948 by school nursing sisters on account of the principal infectious diseases are shown in the following table:— Diphtheria Scarlet fever Measles Whoopingcough Chickenpox Mumps Total 18 81 339 122 145 170 875 Diphtheria immunisation When necessary, special visits were made by assistant school medical officers. Comments on this service will be found on page 42. Scalp ringworm During the year there was a marked falling on in the number of cases of scalp ringworm as indicated in the following table:— 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 1947 191 245 45 78 1948 81 110 16 65 Residential establishments for children There were no cases of scalp ringworm, but there were 13 of body ringworm among children in residential schools and children's homes. A majority of the Council's residential schools are equipped with a Wood's lamp and periodic screening of all contacts is immediately instituted on the occurrence of a case of scalp ringworm. This, with other preventive measures, has in the past resulted in immediate control. Premises Psychiatric service in remand homes In April of this year Marlesford Lodge was closed and the girls transferred to Stamford House which thereafter, as a temporary expedient, housed both girls and boys. Staff On May 1st, Dr. A. P. Rossiter Lewis handed over to Dr. P. Scott, who was appointed on a basis of 2/3 full-time to be responsible for the psychiatric work of the Remand Home, and to supervise the work of the two psychologists. The team was completed in September by the appointment of Mrs. S. McConville as psychiatric social worker. The information available for a given case is now extensive and forms an adequate picture of the background and present status of the individual. The work of the psychiatric social worker is largely intra-mural so that she supplements and does not replace the usual probation officers' reports. Statistics Reports made Boys , Girls Total Percentage Psychiatric report Special Physical (Medical officer or Gynaecologist) General Psychological (Remand Home Staff and Psychologist) Conduct report (Superintendent and Remand Home Staff) Total 632 168 800 56.7 45 79 124 8.8 29 1 30 2.1 71 11 82 5.8 777 259 1,036 73.5 75 Some of the children had reports made under more than one heading. Of the 1,411 children (1,156 boys and 255 girls) remanded to the Home no reports were required in 26.5 per cent. Analysis of cases referred for psychiatric examination in the 6 month period—1st May-3lst October Sex and age 8 years 9-10 11-13 14 15 and over Total Boys 25 41 93 62 98 319 Girls 1 6 20 12 62 101 Total 26 47 113 74 160 420 Disposals ordered by the Court Boys Girls Probation and Supervision Order 131 46 Fit Person Order 40 14 Approved School Order 70 11 Discharged Probation of Offenders Act 26 11 Certified Mental Deficiency Act 2 1 Punitive Detention 1 — Result not known 8 6 Decision Pending 41 12 319 101 Annual trend in number of Psychiatric Reports requested is shown by the following percentages taken from the annual statistics of the Remand Home 1936 11.6 1944 35.3 1937 20.9 1945 33.4 1938 26.5 1946 47.9 1941 19.9 1947 43.0 1942 31.6 1948 56.7 1943 35.3 The completion of the psychiatric team should now make records sufficiently full and reliable to enable research to be carried out. The three difficulties, however, are likely to be lack of time owing to heavy routine work, shortage of clerical assistance and difficulties in securing follow-up information. Possibilities for research Analysis of 345 consecutive cases which had been referred to the Remand Home for psychiatric examination showed that 116 of them had been recommended for psychological treatment. Of these 116, 84 were considered fit to have their treatment at a clinic while remaining at home, and 32 were thought to need placement away from home. Of these latter cases 10 were recommended to have psychological treatment in approved schools while 2 were recommended to be kept under periodic psychiatric surveillance in approved schools. The remaining 20 were recommended for treatment while residing in residential schools or hostel. Psychological treatment Examination of the decisions of the Court in these 116 cases showed close correspondence between recommendation and decision. Rheumatism scheme The great changes in the Council's Public Health Service brought about by the National Health Service Act made the organisation of the Rheumatism scheme very much the same as it was prior to 1930. Between 1926, when the scheme was born, and 1930, the beds required for the institutional treatment of rheumatic children were provided by the Children's Hospitals then under the control of the Metropolitan Asylums Board and the organisation of the Scheme itself was essentially an organisation devised for the purpose of co-ordinating the ascertainment, treatment and 76 supervision of London children suffering from rheumatic disease. Associated with this the Scheme was concerned with the investigation and amelioration, if necessary and possible, of the social environment of the rheumatic child, and the collection of information relating to the incidence and effects of juvenile rheumatism. The acquisition by the Council in 1930 of Children's Hospitals formerly under control of the Metropolitan Asylums Board naturally facilitated a considerable expansion in the number of beds available for institutional treatment, and permitted a much more intimate association of the treatment side with the administrative and supervisory side of the scheme. The advantages of such an intimate association were considerable, and it is to be hoped that under the new regime the benefits of this close co-operation will not be lost. From the point of view of the continuation of the campaign against juvenile rheumatism in London (which during the 22 years the scheme has been in existence has met with no small measure of success) nothing would be more disastrous than a breaking up of the present co-ordinated organisation into a number of regional independent organisations associated with individual hospital treating units. The provision of beds is now a matter for the regional and other hospital boards, but only by the continuance of a central organisation which concerns itself with co-ordination of all the branches of the rheumatic problem, can a true picture be obtained of the position and a satisfactory scheme be maintained. Nominations for admission to hospital were 614, the average figure for the past three years being 637. During the three years before the outbreak of war the average number of nominations was 2,380, which, considering the reduction of the London school population, gives a rate 50 per cent. above the present one. The average number of children under supervision is also much smaller as the pre-war number was 175 per cent. of the present one. On the other hand the percentage of children admitted with established cardiac damage tends still to increase, being 70.2 compared with 41 for the years 1934-38 and 67.7 last year. (Table 33.) These changes may mean that the infection when it does occur is more virulent or that there is a more severe selection before a case is referred to hospital and Dr. Thornton, the physician in charge of the scheme, who is in personal touch with the children while in hospital, favours the first alternative. Social Conditions Reports received relative to the home conditions of rheumatic children are still depressing. Reports of dampness, the results of bomb damage and general dilapidation, are still frequent. The energetic co-operation of the Borough Medical Officers of Health in dealing with such conditions is again gratefully acknowledged. Audiometric testing Tests of the hearing of pupils over seven years of age by means of portable gramophone audiometers, with which specially trained school nurses are able to test forty pupils at one time, were carried out in schools in three divisions during the year. Any child with a loss of nine decibels or more in either ear is tested a, second time by gramophone audiometer, as many, especially younger, children, fail in the first test through lack of attention or other cause. A limited number of children who failed the second gramophone audiometer test were given a further test by puretone audiometer with a view to obviating the reference to special ear centres for treatment of those not in need of it. The total number of pupils tested by gramophone audiometer was 26,572, of whom 6,438 failed in the first test; 2,128 failed in the second test. It was only possible to arrange for 505 of those who failed the second test to be tested by puretone audiometer, of whom 214 failed. The pupils failing the puretone audiometer test, together with the remaining 1,623 of those who failed the second gramophone audiometer test, were referred to special hearing centres. A total number of 726 77 children completed treatment at special hearing centres during the year, and of this number 217 again failed the audiometer test and were referred back to aurists for consideration as to further treatment. All pupils failing to keep appointments at these centres were "followed-up" and new appointments made for them. It is hoped to extend the arrangements for testing by gramophone and puretone audiometers to all nine divisions. Problem children The Council's scheme, established in 1944, to co-ordinate the special children's case work was continued in 1948. Particulars of all school children presenting difficulties in behaviour or of educability are referred to a case conference of senior officers of the Education Officer's and School Medical Officer's departments, in each of the nine divisions into which London is divided for education (and since 5th July, 1948, also for school health) purposes. All cases referred by the conferences for specialist medical examination or for child guidance are submitted to the School Medical Officer. Prior to 5th July, 1948, cases officially referred by the School Medical Officer to voluntary child guidance clinics were paid for at the rate of £7 10s. for each child and progress reports were called for at the end of each term. After that date all such treatment was provided free of charge by the hospitals concerned, under the National Health Service Act, and progress reports were submitted at the discretion of the hospitals. The number of children referred to case conferences during the year 1947-48 was 1,413. These cases were disposed of as follows: 1,009 were referred for child guidance, 27 for attendance enforcement, 50 for medical treatment, 72 to special classes, 14 for boarding education, 10 for foster homes, 52 for ascertainment for maladjustment, 93 for statutory examination to ascertain whether educationally sub-normal and 194 for other forms of educational treatment. The total of 1,413 is less than the total of the analysis as some children fall into more than one group. Progress in dealing with current and previous cases was: 501 no longer considered to be "problems," 69 were in residential accommodation, 62 were on the waiting list for such accommodation, 598 were under treatment at child guidance clinics, 206 were on the waiting list to attend the clinics, and 636 had been otherwise dealt with. At the end of the year five successful classes under specially experienced teachers had been organised for backward children who also presented some form of maladjustment. During the year Peckham Residential Special School was opened to accommodate 42 boys, most of whom attend local schools; some of the younger children are educated on the premises. Maladjusted girls are accommodated at Norwood Children's Home (maladjusted unit) which has 25 children. 97 maladjusted children were in residence at schools belonging to the Council other than at Peckham and Norwood, or in non-Council schools or hostels or boarded out with foster parents. At the end of the year, the Council was responsible for child guidance clinics at Bishop Creighton House and Putney Health Centre. All other child guidance facilities in London were under the control of the Regional Hospital Boards or the Governors of Teaching Hospitals. A survey of facilities for child guidance treatment in the County was undertaken during the year and the question of providing additional facilities was actively pursued. Difficulty in this connection was encountered by reason of the division of responsibility between local education 78 authorities and the Regional Hospital Boards under the new Health Service, the former being deemed to be responsible for diagnosis and the latter for treatment. Discussions between the responsible authorities had reached no conclusion at the end of the year. Diabetic unit The Council's residential diabetic unit for about 50 children is housed within the curtilage of the residential school at Hutton (Essex). The day to day care of the pupils is undertaken by a visiting medical officer and by 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 under the supervision of the consultant. The pupils take part in all school activities, including a fortnight's visit to a holiday camp. 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 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 which cannot be adequately controlled at home, and be of such intelligence as to profit by their stay. Children under 5 years of age Visits continued to be paid during the year to primary schools where there was a number of children under 5 years of age, by a school medical officer and an inspector of the Education Officer's department, with a view to introducing some approximation to nursery class conditions. At the end of 1948 there were 100 nursery classes with accommodation for approximately 3,400 children from 3 years of age and upwards. In addition to a midday meal, these children get one-third of a pint of milk daily and cod liver oil and other vitamin preparations; for those who require it medicaments containing iron are also prescribed. Nursery class children attend during the ordinary school hours of primary school children. Nursery school children attend from 8.30 a.m. to 4.30 p.m. and have breakfast (when necessary), dinner and tea, and two-thirds of a pint of milk daily in addition to the other supplements supplied to the nursery class children. At the end of the year there were 15 maintained day nursery schools with accommodation for 975 children from two years upwards and six aided day nursery schools with accommodation for 273 nursery school children. All the children in nursery classes and schools were daily supervised by school nurses and each child examined in detail every term by a school doctor. There was a total of 9,710 children under five years of age on the day school rolls, 7,871 being in the Council's schools and 1,839 in voluntary or aided schools. There were eight residential nursery schools outside London with accommodation for 461 children from two years of age upwards. In addition to a local visiting doctor the schools were medically supervised by the local maternity and child welfare authority and a medical officer from the County Hall visited each term. Co-operation with hospitals The valuable pre-war arrangements with some of the former voluntary hospitals whereby one or more of the Council's treatment organisers attends, at the request of the hospital authorities, the children's out-patient departments to form a link between the hospital doctors and almoners and the school health service, is still maintained at the London, Guy's, West London, Royal London Ophthalmic, Belgrave, Poplar and 79 London Jewish Hospitals, and the Queen Elizabeth Hospital tor Children, Shadwell and Hackney. Treatment organisers also attend the special sessions to which pupils are referred by the school health service at the following hospitals:— Belgrave Hospital for Children Aural Bermondsey Medical Mission Eyes, minor ailments and teeth Evelina Hospital Eyes Guy's Hospital Eyes, aural, skins, orthopaedic and diphtheria carrier clinic Hampstead General Hospital Rheumatism King's College Hospital Eyes London Hospital Eyes and teeth Princess Louise Hospital Aural Queen Elizabeth Hospital, Hackney Teeth and rheumatism ditto Shadwell Rheumatism Royal Dental Hospital Teeth (orthodontic) Royal Free Hospital Rheumatism Royal Eye Hospital Eyes Royal Waterloo Hospital Rheumatism St. George's Hospital Rheumatism St. Mary's Hospital Eyes and aural South Eastern Hospital for Children Eyes, aural and minor ailments Western Ophthalmic Hospital Eyes Westminster (All Saints Genito-Urinary) Enuresis In addition, the Council refers children for child guidance to the following hospitals and clinics within the National Health Service: Great Ormond Street Hospital, St. George's Hospital, The London Hospital, University College Hospital, West End Hospital for Nervous Diseases, London Jewish Hospital, Guy's Hospital, Maudsley Hospital, Queen Elizabeth Hospital, Hackney Road, Institute for the Scientific Treatment of Delinquency, Institute of Social Psychiatry, the Tavistock Clinic and the Child Guidance Training Centre, but Council organisers do not attend these clinics As an example, the following is a summary of the report of the divisional treatment organiser, three of whose assistants act as the link between Guy's Hospital Children's Out-Patient Department and the special clinics of the School Health Service. Children's Dept. Ear, nose and throat Eyes Orthopaedic Skin General Orthoptic New school children seen 625 715 389 48 149 195 Attendances of current cases 1,564 1,575 — 844 266 563 Discharged—treatment completed 264 459 164 20 90 156 Referred to other departments 83 — 33 — 51 29 Lapsed through non-attendance 52 105 — — 50 — Referred for operation — 248 — 33 27 — Glasses ordered — — 276 — — — Glasses obtained — — 230 — — — No glasses needed — — 93 — — — Retested—no change of glasses — — 111 — — — Referred to Child Guidance Clinic 52 — — -— — 8 The total number of attendances of L.C.C. children in departments covered by the organisers was 6,609. STAFF During the first six months of the year, while the Council was still administering the Hospitals Service, the process of consolidating basic scales of staff pay with the temporary cost-of-living additions granted during and after the war was completed. During this period the Council also applied to many grades of hospital staff further Hospital staff F 80 recommendations of national wage fixing committees and councils. When the time came to hand over the hospitals with the 25,350 staff in the Public Health Department who had been engaged in the Hospitals Service, the Council could fairly claim to have tidied up, either on its own initiative or by the acceptance of nationally agreed rates, the wages position resulting from new conditions created by the war and its aftermath. The number of staff transferred was much below the number provided for in the establishment (page 91) because of shortage of staff and of war damage. For obvious reasons, not many changes in the existing structure of the Hospitals Service were made in the months immediately preceding the "appointed day," but one matter, however, is worthy of mention. Following the much regretted death of Mr. G. F. Stebbing, F.R.C.S., F.F.R., who for many years had held the almost unique position of Specialist in General Surgery and Chief Clinician in the Radiotherapy Department at Lambeth Hospital, the Council decided to divorce the direction of the radiotherapeutic work at the hospital from the general surgery so that the undivided attention of a radiotherapist could be given to the supervision of the work of the busy and widely esteemed radiotherapy department at the hospital. A position styled "Director of Radiotherapy, Lambeth Hospital" was created from and including 1st April. 1948. Reorganisation of department The staffing problems which confronted the Council's Public Health Department during 1948, with its vast changes affecting the health services, were indeed difficult and heavy. For the first six months of the year, the department had three main tasks to complete simultaneously. In the first place, its normal work had to go on. This included the continued administration of the hospital service until 5th July and the detailed and intricate arrangements made for the handing over of the 98 hospitals to the Metropolitan Regional Hospital Boards and to certain Boards of Governors of Teaching Hospitals. At the same time, arrangements had to be made for the taking over of the services to be transferred from the metropolitan borough councils and the general assumption by the Council on 5th July of its duties under the National Health Service Act. This necessarily involved the creation of the nucleus of a new department within the existing framework of the one that was to pass away. In addition, a considerable number of staff experienced in hospital administration were lent in the early part of the year to the metropolitan regional hospital boards to assist them in their heavy task of preparation. All this had to be done without further staffing additions and that it was, in fact, achieved successfully is greatly to the credit of the staff concerned, whose difficulties in handling, over the course of these months in increasing "tempo," problems caused by an unprecedented situation were very great. In preparation for the assumption of its new duties under the National Health Service Act, 1946, the Council approved a scheme for the reorganisation of the Public Health Department. Under this scheme the central medical administrative work was divided into two main branches, one under the direction of the Deputy Medical Officer of Health to deal with environmental hygiene and with the prevention of illness, care and after-care and the other under a Principal Medical Officer to deal with the personal health services for mothers; young children and school children. On the lay administrative side, the work, under the direction of the Administrative Officer, was reorganised into four divisions in addition to the London Ambulance Service. The four divisions are concerned respectively with (a) maternity and child welfare, including school children; (b) co-ordination of planning, mental health, prevention of disease, care and after-care, building work and acquisition of sites; (c) committee work, finance, statistics, health education and other miscellaneous matters; and (d) staff and establishment matters. In addition to these central office changes the Council created three principal administrative positions in each 81 of the nine divisions into which the county had been divided for health purposes. These positions of Divisional Medical Officer, Divisional Administrative Officer and Divisional Nursing Officer were filled partly from the Council's own staff and partly from suitably qualified staff employed by the metropolitan borough councils. These officers did a considerable amount of preparatory work before the "appointed day" in connection with their new tasks and to them is due, in no small measure, the credit for the smoothness with which the transferred services were absorbed into the Council's organisation. The health services taken over from the borough councils were staffed by about 4,850 whole-time and part-time officers and employees comprising medical staff, administrative and clerical staff, health visitors, tuberculosis visitors, nursery nursing staff, domestic staff and home helps. In addition a few officers were taken over from voluntary bodies who had decided not to continue to provide personal health services after the "appointed day"; also a number of health visitors employed by voluntary organisations who were continuing with their functions were taken onto the Council's staff in order to facilitate the creation of an integrated service for the county as a whole. Transferred staff After the urgent initial problems inseparable from the transfer of a large body of staff had been dealt with, the task of applying standard scales of pay and conditions of service to the several categories of staff had to be considered. This task was a good deal lighter than it would have been if the Council had been faced with it a few years ago because of the extension during recent years of wage negotiating machinery for Local Government staffs. Thus, there was found to be a good deal in common as regards pay, and to a lesser extent conditions of service, between the nursing and domestic staff of the Council and of the metropolitan borough councils. For other grades, notably medical and administrative and clerical, the metropolitan borough councils had common scales and conditions though not the same as those of the Council. Standard pay and conditions The first grade of transferred staff to be co-ordinated with the Council s staff was that of Assistant Medical Officer. The Council approved of the application of the scale of salary paid to Assistant Medical Officers in its School Health Service to the whole-time Assistant Medical Officers in the transferred Maternity and Child Welfare Services with effect from 5th July, 1948, provided that the officers concerned accepted the Council's standard conditions of appointment and service. This scale of salary was an improvement on that paid by the borough councils. Specialisation in either maternity or child welfare has been encouraged amongst all Assistant Medical Officers in an endeavour to secure that, as far as possible, medical officers who are best fitted by experience and choice to work in ante-natal and post-natal clinics are allocated to that work and those who are more interested and experienced in child welfare are allocated to child welfare clinics and the School Health Services. Efforts have been made to create and maintain close liaison with the hospitals both as regards the teaching of medical students in Council clinics and the "refreshing" of Council medical officers by attachment for periods to the maternity or children's departments of hospitals. Medical staff It was the Council's intention to combine the staffing of the newly acquired dental service for mothers and young children with its long-standing organisation for school children. Unfortunately, not long after the "appointed day" it became apparent that this priority dental service was in jeopardy. The rates paid on a piecerate basis to dentists employed in the general dental services resulted in an increase in the attractions of this form of practice and many of the Council's dentists resigned in order to take up this work. As it became clear that the setting up of negotiating machinery to deal with salaries of Local Authority dental officers would be a lengthy process, the Council, after consulting with other Local Authorities who agreed that special action was justified in London to stem the flow of dentists away from the Dental services 82 priority services, increased its scale for whole-time dental surgeons to £770 rising to £1,250, an increase of £30 at the minimum and £245 at the maximum. This has helped to stop the exodus and to bring in a few new recruits. Although the Council's plans for extending and improving the dental services committed to its care have had to be held in abeyance, there has, in recent months, been no further deterioration. Health visitors It was amongst health visitors that under-manning was most marked in the transferred health services. There is a nation-wide shortage of health visitors and this shortage was acute in certain areas of London where working conditions are unattractive and the housing shortage very acute, with the result that the health visitor has to live a long way from her district. Recruitment of health visitors on a service basis for London as a whole was commenced immediately the Council took charge of the services and this should have a beneficial effect on the position in the unattractive areas. It is, however, too early as yet to assess the results. In an effort to deal with the root cause of the problem, namely the general shortage of qualified health visitors, the Council set up a scheme for the training of health visitors which is being worked in co-operation with the King's College of Household and Social Science. Twenty-five students embarked on a year's theoretical and practical training during which they were paid at three-quarters of the commencing salary of a qualified health visitor. A Health Visitor Tutor was appointed to supervise the field training. The scheme provides that, if the students are successful in the examination for the Health Visitor Certificate, they will give the Council at least six months' service as health visitor immediately following qualification. No general shortage of staff existed in the transferred Day Nursery Service. Here the most important task was to maintain the efforts of the borough councils to raise the standard of training of many of the existing personnel, particularly in the lower grades. Frequent periodical courses in child care have been arranged for nursery assistants by the Council's Education Department and all such staff are being sent on these courses in turn. Courses for the training of nursery wardens have also been held. Domestic staff Almost all of the transferred domestic staff were employed on the conditions of service of the Joint Industrial Council for Local Authorities Non-Trading services (manual workers). In October, 1948, a 44-hour week (as against 47 previously) was introduced for all grades of staff within the purview of the Joint Industrial Council. This reduction in hours came at a time when the Council was still fresh to the working of the transferred services but, on the whole, the change-over was effected smoothly and with very little increase of staff or working of overtime. Home help service Recruiting in the rapidly expanding Home Help Service continued to be very successful, mainly in the field of part-time workers. In an effort to improve the quality of the work, the Council consulted the National Institute of House-Workers Limited and as a first step it was decided that the Institute should test a representative number of workers whose standard was considered to be comparatively high with a view to the award of the Institute's Diploma to those who were found satisfactory. Considerable progress along these lines had been made by the end of the year. Medical examination of staff The number of references to the department for medical examination or advice concerning the health of staff and the fitness of candidates for appointment totalled 14,689 compared with 16,840 in 1947, the reduction of work being due to the transfer of the Council's hospitals to the Minister of Health on 5th July, 1948, under the National Health Service Act, 1946. Reciprocal arrangements with provincial authorities for the examination locally of new entrants were continued. Provincial Medical Officers of Health arranged examination for 9 entrants to the Council's service and the Council's medical officers examined 23 persons for provincial appointment. The Council's staff medical examiners made 50 home visits to examine members of the staff who were unable to travel. 83 DENTAL SERVICES The Council's Chief Dental Surgeon, Mr. Wm. Ritchie Young, V.R.D., F.D.S., took up his duties on 7th July, 1948, and reports as follows:— Owing to the interest now taken in dental services and their great importance, it is thought advisable to present a statement showing the position before and after 5th July, 1948. Dental facilities in the county of London at the commencement of 1948 were available as under:— (i) By attention from private dental practitioners at expense of the patient, or aided by National Health Insurance payments through "Approved Societies." (ii) By public bodies— (a) Metropolitan Borough Council Dental Services, mainly for "maternity" cases and pre-school children and a certain amount of dental treatment for the tuberculous. In some boroughs a general dental service was provided. (b) The Council's School and Hospital Dental Service of a comprehensive nature for school children and "maternity" cases attending L.C.C. hospitals. [Treatment was provided also for certain other in- and out-patients.] (iii) By voluntary bodies— (а) The Eastman Dental Clinic.—Chiefly treatment of school children on behalf of the Council. (b) The British Dental Hospital.—Mainly treatment of adults including certain work for the tuberculous. (c) Voluntary Hospitals and Dental Teaching Schools. Treatment of school children when arranged by the Education Authority was free. In most of the cases under (ii) and (iii) there was a small charge which, however, could be remitted. When the National Health Service Act came into operation on 5th July, 1948, great changes in responsibility for dental facilities were introduced and were as under:— (1) Private Practice.—wherein the patient pays the dentist—remains, bat anyone can ask the dentist [provided he has joined the Executive Council's list] to give him free treatment as a patient under (2). (2) "The General Dental Service" in which practitioners in their own premises are paid by the Executive Council on a " scale of fees for work done"; while (3) In Provided Premises (Health Centres) they are remunerated by the Executive Council on a salary basis. (4) Hospital Dental Services remain but there are no charges. (5) Dental Teaching Hospitals and Schools are directly under the control of the Minister of Health through specially appointed Boards of Governors. Here, also, treatment is free and the dental surgeons are remunerated on a sessional or whole-time salary basis, 84 (6) "Priority Dental Service" is designed to give special priority to mothers and children by Local Health and Education Authorities— (а) for Expectant and Nursing Mothers and pre-school children by virtue of Section 22 of the National Health Service Act, 1946; (b) for School Children by virtue of Education Act, 1944. This means that everyone is now entitled to free dental treatment. The only limiting factor is the availability of dentists. There is, however, a tripod of administrative responsibility under two Ministries. In the county of London the three legs of the tripod are represented by the London County Council Priority Dental Services. London Executive Council General Dental Services. Metropolitan Regional Hospital Hospital Dental Services including Boards (4) and Boards of Governors dental care of the tuberculous. of Teaching Hospitals (26). The London County Council, therefore, by virtue of Section 22 of the Act is now responsible for the Priority Dental Services in the county and has the duty to make provision for the adequate dental care of expectant and nursing mothers and preschool children, and by virtue of the Education Act, 1944, the Council retains responsibility for the dental examination and treatment of school children in the county. The Council's Hospital Dental Service was transferred to the Ministry of Health's control on 5th July, 1948, when sixty equipped dental surgeries in hospitals and the equivalent of nineteen full-time dental surgeons passed from the Council's control to that of Regional Hospital Boards or Boards of Governors of Teaching Hospitals. These premises and officers were replaced, to some extent, by the transfer to the Council from the twenty-eight metropolitan boroughs and the City of London of the dental services provided, up to then, by them. These services were unevenly developed and were complicated by the fact that six boroughs provided not only dental services under their maternity and child welfare schemes but, under the Public Health (London) Act, a dental service for the general public. Two full-time dentists and thirty-five part-time officers (equivalent to an additional six full time units) were transferred. Most of the dental treatment which had been provided in the boroughs was for expectant and nursing mothers but a proportion was for the tuberculous. The unification of these several Maternity and Child Welfare dental schemes received attention in the latter half of the year but it will be some time before the different dental functions can be disentangled and passed to the appropriate Authority under the Act. It has therefore been necessary for the Council to act in the capacity of "agent" for other authorities, with regard to (a) some provision of dental care of the tuberculous at twelve dental treatment centres on behalf of the Regional Hospital Boards; (b) continuance of General Dental Service in the boroughs of Bermondsey, Shoreditch, Finsbury, Hackney, Stoke Newington and Poplar on behalf of the London Executive Council (after July 5th these technically became Health Centres); and also to (c) the processing of artificial dentures at the Council's Central Dental Laboratory, on behalf of the Regional Hospital Boards, 85 Hospital dental service In the first six months of the year the Council's hospital dental service carried out the following treatments with the equivalent of nineteen full-time dental surgeons General Hospitals Mental Hospitals Other Special Hospitals Total No. of sessions 3,657 810 541 No. of patients inspected Inspection 13,478 7,205 2,190 No. requiring treatment 12,007 4,282 1,533 No. of attendances for treatment 24,173 6,749 3,583 First visits for treatment in current year as either in- or out-patient 9,366 3,350 1,297 Institution Public Assistance Cases Out-patients (1st visits) 148 — — Out-relief 443 — — Ante-natal cases 4,150 — — Welfare of Blind cases 77 — — Others 3,112 — — No. of teeth extracted 16,944 4,527 1,464 Local Anaesthetics 5,891 1,678 833 General (Administrations) 2,455 436 128 No. of teeth completely restored by filling 7,024 711 2,240 No. of fillings 7,619 734 2,439 Temporary dressings or fillings, AgNo3 treatments, uncompleted scalings, gum, mouth or jaw treatments, etc. 3,729 379 366 Scalings completed 1,961 1,174 338 Gingivitis or stomatitis treatment completed 294 44 92 AgNO3 treatments completed (teeth) 72 8 47 Jaw injuries. Treatment completed 9 1 — Appliances fitted for jaw injuries 12 2 2 Patients provided with new artificial dentures 918 219 101 Full New dentures supplied 1,200 294 92 Partial _ 315 64 55 Dentures remodelled 31 1 11 Dentures repaired 211 242 44 Other operations 1,774 606 68 Treatment completed 5,788 2,908 1,276 86 The ratio of in-patients to out-patients treated in general hospitals was 1 to 5.66, while of the total patients treated almost half were ante-natal cases. School dental service In the latter half of the year under review staffing problems became increasingly difficult as dental surgeons resigned to transfer to the General Dental Service under the Local Executive Councils where their earning capacity on a scale of fees method was substantially greater. In all, the equivalent of twenty full-time officers resigned. The staff at the end of the year consisted, only, of forty-three full-time officers and twenty-one part-time officers (equivalent of ten additional full-timers); the number authorised for the School Dental Service was 67. As a result of this loss of staff twenty-seven surgeries out of a total of seventythree were closed or partly closed at the end of the year (in all ninety-three less sessions per week were being worked) and dental inspections in schools had to be curtailed to prevent severe congestion at the centres. Included in this figure of twenty-seven surgeries are seven of the ten mobile dental units which were purchased (ex-R.A.F.) in 1947. This is the more regrettable in that it had been found that at schools served by the mobile units the acceptance rate had seldom fallen below 90 per cent. while at the ordinary clinics not on school premises the acceptance rate from dental inspections in schools throughout the service in 1948 was 59 per cent. The restricted nature of the surgery in the mobile units makes them unpopular with many dental surgeons who prefer a properly equipped static surgery. This preference will be met when proper dental treatment centres are established in school premises, and this policy was pressed forward in the year under review. Preliminary essential dental plumbing was installed in a number of suitable new or reconditioned schools. Since 5th July, 1948, Divisional Health Committees have commented upon the unsatisfactory standards of certain converted houses and shops as treatment centres—both London County Council "school" centres and ex-Borough Maternity and Child Welfare centres. This state of affairs has been appreciated for many years but financial, war and building difficulties have hindered progress. Staff shortage has been turned to advantage by abandoning some of the least satisfactory surgeries and utilising staff in the better appointed premises. The attendance and routine inspection and treatment figures for 1948 are given in the following table with comparison with figures in previous years. Up to July the school dental service was rapidly being restored to its pre-war level and the figures for 1948, as a whole, show a greater volume of work than in 1947, but during the last quarter of the year the ground gained was rapidly lost and the 1949 figures will undoubtedly show a set-back. 1945 1946 1947 1948 Number of Inspection Sessions at Schools 919 1,315 1,588 1,230 Number of Children Inspected at Schools 92,227 138,290 163,528 158,063 Number found to require treatment 64,455 91,441 109,169 102,344 Percentage requiring treatment 69.9% 66.1% 66.8% 64.7% Additional Number inspected at Centres * * * 44,068 Total number found to require treatment. * * * 146,412 Total cases treated 74,874 91,601 104,305 118,439 Attendances 100,641 171,554 199,840 236,175 Temporary teeth extracted 65,591 110,177 116,795 116,664 Permanent teeth extracted 12,341 18,999 18,716 20,641 87 1945 1946 1947 1948 Temporary teeth restored by fillings 14,216 31,117 39,685 43,033 Permanent teeth restored by fillings 44,988 72,303 82,309 94,561 Fillings in temporary teeth 14,953 33,262 42,222 45,617 Fillings in permanent teeth 49,423 79,866 92,335 104,913 Scalings 2,568 6,619 9,550 2,504 (Jan.-Mar.) Temporary dressings, etc. 17,593 32,234 48,317 15,698 (Jan.-Mar.) Other operations—temporary teeth — — — 28,406 (Apr.-Dec.) Other operations—permanent teeth — — — 25,602 (Apr.-Dec.) Local Anaesthetics for extraction 11,622 22,807 24,857 24,859 Local Anaethetics for conservative treatment 3,630 4,003 5,582 5,372 General Anaesthetics 21,867 34,664 38,036 41,292 Cases completed 43,795 73,006 86,166 98,474 Ordinary treatment sessions 8,522 15,017 19,737 22,619 General anaesthetic sessions 941 1,495 1,679 1,774 Ratio of permanent teeth restored to permanent teeth extracted: 1945 4.04 to 1 1946 4.2 to 1 1947 4.93 to 1 1948 4.58 to 1 •Figures not available. During 1948 Lady Mellanby on behalf of the Medical Research Council continued her examinations on the dental condition of five-year-old school children in the county. Lady Mellanby also published in 1948 the results of her similar work in 1947. They show a continued improvement from survey to survey. Her figures are:— Caries Investigations Caries free 1929 4.7% 1943 24.2% 1945 28.1% 1947 37.5% At Hutton Residential School and Hornchurch Residential School investigations into the effect of topical applications of Sodium Fluoride to children's teeth were started in March, 1948, but sufficient time has not yet elapsed to show definite results. Recent reports from America claim great possibilities in this type of preventive dental treatment. Prior to 1948 all cases of malocclusion were referred to expert orthodontists for treatment but, demand far exceeded their potential and in the past year clinicians have been encouraged to treat cases themselves. By this means 229 more children were treated in 1948 than in the preceding year, and a number of the staff have shown themselves very proficient at this work. Some orthodontic comparative figures for past years are given below. Orthodontic treatment 1938 1945 1947 1948 Number of orthodontists 2 2 2 4 (part-time) Number of sessions 434 310 411 542 Total number of new cases 1,114 632 573 923 The reference of orthodontic cases to the orthodontists is controlled by issuing to clinicians reference forms in balance with the treatment potential of the orthodontists. Maternity and child welfare dental service The diverse nature of the dental services transferred from the boroughs, to which reference has already been made, rendered the compilation of reliable statistics for 1948 somewhat difficult, as the methods used in the different boroughs for the keeping of their data did not conform to any standard pattern, 88 Dental Surgeons in the borough treatment centres were engaged on widely differing terms, but most had, in addition to a sessional fee for attendance, a separate fee for each denture provided. The Council's Central Dental Laboratory can provide dentures but it was not possible, until after the end of 1948, to arrange this and to alter this condition of service of the transferred dentist. The Central Dental Laboratory was until then fully occupied with the production of dentures for the transferred hospital dental service and of appliances for the Council's school dental service. It is the intention to integrate the maternity and child welfare dental service with the school dental service but at the end of the year only one treatment centre was furnishing a combined school and maternity and child welfare priority dental service. The number of maternity and child welfare sessions in operation per week at the end of 1948 was 68. Much of the dental treatment for expectant mothers in London is still carried out in the hospital dental service under the control of the regional hospital boards in ex-L.C.C. hospitals. A tabulation of attendances and treatments for the year follows but, owing to the circumstances already mentioned which prevailed throughout 1948, the table is in some respects not complete. Maternity and child welfare service M.C.W. work General Total Attendances Total number of sessions * * 4,982 Ordinary 288 Gas First treatment 10,959 1,916 12,875 Attendances 36,710 11,719 48,429 Treatments Silver Nitrate treatment 416 103 519 Scalings 1,324 684 2,008 Prolonged gum treatment 135 — 135 Fillings 8,549 1,962 10,511 Crowns 1 — 1 Extractions 17,355 7,259 24,614 Dressings 598 527 1,125 Other operations 2,728 1,466 4,194 Anaesthetics Local 349 43 392 General 3,645 1,278 4,923 Dentures Supplied New-full (U. or L.) 1,016 — 1,016 New partial 149 — 149 Others unclassified 1,011 3,892 4,903 Dentures remodelled 8 — 8 Repairs 235 265 500 • Figures not available. Other denial services As already mentioned some of the boroughs provided a general dental service. In two main health centres—Shoreditch and Finsbury—these general dental services had been provided for many years. From the "appointed day" the Council continued these services, gradually separating "priority" from "non-priority" work —the latter being recognised as ultimately, at least so far as employment of the dentists is concerned, the responsibility of the London Executive Council. Somewhat similar action was taken from 5th July to 31st December, 1948, by the South-East Regional Hospital Board in Bermondsey Health Centres, after which the Bermondsey dental services were transferred to the Council, 89 In all, six ex-borough treatment centres provided "general" dental services in addition to their "priority" service, and twelve ex-borough centres provided dental service for tuberculous patients on behalf of the Metropolitan Regional Hospital Boards. The activities, staff and premises of the British Dental Hospital were transferred on 5th July to the respective Regional Hospital Boards in whose areas their four premises were situated, while the activities and staff of the British Dental Hospital on behalf of seven metropolitan boroughs were transferred with the borough premises to the Council. Considerable confusion in functional responsibility resulted as all three authorities are implicated by reason of "priority," "general" and "tuberculous" patients attending. Throughout the latter half of the year the Council continued as far as possible to provide dental services at least equal to those in being prior to 5th July, 1948, but staff resignations rendered this impossible in all areas. HOSPITALS AND ANCILLARY SERVICES General and, special (other than mental) hospitals Under the provisions of the National Health Service Act, 1946, the Council's hospitals passed from the control of the Council to the four metropolitan regional hospital boards on 5th July, 1948, and an account of the Council's Hospital Services will be found on p. 91. It had not been possible, for various reasons, to reopen the following hospitals : Millfield Convalescent Hospital, Littlehampton; Orchard Hospital, Dartford; St. Clement's Hospital, E.3; St. Luke's Hospital, Lowestoft; and South-Eastern Hospital, New Cross. Some of the buildings were used for other purposes than the reception of patients. The Downs Hospital for Children and St. Margaret's Hospital, Kentish Town, remained with the Council as residential nurseries. St. Peter's Hospital, Whitechapel, and the Norwood Hospital for Children remained closed and were retained by the Council. At the beginning of the year, 8,015 patients were under treatment in the acute general hospitals. The number remaining on 4th July, 1948, was 8,155. Acute general hospitals The number of patients in the chronic sick hospitals at the beginning of the year was 2,423. The number remaining on 4th July, 1948, was 2,384. Chronic sick hospitals Continued difficulties were experienced, owing to the shortage of staff, in providing hospital accommodation for the treatment of patients suffering from infectious diseases. The restrictions on the admission of patients suffering from scarlet fever, german measles, chickenpox and mumps continued throughout the period from 1st January to 4th July, 1948. The number of infectious patients at the beginning of the vear was 760. The number remaining on 4th July. 1948. was 707. Acute infectious hospitals No cases of smallpox were admitted during the period. St. Luke's Hospital, Lowestoft, remained closed. 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 lack of staff. Smallpox Tuberculosis hospitals Millfield Convalescent Home remained closed, and the Downs Hospital and Norwood Children's Hospital were used for other purposes. Queen Mary's Hospital, Carshalton, Goldie Leigh Hospital, St. Anne's Home and White Oak Hospital continued to provide accommodation for children. Children's hospitals The two hospitals for epileptics, St. David's Hospital, Edmonton, and St. Faith's Hospital, continued to provide treatment for male and female epileptic patients. Hospitals for epileptics Princess Mary's Hospital, Margate, continued to provide accommodation tor female adult convalescent patients. The number of such patients, admitted from 1st January to 4th July, 1948, was 1,356. Large numbers of male adult convalescent Convalescent hospital (adults) 90 patients were sent to voluntary convalescent homes and female adult convalescent patients, who were not suitable for Princess Mary's Hospital, were also sent to voluntary convalescent homes. Convalescent children The arrangements made with the Invalid Childrens Aid Association, under which children, for whose medical care the Council was responsible, were referred to the Association for placing in convalescent homes, were continued throughout the period. The number of such cases dealt with was 869. In addition to the foregoing arrangement, the long standing practice was continued of accepting financial responsibility for the convalescent treatment of children brought to the Council's notice by the Invalid Children's Aid Association themselves. The number of such cases during the period 1st January to 4th July. 1948. was 609. Other hospitals The Northern Hospital, Winchmore Hill, and Southern and Joyce Green Hospitals, Dartford, continued to receive patients suffering from general and noninfectious conditions from the other hospitals. Venereal diseases Beds for patients suffering from venereal disease were provided at Bethnal Green, Sheffield Street and St. Charles' Hospitals. Admissions to Public Health hospitals The numbers of patients admitted during the period 1st January to 4th July, 1948, are shown below:— Acute general hospitals* 66,014 Chronic sick hospitals 3,012 Convalescent hospital (adults) 1,356 Convalescent hospital (children) 343 Convalescent fever hospitals† 3,286 Acute fever hospitals‡ 7,012 Tuberculosis hospitals 701 Children's hospitals 1,795 Post-encephalitis lethargica unit 9 Venereal diseases hospitals and units 324 Epileptic hospitals 76 Nursery units 264 Total 84,192 *Includes Queen Mary's Hospital, Sidcup. †Hospitals devoted wholly to non-fever patients. ‡Includes general medical patients. Evacuated hospital patients Owing to the extreme shortage of nursing and domestic staff, it was not possible to bring back to London more than a few evacuated hospital patients. The number remaining in the provinces on 4th July, 1948, was 369. Emergency obstetric service During the period 1st January to 4th July, 1948, 56 calls were made compared with 52 for the same period of 1947. An analysis of the calls shows that they were received from 19 boroughs and were answered by units from 11 of the Council's hospitals. Twenty-seven of them came from four boroughs, viz.:—Wandsworth (11), Lewisham (5), Battersea (5), Lambeth (6), and the hospital units answering most of the total calls were St. James' (16), St. Alfege's (9) and Lewisham (6). The calls were made by general practitioners (16), midwives (18), nursing homes (6) and other persons (16). The majority of the calls were to patients where postpartum haemorrhage or retained placenta had occurred. In 39 cases blood transfusion was given. One death occurred of a patient attended by the emergency obstetric service. District medical service Statistics are available for the first quarter of the year only. The total number of persons seen and treated, 16,308, showed an increase of 1,021 on the same period of 1947. Attendances at medical relief stations and surgeries increased from 26,175 91 to 30,035, while domiciliary visits decreased from 13,475 to 10,916 due no doubt to a mild winter. Hospital admissions dropped from 754 to 501. The service was carried out from 89 medical relief districts (46 north of the river and 43 south). Eleven of these districts were served by London County Council whole-time medical staff and the remaining 78 by part-time general practitioners in contract with the Council. District medical service—statistics for period 1st January to 31st March, 1948 By part-time By hospital general medical practitioners officers Medical relief districts served 78 11 Doctors attending at relief stations 40 11 Doctors attending at surgeries 33 — Attendances at relief stations or surgeries 30,035 (26,175) Domiciliary visits 13,475 (10,916) Persons seen 16,308 (15,287) Persons admitted to hospital 501 (754) During the period 1st January to 4th July, 1948, examinations were made in the Group Laboratory and in the subsidiary laboratories at the hospitals and institutions. These tests may be grouped broadly as:— Classification Number of tests Total In group laboratory In subsidiary laboratories Bacteriological 9,866 12,776 22,642 Wasserman and parallel tests 7,153 — 7,153 Biochemical 1,360 3,026 4,386 Histological 129 97 226 Other pathological 3,311 14,708 18,019 Skin tests 306 1,637 1,943 Miscellaneous 22 114 134 Total 22,145 32,358 54,503 Laboratory work Bacteriological tests for typhoid and dysenteric infections again form the largest single group—16,317 in number. THE HOSPITAL SERVICE 1930-1948 On 5th July, 1948, under the provisions of the National Health Service Act, the Council's hospitals passed to the care of the Regional Hospital Boards, and it is fitting, in this last report on the service, that some account should be given of their history and development. Until the Council took over these hospitals from the Metropolitan Asylums Board and Boards of Guardians on 1st April, 1930, its sole hospital responsibility had been for mental hospitals. On that date the Central Public Health Committee was entrusted with the administrative control of 63 hospitals, one children's home and 12 institutions formerly managed by 26 different authorities. One authority, the Metropolitan Asylums Board, controlled 33 of these hospitals but most of the Boards of Guardians had control of only one hospital each. Transferred with these hospitals was a staff of about 20,000 persons ranging from boy messengers and domestic assistants to medical superintendents and chief medical officers of groups of hospitals. On the same date, the Mental Hospitals Committee took over the administration of six transferred mental hospitals. In the nature of things it was obvious that to effect a smooth transfer no hasty changes of procedure should be made, and the first consideration was that the hospitals should continue to function without interruption. Few people can have 92 been aware at the time of transfer of the magnitude and complexity of the operation, which, to the great credit of everyone concerned, was carried out smoothly and efficiently. The change having been made the next step was to decide on plans for a comprehensive service and for this purpose an ordered programme of development was evolved. It was clear from the outset that this would prove an enormous task involving much time and energy and a heavy expenditure of money. To march with the improvements to hospitals by rebuilding and addition, the construction of new nurses' homes and ward blocks and the introduction of new equipment of all kinds from X-ray plants to kitchen machinery were also necessary. Departmental committees were set up to consider and advise on such matters as hospital standards, the treatment of tuberculosis, pathological work in group laboratories, forms and records, an ambulance service, medical supplies, staffing and other subjects, and these, in due course, submitted their reports. The problem was not merely one of the administration of the hospitals and institutions formerly maintained by different authorities, but of producing a central organisation for hospitals which varied greatly in size and were in all stages of development. Difficulties due to the wide divergencies of policy pursued by the different authorities, the variation in the character and quality of the work carried on, the overlapping or deficiency of services, had to be faced. It was necessary to draw up a scheme for the provision of a service catering for the needs of sick persons requiring hospital treatment of all kinds, the acute, the chronic, the tuberculous, maternity, the mentally disordered, sick children, the convalescent, the fever patient and others. Arrangements were also necessary for the co-ordination of a domiciliary medical service for those on relief and for the provision of medical and nursing services in Public Assistance institutions. One of the chief problems was that of releasing accommodation during alteration, and, at the same time, of retaining sufficient beds to provide for admissions. From 1930 to 1939, great improvements were made in hospital accommodation and the Council had reason to look forward with high hopes to the future. Special units for the treatment of certain conditions requiring expensive equipment or highly skilled staff had been opened in certain hospitals, and an ordered programme of development was well under way. Just prior to the war the Council approved plans for the construction of a new hospital in Tooting but this unfortunately was not started owing to the outbreak of War As an indication of the magnitude of the hospital service (other than that provided by mental hospitals), it may suffice to say that in 1938, the last pre-war year, there were available 16,210 beds in general acute hospitals, 4,367 in chronic hospitals, 5,067 in fever hospitals, 1,423 in tuberculosis hospitals and sanatoria and 5,821 in long stay children's and other special hospitals. Total admissions of patients to these hospitals in that year were 232,359 and there were 1,044,829 out-patient attendances. Adequate and proper staff is even more important than adequate and proper buildings and equipment, and great improvements in staffing standards were made by the Council. Medical staff was much increased in numbers and at an early date a comprehensive and co-ordinated service of consultants and specialists was introduced. Further developments were prevented by the threat and outbreak of war but since the war an important improvement was made by the appointment of a large number of whole time specialists for the hospitals. Valuable though this step was, it nevertheless represented only part of proposals which would have been made to the Council but for the impending transfer of the hospitals to the Regional Boards. 93 An important development for which the Council can claim credit is its hospital laboratory service, made up of large and comprehensive group laboratories at certain hospitals and subsidiary laboratories at the others. The nursing services received much attention from the Council. Numbers were increased and hours of duty and other conditions improved. Training was improved, and co-ordinated and centralised preliminary training schools instituted. It is most unfortunate that during and since the war, recruitment of nurses was very unsatisfactory. Reference should be made to the important part played by the Council's hospitals in medical teaching. Hammersmith Hospital was developed into the most important postgraduate medical school in the country. Fever hospitals provided both underand postgraduate instruction. The general hospitals played an increasing part as ancillaries to the undergraduate schools based on the voluntary teaching hospitals. On the outbreak of war the Council was presented with the double problem of providing for the ordinary sick and for air-raid casualties which it was assumed would be heavy. These activities and the great extension of the ambulance and other services required by the war do not need detailed description, but it can be said that through all the dangers and hazards of war and the damage, often severe, caused by enemy air attacks, the hospital service never failed and the citizens of London owe a debt of gratitude to the devoted members of the staff of all grades who made this possible. Many acts of personal heroism received suitable recognition by the award of decorations from H.M. the King. The aftermath of war left a heavy accumulation of work in the restoration of damaged hospitals, the redecoration of wards, etc., which had remained unpainted for a period of nearly six years, and the replacement of furniture, linen and equipment of all kinds; and this, with a general shortage of men and materials, prevented the resumption of major works of improvement on a large scale. Other problems were created by the continuance of the rationing of foods and materials of various kinds. The Council has been a mental hospital authority ever since it came into being, consequent upon the passing of the Local Government Act, 1888. At that time, the Council had four "asylums" and was responsible for some 10,000 patients, about half of whom were housed in the institutions of other authorities. It took over from the Middlesex Justices the task of building another large institution in accordance with plans prepared and on a contract already let. Since then the Council has itself built and opened six more hospitals for the mentally sick, one of which was appropriated for use as a certified institution for the mentally defective; it adapted three other premises for use for defectives; it built a special hospital (the Maudsley) for voluntary mental patients and research, which in addition, is recognised as a school of London University for postgraduate teaching in psychological medicine; and after the passing of the Local Government Act, 1929, it took over from the Metropolitan Asylums Board and a Board of Guardians, six other institutions housing cases of mental defect and chronic harmless persons of unsound mind. At the outbreak of war in 1939, two of the smaller mental deficiency institutions were closed and have not since been re-opened, so that up to July, 1948, the Council was administrating 19 separate mental institutions of all types and was responsible for the care of some 30,000 patients— either mentally sick or mentally defective—in addition to Sutton Emergency Hospital with accommodation for 500 psychoneurotic patients under the emergency hospital scheme. During the war, the mental hospitals made their contribution to the emergency medical service and, in addition to the accommodation at Sutton Hospital, about 6,000 general hospital beds were provided in the Council's mental institutions by a 94 95 re-allocation of the mental patients, which necessitated a considerable increase of overcrowding, for the treatment of civilian and service sick and wounded. In all, about 175,000 patients received treatment in the accommodation thus provided. All that has been said in regard to the improvement in staff and equipment standards, the provision of consultant and specialist services and the development of the laboratory service at the general hospitals can be applied with equal force to the mental hospitals and institutions. Many changes and much progress have been made during the period of nearly sixty years that the Council has been responsible for these hospitals but probably the most impressive advance was the change that has taken place in the attitude to mental illness, which, of course, has been reflected in the improved standards of care and the advance in the methods of treatment. All the modern forms of treatment were provided in the mental hospitals. In 1941, the administration of the mental hospitals, which up to then had been a self-contained department, was transferred to the Public Health Department. Certain of the hospitals which were alongside each other, one for acute and one for the chronic sick, were placed under the same administration and therefore counted as only one instead of two. Other hospitals were so damaged as to be wholly or partly unusable. In the hospitals as a whole, 4,456 beds were completely destroyed by enemy action. In some thousands more, war damage had not been repaired at the time of transfer. Many wards had been taken over to replace departments which had been destroyed and there were nearly 10,000 beds which could have been put into commission if nursing staff had been available. It has obviously not been possible in this report to do more than sketch the outline of the development of the Hospital Service by the Council. A somewhat longer account is given in the book "The L.C.C. Hospitals—A Retrospect." (Staples Press, 7s. 6d.) REPORTS BY THE DIVISIONAL MEDICAL OFFICERS Division 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington. Dr. H. Smith reports: The first six months of the Council's administration were devoted to studying the services taken over, adapting them, where necessary, to fit into the Council's administrative methods (for instance in such matters as financial and supplies procedure), and considering in what respects it was desirable to vary or supplement existing services in order to make them more generally available. No attempt was made to "standardise" the services, but where there were outstandingly good features in one borough they were introduced in the rest of the division as occasion offered. Examples of these were the extension of facilities for chiropody to Hammersmith where no provision had previously existed; the pooling throughout the division of maternity beds at Queen Charlotte's Hospital for women attending the Council's maternity centres; or the establishment of exercise classes for pregnant women, already functioning in Kensington, in another part of the division. Various adjustments of existing facilities were made; additional sessions were provided at overburdened clinics and a centre in North Hammersmith was closed and the patients concentrated in a neighbouring centre, with more adequate and up-to-date premises, lying just inside the borough of Kensington. A useful link with the school girl population, from whom nursery staff are recruited, was formed by arranging for school girls to volunteer for simple duties in some of the day nurseries during the summer holidays. Additional play equipment and toys were urgently needed in many of the day nurseries. These have been provided from the Council's resources and the repair of broken articles has been speeded up. Help, which was much appreciated, was given by the boys at the remand home in Hammersmith and at some local schools. G 96 The members of the divisional health committee have made themselves familiar with the establishments under their control by a series of visits arranged on a rota basis which has the effect that, in the first nine months, all members will have visited each establishment at least once. Members have also made a number of individual visits. Attention has been concentrated, though not exclusively, on the condition of the buildings and orders have been given to the Council's technical officers for improvements or have been incorporated in the programme of building works for the ensuing year. Division 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and Westminster. Dr. H. L. Oldershaw reports: The transfer of the Maternity and Child Welfare services from the Borough Councils on the "appointed day" was accomplished without difficulty, and the services continued to operate smoothly. The Division has a population of 565,420. There are 23 maternity and child welfare centres, 23 day nurseries, 6 school treatment centres and 8 minor ailment centres for school children. The welfare centres in the City of Westminster (3) and Marylebone (2) are buildings specially built for the purpose. A third centre in Marylebone is nearing completion. In Hampstead two converted buildings are in use, together with a building of the Regional Hospital Board, but two plots of land had been secured on which centres will be built. In Paddington, there is one well-planned maternity and child welfare centre, but all the subsidiary centres are in church halls, etc. The welfare centres in St. Pancras are appropriately located, and consist of two specially built centres and two converted houses. The security of tenure of some of these temporary premises is uncertain and efforts are constantly being made towards consolidation. The medical staff engaged in the division on maternity and child welfare work is a combination of full-time assistants and sessional workers, except in St. Pancras where only full-time medical officers are engaged. On the 31st December, there were 54 health visitors working in the Division. This figure is 11 below establishment (adopting the standard of one health visitor to 150 births), but by adjustments between districts covered, every effort was made to ensure that all infants received adequate supervision. Special attention was paid to the care of unmarried mothers and their children, each health visitor acting as a Special Worker under Ministry of Health Circular 2866/44 on her own district. The supervision of children coming within the scope of the Child Life Protection provisions continued to be exercised by health visitors pending the transfer of the function to the Children's Department. Attendances at maternity and child welfare centres were satisfactory and the number of Special Toddlers' sessions was increased. Since the repeal of the Vaccination Acts, every endeavour is being made to secure that all babies are vaccinated. Ten clinics were opened in the Division during the period. A spot check revealed that approximately 46 per cent. of infants under one year of age attending the welfare centres had been vaccinated. This unfortunately is a decrease on the percentage prior to the 5th July, but increased publicity at both welfare centres and day nurseries has been directed to remedy this defect. In addition to the special Diphtheria Immunisation campaign during September, all staff in contact with mothers continue to urge the necessity for immunisation. Further immunisation sessions were commenced where necessary. Inoculations against whooping cough are provided on request, and are usually combined with Diphtheria Immunisation. 97 The dental services for expectant and nursing mothers and children under five years of age were restricted by the difficulty of obtaining the services of dental officers. Nevertheless, 2,184 attendances were made by mothers and 644 by children under five years of age during the period under review. The Invalid Children's Aid Association acted as agents for the Council in arranging for the admission of cases to holiday homes, the charges, where applicable, being collected by divisional staff. In all, 326 cases from this Division were admitted during the period. No difficulty is experienced in obtaining vacancies for mothers and other adults, and normally only a short delay occurs in admitting children. There were only 46 cases on the waiting list at the end of the year. At the physiotherapeutic clinics operating at the Maternity and Child Welfare Centres in the Division, 4,325 attendances were made and the patients received the following treatments, Light, 1,109, Heat 135, Massage 2,688, Exercises 1,822. There are four Foot Clinics in the Division, at three of which treatment is given to expectant and nursing mothers, while the fourth is available to all female inhabitants of the Borough. A total of 404 attendances at 88 sessions were made during the period. Pending further consideration by the Ministry of Health the Council is only permitted to continue pre-July arrangements and not to expand. The demand for day nursery accommodation continues to be greatly in excess of the number of places available. There were at the end of the year, 3,121 cases on the waiting list for the 1,398 places in the twenty-three nurseries. An agreement was concluded with the Westminster Health Society whereby the Society continued to provide nursery accommodation for 30 cases of a special nature. It will be appreciated that most of the day nursery premises in the Division were requisitioned and adapted during the war period. As a consequence there is considerable scope for alteration in detail in many of these nurseries. Reference must be made to the increase in number and quality of the toys and play material since the 5th July; and in particular, tribute must be paid to the Park's Department for the improvement they have effected in the gardens of the day nurseries. To supplement the day nurseries the Daily Minder Service was in operation and 34 minders were caring for 35 children at the end of the year. The Nurseries and Child-Minders Regulation Act, 1948, imposed the duty on the Council of registering and supervising private day nurseries and child-minders looking after three or more children. Investigations were made into applications received, prior to reporting to the Divisional Committee for registration. The scope of the home help service was increased, and 836 cases were being assisted during the last three weeks of the period compared with 540 during the first three weeks after the "appointed day." This increase was principally in respect of St. Pancras, as the Home Help Services of Westminster and Hampstead were already substantially developed. The number of registered home helps at the end of the year was 204, of whom 135 were full-time. Because of the great demand it was necessary to investigate each case carefully and reduce the period of assistance to the minimum necessary. Ten sets of premature baby equipment were located at suitable centres throughout the Division for use where necessary at domiciliary confinements. Every help and assistance has been given to the District Nursing Association operating in the Division. The following figures of the home nursing carried out by the District Nursing Associations during the month of December, 1948, indicates the extent and success of their activities:— No. of new patients visited 512 No. of old patients visited 562 Total No. of visits paid 11,616 98 Division 3, comprising the boroughs of Finsbury, Holborn and Islington. Dr. A. B. Stewart reports: The Division, which covers an area of 4,084 acres, had an estimated population of 300,960. The Divisional Medical Officer has to assist him a Divisional Administrative Officer and a Divisional Nursing Officer, together with the following staff:— Medical 61 (including 56 part-time); Dental 17 (including 5 part-time); Chiropodists 6; Clerical and Administrative 66; Nursing 237; School Treatment organisers 7; Domestics 201; Miscellaneous 9. Total 604 (full and part-time). The administration was reorganised on a divisional basis by stages, and ex-borough council staff were gradually absorbed into the divisional office so that by the end of the year, with the exception of 10 clinic clerks, etc., the whole of the clerical and administrative staff was centralised at Divisional Headquarters. Members of the Divisional Health Committee made 106 reports following visits on a rota basis to the various establishments in the area. Care of Mothers and Young Children.—The Division is served by 12 day nurseries (with places for 661 children), six main and five branch maternity and child welfare centres. In addition there are 2 nursery creches, 2 infant welfare centres and 2 branch clinics operated by grant-aided voluntary committees. Ante- and post-natal clinics are held at seven centres and midwives clinics at 6 centres and in all, 37 infant welfare sessions are held each week. A special child guidance clinic is operating at the John Street maternity and child welfare clinic for 2 sessions each week staffed by a medical officer and a psychiatric social worker on a part-time basis to whom are referred, mainly from the maternity and child welfare clinics, children under 5 years of age where there are problems in relation to feeding, sleeping, habit training, tempertantrums, jealousies, nervous habits and mother/child relationship. About 100 cases are dealt with each year and it is an interesting fact that about 75 per cent. of the cases are first children. Two private nurseries are established in the Division in conjunction with industrial premises both of which were visited regarding requirements under the Day Nurseries and Child Minders Regulation Act, 1948. Eleven women were registered under this Act to mind a maximum of 34 children during the day. In addition to those compulsorily registered there were 88 women (voluntarily registered and caring for 124 children) who were receiving the Council's registration fee of 6s. per week, at the end of the year. One of the Council's day nurseries was closed for a period of 6 weeks owing to an outbreak of Sonne Dysentery. Of 53 persons examined, 19 were found to be affected with the disease. A scheme is in operation at two maternity and child welfare centres in the Division whereby mid-day meals are supplied on a selective basis to expectant and nursing mothers and to children under 5 years. The number of meals supplied during the period 5th July, 1948 to the end of the year was 3,567. Five mothers with their infants and 3 unaccompanied infants were admitted to the Mothercraft Training Centre, Cromwell House, Highgate, the length of stay varying from 4 days to 8 weeks. There were 35 registered Foster Mothers in the Division at the end of the year caring for 34 children, the supervisory work being carried out by health visiting staff. District Nursing.—The Central Council for District Nursing in London has created local organisations with a view to co-ordinating the activities of the District Nursing Associations in London. Divisional Home Nursing Voluntary Committees have been constituted to act as liaison between the Central Council and Divisional Health Committees and to promote co-operation among the Home Nursing Associations and between them and medical and other professional organisations within each Division. 99 The Divisional Medical Officer, and the Administrative and Nursing Officers for Division 3 are members of the Home Nursing Voluntary Committee. Training of Nursery Students.—Ten of the 12 Day Nurseries in the Division are approved as training nurseries for the Nursery Nurses Diploma and during the 6 months July to December, 1948, 24 students were in training. Three students sat for the examination in November, 1948, and all were successful. Foot Clinic.—A Foot Clinic is established at the Finsbury Health Centre, employing 4 full-time and 2 part-time chiropodists ; 13 sessions are held weekly and all needing treatment are permitted to attend. The charge is 1s. 6d. per treatment (reducable on economic grounds under the Council's Assessment Scheme) and there are approximately 280 attendances weekly. Home Helps.—The home help scheme showed a steady expansion from the 5th July, 1948, on which date 217 households were being attended, whereas on the 31st December, 1948, 297 cases, of which 25 were home confinements, were being assisted. 127 home helps were employed at the end of the year, of whom 33 were whole-time and the rest part-time or casual workers. The care of aged and infirm persons constituted a special problem and it is estimated that approximately 30 per cent. of our resources were devoted to the care of this group, many of whom required assistance for prolonged periods. Vaccination.—Successful vaccinations amongst babies under 12 months from 5th July, 1948, to the end of the year numbered 776, representing approximately 30 per cent. of the births occurring during that period. Seven vaccination sessions are held each week at infant welfare centres and 1,502 attendances were recorded. Diphtheria Immunisation.—Six sessions per week were held for diphtheria immunisation and 2,381 completed immunisations were effected from 5th July, 1948 to 31st December, 1948. 10,416 attendances were recorded. A mobile clinic was successfully used during the month of July, 1948 (aided by a loud speaker unit) and 337 injections were given by this method. Local propaganda was carried out by the showing of films and slides in the local cinemas and, as a routine, special letters with pre-paid consent cards were sent out to all parents whose children, having reached the age of 12 months, had not been immunised. Of 29 notified cases of diphtheria in the division 5 only were confirmed during the period under review ; of these, only two had ever been given a dose of prophylactic and there was no death. Assessments.—1,121 cases were assessed in connection with the recovery of charges for various articles and services provided. Tuberculosis After Care Arrangements.—There are 4 Chest Clinics in the division at which patients are seen and any necessary after-care arrangement made. Three Tuberculosis Voluntary Care Committees (one in each of the 3 boroughs) meet at regular intervals to deal with various aspects of after-care work. The Council has granted extra nourishment to 76 cases and 7 beds and bedding have been loaned to patients during the period under review. Publicity.—By the co-operation of the local newspaper editors, items of general interest relating to public health matters have been published from time to time in the newspapers circulating in the area. In addition, articles on the health services are prepared by the Divisional Officers and are published periodically in bulletins issued by the libraries departments of two of the borough councils in the Division. Special publicity by means of leaflets, booklets and posters has been carried out uninterruptedly. School Health Service.—The School Health Service was administered from the Divisional Office as from the 25th October, 1948. There are approximately 35,300 children attending 86 schools and institutes in the Division. 40 school nursing 100 sisters carry out routine examinations for personal hygiene at the schools and 8 treatment centres are established in the area. Routine age group medical inspections, special inspections and reinspections amount to approximately 33,000 annually. Division 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports : Domestic Help Service.—In each of the 3 boroughs in the Division there was a well-developed domestic help service already in operation before 5th July, 1948. Since that date and until the end of the year, the demand for the service showed a steady and substantial increase. During the 6 months the weekly number of hours of service provided increased by 25 per cent., from 6,115 hours during the week ended 7th July, 1948, to 7,630 hours during the last week of the year. Of the total expenditure on the service, less than one-tenth is recovered by way of contributions from those receiving the help. Diphtheria Immunisation.—The arrangements for securing the protection of the child population against diphtheria were reviewed, and a systematic combing of the schools for unprotected children was commenced. This work in the schools was not commenced until September, and did not begin to gain impetus until towards the end of the year. The number of primary immunisations, in particular, is, for this reason, small; the number during the succeeding term will be very much larger. Primary immunisations completed 26 children " Boosting " and " Reinforcing " injections given 519 ,, Attendances of pre-school children at the immunisation clinics were maintained at a satisfactory level. Vaccination against Smallpox.—Vaccination sessions were commenced at the beginning of July at the five centres in the Division at which diphtheria immunisation clinics were held. The numbers of attendances have been reasonably satisfactory. Day Nurseries.—There has been a consistently heavy demand for admission to day nurseries, of which there are 13, providing 709 places, in the Division. The waiting list, which is kept under constant review, includes between 500 and 600 names. A newly-erected day nursery, of the " pre-fabricated, hutted " type, was occupied at the end of the year, and the building previously occupied was taken over for educational purposes. Apart from an outbreak of Sonne Dysentery in one nursery, which was controlled and eliminated in a short time, the health of the nursery children has been very satisfactory. Prior to 5th July, 1948, parties of children from the 2 Shoreditch day nurseries, were sent regularly to stay at the Shoreditch Borough Council's Copthorne Holiday Home, near Horley, Sussex. This arrangement has been continued. Parties of 10 to 12 children from the 2 nurseries have been sent regularly for a 2 weeks' holiday, accompanied by 2 or 3 members of the nursery staff, who were responsible for caring for them. Applications for registration under the Nurseries and Child Minders Regulation Act, 1948, were received in respect of the 5 privately-owned day nurseries, and of 1 child minder, all of which were under consideration at the end of the year. None of the boroughs in the Division had voluntary child minders' schemes in operation before the appointed day. By the end of the year 8 women, who were prepared to undertake the care of children by day, had been enrolled under the Council's scheme, and 9 children had been placed in their care. Recuperative Holidays.—Recuperative holidays were provided for 148 cases (37 children under 5 years ; 76 children over 5 years ; 7 mothers with children under 1 year ; and 28 other adults). 46 patients were awaiting admission to holiday homes at the end of the year. 101 Foot Clinics.—The 3 foot clinics in the Division (1 in each borough) have provided a greatly appreciated service, but in 1 borough the clinic has been unable to cope with the demand for this service, and the waiting list has continued to grow. Family Planning.—Authority has been given for the Family Planning Association to hold a weekly session at one of the maternity and child welfare centres in the Division. Division 5, comprising the boroughs of Bethnal Green, Poplar, Stepney and the City of London. Dr. G. 0. Mitchell reports : This Division forms a compact geographical block bounded in the South by the Thames from the mouth of the River Lea in the East to Temple Station in the West; the Eastern boundary adjoins the County Borough of West Ham, the Northern boundary abuts, from East to West, on the metropolitan boroughs of Hackney, Shoreditch, Finsbury and Holborn, while in the West the Division is bounded by Holborn above and Westminster below. The whole Division is considerably battle-scarred, and is liberally scattered with the open spaces caused by the demolition of buildings, and, in very many cases, of whole streets ; and a great deal of clearance still remains to be done. Apart from the City of London, with its large day population and small residual night population, the Division is almost entirely artisan in character, with industrial development mixed indiscriminately with residential areas. Although the Division is compact on the map, certain riverside districts such as the Isle of Dogs in Poplar and the Wapping and Shadwell districts in Stepney form almost isolated communities owing to docks and bridges, and present their own special problems ; and the population of the Division, with its racial and religious mixtures, and the oriental fringe by the docks, is by no means homogeneous. This variety adds some welcome local colour, although the glamour of Pennyfields and Limehouse has now largely disappeared. The problem of welding these diverse elements into a real divisional whole is a fascinating one which may take some little time and patience to achieve, and the development of the Health Service in the East-end of London, although presenting many complexities, will prove a most interesting and satisfying task. Division 6, comprising the boroughs of Deptford, Greenwich and Woolwich. Dr. F. R. Waldron reports : In the matter of population (approximately 305,000) this is not one of the largest of the 9 divisions into which London has been divided for the purpose of administering the services for which the Council has assumed responsibility under the National Health Service Act, but in size (approximately 14,000 acres), it is very much greater than most of the others, its extreme boundaries abutting Barking to the North, Chislehurst to the South, Camberwell to the East and Erith to the West. The number of inhabited dwellings in the Division is approximately 77,000, and whilst there are good residential areas on the high ground in the Blackheath, Shooters Hill and Eltham districts which are open and almost rural in character, there are congested areas of narrow streets and old houses in Deptford, lower Greenwich and Woolwich. The Division is, however, well catered for in the way of parks and open spaces, the largest being the famous Greenwich Park, Deptford Park, Maryon Park, Eltham Park, Avory Hill Park, Plumstead Common, Bostall Woods and part of Blackheath. The industries in the Division include large meat stores, cable and engineering works, generating stations and wharves and factories along the riverside which extends along the whole of the northern boundary of the Division, a distance of about 7 miles. 102 Divisional Headquarters were temporarily established at the Town Hall, Greenwich, with sub-offices at Woolwich Town Hall, the Deptford Central M. and C.W. Clinic, Amersham Road, and 19, Breakspears Road, S.E.4 (School Medical Service). On the " appointed day " the Council took over from the three metropolitan boroughs indicated, the administration of 23 maternity and child welfare centres and 3 day nurseries as well as the after-care work in connection with 3 chest clinics, a staff of 28 health visitors, the home help service and the provision of holiday home care. All the establishments and staffs concerned were found to be functioning happily and successfully, albeit the administrative systems as between the boroughs were widely dis-similar, particularly as regards the keeping of records, the sale of nutrients, etc. It was apparent from a preliminary survey of the establishments taken over that there were instances where the abolition of borough boundaries would make possible an improved service to the public, i.e., where patients could be given a better and equally convenient service in an adjoining borough than was available within their home borough. At the same time, it was realised that to embark immediately on any large-scale plan to improve the service on these lines would militate against smooth and harmonious assimilation. Both the staffs and the general public were found to be loyal to the borough in which they worked and lived, and it was felt that, in the interests of amicable relations and efficient continuity of service existing arrangements should, as far as possible, remain undisturbed until all concerned had become less parochial in their outlook. In the first 6 months therefore, no revolutionary changes have been attempted, but a start has been made and, indicative of the lines on which future improvements are contemplated, particulars of three successful adjustments already effected are set out below :— 1. An ante-natal clinic held in unsatisfactory accommodation at Evelyn Baths, Clyde Street, Deptford, has been discontinued and residents in the area formerly served by this clinic are now referred to a well-appointed welfare centre in Creek Road, Greenwich, only a few hundred yards distant from Clyde Street. 2. The foot clinic formerly held at Creek Road M. and C.W. centre (Greenwich) has been discontinued and the staff and equipment transferred to Harton Street Foot Clinic (Deptford), about half a mile away. This merger has resulted in an increase in the total number of persons treated of nearly 90 a week. 3. Of the 3 day nurseries taken over, 1 was in Greenwich (Conley Street, S.E.10), and 2 in Deptford (Evelyn Street, S.E.8 and South Eastern Hospital, S.E.14). The Deptford nurseries were open 6 days a week and the Greenwich nursery only on 5 days a week. All 3 have now been put on a 5-day week basis and their hours of opening made uniform. In addition, vaccination sessions (5 a week) have been introduced at clinics in all 3 boroughs to meet a need created by the repeal of the Vaccination Act, and midwives' booking sessions have been started at most welfare centres. Mention should also be made of the very considerable expansion of the home help service since the " appointed day." The " go-slow " policy adopted in the matter of changes in the organisation of the services taken over has yielded the desired results, and it gives me very great satisfaction to be able to record that, thanks to the loyalty and co-operation of all grades of staff, assimilation has been achieved without friction and with no interruption of service to the public. 103 Periodical conferences at Divisional Headquarters with the various grades of staff employed at outside establishments have proved most valuable, not only in resolving difficulties and introducing improvements but in getting the staff to " think Divisionally." All establishments are visited regularly by members of the Divisional Health Committee and their reports have greatly assisted in maintaining a high standard of service to the public. Division 7, comprising the boroughs of Camberwell and Lewisham. Dr. H. D. Chalke reports : The two boroughs differ widely in character. There is a considerable industrial area in North Camberwell, whilst the South-East portion of the borough is residential and is much more thinly populated. Lewisham which is mainly a dormitory borough, has a little light industry only. The London County Council housing estates at Bellingham and Downham are within the Lewisham borough boundary. The Division suffered severely from enemy bombing, which involved damage to or destruction of many premises formerly in use as welfare centres. Premises.—A large number of welfare centres are held in church halls, particularly the infant welfare centres under the control of voluntary bodies, of which there are 7 in Lewisham. The church hall is generally ill-adapted for use as a clinic, and every endeavour is being made to find alternative accommodation. The Council has made available 2 ground floor flats on the new Flower House Estate for use as a welfare centre, and also a former relief station in Camberwell. Additional accommodation has also been obtained at Louise House, Forest Hill, where the upper floor is now being made available for clinic purposes. These premises will be used as soon as the necessary works have been completed. A new school treatment centre is being opened in the near future at Gordon Road. This will replace the somewhat unsatisfactory premises in use previously. A school treatment centre has also been opened at Comber Road School. Clinics.—Ante-natal clinics, which London County Council and District Nursing Association midwives attend, have been set up throughout the Division. Routine blood examination (including the Rh. factor) of expectant mothers is carried out at a number of these clinics, and is rapidly being extended to the remainder. A satisfactory working arrangement exists with hospitals in the Division, whereby expectant mothers may be confined in hospital for non-medical reasons when the social circumstances warrant it. Vaccination clinics have been established at 4 convenient centres in the Division. It is unfortunate that the number of attendances which was initially reasonably good, is now showing an appreciable fall. Some of the infant welfare sessions have become rather overcrowded and additional clinics have therefore been started. An educational session for mothers, which includes lectures and exercises, is being commenced at the Lewisham welfare centre in addition to the 2 already established. One ante-natal clinic is being held at premises which are situated in Division 6, near the divisional boundary. Arrangements have been made for residents in Deptford (Division 6) to make use of the adjoining welfare centre at Honor Oak Park. Home Helps.—A very comprehensive and well organised home help service existed in Lewisham before 5th July, 1948. This continues to run satisfactorily under the local direction of an experienced organiser. The home help service in Camberwell has been rapidly extended ; full advantage is being taken of the additional home helps available. Close liaison is being maintained with hospital almoners, Family Welfare and Old People's Associations and the District Nursing Associations. This is an essential factor in a successful home help scheme. A number of home helps previously engaged by the Camberwell Old People's Association have been taken over. The 104 voluntary workers of this Association continue to co-operate to the full, and the assistance given in home visiting is much appreciated. A scheme has been started whereby, in exceptional cases, home helps can be provided for evening work or for spending the night in a home. This is purely experimental, but there are already indications of its value. Day Nurseries.—There is a considerable waiting list, and it has become necessary to keep strictly to the priorities for admission decided on by the Council. A weekly wardens' class is being held, at which a carpenter, who is giving his services free, attends for one hour. At this class the wardens make simple toys and carry out minor repairs. Health Visitors.—On the basis of one health visitor for 150 births, 34 additional health visitors were required in this Division. The situation has been improved slightly since 5th July, 1948, by the appointment of three additional health visitors. As much clerical assistance as possible is now being given to the health visitors. Attendance of health visitors at vaccination and immunisation clinics has been given up, the work being undertaken by State Registered nurses employed on a part-time basis. By these means health visitors are enabled to devote much more of their time to educational work. Divisional Home Nursing Voluntary Committee.—This committee meets each month at the Divisional Offices. It is proving a most valuable link between the Divisional staff, the District Nursing Associations and the voluntary organisations. Meetings of Divisional Personnel.—Health visitors and day nursery matrons and nursery wardens meet at frequent intervals. The exchange of views at these meetings is of great importance. Conclusion.—The way in which the staff of the Division have co-operated since 5th July last is most praiseworthy. The Medical Officers of Health in carrying out their duties of day-to-day administration, have given invaluable assistance, and their knowledge of local circumstances has been most helpful. These factors have contributed in no small measure to the smooth working of the personal health services during the difficult period of transition. Division 8, comprising the boroughs of Bermondsey, Lambeth and Southwark. Dr. W. H. S. Wallace reports : Administration.—Several members of the Public Health staffs transferred to the Council from the 3 borough councils in the Division were brought to the Divisional Health Offices, 128, Brook Drive, S.E.ll, on 5th July, 1948, to undertake the administrative work. The Medical Officers of Health of the 3 boroughs agreed to continue with the day-to-day administration in their respective boroughs. Staff concerned with home helps, child minders, and nursery admissions remained at the Town Halls. The School Medical Service was taken over on 31st August, 1948, and staff were transferred from Stowey House. The Divisional Treatment Organiser's staff were transferred to the Divisional Health Offices on 23rd October, 1948. Maternity and Child Welfare.—The maternity and child welfare centres in Lambeth have been administered by voluntary organisations. Negotiations were entered into with these organisations for them to continue the administration of the centres and to be paid a 90 per cent. grant from the Council. Two of these voluntary centres, the North Brixton and Stockwell Centres, intimated that they were unable to continue and accordingly their administration was taken over by the Council. The Lady Gomm Hostel Youth Centre, Bermondsey, was opened on 9th December, 1948, and arrangements were made to hold 2 infant welfare and 2 ante-natal sessions at the premises. 105 Vaccination and Immunisation.—Four vaccination clinics were opened, 1 in Bermondsey, 1 in Southwark and 2 in Lambeth. The sessions were held in connection with the Diphtheria Immunisation Clinics and the facilities met the demand. Although the value of Whooping Cough vaccine has not yet been established, the demand for this vaccine is still great and most mothers request to have it carried out in conjunction with diphtheria immunisation. Holiday Homes.—The demand for holiday home accommodation was much greater than was expected. Arrangements were made for the placing of children in holiday homes to be carried out by the Invalid Children's Aid Association and the placing of adults by the Family Welfare Association. All assessments are carried out at Divisional Offices and patients are given the option of making payment to the recommending body or at the Divisional Offices. Old People.—Many problems arose as a result of the difficulty in obtaining hospital accommodation for the aged chronic sick. Health visitors were asked to report on the home conditions of old people recommended for hospital admission to ensure that only urgent cases were sent to hospital. The Emergency Bed Service were, however, still unable to meet the demand for hospital beds for old people. Child Minders.—A number of child minders in Lambeth have been transferred to the Council scheme. Payment of the registration fee to these minders is made at the welfare centre in order to ensure that the children are brought there. Most of the child minders have fewer than three children and only a few have had to be registered under the Nurseries and Child Minders' Act. Home Helps.—Two separate schemes, 1 for domestic helps in ordinary households and 1 for home helps for maternity cases were in operation in Lambeth prior to 5th July, 1948. These 2 services have been consolidated. There has been a great increase in the demand and supply of home helps throughout the Division. Division 9, comprising the boroughs of Battersea and Wandsworth. Dr. Bertha E. A. Sharpe reports : Battersea is compact but Wandsworth is widely spread; consequently, the administration in each borough has necessarily been conducted on different lines. Endeavour is being made to weld the two administrations into one, though the absence of suitable centralised offices renders amalgamation difficult. At present, the administrative work is carried out from 5 different offices, in various parts of the Division. There are in this Division 17 buildings used for maternity and child welfare centres, and in addition, there are 7 school treatment centres and 3 cleansing stations. The clinics for infant welfare, ante-natal, post-natal, toddlers, dental treatment, immunisation, vaccination and minor ailments have been well attended as also the mothercraft classes. In some places it has been possible to combine the midwives, clinics with the ante-natal clinics, which hitherto were held separately, and this has proved advantageous to the maternity service. Home helps have been provided for confinement cases and in cases of need on social and medical grounds, and this service has proved a great boon. There are 16 nurseries in the Division, and in addition there is a voluntary nursery to which a grant is made. All these nurseries have been used to capacity. In addition to minor ailment treatment, Specialist service is provided under the school health service, for vision, squint, ear, nose and throat, nutrition, enuresis, rheumatism, and child guidance for the children attending the 120 schools in the Division. The tuberculosis care committees have continued to function, and handicraft classes have been held regularly. 106 The staff employed in the Division as at the 31st December, 1948, numbered 687, as follows :— Full Part- time. time. Doctors and dentists 12 83 Nursing, including medical auxiliaries and dental attendants 283 5 Administrative, clerical, including organisers 62 — Domestic and miscellaneous 119 123 476 211 Much good work has been carried out despite the difficulties that have had to be overcome in the setting up of a new organisation. In conclusion, I would like to express my appreciation to the Medical Officers of Health of Battersea and Wandsworth for their co-operation and assistance. domiciliary midwifery service—historical sketch I—Introduction Origin The Council's domiciliary midwifery service had its origin in the Midwives Act, 1936, which laid on the Council the duty of securing an adequate service of midwives for attendance on women in their own homes in London. To provide this service the Council employed 47 salaried midwives and entered into agreements with 36 voluntary hospitals and district nursing associations employing 120 midwives. The service commenced on 1st January, 1938. Midwives attended either as midwives on their own responsibility or as maternity nurses under the direction of a doctor. They were encouraged to make the fullest use of the maternity and child welfare services provided by the metropolitan boroughs. The voluntary associations received payment from the Council for each confinement undertaken. Every woman attended by a midwife was charged a fee which was reduced in accordance with the net family income, but medical aid, if summoned by the midwife, was provided free. A choice of midwife was provided for women who desired it. The service proved capable of development to meet increasing demands and of adjustment to meet the difficulties of the war years. It survived the stress of the blitz and the strain of the post-war rise in the birth rate. It underwent no fundamental change under the National Health Service Act, except to become a free service. Compensation When the domiciliary midwifery service commenced, independent midwives were given the option under the Midwives Act, 1936, of relinquishing their practices and, subject to certain conditions, became entitled to receive compensation. Sixtyeight midwives were so compensated, receiving £24,370. As a war-time measure under Defence Regulation No. 33 (1) of 1939, which is still in force, some midwives who had surrendered their certificates under the Midwives Act, 1936, were permitted to resume midwifery for stipulated periods. Administration The direction of the domiciliary midwifery service was delegated by the Council to its Hospitals and Medical Services Committee. This Committee also administered the large hospital service which the Council inherited in 1930 from the Boards of Guardians and the Metropolitan Asylums Board. The close association of domiciliary midwives with a hospital service was of great value to the new service and many valuable features of this close association are still maintained. On 5th July, 1948, the hospitals were transferred to the Minister of Health under the National Health Service Act and the Health Committee was set up to undertake the Council's duties as local health authority under the same Act, including the direction of the domiciliary midwifery service. Areas of practice In planning the service in 1937, one of the main problems was that of the best area for practice and administration. The metropolitan boroughs, who were the M. & C.W. authorities, had claims but were too many and some were too small and the areas of the voluntary organisations were ill-defined and often overlapped both each 107 other and the boroughs. Other considerations were the wide variation in density of population, social and economic conditions. At first, the Council's midwives had no definite limit to the area in which they could book patients. Experience forced the Council to define practising areas for the midwives to prevent the waste of effort involved in midwives "crossing each others' doorsteps " to reach their patients and to save long journeys by patients and midwives, e.g., for ante-natal care. When a patient specially desired to book a particular midwife outside her area this was however arranged. A further definition of areas may have to be made under the National Health Service Act by the adjustment of the areas of district nursing associations and hospital districts with each other and with those of the Council's midwives. All domiciliary and district midwives are inspected by the Council as local supervising authority under the Midwives' Acts to ensure that the rules of the Central Midwives' Board are observed. Originally this was done by medical supervisors, but in January, 1939, two positions of non-medical supervisor were substituted for two of the medical supervisors. The number of non-medical supervisors was subsequentlv increased. Supervision The development of the domiciliary midwifery service was affected, and at times hindered, by a series of outside influences due mainly to the War. The following records for the first three years of the service are of interest as showing the effect of the war in its early stages :— Average weekly number of confinements taken by all the Council's midwives during the periods quoted:— January—June, 1938 60 July—December, 1938 71 January—2nd September, 1939 88 §3rd September—31st December, 1939 133 1st January—7th September, 1940† 166 November-—December, 1940 43 January—June, 1941 61 November—December, 1941 86 § Outbreak of war. † The first bombing began on 7th September, 1940, and heavy bombardment continued until the middle of 1941. As the weight of bombing lessened and the population drifted back to London domiciliary midwifery settled down again, and the number of confinements and of midwives gradually increased. In mid-1944 the attacks with V.l and V.2 missiles were commenced, and there was a fall in confinements. This was followed by the return to London that heralded the end of the war with Germany. Peace brought a new fluctuation in an upward direction, as the birth-rate soared to its post-war peak. By the end of 1947 it had become more steady, but owing to the twin problems of housing shortage for the general population and of hospital bed shortage for maternity cases the domiciliary midwifery service was still unable tc find stability. On 5th July, 1948, it took its place as part of the free National Health Service and it is still too early to assess what effect this may have had on its development. II—Home Confinements With the foregoing generalisations in mind, it is interesting to look at the following figures. Figure I shows the number of confinements attended annually from 1938 to 1947 by all domiciliary midwives and, by way of comparison, the total number of institutional and domiciliary confinements during the same years. Figure II shows the relative number of confinements attended annually from 1938 to 1948 by the Council's midwives, district nursing association midwives and hospital district midwives. It really is amazing when one remembers the facilities available for sending expectant mothers out of London that so many domiciliary confinements occurred there—many of them in small houses—during the bombardment. It is a great tribute to the fortitude of the mothers and the gallantry of the midwives. Development 108 Figure I 109 Figure II 110 III—The Council's Midwives Figure III shows the average case-load for each year and the variation in the number of midwives employed annually from 1938 to 1948. Gallantry during air-raids The devotion to duty and the gallantry of the midwives during the heavy airraids, particularly in September, 1940, and the V.l and V.2 missile attacks of 1944 and 1945, has already been mentioned. Some of their homes were demolished and many more were severely damaged. Fortunately there was only one serious casualty among the midwives. Mention must also be made of the good work done by the midwives who were lent to provincial authorities. A number of school nursing sisters took short refresher courses in midwifery and went with them. Many of the midwives had to organise and run emergency Maternity Homes for evacuated women, very often under the most difficult circumstances. Relief A system of relief has been built up, which gives every midwife a weekly period of rest and off-duty time. The midwives work in groups and relieve each other for off-duty periods and during annual and other leave. Additional relief is obtained if necessary from the district nursing association, and/or by the employment of temporary staff. Accommodation The domiciliary midwife has always been required to reside in a locality and in premises approved by the Council, and, if necessary, to remove to other premises. If she could find suitable premises herself, she practised from them. It has, however, been increasingly difficult for the midwife herself to find accommodation suitable for her practice both in size and situation, and from the commencement of the service the Council, as housing authority, helped in individual cases of difficulty. Midwives in Council's properties paid the normal rent plus 2s. 6d. a week. The Midwives' Salaries (Rushcliffe) Committee in 1943 recommended that local authorities should provide accommodation, for which a flat rate of £26 a year for unfurnished premises should be paid by the midwife. This policy was endorsed by the Ministry of Health in circulars 96/46 and 98/46 and was adopted by the Council in 1946. Progress in the accommodation of midwives is shown in the appended table :— Dale No. of premises No. of midwives provided by the Council accommodated 31-12-45 5 9 31-12-46 38 48 31-12-47 61 70 31-12-48 66 74 Furniture To give further help to midwives in establishing their homes, the Council agreed in 1942 to supply them, if they wished, with furniture on loan for which a monthly charge was made. Equipment, uniform and drugs It has also been the Council's policy to supply all equipment, uniform and drugs needed by its midwives. A new uniform to conform with the style approved by the Central Midwives' Board as a national uniform for midwives will be introduced when stocks are available. A midwife is also supplied, for free issue to her patients, with sterile maternity outfits, containing accouchement sheets and dressings for the confinement. Analgesia The use of gas and air analgesia by the Council s midwives began in June, 1946. The apparatus is not issued to midwives, but is held at selected ambulance stations throughout the County and delivered by ambulance to the patient's house on request from the midwife. The midwife visits the patient when summoned and then telephones for the apparatus, which arrives within a few minutes. The number of midwives qualified to administer analgesia was small in the first place and, owing to pressure of work, it was extremely difficult to release them to take the necessary training. In consequence the progress in the use of analgesia was slow, but. with 111 Figure III H 112 the return of the birth-rate to a more normal level in 1948 it was possible to concentrate on training in analgesic methods. The following tables illustrate the progress made :— Number of L.C.C. midwives qualified to administer analgesia At 31-12-46 50 out of 148 in the service At 31-12-47 94 out of 158 in the service At 31-12-48 148 out of 155 in the service Increase in the number of patients receiving analgesia This is shown for L.C.C. midwives by a comparison of the number of administrations during the half-yearly periods since analgesia was introduced for their use in June, 1946:— Total Percentage of all Period administrations confinements 1946 June to December (7 months) 260 3% 1947 January to June 406 6% July to December 729 13% 1948 January to June 1,345 25% July to December 2,102 44% The increase has been consistent within the half-yearly periods and culminated in December, 1948, for which the monthly return of analgesia administrations was:— Total administrations by L.C.C. midwives in December, 1948. Total administrations Percentage of all confinements 455 59% As a footnote to these figures, it may be added that at the time of writing this report all the Council's midwives are qualified to administer analgesia and every woman (booked by them) who wishes to have relief in childbirth may have it, provided she is certified as medically fit. Transport Various modes 01 transport are used by the Council s midwives in the performance of their duty. Bicycles and motor-cars are used by some who receive special allowances for their use. Travelling expenses are paid for those who have to use public transport. Midwives are assisted in obtaining new cars by means of a priority scheme agreed between the Ministry of Health and the manufacturers. Transport by ambulance vehicle is available in certain circumstances by night and when no public transport is available, and during the day time if specially required. Ante-natal care Ante-natal care tails into three categories :—(1) medical examination at the beginning of pregnancy and at or about the 36th week, or more often as required by the doctor, (ii) intermediate ante-natal examination by the midwife as required by the rules of the Central Midwives' Board, (iii) associated social and educational services. Medical examination is undertaken by a doctor at an ante-natal centre or, if the patient wishes, by her own private doctor ; in either case the midwife receives reports of these examinations from the doctors. The social and educational services are also available at the ante-natal centres. The midwife's own examinations have usually been carried out at her own home where a room was set aside for professional use or at the patient's own homes, when they could not be done at the midwife's home. In some boroughs, it has been possible to develop a closer link by arranging for the midwife to use a room at the borough ante-natal centre and to see her patients there. As has been explained in the report on the midwifery service for 1948, the Council's policy under the National Health Service Act has been that wherever possible the midwives shall use the maternity and child welfare centres to book and examine their patients with a doctor in attendance to whom patients can be referred by the midwife. L.C.C. MIDWIFE STARTS ON HER ROUNDS CONFINEMENT AT HOME By courtesy of "The Nursing Mirror" 113 In 1944 the Minister of Health drew attention to the importance of the care of premature infants as a measure to reduce neo-natal mortality. Midwives were carefully instructed in special measures to be adopted in nursing care for infants born at home, including the provision of warm clothing, and the establishment of breast-feeding or, failing that, artificial feeding. Each premature birth is reported to the supervisors who visit and advise on the care of the premature infant. If the infant is not likely to thrive at home the midwife can arrange for immediate admission to hospital for both infant and mother if advisable. Every care is taken in transporting the infant—a midwife is sent and a special warm cot provided in the ambulance. The hospital is warned to make all preparations for reception. Similarly, newborn infants affected with haemolytic diseases, i.e., Rhesus Factor cases, are admitted to hospital units for observation and treatment. Special care of Babies One of the midwives' duties under the Rules of the Central Midwives' Board is to call in medical aid at any time before or during labour or during the lying-in period. The doctor's fees are paid by the Council as local supervising authority. Medical aid is summoned on the average in 42 per cent. of midwives' cases. This includes care of the infant. Medical aid There has been a great change in the clinical aspects of maternity work during the 11 years, 1938-1948. The sulphonamide group of drugs has had a striking effect upon the infections of the lying-in period. Puerperal infections are not now the menace they were formerly. Ophthalmia neonatorum of a serious degree has been reduced to a negligible figure and many of the young midwives have never had an opportunity of seeing a case of real pemphigus neonatorum on the district. Suspension of midwives coming into contact with serious infection has been reduced from 124 in 1940 to 25 in 1948. Clinical aspects IV—District Nursing Associations and Hospitals Agreements between the Council and the hospitals and district nursing associations lay down conditions under which district midwifery services are provided. The payments made by the Council have varied from time to time as follows:— Date Hospitals District nursing associations £ s. d. £ s. d. 1938-9 2 6 10* 2 14 0 1940-3 3 5 0 3 12 6† 1943-4 3 15 9 4 5 9 1944-5 4 6 6 4 19 0 1946-7 4 18 0 5 7 3 1947-8 5 2 8 5 12 10 From 5th July, 1948 7 13 4 Merged in deficiency grant to cover midwifery and home nursing. Payments to voluntary organisations * Reduced to £1 7s. 6d. when midwife was accompanied by pupil. † From 1-11-40, maternity outfits have been supplied free to district nursing associations. Hospitals were required to provide a suitable outfit to the patient. The district midwives employed by hospitals and district nursing associations are full-time servants of those organisations. Except that they are normally resident in the hospital or district home and work from there, their salaries, conditions of service and conditions of work have, on the whole, approximated to those of the Council's midwives. This approximation was brought about, in the first instance, by the agreements which the Council entered into with the organisations and subsequently by the introduction of national scales and conditions of service as recommended by the Midwives' Salaries (Rushcliffe) Committee. They have the same responsibilities towards their patients as have been described for the Council's midwives. Hospital and district nursing association midwives 114 V—The National Health Service Except that it became a free service, the domiciliary midwifery service was not fundamentally affected by the National Health Service Act, 1946. The main result of the Act is the closer integration of the domiciliary midwifery service with the maternity and child welfare services now provided by the Council as local health authority. It is administered centrally and not through the health divisions. The midwife is able, by making one telephone call, to obtain a bed in a hospital through the Emergency Bed Service and for a patient to be taken there by the London Ambulance Service with the minimum delay. She knows the general practitioner obstetricians selected under the Act to provide maternity medical services as family doctors and co-operates with them in providing the services, including emergency medical aid required by the mother or baby. Under the Council's scheme the whole County is kept under close and constant supervision and the service is being continually adapted to the changing character and requirements of the area and the midwives kept up-to-date in the latest obstetrical methods. STATISTICS Table 1—Population* of the administrative County of London, 1921-1947 Year Mid-year estimate of population Average age Total 0-4 5-14 15-24 25-44 45-64 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 1947 3,309,700 259,000 364,600 2,686,100 1948 3,339,100 269,900 359,500 2,709,700 * Civilian population only from 1939. 115 Table 2—Vital statistics for the metropolitan boroughs and the County of London in the year 1948 (b) Metropolitan boroughs arranged in divisional order Estimated civilian population, 1948 Live births Deaths Infant mortality (pel 1,000 live births) Measles Diphtheria Whooping cough Diarrhœa and enteritis age 0-2 (per 1,000 live births) Pulmonary tuberculosis Pneumonia Other reap dis. Cancer Maternal mortality (per 1,000 total births) Notifications of infections disease Scarlet fever Diphtheria Typhoid fever Erysi pelas Cerebro spinal fever Acute pneumonia Measles Whooping cough Tuberculosi Pulmonary Nonpul monary Division 1 Chelsea 50,890 17.1 11.7 40 — — 0.04 6.8 0.49 0.63 0.55 1.98 — 1.30 0.04 0.04 0.14 0.08 0.28 7.94 4.52 1.41 0.15 Fulham 123,300 18.0 11.5 26 — 0.02 0.02 3.1 0.55 0.53 1.01 2.24 0.87 0.81 0.08 0.02 0.20 0.01 0.23 7.21 2.98 1.62 0.18 Hammersmith 115,800 18.2 11.2 35 — — 0.02 1.9 0.58 0.54 0.91 2.19 0.46 1.16 0.07 0.01 0.22 0.06 0.60 7.74 3.70 1.42 0.17 Kensington 168,800 16.9 10.0 38 0.01 0.01 0.03 3.4 0.45 0.49 0.58 1.90 1.69 0.56 0.08 0.02 0.15 0.02 0.85 5.14 1.55 1.32 0.18 Division 2 Hampstead 95,480 15.4 10.3 29 — — 0.01 2.0 0.39 0.28 0.40 2.00 0.65 0.89 0.03 0.01 0.08 0.01 0.56 6.03 2.68 0.92 0.10 Paddington 128,100 18.1 10.8 36 0.02 — 0.02 3.4 0.54 0.63 0.81 1.88 1.25 1.05 0.02 0.02 0.21 0.02 0.52 7.99 1.95 2.35 0.18 St. Marylebone 75,980 12.6 10.5 32 — — — 3.1 0.37 0.57 0.71 1.91 — 0.47 0.09 0.01 0.24 — 0.63 4.66 1.68 0.97 0.09 St. Pancras 140,200 17.2 11.4 37 0.01 0.01 0.01 2.5 0.64 0.58 0.76 2.29 1.20 0.87 0.12 0.01 0.31 0.04 0.61 9.64 2.50 1.67 0.25 Westminster, City of 100,900 13.5 10.2 38 0.01 0.03 — 10.1 0.57 0.45 0.53 2.14 0.71 0.55 0.08 0.04 0.08 0.02 0.08 3.73 1.82 1.63 0.22 Division 3 Finsbury 35,640 18.6 11.9 33 — — — 1.5 0.65 0.79 1.12 2.55 — 1.60 0.03 — 0.22 0.06 0.65 11.76 3.51 2.01 0.11 Holborn 24,960 14.2 11.3 19 — — 0.04 2.8 0.48 0.44 0.88 2.64 — 0.52 0.08 0.04 0.24 — 0.36 3.49 2.96 1.54 0.31 Islington 238,200 19.0 11.3 35 0.00 — 0.03 2.8 0.66 0.71 0.93 2.20 0.85 1.37 0.03 0.00 0.20 0.03 0.30 8.44 4.00 1.86 0.21 Division 4 Hackney 172,900 17.0 10.5 24 — 0.03 0.01 2.7 0.57 0.69 0.73 2.10 — 1.50 0.23 0.02 0.20 0.02 0.23 10.04 4.55 1.42 0.09 Shoreditch 44,960 18.6 11.8 25 0.02 0.02 0.02 2.3 0.78 0.56 1.02 2.25 1.15 1.67 0.47 0.02 0.36 0.04 0.56 12.61 4.58 1.60 0.17 Stoke Newington 45,370 19.8 11.3 27 — — — 2.2 0.53 0.86 1.04 2.18 — 0.84 0.02 — 0.26 — 0.40 9.65 2.76 1.58 0.15 Division 5 Bethnal Green 60,580 18.6 10.9 24 0.02 — 0.03 1.7 0.68 0.45 0.87 1.91 1.72 1.72 0.30 0.02 0.20 0.05 0.68 14.01 2.99 1.72 0.18 City of London a 4,810 9.8 16.6 21 — — — — 0.62 0.62 0.21 4.16 — 0.21 — — 0.21 — 0.21 2.08 0.42 1.84 0.20 Poplar 74,940 20.7 11.3 33 — — — 1.3 0.79 0.55 1.40 1.95 0.62 2.05 0.09 0.03 0.19 0.05 1.53 13.28 4.36 1.76 0.20 Stepney 99,470 20.5 12.3 28 0.01 — 0.02 3.4 0.68 0.57 0.72 2.40 — 1.89 0.14 0.01 0.27 0.05 0.66 7.67 2.06 1.71 0.16 Division 6 Deptford 75,670 20.3 11.6 22 — 0.01 — — 0.56 0.45 0.89 2.35 0.62 1.48 0.08 — 0.15 0.01 0.77 10.78 1.97 1.22 0.22 Greenwich 84,410 19.4 10.2 26 — — 0.01 1.2 0.62 0.39 0.85 1.72 1.18 0.84 0.11 0.01 0.23 0.05 0.38 10.96 4.56 1.28 0.16 Woolwich 142,800 17.4 11.0 29 0.01 — 0.01 0.8 0.49 0.40 0.72 1.95 0.39 1.66 0.07 0.01 0.21 0.11 1.11 11.18 4.04 1.36 0.21 Division 7 Camberwell 178,200 18.7 11.4 31 0.01 — 0.02 2.4 0.57 0.57 0.88 2.08 1.16 1.66 0.10 0.02 0.17 0.03 0.48 8.71 3.04 1.98 0.18 Lewisham 226,100 18.6 10.0 28 0.01 — 0.03 1.6 0.48 0.42 0.78 1.91 0.46 1.47 0.02 0.01 0.15 0.02 0.30 11.68 3.49 2.03 0.26 Division 8 Bermondsey 60,410 19.8 11.8 16 — — — — 0.74 0.60 1.34 2.47 1.60 3.26 0.12 — 0.20 0.03 0.93 14.85 3.87 1.71 0.44 Lambeth 226,600 18.7 11.1 27 0.02 0.01 0.01 4.9 0.56 0.52 0.90 2.15 0.23 1.61 0.10 0.02 0.24 0.02 0.37 9.90 2.59 1.49 0.11 South wark 94,630 21.4 12.8 37 0.04 0.01 0.03 2.9 0.86 0.71 1.32 2.35 1.43 2.56 0.35 — 0.43 0.06 0.63 12.32 3.28 2.08 0.14 Division 9 Battersea 116,500 19.0 11.3 32 0.01 — 0.02 2.7 0.59 0.64 0.98 1.99 1.31 1.95 0.15 0.02 0.27 0.05 1.28 12.62 5.05 1.60 0.19 Wandsworth 332,500 16.4 11.3 31 0.01 — 0.02 2.3 0.49 0.45 0.88 2.20 0.88 1.35 0.08 0.02 0.28 0.03 0.64 8.09 2.55 1.42 0.12 London, 1948 3,339,100 17.9 11.1 31 0.01 0.01 0.02 2.7 0.57 0.54 0.85 2.11 0.77 1.37 0.10 0.01 0.22 0.03 0.57 9.17 3.13 1.61 0.18 London, 1947 3,309,700 20.9 12.5 34 0.01 0.01 0.03 4.5 0.62 0.75 1.18 2.06 0.96 1.31 0.14 0.01 0.22 0.05 0.64 5.28 2.80 1.58 0.19 (a) Including Inner and Middle Temple. (b) Rates are per 1,000 civil population except for birth-rates and tuberculosis notification rates, which are per 1,000 total population. 116 Table 3—County of London—Principal vital statistics, 1891-1948 Period Annual rate per 1,000 living Annual mortality per 1,000 living (b) Annual mortality per 1,000 Live births Total births (c) Live births Marriages Deaths (all causes) Cerebrospinal fever Diphtheria Enteric fever Scarlet fever Smallpox Whoopingcough Measles Influenza Tuberculosis Pneumonia (all forms) Bronchitis Other respdiseases Heart disease Cancer Diabetes Infants 0—1 Diarrhœa and enteritis 0—2 Puerperal fever Other acc. of oh. birth Pulmonary Non-pulmonary 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 2.15 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) 0.14 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 0.04 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 0.17 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 1.60 1.63 1931-35 13.8 19.5 12.1 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 0.14 63 11.6 1.45 1.61 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 0.77 1.18 1941-45 15.4 23.3 16.0 0.02 0.02 0.003 0.002 — 0.04 0.01 0.14 0.90 0.11 0.91 1.14 0.16 3.99 2.38 0.11 48 8.0 0.93 1.20 1946 20-0 22.1 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 41 0.33 0.90 1947 20.9 23.2 12.5 0.02 0.01 0.00 0.00 — 0.03 0.01 0.09 0.62 0.08 0.75 1.03 0.15 3.37 2.06 0.07 34 4.5 0.32 0.64 1948 17.9 22.7 11.1 0.01 0.01 0.00 0.00 — 0.02 0.01 0.02 0.57 0.06 0.54 0.73 0.12 2.97 2.11 0.06 31 2.7 0.35 0.42 (a) Comparable figures are not available for this period. (b) Death-rates since 1939 relate to the civilian population only. (c) The rates are per 1,000 total births from 1928 when still births were first registered. Prior to this year the rates are per 1,000 live births, and are estimated to be approx. 0.05 in excess of the rate per 1,000 total births. 117 Table 4—Administrative County of London—Civilian deaths in 1948 by cause Cause Sex 0— 1— 5— 15— 45— 65 + Total 1948 1947 1. Typhoid and paratyphoid M - - - 1 - - 1 2 F - - - - - - - 1 2. Cerebro-spinal fever M 6 7 — 2 1 — 16 29 F 10 5 - 2 1 2 20 21 3. Scarlet fever M — - - 1 — — 1 1 F — 1 - - — — 1 1 4. Whooping-cough M 26 8 — — — — 34 41 F 15 6 - - — — 21 42 5. Diphtheria M — 3 7 2 — — 12 14 F — 2 3 — 2 — 7 8 6. Tuberculosis—respiratory M 3 5 2 463 553 209 1,235 1,264 F 4 3 6 487 117 48 665 780 7. Tuberculosis—other forms M 7 19 10 38 25 4 103 132 F 3 20 11 35 16 14 99 120 8. Syphilitic disease M 2 — — 10 77 79 168 219 F 1 — — 6 32 47 86 136 9. Influenza M 3 - — 8 11 20 42 135 F 1 1 - 2 4 28 36 149 10. Measles M 3 13 — — — — 16 12 F 4 6 - — — — 10 11 11. Acute poliomyelitis and polioencephalitis M — 1 2 4 1 — 8 29 F — — — 4 2 — 6 20 12. Acute infectious encephalitis M — 1 1 5 3 1 11 10 F — - - 4 7 2 13 17 Cancer of— 13. Mouth and œsophagus M — — — 9 74 186 269 320 14. Uterus F — — — 36 178 133 347 371 15. Stomach and duodenum M — — — 41 242 314 597 572 F — - - 25 148 349 522 497 16. Breast M — - - — 2 8 10 1 F — - - 69 292 320 681 670 17. All other sites M — 9 1 163 1,080 1,460 2,713 2,582 F — 5 4 140 642 1,124 1,915 1,812 18. Diabetes M — - 1 7 10 34 52 84 F — — — 8 39 85 132 160 19. Intra-cranial vasc. lesions M 1 1 — 40 321 1,025 1,388 1,476 F — - - 20 392 1,562 1,974 2,109 20. Heart disease M — 1 4 195 1,229 3,524 4,953 5,501 F — - 5 143 684 4,121 4,953 5,647 21. Other circulatory diseases M 1 — 1 34 184 706 926 864 F — 1 — 24 146 752 923 992 22. Bronchitis M 46 8 4 43 448 1,044 1,593 2,129 F 17 4 1 13 104 703 842 1,273 23. Pneumonia M 144 36 4 24 228 525 961 1,338 F 122 30 6 32 101 555 846 1,129 24. Other respiratory diseases M 5 2 1 23 98 100 229 297 F 4 4 — 21 56 87 172 198 25. Ulcer of stomach or duodenum M — — — 43 170 170 383 416 F — — 1 7 35 77 120 129 26. Diarrhœa under 2 years M 88 6 — — — — 94 194 F 67 3 — — — — 70 125 27. Appendicitis M — 7 2 9 16 23 57 64 F — 6 3 7 17 20 53 56 28. Other digestive diseases M 11 3 3 33 118 201 369 375 F 6 11 5 24 106 266 418 460 29. Nephritis M — 1 9 53 96 179 338 378 F — 1 9 41 87 231 369 377 30. Maternal sepsis F — — — 22 — — 22 23 31. Other maternal F — — — 26 — — 26 47 118 Table 4—Administrative County of London—Civilian deaths in 1948 by cause—continued Cause Sex 0— 1— 5— 15— 45— 65+ Total 1948 1947 32. Premature birth M 237 - - - - - 237 278 F 175 - - - - - 175 236 33. Congenital malformation, birth injury, other infant diseases. M 412 10 7 19 15 4 467 521 F 275 11 5 18 21 11 341 378 34. Suicide M — — — 78 123 70 271 219 F - - - 55 72 38 165 135 35. Road traffic accidents M — 7 28 34 34 50 153 216 F 1 4 12 12 21 45 95 103 36. Other violent causes M 54 25 18 133 86 158 474 537 F 54 12 11 37 51 300 465 536 37. All other causes M 33 27 27 140 229 661 1,117 1,252 F 28 14 26 140 259 573 1,040 1,243 All causes M 1,082 200 132 1,655 5,474 10,755 19,298 21,502 F 787 150 108 1,460 3,632 11,493 17,630 20,012 Table 5—Live births and Stillbirths—Administrative County of London Year Live births Stillbirths Stillbirth Rate per 1,000 live and stillbirths 1928 72,352 2,417 32.3 1929 70,089 2,335 32.2 1930 69,447 2,448 34.0 1931 65,684 2,205 32.5 1932 62,233 1,987 30.9 1933 56,743 1,934 33.0 1934 56,853 1,844 31.4 1935 55,780 1,854 32.2 1936 56,273 1,857 31.9 1937 55,011 1,864 32.8 1938 54,495 1,711 30.4 1939 52,366 1,579 29.3 1940 46,213 1,405 29.5 1941 33,944 1,046 29.9 1942 40,654 1,225 29.3 1943 45,030 1,137 24.6 1944 44,554 1,138 24.9 1945 45,532 1,095 23.5 1946 65,883 1,598 23.7 1947 71,323 1,554 21.3 1948 60,934 1,191 19.2 119 Table 6—County of London—Infant mortality, 1948 Cause of death Age at death Total Rates per 1,000 live births Under 1 day 1 to 7 days 1 to 4 wks. 4 weeks to 1 year No. Males Females Total Male Female Measles Leg. - - - 7 7 3 4 0.11 0.10 0.14 Illeg. — — — Whooping.cough Leg. — — l 40 41 26 15 0.67 0.83 0.51 Illeg. — — — Influenza Leg. — — — 4 4 3 1 0.07 0.10 0.03 Illeg. — — — Tuberculosis Leg. — — — 17 17 10 7 0.28 0.32 0.24 Illeg. — — — Bronchitis Leg. — — 1 62 63 46 17 1.03 1.46 0.58 Illeg. — — — Pneumonia Leg. — 18 29 216 266 144 122 4.37 4.58 4.14 Illeg. — — 3 Diarrhœa Leg. — — 6 148 155 88 67 2.54 2.80 2.27 Illeg. — — 1 Premature birth Leg. 162 153 44 11 412 237 175 6.76 7.53 5.94 Illeg. 19 20 3 Congenital malformation, birth injury and other diseases of early infancy. Leg. 219 231 74 131 687 412 275 11.27 13.10 9.33 Illeg. 14 15 3 Other causes Leg. 2 9 18 166 217 113 104 3.56 3.59 3.53 Illeg. 20 1 1 All causes Leg. M. 233 227 105 421 1,702 986 716 30.02 33.64 26.14 F. 150 184 68 314 Illeg. M. 30 22 7 37 167 96 71 39.39 44.59 3402. F. 23 14 4 30 Total 1948 436 447 184 802 1,869 1,082 787 30.67 34.39 26.70 Total 1947 510 526 253 1,165 2,454 1,413 1,041 34.41 38.58 30.00 1947 Leg. M. 251 274 139 630 2,230 1,294 936 33.51 37.87 28.91 F. 190 209 91 446 Illeg. M. 38 24 14 43 224 119 105 46.92 48.49 45.26 F. 31 19 9 46 Table 7—Infant mortality in London by cause 1911—1948 (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 1943 to 1946 1946 1947 1948 Measles 3.40 3.84 1.64 2.02 2.07 1.44 0.95 0.22 0.21 0.12 0.11 0.11 Whooping-cough 3.63 4.45 2.50 2.60 3.14 2.27 2.01 1.43 1.07 0.52 0.76 0.67 Influenza 0.27 1.10 0.81 0.38 0.48 0.40 0.24 0.39 0.29 0.27 0.17 0.07 Tuberculosis 3.40 3.20 1.52 1.26 0.89 0.77 0.56 0.63 0.36 0.36 0.35 0.28 Bronchitis 6.41 6.72 4.42 2.91 2.30 2.16 1.97 1.81 1.36 1.08 0.94 1.03 Pneumonia 12.28 14.96 12.60 11.51 12.10 11.45 10.39 7.64 6.74 5.60 5.61 4.37 Diarrhœa 24.28 16.10 12.16 9.36 8.87 10.86 12.10 6.96 6.93 3.96 4.30 2.54 Premature birth 18.16 17.42 17.00 14.74 14.17 14.91 13.41 12.51 10.38 9.15 7.21 6.76 Congenital mal., etc. 14.69 14.66 11.26 8.39 7.38 7.22 6.35 10.08 11.96 12.52 10.75 11.27 Other causes 21.48 20.55 15.09 11.83 12.60 13.52 12.30 8.14 5.83 4.77 4.21 3.56 All causes 108 103 79 65 64 65 60 50 45 38 34 31 120 Table 8—Maternal mortality—London and England and Wales 1939-48 (Rates per 1,000 total births) 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 Puerperal fever:— London 0.61 0.95 1.42 1.10 0.93 0.74 0.69 0.33 0.32 0.35 England and Wales 1.02 0.81 0.83 0.77 0.73 0.60 0.49 0.31 0.26 0.23 Other causes:— London 1.24 0.97 1.52 1.34 1.15 0.92 1.20 0.90 0.64 0.42 England and Wales 2.11 1.87 1.97 1.71 1.50 1.33 1.31 1.12 0.91 0.78 Table 9 —Maternal mortality in London 1931-48 Metropolitan boroughs arranged in divisional order Childbirth deaths (a) per 1,000 total-births Number of deaths (b) in childbirth 1948 1931-40 1941-48 Puerperal fever Other causes Total Puerperal fever Other causes Total Puerperal fever Other causes Total Division 1. Chelsea 1.5 1.8 3.3 0.6 1.3 1.9 — — — Fulham 1.1 1.6 2.7 0.5 0.9 1.4 — 2 2 Hammersmith 1.0 1.1 2.1 0.6 0.8 1.4 1 — 1 Kensington 1.5 1.5 3.0 0.6 1.0 1.6 1 4 5 Division 2. Hampstead 0.8 1.3 2.1 0.3 1.3 1.6 1 — 1 Paddington 1.8 2.1 3.9 1.0 0.9 1.9 2 1 3 St. Marylebone 1.4 2.0 3.4 1.3 1.3 2.6 — — — St. Pancras 1.4 1.6 3.0 1.0 0.8 1.8 3 — 3 Westminster, City of 1.9 1.4 3.3 1.2 0.9 2.1 1 — 1 Division 3. Finsbury 0.8 0.7 1.5 1.1 0.9 2.0 — — — Holborn 2.0 1.3 3.3 1.9 0.5 2.4 — — — Islington 1.1 1.4 2.5 0.7 0.8 1.5 3 1 4 Division 4. Hackney 0.8 1.3 2.1 0.4 0.7 1.1 — — — Shoreditch 0.7 1.4 2.1 1.0 0.8 1.8 1 — 1 Stoke Newington 0.6 2.8 3.4 0.5 1.3 1.8 — — — Division 5. Bethnal Green 1.1 1.0 2.1 0.7 0.6 1.3 1 1 2 City of London 3.1 — 3.1 - - - - - - Poplar 1.3 1.1 2.4 0.7 0.7 1.4 — 1 1 Stepney 0.9 1.6 2.5 0.5 1.1 1.6 — — — Division 6. Deptford 1.0 1.3 2.3 0.6 0.9 1.5 — 1 1 Greenwich 1.2 1.5 2.7 0.4 1.0 1.4 1 1 2 Woolwich 0.8 1.1 1.9 0.3 0.9 1.2 — 1 1 Division 7. Camberwell 1.2 1.5 2.7 0.8 1.1 1.9 2 2 4 Lewisham 1.1 1.5 2.6 0.4 1.2 1.6 1 1 2 Division 8. Bermondsey 1.3 1.5 2.8 0.7 1.7 2.4 — 2 2 Lambeth 0.9 1.0 1.9 0.6 0.9 1.5 — 1 1 Southwark 0.9 1.6 2.5 0.5 1.2 1.7 1 2 3 Division 9. Battersea 1.1 1.5 2.6 0.5 0.7 1.2 1 2 3 Wandsworth 1.4 1.3 2.7 0.7 0.9 1.6 2 3 5 London County 1.1 1.4 2.5 0.6 0.9 1.5 22 26 48 (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 1948 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 1948 and for London as a whole are, however, set out in table 2. 121 Table 10—Death-rates from certain infectious diseases—London and England and Wales—1931-48 Rates are per 1,000 living except for diarrhœa and enteritis where it is expressed per 1,000 live births Year Measles Whooping-cough Scarlet fever Diphtheria Diarrhœa & 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 0.066 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 1947 0.007 0.015 0.025 0.022 0.0006 0.001 0.007 0.006 4.47 5.40 1948 0.008 0.008 0.016 0.017 0.0006 0.0009 0.006 0.004 2.69 3.13 122 Table 12—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 primary notifications 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 (c) 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 (c) 0.78 614 0.21 224 (c) 0.09 1946 5,137 1.57 1,940 (c) 0.62 611 0.19 243 (c) 0.08 1947 5,421 1.58 2,044 (c) 0.62 662 0.19 252 (c) 0.08 1948 5,473 1.61 1,900 (c) 0.57 600 0.18 202 (c) 0.06 (a) Excluding posthumous cases. (b) Not checked for duplicates. (c) Excluding non–civilians from 3 Sept., 1939. Rates based on civil population. Table 13(a)—Tuberculosis—Primary notifications in London during the year 1948 Form of tuberculosis notified Sex Number of formal primary notifications of new cases of tuberculosis Total all ages 0– 1– 5– 10– 15– 20– 25– 35– 45– 65– 65+ Pulmonary tuberculosis M. 24 125 88 70 244 403 743 483 422 351 184 3,137 F. 12 112 99 72 363 550 636 248 106 86 52 2,336 Other forms of tuberculosis M. 7 48 50 37 27 38 29 22 8 9 12 287 F. 7 31 36 33 49 40 57 25 13 14 8 313 All forms of tuberculosis M. 31 173 138 107 271 441 772 505 430 360 196 3,424 F. 19 143 135 105 412 590 693 273 119 100 60 2,649 Table 11—County of London—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—1931.1948 Year Anthrax Cerebrospinal fever Continued fever Diphtheria Dysentery Encephalitis lethargica Enteric fever Erysipelas Malaria Measles Ophthalmia neonatorum Pneumonia Polioencephalitis Poliomyelitis Puerperal pyrexia Scabies Scarlet fever Smallpox Typhus Whooping. cough 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 Rate 1931 2 0.0005 175 0.040 3 0.0007 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 0.012 828 (a) 12.20 (b) (b) 12,025 2.73 1,452 0.330 — — (b) (b) 1932 3 0.0007 247 0.057 4 0.0009 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 0.018 741 11.54 (b) (b) 14,119 3.26 1,131 0.261 — — (b) (b) 1933 3 0.0007 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 0.014 838 14.28 (b) (b) 21,911 5.11 531 0.124 — — (b) (b) 1934 3 0.0007 137 0.032 4 0.0009 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 0.016 758 12.91 (b) (b) 18,238 4.32 144 0.034 — — (b) (b) 1935 2 0.0005 105 0.025 3 0.0007 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 0.019 652 11.31 (b) (b) 10,954 — — — — — (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 0.009 635 10.92 (b) (b) 10,705 — — — — — (b) (b) 1937 3 0.0007 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 0.023 793 13.94 (b) (b) 8,455 — — — — — (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 0.030 853 15.18 (b) (b) 8,093 — — — — — 1,891 (c) 10,537 1.87 1939 3 0.0008 169 0.045 3 0.0008 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 0.025 704 13.05 (b) (b) 5,677 1.51 — — — — 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 0.006 472 10.66 (b) (b) 2,498 0.81 — — — — 669 0.218 1941 1 0.0004 706 0.298 2 0.0008 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 0.015 340 12.06 (b) (b) 2,372 — — — — — 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 0.010 505 12.06 (b) (b) 4,416 1.84 2 0.0008 — — 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 0.016 471 10.20 9,689 (d) 16,450 9.18 9,477 3.80 — — — — 6,661 2.67 1944 (e) — — 150 0.061 — — 758 0.308 1,450 0.589 2 0.0008 30 0.012 916 0.372 78 0.032 7,329 2.98 211 4.74 2,292 0.931 2 0.0008 15 0.006 399 8.73 6.70 3,862 1.57 2 0.0008 — — 7,136 2.90 1945 (e) — — 145 0.056 1 0.0004 801 0.308 1,867 0.718 3 0.001 28 0.011 818 0.314 93 0.036 23,486 9.03 222 4.88 1,930 0.742 1 0.0004 62 0.024 515 11.05 14,753 5.69 4,079 1.57 3 0.001 3 0.001 3,264 1.25 1946 (e) — — 184 0.059 — — 747 0.240 845 0.272 6 0.002 44 0.014 844 0.271 168 0.054 22,846 7.35 268 4.08 2,125 0.683 3 0 001 26 0.008 553 8.19 11,892 3.84 4,402 1.42 2 0 0006 — — 6,887 2.22 1947 (e) 2 0.0006 166 0.050 — — 451 0.136 309 0.093 7 0.002 48 0.015 742 0.224 47 0.014 17,486 5.28 231 3.24 2,110 0.638 50 0.015 652 0.197 441 6.05 5,304 1.60 4,331 1.31 3 0.001 1 0 0003 9,267 2.80 1948 (e) 1 0.0003 110 0.033 1 0.0003 335 0.100 704 0.211 1 0.0003 48 0.014 719 0.215 33 0.010 30,608 9.17 224 3.68 1,891 0.566 8 0.002 133 0.040 460 7.40 2,484 0.74 4,568 1.37 — — — — 10,450 3.13 (a) Rate per 1,000 total births. (b) Comparable figures not available for this period, (c) Cases relate to last quarter only—Rates are adjusted on an annual basis. (d) Oases relate to last 22 weeks only—Rates are adjusted on an annual basis, (e) In order to preserve uniformity with published national figures the recently instituted practice of the Registrar General has been followed in producing this table, namely in taking full account of any known changes in diagnosis after the receipt of the original notification. These corrections were not available prior to 1944, and for 1931.43 uncorrected figures are given, but on the basis of dual records kept from 1944.47, comparable figures can be obtained by multiplying the uncorrected notifications by the following factors:—Cerebrospinal fever 0.730, Diphtheria 0.599, Dysentery 0.908, Encephalitis lethargica 0.546, Enteric fever 0.721, Erysipelas 0.977, Measles 1.001, Ophthalmia neonatorum 1.004, Pneumonia 0.964, Poliomyelitis and polioencephalitis 0.845, Puerperal fever 0.840, Puerperal pyrexia 1.002, Scarlet fever 0.950, and Whooping cough 1.002. Correction factors are not available for malaria and scabies and in these two diseases the corrected figure of notifications is given for 1947 only. 123 Table 13(b)— New cases of tuberculosis in London found by other means than notification, 1948 Form of tuberculosis Sex New cases of tuberculosis coming to knowledge otherwise than by formal notification 0- 1- 6- 10- 15- 20- 25- 35- 45- 55- 65 + Total Pulmonary tuberculosis M. 2 11 19 7 29 109 264 146 118 81 76 862 F. 6 18 17 8 44 176 208 87 37 25 30 656 Other forms of tuberculosis M. 4 18 9 7 8 11 8 8 6 5 1 85 F. 1 9 3 4 13 10 22 8 4 7 4 85 All forms of tuberculosis M. 6 29 28 14 37 120 272 154 124 86 77 947 F. 7 27 20 12 57 186 230 95 41 32 34 741 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 171 31 transferable deaths from Registrar-General 187 26 Posthumous notifications 34 10 "Transfers" from other areas 1,087 98 Other sources 39 5 Table 13 (c)—Numbers on the registers, for the whole county, 1941-1948 Cases on the register at the end of the year— 1941 1942 1943 1944 1945 1946 1947 1948 Pulmonary— Males 12,677 12,894 13,608 14,340 15,018 15,695 16,374 17,224 Females 9,119 9,441 10,232 10,990 11,496 12,262 12,862 13,549 Other forma— Males 2,916 2,785 2,847 2,866 2,813 2,821 2,699 2,889 Females 3,044 2,963 3,074 3,185 3,123 3,099 3,142 3,147 Total 27,756 28,083 29,761 31,381 32,450 33,877 35,077 36,809 No. per 1,000 of population 11.9 11.7 11.9 12.7 12.5 10.9 10.6 11.0 124 Table 14.—New cases (a) of tuberculosis in London (A.C.) by age 1938.39 and 1946—48 Morbidity rates (i) Pulmonary Age Group 1938 1939 1946 1947 1948 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 0­4 105 0.42 76 0.35 199 0.94 223 1.04 282 1.01 5­14 228 161 349 384 351 15­24 1,484 1.52 1,353 1.46 1,482 1.76 1,545 1.75 1,551 1.82 25­64 3,262 2,917 2,982 3,111 3,149 65 + 224 236 244 262 290 Not stated 2 24 30 49 41 Total 5,305 1.31 4,767 1.26 5,286 1.62 5,574 1.63 5,664 1.67 Ratio to 1938 per cent. 100 96 124 124 127 (ii) Non—Pulmonary Age Group 1938 1939 1946 1947 1948 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate per 1,000 0­4 142 0.50 112 0.47 99 0.49 121 0.46 99 0.41 5­14 253 200 187 147 156 15­24 272 0.20 217 0.18 142 0.13 137 0.14 154 0.13 25­64 346 302 201 241 181 65 + 40 26 15 18 20 Not known — 2 3 6 — Total 1,053 0.26 859 0.23 647 0.20 670 0.20 610 0.18 Ratio to 1938 per cent. 100 88 77 77 69 (a) Including posthumous notifications and new cases reported otherwise than by primary notification but excluding transfers of cases already notified. 125 Table 15—New cases of non—pulmonary Tuberculosis in London (A.C.) 1938.1939 and 1946.1948. Distribution according to site Rates for 1,000 living are shown in parenthesis against the number of cases Age group Year Bones and Joints Abdomen Site of tuberculous lesion Other sites (a) Total Peripheral glands Meninges 1. Under 15 years of age. 1938 99 (0.126) 43 (0.055) 123 (0.156) 89 (0.113) 41 (0.052) 395 (0.501) 1939 95 (0.142) 23 (0.034) 113 (0.169) 55 (0.082) 26 (0.039) 312 (0.466) 1946 60 (0.103) 25 (0.043) 120 (0.207) 44 (0.076) 37 (0.064) 286 (0.493) 1947 50 (0.085) 26 (0.044) 105 (0.179) 63 (0.108) 24 (0.041) 268 (0.457) 1948 54 (0.086) 17 (0.027) 97 (0.154) 50 (0.079) 37 (0.059) 255 (0.405) Rates expressed per cent. of 1938. 1938 100 100 100 100 100 100 1939 113 62 108 73 75 93 1946 82 78 133 67 123 98 1947 68 80 115 96 79 91 1948 68 49 99 70 113 81 2. Over 15 years of age. 1938 190 (0.058) 84 (0.026) 141 (0.043) 45 (0.014) 198 (0.060) 658 (0.201) 1939 175 (0.056) 52 (0.017) 136 (0.044) 40 (0.013) 144 (0.046) 547 (0.176) 1946 109 (0.040) 38 (0.014) 87 (0.032) 20 (0.007) 107 (0.040) 361 (0.134) 1947 114 (0.040) 55 (0.019) 94 (0.033) 15 (0.005) 124 (0.044) 402 (0.141) 1948 111 (0.040) 36 (0.013) 82 (0.030) 22 (0.008) 104 (0.037) 355 (0.128) Rates expressed per cent. of 1938. 1938 100 100 100 100 100 100 1939 97 65 102 93 77 88 1946 70 54 74 50 67 67 1947 70 73 77 36 73 71 1948 70 50 70 57 62 64 (a) Includes miliary and genitourinary. Table 16—New cases of Tuberculosis in London (A .C.) 1938.1948—Sex Ratios (i) Pulmonary Year 0—14 15—24 25—64 65 + Age Group Total (a) M F M/F M F M/F M F M/F M F M/F M F M/F 1938 173 160 1.08 661 823 0.80 2,133 1,129 1.89 152 72 2.11 3,121 2,184 1.43 1939 111 126 0.88 654 699 0.94 1,913 1,004 1 .91 170 66 2.58 2,868 1,899 1 .51 1940 70 93 0.75 573 669 0.86 1,835 898 2.04 152 50 3.04 2,638 1,720 1.53 1941 164 138 1.19 621 722 0.86 2,001 880 2.27 188 64 2.94 2,987 1,815 1.65 1942 173 151 1.15 664 813 0.82 1,914 966 1.98 173 54 3.20 2,941 1,994 1.47 1943 214 179 1.20 625 713 0.88 2,005 1,304 1.54 173 62 2.79 3,035 2,279 1.33 1944 223 178 1.25 701 840 0.83 1,809 1,027 1.76 319 62 5.15 3,081 2,120 1.45 1945 216 199 1.09 650 822 0.79 1,853 1,025 1 .81 209 58 3.60 2,950 2,116 1.39 1946 287 261 1.10 651 831 0.78 1,884 1,098 1.72 180 64 2.81 3,023 2,263 1.34 1947 319 288 1.11 662 883 0.75 1,956 1,155 1.69 206 56 3.68 3,175 2,399 1.32 1948 324 309 1.05 638 913 0.70 2,052 1,097 1.87 221 69 3.20 3,260 2,404 1.36 (ii) Non-pulmonary 1938 223 172 1.30 144 128 1.13 154 192 0.80 12 28 0.43 533 520 1.03 1939 165 147 1.12 107 110 0.97 142 160 0.89 14 12 1.17 428 431 0.99 1940 117 125 0.94 80 94 0.85 142 120 1.18 10 14 0.71 353 353 1.00 1941 141 136 1.04 87 111 0.78 116 113 l .03 14 26 0.54 360 388 0.93 1942 176 149 1.18 104 116 0.90 120 152 0.79 12 20 0.60 413 443 0.93 1943 161 146 1.10 96 105 0.91 108 197 0.55 5 24 0.21 375 473 0.79 1944 163 121 1.35 72 91 0.79 106 135 0.79 9 12 0.75 351 360 0.97 1945 136 128 1.06 67 101 0.66 102 95 1.07 5 12 0.42 311 339 0.92 1946 142 144 0.99 65 77 0.84 99 102 0.97 7 8 0.88 316 331 0.95 1947 150 118 1 .27 45 92 0.49 99 142 0.70 9 9 1.00 306 364 0.84 1948 145 110 1.32 65 89 0.73 68 113 0.60 12 8 1.50 290 320 0.91 (a) Including cases in which the age is not known. 126 Table 17—Cases of infectious illness reported from schools in 1948 and preceding years Year Chicken-pox Diphtheria German measles Impetigo Measles Mumps Ophthalmia and conjunctivitis Poliomyelitis Ringworm Scabies Scarlet fever Whooping. cough 1938 11,018 3,576 2,383 1,018 31,852 4,805 342 – 278 2,718 3,988 4,067 1946 5,602 290 349 381 8,291 5,296 251 5 245 1,488 1,654 2,421 1947 7,423 263 1,571 264 6,684 2,845 233 153 180 650 1,974 3,660 1948 7,745 187 491 243 11,545 9,162 297 34 119 323 2,078 3,691 Table 18—Diphtheria Immunisation—Year ended 31.12.48 Immunisation in relation to Child population Divisions Totals Age at 31-1-48 1 2 3 4 5 6 7 8 9 Under 5 years (born 1944.1948) Child population 33,505 33,913 25,085 22,508 21,098 27,973 35,906 33,240 36,695 269,923 Immunised 16,990 18,247 14,561 12,596 9,157 15,817 16,131 14,983 20,341 138,823 Per cent. 50.7 53.8 581 55.9 43.4 56.5 44.9 45.1 55.4 51.4 5.14 years (born 1934. 1943)— Child population 44,804 42,691 33,607 30,591 30,399 36,714 47,364 45,197 48,177 359,544 Immunised 35,037 24,107 26,317 21,682 15,460 26,518 33,455 22,704 23,066 228,346 Per cent. 78.2 56.4 78.3 70.8 50.8 72.2 70.6 50.2 47.8 63.5 0.14 years (born 1934. 1948) — Child population 78,309 76,604 58,692 53,099 51,497 64,687 83,270 78,437 84,872 629,467 Immunised 52,027 42,354 40,878 34,278 24,617 42,335 49,586 37,687 43,407 367,169 Per cent. 66.4 55.3 69.6 64.6 47.8 65.4 59.5 48.1 51.1 58.3 Diphtheria Notifications and Deaths in relation to immunisation during 1948 Cases notified— Immunised 5 18 4 12 9 6 2 11 3 70 Not immunised 10 16 3 37 26 8 15 42 21 178 Deaths— Immunised – – – – – – – – – – Not immunised 2 3 — 7 — — — 3 — 15 127 Table 19—Treatment of venereal disease at London clinics 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 1947 2,207 1,301 128 6 7,236 1,408 9,571 2,715 13,847 7,132 1948 1,949 1,155 102 6 7,008 1,346 9,059 2,507 16,349 6,821 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 688,815 263,908 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 1947 269,435 147,717 6,989 8,447 266,551 88,237 1948 268,203 148,212 6,140 8,379 not known not known 128 Table 20—Leaver contra-indications for employment Contra-indication Boys Girls Number Per cent. of inspected pupils (11,944) (a) Number Per cent. of inspected pupils (11,102) (a) Heavy manual work 366 3.1 276 2.5 Sedentary confined work 57 0.5 57 0.5 Exposure to bad weather 185 1.5 219 2.0 Dusty atmosphere 150 1.3 73 0.7 Climbing 68 0.6 65 0.6 Proximity to moving machinery 56 0.5 32 0.3 Prolonged standing 264 2.2 383 3.4 Eye strain 925 7.7 1,036 9.3 Acute distant vision 921 7.7 895 8.1 Acute hearing 61 0.5 48 0.4 Food preparation 139 1.2 184 1.6 Number of pupils with contra-indications (6) 1,949 16.3 1,970 17.7 (а) Excluding special schools and certain grammar schools at which the Leaver contraindication slip is not in use. (b) The total number of contraindications is greater than the number of pupils for the reason that an individual pupil may be noted for two or more contra-indications. "ASCERTAINMENT" OF HANDICAPPED CHILDREN Table 21—Vision cases A. Children not in special schools :— Boys Girls Total Found to be blind Over 11 6 2 8 Under 11 4 — 4 12 Found to be partially sighted Over 11 9 5 14 Under 11 45 38 83 97 Found to be fit for ordinary schools with " care " Over 11 9 19 28 Under 11 10 13 23 51 Found to be fit for ordinary schools Over 11 8 11 19 Under 11 12 9 21 40 B. Children already in attendance at partially sighted schools :— Considered suitable to continue at the special school 11 3 14 Given advice as to future occupation 1 3 4 Considered fit to return to ordinary schools 3 5 8 Given various advice 3 7 10 129 Table 22—Hearing cases A. Children not in special schools :— Boys Girls Total Found suitable for deaf school Over 11 5 3 8 Under 11 26 25 51 59 Found suitable for partially deaf school Over 11 2 2 4 Under 11 16 12 28 32 Found suitable for ordinary school with individual hearing aid and/or to sit in front row, etc. Over 11 12 11 23 Under 11 11 10 21 44 Found suitable for ordinary school Over 11 3 4 7 Under 11 5 2 7 14 Recommended for treatment before decision taken 3 6 9 B. In addition 2 boys, already attending deaf schools, were examined and found to be suitable for ordinary schools ; 3 boys and 3 girls attending partially deaf units were examined and found to be suitable for ordinary schools. Table 23—Epilepsy cases A. Children not in special schools :— Boys Girls Total Found suitable for residential special school for epileptics Over 11 4 10 14 Under 11 5 6 11 25 Found suitable for ordinary school Over 11 3 6 9 Under 11 8 3 11 20 Found suitable for E.S.N. school Over 11 – 1 1 Under 11 — — — – 1 Recommendation postponed Over 11 – – – Under 11 — 1 1 1 B. 2 boys and 1 girl from residential special schools for epileptics were examined and found to be fit to attend ordinary schools. 130 Table 24—Educationally sub-normal A. Children not in special schools :— Boys Girls Total Found suitable for day E.S.N. school Over 11 9i 72 163 Under 11 265 176 441 604 Found suitable for residential E.S.N. school Over 11 9 6 15 Under 11 36 36 72 87 Found suitable for special E.S.N. class in ordinary school. Over 11 98 42 140 Under 11 308 146 454 594 Found to have no disability of mind and fit for ordinary school. Over 11 45 19 64 Under 11 217 79 296 360 Found to be unsuitable for school (e.g., ineducable) Over 11 7 5 12 Under 11 31 32 63 75 Decision postponed Over 11 – – – Under 11 6 5 11 11 Table 25—Delicate children 1,593 children were recommended for admission to residential schools for delicate children. Of these 871 were boys and 722 were girls. 448 children (260 boys, 188 girls) were recommended for admission to day schools for delicate children. 251 (145 boys, 106 girls) were found to be no longer in need of special educational treatment in day schools for delicate children. B.i. Children in attendance at special E.S.N. schools specially examined and— Boys Girls Total Found to be no longer in need of special educational treatment 1 1 2 Found to be suitable for transfer to special E.S.N. classes in ordinary schools 4 4 8 Found to be unsuitable for retention because ineducable, etc 34 35 69 Found to be suitable to continue in special school 36 33 69 Recommended for transfer to Residential Special E.S.N. school 24 8 32 B.ii. Children in attendance at special E.S.N. classes in ordinary schools; specially examined and— Boys Girls Total Found to be suitable for special E.S.N. school 17 15 32 Found to be suitable for ordinary school 17 5 22 Found to be suitable to continue in E.S.N. class 16 6 22 Total examinations 1,987 131 Table 26—Physically handicapped children A. Children not in Special schools— Boys Girls Total Found to be suitable for Day Special School for physically handicapped (see (i) below) 203 159 362 Found to be suitable for Residential Special school for physically handicapped (see (i) below) 21 20 41 Found to be suitable for ordinary school (see (ii) below) 28 22 50 Found to be unsuitable for education at school, but suitable for Home tuition under Sec. 56 of Education Act, 1944 ... 10 6 16 Decision postponed 6 11 17 Total 486 (i) Number of these children recommended for P.H. schools :— Morbid condition Day Residential Grand total Boys Girls Total Boys Girls Total Infantile paralysis 22 16 38 2 2 4 42 Cerebral palsy 22 16 38 3 4 7 45 Various paralyses 1 2 3 — 1 1 4 T. B. of bones and joints 16 17 33 3 — 3 36 Osteomyelitis 9 2 11 — — — 11 Perthé's disease 9 2 11 — — — 11 Rickets and resultant deformities 5 1 6 — 2 2 8 Congenital deformities 10 12 22 2 1 3 25 Spinal deformities 2 2 4 2 1 3 7 Traumata and amputations 9 2 11 1 2 3 14 Non-T.B. arthritis and synovitis 3 1 4 — — — 4 Rheumatism and chorea 4 8 12 — — — 12 Heart disease— Congenital 23 21 44 — 3 3 47 Rheumatic 41 39 80 2 — 2 82 Non-rheumatic 2 3 5 — 1 1 6 Other diseases 25 15 40 6 3 9 49 203 159 362 21 20 41 403 (ii) Number of these children recommended for ordinary schools :— Morbid condition Boys Girls Total Infantile paralysis 3 4 7 Cerebral palsy 1 1 2 Various paralyses — — — T. B. of bones and joints 1 — 1 Osteomyelitis 1 — 1 Perthes Disease 2 — 2 Rickets and resultant deformities — 1 1 Congenital deformities 3 — 3 Spinal deformities — 2 2 Traumata and amputations 3 — 3 Non- T. B. arthritis and synovitis 1 1 2 Rheumatism and chorea 1 1 Heart disease- Congenital 4 2 6 Rheumatic 2 4 6 Non-rheumatic — 1 1 Other diseases 6 6 12 28 22 50 132 B. Children already in attendance at Special (P. H.) Schools :— Boys Girls Total Found to be no longer in need of special educational treatment (see (i) below) 103 53 156 Found to be medically unfit to remain in Special school 2 3 5 Other recommendations (see (ii) below) 67 25 92 Total 253 (i) Number of these children found to be no longer in need of special educational treatment:— Morbid condition Day P. H. Schools Res. P. H. Schools Grand total Boys Girls Total Boys Girls Total Infantile paralysis 6 3 9 — — — 9 Cerebral palsy 5 — 5 — — — 5 Various paralyses — — — — — — — T. B. of bones and joints 8 10 18 1 — 1 19 Osteomyelitis 18 1 19 1 — 1 20 Perthé's disease 9 2 11 — — — 11 Rickets and resultant deformities 2 1 3 — — — 3 Congenital deformities 13 4 17 — — — 17 Spinal deformities 3 1 4 — — — 4 Traumata and amputations 2 — 2 — — — 2 Non- T .B. arthritis and synovitis 2 2 4 — — — 4 Rheumatism and chorea 2 2 4 — — — 4 Heart disease— Congenital 6 5 11 — — — 11 Rheumatic 13 16 29 1 — 1 30 Non-rheumatic 2 2 4 — — — 4 Other diseases 9 4 13 — — — 13 100 53 153 3 — 3 156 (ii) Other recommendations :— Morbid condition Day P. H. Schools Residential P. H. Schools Continue Day School Transfer to Res. School Continue Res. School Transfer to Day School Grand total B. G. T. B. G. T. B. G. T. B. G. T. Infantile paralysis 8 4 12 1 1 2 — — — — — — 14 Cerebral palsy — 1 1 1 1 2 1 1 2 — 1 1 6 Various paralyses — — — 1 — 1 — — — — — — 1 T. B. of bones and joints 11 7 18 — 1 1 — — — 1 — 1 20 Osteomyelitis 5 — 5 — — — 2 — 2 — — — 7 Perthé's disease 1 — 1 — — — — — — — — — 1 Rickets and resultant deformities — — — — — — — — — — — — — Congenital deformities 6 3 9 — — — 7 — 7 1 — 1 17 Spinal deformities 2 — 2 — — — — — — — — — 2 Traumata and amputations 3 — 3 — — — — — — — — — 3 Non- T. B. arthritis and synovitis 1 — 1 — — — — — — — — — 1 Rheumatism and chorea — — — — — — — — — — — — — Heart disease— Congenital 3 1 4 1 1 2 — — — — — — 6 Rheumatic 1 1 2 — — — — — — — 1 I 3 Non-rheumatic — — — 1 — 1 — — — — — — 1 Other diseases 1 1 2 7 — 7 1 — 1 — — — 10 42 18 60 12 4 16 11 1 12 2 2 4 92 133 Table 27—Dual defects The following children were found on examination to suffer from more than one handicap:— Boys Girls Total Recommended for Rayners (dual defects) School 22 7 29 „ for other schools for dual defects — 3 3 „ for E.S.N. schools 16 16 32 „ for P. H. schools 16 8 24 ,, invalid pending the provision of a suitable dual defect school 7 4 11 ,, partially sighted school 2 3 5 „ open-air school 4 4 8 „ deaf school 6 1 7 „ epileptic colony (Ep. and Blind) — 1 1 „ blind school (Blind and E.S.N.) 1 — 1 121 Table 28—Speech defects Boys Girls Total Recommended for speech therapy because of stammer 82 24 106 Recommended for speech therapy because of speech defect 131 51 182 Found to be unsuitable for speech therapy 27 4 31 319 In addition 2 children were recommended for admission to Moor House Residential Special School for Speech Defects. Table 29—Maladjusted children Boys Girls Total Deemed to be maladjusted and suitable for residential placement 136 48 184 Deemed to be maladjusted and suitable for special classes 49 15 64 248 Deemed to be no longer in need of special educational treatment as maladjusted 22 2 24 In addition the Consultant Psychiatrist examined 44 special cases, and made reports on them. Table 30—Diabetic children Number of children found to be diabetic and suitable for residential treatment:— Boys Girls Total London children 4 1 5 Out-County children 2 2 4 9 Table 31—Re-classification The following table shows the number of children re-classified (i.e., found upon examination to be in need of different special educational treatment):— Boys Girls Total From physically handicapped to E.S.N. — 2 2 „ blind to partially sighted 1 — 1 „ partially sighted to blind 1 — 1 ,, deaf to E.S.N. 1 — 1 „ deaf to partially deaf 1 — 1 „ partially deaf to E.S.N. 1 — 1 „ partially deaf to deaf 3 1 4 „ Rayners (dual defect) to E.S.N. — 1 1 134 RHEUMATISM Table 32—Nominations for treatment under the scheme 1946 1947 1948 Received from hospitals 473 538 528 „ „ rheumatism supervisory centres 89 90 64 „ ,, school doctors 28 41 10 „ „ other sources (private practitioners, welfare organisations, etc.) 15 23 12 605 692 614 Number outstanding from previous year 13 3 35 618 695 649 Number withdrawn before consideration 5 5 11 613 690 638 Found unsuitable for admission to unit 40 45 27 Died before admission 2 1 2 Parents' consent to admission refused 9 19 17 Accepted nominations subsequently withdrawn 14 27 65 Admitted to Rheumatism Unit 545 563 523 Awaiting admission on 31st December 3 35 4 613 690 638 Supervision Number of children under supervision of school doctors on 31st December 187 268 382 Number of children under supervision at rheumatism supervisory centres 31st December 2,440 2,890 3,216 Number of supervisory centres 22 22 23 Number of sessions at supervisory centres 702 849 893 Number of children attending for first time 1,417 1,508 1,468 Total number of attendances at centres 8,117 9,333 10,505 Number of beds at Rheumatism Unit 240 250 250 Table 33—Admissions to Rheumatism Unit, 1948 Rheumatism and/or chorea with cardiac involvement Rheumatism and/or chorea with no cardiac involvement Sex No. Percentage of Total No. Percentage of Total Total Boys Girls 161 206 71.2 69.4 65 91 28.8 30.6 226 297 367 70.2 156 29.8 523 135 End results of treatment Sex Fit for ordinary school or any employment Fit for p .h. school or light employment Unfit for school or work Died Total No. Percentage of total No. Percentage of total No. Percentage of total No. Percentage of total Boys 209 89.7 14 6 10 4.3 — — 233 Girls 281 82.4 28 8.2 29 8.5 3 0.9 341 490 85.4 42 7.3 39 6.8 3 0.5 574 Table 34-Percentage number of children with cardiac involvement admitted to the rheumatism units, 1934-1948 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 46.9 40.5 37.7 43.1 36.7 35.4 32.1 40.7 67.3 66.7 68.4 60.3 62.4 67.7 70.2 Table 35 County of London—Statistics of the administrative work carried out by the Metropolitan Borough Councils during the year 1948 Sanitary authority Cowsheds Slaughterhouses Offensive trades Smoke nuisances Common lodging houses Cleansing of persons and rooms Water supply Milk- shops ice cream premises Restaurants and eating houses No. licensed No. of inspections No. licensed No. of inspections No. authorised No. of inspections Observations Intimations Complaints Notices Houses licensed No. of inspections Persons Rooms or premises Tenement houses extra supply No. on register No. of inspections No. on register No. of inspections No. of places No. of inspections Adults Children After infectious diseases For vermin City of London — — — — — — 5 — — — I 2 145 2,477 35 78 — 49 46 51 101 579 768 Battersea — — 1 53 3 4 138 5 8 — 1 30 495 3,266 777 262 16 133 338 63 233 146 335 Bermondsey — — — — 11 107 87 1 3 1 45 45 424 2,491 100 386 25 102 274 83 38 53 144 Bethnal Green — — — — 1 4 1 — — — I 7 113 26 28 777 — 166 298 102 261 86 230 Camberwell 1 7 3 12 8 — 40 2 6 — I 38 344 2,476 1,079 983 — 265 93 305 670 253 421 Chelsea — — — — — — 25 — 18 — — — 20 280 196 302 22 40 123 16 44 52 204 Deptford — — 2 2 1 5 10 — 4 — 1 6 436 1,411 240 437 — 72 97 78 155 75 326 Finsbury — — 1 1 4 60 118 — 29 — 1 26 61 1,741 452 351 10 115 84 90 119 157 175 Fulham — — — — — — 15 2 6 — — — — — 245 968 40 73 450 49 149 156 159 Greenwich — — 2 — — — 128 — 21 — — — 779 1,782 148 32 19 59 115 133 494 98 984 Hackney 1 — 1 2 5 5 13 2 15 — 1 7 376 1,805 915 359 15 297 655 253 328 202 315 Hammersmith — — 3 3 — — 30 3 16 — — — 775 2,077 75 410 6 76 381 144 719 281 194 Hampstead — — — — — — 8 — 1 — — — 28 11 582 142 12 64 41 89 207 192 135 Holborn — — — — — — 74 — 11 — 2 3 135 81 120 133 3 57 222 40 357 513 1,640 Islington — — 6 47 12 52 75 5 46 — — — 517 1,897 520 597 43 495 696 494 622 525 1,547 Kensington — — — — — — 28 — — — — — 683 3,244 490 1,747 18 194 240 349 247 214 342 Lambeth — — 1 6 1 2 — — 17 — — — 420 210 1,057 1,879 * 197 77 502 126 213 391 Lewisham — — 2 13 — — 4 — 16 — — — 273 1,592 583 179 — 188 293 247 505 161 540 Paddington — — — — — 6 — 2 — 1 43 395 130 312 1,469 8 118 458 146 333 139 742 Poplar — — 3 — 2 22 120 9 29 1 2 138 203 1,371 271 732 5 36 198 103 174 69 229 St. Marylebone — — 1 10 — — 165 6 11 — 2 67 518 1,153 811 535 20 160 260 121 200 848 1,295 St. Pancras — — 2 — — — 31 — 25 — — — 1,360 2,731 471 678 * 309 610 292 935 333 890 Shoreditch — — — — 1 12 226 1 — 1 1 5 144 113 347 1,251 115 91 344 100 378 178 1,024 Southwark — — 1 4 5 12 32 — 23 — 6 30 1,413 4,171 448 1,495 — 186 519 158 137 261 299 Stepney 1 29 — — 16 117 142 10 31 — 4 75 405 89 448 1,246 167 245 406 176 536 320 906 Stoke Newington — — — — — — — — — — — — 84 1,124 95 454 — 36 162 60 53 46 175 Wandsworth — — 3 46 — — 23 4 6 1 — — 350 111 762 435 23 301 1,685 459 1,712 462 1,485 Westminster — — — — — — 670 1 48 — 5 49 524 706 603 807 67 130 294 118 165 2,621 4,508 Woolwich — — 2 — 2 † 47 2 12 — 2 56 341 2,141 465 215 — 49 130 244 882 240 886 Total 3 36 34 199 72 402 2,261 53 404 4 34 627 11,761 40,707 12,684 19,339 634 4,303 9,589 5,065 10,880 9,473 21,289 Note: In the columns above a dash signifies a nil return ; † daily supervision and * information not available. Seamen's Lodging Houses, 8—Bermondsey 1 (12 inspections) ; Poplar 3 (72 inspections) ; Stepney 4 (62 inspections). Prosecutions : Ice Cream—St. Pancras 2, Stepney 2, Wandsworth 1 ; Milkshops—Hackney 2, Islington 4, Lewisham 1, St. Panoras 5 ; Smoke Nuisances Bermondsey Restaurants—St. Pancras 1, Stepney 1, Westminster 43 ; Water Supply—Chelsea 2, Poplar 1, St. Pancras 6. Table 36 Statistics of the administrative work carried out by the Metropolitan Borough Councils during 1948 Borough No. of houses in borough Public Health Act Housing Acts, 1936 No. of houses inspected on account of complaints or illness No. of statutory notices served No. of houses repaired No. of houses inspected Section 25 Sections 9 & 10 Number of houses demolished Closing Orders Overcrowding No. of dwellings for working classes erected during the year Underground rooms Houses let in lodgings No. of houses represented No. of houses demolished No. of houses repaired No. of families overcrowded No. of families alternative accom-obtained No. occupied but unfit No. closed or modified occupation approved No. in borough No. of inspections No. of prosecutions No. of complaints remedied Section 11 Voluntarily No. made No. determined By owners By L. A. City of London 2,166 13 — 10 7 — — 2 — — — — — 22 11 — 5 — 26 15 — — Battersea 26,974 4,890 2,727 11,759 — — — — — — 1 — — 710 326 67 * 1 — — — — Bermondsey 15,598 5,359 1,264 4,013 1,238 — — — — 24 — 1 — 184 37 65 859 1 419 1,024 — 15 Bethnal Green 16,512 4,989 5,323 2,856 — — — — — — — — — 361 1,477 68 — — 204 602 — — Camberwell 38,463 8,823 2,746 4,573 — — — 1 — — — — — 383 234 — * 2 2,800‡ — — — Chelsea 14,935 2,230 741 828 109 — — — — — — 1 — 69 8 108 — — 575 — — — Deptford 16,789 3,350 1,160 2,735 — 9 — — — — — 9 — 165 30 151 — — * — — — Finsbury 9,890 1,986 45 1,061 — — — — — — — — — 97 300 — 1,400 — 478 578 — — Fulham 30,518 5,288 1,936 22,789 — — — — 7 4 — — — 195 50 68 1 — — — — — Greenwich 20,863 2,967 450 2,151 99 — — — — — — 9 — 160 394 159 69 15 3 36 — 1 Hackney 38,289 10,928 2,148 5,795 67 27 24 — — 2 — — — 476 357 240 214 1 * * * * Hammersmith ‡24,000 4,979 1,889 3,417 — — — 1 2 — — — 2 521 237 62 3 — ‡19,600 — — — Hampstead 19,468 2,590 907 1,820 10 — — — 1 — — — — 375 * 43 516 11 — — — — Holborn 5,674 635 85 1,161 9 — — — — — 8 1 — 61 31 50 523 17 311 351 — 22 Islington 40,462 11,138 5,564 12,153 — — — — — — 78 21 — 924 1,023 375 * 2 * — — — Kensington 36,416 8,302 1,939 3,086 279 — — 59 28 11 7 2 33 664 85 — ‡4,000 187 4,615 279 — 27 Lambeth ‡45,000 16,431 2,433 16,076 1 1 — — — — — — — 811 258 140 — 13 — — — Lewisham 58,113 7,084 955 2,743 — — — 1 — 3 — 6 — 1,401 * 119 * * 11 — — Paddington 22,041 5,166 1,520 4,511 — — — 2 — — — 5 7 290 369 48 * 27 ‡6,000 * 178 1,077 Poplar 15,688 4,897 2,114 4,061 — — — — — — — 2 2 283 212 74 15 15 141 466 — 36 St. Marylebone 21,500 2,317 239 1,164 375 — — — — — — 3 1 1,200 126 — ‡2,500 37 1,957 6,280 21 32 St. Pancras 25,719 8,102 3,498 6,567 — — — — — — — 1 — * 688 134 * 68 * — 212 — Shoreditch 9,450 4,283 537 585 1,364 20 — 24 12 — — — — 303 153 48 44 26 * * — — Southwark 23,124 5,667 927 3,000 — — — — — — 1 2 — 354 265 53 * 5 * — — — Stepney 25,130 10,524 1,235 5,585 122 — — — — — — — — 414 485 163 ‡4,000 7 1,813 939 1 8 Stoke Newington ‡8,500 2,163 297 798 — — — — — — — — — 65 38 135 — 92 10 15 — — Wandsworth 93,737 15,193 9,621 9,126 — — — — — — — 2 2 240 58 191 20 13 — — — — Westminster, C. of 22,536 1,944 116 1,313 412 — — — — — — 9 5 109 79 — 2,644 70 3,350 2,513 — 23 Woolwich 37,366 6,303 830 2,279 103 — — — — 8 — 2 — 219 86 465 * 4 58 91 — 22 Total 764,921 168,541 53,646 138,012 4,198 57 23 90 50 52 95 76 52 11,050 7,415 3,026 16,813 114 12,360 13,200 412 1,263 * Information not available ‡Estimated. 138 INDEX Page Ambulance service 44 Analgesia 38, 1.10 Anthrax 14 Audiometry 76 Blind persons 23 Bronchitis 7 Cancer 7 Care of mothers and young children 30 Cerebral palsy 71 Cerebro-spinal fever 14 Chemical branch 24 Child life protection 40 Child minders 34 Dental services 83 Diabetes 7, 78 Diarrhoea and enteritis 15 Diphtheria 14 Diphtheria immunisation 42, 65 District Medical Service 90 Domestic Help Service 41, 82 Domiciliary Midwifery Service 37, 106 Dysentery 14 . Emergency obstetric service 90 Enteric fevers 16 Enuresis 70 Erysipelas 17 Fertility 5 Food poisoning 21 Foot defects 54, 70 Handicapped children 71 Health Centres 28 Health education 57 Health visiting 40 Heart disease 7 Holiday Homes 36 Home nursing 41 Hospitals and ancillary services 89 Hospital service, history 91 Housing 21 Illegitimacy 5, 35 Immunisation against Diphtheria 42, 65 Infant Mortality 10 Infectious Diseases 14 Do. in schools 19, 74 Influenza 17 Introduction 1 Laboratory work 91 Map of Divisions 94 Mass Miniature Radiography 51 Maternal Mortality 12 Maternity Outfits 33 Meals for school children 73 Measles 17 Medical inspections of school children 62 139 INDEX—continued Page Medical treatment of school children 68 Mental Health Services 57 Midwifery service 37,106 Migration 4 Mortality 6 Nurseries, day 33 Do. residential 34 Nursing home registration 24 Occupation centres 60 Ophthalmia Neonatorum 18 Pneumonia7, 18 Poliomyelitis 18 Premature infants 33 Prevention of illness 49 Problem children 77 Psychiatry 74 Puerperal fever and Pyrexia 12, 18 Remand homes 74 Reorganisation of department 80 Reports of Divisional Medical Officers 95 Rheumatic fever 18 Rheumatism scheme 75 Ringworm 74 Road accidents 10 Sanitary inspection 23 Scabies 19, 68 Scarlet fever 19 School Health Service 62 School children under 5 years 78 Smallpox 19 Special clinics 54 Special schools 71 Staff 79 Statistical Tables 114 Stillbirths 6 Tuberculosis 7, 19, 49 Tuberculous milk 22 Typhus fever 19 Vaccination 43,65 Venereal diseases 54 Vital statistics 4 Voluntary organisations 32 Welfare foods 33 Whooping Cough 19