LCC 55. LONDON COUNTY COUNCIL REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1949 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.1, Agents for the sale of the publications of the London County Council 1950 No. 3705. Price 2s. 6d. By post 2s. 10d. The County Medical Officer of Health regrets the delay in the publication of this report which has been due to disturbances in the printing trade LQNDON COUNTY COUNOIL. LONDON'S HEALTH IN 1950. Preliminary report by the County Medical Officer of Health, Sir Allen Daley, M.D., F.R.C.P. VITAL STATISTICS. Births after an estimated correction for residence numbered 54,100. The provisional birth rate for 1950 is 15.9. There has been a progressive decline since 1947, as will be seen from the following figures:— 1950 15.9 1949 16.7 1948 17.9 1947 20.9 1946 20.0 1945 15.7 1931-40 13.8 It is as yet too soon to suggest any level at which post-war fertility may stabilise. (In 1922, four years after World War I, the rate was 20.9, but by 1930, the rate had fallen to 15.8 and in 1939, the rate was 13.4.) Deaths numbered 38,500 (after the actual registrations have been adjusted by an estimated correction for residence). The provisional death rate for 1950 is 11.3. This compares with 1949 11.7 1948 11.1 1947 12.5 1946 12.6 1945 14.1 1931-40 12.7 Since the war the death rate has been declining, though there have been fluctuations downward as in 1948 (a year of light respiratory mortality) and upward as in 1949. The rate for 1950 is more in accordance with the general trend. Infantile mortality-The provisional rate of infantile mortality for 1950, is 25, per 1,000 live births. This, if confirmed, is the lowest ever attained in London and compares with 1949 27 1948 31 1947 34 1946 38 1945 44 1931-40 60 The provisional neo-natal mortality (i.e., of children under 4 weeks) was also a record, namely l6.5 per 1,000 live births and compares with 1949 17.5 1948 17.5 1947 18.1 1946 22.2 1945 23.0 1931-40 24.0 Maternal mortality - The provisional rate is 0.56 per 1,000 live and still births. This also is a record. Comparable figures are- 1949 0.69 1948 0.77 1947 1.00 1946 1.23 1945 1.89 1931-40 2.51 Epidemic diseasesMeasles - incidence average; mortality low - only 6 deaths registered. Whooping cough - Incidence average; mortality low - 30 deaths do. P.T.O. Scarlet fever-incidence average; mortality low - (there were 3 deaths from scarlet fever and streptococcal sore throat) Diphtheria-incidence low; only 3 deaths registered Typhoid fever-incidence slightly higher than average; only 3 deaths Infantile diarrhoea-incidence below average; mortality much below average - 60 deaths. Poliomyelitis-incidence moderate; mortality average for recent years; 35 deaths. Diphtheria is rapidly being overcome as a killer of children, thanks to the immunisation campaign. Pre-war, there were 7,500 cases a year and 250 deaths. In 1950, there were only just over 100 cases and three deaths. Over 60 per cent. of infants under the age of 5 are immunised, and at school ages, the percentage reaches 75. Further progress depends on the maintenance of this level of immunisation. The infantile diarrhoeal death rate is the lowest ever recorded. The first really serious epidemic of poliomyelitis in London was in 1947. 1948 was a year of average incidence but in 1949, it flared up again with an incidence almost as great as in 1947, and a similar mortality - 7% of the cases. In 1950, incidence was again high, 456 cases being notified. There wore 35 deaths7.7 per cent. Tuberculosis-The annual notifications have fallen for the first time (from 6,252 to 5,725) since the end of the last war and there has been a further decline in the death rate. The provisional death rate for 1950 is 0.39 per 1,000 - a new low recordcompared with 0.52 in 1949. Nevertheless, the deaths in 1950, numbered over 1,300. Tuberculosis remains the most serious chronic infectious disease affecting the community. Fatal road accidents caused 245 deaths (provisional figure). This is a small' reduction on 1949, when there were257 deaths. Cancer caused some 7,500 deaths. The provisional death rate was 2.2 per 1,000 and when allowance is made for the new inclusion of Hodgkin's disease and Leukemia in this group, this can be compared with the same rate in 1949 (the exact comparison cannot be made until precise figures of re-allocation of registrations by residence (which at present have only been estimated) have been furnished by the Registrar-General; a substantial number of patients from outside London die within the County). GENERAL STATISTICS. Sessions of ante-natal, post-natal and Infant clinics788 a week. Attendances at ante-natal and post-natal clinics average 4,200 a week and at infant clinics 18,645 a week. Over 50 per cent. of expectant mothers attend the Council's clinics and 83 per cent. of the children under 1 year of age attend. Health Visitors paid about 884,000 home visits during the year. Under the Council's Domiciliary Midwifery Scheme 13,745 mothers were attended in their confinements. During the year Home Helps attended 28,000 households. About one-tenth were confinement cases, the rest illness. Home Nurses provided by the Council through the agency of the District Nursing Associations paid about 1,275,000 visits. The Ambulance Service during the year surpassed all prevvious records, the number of patients conveyed by directly provided and agency services exceeding 630,000, involving a mileage of over 5,500,000. These figures include 84,000 emergency calls, as against the previous year's figure of 76,000. January, 1951. London County Council REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1949 By Sir Allen Daley, M.D., F.R.C.P. County Medical Officer of Health and School Medical Officer INTRODUCTION This report records the activities of the Public Health Department for the calendar year 1949, the first full year of the operation of the National Health Service Act of 1946. Much time was spent in discussions with the new hospital authorities and with Executive Councils with a view to avoiding any failure of the service which might result from a transfer elsewhere of functions formerly carried out direct by the Council. The interlocking responsibilities of hospital authorities, Executive Councils and the Local Health Authority affect almost every branch of the Council's Public Health work, e.g., maternity and child welfare, the school health, home nursing, chronic sick, tuberculosis, mental health, mental deficiency, dental and ambulance services to mention only the more obvious. The effect has been felt most perhaps in the Council's school health service, particularly in the ophthalmic and dental services. There is a delay of some months between the prescription of glasses and their supply and dentists are leaving the Council's "priority dental" service to participate in the more highly remunerated "non-priority" work. Much work was occasioned by the assimilation of the new and expanding services of the Council. The scheme of decentralisation of the principal health services has proved very satisfactory although there have naturally been "running-in" troubles from time to time. Regular meetings of the divisional medical, nursing and administrative officers and the appropriate central officers were held at County Hall. Brief reports of the divisional medical officers will be found in pp. 107 to 118. A summary of the vital statistics for the year shows a small increase in the civil population from 3,339,100 at mid-1948 to 3,375,470 at mid-1949. This is 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 (16.7 per 1,000 of the total population) has declined considerably from the peak post-war rate of 1947 (20.9). The general death-rate of 11.7 per 1,000 of the civil population was slightly higher than the exceptionally low figure of 11.1 for 1948. There were further substantial falls in infant and maternal mortality and new low records have again been attained. The rate of infantile mortality was 27 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 0.69 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 start treatment early and provide for the segregation of infectious patients by reducing the present far too long waiting lists for sanatoria and hospitals. Mortality shows a continued decline but the notification rate still shows a small upward tendency. It must, however, be borne in mind that the detection of early cases is now more efficient than formerly and in consequence the recorded new cases are more numerous than 2 they would have been without mass radiography, etc. The rise in the incidence is, however, ominous. The following comparison of the number of deaths in London from the principal infectious diseases is of interest:— Disease Number of deaths 1900 1949 Scarlet Fever 329 1 Typhoid Fever 767 2 Diphtheria 1,593 9 Measles 1,946 16 Whooping Cough 1,957 27 Infantile Diarrhoea (under 2 years of age) 3,401 98 On the other hand cerebro-spinal fever and poliomyelitis were more prevalent than 50 years ago. Poliomyelitis was, in fact, epidemic during the year, and there were 668 cases with 50 deaths, almost equal in magnitude and severity to the 1947 outbreak. There were 19 deaths from cerebro-spinal fever compared with one only in 1900. The significant drop in the number of infants vaccinated persisted, and by the end of the year only about 25 per cent. of those born in 1949 had been vaccinated (page 61). The success of diphtheria prophylaxis is gratifying but its continuance is 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. This procedure suffered a slight set-back during the outbreak of poliomyelitis in the summer (page 61). The number of new cases of venereal disease shows a reduction on the figures for 1948, and has fallen to pre-war level. The number of calls on the accident ambulance service again increased by 11 per cent. over the figure for 1948 and the demand is now 35 per cent. above the pre-war level. The demand on the general or "removals" section in terms of persons conveyed increased by 52 per cent. over 1948. This section has dealt with 183,000 more patients than in the previous year and the miles run have increased by over 30 per cent. The Hospital Car Service, which provides conveyance of persons to hospitals, usually for out-patient treatment, by means of private cars on a mileage payment system, more than doubled its activities (page 69). This year the historical section of the report is concerned with the ambulance service and will be found in pages 63 to 69. The new health centres provided for in the Act have suffered in the general curtailment of new building construction but work on the centre at Woodberry Down has started, the Minister of Health himself performing the initial ceremony (see page 43). Some of the work of the department connected with deprived children was transferred to the new Children's Department during the year together with some of the head office staff. The work of the chemical branch continued to grow, and a summary of its activities in connection with the measurement of atmospheric pollution is included this year (page 33). Monuments would not seem to have any place in a medical officer's report, but on page 32 will be found an account of the department's co-operation in the cleaning of Cleopatra's Needle. Attendances at the maternity and child welfare centres were well maintained, and approximately 84 per cent. of all infants born in 1949 were taken to the centres (page 44). The demand on the Home Help Service tends to outstrip supply, and the cost has more than doubled since 1947-48 (page 57). 3 Visitors to the Departments The shortage of beds in observation wards led to difficulties in the administration of the Mental Health Service (page 79). We have had the privilege of receiving during the year a large number of visitors who came to examine for themselves how the public health service was developing and responding to the changes effected by the National Health Service Act. Apart from groups there were 147 individual visitors. They were shown not only the best that London possesses, but also, in response to specific requests, particularly from countries which are in the early stages of developing their health services, examples of establishments which function under less favourable conditions as regards building, etc. (e.g., converted premises). They spent periods ranging from a day to 3 or 4 weeks in visiting various establishments and in talks with senior officers of the department. In addition, many of them who desired to extend their enquiries to the Metropolitan Borough Council services or the Provincial areas, whether large cities or rural districts, were advised on their programmes and put into touch with appropriate officers of other authorities. These individual visitors came from the following 40 countries and included 60 ladies. The figures in brackets show the number from each country: Australia (12), Bhutam (1), Brazil (2), Canada (6), Ceylon (1), China (2), Columbia (1), Czechoslovakia (1), Denmark (4), Equador (1), Egypt (3), Einland (1), France (1), Germany (5), Greece (2), Holland (4), Hong Kong (3), Hungary (1), Iceland (1), India (27), Iran (4), Italy (2), Jamaica (1), Jugoslavia (1), Malaya (1), Mauritius (1), New Zealand (1), Northern Ireland (1), Norway (2), Pakistan (4), Siam (2), Singapore (1), Sudan (6), Sweden (6), Switzerland (2), Tangier (1), Trinidad (1), Turkey (1), Uruguay (1), United States of America (28), Venezuela (1). These visitors included 61 doctors (general practitioners, medical officers of the Local or Central Government Service and University professors). The remainder of the visitors were nurses (14), teachers, students, journalists, welfare and social workers and administrative officials of Local or Central Government. In addition to these individual visitors several delegations numbering in all 203 persons visited County Hall in order to obtain information on the Council's Health Service. They included: 14 members of the House of Representatives of the United States of America and, later, officials of the United States Federal Government led by Mr. Oscar E. Ewing, Administrator of the Federal Security Agency. The work of the department was explained to them, questions were answered and visits paid to maternity and child welfare centres. 8 Greek members of Parliament who visited a maternity and child welfare centre and a day nursery. 45 nurses from the U.S.A., Finland, Turkey, etc., who had been attending the International Nursing Conference at Stockholm were given a programme of visits covering 12 days. 23 Asiatic public health workers who visited a maternity and child welfare centre and day nursery. A delegation from the Glasgow Corporation had our mental health services explained to them and afterwards visited an occupation centre. The London Ambulance Service excites much interest and was visited by several parties, including 4 groups of staff from the Ministry of Health, 13 members of the St. John Ambulance Brigade, members of the Staffordshire County Council's ambulance staff, and members of the Association of Ambulance Officers. The unique control room of this service is always of great interest to visitors to the department. Deaths I regret to record the death on 16th September, 1949, of Dr. H. Smith, the Divisional Medical Officer for Division 1. Resignation Dr. F. R. G. Heaf, a senior medical officer, resigned in December, 1949, on his 4 appointment to the chair of tuberculosis in the Welsh National School of Medicine. He had previously been loaned part-time to the Ministry of Health as adviser on the B.C.G. scheme. Appointments Appointments of senior staff were Dr. G. D. Pirrie as senior medical officer for the School Health Service, Dr. H. G. Williams as psychiatrist and Dr. Violet Russell as Divisional Medical Officer for Division 1. Population VITAL STATISTICS The Registrar-General estimates the total population of the county in the middle of 1949 to have been 3,389,850. The civil population was 3,375,470 compared with 3,339,100 a year earlier. The corresponding estimates for metropolitan boroughs are shown in Table 2 on p. 119, 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; according to age-group estimates made by the RegistrarGeneral at the end of 1947, 10.8 per cent. of the population of the county was then over the age of 65. 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. The present effort to restrict the size of the population by transferring Londoners to housing accommodation outside the county must be borne in mind as a continuing factor. Fertility The total births allocated to London for 1949 were:— Live 56,545 Still 1,134 Total 57,679 The live birth-rate was 16.7 per 1,000 total population, compared with 17.9 in 1948. 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 10 per cent., i.e., some 5,800 births in 1949. The corresponding figure in 1948 was 5,500. The number of marriages registered was 35,726, or 21T persons married per 1,000 of the total population, compared with 22.7 in 1948. The birth-rate in London tends to follow the same trend as for the country as a whole, but at a lower level. The following diagram shows the course of the two rates since 1931. The actual rates for London are given in Table 5. 5 LIVE BIRTH RATE IN ENGLAND AND WALES AND LONDON (A C.) 1931-1949 PER 1,000 TOTAL POPULATION ENGLAND AND WALES LONDON (A C.) 6 Partly as a natural consequence of the return of men from 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 took place. The point of interest now lies in how far the decline may proceed. The 1949 rate is still well above the pre-war level. The Royal Commission on Population have affirmed that the statistical evidence laid before them indicated that the high birthrates 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. Illegitimacy There were 3,880 illegitimate births (6.9 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 1949 6.9 5.1 The peak of the war-time rise occurred in 1945, with a rapid reduction after the end of hostilities. The percentage for 1949 taken together with those for the two preceding years indicates that the rate is now fairly stable. Deaths under one year among illegitimate infants amounted to 41 per 1,000 illegitimate live births, compared with a rate of 26 for legitimate births. The corresponding rates in 1948 were 39 and 30 respectively. A detailed comparison of deaths in the legitimate and illegitimate groups is given in Table 6 (p. 123). Still-births There were 1,134 still-births in 1949 or 1.97 per cent, of all births (legitimate 1.93, illegitimate 2.46). The number of still-births and the rate per 1,000 total births in each year since 1928 is shown in Table 5, from which it will be seen that after remaining stable for many years the still-birth rate fell sharply in 1943 and though it has since followed a downward trend there has been in no year an improvement comparable with that between 1942 and 1943. 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 of increased emphasis upon dietary supplementation, of more effective ante-natal care generally, and of more skilled obstetric service had led to a sharp fall in the still-birth rate. Since that review was made the special character of the fall between 1942 and 1943 has become more apparent; this must have been due either to some contemporary factor such as the food priorities which were authorised about that time or to some new factor. There is a possibility that the higher fertility rates now obtaining may in part be due to less voluntary or deliberate restriction of families in the middle classes, than before the war. Mortality The total civilian deaths in 1949 amounted to 39,455, or 11.7 per 1,000 of the civil population. Detailed figures are given in Tables 2, 3 and 4, on pp. 119, 120, 121. 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 diagram (on p. 8). The sharp changes between 1939 and 1940 are attributable to two causes. In the first place, the Registrar-General abandoned the rules of selection which had hitherto operated in multiple causes of 7 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:— Cause Approximate change as a percentage of those formerly assigned to this cause* Influenza — 11 per cent. Cancer — 3 ,, Diabetes — 30 ,, Heart disease — 10 ,, Other circulatory diseases — 6 ,, Bronchitis + 100 ,, Pneumonia +5 ,, Other respiratory diseases + 50 ,, Nephritis + 12 ,, Diseases of pregnancy, etc. + 10 ,, •Based on the dual classification of deaths for England and Wales, 1939. The second cause 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. In so far as the slopes of the curves before and after 1940 are more important than absolute figures, it is possible to consider the diagram as a whole and to observe the continuity in trend. To reduce the confusing effect of the large scale reclassification of deaths, heart diseases and bronchitis have been combined. The death-rate from all causes, which, with the increasing age of the population, had been slowly rising before the war, rose sharply in 1940. This rise was partly a feature of the war-time statistical basis as explained above, but the heavy toll of air raids was an important contributory factor. The rate for 1949, at 11.7, is slightly higher than in 1948, but it must be borne in mind that 1948 was an exceptional year with low respiratory mortality and low mortality from heart disease. There are, of course, ups and downs even in a general descending trend. Tuberculosis Another cause of the rise in the death rate, notably in 1941, was the increase in deaths from tuberculosis. This rise was only temporary and measured the effect of war conditions in hastening the death of those with advanced disease. Recent experience in both mortality and morbidity is more fully discussed in a later paragraph. Bronchitis and heart disease The death-rate for the bronchitic 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 (p. 120). 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 fall was a compensatory downward swing. The rate for 1949 (4.21 per 1,000) is once more an upward swing but is not out of keeping with the general downward post-war trend. Other circulatory disease The death-rate from circulatory disease other than heart disease was 0.65 per 1,000 compared with 0.55 in 1948 and 0.56 in 1947. This is a sharp rise, the cause of which is unknown. Cerebral haemorrhage The death-rate from intracranial vascular lesions in 1949 was 1.07 per 1,000 compared with 1.01 in 1948. The average rate for 1941-45 was 1.15 but a large proportion of the apparent reduction is due to the increase in the civil population upon demobilisation, a purely "statistical" effect. Nephritis For nephritis the death-rate in 1949 amounted to 0.18 per 1,000 compared with 0.21 in 1948 and an average of 0.36 over the decade 1931-40. 8 TREND OF MORTALITY-LONDON 1936-49 DEATH RATE PER 1,000 9 TREND OF MORTALITY-LONDON 1936-49 DEATH RATE PER 1,000 10 Degenerative disease If, as an indication of mortality from degenerative disease, we combine heart disease, other circulatory diseases, cerebral vascular lesions, nephritis and (for reasons indicated above) bronchitis, the following trend becomes apparent:— Year Mortality (per 1,000) from cardiovascular-renal disease and bronchitis 1931-40 (average) 5.33 1941 7.93 1942 6.93 1943 7.23 1944 7.12 1945 6.67 1946 6.11 1947 6.27 1948 5.47 1949 6.11 The true effects of the war cannot be separated from the statistical influences described on p. 6 (particularly the change in 1940) but rates in recent years appear to be running lower than during the war. The total death-rate is more than half accounted for by causes which are mainly degenerative and which, as the more tractable causes of death at younger ages are conquered, and as the population gets older, now attain greater relative importance. Pneumonia and other respiratory diseases 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 pneumonia death-rate for 1949 was 0.61 per 1,000 and the rate for "other respiratory diseases "was 0.15. These fluctuations are similar to those for bronchitis and heart disease. Diabetes Diabetes mortality had been falling steadily between 1939 and 1947, partly as a result of more effective treatment and partly as a result of the dietary stringency of the war and post-war years but in the last three years the death rates have been 0.07, 0.06, 0.07, indicating an arrest in the decline. At ages under 55, however, where treatment is more effective, the number of deaths in 1949 was 26 — which compares with an average of 29, in 1946-8. Cancer The cancer death-rate for all ages for 1949 was 2.10 per 1,000, slightly lower than in 1948, after two successive years in which slight rises had been recorded. Cancer is a disease mainly 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 statistically constant over the period under consideration. Thus, for England and Wales the crude cancer mortality rates between 1938 and 1945 rose 37 per cent. for males and 7 for females, but the standardised mortality rates (C.M.I.) were almost stationary, a small rise for males and a small fall in females. 11 The difference between the crude and standardised rates fur 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 regular age group population estimates are once more available. Up to 1948 for England and Wales, the comparative mortality index for females had fallen to 0.941 (1938=1.000) while the male index has risen to 1.057. In London, for both sexes combined the long-term trend of cancer mortality can be seen from Table 3 (p. 120). The increase there shown between 1891 and 1940 is due partly to the increasing age of the population, and partly to improved diagnosis, but some part is attributable to increased incidence e.g. lung cancer. The important changes in mortality in London between 1931-33 and 1947-49 in relation to certain specific sites are summarised below. London : Changes in Mortality Rates from Cancer between 1931-33 and 1947-49 (All Ages) Site Males Females Mean death- rate 1947-49 per 1,000 Change between 1931-33 and 1947-49 Mean death- rate 1947-49 per 1,000 Change between 1931-33 and 1947-49 Buccal cavity 0.098 Decrease 41 per cent. 0.022 Decrease 8 per cent. Respiratory system 0.739 Increase 213 per cent. 0.133 Increase 142 per cent. Digestive system 1.058 Increase 13 per cent. 0.849 Increase 22 per cent. Breast 0.373 Increase 22 per cent. Genito-urinary organs 0.296 Increase 40 per cent. 0.392 Increase 5 per cent. All sites 2.34 Increase 40 per cent. 1.88 Increase 24 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 accentuated 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 1.063, 1.057, 1.055; and the increase now appears to be halted. For females the death-rates have been 0.818, 0.868, 0.860; and the increase, which had been progressive up to 1948, has at least suffered a temporary pause. 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 five years have been 372, 441, 433, 456 and 470. Digestive The mortality from digestive diseases (other than diarrhoea under two years of age and cancer) was 0.42 per 1,000, the same as in 1948. Within this group the death-rate from ulcer of the stomach or duodenum fell from 0.17 to 0.15 per 1,000. The death-rate from appendicitis was 0.032 per 1,000) in 1949, compared with 0.033 in 1948. Road accidents Deaths from road accidents in 1949 amounted to 257, compared with 248 in 1948, and 319 in 1947. While the addition to the death-rate caused by road accidents is small the public should be reminded that each year a heavier toll is taken by the roads than by any poliomyelitis outbreak so far experienced and more die in street accidents than succumb to diabetes. 12 General The leading causes of death in London in 1949, were as follow:— Deaths Per 1,000 population 1. Diseases of the heart 11,157 3.31 2. Cancer 7,090 2.10 3. Pneumonia, bronchitis 5,093 1.51 4. Intracranial lesions of vascular origin 3,602 1.07 5. Other circulatory 2,179 0.65 6. Tuberculosis 1,741 0.52 7. Violent causes 1,560 0.46 8. Digestive diseases 1,404 0.42 9. Diseases of early infancy (prematurity, birth injury, congenital malformation, etc.) 1,144 0.34 10. Nephritis 623 0.18 11. All other causes 3,862 1.13 39,455 11.69 Infant mortality The infant mortality rate in 1949, 27 per 1,000 live births, consitutes a new low record, and is an improvement on the rate of 31 per 1,000 live births in 1948. The movements of the death-rates from the principal diseases at ages below one year since 1911 are shown in Table 7, (p. 123). 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 subtantial. 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. Neonatal mortality Deaths in various periods of the first year of life are shown in detail in Table 6 (p. 123). Deaths under 4 weeks numbered 988 or 17.5 per 1,000 live births, the same as in 1948. Comparative rates for London and England and Wales in recent years are:— London England and Wales 1931-35 25.1 31.4 1936-40 22.9 29.0 1941-45 23.4 25.9 1946 22.2 24.2 1947 18.1 22.7 1948 17.5 19.8 1949 17.5 19.3 There is some irregularity in the decline in both sets of rates and the margin between them has varied in extent. In London there was a war-time rise arising from the severe conditions but this setback was soon recovered at the end of the war. 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 deaths within the first four weeks of life, which arise mainly from prematurity, congenital malformations and birth injury, have been more resistant to reduction. 13 INFANT MORTALITY MORTALITY PER 1,000 LIVE BIRTHS 14 The distribution of causes of death in the first four weeks of life in 1949 was as follows:— Cause No. of deaths % Total Prematurity 355 35.9 Birth injury 139 14.1 Congenital malformations 145 14.7 Other diseases of early infancy 254 25.7 Broncho-pneumonia 53 5.4 Diarrhoea and Enteritis 2 0.2 All other causes 40 4.0 Total 988 100.0 Thus deaths from prematurity, birth injury and congenital malformation account for 64.7 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 6.31 in 1949, and this comparatively large advance is doubtless associated with the contemporary emphasis on the care of premature infants. Birth injuries will, it is hoped, be reduced as specialised obstetrical assistance become more general. The average neonatal rate from this cause over the period 1936-40 was 2.20 per 1,000 live births but was 2.41 in 1949. The average neonatal death-rate from congenital malformation was 2.84 per 1,000 life births over the period 1936-40 and in 1949 the rate was 2.34. In view of the more intractable nature of these three causes compared with causes of an infective type it reflects credit on all workers that in 1949 the neonatal mortality rate was only two-thirds of the average rate for 1931-35. There is, however, no room for complacency and research organised by the Department is being actively pursued to ascertain, with more precision, the exact causes of neonatal death in order to improve preventive measures. Puerperal fever and pyrexia, maternal mortality A summary of maternal mortality statistics is 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 (p. 124). London: Year Live and still births Deaths Notifications Maternal sepsis Other childbirth Puerperal pyrexia No. Rate No. Rate No. Rate 1948 62,125 22 0.35 26 0.42 460 7.40 1949 57,679 14 0.24 26 0.45 433 7.51 Rates per 1,000 total births. The maternal mortality rate (0.69) in 1949 constitutes a new low record. While the downward trend of the total maternal mortality rate is unmistakable it should be noted that owing to the small number of deaths the laws of chance applicable to small numbers operate and the rates for component causes are liable to considerable fluctuation without any significance necessarily being attached thereto. 15 The analysis of maternal deaths into (i) post-abortion; (ii) other; is as follows:— Cause of death Post abortion Other Total Maternal sepsis 14 — 14 Other childbirth 6 20 26 Total maternal deaths 20 20 40 This is the first year in which there was not a single death from sepsis following child-birth. All the fourteen deaths from maternal sepsis followed abortion. 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. There has been no significant change in the notification rate between 1948 and 1949. 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 the middle thirties, resulting 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 arresting temporarily the decline in maternal mortality in London is shown by the following diagram, which indicates the movement of the rates in both London and over the country as a whole. The sharp rise in London in 1941 was not shared by the country as a whole, and can be attributed to the effect of the bombardment, which reached its peak intensity in that year, and the consequent evacuation. These factors rendered it difficult to maintain the normal high standards of maternal care. MATERNAL MORTALITY MORTALITY PER 1,000 TOTAL BIRTHS ENGLAND&WALES LONDON B 16 Infectious diseases The attack rates and death rates of the principal infectious diseases in London during 1949 and earlier years, and for the constituent metropolitan boroughs in 1949, 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 (p. 125). 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 Three cases of anthrax were notified during the year and they were all confirmed bacteriologically. One case was a lorry driver employed in delivering sacks of fertiliser, another was a rag sorter and the third was a fur dresser. Appropriate precautionary action was taken by the responsible Medical Officers of Health of the metropolitan boroughs concerned and no secondary infections occurred. Cerebrospinal fever Prior to the war the attack rate for cerebro-spinal fever had fluctuated mainly between 0.02 and 0.05 per 1,000. Not unexpectedly the rate rose during 1940-41 to 0.3 per 1,000, a similar rise being experienced by most of the combatant nations coincidental with military and industrial mobilisation. Subsequently the rate fell rapidly. In 1949 the incidence was only 0.023 per 1,000 (76 cases), the rate being the lowest since before the 1914-18 War. The ratio of notifications to deaths was 4: 1, but owing to imperfect notification the case fatality from the disease is less than would appear from this ratio. Mortality is greatest at the extremes of age. Twothirds of the cases were in infants under the age of five years. 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 dysenteric infection has become increasingly recognised. In London, the death-rates from dysentery since the beginning of the century have been as follow:— Mean annual deathrate 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 1949 0.0012 In 1948 there were, however, only three deaths compared with 11 in 1947, and in 1949 there were only 4 deaths. There can be little doubt that the rise in incidence with lowered fatality that began about 1935 was associated with increased recognition of the comparatively mild Sonne infection. It is not known to what extent increased incidence may be due to the increased awareness, and use, of Public Health bacteriology. Diphtheria 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 1949 there were only 221 cases or 0.065 per 1,000 living, at all ages, compared with a rate of 0.100 in 1948. 81 per cent. of the cases under age 15 were among those who had never been immunised and having regard to the relative size of the unimmunised population this means that the attack rate among them was ten times as great as among those who had at some time been immunised. The effects of the immunisation campaign are illustrated by the subjoined diagram, on which the continuous lines indicate the trend of the notification rates in the three age groups 0-4, 5-14, 15+-, and the broken line indicates the percentage not artificially 17 immunised. During 1949 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. DIPHTHERIA — AGE INCIDENCE NOTIFICATIONS PER 1,000 LIVING IN AGE GROUPS There were 9 deaths from diphtheria in London in 1949. Detailed reports show that none had 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 sustaining and even 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. In 1939 there were over two thousand confirmed cases of diphtheria in London and 98 deaths. A note on the connection between poliomyelitis and immunisation will be found on page 61. Diarrhoea and enteritis The mortality from diarrhoea and enteritis under two years of age (98 deaths) amounted to 1.73 per 1,000 live births, compared with 2.69 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 18 rates are declining. There is no doubt that further progress is possible and officers of the Public Health Department are at present engaged in an intensive study of causal factors in order to improve preventive measures. DIARRHŒA AND ENTERITIS MORTALITY PER 1,000 LIVE BIRTHS Enteric fevers Erysipelas Influenza Measles Notification of fevers of the enteric group numbered 58 compared with 48 in 1948. There were only two deaths. In 1900 there were 797 deaths. 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 and a detailed account of this progressive improvement was given in the report for 1948. 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. There were 583 cases of erysipelas in 1949, giving an attack rate of 0.173 per 1,000 compared with 0.215 in 1948. The incidence of this disease has been declining continuously since 1941. There was 1 death in 1949. There were 372 deaths (0.023 per 1,000) from influenza during the year; 1948 had been an exceptionally light year for respiratory mortality generally with only 78 influenza deaths and a much larger figure was expected in 1949. 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 1948 78 1949 372 There has been no major attack of influenza since 1937, although there has frequently been bacteriological evidence of the presence of the virus. Measles became notifiable in London in 1938. Before this year records of incidence were built up from reports of absences from school, from hospital admissions and from mortality records. Up to the outbreak of the war of 1939-45 there had been biennial epidemics of such magnitude that more than 70 per cent. of children suffered an attack before age 15. The evacuation movements of 1939 and subsequent years disturbed this biennial rhythm and since 1940 the outbreaks have been annual and of the same order of magnitude each year. The overall incidence has been reduced to such an extent that the risk of attack before age 15 has now fallen to 60 per cent. 19 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 0.085 1949 28,816 16 0.056 *Actual notifications from 1939. Most measles deaths are due to respiratory complications and the more recent reduction in mortality can largely be attributed to the use of the sulphonamides and anti-biotics in the prophylaxis and treatment of the respiratory complications. 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. 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 186 cases in 1949 (3.3 per 1,000 live births), full details of which are shown below. 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. Ophthalmia neonatorum Ophthalmia Neonatorum Number of cases Domiciliary Confinements Institutional Confinements Total Notified during the Year 79 107 186 Visited by officers of the Authority 78 101 179 For whom home nursing was provided by the Authority 5 5 Removed to hospital for special treatment 28 25 53 The condition at the end of the year of the 186 cases notified was:— (a) Vision unimpaired 173 (b) Vision impaired — (c) Vision lost — (d) Died — (e) Under treatment 3 (f) Removed from the county 10 Total 186 Pneumonia Notified cases of pneumonia in 1949 numbered 1,858, or 0.550 per 1,000, compared with 0.566 per 1,000, in 1948. Dr. Stocks is of opinion that pneumonia is considerably under-notified particularly at ages over 65, and that over the whole age range only about one-quarter to one-third of the total cases are notified. There is, however, no reason to suppose that this fraction varies from year to year so that notifications may still be used as a relative index of incidence. It will be seen from Table 11 that the 1949 notification rate is lower than either war-time 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. See p. 10 for comment on the death-rate. Poliomyelitis and polioencephalitis 20 In 1949 poliomyelitis once more became epidemic. During the year 668 cases occurred (corrected notifications) and there were 50 deaths giving a crude case mortality of 7.4 per cent. In the 1947 outbreak there were 702 cases and 49 deaths so that the two outbreaks are of almost equal magnitude and severity. The effect of the 1947 outbreak in immunising to some extent the population then living was seen in 1949 in a much younger age distribution of cases (55.3 per cent. of cases were of infants under 5 years of age compared with 27.9 per cent. in 1947) and in the changed geographical distribution of cases. Many areas which had heavy incidence in 1947 had only light incidence in 1949 and vice versa. A full account of the outbreak has been published.* The following account of an outbreak at the Ladywell Nursery is of interest The first outbreak occurred on the ground floor of Block B containing about twenty-six children. The first indication of infection occurred on 1st July when a small boy, R.C., complained of a sore throat. He made a normal recovery in a few days. On 2nd July another child, R., was transferred to hospital with measles and a domestic assistant, J., who worked in the block reported ill with tonsillitis. The following day a nursery assistant, H., reported a sore throat and a child aged two, K.G., was found to have a temperature in the morning without apparent cause. In the evening it was normal but there was again some slight pyrexia the next day. He vomited once but his temperature appeared to be normal until 8th July when he was noted to have a slight stiffness of the neck. The following day he was transferred to hospital as a case of poliomyelitis. On 6th July, a child M.F., aged nineteen months, was unable to walk and had slight pyrexia. On 9th July she was transferred to hospital as a case of poliomyelitis. In both these cases the diagnosis was confirmed. Although most of the staff live in Lewisham where poliomyelitis had been present since June no outside contact was established. No further cases occurred until September when a part-time staff nurse L., working on the upper floor of another block P complained of headache, sore throat and a stiff neck on September 19th. No paralysis occurred but she may have suffered an abortive attack. On 21st September a child, R.G., on the Ground floor of block P was noted to be reluctant to walk, to refuse food and to be generally miserable. He was diagnosed as suffering from poliomyelitis and transferred to hospital. The following day a child, M.O'R., on the upper floor of the block was noted to have suddenly developed paralysis of the left leg. She was admitted to hospital and the diagnosis of poliomyelitis confirmed. It is stated that about a week previously, 16th September, this child had had a mild bout of pyrexia and had vomited, an incident which may be taken to represent the first phase of a double-phase attack. On 23rd September, the child in the adjoining bed, B.H., was transferred to hospital paralysis of the left leg having been noted. The diagnosis was confirmed, but in his case there was no history of a previous febrile attack. Even if it is assumed that the staff nurse actually suffered from an abortive attack of poliomyelitis, she can hardly have originated the outbreak, since her illness ante-dated an overt confirmed case by only a few days and occurred three days later than the first phase of M.O'R's attack. It was noted that an assistant nurse, E., who also worked on the upper floor, had been off duty for two weeks from 5th September. It was stated that she complained of sore throat, headache and stiff neck and had also vomited, but that her doctor made no suggestion of poliomyelitis and treated her as a case of upper respiratory infection. It is possible that she may have been an abortive case of poliomyelitis and was the starting point of this small epidemic. There was no history of contact between any of the above cases and a known case of the disease outside the institution, nor that any of the staff of the nursery had come in contact with a case of poliomyelitis before the outbreak of this epidemic. * Breen, G. E. and Benjamin, 13. (1950) B.M.J, ii 1473 21 Following the outbreak in the other block there was rigorous segregation of the children and of the staff and it must be assumed that the second outbreak had had no connection with the first. During 1949, 433 cases of puerperal pyrexia were reported, or 7.51 per 1,000 total births, compared with 7.40 in 1948. Deaths in London from rheumatic fever in 1949 numbered 16, of which 6 were were among children under fifteen years of age. Corresponding figures in 1948 were 30 and 15 respectively. 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 in recent years. Puerperal pyrexia Rheumatic fever Deaths from Heart Disease under 45 Years Year 0—4 5—14 15—44 Total 1946 1 10 376 387 1947 1 11 398 410 1948 1 9 338 348 1949 5 3 350 358 No clear post-war trend can be discovered but if anything the tendency is downward. Scabies became notifiable in London in August, 1943. Notifications in 1949 numbered 1,311, compared with 2,484 in 1948. The effect of improved control resulting from notification is evident from the persistent decline in incidence shown by the figures in Table 11 (p. 126). Great progress has been made and the attack rate in 1949 was less than one-twentieth of the rate experienced six years earlier. The incidence of scarlet fever was slightly higher than in 1948; there were 4,945 cases (1.46 per 1,000), compared with 4,568 (1.37 per 1,000) in the previous year. There was only one fatal case in 1949. Fifty years ago the annual death roll in London amounted to over 1,000. There were three notifications of smallpox. All three cases, temporarily residing in London, were passengers from an infected ship. One case was fatal. The Medical Officers of Health of the Metropolitan Boroughs concerned took immediate action to trace and observe all contacts ; no secondary cases 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. No case of typhus fever has occurred in London since 1947. There were 5,754 notifications of whooping-cough during the year, compared with 10,450 in 1948. As can be seen from Table 11 the incidence varies considerably from year to year. There were 27 deaths, giving a death-rate of 0.008 per 1,000 (crude case mortality 0.47 per cent.). Corresponding rates for 1948 were 0.016 per thousand and 0.53 per cent. It will be seen from Table 3 that the fatality from this disease is now a sixtieth of what it was fifty years ago. The numbers of cases of infectious disease reported from schools in 1949 and other years are shown in Table 16 (p. 130). 1949 was again a light year for German measles. The decline in the incidence of ringworm continues. The downward trend of scabies, already remarked upon, is reflected in the school figures. There was also a further fall in the incidence of impetigo. The incidence of scarlet fever was a little higher than in 1948. Cases of whooping-cough were much less frequent than in the previous year. The incidence of measles and of chicken-pox also was light. Cases of mumps were much less numerous than in 1948, when the incidence was exceptionally high. Scabies Scarlet fever Smallpox Typhus fever Whoopingcough Infectious disease in schools 22 In June and July a small but severe outbreak of diphtheria occurred in a school in Bermondsey. The first school child affected was a girl, who had not been immunised, who developed the disease on 29th May, and becoming rapidly worse, died the same day before removal to hospital. A further case was notified on 14th June, but this child had not been in school for the 10 previous days. On 21st June, 8 children were absent with sore throats, 3 of whom developed diphtheria. On the following day 5 more were absent and 3 of these also developed the disease. Information of this outbreak reached the Public Health Department (the Divisional Medical Officer) on 24th June, when the school was closed for the day because of the election. The next day, the Divisional Medical Officer with the Medical Officer of Health for the Borough visited the school and decided to close it temporarily in an endeavour to reduce the spread of infection. In all, 12 children from this school, 11 of them from one class, developed diphtheria and 3 of them died. There were 15 notifications among children in neighbouring schools with no death, 11 with one death in children under school age and 10 cases with no death amongst adults in the neighbourhood, a total of 48 notifications and 4 deaths. None of the children who died had received immunising injections. When the outbreak was apparent, arrangements were immediately made to immunise all children in the school and in the neighbourhood. In 4 days, 1,500 children received a first injection, including practically the whole of the school affected where previously only about 20 per cent. of the children had been immunised. The static clinics were supplemented by the mobile immunisation van from another division. The school was re-opened on 4th July, and continuous efforts were made to increase the percentage of children immunised. This outbreak underlines the need for the close co-operation which exists between the Borough Medical Officer of Health, who is responsible for the control of the spread of infectious diseases and who receives notifications of such diseases from the general practitioners, and the County Medical Officer, who is responsible for the health of the children in the schools and for the provision of immunisation against some of these diseases. Detailed figures of new cases of tuberculosis notified in 1949 are shown in Tables 12 to 15 (p. 126 to 130). 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. 126), and is also illustrated by diagram (p. 23). The consistent 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, associated with the discharge of tuberculous patients from hospitals to make room for air-raid casualties, 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 short-lived and the mortality quickly began to decline again as the war progressed. By 1946 the mortality rates had fallen below the pre-war levels Tuberculosis 23 and for the present at least they may be regarded as having fallen below even the level to which they might have declined if the pre-war trend had not been interrupted. Civilian death-rates per 1,000 living in 1949 in London and for the whole country were:— Pulmonary Non-pulmonary London 0.470 0.046 England and Wales 0.403 0.054 TUBERCULOSIS MORTALITY & MORBIDITY 1921-1949 ANNUAL DEATHS PER 1,000 LIVING ANNUAL NOTIFICATIONS PER 1,000 LIVING 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 since 1946 has risen very slightly and it appears that the decline has temporarily ceased. The morbidity level for pulmonary cases is at present 30 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 24 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. It is almost certain that pre-war and post-war rates are not strictly comparable. 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 and have continued to decline. 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 has been rising since 1947 by about 3-4 per cent. each year 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) 1949 0.97 (622) 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 incidence of abdominal tuberculosis continues to be very much lower than before the war and in children at least is still declining. It is difficult to make any statement about the incidence of meningeal tuberculosis as there is reason to believe that many cases are not notified owing to difficulties in diagnosis. A few years ago the death figures sufficed to measure incidence but since the introduction of streptomycin a large number now survive. The incidence of tuberculosis of bones and joints seems stationary. Tuberculosis of the peripheral glands which showed in children a large war-time rise, is now steadily becoming a rarer event. GENERAL PUBLIC HEALTH Housing During the year 14,170 houses and flats were erected or brought into commission by repairs by the Council and the Metropolitan Borough Councils. Of these 8,659 were in London (3,970 by the Council and 4,689 by the Borough Councils) and the remainder (5,511) were erected by the Council outside the London area. The total number of houses or flats owned by the Council at 31st December, 1949, was 125,611 (an increase in the year of 10,573) of which 64,216 are situated in London and 61,395 outside the London area. At 31st December, 1949, the Council's list of applicants waiting for accommodation contained 162,000 names, 55,998 new applications having been made during the year. In this period no fewer than 33,300 requests for preference in rehousing on health grounds, apart from infectious tuberculosis, for which exact figures are not available, were considered and suitable recommendations made to the Director of Housing. Some 10 per cent. of these were for review of applications already reported Rehousing on medical grounds 25 upon; the total number of new applications was therefore about 30,000, compared with 19,903 in 1948 and 13,662 in 1947. With such a large number of applications supported by medical evidence of illness great care is necessary in selecting those which merit special preference and much work is entailed in making enquiries to ensure that all necessary information is available to enable a fair decision to be made. The assistance given by medical officers of health of metropolitan boroughs and out-county authorities, of hospitals and of doctors is gratefully acknowledged. On the average special preference is recommended for 40 to 50 per cent. of the applications which are supported by medical evidence. Analysis of one batch of 1,000 applications considered towards the end of the year, showed that 10 per cent. were classified as "most urgent" and 37 per cent. as less urgent, but justifying preference on health grounds. After careful consideration it was decided that the degree of medical urgency disclosed by the doctors' certificates did not warrant additional preference for the remaining 53 per cent. Early in the year consideration was given to the resumption of the clearance of insanitary and unhealthy dwellings and it was decided that, as a first step, six areas which before the war had been represented by the Medical Officer of Health as unfit or had been declared by the Council to be clearance areas but in respect of which powers had not been obtained, should be re-surveyed with a view to clearance action being commenced under Part III of the Housing Act, 1936. As a result representation was made by the Medical Officer of Health to the Housing Committee in respect of one of these areas, extending over 2.4 acres and containing 161 unfit houses. The survey of the other areas was also put in hand. One other small area comprising 38 houses was represented during the year. Three areas were declared by the Council to be clearance areas and public local enquiries were held by the Minister of Health. Compulsory purchase orders were subsequently confirmed, without modification, in respect of the three areas. A notification under section 33 of the Housing Act, 1936, of intention to deal with thirteen unfit houses as a clearance area was received from the Fulham borough council. Surveys were made of 1,241 houses contained in sixteen areas apart from those mentioned above, in connection with proposals for their acquisition by the Council and consultations took place between officers of the Council and of metropolitan borough councils concerning 191 houses on which slum clearance action was contemplated under the Housing Act, 1936. Conferences also took place with officers of a number of metropolitan borough councils with a view to the completion in 1950 of a survey of insanitary areas throughout the County. Many houses which are structurally sound are lacking in modern amenities and means of securing the improvement of such houses by advances, grants and exchequer aid are now available to local authorities under the Housing Act, 1949. Such assistance is to be given subject to the houses being capable of improvement to a specified standard and to their having a useful life of a further 30 years. During the year 3,776 searches were made in connection with enquiries concerning properties scheduled as dangerous structures. Clearance areas Housing Act, 1949 Dangerous structures 26 Tuberculous milk The following are details of the sampling for bacteriological examination of milk coming into London in churns by road and rail and the results of the examinations:— Source of sample Designation. Samples Percentage positive of completed samples Total Positive Incomplete Negative 1949 1948 (a) Supplied to London by road and rail in churns Ordinary 840 †20 29 791 2.5 4.6 Accredited 36 †3 33 * * Tuberculin tested 26 26 — — (b) Plant at London depots Pasteurised 15 — – 15 – — (c) Residential Schools Ordinary 3 — — 3 — — Total 920 23 29 868 2.6 4.4 *The number of samples (36) is so few that a percentage could not be regarded as reliable. †These figures include a second positive sample which was obtained from milk supplied by each of two ordinary and one accredited herds. The total numbers of herds involved were 18 ordinary and 2 accredited. Investigations by officers of the Ministry of Agriculture into the origin of the positive samples disclosed the presence of infection in 12 herds. As a result 14 cows were slaughtered under the provisions of the Tuberculosis Order, 1938. Negative results were obtained from the Ministry's investigation of 8 other herds but 8 cows, which were presumed the source of the infection, had been removed from 5 of these herds before the Ministry's investigations were completed. Sanitary inspection Reports of 240 instances of infestation were received from 218 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 208 disinfestations were satisfactorily completed by the end of the year. 2,800 visits of inspection were made to 589 civic restaurants, kitchens and school meal centres. Regular inspections, at least once a quarter, were made of 61 homes, hostels, rest centres and other premises in connection with sanitary conditions. A large number of complaints of insanitary home conditions were received from the public. These were referred to Borough Health Departments. Blind and partially-sighted persons The following figures show the number of persons examined under the National Assistance Act, 1948, for certification for blindness and the results:— infestation Restaurants and catering Welfare establishments Complaints 27 Examinations by the Council's Ophthalmologists Classification Certified blind Not blind Grand total Male Female Total Male Female Total New cases 281* 466* 747* 66 138 204 951* Previously blind, still blind 19 17 36 — — — 36 Previously not blind, now certified 15 23 38 – – – 38 Previously not blind, still not blind – – _ 20 26 46 46 Previously blind, now not blind — — — 9 4 13 13 Total 315* 506* 821* 95 168 263 1,084* *These figures include 17 male and 10 female children under 5 years of age but do not include children of school age, details of whom are included in the table on page 133. The standards used are those prescribed by the Ministry of Health (Circular 1353-5.10.33). The reason in the majority of cases "previously blind, now not blind" is that cataracts have been removed surgically. In addition 208 certificates were accepted from other authorities, hospitals and private ophthalmologists as follows:— Blind persons 201 (94 male, 107 female) Not blind persons 7 (4 male, 3 female) The causes of blindness in the 27 children under five years of age who were certified during the year were:— Retrolental fibroplasia 12 Optic atrophy 5 Microphthalmos 3 Colobomata 2 Cataract 2 Glioma 1 Buphthalmos 1 Corneal dystrophy 1 The number of partially-sighted persons, excluding children, recommended for inclusion in the Observation Register was 203 (71 male, 132 female). Blind persons examined as to suitability for training and the results were :— Male Female Total Suitable for training 25 8 33 Not suitable for training 1 1 2 Totals 26 9 35 Registration of Nursing Homes At the end of the year 58 nursing homes on the register were functioning compared with 62 registered homes open at the end of 1948. Four new registrations of homes took place and 8 homes were closed during the year. In the 58 homes there were 1,023 beds distributed as follows : Number of beds in home Number of homes Type of patient accommodated Total Maternity only Maternity and others Others 25 or over 7 — 233 139 372 20 to 24 11 21 36 179 236 15 to 19 9 17 56 78 151 10 to 14 13 — 40 108 148 5 to 9 14 — 63 44 107 Under 5 4 1 2 6 9 Total 58 39 430 554 1,023 28 Forty exemptions from the operation of Part XI of the Public Health (London) Act, 1936, were granted. Regular visits of inspection were made to the nursing homes. The general standard was reasonably maintained. There are indications of a lessened use of some nursing homes since 5th July, 1948, for maternity and surgical cases. On the other hand there is an increasing demand for accommodation for the near-patient type of senile persons of both sexes. Arrangements were made for the medical supervision of all types of establishments under the control of the Welfare Committee, i.e., large homes, mother and baby homes, rest centres, reception centres for persons without a settled way of living, lodging houses, small homes for the aged and infirm, homes for the blind and hostels for persons in employment. Welfare establishments 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 diamond jubilee of the London County Council having been celebrated during 1949, it is of interest to recall that the use of Chemistry in the service of the local government of London dates back to at least twenty years before the time of its formation as successor to the Metropolitan Board of Works. The Chemical and Gas Department was, in fact, one of its original departments, the duties at that time being largely concerned with sewage treatment and gas supplies though other work on general stores was also done. In 1912, the Chemical Branch became a part of the Public Health Department and the extent to which its field of operation has widened in the intervening years will be evident from the subsequent paragraphs. This development has naturally followed from the ever increasing knowledge derived from scientific research and the consequent increased application of chemistry to the uses of every day life: for example, in industry, plastics and synthetic resins were unknown 60 years ago; so also were vitamins which are so important to health. The amount of consultative, advisory and committee duties continued to increase in 1949 as did also the ordinary analytical and testing work. Many of the former duties did not entail the actual examination of samples, the list of which for 1949 is shown below. The total number of samples examined was 23,729 compared with 21,400 in 1948. Air, tunnels, etc. 292 Bacteriological, miscellaneous 38 Building materials 332 Chemicals, drugs and medical supplies 39 Clay, sub-soils and borehole waters, etc. 554 Compost (manurial use), etc. 14 Detergents 63 Disinfectants 13 Explosives, fireworks, etc. 25 Fertilisers and Feeding Stuffs 98 Floor oils and polishes 29 Fuel (coal and coke) 26 Foods, etc. 575 Gases, flue, degreasing and rubber spreading plants, etc. 189 Gases, sludge digestion plant 269 Insecticides 10 Lamps, gas detector 289 Liquor, effluent from gas works 355 Meals 85 Metals 35 Milk, liquid, condensed, dried 215 Miscellaneous 281 Oils, lubricating, fuel, etc. 73 Paints, varnishes and distempers 1,607 Petroleum and allied samples 125 Rain water (atmospheric pollution) 84 Rubber and substitutes 10 Sewage and effluent 3,782 Sludge, primary and digested 1,938 Sludge, activated 1,290 Sulphur gases and smoke in air 1,824 Water, steam raising plants 2,032 Water, drinking 2,337 Water, river 3,844 Water, swimming bath 855 Water, miscellaneous 102 TOTAL 23,729 (The water samples include both chemical analyses and bacteriological examinations.) 29 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 and departments of the Council. Due to progressive activity in the redecoration of premises a further considerable increase occurred in the amount of work required on paints and allied surface coatings. Many samples were also examined in connection with the revision of the Council's approved list of paint manufacturers whose products may be tendered for direct use by the Council or used by contractors on housing work, and for checking the quality of those actually being applied on jobs in order to ensure that they were up to standard. Many samples were reported upon adversely. Some special materials were also submitted for examination such as (a) a preparation claimed to be suitable for "cold galvanising": (b) a wall paint said to reduce fire risk: (c) distempers which claimed special insecticidal properties as containing D.D.T. A number of complaints of paint failure were inspected and samples taken for subsequent examination in the laboratory. For example: (d) a failure was ascribed to the use of lithopone as a constituent of an exterior paint: (e) another paint failure was found to be due, not to the paint itself, but to the faulty preparation of the wood surface before the application of the paint. Other building materials examined included plasters, Portland and high alumina cements, bricks, asphalts, road surfacings, clinkers, synthetic floorings, mortars, granite, size, etc. Special matters which might be mentioned are: (f) the possible danger of the effect of sulphates in ground water or clays on portland cement concrete was watched and in some cases special precautions were recommended: (g) two cases of failure of concrete with an aggregate containing brick rubble were ascribed to incomplete wetting; the use of surface active agents was advised to aid effective wetting: (h) jointless synthetic flooring materials were examined on a systematic basis as to their use in kitchens: (i) black patches on a newly papered wall were found to be due to a mould: (j) cases of suspected dry rot were investigated. 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 1949 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 per cent. 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 was 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. Research work was also done on several aspects of the sewage treatment problem and particularly in reference to the dewatering of sludge by a new process involving freezing after the addition of chemicals. A laboratory scale plant was operated on an experimental basis and the Council authorised the filing of a complete specification for patents both in this country and in the United States in the names of three officers of the Chemical Branch (the Chemist-in-Chief, Mr. G. S. Clements and Dr. R. J. Stephenson). Research also led to the adoption of a new method for the chemical Housing Main drainage 30 cleaning of diffuser tiles for the air supply in the activated sludge plant, and to the publication of two papers on improved analytical methods. 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. Safety lamps used in sewers were tested and adjusted periodically and an officer of the Chemical Branch gave advice and assistance in training men employed on sewerage work in the use of oxygen breathing apparatus under emergency conditions. The sewage treatment service is a joint function of the Chief Engineer's and Public Health departments and special mention should be made of the cordial relations which have so greatly helped in maintaining the efficiency of the operations. Weekly conferences of the Divisional Engineer (Main Drainage) and the Chemist-in-Chief and their senior officers have been of the utmost value in this respect. The Chemist-in-Chief was appointed in 1949, to be a member of the "Thames Survey Committee" set up by the Department of Scientific and Industrial Research at the request of the Port of London Authority. Regular chemical analyses and bacteriological examinations were made of the drinking waters derived from private wells at various Council premises and also at a number of hospitals, this service having been continued at the request of the various hospital committees. All these water supplies are chlorinated before use and the dosage was periodically checked. 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. On the medical examination and diagnosis side a few cases of interest might be mentioned. A man employed on cutting up old galvanised sheeting by the use of an acetylene flame reported sick: on investigating the circumstances it was suggested that the cause was zinc fume fever and this was confirmed by subsequent analytical tests. Dermatitis was, in another case, suspected to have been caused by the use of a paint remover: analysis showed that on dissolving the preparation in water, caustic soda was produced by interaction: this material needs special precautions in handling, such as the use of protective rubber gloves. Similar precautions were advised in regard to another substance used in a print developing process which had affected the user's hands. An apron (private property) used in a Council's kitchen caught fire and injured the wearer: a similar article was examined and was found to be highly inflammable and not suitable for use near heated metal: the danger arose from a plasticiser incorporated in the coating material. 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. The few whole day food intakes assessed at residential schools were found to be up to the nutritional requirements. Other matters which might be mentioned shortly were: (a) comparison of thermal insulation efficiencies of different types of container: (b) devising a method for removing stains from plastic plates : (c) comparison of different procedures for cooking green vegetables with a view to the retention of the maximum possible amount of the ascorbic acid (Vitamin C) content. Public Health School and other meals 31 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 number was reported upon adversely; for example, the free lime contents of some garden lime samples were deficient, apparently owing to the absorption of carbon dioxide and water from the air through the paper packets. Many samples were also examined under the Petroleum (Consolidation) Act, 1928, the London Building Act (1930), and the Explosives Acts. Those in connection with the first were in relation to the issue of licenses for the storage of petroleum: in regard to the second this question was generally as to whether the process in operation constituted a dangerous business and the actual sites were visited in such cases: the Explosives Act samples were concerned with the manufacture of indoor fireworks. 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 some cases where this was not so, legal proceedings were attended by an officer of the Chemical Branch to support the certificate given. Premises of degreasers and rubber spreading works operating under licence were visted 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 the 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. The water of natural ponds used for bathing was also tested. Samples of soil were analysed as to their content of plant nutrient substances. The materials examined for this service covered a very wide field. Foods of all types formed a considerable proportion of the total: they were examined (a) to allocate contracts (b) to check the quality of deliveries and (c) to investigate complaints. In assessing samples under class (a) the principle of obtaining the best value for money is paramount. Generally in 1949 a high standard of quality was maintained and few complaints were found to be justified. The need for continued examination was, however, emphasised by the low standard of quality of some of the samples tendered — but not accepted: for example, gelatine, flavouring essences, ice cream, etc. 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 might be used. Many proprietary substances were submitted for analysis, and report was made as to whether the makers' claims for them were justifiable: for example, a "meat tenderiser," and materials for cake making. In the latter a gum was generally incorporated instead of egg albumen with, of course, a lessening of food value: the provisions of the Foods (Labelling) Order were borne in mind in such cases. Some tendered samples of ice cream were again very low in fat content which is of importance when this material is used as the sweet course of a meal. 10 per cent. is desirable and below 8 per cent. is considered definitely unsatisfactory. Public Control Parks Supplies 32 Chemicals, drugs and medical supplies of various types were submitted for analysis and report, and also lubricating and other oils, floor and tile polishes and silver plate 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 modern insecticides (based on D.D.T. and Gammexane) for the various 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. Disinfectants were examined as to their germicidal value, stability of emulsion and freedom from staining linen fabrics. 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, and also coloured chalks: some of these were reported on adversely as containing deleterious colouring ingredients (lead chromate, antimony compounds). Instructional visits of school parties to both the Headquarters and Northern Outfall Works laboratories might also be mentioned. Much consultative and advisory work was done for both the Chief Engineer's and Architect's departments 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-metaphosphate 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) several cases of severe scaling were successfully dealt with by the adoption of the hexa-metaphosphate or micromet treatment; for example, in a series of electrically heated tea boilers: (b) extensive corrosion of iron pipes having occurred at some out county premises the installation of copper pipes was recommended having regard to the nature of the water supply and other circumstances. At the request of the Architect this matter was dealt with extensively in 1949. The most important case was Cleopatra's Needle. The last full treatment of this was in 1911 and on re-examination it was found that the wax then used had crystallised in plates and the deposited dirt had penetrated behind it on to the stone; there was also some evidence of flaking of the stone. After laboratory investigation and bearing in mind the need for care to avoid further injury to the stone and the inscribed hieroglyphics, the treatment adopted was first of all to soften the wax and dirt with a mixture of carbon tetrachloride and benzole and then to emulsify and remove it by the use of a non-ionic synthetic detergent. A low melting point paraffin wax dissolved in white spirit was applied and the wax subsequently carefully melted into the stone by means of a blow lamp. This effectively sealed the microscopic fissures, preventing the ingress of water. Other monuments, etc., dealt with were Boadicea's Statue, several commemorative plaques, and ceremonial bronze doors. Each case had to be considered separately as to the best method which could be devised for its particular circumstances and material. Many other matters were dealt with of which may be mentioned: (a) The death of fish in an ornamental pond was attributed to the effect of a violent storm of rain in hot weather which disturbed the mud at the bottom and caused the depletion of the dissolved oxygen content of the water: (b) an investigation was made into the possibility of installing simple instruments for measuring the consumption of hot water in separate flats whose supplies are drawn from a central Education Steam raising, heating, etc., plants Cleaning of Monuments, etc. Miscellaneous 33 installation: (c) plated bath fittings were found to be pitted due to their poor condition before plating; the coating of deposited chromium was also very thin: (d) a fractured bibcock revealed crevices in the metal and also blowholes, the opinion being expressed that the casting was poor. Attention was paid to the development of new analytical methods and close liaison was maintained 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, two of the Department of Scientific and Industrial Research and five of the British Standards Institution. He also was a member of Council of the Society of Public Analysts. The Deputy Chemist (Dr. S. G. Burgess) served on a Committee of the Ministry of Food and on two committees of the British Standards Institution. Two papers were published during the year: "The estimation of grease in sewage sludge" by Dr. R. J. Stephenson, and "A rapid method of estimation of ammonia nitrogen in sewages and effluents " by Mr. J. E. Houlihan. Atmospheric Pollution Introduction — It was considered that it would be of interest to include in this report an extended section on atmospheric pollution for this is a subject to which much attention has been devoted since the end of the war on both public health and amenity grounds. It is also one with which the Chemical Branch has been concerned for many years, in fact since 1912 when an advisory Government Committee was formed which was first attached to the Meteorological Office; later, in 1927, this Committee was taken over by the Department of Scientific and Industrial Research and, as the Atmospheric Pollution Research Committee, it is now a constituent Committee of the Fuel Research Board. This association of the investigation of atmospheric pollution with that of fuel research is a very logical arrangement for almost the whole of the pollution normally arises from the burning of coal and other fuels derived from it, only a small part being due to waste products from industrial processes and other sources. Evolution of smoke from a chimney indicates incomplete combustion of the fuel being used and hence waste of fuel and its equivalent heat value. Therefore it is in the interests of economy in addition to those of public health and amenity that atmospheric pollution should be prevented. The first coal to be mined in England was dug out from the seashore about a.d. 1200 and hence it was known in the early days as "sea coal" to distinguish it from "charcoal." As soon as its use became general the smoke nuisance made itself felt. In London it is recorded that in 1273 "sea coal" was prohibited from being used as being " prejudicial to human health." The pamphlet "Fumifugium" written by the diarist, John Evelyn, in 1661 is famous: in it he refers to London smoke as "that Hellish and dismall clowd of sea coal which is not only perpetually imminent over her head but so universally mixed with the otherwise wholesome and excellent Aer, that her Inhabitants breathe nothing but an impure and thick Mist accompanied with a fuliginous and filthy vapour, which renders them obnoxious to a thousand inconveniences, corrupting the Lungs, and disordering the entire habits of the Bodies; so that Catharrs, Phthisicks, coughs and consumptions rage more in this city than in the whole Earth besides." This is a rather wholesale indictment and suggests that the methods then employed for burning coal were not even up to present day standards of efficiency, particularly since the amount consumed at that time must have been only a small fraction of that now used. 34 Methods of estimation and results — The methods of measurement used for estimating atmospheric pollution are:— (a) Collection and examination of total deposit in the Standard Deposit Gauge. (b) Estimation of the active sulphur gases in air by the Lead Peroxide Cylinder. (c) Estimation of the total sulphur gases in air by the Volumetric method. (d) Measurement of the smoke (or black suspended matter content) in the air. Method (a) — The deposit gauge is essentially a rain gauge. The method claims only to measure the amount and nature of the matter deposited from the air on a particular area during a stated period : not all the impurity present in the air over any length of time will be deposited. The rainfall is a complicating factor for not only the "amount" but also the "duration" of it come into account. Nevertheless a heavier level of pollution at one place than another must be expected to be reflected in the nature and magnitude of the deposits. This has been borne out over a period of nearly 40 years from a study of the results of this method obtained at a number of observation stations. Table 39, p. 145, shows the results of some recent yearly averages and some period averages for seven deposit gauges examined by the Chemical Branch. The nature and sources of the components estimated need description. "Tar" includes the more volatile matters given off in the earlier stages of heating coal or wood. "Carbonaceous matter, other than tar" may consist of fine particles of unburnt fuel and soot, with hairs, plant remains, etc. The "Ash of the insoluble matter" is mainly the mineral matter from this unburnt coal together with sand, etc., from disintegrating building materials. The "Soluble matter" is largely derived from the leaching action of the rain on the solid matters in the gauge: the rain brings down sulphur dioxide and carbon dioxide which assist in the solution of the lime and other bases. The "sulphates" are almost wholly derived from the combustion of fuel. The "Chlorides" may come originally in part from sea spray but coal also has a chlorine content. The significance of these constituents can easily be recognised: thus a high "tar" figure is due largely to pollution from domestic chimneys or very inefficient furnaces with bad combustion. A high deposit of "carbonaceous matter other than tar" indicates uneconomical adjustment of air supply and furnace conditions by which solid combustible particles escape in excessive amount. Considering the figures in Table 39, it must first be pointed out that the total rainfall for 1949 was below the yearly average and its incidence as between the various months was very uneven: this is made apparent by the low figure shown for the available eleven months samples at Finsbury Park as compared with the remaining stations which included twelve months; the missing month (October) was a very wet one. The figures for "tar" are, of course, very small but the results for 1949 were similar to those for former years and on the whole tended to show a slight decrease. It might be remarked in passing that this may be due to the low rainfall since it has been shown that a decrease in this tends to lower the proportion of atmospheric contaminants as measured by this method. The comparison of the "carbonaceous matter other than tar" results showed fluctuating differences: on balance those for 1949 were rather less than those for 1948, but in some instances they were greater than the averages tor previous periods of years. The "ash of the insoluble matter" variations were generally, as would be expected, in line with the "carbonaceous matter other than tar" results. 35 The "total soluble matter" though greater in some cases and less in others on comparing 1949 with 1948, was generally less than that of the pre-war period averages. This brings us to the "total solids" probably the most important figure of this series. Generally for 1949, in localities where this figure was high it showed some decrease as compared with that for 1948 (e.g. Archbishop's Park, Battersea Park, South Kensington). In districts where it was low there was a small increase (e.g. Kew). Battersea Park remained the worst situation with Archbishop's Park next on the list. The difference between the London results and those of the two out-county gauges at Kew and Godalming is noteworthy, the total deposits for these being much less and, in turn, that at Godalming was less than that at Kew. The variations over the years on these "total solids" are more clearly shown graphically in Figure 1 for five stations, four in London and also that at Kew. The fluctuations are so different in the various cases that it is not possible to summarise shortly, though on the whole there was a tendency towards reaching a minimum in 1939, with, in most cases, a subsequent rise, which was particularly marked at Battersea Park up to a maximum in 1947. The "Sulphates" were generally lower in 1949 than in 1948, and, on the whole, than those for the average of previous periods of years. Method (b) — This method measures the amount of sulphur gases "fixed" by a cylinder of oxidising material exposed in air for a period of one month. The result may be taken to be an indication of the "activity" of the sulphur gases and thus is specially useful in considering effects on buildings, etc., for which purpose the method was originally devised. It is a more recent one than the deposit gauge dating as it does only from 1935. Table 40, p. 147, shows the averages for some of the stations operated during 1949, these being yearly averages of the monthly results. The figures are expressed as S03 milligrammes per 100 sq. cms. per day. Considering first the average for the selected five stations: it will be seen that the average figure for 1949 was the lowest of the series of years so far examined, except for 1940 and 1941 during the war (see Figure 2 also). The average for the five year period 1945-9 was, however, slightly greater than that for the wartime period 1940-4, but less than that of the immediate pre-war quinquennium. Figure 2 shows the variation of the average results of these five stations throughout the years during which they have been operated, and also that for the country district of Godalming for comparison. In the former, the minimum at 1940 is well marked and is followed by a rising tendency to a maximum at 1944-5 with a subsequent slight fall: it should be pointed out that these stations have been specially selected for the comparison because they are all situated in parks and so removed from immediate local pollution. The effects of this last mentioned factor are again evident (Table 40) in considering the County Hall figures as obtained at different points on the roof: with the prevailing S.W. wind the S.W. corner gets air direct from the river without local contamination, whereas the other two points may be affected by gases from the heating plant chimney. The particularly high figures at Beckton are noteworthy: this station is at the Council's Northern Outfall Works and is situated immediately between the largest gas works and the largest electricitv generating station in this country, which fact no doubt accounts for the bad atmospheric conditions and the notoriously great corrosion of metal and paintwork which occurs in this area. The very low figures for the country district outside Godalming are significant of the difference in this respect between the air of such a neighbourhood and that of an industrial town. Method (c) — The Volumetric method measures the actual amount of sulphur dioxide in a known volume of air taken at an even rate during the period of the 36 37 38 test which is normally 24 hours. This method has been used since 1931 and has the advantage over the previous one in that it is an actual measurement of the total amount of sulphur dioxide present in the air: but it is more time-consuming in that a determination has to be made each day and the apparatus required is more extensive. Table 41 shows the yearly averages of the results expressed as SO2 parts per million by volume. In the cases of Beckton and County Hall the figures for 1949 are less than the corresponding ones for 1948 but are similar to those for 1947 and, in the former case, to those for the period averages for 1940-4 and 1945-9. At Crossness the 1949 figure, as would be expected, was of a much lower order and generally similar to those of 1940-4 and 1945-9. In all three cases the present figures are less than those for the seven year average 1932-38. The volumetric sulphur determination is made on a 24 hour basis and Table 42 shows the frequency of the daily occasions upon which the degree of pollution exceeded 0.2 parts per million by volume of SO2 or was less than 0.1; the figures are expressed as percentages of the total number of estimations made. The results indicate that, in this respect, atmospheric conditions were generally rather above the average in 1949 and again demonstrate the better condition at Crossness as compared with Beckton and County Hall. Method (d)—For many years up to 1939 estimations of Smoke (black suspended matter content) were made by the Owens Automatic Air filter which gave approximately hourly readings but required a fair amount of attention and a constant water supply. Since the war this technique has been superseded by the installation of three smoke filters each run in conjunction with the Volumetric method for the determination of sulphur gases: the results therefore are on a daily basis which, once having established the normal variation over the 24 hours of the day (to be mentioned later), has certain advantages as regards accuracy of estimation. Table 43 shows the monthly average figures for 1949 and some previous yearly averages of the smoke concentration in the air at the three stations operating this test. The results are expressed as milligrammes of black suspended matter per cubic metre. The seasonal variation through the year is clearly shown, the figure being notably higher in the winter than in the summer. This seasonal variation in the degree of pollution had also been demonstrated in the past by the monthly results for all the other methods previously described. The comparison of the results at Beckton and County Hall with those at Crossness again demonstrates the difference between an industrial town air and one on the outer fringe. A comparison of the few yearly average figures shows no particular trend. Discussion—Atmospheric contaminants may be roughly divided into three classes: (a) smoke: (b) ash and grit: (c) sulphur gases. It has been estimated that the total amount of smoke produced in this country is about equally domestic and industrial in origin but that ash and grit, and sulphur are mainly industrial. (a) Smoke—This is due to incomplete combustion, and the inefficient domestic open grate, especially the older patterns, is a major cause of its emission. Much has been done in recent years by the installation of more efficient types to minimise smoke from domestic fires. The great effect of these on the smoke (black suspended matter) content of the air was proved in the early years of the investigation by the results of the Owens Automatic Air filter which has already been mentioned. For a winter week day the hourly records from midnight to about 6 a.m., showed low figures but then a sharp rise occurred after the fire lighting, and a more gradual one up to 10 a.m.; a small decrease then took place followed by a period of constant value until about 5 p.m. when a small rise again occurred to a peak value at 6-8 p.m. which was only slightly below the 9-10 a.m. peak: after 8 p.m. there was a gradual decrease to a minimum from 2-6 a.m. By a comparison of such results in winter and summer (domestic fires being much fewer in the latter season), the approximately equal order of effect of them was 39 assessed as against that of industrial processes, which generally continue to be of the same order of intensity throughout the year. Nevertheless, the inefficiently operated industrial plant can be a great nuisance from the smoke emission aspect. As to the possible future diminution of this, on the domestic heating side, apart from the replacement of old grates by properly designed appliances, the main hope is in the increased use of gas or electricity or smokeless fuel. On the industrial side it must be by the proper control of firing and draught conditions and by the provision of special attachments where necessary for giving a more flexible adjustment of draught when firing is being done. As also applies still more to the next section on ash or grit, the provision of a suitable type of fuel for the particular furnace and an increase in the provision of washed coal would be advantageous. (b) Ash and Grit. The proportion of this from domestic fires is only small, it being mainly industrial in origin. The prevention of it (by e.g. electrostatic precipitation and grit arresters) is reasonably easy and should be increasingly adopted. (c) Sulphur gases.— The reduction of these is the most difficult problem. Something can be accomplished by an increasing use of coal washing before delivery to the consumer since this removes some of the extraneous sulphur-containing compounds. Otherwise the normal burning of coal will inevitably emit the oxidised sulphur into the atmosphere : no removal process from flue gases on a small scale is feasible. For large consumers such as electricity generating stations gas washing processes have been devised which have attained an efficiency of removal of 90-95 per cent. In fact two large power stations (Battersea and Fulham) were operating on two rather different processes before the last war, having been statutorily required to do so as the result of public enquiries. The washing lapsed during the war and no part of it has yet been resumed at Fulham: at Battersea 30 per cent, was in operation up to June, 1949, and 70 per cent, at the end of the year. Unfortunately the average efficiency of removal has recently been relatively poor in this case and, in view of the cooling effect of the process on the effluent gases, and consequently more rapid diffusion downwards, it is essential that a high percentage of removed shall be maintained if the procedure is to be of benefit to the surrounding areas as far as sulphur gas reduction is concerned. This question of the formation of relatively high local concentration of sulphur gases in the neighbourhood of large coal consumers is of importance even when taking into account the increased diffusion effected by the use of tall chimneys. The increase in such concentrations of use is of interest as evidenced by the fact that, for the whole country, in 1938 only 8 per cent, of the total coal consumed was used at electricity generating stations, whereas in 1949 the figure was 15 per cent. The contrast is even more striking in the case of London where calculation from the Ministry of Fuel and Power's Statistical Digest shows that 27.7 per cent, of the sulphur pollution in the London region originated from coal burnt at electricity generating stations: this estimate takes into account the fact that the coal supplied for these stations is, at least in some cases, of special quality with a low sulphur content. The actual proportion of coal burnt is somewhat higher. It must, of course, be emphasised that the power produced by the use of this coal at the stations will be employed elsewhere in lieu of burning coal and producing sulphur gases in the process ; but the local concentrations caused in the areas around the stations need careful consideration especially bearing in mind the continuing programme of extensions and new construction of stations. It must also be borne in mind that the old processes of gas washing are very expensive and the results of the investigations now being conducted by a working group (of which the Chemistin-Chief is a member) under the auspices of the Department of Scientific and Industrial Research on the possible development of a new method for the removal of sulphur compounds from industrial gases are awaited with much interest. 40 HEALTH SERVICE PREMISES As noted last year, many of the clinics and nurseries are in premises which are held on short tenancies or in requisitioned buildings. Much work was involved in negotiating new leases when tenancies expired and in finding replacements for premises which had to be given up. The Government's policy of restricting the erection of new buildings continued but some progress nevertheless can be recorded. In only one instance during the year had buildings to be given up without alternative accommodation being found. This occurred in North Paddington, where a maternity and child welfare centre in a vicarage had to be closed because the Vicar needed his house. No other vacant premises could be found in the district and the work had to be distributed amongst other centres in the vicinity. Negotiations for the purchase of sites and the planning of buildings proceeded in anticipation of other premises having to be relinquished in the future. Replacement of Buildings The following premises were opened during the year to replace buildings which had to be relinquished :— Division 4. Cawley and Wetherell Road Day Nursery, Hackney, was opened on 3rd January, 1949, to replace the war-time nursery which had been accommodated in the French Hospital. The new nursery was built with prefabricated units erected by direct labour employed by the Hackney Metropolitan Borough Council, who had prepared the plans for the nursery before the " appointed day." The cost of erecting the nursery was, however, borne by the Council. Division 5. Christian Street Day Nursery, Stepney, was similarly erected on behalf of the Council by the Stepney Metropolitan Borough Council, who had completed plans for the work before the " appointed day." The new nursery was brought into use in April, 1949, to replace a war-time nursery in Queen Elizabeth Hospital, Glamis Road, Stepney, where accommodation was again required for hospital purposes. Division 8. Tulse Hill Housing Estate Maternity and Child Welfare Centre.— A specially designed centre was opened on 16th September, 1949, in Block 20 of the Council's housing estate at Tulse Hill. The centre was so designed that when a comprehensive health centre can be built for the area the accommodation occupied by the maternity and child welfare centre can be converted readily into flats. The opening of this centre enabled the use of a church hall to be given up. Division 1. St. Dunstan's Road School Treatment Centre, Fulham.— A former special school building was adapted as a school treatment centre and brought into use in September, 1949. This replaced a centre formerly at Creighton House which had to be closed during the war because the Creighton House authorities needed the accommodation for their own services. Division 6. Deptford School Treatment Centre.— The Lady Florence Institute, Reginald Square, S.E.8, the property of a voluntary organisation, resumed work after reinstatement of war damage, and clinics which had been temporarily accommodated elsewhere were brought together again. Division 7. Gordon Road School Treatment Centre was opened by the conversion of a cottage belonging to the Council in Gordon Road, S.E.15. This replaced the former Rye Lane School Treatment Centre which had to be closed because the owners sold the premises for other purposes. Division 9. Gatton Road Bathing Centre, S.W.17.— A new building was opened on 5th January, 1949, on the site of the former centre, which had been destroyed by enemy action in 1944. The service had been maintained since that year in temporary accommodation. Maternity and Child Welfare Services School Health Services 41 Improved Accommodation It was possible to transfer maternity and child welfare centres, as set out below, to better premises during the year:— Division 5.— The centre at Riverside Mansions was combined with the school treatment centre at Pier Head, Stepney, on 28th December, 1949, after adaptations had been carried out. Division 7. (a) The centre previously held in cramped quarters in Shaftesbury House Day Nursery was transferred on 31st August, 1949, to All Saint's Parish Hall, S.E.26. (b) On 10th October, 1949, a centre was opened in St. Barnabas Church Institute, Townley Road, S.E.26, where better accommodation was available than in the church premises which had previously been leased. (c) In June, 1949, a centre in a church hall in Barforth Street was transferred to 221, Consort Road, S.E.15. formerly a medical relief station belonging to the Council, which was adapted for its new purpose. Additional Maternity and Child Welfare Centre Division 2. A maternity and child welfare centre in temporary buildings which were erected under the supervision of a firm of private architects was opened on 22nd November, 1949. The building occupies a part of a large site which has been acquired for a comprehensive health centre. The preliminary work involved in acquiring the site and planning the building had been completed before the "appointed day " and the Council continued the work initiated by the Hampstead Metropolitan Borough Council. Building Work in Progress At the end of the year plans had been completed, and Ministry sanctions obtained, where necessary, for the following schemes which were under construction Division 1. Mulgrave Road Day Nursery, Fulham.— The site on which there was a partially completed war-time day nursery, on which work had been suspended at the end of the war, was purchased and construction resumed to bring the building into use to enable a vicarage used as a day nursery to be relinquished. The Ministry of Works prefabricated buildings on the site were purchased from the Government. Division 2. Barrow Hill Road Housing Estate.— The St. Marylebone Metropolitan Borough Council proceeded with the construction of a maternity and child welfare centre which had been planned before the " appointed day " in a block of flats on a housing estate. The accommodation will be leased by the borough council to the Council. Division 5. Whitechapel School Treatment Centre.— The work of converting vacant accommodation in the Mary Hughes Centre, Underwood Road, Stepney, which houses a day nursery and maternity and child welfare centre, into a school treatment centre proceeded. Bethnal Green School Treatment Centre.— The adaptation of former special school buildings in Mowlem Street, Bethnal Green, into a school treatment centre was begun. Division 7. Downham Health Centre.— The rebuilding of the Downham Health Centre, Lewisham, which had been destroyed by enemy action, had reached an advanced stage by the end of the year. The centre will accommodate a maternity and child welfare centre and a school treatment centre, both of which have functioned in improvised accommodation since the destruction of the centre. Flower House Maternity and Child Welfare Centre.— With the consent of the Housing Committee two ground floor flats which were made inter-communicating 42 in a block under construction on the Flower House Estate were allocated for use as a maternity and child welfare centre to serve this estate, and part of the Council's Bellingham Estate, Lewisham, and enable a centre in a church hall to be given up. The new centre will be replaced as soon as possible by a permanent building on a health centre site, and the clinic accommodation in the block of flats will then be turned into two flats. Schemes in Preparation To avoid abortive work in the preparation of schemes which might not receive the sanction of the Ministry of Health when the time arrived for the Council to apply for a starting date, the practice was adopted of consulting the Ministry of Health at an early stage when both the need for new buildings and the scheme plans were discussed. At the end of the year the following schemes were under consideration :— Division 1. Westway, Hammersmith.— A permanent day nursery to replace the war-time nursery in Australia Road which had to be closed to permit the erection of a new school on the White City Estate. Division 2. Peach Street, Paddington.— A permanent day nursery to replace a wartime day nursery which will have to be closed to permit the erection of a block of flats. Division 3. Basire Street, Islington.— A day nursery to replace a war-time day nursery which will have to be closed when a block of flats is erected. Division 4. Victorian Grove, Stoke Newington.— An extension of an existing day nursery. Ickburgh Road, Hackney.— A large permanent day nursery to replace two wartime nurseries in requisitioned premises. Division 5. Sugar Loaf Walk, Bethnal Green.— An extension to an existing day nursery to permit accommodation rented from University House Settlement to be given up. The following schemes had been approved in principle by the Ministry of Health and the Ministry of Education and plans were approaching the final stages :— Division 4. Springdale Road Day Nursery, Stoke Newington, planned to enable a day nursery in requisitioned premises to be closed. St. John's Rectory Gardens, Hackney, planned to enable a day nursery in Ram's Episcopal School buildings to be released for educational purposes. Division 5. Peel Grove, Bethnal Green, a maternity and child welfare centre to provide more adequate accommodation than had been available in the past in the single centre in Bethnal Green. Division 9. 23 Weir Road, Wandsworth.— The conversion of a former civil defence building into an additional day nursery. Holiday Home.— The purchase of Roland House, Littlehampton, was approved with a view to its use by the Council under Section 28 of the National Health Service Act, 1946, to provide recuperative holidays for 37 children up to 8 years of age. Child Guidance Centre, 19 Water Lane, Lambeth.— The Ministry of Education approved the purchase of the former provident dispensary premises in Water Lane so that a full-time child guidance centre could be established. Day Nurseries 43 Health Centres Plans for the Council's first comprehensive health centre at Woodberry Down were approved by the Minister of Health, and on 16th March, 1949, the Minister, the Rt. Hon. Aneurin Bevan, M.P., turned the first sod at a ceremony held to mark the commencement of the work. A tender for the building work (including the cost of a day nursery) amounting to £149,956, was accepted by the Council later in the year. It is expected that the centre will open in 1951. Consideration was given during the year to the erection of a comprehensive health centre on a site in East India Dock Road, Poplar, but at the suggestion of the Ministry of Health the project was postponed. Two other schemes to provide health centres by converting existing buildings reached the stage where consultations were held with the Local Medical Committee and with the general practitioners in the areas concerned. It had been hoped to include in one of these schemes a " university health centre " for the postgraduate training of general practitioners and to accept a grant offered by the Rockefeller Foundation to meet the cost of improvements and salaries of a director and research personnel. It was not possible, however, under the National Health Service Act, 1946, to give the general practitioners practising in the neighbourhood the assurances they desired as to the conditions under which they would be prepared to participate in the scheme and the conversion of the buildings was, therefore, postponed. Acquisition of Sites Although it may not be possible to embark upon a large programme of building health centres for some years, it is necessary that some suitable sites should be reserved if they are to be available when building on a wider scale becomes practicable. This problem is dealt with in two ways — first, by purchasing cleared sites or reserving sites on land already purchased for housing estates; and second, by the designation of sites in the development plan which is being prepared in accordance with Section 5 of the Town and Country Planning Act, 1947. Proposals for the purchase of two cleared sites were submitted to the Executive Council and the Ministry of Health, and by the end of the year approval to the purchase of one of these at Brockley Rise, Lewisham, had been received. Other cleared sites were under investigation, but the proposals had not reached the stage of consultations with the Executive Council and the Ministry of Health. The number of cleared sites likely to be available for building health centres is limited, and to supplement these it is necessary to designate further sites in the Town Planning Development Plan for acquisition during the period 1951-1961. A survey of London has been made and a number of blocks of property have been selected for consideration in consultation with the Executive Council and the Ministry of Health. In most cases sites to be designated will consist of old property which is still occupied, and some rehousing will be necessary before the property can be demolished. The building of health centres on these sites must, therefore, await the provision of new housing accommodation and in some cases the resumption of slum clearance. Equipment of Health Centres In order that standard equipment for day nurseries, maternity and child welfare centres, and other health service buildings, might be devised a departmental committee was appointed with the following order of reference:— To consider and report to the Medical Officer of Health as soon as possible on — (i) The range and number of articles of furniture and equipment which would normally be supplied to day nurseries, maternity and child welfare centres, school health establishments, holiday homes and comprehensive health centres. 44 (ii) The type, size and specification of particular items which should normally be supplied where more than one type or size are available. The Committee held four meetings during the year and dealt first with the equipment for the Woodberry Down Day Nursery. CARE OF MOTHERS AND YOUNG CHILDREN Administration During 1949 the Council's divisional health organisation settled down to the task of maintaining, re-organising and improving the personal health services. Elected and co-opted members of the nine divisional health committees, to which the Council delegated the day to day administration of these services, regularly visited the establishments in their areas where services are* provided under the National Health Service Acts. Divisional medical officers and other administrative staff (who are responsible for the co-ordination of the personal health services in the divisional areas) have been faced with a variety of problems which have been further complicated by staff shortages, but the experience gained since the appointed day has enabled the difficulties to be faced with increasing confidence. Expansion of Services The provision of new maternity and child welfare centres is dealt with on p. 40. The Council assumed responsibility for the administration of maternity and child welfare services for military families in the Woolwich Barracks area and by permission of the military authorities provided in premises owned by the War Office similar services for civilian families. This caused some reduction in the pressure on other centres in Woolwich. The following table shows the number of attendances at the various types of sessions (excluding dental) which were held in the centres during 1948 (approximate figures only available) and 1949:— Type of session Attendances 1948 (approx. figures) 1949 First Total First Total Infant welfare — Under 1 year 47,600 689,200 48,489 683,089 Over 1 year 7,580 285,800 6,641 282,202 Special toddlers' — 21,500 — 35,500 Ante-natal 33,950 194,250 29,917 184,018 Post-natal 4,780 9,190 5,839 7,486 Breast feeding 1,700 4,250 1,559 2,851 Educational and Advisory — 17,100 — 23,688 Light and massage 6,400 95,400 6,440 108,545 First attendances under one year of age at infant welfare centres amounted to approximately 84 per cent, of all infants born during 1949, compared with 81 per cent, in 1948. Total attendances were well maintained. During the first 8 or 9 months when the mother is anxious about the progress of her infant, attendances for weighing, medical advice and mothercraft guidance are frequent, averaging 12, but with the normal progress of the child attendances fall off rapidly. All mothers are encouraged to bring children of 1 to 5 years of age to the infant welfare clinics or to special toddlers' clinics. About one-fifth of the children who attend are referred for treatment, an indication of the need for this service and for the mothers to avail 45 themselves of it, as many would probably not "bother their doctor" had not the clinic doctor recommended them to seek his advice. An attractive birthday card is sent to remind them of these facilities. First attendances at ante-natal clinics amounted to 52 per cent, of all women needing ante-natal care during the year (as estimated from confinements over a corresponding later period) compared with 56 per cent, in 1948. Nowadays practically every expectant mother has ante-natal care. The balance of 48 per cent, receive it from the hospitals where they will be confined, or from the doctor who has been booked. Several hospitals refer their booked cases to the Council's ante-natal clinics for intermediate supervision. The mothers attend the hospitals to book and are referred from the Council's clinics to the hospital at once if any serious complication arises. Though expectant mothers value the medical supervision which they receive at the Council's clinics from experienced medical officers (they attend about six times during their pregnancy), it is to be expected that they will tend more and more to avail themselves of the general practitioner obstetrician service. Towards the end of 1949 there was a decline in pressure greater than could be accounted for by the fall in the birth-rate, though this did not greatly affect the total attendances for the year, which were well maintained. Attendances at breast feeding clinics declined, largely owing to the fact that breast feeding advice is given in the ante-natal and infant welfare sessions, at the latter of which test feeds are also carried out. There was an expansion in attendances at educational and advisory sessions. Attendances were well maintained at the light and massage clinics. Comments on the work of the dental clinics will be found in the report of the Chief Dental Surgeon (page 102). Joint arrangements with other Local Health Authorities Arrangements were made with the Kent county council whereby expectant mothers and those with young children living in the Mottingham area may attend the maternity and child welfare centre nearest to their homes irrespective of whether the local health authority administering the centre is the same as the authority in whose area they live. This has saved the women concerned a great deal of travelling, and it has been agreed that no financial claims will be made in respect of this reciprocal service. The Council also agreed to the attendance at its ante-natal, infant welfare and foot clinics in Fernhill Street, North Woolwich, of women and young children living in that part of the county borough of West Ham adjacent to North Woolwich. It has also been agreed that, should these extra attendances overcrowd the Council's clinics, the West Ham residents may attend sessions administered by the East Ham county borough council in the same premises. Both arrangements are reciprocal without financial adjustment between the authorities. Should similar arrangements prove to be required elsewhere on the periphery of the county area, the Council will be prepared to co-operate with other local health authorities on the same basis. Voluntary Organisations The agreements made under Section 22 of the National Health Service Act, 1946, between the Council and the twenty voluntary organisations providing maternity and child welfare clinics have been in operation for eighteen months and have in general proved satisfactory. New agreements are being negotiated, and the experience gained since the "appointed day" is proving most valuable in reviewing the terms and conditions on which the Council gives financial aid to these bodies. It is proposed that the centres shall continue to be managed by the voluntary committees and that the Council shall continue to be represented on those committees and have powers of inspection of the premises. Providing M. and C.W. Clinics 46 Providing Day Nurseries and Creches Arrangements with the six voluntary associations providing day nursery facilities continued satisfactorily during the year and were subject to the general review undertaken before the agreements expired. Applications for financial assistance towards the maintenance cost of providing day nursery and creche facilities were received from a further two voluntary bodies, and negotiations were still proceeding at the end of the year. The Hampstead Health Institute, a trust providing accommodation for some of the Council's health activities as well as for other benevolent purposes under a scheme approved by the Charity Commissioners, applied to the Council for financial assistance in view of increasing costs and diminishing income. The Council negotiated a new tenancy agreement with the Institute at an increased rent and took over direct responsibility for the administration of the health services concerned. Considerable use was made by the Council of the facilities available at the Mothercraft Training Society, Highgate Hill, and the Violet Melchett Infant Welfare Centre, Chelsea, for the in-patient treatment of mothers and babies experiencing breast-feeding difficulties and of babies with dietetic upsets. Both organisations are assisted financially by the Council, and patients recommended for admission pay at an agreed rate. Children under 6 months old accompanied by their mothers are admitted free. Providing other Health Services Providing residential accommodation Clinics Variations in the attendances at sessions of different types held in the maternity and child welfare centres are shown in the table on page 44. The areas served by the various centres are now more clearly defined, and it is to the advantage of mothers and children to attend the appropriate centre, so that contact with the health visitor of their area can be maintained. There is, however, freedom of choice as to which centre is attended. Where areas served, for example, by municipal centres and hospital centres have overlapped, agreement with the hospital authorities has been sought to adjustments to eliminate duplication of service. Clinic medical officers, many of whom are general practitioners holding parttime appointments with the Council, have, where possible, been allocated according to preference, to infant welfare or ante-natal and post-natal work. Every expectant mother attending the Council's ante-natal clinics for the first time can now have a specimen of her blood taken in order that tests may be made for the Rhesus factor and the Wassermann reaction. Arrangements have been made with the metropolitan regional hospital boards and the boards of governors of teaching hospitals for the necessary laboratory services, including those needed in connection with outbreaks or suspected outbreaks of acute infectious disease, to be carried out in the boards' laboratories free of charge to the Council until such time as these services can be made available by the public health laboratory service. Arrangements with private laboratories which existed in some areas have been terminated. Pregnancy diagnosis tests have been carried out for the Council since 1st April, 1949, at the Ministry of Health's laboratory in Shrodell's Hospital, Watford. Two hospitals in London which were doing this work for metropolitan borough councils before the "appointed day" have continued to provide the service for the Council. The Family Planning Association continued to hold clinics in premises transferred to the Council under the National Health Service Act, and some extension of the facilities has been necessary. A payment of 12s. 6d. is made for every woman referred by the Council's medical staff ; 614 cases were so referred during the period 5th July, 1948, to 31st December, 1949. Tests Family Planning 47 Care of Premature Infants The special equipment provided for use when a premature infant is being nursed at home was reviewed in the light of experience in use, and some modifications made. Three sets of the equipment have been provided in each of the nine divisions, and are available on request by day or night. A deposit has to be made for the loan of a set and is refunded in full on return of the set. The arrangements outlined in my report for 1948 with respect to special transport arrangements when these infants have to be removed to hospital have operated throughout 1949. The specially heated cots carried on the ambulances were used on 72 occasions for premature infants and on 180 for other babies requiring removal to hospital. Specialist Clinics Among the services taken over from the metropolitan borough councils on the "appointed day" were a number of specialist clinics for expectant and nursing mothers and consultative infant welfare clinics for healthy children under 5 years of age. It was apparent that although these had been provided under the maternity and child welfare powers of the borough councils they were not necessarily functions of the local health authority under the National Health Service Act. Discussions were therefore held with the metropolitan regional hospital boards as a result of which it was agreed that the regional hospital boards should provide and pay specialists for consultative infant welfare clinics and should accept entire responsibility for gynaecological clinics. Negotiations between the Council and the boards are now proceeding with a view to the detailed implementation of these proposals. Maternity and Child Welfare Services provided by Hospitals Many of the former voluntary hospitals provided maternity and child welfare services (ante- and post-natal clinics, infant welfare clinics, health visiting services, etc.) before the " appointed day," often by arrangement with one or more of the metropolitan borough councils, which assisted them financially in return for the services. Two of the Council's former hospitals provided ante-natal and post-natal facilities for metropolitan borough councils by agreement but without payment, and others provided dental services for expectant and nursing mothers and children under 5 years of age, payment being made on a case basis. The question arose whether the Council had inherited under the National Health Service Act the liability to continue the payments made by the metropolitan borough councils and the extent, if any, to which the services could now properly be provided by hospitals. The matter was referred to the Ministry of Health, who ruled that hospital authorities were not empowered to provide any services which, under Part III of the Act, were the functions of a local health authority. Such services could be provided only by the local health authority, either directly or through a voluntary organisation acting as its agent. It therefore appeared to the Minister that, in the case of teaching hospitals with their special responsibilities for the training of medical undergraduates, either the Council should take over the Part III services being provided and, where it wished to continue them in the same premises, should rent the accommodation from the board of governors of the hospital; or else the committee of the medical school concerned, which could be regarded as a "voluntary body" under Section 22 of the Act, could provide the services with financial assistance from the Council. At hospitals under the control of the regional hospital boards there is no medical school or other voluntary body and consequently the only possible course is for the local health authority, if it wishes to continue the service, to take it over and administer it direct. This ruling has necessitated negotiations between the Council, ten of the D 48 teaching hospitals and three of the metropolitan regional hospital boards to determine the future organisation and administration of (a) infant welfare and allied services, (b) health visiting, and (c) medical ante-natal care of women booked for confinement at home. These negotiations were still proceeding at the end of the year. Where a medical school decides to assume responsibility for the provision of services as the agent of the Council, it is proposed that the Council's financial assistance shall be generous (up to 90 per cent, of approved net expenditure on the services) and that, subject to safeguarding the interests of the Council and of the people for whose welfare it is responsible, the special requirements of the teaching hospital will be borne in mind, e.g., in such matters as the appointment of medical staff acceptable to the medical school. The Minister has authorised the Council to pay those hospitals which were formerly given grants by the metropolitan borough councils a sum based on the former grant in so far as it related to services for which the Council is now responsible, such payment to be in respect of the period from 5th July, 1948, until the new administrative arrangements come into operation, or until 30th June, 1950, whichever date be the earlier. Dental Care Details of the priority services for expectant and nursing mothers and babies will be found on page 105 in the report of the Council's Chief Dental Surgeon. Welfare Foods, Drugs, etc. The list of welfare foods, nutrients, drugs and medical requisites recommended by a special departmental committee for use in the Council's maternity and child welfare centres and day nurseries has been reviewed from time to time during the year and suggestions received, mainly from the local officers actually prescribing the items have been considered. Further reviews will be undertaken periodically, but there are indications that the present list is proving satisfactory. Special foods and nutrients which are not on the approved list may be supplied for individual cases at the discretion of the divisional medical officers. Sunday Cinema Grants It was possible for allocations to be made from the contributions received by the Council from Sunday cinematograph entertainments for the provision of amenities in the maternity and child welfare centres and day nurseries, the cost of which cannot be defrayed out of public funds — e.g., Christmas parties, seaside and country excursions, etc. The moneys allocated to each establishment were administered by a voluntary committee set up for the purpose, the divisional administrative officers being responsible for the accounting arrangements. These extra amenities were greatly appreciated by the children and their mothers and it is hoped that similar allocations will be forthcoming in future years for this purpose. Marriage Guidance Following the publication of the report of the Departmental Committee on Marriage Guidance set up by the Secretary of State for Home Affairs (the " Harris Report " — Cmd. 7566), application to the Council for financial assistance in this field was made by the London Marriage Guidance Council, the Catholic Marriage Advisory Council and the Family Discussion Bureaux organisation of the Family Welfare Association. Representatives of all three bodies have been seen and the appropriate committee of the Council is considering whether such assistance should be given and, if so, to what extent, 49 Notification of Births Notifications were received during the year of 62,462 live and 1,255 stillbirths. These are of actual births occurring in the county and have not been corrected according to the place of residence of the parents. The corrected figures (based on births registered) are used for the vital statistics (page 4). It is interesting to note that 5,471 of the births notified were to women residing outside the county. Day nurseries, cr'cches and nursery play centres During the year two day nurseries were opened to replace existing nurseries which had to close because the premises were no longer available for day nursery purposes. The number of places provided in day nurseries, including creches, was 6,615 and on 31st December, 1949, there were 9,549 children, of whom 4,797 were in priority categories, on the waiting list. The demand for day nursery facilities continued at high pressure and the Council's scheme of priorities for admission to day nurseries remained in operation. The comparatively high cost of maintaining a child in a day nursery caused concern, and attempts were made to effect economies. Instructions were issued as to economical ordering of supplies and preparation of meeds. Standards of equipment, toys and play material and clothing are being evolved, and enquiries are being pursued into staffing and laundry costs in day nurseries. Revised instructions for the exclusion from day nurseries of children suffering from, or in contact with, infectious disease are in the course of preparation. A considerable number of unlawful entries were made into day nursery premises, and a survey was carried out to determine the most satisfactory method of precaution against burglaries. A small increase in nursery play centre facilities was made during the year. Nurseries and Child-Minders Regulation Act, 1948 The full effect of this Act was felt during 1949, and the growth in number of persons and nurseries registered is shown in the table below. Persons (other than relatives) who, for reward, look after, during the day, more than two children under the age of five years, from different households, are required under the Act to register as child-minders with the Council. Child-minders who are not statutorily registrable under the Act, may voluntarily register with the Council. They then become subject to inspection and may be recommended to mothers who apply to have their children minded during the day. The number of child-minders both statutorily and voluntarily registered, and the number of private day nurseries statutorily registered on 31st December, 1949, together with the number of children looked after, are given in the following table. The corresponding figures for the previous year are also shown. On 31s/ December, On 1949 31s/ December, 1948 Number of child-minders statutorily registered 73 35 Number of children minded 501 243 Number of child-minders voluntarily registered 584 284 Number of children minded 579 323 Number of private day nurseries statutorily registered .. 28 8 Number of places provided 972 367 One appeal against the Council's decision to refuse an application for registration under the Act of a person as a child-minder was made to a court of summary jurisdiction, and was allowed — subject to certain conditions, which were acceptable to the Council. Apart from this instance, the administration of the Nurseries and Child-Minders Regulation Act proceeded smoothly. 50 Residential Nurseries In the report for last year, I stated that a Children's Committee had been set up by the Council and a Children's Officer appointed, as required by the Children Act, 1948. By arrangement, the management of the residential nurseries (except those at hospitals, viz., New Cross, Queen Mary's, Carshalton and the South Western) including the filling of vacancies, was transferred to the Children's Officer on 1st Tuly. The position as regards residential nursery accommodation on 30th June was as follows:— Total accommodation Number of children in residence Public Health Department Nurseries Five in the Country 293 cots 469 428 Three in London 164 cots Coram Nursery (Not L.C.C.) 12 cots Welfare Department Nurseries Four in London (One closed in May, 1949) 376 329 Totals 845 757 Tudor Lodge, a large house facing Wimbledon Common, which had been acquired by the Council, was partially opened as a residential nursery early in July, 1949. In order that the premises should be brought into use without delay, it was found possible, by reducing structural alterations to the minimum, to provide accommodation for 28 children from 1-5 years of age. After the completion of all the structural alterations and when fully opened, 44 children from 0-5 years of age will be accommodated. The management of this nursery was transferred to the Children's Officer immediately after it was opened. The residential nursery at the South Western Hospital was closed in December, 1949, and the children transferred elsewhere. The children in the residential nurseries are under the medical care of visiting medical officers who examine them periodically, as well as on admission and discharge, and as may be required. Close co-operation is kept with the Children's Officer in regard to questions affecting the children's health. With this in view, the nurseries are visited at regular and frequent intervals by senior members of the Council's medical and nursing staff. The Care of Unmarried Mothers and their Children The Council has continued to have regard to the advice given by the Ministry 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 moral welfare associations." The welfare authorities referred to were the then maternity and child welfare authorities, i.e., in London, the metropolitan borough councils, whose duties in this regard were transferred to the Council in July, 1948. The care of the unmarried mother and her child is administered by the Council as follows. Voluntary homes take expectant mothers during the later stages of pregnancy and for several weeks after confinement. With the exception of two homes, confinements take place in hospitals. Since July, 1948, the Council, as local health authority, has continued to pay grants under Section 22 of the National Health Service Act, to voluntary organisations maintaining mother and baby homes. 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 Voluntary Homes 51 subject to the carrying out by the voluntary bodies of any improvements suggested by the Council. The homes are registered or exempted from registration, under Part XI of the Public Health (London) Act, 1936, as necessary. Some of the homes are also registered under Section 29 of the Children Act, 1948. There are 24 grantaided homes, and the approximate total grant for the financial year was £15,788. The denominations responsible for the management of the homes are Church of England 8, Roman Catholic 4, Salvation Army 3, Church Army 2, Jewish 1, Methodist 1, undenominational 5, but all homes are undenominational where admissions are concerned. The Council is represented by medical officers of the department on the governing bodies of the homes which receive grants. Social work, both pre-natal and post-natal is, in the main, done by moral welfare associations whose trained workers attach the greatest importance to it. The primary object is to re-establish the mother in her own life, together with her baby if possible. In London 33 moral welfare workers are employed by five associations which received grants anounting to £7,200 from the Council during the financial year. The voluntary committees of the mother and baby homes give valuable assistance in the work. There is the closest co-operation between the health visitors and the moral welfare workers. Unmarried mothers are put into touch with the moral welfare workers and the health visitors see that the maternity and child welfare services arc made available to them. Where necessary, financially necessitous cases are referred to the Welfare Department. Women in need of residential accommodation and considered unsuitable for admission to voluntary homes are cared for in the homes maintained by that department. Rccupcrativc Holidays The demand for recuperative holidays increased during the year, and additional recuperative holiday home accommodation was approved for the reception of al categories of persons medically recommended for holiday. The services of the Invalid Children's Aid Association continued to be used foi the placing of unaccompanied children in recuperative holiday homes (4 weeks oi more). In addition, the Council itself increased the accommodation available foi children sent by it for shorter holiday periods (2-3 weeks). Direct arrangements included the use of recuperative holiday homes maintained by the Jewish Board of Guardians, the Wandsworth Peace Memorial Committee, the National Institute for the Blind, and a successful experiment was carried out in sending selected children to private hotel accommodation on the approved list of the School Journey Association of London, in the care of holiday organising staff appointed by the Council. At the end of the year discussions were taking place with the Children's Country Holidays Fund for the use of further accommodation for children's recuperative holidays. Arrangements were also made for the use of a holiday home owned by the Women's Voluntary Services for a longer holiday of up to three months for children with non-tuberculous chest infections. Full use was made of the Council's own recuperative holiday home for children at Mayfield, Sussex, and it was decided to acquire a further home for children aged 4-8 years old. Use was made of the Family Welfare Association as a placing agency for adults and accompanied children recommended for recuperative holidays. The approved holiday accommodation for expectant and nursing mothers, with their young children, and for other adults was, however, increased so considerably during the year that the majority of persons in these categories recommended for recuperative holidays should be able to be placed in future without recourse to the services of a placing agency. Arrangements were made during the year with the Spero Fund for the Welfare of Tuberculous Workers, for adults with non-active tuberculosis to be sent for recuperative holidays. Social Work Participation of Health Visitors Children Expectant and nursing mothers and young children and other adults 52 The following is a statement of persons admitted to recuperative holiday home? in 1949. The comparable figures for the period 5th July, 1948, to 31st December 1948 (six months), are given in brackets:— Unaccompanied Children Expectant and Nursing Mothers and Accompanied Young Children Other Adults Under Five Years Schoolchildren Mothers Children 1,517 (637) 3,121 (1,098) 379 (128) 671 (148) 2,779 (754) L.C.C. midwives DOMICILIARY MIDWIFERY SERVICE The continued fall in the birth rate 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 1946 805 10,834 11,639 1947 899 12,025 12,924 1948 630 9,533 10,163 1949 749 7,831 8,580 Another factor in reducing the number of home confinements was the attraction of hospital confinement owing to the low cost to the patient and the increase in the number of beds available. Of these 8,580 confinements during 1949, 1,280 were primigravidae and 7,300 multigravidae ; the figures do not include women booked by the Council's midwives who were subsequently admitted to hospital before confinement suffering from toxaemia, ante-partum haemorrhage or other condition requiring hospital care. The number of midwives employed at the end of the year was 140 compared with 155 at the end of 1943 and 158 at the end of 1947. The average number of confinements taken by each midwife, including their sick and holiday reliefs, was approximately 58 compared with 65 in 1948 and 81 in 1947. Part-time midwives were employed for various periods during the year to assist in the nursing of mothers during periods when the Council's midwives were absent on annual or sick leave. Ambulance cars continued to be available for the transport of midwives in emergency particularly at night and when undertaking additional relief duties, and 12,974 miles were run on this service during the year compared with 15,523 miles in 1948. Agency Organisations There was also a decrease during the year in the number of confinements undertaken by the district nursing association and hospital district midwives. Year Maternity nursing eases Midwifery cases Total Grand Total 1948 Hospital District Service 116 5,095 5,211 District nursing associations 290 2,940 3,230 8,441 1949 Hospital District service 112 4,532 4,644 District nursing associations 285 2,581 2,866 7,510 The number of midwives employed on 31st December, 1949, was:— Supervisors Midwives Hospital district service 16 52 District Nursing Associations 5 33 In addition a small number of part-time midwives and some full-time staff of district nursing associations did part-time midwifery and part-time home nursing. 53 There was one death among women confined at home. The cause of death wa: obstetric shock and adherent placenta. The chief development this year was the increased co-operation between th< midwife, the general practitioner obstetrician, the hospitals and the pathologica services available. There was also a marked increase in the number of womer receiving analgesia during childbirth (see below). Midwives' sessions for booking patients and for ante-natal examinations at the maternity and child welfare centres was developed. By the end of the year 117 o: the Council's midwives, compared with 111 at the end of 1948, were regularl} holding such sessions. A few midwives, however, had to book and examine theii patients at home. There was a large increase during the year in the number of mothers receiving analgesia from midwives: the following table sets out the numbers receiving analgesia throughout the year and the percentage which they represent of all con finement cases attended. In addition to the figures quoted, there were some mother whom the midwives attended as maternity nurses under the direction of doctor: who themselves administered anaesthesia or analgesia and in respect of which nc figures are available :— Maternal deaths Developments in 1949 Ante-natal sessions Gas and air analgesia Confinements attended by January to June July to December Total London County Council midwives 2,882 (63%) , 2,597 (65%) 5,479 (64%) Hospital district midwives 767 (51%) 804 (59%) 1,571 (55%) District Nursing Association midwives 1,555 (62%) 1,478 (69%) 3,033 (65%) These figures compare very favourably with the totals for 1948 which were as follow:— London County Council domiciliary midwives 3,447 (34%) Hospital district midwives 1,838 (35%) District Nursing Association midwives 903 (28%) There are still mothers who decline analgesia and in others the birth occurs before the midwife's arrival. The Council has continued to provide accommodation for domiciliary midwives as recommended by the Midwives Salaries (Rushcliffe) Committee. On 31st December, 1949, 75 midwives were housed in 67 houses or flats, of which 43 were provided by the Council and 24 taken on lease or on licence either from borough councils or direct from private owners. The regional hospital boards have continued to co-operate in arranging for the temporary accommodation of midwives in hospital staff quarters. Two midwives were supplied with furniture during the year valued at approximately £241 lis. 2d. in return for a monthly hire charge. The Council continues to provide water-heating appliances to midwives occupying premises provided by the Council. It is recognised that there should be close co-operation with the regional hospital boards and teaching hospitals. During the year 48 calls were made for emergency obstetric units which are sent out from the hospitals. Drugs and dressings from the hospital dispensaries continued to be issued to the Council's midwives and pupil midwives from Part II training schools receiving their district training with the midwives employed either by the Council or by the district nursing associations. Some hospitals which were Part II training schools also crave their Dunil midwives district experience with their own midwives. Housing of midwives Furniture and appliances Co-operation with hospitals 54 Payments to district nursing associations and hospitals Payments to district nursing associations under Section 23 of the National Health Service Act for domiciliary confinements are now merged in the grants made to them for home nursing under Section 25 of the Act. The rate of payment to hospitals has continued throughout the year at £1 13s. 4d. a confinement. Notifications of intention to practise Midwives Acts, 1902 to 1936 The number of notifications of intention to practise, compared with the previous vear, was:— 1948 1949 As midwives 1,213 1,252 As maternity nurses 289 242 An analysis of the notifications shows:— Midwives Maternity Nurses Practising in Hospitals 842 — Practising in Nursing Homes 24 71 L.C.C. Domiciliary 165 — District Nursing Associations 113 — Hospital Districts 93 — Nursing Co-operations — 155 Independent ... ... ... 15 16 1,252 242 It should be borne in mind that notification to practice as a midwife includes practice as a maternity nurse. The Council, as local supervising authority under the Midwives Acts, continued to inspect midwives and maternity nurses in accordance with the rules of the Central Midwives Board. The supervisors of midwives investigate all cases of puerperal pyrexia and all children with skin and eye affections. On 15 occasions midwives were suspended from practice for varying periods to prevent the spread of infection. Lectures, etc., to midwives Two courses each of six post-certificate lectures, and five courses of four antenatal and post-natal demonstrations were arranged in conjunction with the Middlesex and Surrey County Councils. The number of tickets issued to midwives for the lectures was 491 and 60 for the demonstrations. Summoning of medical aid, doctors' fees. etc. The number of cases in which medical aid was summoned by midwives during the year under Section 14(1) of the Midwives Act, 1918, was as follow:— Domiciliary cases 6,709 For cases in institutions 330 Total 7,039 As from 16th December, 1949, the National Health Service (Amendment) Act, 1949, extended the period for submission of claims for fees under the Midwives Acts from two months to three months. This amendment has been made to give doctors adequate time to carry out post-natal examinations. Fees paid under the Midwives Acts to medical practitioners called-in by midwives in emergency were as follow:— 1948 1949 Number of claims 6,354 5,368 Amount paid £15,594 £15,829 The slight rise in the amount of fees paid in 1949 is due to the increased scale of fees introduced by the Medical Practitioners (Fees) Regulations as from 18th April, 1948. The reduction in the number of claims received is attributed partly to the fall 55 of 6.7 per cent, in the birth-rate for London and also to the effect of the maternity medical services provided under the National Health Service Act, 1946. Where maternity medical services are provided the midwife is informed of the result of the general practitioner's ante-natal examinations and for this purpose a form has been brought into use. The midwife also should know whether she is to act as a maternity nurse or as a midwife and the doctor enters his directions on the form. At the end of the year there were 480 General Practitioner Obstetricians on the list of the London Executive Council. The Clerk of that Council has kindly provided the following details of claims received from doctors during the year 1949 for maternity medical services. The figures quoted do not represent the total number of cases attended during the year as there is no time limit for the submission of claims for fees on maternity medical services and some claims were, therefore, received too late for inclusion in these figures:— Maternity Medical Service Service Provided 1949 Quarter Claims from General Practitioner Obstetricians Claims from General Medical Practitioners Total Full March 482 89 571 June 428 73 501 September 582 72 654 December 990 51 1,041 2,482 285 2,767 Partial March 203 201 404 June 500 243 743 September 700 259 959 December 745 448 1,193 2,148 1,151 3,299 Emergency March 5 1 6 June 14 2 6 September 24 2 16 December 45 5 50 88 10 98 Full maternity medical service, for which a fee of £1 7s. 0d. is paid to general practitioner obstetricians or £5 5s. 0d. to other medical practitioners, entails the carrying-out of two ante-natal examinations, attendance at the confinement if necessary and availability for emergencies, together with the care of mother and child for fourteen days after confinement and a post-natal examination of the mother at about six weeks after the birth. Payment is also made, according to approved rates, for partial services, i.e. when the full maternity medical service is not given. The London Executive Council also pay for attendances by medical practitioners in emergency on unbooked maternity patients, where the practitioner is not called-in by a midwife. HEALTH VISITING A move has been made towards greater fluidity between the health visiting, tuberculosis visiting and school nursing staffs, which has been of great assistance, particularly at times of pressure, and has considerably widened the interests of the staff. This is only the first step towards undertaking the wider duties of the health visitors envisaged in Section 24 of the Act. 56 Child Life Protection By arrangement with the Children's Officer, who did not take up his duties until the Spring, I have continued to be responsible for duties under Part XIII of the Public Health (London) Act, 1936, as amended by Part V of the Children Act, 1948. The visiting of foster-children and the inspection of the premises in which these children are living have, therefore, continued to be undertaken by health visitors, designated as child protection visitors. Towards the end of the year, 575 foster-children were being supervised under these arrangements. HOME NURSING The Home Nursing Service is provided on the Council's behalf by the voluntary nursing associations in the county, the Central Council for District Nursing in London acting as the liaison and advisory body and distributing the Council's grant to the individual associations. The service has been subjected to considerable pressure, necessitating the recruitment of additional staff during the year. This has been largely due to the increasing number of aged and chronic sick and tuberculous persons being nursed at home owing to the difficulty in obtaining admission to hospitals or sanatoria. 1,087,226 visits were made during the year compared with 453,222 visits from 5th July to 31st December, 1948. The principal details of work done by the District Nursing Associations 01 behalf of the Council during the year were :— Health Division Population T reatments No. of completed treatments per 1,000 population Total visits Total visits per 1,000 population Commenced, Completed 1 469,930 5,532 6,079 12.9 134,252 285.7 2 553,930 5,598 5,592 10.1 152,064 274.5 3 301,330 2,420 2,584 8.6 68,234 226.4 4 265,020 3,133 3,251 12.3 85,592 323.0 5 239,380 2,637 2,526 10.6 99,891 417.3 6 314,300 3,346 3,366 10.7 122,670 390.3 7 406,210 4,325 4,444 10.9 144,226 355.1 8 387,000 5,016 5,039 13.0 150,335 388.5 9 452,750 4,728 4,974 11.0 129,962 287.1 Totals 3,389,850 36,735 37,855 11.2 1,087,226 320.7 It will be noted that home nursing per unit of the population varies between divisions. Visits to patients are relatively more numerous in certain divisions, but it is not at present possible to say whether divisional differences are due to variations in the incidence of chronic sickness or to the numbers of staff available. There were 37,855 treatments (series of visits to individual patients) completed, leaving 5,959 patients in nursing care at the end of the year. The total number of nurses at the end of the year was 307 whole-time, and 103 part-time, a whole-time equivalent of 361. The average case load per nurse at any one time was 16 to 17 patients, and each nurse made an average of 11 visits per day. Analysis of completed treatments is shown in Table 38 (p. 144) in which the percentages given are of the total number of cases treated during the year. In the early part of the year the information given was not sufficient to classify the conditions treated under the heading of a specific disease in 14 per cent, of the cases, but towards the end of the year a greater appreciation by the nurses of the use to which the records were being put, led to a decline in the numbers of unclassified cases. It is noteworthy, taking both sexes together, that 52 per cent, of all cases 57 were over 60 years of age, and that females formed 67 per cent, of the total patients treated. The main conditions treated, ignoring age and sex distinctions, were:— Per cent, of T otal Infectious and parasitic disease 4.8 Tuberculosis 2.1 Cancer (and other neoplasms) 5.1 Diabetes 5.5 *Diseases of sense organs and mental and nervous diseases 5.4 Cerebral lesions of vascular origin 4.6 Heart and arteries 8.4 Veins and other circulatory diseases 1.4 Respiratory diseases (excluding Tuberculosis) 10.7 Digestive diseases 11.4 Genito-urinary 10.2 Pregnancy 2.8 Skin 8.2 Bones and organs of movement (mainly rheumatism) 3.0 Injuries 2.8 Other diseases or ill-defined 13.6 100.0 (•Mainly ear and eye conditions) Patients were referred to the Nursing Associations in 69 per cent, of the total by general practitioners, 23 per cent. by hospitals, 2 per cent, by the Council's officers; the remaining 6 per cent, were received through direct application. The number of cases referred by general practitioners increased from 63 per cent, in the first quarter to 75 per cent, in the last quarter of the year. Nearly one quarter of the cases visited were convalescent or chronically ill following a period of hospital treatment. The reasons given for cessation of treatment were recovered or relieved 25 per cent., convalescent 45 per cent., admitted to hospital 17 per cent., gone away or lapsed 1 per cent., and died 12 per cent. The substantial fraction of admissions to hospitals (one-sixth), and of deaths (one-eighth) are indications of the advanced age of the patients and the degenerative nature of many of the illnesses. Mortality appeared to be rather higher in some districts than in others, but this is regarded as partly due to local difficulties in getting patients admitted to hospital, and partly due to some areas having a relatively higher proportion of degenerative diseases of advanced age. The arrangements for the loan of equipment to patients being nursed at home made with the district nursing associations and the British Red Cross Society in 1948 were continued and efforts were made by these organisations to increase the amount of equipment available for hire at small charges. However, it was not always possible for these organisations to meet the demand, and the Council itself through its own Supplies Department, has had to arrange for the purchase of some of the larger items of equipment, such as Dunlopillo mattresses and special beds for paraplegics for loan in certain special cases. DOMESTIC HELP SERVICE It was recognised long ago that domestic help in the home immediately after a birth had taken place and whilst the mother was in the convalescent stage was the chief factor in relieving the mother's mind of anxiety for the welfare of her family. It was thought that the mother in the ordinary artisan home would usually be able to make her own arrangements for the provision of these services without cost to the State and need not be encouraged to look to public funds for assistance. But there were some cases where the family was in such poor circumstances as to preclude the possibility of this without help from outside sources. History of the service 58 In 1929, a Departmental Committee on the training and employment of midwives urged that local authorities should be encouraged to make use of their powers under the Maternity and Child Welfare Act, 1918, to provide a home help service. Some authorities did in fact take up their powers under the 1918 Act but little progress was made until the passing of the Public Health Act, 1936 (in London, the Public Health (London) Act, 1936). A number of authorities started home help schemes but not all those commenced were successful and many authorities did little or nothing. Towards the end of 1944, welfare authorities were informed of the extension of their powers under the 1936 Act by the issue of Defence Regulation 68E, whereby domestic help could be supplied in cases of illness and infirmity as well as in maternity cases. In London, prior to July, 1948, all the metropolitan boroughs (but not the City of London) operated a scheme for providing home helps for maternity cases. Every borough (except Bethnal Green) and the City of London operated a scheme for the provision of domestic help for sick or infirm persons who were not themselves able to provide such assistance. The extent of the provision, however, varied considerably from borough to borough. Generally both whole and part-time staff were employed and in a few instances casual labour was used. This was the position when the Council assumed responsibility for the service in Tulv. 1948. Types of household attended At present all types of household eligible for domestic assistance under Section 29 of the National Health Service Act, 1946 (namely, "any person who is ill, lying-in, an expectant mother, mentally defective, aged, or a child not over compulsory school age"), are served subject to the resources available. Every endeavour is made to provide some service for all cases in need, but this is achieved only by rationing the hours of service among the households on the books and, in some instances, refusals have had to be made of the less urgent cases. It has been found exceedingly difficult to grade applications for domestic help into categories because individual circumstances vary so much, but obviously some order of priority had to be established. After a year's experience of the service the Health Committee agreed to the following order of priority, but decided that it should not be rigidly applied, discretion being used in determining in which cases help is most needed: (1) confinement cases, (2) acute or chronic illness, (3) aged and infirm and the blind, (4) a mental defective in the household, or large families of children under compulsory school leaving age. Each case in category (2) has to be covered by a medical certificate before being granted help. Statistics The following table shows the progressive growth of the service:— 1946 1947 1948 (a) 1949 Cases assisted 6,000 (c) 7,389 11,302 25,933 Hours 575,000 (c) 703,000 (b) 1,211,000 (b) 2,783,000 Home Helps (whole time and part time) employed at end of year 665 (c) 826 1,932 2,310 Equivalent to whole time of 400 (b) 490 (b) 1,101 1,265 £ £ £ £ Cost of service (estimated) 58,000 140,000 240,000 380,000 Income received (estimated) 19,000 23,000 32,000 46,000 (а) For the period 5th July to 31st December, 1948; because of the transfer of powers statistics were not collected for the earlier part of the year (б) Estimated (c) Approximate 59 In spite of this increase the demand on the service tended to outstrip the supply as is indicated by the following figures for the year:— Type of case Maternity Other Applications received 5,708 19,769 Households attended: (a) Completed periods of assistance 2,794 15,306 (fc) Service commenced but uncompleted at end of year 164 7,669 In maternity cases refusal to supply home help because of inability was rare and though there was an excess of applications over periods of service this was due to the large number of cases where the application was not proceeded with owing to the applicant either obtaining alternative assistance or being removed to hospital for the confinement. It will be seen that in non-maternity cases the number of applications exceeded the number of households completely assisted during the year, and in fact about 3,500 applications had to be refused owing to inability to supply home helps. In maternity cases the service is normally provided for two 44-hour weeks and in other cases the average number of hours per week is 6 continued over an average period of 25 weeks. It should, of course, be borne in mind that these general cases include illnesses covering a wide range of short and long duration, and in calculating the average very short illnesses help to offset the very long. The average, though of value in indicating the length of assistance given, does not reveal what is a fact underlying the problem of chronic sickness in the aged, namely that many of these households receive continuous service for periods considerably above 25 weeks. The home helps are paid at the rate of 2s. 6d. (male) or 2s. lfd. (female) per hour, with the addition of Id. an hour where the home help has obtained the certificate of the National Institute of Houseworkers Ltd. The standard rate for the service is the average cost (including supervisory charges), i.e. 2s. 6d. an hour. Where the recipient of the service is unable to meet the full cost the charge is abated in accordance with a scale suggested by a panel of financial advisers and approved by the Ministry of Health (circular 100/48). Assessments are made by the divisional staff and are based on the total income from all sources, offset by necessary weekly expenses. Of the resulting amount deemed to be available to meet the cost only a proportion is charged and a reduction is made after three weeks. The cost of the service has risen steeply from £140,000 in 1947-48 to a present figure of about £380,000 a year. Payment by householders for the service amounts to about £46,000. Verification of the income stated on the form of application for abatement was made in a number of cases and the result demonstrated that many applicants were giving incorrect information. The investigation has been extended to 10 per cent, of the cases and the result, which will be more fully reported next year, confirms the original impression. Finance IMMUNISATION AND VACCINATION Diphtheria Immunisation Special diphtheria immunisation sessions at infant welfare centres continued and, in addition, immunisation, when necessary, was given during normal infant welfare sessions without special appointment. The number of cases of diphtheria reported from day schools and from the Council's residential establishments for children in London was lower than in the year 1948. The attention of teaching staff and of superintendents of homes for children is from time to time drawn to the importance of urging the parents of children to consent to diphtheria immunisation in order to maintain a high level of Welfare centres Day schools and residential establishments for children in TnnHnn 60 immunity among the school population and among the residents of children's homes. The arrangements for immunisation work at welfare centres, at day schools and at the Council's residential establishments for children in London are merged. General practitioners General practitioners take part in the Council s scheme, as many parents prefer the family doctor to immunise their children. Under this scheme, the family doctor is paid a fee of 5s. for completing the record of immunisation and returning it 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 its scheme. Residential establishments outside London Since 1st May, the local health authority of the area in which the residential establishment is situated has been responsible for making arrangements for immunisation against diphtheria of the children accommodated in the Council's residential establishments outside the Administrative County, and for paying the visiting medical officer the fee of 5s. for completing the record of immunisation. Immunisation At the end of the year, 86 per cent. of the children then in residence had been immunised or were in the process of being immunised. Of the remainder, in most cases parental consent had not been received. Statistics The total number of children immunised against diphtheria at infant welfare centres, at schools, at the Council's residential establishments for children in London or by general practitioners during the year was 56,030, and, in addition, 38,312 " boosting " doses were given. Table 17, page 131, shows the number of infants in London who at the end of 1949 had received a course of diphtheria immunisation injections. This table also shows the number of cases of diphtheria and deaths occurring in immunised and unimmunised children. It will be noted that out of the 9 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:— Age Population Number immunised Per cent. 0-4 276,200 151,092 54.7 5-14 367,000 253,855 69.2 Total 643,200 404,947 63.0 There are reasons for believing these figures to be an understatement of the figure of immunisation. 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. Until recently, returns from general practitioners were not complete. On the other hand, records obtained at routine medical inspections at schools indicate that 83 per cent. of school-children claimed to be immunised. This latter figure is equally likely to be an overstatement, 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-children have been immunised is not likely to be greatly in error.* 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 10 per cent. of that in the *The Registrar-General estimated that in England and Wales the proportion immunised at 5-14 had risen to 75 per cent. by the end of 1947. (See Annual Report of Chief Medical Officer Year Ended 31st March, 1948). 61 unprotected, and judged by 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. 16). In London the notification rate 0-4 has fallen from 5.88 per thousand in 1938 to 0.17 per thousand in 1949. The rate at age 5.14 has fallen from 4.43 to 0.32. In 1938 there were 205 deaths of all ages, and in 1949 only 9. Whooping Cough Immunisation A limited amount of immunisation against whooping cough has been undertaken, the antigen used being Glaxo pertussis or Glaxo A.P.T. combined. In the majority of cases, the children attending immunisation sessions at infant welfare centres were injected with the combined antigen. Welfare centres In seven of the Council's residential nurseries and at one of the Council's residential homes for children in London, whooping cough immunisation has been undertaken and at the end of the year 48 per cent. of children then in residence at these establishments had been so immunised or were in process of being immunised. Residential establishments for children in London In 1947 and 1948 advantage was taken of the opportunity afforded by the facilities for observation at the London residential nurseries to carry out a controlled investigation of whooping cough immunisation using the Glaxo combined diphtheria and pertussis antigen. The results which were reported in detail in the medical press (Beck, A., Breen, G. E. and Benjamin, B.—Lancet 1950-i-198) showed a significant difference in the incidence of whooping cough as between the vaccinated and the controls. It was concluded that the antigen conferred a useful degree of protection against whooping cough. The antigenic potency of the pertussis vaccine was confirmed by complement-fixation tests though no conclusions could be drawn from these on the presence of protective anti-bodies. The arrangements at these establishments, as in the case of diphtheria immunisation, are made by the local health authority in whose area the establishment is located. Not all the local health authorities concerned include immunisation against whooping cough in their scheme under Section 26 of the National Health Service Act, 1946, but if the medical officer of the establishment wishes to undertake this work, the Council itself supplies the antigen, as mentioned above. In 12 establishments immunisation against whooping cough was performed during the year and at the end of the year 58 per cent. of children then in residence at these establishments had been so immunised or were in the process of being immunised. Table 18, p. 131, shows the number of children in London who, at the end of 1949, had received a course of whooping cough immunisation injections. Residential establishments for children outside London During the poliomyelitis epidemic of 1949 attention was drawn to the fact that a small number of children developing the disease had been given combined diphtheria and whooping cough prophylactic during the previous month. It was not possible to decide if this observation was anything but a coincidence. The matter was reported to the Ministry of Health who decided to carry out a general statistical investigation throughout the country. Pending the result of this investigation the use of combined diphtheria and whooping cough prophylactic was discontinued until the poliomyelitis epidemic was over. Possible connection with Poliomyelitis Vaccination Special sessions for vaccination are held at welfare centres and general practitioners who wish to do so carry out vaccination on the Council's behalf. The lymph is supplied free of charge to the Council by the Ministry of Health through their Public Health Laboratory Service and general practitioners are also able to obtain supplies from the same source, Welfare Centres and General Practitioners 62 Where vaccination is carried out by general practitioners, a fee of 5s. is paid by the Council to the practitioner for completing the record of vaccination, as in the case of immunisation against diphtheria. Residential establishments for children in London Ministry of Health Memorandum 312/MED (1948) advocated the vaccination of all children up to the age of 5 years and after that only if they were exposed to smallpox infection. Re-vaccination for those primarily vaccinated in infancy was recommended at about 5+ and again at school leaving age, the re-vaccination at 5+ being dispensed with in the case of a child who had been primarily vaccinated within the previous twelve months. Vaccination or re-vaccination of children accommodated at the Council's residential establishments for children in London is carried out by the visiting medical officers on the lines recommended by the Ministry subject to parental consent. At the end of the year, 60 per cent. of the children in residence at the seven Council nurseries in London had been vaccinated or were awaiting vaccination. Of the remainder, parental consent had either been refused or was awaited. The significant drop in the number of infants vaccinated following the repeal of the Vaccination Acts has persisted and at the end of the year the percentage of infants born during the year who had been vaccinated was only 25. This may be only a temporary drop as the fees for records of vaccinations by general practitioners were not fixed until the end of 1949. The following tables give particulars of the number of persons who were vaccinated either at welfare centres or by general practitioners:— Number of persons vaccinated (or re-vaccinated) during the year Age at 31st Dec., 1949 Under 1 1 to 4 5 to 14 15 or over Total i.e. born in years: 1949 1945 to 1948 1935 to 1944 Before 1935 Vaccinated— Division 1 3,513 213 38 60 3,824 2 1,959 1,483 138 195 3,775 3 1,073 839 52 89 2,053 4 1,090 677 57 123 1,947 5 395 295 38 55 783 6 1,119 693 56 56 1,923 7 920 836 52 102 1,910 8 1,411 1,091 71 67 2,640 9 2,416 70 7 159 2,652 Totals 13,896 6,197 508 906 21,507 Re-vaccinoted— 1 197 13 26 288 524 2 — 18 61 885 964 3 — 9 6 191 206 4 — 4 21 233 258 5 — 2 14 137 153 6 2 21 23 136 182 7 4 6 41 246 297 8 2 5 16 185 208 9 115 1 — 4 120 Totals 320 79 208 2,305 2,912 No cases of generalised vaccinia or post-vaccinal encephalomyelitis and no deaths from other complications arising from vaccination were reported. Residential establishments for children outside London The arrangements for vaccination, as for diphtheria and whooping cough immunisation, are made by the local health authority in whose area the establishment is situated. The visiting medical officers, who are, as a general rule, local general practitioners, perform vaccination or re-vaccination according to the recommendations of the Ministry of Health. At the end of the year, 73 per cent. of 63 the children at five nurseries and ten nursery schools had been vaccinated or were awaiting vaccination. Of the remainder, parental consent had either been refused or was awaited. LONDON AMBULANCE SERVICE Historical sketch of the Origins, Development and Present Organisation Origins Ambulances were originally devised to serve the purposes of a military campaign and their use in civil life was a secondary development. It was Baron Larrey who first contrived "ambulances volantes" for the "Grande Armee" under Napoleon. Originally they were spoken of as "Hospitals Ambulants," thus indicating the true nature of the service—an extension from a base hospital to the site of the casualty. One would assume that most people would value their lives more highly than their property but it is, nevertheless, true that while for generations the property of Londoners has been protected it is only comparatively recently that anything has been done for those who fall ill or meet with accidents in the streets. The early remedies for dealing with fires were primitive enough and can hardly be compared with the elaborate modern fire fighting organisation but, whereas the London Fire Brigade can trace its history back at least to the end of the 17th century, an ambulance service in London dates only from about the middle of the last century. Introduction The need for conveying fever patients expeditiously to hospital from their homes brought about the first ambulance service in London, that of the Metropolitan Asylums Board. Sir Allan Powell, C.B.E., the Clerk to the Board, wrote, "After the opening of the Board's Hospitals, attention was drawn to the defects in the arrangements for the removal of patients to hospital. This duty still rested with the Boards of Guardians. In many instances, the vehicles were quite unsuitable in themselves and were housed in a dangerous way, as, for example, when a carriage after being used for the removal of a smallpox case was placed in a yard surrounded by tradesmen's carts. Frequent complaints were made of the carriages conveying patients to hospital stopping at public houses, into which the driver and the patient's friends went for refreshment, and difficulty was frequently experienced in obtaining a carriage when required." In 1879 the Board obtained powers to provide ambulances and the first ambulance of the Board was a horsed conveyance containing stretchers for two patients lying down and a seat for the attendants, generally bearded, who accompanied them. Horse ambulances were exclusively used until the end of the 19th century and it was a common sight in London to see urchins running behind them shouting, "Fever!" In 1902 the Board first used a steam ambulance carrying eight stretchers and attaining a speed of five miles an hour. From 1904, when a motor ambulance was introduced, horse ambulances were gradually superseded until the last was abandoned in 1912. From the days when smallpox cases ware isolated in ships moored in the Thames, the Board had run a river ambulance service with three wharves and five steamers but this was discontinued in 1932. Infectious cases For non-infectious cases, the earliest attempt to provide an ambulance service in London appears to have been the foundation of the London Horse Ambulance Service under the Presidency of the Duke of Cambridge in 1882. This unfortunately came to an end when the ambulances wore out. Noninfectious cases Provision for dealing with the sick and injured in streets and other public places was first conceived and undertaken by voluntary philanthropic agencies rather than as part of municipal administration. The Order of St. John of Jerusalem afforded first aid instruction and provided litters and stretchers at certain stations in London. It also co-operated with the E 64 Volunteer Medical Staff Corps and the police in dealing with casualties on occasions of public processions and gatherings of large numbers of persons in the streets. At that time accidents and cases of sudden illness in the streets were dealt with mainly by the police, who had to use a hand litter or to commandeer a passing vehicle to convey the patient to a hospital or other place where he could receive medical aid. Wheeled litters, introduced in 1880, were an improvement but, as ambulance work was hardly one of their main duties, the police did not feel justified in going to the heavy expense of installing a complete system of such litters. In 1889 Mr. H. L. Bischoffscheim established, at his own expense, a service of 62 wheeled litters operating from police stations and, concurrently, the number of police litters of which there had been only 73 in 1883, increased until in 1909 there were nearly 400. These two services were still lurther supplemented by the St. John Ambulance Association, whose 35 first-aid stations in London had each a wheeled litter, a stretcher, or both. At some stations trained men were on duty during the day. Finally, there were the horse ambulances provided by the Guardians to convey patients to and from the infirmaries and workhouses. In 1907 the City Corporation inaugurated for the City an electric motor ambulance service and a system of 52 street call boxes. Careful observation during 1898 showed that in a period of four weeks 994 injured persons were taken to the ten principal London hospitals otherwise than on their legs. Of these, 642 arrived in cabs or carts, 302 in police litters, etc., and 50 in other ways. It was estimated that 70 per cent. of the casualties were taken to hospital in some entirely unsuitable conveyance which was very likely to aggravate their illness or injury. The Superintendent of Guy's Hospital said at the time, " It is very painful to watch the arrival of accidents at hospitals under the present system." The Council in 1906 tried unsuccessfully to obtain from Parliament power to provide a motor ambulance service and the necessary staff. In 1909 a departmental committee of the Government reported on the whole question and by a majority recommended that the Metropolitan Asylums Board should be empowered to provide ambulances for non-infectious and accident cases. Sir William Collins, however, a member both of the Committee and of the Council, opposed the suggestion and introduced into Parliament on his own account a Bill to confer the powers on the Council. The House of Commons passed this Bill in preference to one based on the recommendations of the departmental committee. The Council thereupon sought to organise into one system ambulances belonging to the Metropolitan Asylums Board, the Port of London Authority and some of the metropolitan boards of guardians but the attempt was not successful and on 10th March, 1914, the Council decided to form an entirely independent accident ambulance service of its own. Development Stimulated by the gift of a then up-to-date motor ambulance by the late Grand Duke Michael of Russia, the new service was first put into operation in February, 1915, under the control of the Chief Officer of the Fire Brigade. A station was opened in Fulham in February, 1915, and five other stations, located in Bloomsbury, Shoreditch, Newington, Lee and Brixton, before the end of the year. Nine ambulances were provided, manned by an operative staff of 50. From the figure of 2,405 recorded in 1915, the number of calls mounted steadily during the years until in 1928 the number of calls received was 41,189. To cope with the ever increasing amount of work, more ambulance stations were opened and by 1928 numbered thirteen. Poplar station opened in 1922, Battersea, Highbury and Paddington in 1924, Woolwich in 1925, and Westminster and Old Kent Road in 1926. Three years later, in 1929, Hackney Station was opened and at the time of 65 the passing of the Local Government Act, 1929, the service had 14 stations in commission, with 20 ambulances and a total staff of 165. Or 1st April, 1930, the Local Government Act, 1929, came into operation and resulted in the transfer to the Council of the powers of the former Metropolitan Asylums Board and of the 25 Boards of Guardians. With these transfers came the ambulance services previously maintained by these authorities. Six large ambulance stations, 107 vehicles and a staff of about 270 became absorbed into the Council's service and as a result the General Section of the London Ambulance Service, as distinct from the Accident Section, came into being. The Accident Section was transferred from the Fire Brigade to the Public Health Department. In 1931 another accident station was opened at Streatham and yet another at North Kensington in 1932. The work of the service steadily mounted and in 1938 the Accident Section received a total of 56,318 calls, while the General Section conveyed 217,908 patients to hospitals, etc., and carried 102,520 patients' relatives, staff, etc., a total of 320,428 persons. At the outbreak of the war in 1939, the strength of the service stood at:— 6 General Ambulance Stations 16 Accident Ambulance Stations About 200 vehicles (including 20 ambulance-buses) 422 operative staff including Superintendents and Station Officers Local Government Act, 1929 When war came the London Ambulance Service formed the nucleus of the London Auxiliary Ambulance Service, which was created to deal with the conveyance of air raid casualties, and the development of the auxiliary service was a remarkable example of the adaptation of a peace-time organisation to war-time needs and conditions. Recruiting had already begun in 1938 and by September, 1939, the number of enrolled volunteers available for duty was about 5,000, of whom about half were women. The six general ambulance stations were supplemented by the establishment of some ll2 auxiliary stations and by 1940, just before the bombing of London began, the number of vehicles in commission had increased to about 900 ambulances and 700 motor cars for " sitting." cases. The personnel numbered 7,000 and eventually reached a maximum of 8,500. Operational control of the auxiliary service was decentralised to the metropolitan borough councils but operational control of the regular service remained centred at the Headquarters at County Hall, where a reserve switchboard was installed in a basement for use in the event of damage to the main Control Room. Another emergency switchboard was provided at one of London's underground railway stations but it so happened that the former was utilised only on one or two occasions and no recourse to the latter was necessary. During the period of the war the service conveyed 48,709 war casualties to hospitals and first-aid posts. The ambulance stations themselves bore their share of the damage caused by enemy action and 14 members of the staff were killed and 85 injured while on duty. Ambulance auxiliaries earned 3 George Medals, 11 British Empire Medals and 5 Commendations. War-time service With the cessation of hostilities and the disbanding of the auxiliary service came the task of continuing the pre-war development of the regular service. Additional facilities were made available to the people of London and by 1948 the work undertaken by the service, in addition to the conveyance of casualties and the removal of patients being admitted to or discharged from hospital, included the conveyance by accident ambulances of analgesia apparatus for use by midwives in attendance upon parturient women being confined in their own homes; the conveyance of the emergency obstetric units provided at certain hospitals to deal with cases in which complications arise during childbirth at home and the transport, by a special vehicle reserved for the purpose, of resuscitation ("iron lung") apparatus in cases of emergency. Post-war development 66 Extension of free facilities It had been the Council's policy, over a period of years, to extend from time to time the range of facilities which were provided by the ambulance service without charge to the public. For example, the free conveyance of patients to hospital was at first available only in respect of the Council's own hospitals and a small charge was made for removals to voluntary hospitals. From 1st April, 1946, however, the latter, also, were carried out free of charge except where the patient was being admitted to a private ward. There remained some purposes, not covered by these free facilities, for which ambulances could be hired but the Council was always ready to consider sympathetically any case in which payment of a hire charge would result in financial hardship and in no circumstances was an ambulance ever withheld through doubt as to whether or not the fee would be paid. Ninety-five per cent. of all journeys undertaken during 1947 were carried out free of charge and it will be seen, therefore, that the Council at that time had already gone a long way towards the provision of the free service which, on 5th July, 1948, became available to all under the provisions of the National Health Service Act, 1946. Present Organisation Accident Section For accident and other emergency calls there are now 18 ambulance stations, so situated that no part of the Administrative County of London is more than about 2 miles from one of them, and the average time taken to reach a street accident is a fraction over seven minutes from the time the call is first received in the Control Room. The ambulances attached to these accident stations carry, in addition to the normal first-aid equipment, a comprehensive range of special equipment and appliances including oxygen-CO2 apparatus, sterile surgical instruments, drugs, carrying chairs, hacksaws, rope and special apparatus for raising or lowering the injured from positions otherwise difficult of access. General Section For the removal of sick persons there are the six large "general" ambulance stations geographically placed so as to provide equal facilities throughout the county. Each of these stations has a fleet of about 30 ambulances supplemented by a small number of cars for the conveyance of sitting cases. Some of the stations have, in addition, a number of ambulance-buses capable of carrying a large number of patients, either sitting or recumbent or some of each. The ambulances operating from these stations are provided with first-aid kit to enable their crews to treat any injured persons they may encounter while engaged on their duties. Infectious cases The removal of patients suffering from infectious diseases is undertaken by vehicles from the "general" stations and special apparatus is provided for the cleansing and disinfecting of the vehicles and their equipment. Method of dealing with calls Normally, calls lor ambulances are received centrally in the Control Room at the Headquarters at County Hall. Here a specially designed telephone switchboard is installed and gives direct communication with each ambulance station. The calls either come in directly, from hospitals, doctors, midwives, the police, etc., or are relayed to the Control Room by telephone exchanges which have received them as emergency "999" calls. This central system of control enables the resources of the entire service to be used to the best advantage by the diversion of work from one station to another according to the fluctuating pressure. The Control Room is in the immediate charge of a Supervisor and an Assistant Supervisor and is manned throughout the day and night by a clerical staff totalling about 30 working on a shift rota. The daily number of calls for ambulances received in the Control Room is about 250 for accidents or other emergencies and about 600 for general removals. Decentralisation Other calls for general ambulances for the conveyance of out-patients are made directly to the ambulance stations by certain hospitals which have a large volume 67 of this kind of work and in the case of some hospitals with large and busy outpatient departments ambulances are sent each morning to the hospital and remain for the day at the disposal of a Transport Officer who is a member of the hospital staff. Such a system requires careful planning and a high degree of co-operation between the hospital authorities and the ambulance service but it has already been put into operation at some 30 hospitals with mutually satisfactory results and is being extended as and when the demand requires and resources permit. The daily number of calls dealt with under these decentralised arrangements is upwards of 600. In addition to being in direct telephonic communication with the Control Room, each general ambulance station has two telephone lines and each accident station one line through the local exchange for administrative use and as a stand-by in case of breakdown in the direct line. The Control Room itself has, in all, 22 direct lines and 15 exchange lines which are routed through six different telephone exchanges as a safeguard against failure of the communications system. The crews of accident ambulances report by telephone to the Control Room upon arrival at hospital and an electrically operated indicator board in the Control Room shows at a glance whether any particular accident ambulance is in its station, on the way to a call or returning to its station. The Control Room officer concerned is thus able to follow, from minute to minute, the movements of the entire fleet of accident ambulances and so to ensure that emergency calls are answered with the minimum of delay. Similarly, the crews of "general" ambulances, upon arrival at hospitals, etc., report to the control room of their respective stations in order that they may, if necessarv. be sent on to other calls without delay. System of communications The report for 1949, which follows this short historical sketch, gives on pages 73 and 74 some recent statistics of the work performed by the London Ambulance Service, but it may be of interest to give here some of these figures and to add, for comparison, others relating to earlier years:— Statistics Accident Section Year No. of calls 1916 (first full vear) 9,244 1920 19,149 1930 43,746 1940 44,700 1947 64,560 1948 66,373 1949 75,901 General Section Year No. of patients carried Miles run 1930 141,396 1,412,043 1940 135,745 1,352,029 1947 182,206 1,768,550 1948* 274,663 2,706,714 1949* 480,187 4,681,204 (*Figures include work done under agency arrangements by the Home Service Ambulance Department and the Hospital Car Service.) An interesting point, which shows how accustomed Londoners have become to the use of the accident ambulance service, is the fact that whereas in the year 1920 only 2,455 of the 19,149 emergency calls received were made by members of the public, the number of calls made in this way in 1949 was 46,940 out of a total of 75.901. The foregoing figures give some indication of the greatly increased demand for ambulance transport which has taken place since the introduction of the National Health Service. New measures are constantly being devised to cope with it and, Increase in demand for ambulance service 68 since a large proportion of the increase is accounted for by the marked rise in the number of patients conveyed to and from hospital for out-patient treatment, among the most successful of these measures are the arrangements, to which reference has already been made, under which ambulances are stationed at hospitals and operated during specified periods by transport officers appointed by the hospital authorities. Analgesia apparatus An increasing number of requests are being received, also, for the use of the analgesia apparatus provided by the Council for parturient women being confined in their own homes. This apparatus is located at accident ambulance stations and the number of sets has been increased in order to ensure that, upon receipt of a call, the apparatus can be delivered without delay at any address within the County. Enlargement of fleet Steps have been taken also to increase the number of men and vehicles available for both emergency and general work and at the Headquarters Station a "flying squad" of ambulances has been established to provide, from day to day, a reserve of vehicles and men to relieve those of the general ambulance stations at which the pressure of work is greatest. Removals by train When the Council was itself a hospital authority, experience gained over many years showed that, when a patient had to travel a long distance (e.g., to a distant sanatorium, etc.), satisfactory arrangements could be made with the railway authorities for the major portion of the removal to be carried out by train when the condition of the patient permitted and rail transport would be quicker and more comfortable than a long journey by road. With the co-operation of the present hospital administrations and their medical officers, these arrangements have continued to be made in appropriate cases. Reserved accommodation is arranged on the train and ambulance transport is provided as necessary at each end of the rail journey. Not only is the appreciable shortening thus achieved of the time taken for the overall journey a significant factor in minimising the fatigue occasioned to the patient but the saving gained in vehicles and manpower affords valuable relief to the ambulance service. New type of ambulance It may be of interest to include here a brief reference to the new type of ambulance which has now been accepted as standard for the London Ambulance Service. At the end of the 1939-45 war it was apparent that there was an urgent need to replace a large number of the vehicles in the ambulance fleet, many of which were more than 10 years old. The Council's technical officers gave much time and thought to the design of an ambulance which would provide the maximum comfort for the patient. Eventually, after many trials and experiments, a prototype was evolved. Trade enquiries drew from a well known firm of manufacturers of motor vehicles an offer to produce an ambulance which would embody practically every feature of the Council's prototype, including the requirements regarded as essential by a Working Party which had been appointed to advise the Minister of Health on this same subject. The result of these co-operative efforts was the production of an ambulance which has now been adopted by the Council as standard for the London Ambulance Service. An example of this ambulance was exhibited at the Commercial Motor Show at Earl's Court, London, in October, 1948, and at the British Motor Show in New York in April, 1950. The salient features of the new vehicle are low loading; a roomy, well equipped and easily cleaned interior; a high-powered engine; fluid transmission; a pre-selective gearbox and an off-set transmission shaft. These features, combined with excellent suspension, including independently sprung front wheels, give smooth, comfortable and silent riding for both patients and crew. HORSE-DRAWN AMBULANCE, 1893 (Metropolitan Asylums Board) FIRST MOTOR AMBULANCE, 1905 (Metropolitan Asylums Board) FIRST LOW-LOADING TYPE AMBULANCE, 1929 (Metropolitan Asylums Board) AMBULANCE, 1932 (London Ambulance Service) SITTING-CASE AMBULANCE, 1948 —WITH PROVISION FOR ONE RECUMBENT PATIENT (London Ambulance Service) AMBULANCE BUS, 1949 — FOR CONVEYANCE OF FIVE RECUMBENT AND NINE SITTING PATIENTS (London Ambulance Service) AMBULANCE, 1949 (London Ambulance Service) HEADQUARTERS CONTROL ROOM (London Ambulance Service) 69 The present strength of the service is:— 1 Headquarters Ambulance Station 6 General Ambulance Stations 17 Accident Ambulance Stations 270 ambulances 26 ambulance-buses 11 Single-stretcher ambulances 21 sitting case cars 625 operative staff including Superintendents and Station Officers Present strength of service The increasing demand for ambulance transport has necessitated the planning of additional vehicle accommodation at some of the general ambulance stations. Plans have also been prepared for the erection of three additional accident ambulance stations. Future development REPORT FOR 1949 This service operates under the immediate supervision of Mr. A. G. Hellman, O.B.E., the officer-in-charge. Increase in demand for ambidance service The demand for ambulance transport which took an immediate and substantial upward trend upon the introduction of the National Health Service on 5th July, 1948, continued to increase steadily throughout 1949, and only by the most efficient and economic use of available resources was it possible for the Service to carry out its statutory obligations. At the end of 1948 the number of patients removed daily was 35 per cent. greater than at the beginning of the year and it was then felt that some levelling out of demand might reasonably be expected. In December, 1949, however, the number of patients removed by general section ambulances was over 8,000 more than in January, 1949—an increase of nearly 30 per cent.—while the number of calls dealt with by the accident section during the corresponding months showed an increase of 799—nearly 14 per cent. Even more striking were the mileage figures which showed that during 1949 the mileage run by directly provided, agency and supplementary service vehicles was over 3 million more than the mileage run by London Ambulance Service vehicles in 1947. Agency arrangements As a consequence of the recruitment of additional operative staff to the Service during 1949, and the increased use of trains for the greater part of long journeys, there was a falling off in the number of removals passed to the Home Service Ambulance Department of the Joint Committee of the Order of St. John of Jerusalem and the British Red Cross Society. The number of journeys carried out by that organisation on behalf of the Council was 318 in December, as against 585 in the first month of the year. Home Ambulance Service The work of the County of London Hospital Car Service on the other hand steadily increased from 4,319 journeys in January to 7,167 in December. In November a letter was sent to all the hospitals from whom orders for this service were received stressing the need for economy, and appealing for their co-operation in ensuring that cars were ordered only in cases of medical necessity, but in spite of this the demand continued to increase. Hospital Car Service The West Ham County Borough Council continued to provide ambulance services on behalf of the Council in that part of Woolwich which is north of the Thames but, following negotiations, it was agreed that, in future, the Council would pay for such services at the nationally agreed rate of 2s. a mile instead of at a fixed rate per journey as formerly. West Ham County Borough Council 70 City of London Corporation The arrangement made with the City of London Corporation, whereby the City of London Police Ambulance Service continued on an agency basis on behalf of the Council to provide ambulance services in the City of London for one year after the introduction of the National Health Service, was terminated on 5th July, 1949, when the City of London Police Ambulance Station and two ambulances were absorbed into the London Ambulance Service. Staff The continuing increase in the demands upon the Service made it necessary for the Council to increase the fixed establishment of operative staff by 60 positions (to a total of 574), and of ambulance clerks by 5 positions (to 58), with effect from 5th May, 1949. The operative staff were brought within the purview of the London District Council of the Joint Industrial Council for Local Authorities' NonTrading Services (Manual Workers) with effect from 31st March, 1949, and, in consequence, their working week was reduced from 48 to 44 hours. This necessitated a further increase of 52 positions in the establishment, which was authorised by the Council to take effect when revised shift rotas, based on the 44-hour week, could be brought into force. It was decided, at the request of the Trade Unions, to revise the constitution of the Consultative Committee to which reference was made in the Annual Report for 1948, and the first meeting of the new Joint Consultative Committee of the Operative Staff of the London Ambulance Service was held in November, 1949. The Committee is designed to ensure a regular exchange of views with the operative staff, to give them a wider interest in, and greater responsibility for, their working conditions, to ensure the observance of collective agreements and to improve staff relations. The preliminary meeting and another which followed shortly after gave every indication that these objects would be realised. The Committee immediately undertook the consideration of revised shift rotas. The strength of the service, which was represented at the beginning of the year by 260 ambulances, 20 ambulance omnibuses, 33 ambulance motor-cars and 2 tenders, operated by a uniformed staff of 570, increased during the year to a total of 274 ambulances, 22 ambulance omnibuses, 26 ambulance motor-cars and 2 tenders, operated by a uniformed staff of 625, including temporary staff in excess of establishment employed as reliefs for drivers absent owing to sickness. The specially designed telephone switchboard, in the Control Room at the Headquarters of the Service in the County Hall, was kept in continuous commission by supervisory and clerical staff (men and women) numbering 31, and there were 45 male clerical staff employed at the six general section ambulance stations. Vehicles In 1947 the Council approved a three-year programme for the replacement of vehicles in the London Ambulance Service fleet but certain modifications of this scheme were subsequently found to be necessary because of trade conditions and the demands of the export drive. As stated in the report for 1948, these modifications included the ordering of 120 ambulances conforming to the prototype ambulance produced at the Council's Motor Vehicle Repair Depot. The hoped-for rate of delivery of these vehicles was 100 by the end of 1949, and the full 120 by 31st March, 1950, but, although the first was taken into commission as early as 18th February, 1949, it was not until the last few weeks of the year that regular deliveries came to be made. By 31st December, 1949, there were 39 new ambulances in commission. Because of this slow rate of replacement and the ever-increasing demands on the Service which necessitated the utilisation of every available vehicle, many of the ambulances in commission during the year were below the high standard which 71 it has always been the aim of the Council to maintain, but it is hoped that within the next year the majority of the old and sub-standard vehicles will be replaced. Other new vehicles brought into use during the year as part of the three-year replacement plan were:— 10—30 cwt. Bedford ambulances. 11—Single-stretcher and sitting-case ambulances. 10—Sitting-case cars. The prototype of the single stretcher ambulance also was produced at the Council's Motor Vehicle Repair Depot and these vehicles have proved an extremely valuable addition to the ambulance fleet and are used mostly for conveyance of patients attending out-patient departments at the larger hospitals. In December, a second three-year replacement programme (1950-1953) was submitted to the Health Committee recommending the provision" of a further 140 new ambulances, 16 single stretcher ambulances, 2 breakdown tenders and 1 vehicle specially adapted for the conveyance of an "iron lung." Decentralisation During the year there was an extension of the decentralisation measure, first introduced in 1948, whereby those hospitals requiring ambulances for large numbers of out-patients make their applications direct to the nearest general ambulance station instead of centrally to the Control Room. Further steps to effect economies by decentralisation were also taken by stationing at hospitals during the day time one or more ambulances, according to need, and arranging for the ambulance crews to bring out-patients to the hospitals and take them home at the order of the hospital transport officer. Thus, by collecting and returning patients in batches from conveniently grouped addresses, it has been found possible to effect substantial savings of time and mileage run. By the end of 1949, these arrangements had been introduced at 14 hospitals and in every case were working to the advantage and satisfaction of both the hospital authorities and the Ambulance Service. Opportunity will be taken to extend them to other hospitals whenever the amount of work involved is shown to justify such a course. Train Journeys Apart from the decentralisation arrangements referred to in the foregoing paragraph, the most effective economy measure secured during the year has resulted from a careful scrutiny and enquiry into all applications for the removal of patients to distant addresses and the substitution, wherever possible, of rail for road transport over the major portion of such journeys. As in the case of decentralisation, this has been achieved only as a result of close and harmonious co-operation between the senior administrative staff of the Service and the medical and lay staff at the various hospitals. Thanks are due also to the Railway Executive staffs who have at all times been most helpful in the matter of reserving the necessary accommodation, and in their general solicitude for the comfort of the patients concerned. Major Accidents Four major incidents involving calls on the accident section of the London Ambulance Service occurred during the year. The most serious of these was an outbreak of fire at the Covent Garden Flower Market, on 20th December, which lasted for more than 48 hours. The first call on the London Ambulance Service was received at 11.40 a.m. when two firemen were taken to hospital, and from that time until the ambulances were dismissed at 10.31 p.m. on the following day from one to three vehicles, according to need, stood by continuously. In all 41 firemen, one of 72 whom died, were taken to hospital and very many more were given first-aid treatment in the standing-by ambulances, after which they were able to resume their duties. In his report to the Council on this disaster, the Chief Officer of the London Fire Brigade paid generous tribute to the efficient co-operation of the London Ambulance Service personnel. The other major incidents were:— On 19th January—Omnibus in collision at Rotherhithe with a lorry laden with timber. Ten injured persons were conveyed to hospital. On 24th July—Train smash at London Bridge Station; seven casualties were dealt with. On 6th August—Train smash at Euston Station; 32 casualties were removed to hospital. National agreement on ambulance charges and new legislation In February and April, 1949, conferences were held of representatives of the County Councils Association, the Association of Municipal Corporations and the London County Council to consider the incidence of the cost of, and the rates of charge made for, ambulances required for the removal of patients by one local health authority on behalf of another. The published reports of these conferences included recommendations as to the basis on which such charges should be made and the rates of charge. These were adopted by the Council and, with minor individual qualifications, by local health authorities throughout the country with effect from 1st October, 1949. It was also agreed at the conferences that representations should be made to the Minister of Health recommending that, when opportunity occurred, Section 27 of the National Health Service Act, 1946, should be amended to provide that where a person had travelled from the area of one local health authority to that of another for the purpose of attending at, or being admitted to, hospital and, immediately after such attendance or on the termination of his period of accommodation in the hospital, returned to an address in the area from which he was admitted, the local health authority for that area should repay to the local health authority in which the hospital was situated the cost of ambulance or other means of transport provided under Section 27 of the Act of 1946, provided that the date of the patient's return was not more than three months after the date of his admission. A section to this effect was subsequently included in the National Health Service (Amendment) Act, 1949 (Section 24), which received the Royal Assent on 16th December, 1949, but a sub-section added the proviso that "any local health authority may agree to waive their rights under this section against any other local health authority, either in consideration of a periodical payment or without consideration." As the number of patients removed by the London Ambulance Service from London hospitals to out-county addresses is approximately 3,000 a month, this new legislation has added a considerable burden to the administrative work of the Service, since the cost of all such journeys is potentially recoverable and in order to determine liability the date of the patient's admission and the address from which admitted has to be ascertained in every case. Further enquiry is, of course, necessary in the case of those journeys where it is established that the cost is recoverable, as to the mileage run and type of vehicle used. It is hoped, however, that when experience of the financial implications has been gained—say, at the end of 12 months—it may be found possible, by agreement with other local health authorities concerned, to minimise the amount of detailed accounting involved. Smallpox Miscellaneous The special arrangements for the removal to hospital of patients suffering from smallpox, which are made available on request to other authorities within a 73 distance of 40 miles beyond the County boundary, were fully tested when an outbreak of smallpox occurred in April. Between 7th and 23rd April twelve smallpox cases were removed to hospital from addresses within and outside the London area, and the arrangements were found to be satisfactory in all respects. In July the Service received a call for assistance from the authorities of University College Hospital who, at very short notice, were required to evacuate part of the hospital while a 2,000 lb. unexploded bomb was excavated from an adjoining site. Six ambulance-omnibuses (each capable of conveying 6 stretcher cases or 18-20 sitting cases) and five ambulances were provided and nearly 100 patients were removed to other hospitals or to their homes. Five days later when the bomb had been removed the patients were taken back to University College Hospital by the same means. Both these operations were carried through without interruption to the normal service and in a manner which brought forth high praise from the hospital authorities. Partial evacuation of University College Hospital During the year the Service was leatured at the Radiolympia exhibition held at Olympia from 28th September to 8th October, a demonstration of the working of the Ambulance Control Room and of an ambulance station being included in the G.P.O. stand, demonstrating the operation of the Emergency ("999") telephone service. Statistics (i) DIRECTLY PROVIDED SERVICE Comparative statistics for 1938 (the last full year before the war), 1947 (the last full year before the operation of the National Health Service Act, 1946) and the vears 1948 and 1949 are:— Exhibitions Accident Section No. of calls No. of cases Mileage 1938 56,318 58,196 293,166 1947 64,560 66.143 362,880 1948 66,373 67,676 367,627 1949 75,901 77,380 410,917 The number of calls answered by this section in 1949 established a new record, the previous highest number (in 1948) being exceeded by over 9,500. The average time taken to reach street accidents was 7.2 minutes as against 7.1 minutes during 1948. The hourly record again shows that the peak period commenced between 11 a.m. and 12 noon and continued at a high level until 5 p.m. As in previous years there was a sharp rise in the number of calls received between 10 p.m. and midnight. The lowest number of calls was received between 6 a.m. and 7 a.m. The nature of the cases dealt with and comparative figures for 1948 were:— 1948 1949 Increase or decrease Street accidents 9,565 10,379 + 814 Other accidents 11,553 14,588 + 3,035 Assault cases 1,095 1,216 + 121 Attempted suicide 612 590 - 22 Mental 684 443 - 241 Epilepsy 1,315 1,349 + 34 Other sudden illness 10,915 14,155 + 3,240 Maternity 22,969 23,187 + 218 Analgesia apparatus delivered to women being confined at home 3,791 6,972 + 3,181 Special cases (mainly conveying mobile emergency obstetric units to women being confined at home) 146 138 8 Transfer of accident cases taken to hospital within previous 24 hours 1,192 82 — 1,110* Ambulance not required ... 3,839 4,281 + 442 67,676 77,380 •The bulk of this work is now carried out by the General Section. 74 General Section Persons conveyed Patients Others Total Mileage 1938 217,908 102,520 320,428 1,930,172 1947 182,206 129,599 311,805 1,708,650 1948 239,157 130,335 369,492 2,072,545 1949 362,963 189,468 552,431 2,808,550 (ii) AGENCY AND SUPPLEMENTARY SERVICES Comparative statistics for the period 5th July, 1948 (the "appointed day" under the National Health Service Act, 1946), to 31st December, 1948, and the year ended 31st December, 1949, are:— 5th July to 31st Dec., 1948 Year 1949 Patients carried Mileage 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 9,557 376,564 County of London Hospital Car Service 30,052 430,121 107,667 1,496,090 City of London Police Ambulance Service 907 2,546 *835 2,619 West Ham Ambulance Service 37 469 113 1,468 Totals 36,450 637,184 118,172 1,876,741 * Agency arrangements terminated 5th July, 1049. PREVENTION OF ILLNESS, CARE AND AFTER-CARE Treatment of Tuberculosis Chest Clinic Service The number of cases of tuberculosis on the notification registers at 31st December, 1949, was 38,193 compared with 36,809 at the end of 1948 and 30,091 at the end of 1938. The arrangement under which the chest physicians, as officers of the Council, devote part of their time to prevention, care and after-care, and the remainder of their time, as officers of the regional hospital boards, to the treatment of patients, has continued to operate satisfactorily. Extra nourishments for tuberculous persons The provision of extra nourishment for tuberculous persons on the recommendation of the chest physicians was continued, a charge being made in accordance with a scale of assessment approved by the Council. Persons in receipt of National Assistance allowances were excluded from the arrangement since, as tuberculous persons, they receive allowances on a higher scale than non-tuberculous persons, to cover the cost of the extra nourishments they require. Boardingout 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 other arrangements for the care of the children were not possible. The arrangements for boarding-out continued to be made by the Invalid Children's Aid Association on behalf of the Council. Because of the shortage of suitable foster-homes, much accommodation was provided by the Council in its residential schools, homes and nurseries, but as the number of fostermothers gradually increased the number of children placed in the Council's establishments was reduced. The position at the end of the year was that about half the children were accommodated with foster-mothers and half in the Council's establishments. There was a steady increase throughout the year in the number of children boarded-out, the average during the first half of the year being 305 and for the 75 second half of the year 347. The average number boarded-out at any one time during the year was 326, compared with between 130 and 140 before 1939, 180 in 1946, 230 in 1947 and 257 in 1948. The total number of children accommodated during the year was 682, of whom 403 were new cases and 279 were children whose stay extended from 1948. Children with a history of tuberculosis 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 1949 were:— Burrow Hill Colony School, Frimley; George Rainey School, St. Leonard's-on-Sea; Wanstead House, Cliftonville; Swanley Residential School, White Oak Hospital, Swanley; Kathleen Schlesinger School, near Henley; Bowden House School, near Seaford; and Wainwright Residential School, Broadstairs. At the end of 1949 the number of children with a history of tuberculosis accommodated at these schools was 34. Residential open-air schools The Council submitted to the Minister of Health a proposal under Section 28 of the National Health Service Act, 1946, to provide vaccination with B.C.G. (Bacillus Calmette-Guerin) vaccine, by chest physicians, of (a) persons known to have been in contact with tuberculous infection, or (b) selected groups of the population, subject to the necessary preliminary tests. The proposal was approved by the Minister and it is intended to bring the arrangements into operation, initially for tuberculosis contacts, in 1950. B.C.G. Vaccination The Council co-operated with the Tuberculin Survey Committee of the Medical Research Council in a survey to assist in determining the prevalence of tuberculous infection in the population of England and Wales. In association with the head teachers of certain schools, the chest physicians, the Medical Directors of the Mass Miniature Radiography Units of the South-East and the South-West Metropolitan Regional Hospital Boards, and a medical officer appointed by the Medical Research Council, arrangements were made for tests to be carried out in the Boroughs of Fulham and Southwark in respect of school children aged 5 to 15 years and other persons not attending school up to the age of 20 years. The results are not yet available. Tuberculin sensitivity Patients requiring rehabilitation following treatment for tuberculosis were placed by the Council at certain village settlements. Posthospital rehabilitation placed by the Council at certain village settlements. At the end of 1949 the nun of persons accommodated at each of these settlements for whose maintenance Council had accepted financial responsibility was:— British Legion Village, Maidstone 20 Papworth Village Settlement, Cambridge 11 East Lancashire Tuberculosis Colony, Barrowmore Hall, near Chester ... 3 Total 34 In the report for 1948, reference was made to the Council's intention to provide special residential accommodation in the form of "night sanatoria" for patients, who, while well enough to be discharged from hospital to work during the day, needed lodging and facilities for rest under medical supervision, and to arrange with the Disabled Persons Employment Corporation for the provision of workshop facilities in connection with these sanatoria. Night sanatoria F 76 During the year work proceeded on the preparation of plans for the erection of the first night sanatorium and workshop on a site in the East End of London. Tuberculosis Care Committees The Council reviewed the Tuberculosis Care Committee arrangements during the year and, as a result, decided that a Divisional Care Committee should be appointed by each Divisional Health Committee to co-ordinate the activities of the Tuberculosis Care Committees, Sub-Committees or other groups of persons authorised by the Divisional Care Committee to deal with tuberculosis care work in the division. Mass Miniature Radiography The Council has co-operated with the four Metropolitan Regional Hospital Boards in arranging for the Boards' mass miniature radiography units to visit areas in London for the X-ray examination of volunteers from factories, business organisations and the general public. Particulars of the number of persons examined are as follows:— Boroughs Number of miniature films taken Number of persons referred to chest clinics Bethnal Green, City of London, Hackney. Poplar, Shoreditch, Stepney, Stoke Newington, Hampstead (part), Holborn, Paddington, St. Marylebone, St. Pancras (part), Camberwell, Southwark, Woolwich, Battersea, Fulham, Lambeth, Wandsworth, Westminster *133,298 1,234 •Includes a small number of out-county cases but excludes 3,604 school children in Southwark and 4,026 in Fulham, who were X-rayed and skin tested under the Medical Research Council's Tuberculin Survey. Foot Clinics The Council continued to administer the 26 foot clinics which had been established by the metropolitan borough councils before 5th July, 1948. No steps were taken to extend the service pending a decision by the Minister of Health as to whether chiropody was a form of treatment which should be provided bv local health authorities. The following are particulars of sessions, attendances, etc., for the year:— *Clinic Sessions New Cases Attendances Staff (in terms of whole-time units) 7,673 9,446 129,682 35 •Some sessions are attended by more than one chiropodist. The majority of treatments provided at the clinics are for superficial excrescences (corns, callosities, etc.) and malformed nails. Advice is given on shoe fitting, foot hygiene and exercises. Venereal diseases A summary of work done in 1949 at the London V.D. clinics will be found in Table 19, p. 132. Approximately 74 per cent. of the patients were resident in the County. The figures show a continued improvement and the number of patients diagnosed as suffering from V.D. who attended these clinics during the year was, except for the period 1940-45 when a large proportion of the London population was evacuated or in the Forces, lower than it has ever been since the London and Home Counties scheme was formulated. There has been a marked reduction in the number of patients suffering from syphilis compared with the year 77 1948, the number of males and females having declined by as much as 20 per cent. and 30 per cent. respectively. The number of non-venereal patients was, however, still very large. This has been a noticeable feature of the work done at the clinics since the end of the war and is due undoubtedly to public enlightenment on the subject. The graphs reproduced below show the incidence of early syphilis in London among persons attending V.D. clinics in the past eleven years compared with the estimated population. They do not take into account any other patients, treated by general practitioners, of whom no statistics are available but it may be that attendance at the clinics follows the general trend in the total incidence of this disease. 78 There appears to have been some improvement in the defaulter rate though it is still serious, and 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 1949: Syphilis Gonorrhoea Male Female Male Female Number of patients discharged after completion of treatment and final tests of cure 1,030 808 3,045 787 Number of patients who ceased to attend after completion of treatment but before final tests of cure 859 530 2,186 445 Number of patients who ceased to attend before completion of treatment 458 375 438 89 Number of patients who died from the disease while still undergoing treatment 8 3 — — Under Section 28 of the National Health Service Act, 1946, the Council's male and female welfare officers have continued to undertake the tracing of contacts of patients, details of whom have been provided by hospitals, by medical services of the British, Dominion and United States Armed Forces, and by local health authorities. The welfare officers have also been available to assist clinics in case of difficulty in following up patients who have defaulted. On 30th September, 1949, a conference was held at the County Hall, to which the Directors and Almoners of the London V.D. clinics were invited, to explore the means by which the Council could help the clinics in case holding and contact tracing and also ensure that its responsibilities as regards V.D. under the National Health Service Act for the prevention of illness and the care and after-care of sick persons were being fulfilled. It was agreed that in general the primary means of getting contacts to seek treatment would continue to be by encouraging the patient to persuade the contact to attend a clinic but that if home visits were necessary they should be undertaken by the local health authority's welfare officers. The following up of defaulting patients, including home visiting, would, however, be undertaken by the hospital staff unless special difficulties arose which made it desirable to enlist the assistance of the Council's welfare officers. Twenty-one notifications were received from the services of demobilised men who were under treatment or surveillance for V.D. and these men were interviewed with a view to persuading them to continue attendance at civilian clinics. Health Education The main health education effort continued to be that of the health visitors to individual mothers and to small groups. These talks take place both in the centres and in the homes. Where space and staff permit organised talks have been given to larger groups in the centres. The posters and leaflets issued by the Central Council for Health Education, the Royal Society for the Prevention of Accidents and other similar bodies have been used throughout the year. The exhibition stand produced by the Central Council has circulated in the county and three additional stands were purchased during the year so that a quicker circulation could be arranged. Thanks are due to the borough councils and to other authorities (including some of the large Stores) who kindly found space for the stands. There was some criticism of the way in which certain of the topics were presented but on the whole it was agreed that the effort was a useful one. The intensive campaign on diphtheria immunisation held in 1948 was repeated in the last quarter of 1949. Newspaper advertisements giving times of sessions were 79 inserted in the local newspapers and large quantities of posters and leaflets distributed. In one division a mobile unit accompanied by a car fitted with a loudspeaker was used during the summer months to offer immunisation on the spot; it toured busy shopping centres and was the means of drawing attention to the service. There were 1,600 attendances at 15 courses of lectures on sex education arranged for youth clubs. Five of the courses were illustrated by films and three by film-strips. In the case of mixed clubs the course of three lectures is arranged so that one of the lectures is given separately to boys and girls; it has been found that this facilitates the answering of the more intimate questions. At the request of parent-teacher associations and of mothers' meetings, 17 talks were given on the subject—mainly dealing with the way in which sex should be taught to children. Four of the talks were illustrated (two by films and two by film-strips). The largest audiences were of 500 parents at a girls' secondary school and of a similar number at a junior mixed school. The total attendance at these 17 talks was 1,490. Exhibitions The Council co-operated in two exhibitions during the year. The Hammersmith Metropolitan Borough Council in connection with their Civic Week (5th to 12th March) arranged an exhibition in their Town Hall and asked that the maternity and child welfare services provided by the Council should be included. A stand was accordingly equipped with photographs and models showing the various facilities available and was attended throughout the week by health visitors and domiciliary midwives. A modern ambulance and a mobile dental unit were also available for inspection outside the Town Hall. In November (23rd to 30th) a mothercraft exhibition was held at the Central Hall, Westminster, and at the request of the organisers the Council's premature baby service was demonstrated by domiciliary midwives. Provision of care and treatment for the mentally ill MENTAL HEALTH SERVICES Lunacy and Mental Treatment Acts, 1890—1930 The duty of taking initial steps to provide care and treatment for persons suffering from mental illness is still carried out centrally from County Hall. The proposal to decentralise the work to four district offices and subsequently to the nine divisional offices has had to be postponed again owing to difficulties created by the shortage of beds in observation wards and other problems but the matter is being kept under review in order that decentralisation may be effected as soon as circumstances permit. Throughout the year the number of cases brought to notice tended to rise and it was necessary to increase the staff to fifteen (compared with 13) mental welfare officers and five assistants in addition to the senior officer. The following table shows the number of cases dealt with by the mental welfare officers during the year together with the action taken:— Male Female Total Number admitted to hospitals designated under Section 20 (i.e. for observation) 2,323 3,003 5,326 Number dealt with in their homes, etc., under Section 14 7 9 16* Number admitted direct to mental hospitals under Section 11 3 5 8 Number in which no action under the Lunacy Acts was considered necessary 644 970 1,614 Total 2,977 3,987 6,964 *Of these, six men and eight women were certified and admitted to mental hospitals. Of those patients admitted to hospitals for observation, 787 men and 1,423 women were subsequently certified and admitted to mental hospitals. It is not 80 Recuperative holidays possible to give information regarding the ultimate disposal of cases other than those certified, as the arrangements to provide other means of care, e.g., voluntary treatment, are made by the staff of the hospitals. During the year 120 persons suffering from some form of mental illness were provided with recuperative holidays of four to eight weeks' duration in Mental After Care Assocation homes. Of these, 23 persons had been receiving treatment in general hospitals, 17 at psychiatric out-patient clinics and 72 (54 voluntary patients and 18 discharged from certificate) in mental hospitals. After-care Arrangements were completed with the Mental After-Care Association and the National Association for Mental Health for those bodies to provide an after-care service on the Council's behalf for persons living in London suffering from mental illness but not requiring in-patient treatment and the service was inaugurated on 1st May, 1949. The Council agreed to contribute 90 per cent. of the approved cost of the services provided. 467 patients were visited under the scheme, 282 by the National Association for Mental Health and 185 by the Mental After-Care Association. Most of these patients were referred direct to the two Associations by mental hospitals, psychiatric out-patient clinics or voluntary organisations. The Council agreed to proposals of the Institute of Social Psychiatry to open (a) an additional psychotherapeutic social club, in N.W. London, making in all six clubs run by the Institute for mental patients needing social re-adjustment, and (b) an occupation centre in S.E. London for the rehabilitation of various types of mental patient of both sexes. The Council contributes 90 per cent. of the approved cost of these activities. Medical adviser on mental health The opportunity was taken, on his retirement on reaching the age limit from the position of physician superintendent of Banstead Hospital, to extend the engagement of Dr. A. A. W. Petrie, C.B.E., as medical adviser to the Council on mental health to provide for service on approximately 10 half days a month. Mental Deficiency Acts, 1913—1938 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 1948 1949 Totals from 1st April, 1914, to 31st Dec., 1949 Supervision Section 15 8 1,541 Local education authority 389 357 14,091 Police authority (Section 8) 32 28 1,871 Transfers from prison (Section 9) ... 1 1 228 Transfers from approved schools (Section 9) 3 5 561 From hospitals and institutions (from July, 1948, only) 87 111 198 Miscellaneous 140 168 9,956 Total 667 678 28,446 Position as at 31st December, 1949, with regard to the cases referred to in the last column of the preceding table:— Detained in institutions 7,720* Discharged from institutional care 2,584 Removed to mental hospitals under the Lunacy Acts 509 Ascertained not subject for action 9,098 Died 4,251 Total removed from active list — 24,162 Under guardianship 246 In places of safety awaiting the presentation of a petition for an order 11 Under supervision 3,964† In institutions awaiting the presentation of a petition for an order 54 Still under consideration 9 Total remaining on active list — 4,284‡ Total 28,446 81 Summary of cases dealt with during 1949 Placed in institutions 293 Placed under guardianship 12 Placed in places of safety pending the presentation of a petition 23 Placed under supervision 453 Discharged from institutional care or guardianship 212 Removed to a mental hospital under the Lunacy Acts 22 Ascertained not subject for action 329 Died 111 Total 1,455 *This figure includes 338 cases on licence who are visited at regular intervals by officers of the Council on behalf of the Regional Hospital Boards. †In addition to the 3,964 cases under supervision, 970 cases of persons known to the local authority to be mentally deficient but not subject to be dealt with are visited on a voluntary basis. The department has continued to carry out the work of placing in employment mentally deficient children who leave E.S.N, schools and supervising them up to 18 years of age. On 31st December, 1949, 439 mentally deficient children were being afforded the benefits of this scheme. This work was performed by the Council as paid agent of the Ministry of Labour until 30th September, 1949, but on that date the Education Committee undertook responsibility for the work as part of the Youth Employment Service although, for the time being, the Public Health Department carried on the work. Arrangements have been made for the work to be transferred to the Education Department on 1st April, 1950. ‡Of these 135 were awaiting the provision of institutional care. Accommodation in Institutions Throughout the year the shortage of beds available for the mentally defective (especially children) caused grave concern to the Council. When the institutions for the mentally deficient were transferred to the Minister of Health in July, 1948, there were approximately 26 beds per 10,000 of the population available for the reception of mentally deficient persons in the County of London. Under the "catchment area" schemes introduced by the four Metropolitan Regional Hospital Boards a substantial part of this accommodation was allocated to other local health authorities who had made little or no provision for patients from their areas. As a result, notwithstanding a slight revision of the schemes in the Council's favour during the year, the accommodation available for London cases, based on the proportion of vacancies allotted, was at 31st December, 1949, only 17 per 10,000 of the population. Thus the accommodation for London patients has been reduced by approximately one-third and the division of this accommodation among the four Regional Boards imposes further restrictions upon its use. The result is that the Council is unable to secure the provision of institutional care for London patients needing it without serious and, in some cases, prolonged delay. At December 31st, 1949, the number of patients awaiting admission was 135, which included 107 children awaiting admission to the Fountain Hospital. The position is most serious in respect of infants and low-grade children of the type suitable for admission to this hospital. Of the 107 London children on the hospital waiting list, 68 were classed as urgent. As there is no other institution to which these children can be sent, and vacancies at the Fountain Hospital arise infrequently, it will be many months before even the urgent cases can all be admitted. Representations as to the inadequacy of the provision for London patients have been made by the Council to the four Metropolitan Regional Hospital Boards and to the Minister of Health. The problem is a national one and the institutional provision made by London before the National Health Service began must contribute towards the needs of other authorities who had not made adequate provision. No early solution of the problem appears to be in sight. Guardianship There was a substantial reduction in the number of cases under guardianship during the year. This was almost entirely due to the fact that the National Assistance Act, 1948, enabled mentally deficient persons over 16, who were in need of financial assistance, to receive a grant from the National Assistance Board, which rendered unnecessary the continuance of guardianship orders which had been made to enable financial assistance to be given under the Mental Deficiency Acts. Fiftyone patients were discharged from the Mental Deficiency Acts during the year after 82 arrangements had been made for them to obtain an assistance grant. The saving to the Council as a result of these arrangements will amount to approximately £2,500 a year. It is not expected that any further patients will be placed under the guardianship of their friends and relatives solely with a view to affording them financial assistance unless there are very exceptional circumstances. Occupation centres By the end of 1948 the Council had established seven occupation centres for mentally deficient persons under guardianship, supervision or on licence from institutions (5 for children of both sexes under 16 years of age, 1 for girls and women over 16 years and 1 for boys and men over 16 years). During 1949 nine more centres were opened (4 for children, 1 for children and elder girls, 2 for elder girls and 2 for elder boys) and three centres were removed to other premises. The sixteen centres in operation at the end of the year provided for a maximum total roll of approximately 490. Plans were also nearly finished for the opening of two further centres (1 for children and 1 for elder boys) early in 1950, to complete the programme for the provision of accommodation for approximately 550 persons. The centres are open from 10 a.m. to 4 p.m. daily from Monday to Friday during primary school terms. With one exception (Branstone Street) the centres have been established in hired premises (mainly church halls or similar accommodation) which are the best obtainable but in many cases are not entirely suitable. At Branstone Street premises originally used for education purposes serve the needs of that centre very satisfactorily. The following table gives particulars of the centres established by 31st December, 1949, with numbers on roll and average attendances in December:— (1) Date of opening (2) Address (3) Borough (4) No. on roll (5) Average daily attendance Centres for children 1948 London Mission, Methodist Hall, Shepherd's Bush Road, W.6 Hammersmith 24 19 1948 St. Margaret's House, 19, Old Ford Road, E.2 Bethnal Green 15 13 1948 Lewisham Methodist Hall, Albion Way, S.E.13 Lewisham 30 23 Jan., 1949 Oxford House, Mape Street, E.2 (replacing St. Augustine's, E.9, opened in 1948) Bethnal Green 25 22 Feb., 1949 Unity Hall, 56, East India Dock Rd., E.14 Poplar 28 24 Feb., 1949 St. Peter's Hall, Clapham Manor Street, S.W.4 Wandsworth 27 20 Feb., 1949 Metropolitan Tabernacle, Newington Butts, S.E.ll Southwark 36 27 June, 1949 Branstone Street, North Kensington, W.10 (also takes elder girls) Kensington 45 35 Oct., 1949 Christ Church Hall, Mowll Street, Brixton Road, S.W.9 Lambeth 17 14 Nov., 1949 Claremont Central Mission, White Lion Street, N.l (replacing Caxton House, N.7, opened in 1948) Islington 34 22 Centres for elder girls 1948 Fellowship Hall, 182, Hammersmith Road, W6 Hammersmith 26 24 Jan., 1949 Old Gravel Pit Hall, Valette Street, E.9 Hackney 22 19 Jan., 1949 St. Chrysostom's Hall, Goldsmith Road, S.E.15 Camberwell 36 29 83 Centres for elder boys 1948 . St. Michael's Hall, Darley Road, S.W. 11 Battersea 23 21 Sept., 1949 19, Compton Terrace, N.l Islington 23 19 Nov., 1949 . All Saints' Hall, Blenheim Grove, S.E.15 (replacing Orchard Mission, Mission Place, S.E.15, opened in February, 1949) Camberwell 31 26 Total 442 357 Authority has been given for the conveyance of children to Branstone Street Centre from outlying districts by school buses when redundant vehicles are available from the Education service. The Organiser of Occupation Centres appointed by the Education Committee was formally transferred to the Public Health Department on 1st August, 1949. Two supervisors (one woman and one man) were granted leave of absence with pay for a year from 6th September, 1949, to attend the course of training for staffs of occupation centres, etc., arranged by the National Association for Mental Health. As few of the centres have playgrounds or open spaces nearby, outings by school bus to parks or open spaces were arranged for recreational purposes approximately once a fortnight during the suitable months of the year. Open days were held at most centres during the year for the sale of articles made and to give parents and friends an opportunity of seeing the work of the centres. The sums realised were £18 15s. 4d. at junior centres, £87 9s. l1d. at elder boys' centres and £40 7s. 3d. at elder girls' centres. In addition, a number of toys and pieces of apparatus were made in the boys' centres for use at junior centres. During December, Christmas parties were arranged at all of the centres. SCHOOL HEALTH SERVICE Organisation The work of the School Health Service is largely dependent upon the duties imposed upon every local education authority by the Education Acts, 1944-48, and the Handicapped Pupils and School Health Service Regulations made thereunder. The arrangements for medical inspection and the special education of handicapped pupils continued as before, but in consequence of the National Health Service Act, 1946, the arrangements for medical treatment were somewhat modified. The School Care Committees established in 1907 continued to carry out the work of following up the medical recommendations. The value of this method of obtaining the co-operation of parents is apparent in the results. The number of voluntary workers rose to over 1,600 and they gave much devoted service in the medical and other fields to the children of London. A full-time psychiatrist was appointed in March, 1949, and a full-time speech therapist in September. At the end of the year there were three part-time consultants : for ophthalmology, for diseases of the ear, nose and throat, and for psychiatry. The orthopaedic consultant was unable to continue the work after 31st October, 1949, and from that date temporary consultants have been employed. Pupils on school rolls At the end of 1949 there were 283,563 children of primary and secondary school age in County schools and 96,229 children in voluntary or assisted schools, making a total of 379,792 pupils. 84 Medical Inspections The following table gives a summary of the medical inspections made during the year and comparisons with previous years:— Routine (detailed) Inspections 1938 1947 1948 1949 No. % No. % No. % No. % Nursery (a) — 7,074 4.9 8,953 5.7 10,021 6.2 Entrants 47,301 25.3 33,439 23.3 37,793 23.8 40,287 24.8 7 years old 39,044 20.9 26,046 18.2 26,222 16.5 29,541 18.2 11 years old 41,576 22.2 28,556 19.9 32,961 20.8 31,725 19.6 Leavers 42,074 22.5 6,433 (b) 4.5 26,817 16.9 26,382 16.3 Other ages — — 40,516 28.2 23,558 14.9 22,115 13.6 Higher Education 16,208 8.6 (c) — — — — — Special schools 975 0.5 1,203 0.8 1,581 1.0 1,633 1.0 Training colleges Nil — 268 0.2 648 0.4 465 0.3 Total 187,178 100.0 143,535 100.0 158,533 100.0 162,169 100.0 Other Inspections Special inspections† 170,682* — 101,707* — 107,844* — 110,026 — Re-inspections 132,240 — 84,227 — 88,243 — 87,915 — Residential schools (d) — (d) — 7,920 — 9,845 — Total 302,922 — 185,934 — 204,007 — 207,786 — Grand total 490,100 — 329,469 — 362,540 — 369,955 — (a) Nursery children recorded separately only from 1946. (b) School leaving age raised in this year. (c) Now included in the "Leavers" and "Other Ages" groups. (d) Not recorded before 1948. *As the 1949 figure does not include inspections at rheumatism supervisory centres, special ear clinics, vision centres and nutrition centres, the figures for 1938, 1947 and 1948 have been amended accordingly. †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 (for their special defect), etc. Although the volume of work carried out by the school health service on medical inspections in 1949 showed an overall increase on 1947 and 1948, it was still below the pre-war level. On comparing the number of routine and other inspections with the school populations for these years the ratio of routine inspections is found to be fairly constant but the proportion of non-routine inspections has fallen considerably:— 1938 1947 1948 1949 School population 457,000 353,000 373,000 379,792 Routine inspections 187,178 143,535 158,533 162,169 Percentage 41.0 40.7 42.5 42.7 Other inspections 302,922 185,934 204,007 207,786 Percentage 66.3 52.7 54.7 54.7 85 The numbers and percentages of children seen at routine inspections who were referred for treatment (other than for infestation or teeth) in 1949 are shown in the following table and for comparison the percentages for 1948 are also given:— Pupils referred for treatment Age group and sex Number of pupils examined Number of pupils referred for treatment No. Percentage 1949 1948 Nursery Boys 5,048 835 16.5 16.2 Girls 4,973 723 14.5 14.4 Boys and Girls 10,021 1,558 15.5 15.3 Entrants Boys 20,775 3,885 18.7 19.1 Girls 19,512 3,354 17.2 16.5 Boys and Girls 40,287 7,239 18.0 17.8 7 years old Boys 15,145 3,273 21.6 21.8 Girls 14,396 2,966 20.6 21.2 Boys and Girls 29,541 6,239 21.1 21.5 11 years old Boys 15,984 3,004 18.8 19.0 Girls 15,741 3,214 20.4 21.4 Boys and Girls 31,725 6,218 19.6 20.2 Leavers Boys 13,429 1,931 14.4 14.8 Girls 12,953 2,443 18.9 20.3 Boys and Girls 26,382 4,374 16.6 17.5 Other ages Boys 11,632 2,095 18.0 19.6 Girls 10,483 2,470 23.6 23.3 Boys and Girls 22,115 4,565 20.6 21.3 Total Boys and Girls 160,071* 30,560 18.9 19.3 *Does not include special schools or training colleges. The following table shows the percentages of the principal defects in children of all age groups inspected at routine inspections and referred for treatment or observation, with comparable figures for 1938, 1947 and 1948:— Defects found on medical inspection to require treatment or observation 1938 1947 1948 1949 Numbers examined 169,995 142,064 156,304 160,071 Percentages Skin diseases 0.80 1.20 1.22 1.22 External eye diseases 0.53 0.67 0.61 0.58 Defective hearing 0.14 0.32 0.39 0.41 Otitis media 0.51 0.47 0.70 0.75 Enlarged tonsils and adenoids 7.55 7.61 8.16 8.91 Defective speech 0.16 0.43 0.53 0.62 Enlarged cervical glands 0.63 0.99 1.01 1.33 Heart and circulation 1.00 0.62 0.73 0.68 Lung disease (not T.B.) 1.15 1.32 1.30 1.44 Orthopaedic defects (a) 4.02 4.67 4.66 Defects of nervous system (a) 0.33 0.30 0.34 Psychological defects (a) 0.42 0.72 0.75 Anaemia 0.31 0.31 0.29 0.31 (a) No exact comparison can be given. New classification introduced in 1947. The incidence of skin diseases though higher than in 1938 remained stable; it was again the highest in the leaver, girls, group. Dealing with the significant increases in 1949 figures over those of 1948, the increase in otitis media occurred in the entrant and 7 year age groups of both sexes and may be associated with the difficulty compared with pre-war of obtaining operative treatment for adenoids and enlarged tonsils. Enlarged tonsils and adenoids increased in incidence in nursery and entrant groups. Increased incidence 86 in the younger age groups accounted in the main for the increase in the figures for cervical glands, defective speech, psychological defects (for this latter diagnostic group the increase would have been greater had not the increases in young ages been partly compensated by reductions in older ages). Slight increases in lung disease (non-T.B.) occurred in most age groups for boys but in the entrant girls group there was a percentage incidence of 2.5 per cent. against 1.8 per cent. in 1948. Comparison with 1938 showed an increase in every comparable defect listed except for anaemia, which remained at the same level, and heart and circulation, which had decreased. Nutrition Classification of General Condition A—Good B—Fair C—Poor 1947 42.0 54.3 3.7 1948 40.8 56.0 3.2 1949 41.8 55.1 3.1 The percentage of children referred for treatment or observation on account of nutrition was, in percentages:— 1938 1947 1948 1949 Referred for treatment 1.0 1.1 1.0 1.0 Referred for observation 0.4 0.5 0.5 0.7 Total 1.4 1.6 1.5 1.7 These figures, though satisfactory, relate only to the worst cases (which are referred for treatment) and these evidently form a fairly stable fraction. More objectively, however, the 1949 survey of heights and weights of London schoolchildren showed that between 1947 and 1949 there had been an overall improvement in physique. The findings of this survey may be summarised as follows:— (1) Between 1938 and 1949 the average height of London school-children increased by about 2 cm. (¾in.), and the average weight increased by about 0.8 kg. (1¾ lb.). (2) Despite these substantial changes the pre-war relationship between weight and height was generally maintained. By pre-war scales of growth, postwar children appeared three months older than their true ages. (3) Though the greater improvement has been in those districts which were above average in 1938, there was a definite improvement in the worst areas where war conditions produced greatest retardation and where it was known that progress would be most difficult to achieve. Cleanliness The percentage of pupils found to have vermin in the hair at routine inspections during 1949, with corresponding figures for 1938, 1947 and 1948, is shown below:— Percentage with verminous heads 1938 1947 1948 1949 Entrants Boys 1.6 0.7 0.3 0.2 Girls 2.3 1.5 0.7 0.4 7 years old Boys 1.9 0.9 0.4 0.3 Girls 3.2 2.1 1.2 0.4 11 years old Boys 1.7 0.9 0.4 0.2 Girls 3.5 2.3 1.0 0.7 All ages Boys 1.7 0.7 0.3 0.2 Girls 2.9 1.8 0.9 0.5 87 A very great improvement among all age groups of girls was manifest in 1949 although, of course, the personal hygiene of scholars was shown at its best at routine inspections as parents were notified in advance of the day of inspection. Even so, the results year by year are strictly comparable and the table below, showing an improvement in the percentage of verminous children found at the nurses' monthly inspections, confirms the results of the routine inspections:— Total number of inspections Number found to be verminous Percentage found to be verminous 1938 1947 1948 1949 Boys 437,915 8,174 (a) 2.5 2.1 1.9 Girls 463,073 28,267 (a) 7.5 6.4 6.1 Infants' 465,111 15,941 (a) 4.7 3.9 3.4 Totals 1,366,099 52,382 7.3 4.9 4.2 3.8 (a) Not available. As in previous years many children were found to be verminous at more than one inspection. The number of individual children found during the year to be verminous was 26,063 (29,970 in 1948, 37,978 in 1947 and 65,292 in 1938). The number of advice cards issued during the year compared with 1948 was 32,422 (32,677). The number of children who attended the cleansing centre after the issue of advice cards was 22,032 (26,102); the number of statutory notices served was 5,133 (7,626); 1,564 (2,212) of the children concerned attended voluntarily and 3,182 (4,197) were compulsorily cleansed. Only 7 of 160,071 pupils inspected had body vermin. Vaccination The upward trend of the figure of pupils vaccinated against smallpox noted in the past two years continued in 1949. The proportion vaccinated rose from 52.9 per cent. in 1948 to 54.9 per cent. in 1949. Diphtheria immunisation For diphtheria immunisation the percentages of pupils stated to have been immunised followed closely those of 1948; the overall figure for 1949 was 84.4 per cent. compared with 83.1 per cent. in 1948 and 82.7 per cent. in 1947. As pointed out previously the former borough records were incomplete owing to children in older age groups having been immunised whilst evacuees and because general practitioners had not notified the boroughs of all immunisations carried out by them. On the other hand school records usually overstate the proportion immunised. Experience gained in checking borough figures against the school figures and the analysis of the general trend led to the conclusion that the true figure is at least 76 per cent. Dental standard The percentage of pupils in the different age groups (disregarding the nursery group) found to have defective teeth is given below. Whilst these figures are not as reliable an index as the more exacting inspections of the school dental surgeons, they do provide an index for comparative purposes and indicate continued improvement:— 1938 1947 1948 1949 Entrants 40.3 28.9 27.6 26.7 7 years old 30.3 27.2 26.3 25.6 11 years old 22.7 17.5 16.7 16.3 Leavers 24.9 11.9 12.7 12.8 Other ages — 17.7 17.4 17.6 The report of the Chief Dental Surgeon is on page 102. 88 Vision The table below contains the statistics as to the standard of visual acuity of pupils whose sight was tested at routine inspections. The numbers shown as being in possession of spectacles are regarded as an understatement rather than otherwise, as instances of failure to record this information have been noted:— Visual acuity—Percentage with standard, vision (6/6) (With glasses, if worn) 1938 % 1947 % 1948 % 1949 % 7 years old Boys 63.8 80.0 79.2 78.2 Girls 63.6 77.4 78.2 76.5 11 years old Boys 70.8 80.7 81.7 80.1 Girls 67.8 76.7 78.1 76.9 Leavers Boys 71.4 80.7 80.9 79.7 Girls 68.9 77.3 76.7 76.0 Other ages Boys — 80.8 81.2 77.4 Girls — 76.8 76.4 73.4 A further table shows the percentage of cases of vision defect referred for treatment 1938 % 1947 % 1948 % Already wearing spectacles Not wearing spectacles Total 7 years old Boys 6.5 6.0 7.4 0.7 6.1 6.8 Girls 7.3 7.9 7.4 0.7 6.8 7.5 11 years old Boys 9.7 91 8.9 2.0 7.3 9.3 Girls 10.3 10.9 11.1 2.2 8.2 10.4 Leavers Boys 9.9 9.1 9.5 2.4 6.9 9.3 Girls 11.1 10.6 12.2 3.4 9.0 12.4 Other ages Boys — 9.2 9.8 1.6 7.7 9.3 Girls — 11.5 12.0 3.3 8.7 12.0 It will be seen that a proportion of those referred for treatment for defective vision were already wearing spectacles. For 1949 this proportion rose from onetenth at age 7 (boys, 10.3 per cent.; girls, 9.7 per cent.) to rather more than a quarter at age 15 (boys, 25.7 per cent.; girls, 27.8 per cent.). The rise at higher ages in the total percentage of all children referred for treatment was almost wholly due, not to increased incidence of vision defect (which remained fairly stable from age to age), but to increasing frequency of cases needing natural adjustment of refraction correction with the passage of time. Considered together, the two tables above show that while the incidence of defective vision was considerably lower than in pre-war years, particularly in the 7 years old group, the percentage of pupils referred for treatment on account of defective vision remained unchanged. This would appear to indicate that errors of vision were more completely detected. Conforming to previous experience over many years the incidence of defective vision is higher in girls than boys. The incidence of squint should be considered in conjunction with vision. Figures show that the prevalence of squint was highest in the entrant group, falling to an insignificant level in the leaver group. The overall figure for pupils referred for treatment for squint was 1.1 per cent. compared with 1.0 per cent. in 1947 and 1948, and 0.6 per cent. in 1938. It is doubtful if this was a real rise in incidence, it is likely that it indicates more intensive case finding. Cooperation of parents and care committee The percentage attendance of parents and representatives of the children's care committee at routine inspections showed that the co-operation of parents, as judged by this test, especially for the earlier age groups, was quite good, being 92 per cent. for entrants. The attendance of care committee representatives was around the 90 per cent. level. Pupils referred for treatment Prior to 1947, there were no figures for pupils referred for treatment for malnutrition. Bearing in mind that 1 per cent. of pupils were referred for treatment for this condition an increase in the total figure of pupils referred for treatment of any 89 defect in the last three years should be expected, though not necessarily an increase of one per cent., as children may be referred for more than one defect. In fact, it was found that compared with 1946 there was an actual decrease of 0.1 per cent. in 1947 in the overall figure, an increase of 0.5 per cent. in 1948, and an increase of 0.1 per cent. in 1949. None of these small changes can be regarded as of any moment. Choice of employment Comparison of 1949 with 1948 in numbers advised against particular forms of employment shows a reduction in the overall figure for both sexes together from 17.0 to 15.8 per cent. The order of ranking of the contra-indications places defective vision at the head of the list for both boys and girls, followed by heavy manual work for both sexes and exposure to bad weather for girls. The details are shown in Table 20, p. 133. Following up and re-inspection 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 inspection 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. During the year, 87,915 re-inspections were made of children so referred. The number of defects on account of which children were were referred for re-inspection were:— No. of medical defects No. of dental defects Total defects First re-inspections 26,302 22,752 49,054 Second ana subsequent re-inspections 18,938 12,096 31,034 45,240 34,848 80,088 The percentages of follow-up results showed that treatment was obtained or commenced as follows:— 1938 1947 1948 1949 Excluding dental defects 84.5 90.5 89.4 90.2 Including dental defects 82.0 87.1 87.0 87.3 The post-war figures are consistently higher than those of 1938. Medical Treatment This was the first full year in which every child was entitled to free general practitioner services. The new hospital authorities allowed special arrangements for school children's clinics to continue. The greatest change compared with the former regime, was in the ophthalmic service and it now takes many months for a pair of spectacles to be obtained. 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 authorised. 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. Treatment Centres At the end of 1949 there were 84 school treatment centres, and in addition 24 hospitals continued to provide special sessions for the medical and dental treatment of school children. 90 Statistics of the clinics held in hospitals in association with the Council's treatment scheme and in the school treatment centres were:— Type of centre Number of new cases 1938 1947 1948 1949 Vision 37,359 29,344 31,377 32,292 Ear, nose and throat 12,726 2,344 3,281 4,154 Minor ailment 128,819 133,731 170,181 171,731 Dental 138,639 104,305 118,439 102,495 E.N.T. (formerly specialear) 1,830 1,520 1,691 1,689 Rheumatism 1,885 1,508 1,468 1,375 Nutrition 641 1,065 1,178 1,222 Enuresis — — 86 830 These figures show a general overall increase in the volume of work in 1949 with the exception of the dental centres. The shortage of school dental surgeons as a result of resignations to participate in the general public dental service which is remunerated on a piece-work basis, has had a serious effect on the "preventive" services for school-children. A more complete picture of the volume of work carried out at the centres and clinics can be obtained by consideration also of the total attendances, which are given below:— Type of centre Attendances in 1949 Vision 79,777 Minor ailment 1,002,051 Dental 203,523 E.N.T. (formerly special ear) 7,945 Rheumatism 10,887 Nutrition 9,420 Enuresis 3,977 Scabies, impetigo and ringworm The number treated for scabies in 1949 was 2,173 as compared with 3,051 in 1948. Although a rise in the number of verminous individuals treated at bathing centres is apparent in 1949 the number of treatments needed is far below that for 1948, which suggests that more of the "hard-core" cases are improving their standard of hygiene. The total number of cases treated for impetigo in 1949 at minor ailment centres and bathing centres was 2,954 as against 4,857 in 1948, a considerable decrease. The incidence of scalp ringworm continued to fall. Vision Spectacles for school pupils prescribed at school treatment centres continued to be 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. At centres within the areas of the North-West, South-East and South-West Metropolitan Regional Hospital Boards, the refractionists, whose names must be on the Executive Council's Ophthalmic List, are employed and paid by the Council, and the London Executive Council reimburses the Council on a per capita basis ; those employed at centres within the area of the North-East Metropolitan Regional Hospital Board are appointed and remunerated by that Board. 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. Speech therapy At the end of 1949 there were 18 special classes for speech defects conducted by part-time speech therapists under the supervision of a principal assistant medical 91 officer. Each child attends twice weekly for a period of 50 minutes and the maximum number of children attending a session is nine. The number of new cases admitted during the year was 230 and the total number of individual pupils in attendance was 670. Forty-seven children were discharged as cured and 42, most of whom were improved, left for various reasons. The remainder were still under treatment at the end of the year. 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. Enuresis The arrangements made with the Westminster Hospital (All Saints genitourinary department) for reference on two sessions a week of pupils from Council schools suffering from enuresis, continued. An average of 9 new patients and 42 old patients were seen each week by appointment, plus 2.3 sporadics. At the end of the year there were 534 current cases attending the clinic, and the records showed an average improvement of 33⅓ out of each possible 100 dry beds among all age groups (ranging from 4 to 17 years) attending. Forty-four pupils were discharged as cured. Sixty-two cases ceased to attend because cured. In addition to the clinic established by the Council at the Clapham Park School Treatment Centre in 1948, new clinics were opened during the year at the Tooting and Wandsworth Centres. Of 226 pupils who attended at these clinics regularly, 51 (22 per cent.) were cured, 133 (59 per cent.) improved, and 42 (19 per cent.) did not respond to treatment. 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 attendances 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. Tonsils and Adenoids In view of the fact that the waiting lists for tonsils and adenoid operations for London school children had risen to well over 3,500 by March, 1949, negotiations were entered into with the four Metropolitan Regional Hospital Boards for the purpose of setting up special units in hospitals to deal with the problem. Arrangements were completed with the North-East and South-East Metropolitan Regional Hospital Boards, under which this Council provided nursing staff from volunteers from the School Health Service, and the Boards provided the services of surgeons and facilities for operations. The scheme in the North-East region had only been functioning for a few weeks, and the scheme in the South-East region had not been implemented, when, due to the heavy incidence of poliomyelitis in August, operative treatment was suspended. Classes for foot defects Special classes to correct foot defects, before they develop into permanent disabilities, had been formed in 78 schools during 1948. These classes were under the supervision of a part-time specialist in physical medicine, who selected suitable children, and of trained teachers, selected by the Council's organisers of physical training. By the end of 1949 this figure dropped to 70. Growing difficulties with regard to both staffing and accommodation led to this fall and the fact that the number of schools holding classes was as high as 70 was due to the interest and cooperation of the head teachers and staff concerned. It was suggested that remedial gymnasts should be appointed for the work, G 92 Handicapped Children 7,069 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. The number in each category was:— Vision 243 Hearing 207 Epilepsy 80 Educational subnormality 2,579 Delicate 2,579 Physical conditions 717 Dual defects 62 Speech defects 519 Various examinations 83 In addition 317 children were presented because of alleged maladjustment and 10 because of diabetes. Tables 21 to 31 in the appendix show the results of the examinations. Accommodation Day Special Schools Defect No. of schools Roll Boys Girls Total Partially sighted 6 197 196 393 Deaf 4 147 135 282 *Partially deaf 4 39 34 73 Physically handicapped 20 802 745 1,547 Delicate 10 656 484 1,140 Educationally subnormal 24 1,615 1,034 2,649 Total 68 3,456 2,628 6,084 *Special classes held in normal schools. Residential Special Schools Defect No. of schools Accommodation Roll Residential Day Blind 2 80 30 74 *Deaf 3 162 68 169 Physically handicapped 2 102 — 102 Delicate 7 431 — 295 Educationally subnormal 3 288 — 288 Diabetic 1 63 — 60 Maladjusted 1 45 — 45 Totals 19 1,171 98 1,033 *Including Rayners for double defects. In addition to the handicapped children in the Council's own residential special schools there were at the end of the year 777 London County Council children in non-Council residential special schools catering for the following defects:— Blind 51 Partially sighted 6 Deaf and Partially deaf 36 Physically handicapped 52 Delicate 236 Educationally subnormal 95 Epileptic 56 Maladjusted 240 Speech defect (Moor House) 5 Total 777 93 Hospital Schools The Council provided education for handicapped children in the following three hospitals:— Hospital Roll Boys Girls Goldie Leigh 36 28 Guys (and Evelina) 50 36 St. Mary's, Paddington 11 11 Total 97 75 In addition, individual tuition otherwise than at school was given under Section 56 of the Education Act, 1944, to 44 children in hospital or at home. Residential Schools There are seven residential schools with accommodation for about 2,575 children committed to the care of the Council under the Children Acts. 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. Arrangements are made for the 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. Provision of Meals The following information is supplied by the Chief Officer of the Restaurants and Catering Department:— The number of kitchens increased from 552 to 578, and dining centres from 794 to 829 between October, 1948, and October, 1949. The School Meals Service aims at concentrating the maximum food value into the quantity of food a child is willing to eat. It has set the following standard:— Age group No. of calories I Under 7 years 500 II 7-11 years 650-750 III Over 11 years 850-950 Meals for children in Group III should contain 20-25 grammes of first-class protein ; 25-30 grammes of fat; and 400 milligrammes of calcium. The diet of the children taking meals is under the supervision of the Council's honorary nutritional consultant, Dr. T. F. Macrae, O.B.E., D.Sc. Random samples of served meals continued to be analysed by the Council's Chemist to keep a close check on the quantities and qualities aimed at. Day schools Infectious diseases in schools The numbers of infectious cases reported from the day schools during the year are shown in Table 16. d. 130. The number of visits to schools made during 1949 by school nursing sisters in connection with outbreaks of the principal infectious diseases were:— Diphtheria Scarlet fever Measles Whoopingcough Chickenpox Mumps Poliomyelitis Other diseases Total 35 176 286 36 117 48 119 363 1,180 Diphtheria immunisation Scalp ringworm When necessary, special visits were made by assistant school medical officers. Comments on this service will be found on page 59. During the year there was a falling off in the number of cases of scalp ringworm as indicated in Table 16, 94 There were six cases of scalp ringworm, but there were no cases 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 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. School buildings and furniture The Chief Medical Officer of the Ministry of Education in his report on the Health of the School Child for the years 1939-45, introduced a chapter on school buildings and school furniture. He referred to the need for the modernising of many school buildings that were below accepted standards of hygiene and to the necessity for modem furniture both for new schools and for replacing out of date equipment in existing schools. He added that the school medical officer was specially concerned in the type of furniture necessary for schools since furniture and equipment often had a direct influence on the health of the pupils. The Building Regulations, 1945, which prescribed the new standards were modified by the recommendations of the Technical Working Party on School Construction which were presented to the Minister of Education in August, 1948. Circulars 209 and 210 issued in October, 1949, by the Ministry of Education introduced further modifications in the standards of educational building and stated that amendments to the Building Regulations were under consideration. A Sub-Committee of the Ministry of Works Standards Committee appointed in 1944 made recommendations for the standardisation of materials, components, furniture and fittings in school buildings. The Council decided to spend one and a half million pounds on refurnishing the schools during the next five years. In November arrangements were made with the Technical College for the Furnishing Trades and with Shoreditch Training College for the design of school equipment to be undertaken by senior students as a project. A furniture design advisory panel was constituted (with representatives from those colleges and the Central School of Arts and Crafts and appropriate officers from the Architect's, Education Officer's, Public Health and Supplies Departments) and considered the current trends in the design of school furniture both in this country and in Europe. The plans for all new school buildings are seen by the School Medical Officer. Some progress was made in improving the conditions in existing schools. The recommendations of the Ministry Sub-Committees on furniture were closely followed in deciding the design and sizes of new furniture. Psychiatric service in remand homes Dr. P. D. Scott, M.A., M.D., D.P.M., reports as follows:— Work done (compared with previous year) 1948 1949 Boys Girls Boys Girls "Special" psychological reports 632 168 742 160 General psychological reports 29 1 16 3 Conduct reports (by the Superintendent) 71 11 83 1 Special physical reports 45 79 24 24 Total admitted to the Remand Home 1,156 255 1,317 268 This showed an increase, in special psychological reports, of 102, on 1948. In addition, 21 boys and 10 girls who had been remanded on bail and therefore did not appear on the books of the remand home were examined for the purpose of a " special" report. 95 The total increase in work done was offset by help received from other psychiatrists of the Council, who examined 142 children. The Psychiatric Team, remained unaltered and consisted of: 1 psychiatrist (two-thirds full-time), 1 psychiatric social worker, 1 full-time psychologist and 1 part-time psychologist. The usual full co-operation was received from the Superintendent and his staff, from the Medical Officer responsible for the physical care of the children and from outside agencies, notably the Council's Special Officers and the Probation Service. The Psychiatric Social Worker wrote to 621 parents or guardians of remanded children requesting their attendance for interview. Of these, 398 attended and 223 failed but of the latter, half telephoned or wrote giving their reasons for not coming. The expert social reports were of great usefulness. The work of the psychologists consisted of:— (a) A careful assessment of intelligence and (in some cases) an assessment of practical ability. Each individual was given a routine individual test of intelligence (the Terman-Merrill Revised Stanford-Binet Test) and an Intelligence Quotient was calculated for each. In those cases where further tests were found necessary because of various factors affecting the reliability of the test — e.g. poor verbal ability, emotional disturbance, educational retardation— other verbal or non-verbal intelligence or performance tests were given, e.g.: Cattell's Intelligence Test (verbal), Raven's Progressive Matrices (non-verbal), Porteus Mazes (non-verbal), Goodenough Drawing Scale (non-verbal), Healy Completion Test 1 (performance), Healy Completion Test 2 (performance) and Alexander's Performance Scale. Although it would have been ideal to have given all more than one type of Intelligence Test, such a procedure was entirely out of the question because of the heavy case load throughout the year. Group testing with suitable group tests, though useful as an emergency measure or as additional information, was not considered to be a fair measure of intelligence on its own, or as useful as an individual test for an assessment of personality. Such tests do not differentiate adequately between the dull and the disturbed children. (b) An examination of educational attainment. All were given Burt's Reading Accuracy Test or Schonell's Graded Word-Reading Test to obtain a Reading Age Level. Where the Intelligence Quotient was normal, but educational retardation was indicated in school reports, further Standardised Scholastic Tests by Burt or Schonell were given to determine the extent and the cause of retardation. Here again, the time factor and case load predetermined the extent of the diagnostic interview and any preliminary remedial work that might have been indicated. (c) A general assessment of temperament and personality was made during the administration of the tests, based on:— 1. Observation of the individual. 2. The Individual's reaction to the psychologist. 3. The Individual's reaction to the test and the test situation. 4. The Individual's reaction to a word reaction test. (d) The preparation of a report based on the interpretation of (a), (b) and (c) in the light of historical details and information provided by the Remand Home reports and those of the Special Officer, the Probation Officer and the School. Analysis of case material Although no systematic investigation or research could be undertaken, several points of interest emerged from a preliminary study of the results of the Psychological Examinations. It is hoped that more details and fuller results will be published later elsewhere. 96 (a) Relationship between Intelligence and Delinquency. From the examination of 545 boys, ranging in chronological age from 7 years, 4 months, to 16 years, 11 months, and in Intelligence Quotients from 56 per cent, to 147 per cent., it appeared that:— 1. Only 9 per cent. (49 boys) had an I.Q. under 75 per cent. (i.e., are Educationally Sub-normal). 2. 80 per cent. (431 boys) were between the I.Q. range of 81 per cent. to 120 per cent. 3. 66 per cent. (357 boys) were between the I.Q. range of 86 per cent. to 115 per cent. (i.e., were of low average to high average intelligence). 4. 50 per cent. (271 boys) were below an I.Q. of 95 per cent. 5. 50 per cent. (274 boys) were above an I.Q. of 95 per cent. It must be noted also that it was possible for the general level of intelligence to be even higher than shown in the statistics in view of the fact that where emotional inhibitory factors were present, the tendency would have been for the assessment of Intelligence to have been an underestimate. From this preliminary review and with this material the evidence did not support the view, held by some, that the majority of delinquents come from the lower levels of intelligence. (b) Relationship between Reading Ability and Mental Age amongst 397 delinquent boys remanded for a psychological examination. Here again, from a comparison of Reading Age and Mental Age, very serious retardation did not appear to be quite so extensive among delinquents as is generally supposed. This was all the more surprising since a number of those examined had at some time or other truanted from school. Retardation undoubtedly existed in this sample, both among the higher and the lower levels of Intelligence (I.Q.s 57 to 140) and at all ages (from 7 to 16 years). Out of 397 cases, in a comparison between Reading Age and Mental Age, a group of about 50 per cent. were either above the level of their Mental Age in Reading ability, of an identical level or less than one year below it. Only a group of less than 8 per cent. could not read any words at all. The amount of retardation would probably have been greater if chronological age had been taken as a basis of comparison instead of Mental Age. It was felt, however, that the chronological age would not have been a true measure as Intelligence must necessarily be an important factor in attainment. This view was supported in an analysis of the results among the lower levels of Intelligence, where the individual was able to attain a Reading Age level approximating to his Mental Age, but nevertheless, well below his chronological age. In considering the tentative conclusions in both sections it must be remembered that the boys submitted for a Psychological Examination were really a carefully selected group. Before any definite conclusions can be made more records must be analysed and a comparison must be made with the results of an examination of other delinquents in the Remand Home, who have not been selected for a Psychological Examination. Epileptics and "Difficult" Girls A random sample of 213 cases, male and female, referred for "special" examination during the 1948-49 period was searched for the incidence of epilepsy. Through the generous co-operation of the Maudsley Hospital Electro-encephalographic Department it was possible to check doubtful cases through this special examination. The results of this analysis were as follow:— Frankly epileptic 4 cases. Suggestive Electro-Encephalogram (no fits) 1 case. 97 Relating this with the total number of children examined in a year it was estimated that approximately 10 epileptic cases pass through the remand home during a year. Largely owing to associated personality defects, the difficulties which they offer, as regards control and disposal, are often out of all proportion to their numbers. Rheumatism Scheme (I am indebted to Dr. C. T. Thornton, who not only supervises the whole scheme but who is also the physician to the cardiac wards at Queen Mary's Hospital for Children, for the information in this section of the report.) In reviewing the work of the Council's Rheumatism Scheme during 1949, the most interesting fact revealed is the extraordinary decrease in the number of children nominated for institutional treatment (Table 32, p. 139). In 1949 the number of nominations received was only slightly more than half the number received during each of the preceding two years. Not since 1927 (the first complete year the Scheme was in existence) have there been so few nominations, and if this number can be regarded as an index of the prevalence of juvenile rheumatism in London, it indicates a most unusual decrease. In the annual report of the School Medical Officer for 1948, it was pointed out that during the three post-war years (1946, 1947 and 1948) the number of nominations for institutional treatment had remained fairly constant (613, 690, 638 for the respective years) but at a much lower level than in the pre-war years when, in an average year, about 2,000 nominations were received. This decrease was much greater than could be explained by the decrease in the school population in the years succeeding the war. In the same report it was suggested that the decrease might be in part due to an increasing tendency to nominate only the more severely affected children instead of (as in pre-war years) regarding prolonged institutional treatment desirable for even the mildest attacks of rheumatic infection. But although there may have been some truth in this supposition, it would be unlikely to be the explanation of the remarkable decrease revealed by this year's figures. It may be that hospitals are now tending to deal with the cases themselves or through the regional hospital organisation instead of through the school health service but there is no definite information on this, one way or the other. Apart from this possibility the figures seem definitely to point to an absolute decrease in the prevalence of rheumatic infection. It may be that this decreased prevalence during 1949 was a temporary phenomenon associated with the exceptionally "fine" weather which prevailed during the greater part of the year which, doubtless, reduced the incidence of upper respiratory infections in children. If this was so, it may be expected that a more "normal" year, from a weather point of view, will be conjoined with an increase in rheumatic infection. There is, however, another factor which may in the future have an increasing influence on the prevalence of rhematism. During the last few years (and probably especially during 1949), sulphonamide and penicillin therapy for throat infections has greatly increased. The treatment of throat infections by these compounds usually quells the infection within a few hours with a consequent greatly diminished risk of an allergic rheumatic reaction. It may be that the decrease in the number of nominations for institutional treatment indicates a real decrease in the prevalence of juvenile rheumatism. Whether or not this decrease will continue remains to be seen. Cardiac damage Figures showing the percentage incidence of cardiac involvement in children admitted each year to the rheumatism units between 1935 and 1949 inclusive are given in Table 35. This year, for the first time since 1940, a substantial decrease is evident, although the figure is still much higher than the figure for 1940 (51.7 per cent. in 1949 compared with 32.1 per cent.). It must be, however, emphasised that these figures refer to cardiac involvement and do not imply that permanent cardiac 98 damage occurred to this extent; in fact, of the 331 children admitted to Queen Mary's Hospital, Carshalton, in 1949, permanent cardiac damage was present in only 29 per cent. It is of interest to compare these figures with those obtained by an analysis of the extent of permanent cardiac damage found in 1,094 rheumatic children in 1934. In that year cardiac involvement was found to be present in 54.8 per cent, of children admitted to the units, and permanent cardiac damage ensued in 41.2 per cent, of admissions. The difference in the percentage of children with cardiac involvement in 1934 and 1949 is negligible, but the difference in the percentage of children who suffered permanent cardiac damage is substantial. Table 34 shows the end results of treatment so far as fitness for school or work is concerned. As in the preceding year about 85 per cent, of the children discharged were regarded as fit to attend an ordinary school or to take up ordinary occupations on leaving school. This, of course, does not imply that the heart had entirely escaped damage and with younger children a recurrence of the rheumatic infection might entirely alter the final picture. Supervision An additional supervisory centre was opened at Wick School Treatment Centre, Hackney Wick, E.9, in 1949, making a total of 24. The number of attendances at the centres increased slightly during 1949. It has been agreed that the responsibility for such specialist clinics as these supervisory centres will in future be that of the Regional Hospital Boards or Teaching Hospitals. So far this has made little difference but when the out-patients clinics at the Royal Waterloo Hospital were closed, the supervisory centre which was there was removed to St. Thomas's Hospital and opened as part of the paediatric department. While the centres have served a most important function, it is considered desirable to associate them closely with a cardiological department so that full advantage may be taken of modern equipment. Reports by Care Committee workers on the home conditions of rheumatic children in 1949 show that there has been some improvement but very many families are still deplorably housed. Reports of damp, dilapidated and overcrowded dwellings were very numerous. The local medical officers of health were informed of these and it is desired gratefully to acknowledge their ready co-operation in taking such action as was possible to ameliorate the insanitary conditions found to be present. Prognosis During the year a beginmng was made of an investigation into the ultimate outlook when a child has suffered from rheumatic infection. It is hoped that it may be possible eventually to trace a statistically significant number of the children who have been treated at Queen Mary's Hospital, Carshalton, since 1926. The workers in the School Care Organisation are co-operating in this arduous task, and for this and their social work in connection with investigations into home conditions of rheumatic children I tender my grateful thanks. Audiometric Testing Tests of the hearing of pupils over 7 years of age, by means of portable gramophone audiometers with which specially trained school nursing sisters are able to test forty pupils at one time, were carried out in schools during the year. Three audiometers were used, originally in three divisions, but the work was extended into neighbouring divisions as far as possible. Arrangements are in hand for the purchase of more audiometers so that testing may be carried out in every division. Any child with a loss of nine decibels or more in either ear was tested a second time with the 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 99 test with a pure tone audiometer with a view to obviating the reference to special E.N.T. centres for treatment of those not in need of it. The total number of children tested by gramophone audiometer was 26,241, of whom 5,831 failed in the first test and 1,386 in the second test. It was only possible to arrange for 608 of the latter to be tested by pure tone audiometer and, of these, 303 failed. Those who failed the pure tone test, together with the remaining 778 of those who failed the second gramophone test, were referred to special E.N.T. centres. A total number of 728 children completed treatment at these centres during the year and of this number, 198 again failed the audiometer test and were referred to aurists for consideration as to further treatment. Problem, Children The Council's scheme, established in 1944, to co-ordinate the local arrangements for special children's case work was continued in 1949. Particulars of all schoolchildren presenting difficulties in behaviour are referred to a case conference of senior officers of the Education Officer's and School Medical Officer's departments. There is one in each of the nine divisions into which London is divided for education and school health purposes. Suitable cases are referred by the conferences to child guidance clinics provided by hospitals, by voluntary associations, and by the Council. Treatment is free. The number of children referred to case conferences during the year 1948-49 was 1,566. These cases were disposed of as follows: 1,107 were referred for child guidance, 11 for attendance enforcement, 78 for medical treatment, 128 to special classes, 16 for boarding education, 10 for foster homes, 113 for ascertainment for maladjustment, 80 for statutory examination to ascertain whether educationally sub-normal, and 261 were dealt with in other ways. The total of 1,566 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: 573 were no longer considered to be "problems," 124 were in residential accommodation, 69 were on the waiting list for such accommodation, 830 were under treatment at child guidance clinics, 199 were on the waiting list to attend the clinics, and 746 had been otherwise dealt with. At the end of the year eight successful classes under specially experienced teachers had been organised for children who presented some form of maladjustment. The Council's residential accommodation for maladjusted childern was as follows:— (1) Peckham Residential Special School (renamed Bredinghurst)—45 boys, most of whom attended local schools, some of the younger children being educated on the premises. (2) Braughing Hostels, near Ware, Herts.— 25 boys and girls. 260 maladjusted children were in residence at other schools belonging to the Council 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 units at Bishop Creighton House and Putney Health Centre. All other child guidance facilities for children of school age were under the control of the Regional Hospital Boards, the Governors of Teaching Hospitals or Voluntary Associations. A further survey of psychiatric services in London was completed early in the year. It was decided to proceed with the establishment of a child guidance unit, at Water Lane, Brixton, in co-operation with the Governors of the Maudsley Hospital, who would use it for teaching purposes in child guidance. The term "child guidance unit" is used to indicate that the work of both a "child guidance clinic" and a "child guidance centre" is done there. 100 Diabetic Unit The Council's residential diabetic unit for about 50 children is housed in the residential school at Hutton, Essex. During their stay at Hutton the children are taught the principles of the control of their disease and the importance of dietary. They are also trained to give themselves injections of insulin. The only restriction placed on the 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. The day to day care of the children was undertaken by a visiting medical officer and by nursing staff with special experience. A consultant visited fortnightly and at such other times as were necessary. The laboratory work to ensure control was undertaken by the staff under the supervision of the consultant. The pupils took part in all school activities, including a fortnight's visit to a holiday camp. About half the children at the school are sent and maintained by authorities other than London. Children under 5 years of age During the year an inspector of the Education Officer's Department visited primary schools where there was a number of children under 5 years of age. Where she was prepared to approve a nursery class, the Divisional Medical Officer was consulted, and arrangements made with a view to introducing some approximation to nursery school conditions. At the end of 1949 there were 114 nursery classes with accommodation for approximately 3,800 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. In contrast, 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 16 maintained day nursery schools with accommodation for 1,047 children from two years upwards and six aided day nursery schools with accommodation for 263 nursery school children. All the children in nursery classes and schools were supervised daily by school nurses and each child examined in detail every term by a school doctor. There was a total of 12,160 children under five years of age on the day school rolls, 10,492 being in the Council's schools and 1,668 in voluntary or aided schools. There were nine residential nursery schools outside London with accommodation for 429 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 County Hall visited each term. Co-operation with hospitals Arrangements continued to be made with some of the former voluntary hospitals whereby one or more of the Council's treatment organisers attends the children's out-patient departments, at the request of the hospital authorities, to form a link between the hospital doctors and almoners and the school health service. The hospitals concerned are the London, Guy's, West London, Royal London Ophthalmic, Belgrave, Poplar and London Jewish Hospitals, the Queen Elizabeth Hospital for Children, Shadwell and Hackney and the Children's Hospital, Sydenham. These arrangements have, in some instances, been extended to other departments. 101 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 Minor ailments. Eastern Hospital Aural Evelina Hospital Eyes Guy's Hospital Eyes, aural, skin, orthopaedic and diphtheria carrier clinic Hampstead General Hospital Rheumatism King's College Hospital Eyes and Rheumatism London Hospital Eyes and teeth Moorfields, Westminster 1. City Road— Eyes and orthoptic and Central Eye Hospital 2. High Holborn — Eyes and orthoptic Paddington Hospital Aural 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 National Throat, Noseand Ear Hospital Aural St. Mary Abbott's Hospital Aural St. Marylebone General Dispensary Rheumatism St. George's Hospital Rheumatism St. George's in the East Hospital Aural St. Mary's Hospital Eyes, aural and rheumatism St Olave's Hospital Aural St. Thomas' Hospital Rheumatism South Eastern Hospital for Children Eyes, aural and nutrition Western Ophthalmic Hospital Eyes Westminster (All Saints Genito-Urinary) Enuresis There are in addition several hospitals where the treatment organiser undertakes the making of appointments for the tonsil and adenoid department although she is not present at the session. She also does the following-up of schoolchildren in co-operation with the Almoner. 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, the special clinics, the School Health Service doctors and the voluntary school care committees:— Children's Dept. Ear, nose and throat Eyes Orthopaedic Skin General Orthoptic New school children seen 427 532 211 76 171 117 Attendances of current cases 1,437 1,337 — 752 257 483 Discharged—treatment completed 220 251 89 14 87 31 Referred to other departments 117 — — — 28 4 Lapsed through non-attendance 50 — — — — — Referred for operation — 201 — 51 24 — Glasses ordered — — 231 — — — Glasses obtained — — 162 — — — No glasses needed — — 105 — — — Re-tested—no change of glasses — — 186 — — — Referred to Child Guidance Clinic 32 — — — — 2 The total number of attendances of L.C.C. children in departments covered by the organisers was 6,647. 102 DENTAL SERVICES The Council's Chief Dental Surgeon, Mr. Wm. Ritchie Young, V.K.D., F.D.S., R.C.S. (Eng.), reports as follows :— Throughout 1949 efforts were continued to disentangle responsibility for dental services in accordance with the various directives operating the National Health Services. In the dental treatment centres* remaining thoughout the year under the jurisdiction of the Council arrangements were made, as far as possible, to have dental treatment carried out by the responsible authority under the National Health Service Act, 1946. Authorities responsible for dental care as laid down in the Act are:— Regional Hospital Boards (Part II of the Act) — Dental care in hospitals including dental care of tuberculous and mental patients. Local Health Authorities (Part III of the Act) — "Priority" dental services for expectant and nursing mothers and children of pre-school age. (N.B. In addition under the Education Act, 1944, children at school). Local Executive Councils (Part IV of the Act) — The "General Dental Service" for any person in private premises and/or in health centres. All three dental services remained intermingled although there was some clarification during the year by allotting specific individuals and specific surgeries for use on only one service. Following pre-5th July, 1948, arrangements, certain Part IV (General) and Part II (T.B.) dental services continued under the Council's auspices in thirteen treatment centres. The greater financial attraction of dental practice elsewhere continued to reduce the Council's dental staff and for a second year it was not possible to extend and improve the dental services committed to the Council's care, and the Council's policy has had to continue to be held in abeyance. As a result of loss of staff throughout the year and inability to recruit on a firm basis, fifty-eight surgeries out of a total of ninety-six were closed or partly closed at the end of the year. Included in this figure (58) are all ten of the mobile dental units purchased in 1947, and which, for a short time, proved so successful until staff resignations necessitated their withdrawal from service. The two dental fields in which the Council has statutory obligations are (a) the dental inspection and treatment of school children (Education Act, 1944), and (6) the dental care of expectant and nursing mothers and pre-school children (Section 22 National Health Service Act, 1946). It is the ultimate intention of the Council to integrate these two services to form a "priority" service as envisaged in the National Health Service Act, 1946 but it has only been possible during 1949 to do so in seven full-time treatment centres. Other centres deal mainly with either one or the other type of service and it is, therefore, convenient to present tables of the work carried out and the staff position under the two headings "School Dental Service" and "Maternity and Child Welfare Dental Service." School Dental Service STAFF Full-time Part-time Equivalent to Full-time Total Full-time Establishment Full-time At end of 1948 43 21 10 53 67 At end of 1949 31 27 14 45 07 *Some centres have more than one dental surgery. 103  1946 1947 1948 1949 Number of Inspection Sessions at Schools 1,315 1,588 1,230 946 Number of Children Inspected at Schools 138,290 163,528 158,063 96,201 Number found to require treatment 91,441 109,169 102,344 61,445 Percentage requiring treatment 66-1% 66-8% 64-7% 63-9% Additional number inspected at Centres * * 44,068 65,380 Total number found to require treatment * * 146,412 126,825 Total cases treated 91,601 104,305 118,439 102,495 Attendances 171,554 199,840 236,175 203,523 Ordinary treatment sessions 15,017 19,737 22,619 19,133 General anaesthetic sessions 1,495 1,679 1,774 1,685 Temporary teeth extracted 110,177 116,795 116,664 109,467 Permanent teeth extracted 18,999 18,716 20,641 18,103 Temporary teeth restored by fillings 31,117 39,685 43,033 34,506 Permanent teeth restored by fillings 72,303 82,309 94,561 67,395 Fillings in temporary teeth 33,262 42,222 45,617 36,341 Fillings in permanent teeth 79,866 92,335 104,913 73,740 Other operations — temporary teeth — — 28,406f 38,649 Other operations — permanent teeth — — 25,602f 32,888 Local Anaesthetics for extraction 22,807 24,857 24,859 24,328 Local Anaesthetics for conservative treatment 4,003 5,582 5,372 2,926 General anaesthetics 34,664 38,036 41,292 39,455 Cases completed 73,006 86,166 98,474 85,755 Statistics 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 I 1949 3.72 to 1 *Figures not available, †Figures for April to December only. Routine dental inspections in schools were, for the second consecutive year greatly curtailed to prevent severe congestion at the remaining treatment centres. Dental care of children in approved schools and residential establishments also had setbacks. At most of the Council's establishments of this nature part-time local dental surgeons attended prior to 5th July, 1948 and, as their private commitments increased following the introduction of the National Health Service Act, many of them resigned. Residential Establishments The position in 1949 compared with 1947 and 1948 was as follows :— 1947 1948 1949 Ordinary treatment sessions 643 645 572 General anaesthetic sessions 9 11 12 Number of children inspected 6,523 6,781 5,648 Number found to require treatment 3,329 2,996 2,333 Percentage requiring treatment 51.0% 44.2% 41.3% Attendances for treatment 3,792 4,688 4,179 Temporary teeth extracted 1,033 1,097 1,128 Permanent teeth extracted 336 390 271 Temporary teeth restored by fillings 855 1,202 1,058 Permanent teeth restored by fillings 1,967 1,916 1,555 Fillings in temporary teeth 1,048 1,354 1,161 Fillings in permanent teeth 2,166 2,128 1,715 Completed scalings 706 914 700 Temporary dressings, etc. 631 709 745 Local anaesthetics for extraction 793 830 832 Local anaesthetics for fillings 61 133 71 General anaesthetics 163 183 163 Cases completed 2,284 2,524 2,357 At the end of 1949 a number of these establishments had local pain-relief services only and no systematic examination and treatment was being carried out. 104 Sodium Fluoride treatment In 1948 I reported certain investigations at Hutton and Hornchurch Residential Schools on the effect of topical applications of sodium fluoride to children's teeth. At both schools results were inconclusive as movements of children destroyed continuity of treatment and subsequent investigation. In September, 1949, the Council appointed three dental hygienists in order to conduct a more comprehensive investigation of the efficacy of sodium fluoride and this staff, under the supervision of full-time dental surgeons, will treat throughout a period of two years a number of caries-free or dentally fit children. Half the number will receive careful dental prophylaxis only while the remainder will be treated in addition with 2 per cent, sodium fluoride. At the end of a year revisional examination should indicate the degree of recurrence of dental caries in the two groups. Caries investigation Further examinations of the dental condition of five-year-old school childre were undertaken during 1949 by Lady Mellanby on behalf of the Medical Researc Council, and the following table shows the results of her findings during 1929-194J Year Children Teeth Total number examined per-cent caries-free per-cent caries-free + those almost caries-free Total number of teeth per-cent caries-free 1929 1,293 * 4.7 - - 1943 1,870 14.9 24.2 36,196 69.9 1945 691 24.2 28.1 13,381 73.5 1947 1,590 28.1 37.5 30,839 79.7 1949 692 14.9 24.9 13,328 73.3 *The percentage of caries-free children at this time was negligible. In the report on her findings, Lady Mellanby states "it is difficult at present to suggest a reason for this apparent lapse between 1947 and 1949, following the previously observed improvement in the dental condition of children of the same age group; it may represent merely a periodic fluctuation, or it may mark the beginning of a progressive deterioration. It is hoped to make a sixth survey in 1951, when it will be seen how the trend has resolved itself." Orthodontic treatment The revised method, introduced during 1948, lor obtaining treatment of dental deformities was continued throughout the year under review and an increased number of children were given orthodontic treatment without reference to specialist orthodontists. Throughout the year the Council's four part-time orthodontists completed 418 cases while, in addition, 649 (compared with only 229 in 1948) were treated by the dental surgeons, and 67 cases were accepted by hospitals; a total of 1,134. 1947 1948 1949 Number of orthodontists (part-time) 2 4 4 Number of sessions 411 542 569 Total number of new cases 573 923 1,134 In the ordinary treatment centres most orthodontic cases are treated by means of removable appliances all of which are fashioned at the Council's Central Dental Laboratory. The increased demand on the laboratory for this highly skilled service has offset the decreased demand for dentures consequent upon the transference of much of the adult dentistry to the Regional Hospital Boards. As and when the Council's dental service for mothers is developed the demand for dentures is likely again to increase. 105 Maternity and Child Welfare Dental Service The number of maternity and child welfare dental sessions in operation per week at the end of 1949 was seventy compared with sixty-eight at the end of 1948. The state of this service would have been much worse but for the fact that forty-two sessions were taken from school-work by the transference of school Dental Officers in order to bolster up the almost collapsed maternity and child welfare service, as during 1949, eleven out of 23 part-time dental surgeons engaged on maternity and child welfare duties resigned. Owing to the inadequate staffing of the Council's dental service, an unknown volume of dental treatment for expectant and nursing mothers (Part III service) continued during 1949 to be carried out by the dental surgeons in the hospitals (Part II service) transferred from the Council to the Metropolitan Regional Hospital Boards in 1948 and many mothers, no doubt, obtained treatment under the Part IV (General Dental Service) Scheme. Dentures for maternity and child welfare patients continued in some centres, as pre-5th July, 1948, to be made in private laboratories on a piece-rate payment basis, but in 1949, whenever possible, their production was transferred to the Council's laboratories. A tabulation of attendance and treatment figures for the year is given below with comparative figures (where available) for 1948. 1948 1949 Number of Ordinary Sessions 4.982‡ 2,682 Number of General Anaesthetic Sessions 288‡ 364 Number of appointments offered * 31,338 Failed to attend * 6,477 Attended— By appointment 36,710 24,861 Others 5,392 Examinations * 12,057 Treated— First treatment 10,959 7,032 Others * 13,447 Silver Nitrate Treatment 416 2,938 Scalings 1,324 1,364 Prolonged Gum Treatment 135 212 Fillings 8,549 8,564 Inlays * 23 Crowns 1 5 Number of Teeth Conserved * 7,988 Extractions 17,355 16,560 Dressings 598 2,236 Anaesthetics — Local 349 1,784 General 3,645 4,563 Number of Patients prepared for dentures * 3,359 Number of Patients supplied with upper or lower dentures * 960 Dentures supplied — New Full (upper or lower) 2,176 652 New Partial 775 Remakes 8 7 Repairs 235 126 Number of Patients X-rayed * 56 Number made dentally fit * 5,283 ^Includes sessions at which attendances, not included in the analysis, were made by other than maternity and child welfare patients. •Not available; mainly because of variations in record keeping by the metropolitan borough council dental clinics prior to July, 1948. It may be observed that the dental examination and treatment for which the Council is responsible was reduced under nearly all headings during 1949 and a report on the parlous state of their Priority Dental Service was presented to the appropriate Committees towards the end of the year. The concluding sentence of that report stated, "unless some method of remuneration is agreed upon for all three branches (i.e. General, Hospital and Local Health Authority) which gives approximately the same reward for the same amount of work it is unlikely that the local health authority Priority Dental Service will improve but will continue to disintegrate." 106 STAFF During 1949 there were no large scale developments affecting the staff of the department and the principal, but not spectacular, task was to proceed as far as possible with the solution of the many problems arising from the legislation which came into force in 1948. Nurses' salaries The recruitment position as regards nursing staff at welfare institutions has been very difficult for some time past. In October, 1949, the Nurses' and Midwives' Whitley Council announced that the revised scales of pay and conditions of service announced earlier in the year for hospital nurses should be applied to nurses at welfare institutions. The increased scales of salary were therefore applied to the nursing staff at the Council's welfare institutions engaged in the nursing of the chronic sick or employed in the mother and baby units. These increased salaries which rise to £500 a year for ward sisters and £415 a year for staff nurses should result in some improvement in recruitment. There were no Whitley Council awards during 1949 affecting other nursing staff in the Public Health Department. Health visitors I am pleased to state that there was a significant improvement in the recruitment of health visitors and tuberculosis visitors. So far as the health visitors are concerned, this is due to some extent to the training scheme which the Council initiated in 1948, in conjunction with the Kings College of Household and Social Science, to alleviate the shortage of health visitors in London. The student health visitors are trained nurses with a midwifery qualification and are paid three-quarters of the qualified health visitors' salary during their training but are responsible for their own tuition expenses. The first students to complete the one year's course of training sat for the examination of the Royal Sanitary Institute and all succeeded in obtaining Health Visitors Certificates. The full quota of twenty-four students commenced the second course of training in October. 1949. Co-operation with hospitals In order to afford medical staff of child welfare centres, whose duties also include the inspection of schoolchildren, opportunities to broaden their experience with sick children arrangements were made for the exchange of medical staff between the Council and the Hospital for Sick Children, Great Ormond Street. Under this scheme a number of the Council's assistant medical officers take sessions in the out-patient department of the hospital on one morning a week each and in return, senior registrars of the hospital take an equivalent number of sessions in the Council's maternity and child welfare centres. Training of postgraduate medical students Arrangements were also made for the Council to continue co-operation with the Institute of Child Health in the training of postgraduate students which was carried out by the St. Pancras Borough Council prior to 5th July, 1948. One of the Council's divisional medical officers holds the appointment of Director of Field Studies at the Institute and two of the assistant medical officers were appointed Demonstrator in School Health and Demonstrator in Child Health respectively. Each student from the Institute visits a child welfare clinic where he or she remains with the doctor throughout the session and learns the layout of the centre, its administration, the aims of the child welfare scheme, and the type of advice which is given. Similarly each student attends a school medical inspection while small groups visit school treatment centres, nurseries, and the main types of schools for handicapped children. Staffing of dental services I referred in my report for 1948 to the problem of the staffing of the priority dental services. The Whitley Council for dental surgeons employed by local health authorities did not meet until after 1949. The remuneration paid to dentists in general practice continued to be considerably in excess of that paid by local health authorities which had a very unfortunate effect on the Council's service. Authority was given, as an experiment, for four specially trained dental hygienists to be engaged at a rate of pay of £7 a week to carry out prophylactic 107 treatment of children's teeth by the topical application of a solution of sodium fluoride. The following statement shows the number of staff employed in the Public staff of the Health Department in mid-1949 (Part-time staff being expressed as whole-time DePartment equivalents). Type of staff Location Total Head office staff Divisional staff Staff employed at other establishments (a) Administrative and clerical (including ambulance clerks) 229 583 69 881 Medical staff 20 159 (b) 179 Dental staff 2 64 (c) 66 Chemists 16 — 7 23 Inspectors 15 — — 15 Nursing staff 11 2,699 356 3,066 Medical auxiliaries (d) — 122 22 144 Social worker grades (including mental health) 28 147 79 254 Supervisory staff (London Ambulance Service) 3 - 13 16 Manual workers, operative staff (L.A.S.), domestic grades, etc. 3 2,028 616 2,647 Totals 327 5,802 1,162 7,291 NOTES (a)These establishments include residential schools and nurseries, welfare establishments, ambulance stations, occupation centres for mentally defective children, main drainage outfall works, clinics and dispensaries, district offices (mental health), central dental laboratory, etc. (b) There are some 70 visiting medical officers employed at residential establishments on a part-time basis whom it is not possible to compute in terms of whole time units of staff. They have, therefore, been omitted from the table. (c) There are 12 visiting dental surgeons employed in a similar manner as the medical staff referred to in note (b) above who have been omitted from the statement. (d) Including physiotherapists, chiropodists, speech therapists, orthoptists and dental attendants. 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 12,184 compared with 14,689 in 1948. Medical examinations Reciprocal arrangements with provincial authorities for the examination locally of new entrants were continued. Provincial medical officers of health arranged examinations for 19 entrants to the Council's service and the Council's medical officers examined 14 persons for provincial appointment. The Council's staff medical examiners made 81 home visits to examine members of the staff who were unable to travel, compared with 50 during 1948. REPORTS BY THE DIVISIONAL MEDICAL OFFICERS Divisioti 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington. Dr. Violet Russell reports:— During the greater part of the year the administration of the medical services in the Division was handicapped by the long absence on sick leave of Dr. Harry Smith, the late Divisional Medical Officer, and his untimely death in September. This sad loss is regretted by all his colleagues and will be felt for some time to come. Nevertheless, the result of the year's work may be regarded with satisfaction. Difficulties arising from the momentous administrative change of July, 1948, have been surmounted, and stabilisation is being followed by steady and satisfactory progress in many directions. In this Division the maternity and child welfare work dates back to the days of the pioneers, with the consequent disadvantage that many of the welfare centres H 108 are in old and unsuitable buildings. The same can be said of many of the medical inspection rooms in the schools, and of the treatment centres. An additional school treatment centre was opened in Fulham during the year, and the Council's plans include improved premises for several of the welfare centres in the Division in the near future. In the borough of Chelsea the Council's maternity and child welfare work is efficiently carried out by the voluntary committee of the Violet Melchett Infant Welfare Centre, and co-operation between this centre and the divisional organisation is excellent. In the other three boroughs importance is attached to the development of a team spirit among the maternity and child welfare medical officers. At their periodical conferences matters of medical and administrative interest are discussed, and advances made in one area are followed in the others. By this means the progress of " levelling-up " the difference in the three boroughs has been continued, and doctors are encouraged to keep up-to-date in their teaching. Attendances of mothers and children at welfare centres have been satisfactory, and special sessions for the routine examination of toddlers have been introduced throughout the Division. The great demand for admission to day nurseries continues, and there is always a long waiting-list. A few sporadic cases of poliomyelitis occurred in the nurseries during the summer, but fortunately did not assume epidemic proportions. An outbreak of Sonne dysentery in one nursery was quickly brought under control. The day nurseries are supplemented to some extent by the registered child-minders, but the greater cost of the latter service to the mothers is a deterrent. The shortage of hospital and sanatorium beds has added considerably to the work both of the district nurses and of the Council's home helps. The four district nursing associations have carried out sterling work throughout the year. The home help service is extremely popular and, although the provision has been increased from the preceding year, the demand still exceeds the supply. A number of home helps were successful in obtaining the diploma of the National Institute of Houseworkers. The medical work in the schools has progressed smoothly. An unfortunately large number of children need to be referred for child-guidance treatment; it is hoped that this state of affairs may improve as the war years recede and housing becomes more adequate. One feels, however, that education of young people in parentcraft will bring in useful dividends. It is satisfactory to record that this health education, which should be the key-note of the personal health services, is being carried out by the health visitors in the Division, and at several welfare centres they have organised systematic courses of lectures in parentcraft. This work is of very great importance, and it is hoped that neither shortage of staff nor any increase in the health visitors' duties will be allowed to interfere with its expansion. The successful functioning of the Council's organisation in the division depends not only on the efficient execution of its own duties, but also on effective co-operation with a wide range of other agencies, both public and private. This co-operation is a continuous process, but I may mention two examples of joint work which were outside the normal. In February a meeting with officers of the Ministry of Food and voluntary organisations was held in Kensington, at which Dr. Geoffrey Bourne gave an address on the value of vitamin supplements. In March the Divisional staff collaborated with officers of the Hammersmith Borough Council in the exhibition in connection with Hammersmith Civic Week (see p. 79). In conclusion, I would thank the borough medical officers of health for their invariable and helpful co-operation, and would like to pay a tribute to the Council's staff in the Division, who have carried out their work with loyalty and efficiency during the year. 109 Division 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and Westminster. Dr. H. L. Oldershaw reports:— Premises. — The question of accommodation for health service establishments has caused some concern, and a large number of sites and buildings have been investigated as to their suitability for use as day nurseries or maternity and child welfare centres. It is hoped that substantial improvement in security of tenure will result from the purchase, or negotiation of long leases, in respect of 10 day nurseries and two maternity and child welfare centres formerly held on requisition or short term lease. During the year it was necessary to relinquish the tenancy of one part-time welfare centre in Paddington. In Hampstead a new maternity and child welfare centre was opened in a temporary prefabricated building, and the attendances since opening have been highly satisfactory. School Health Service.—The work of medical inspection in the 113 schools in this Division proceeded smoothly during 1949. During the latter part of the year a special " drive " was instituted to raise the general level of immunity against diphtheria among the primary school population of 44,120 by means of " boosting " doses of antigen. More than four thousand children were inoculated in the course of this " drive," while during the year a rather larger number was inoculated at the ordinary medical inspection sessions, giving a total of between eight and nine thousand in all. The number of Vision Clinics has been increased, but there is still too long a delay in the provision of spectacles. An additional Nutrition Clinic has been opened. A special Ear Clinic has been transferred to the Throat, Nose and Ear Hospital, and the re-arrangement is proving satisfactory. Maternity and Child Welfare. — The 54 Health Visitors engaged in the Division made a total of 120,490 home visits. The success of this section of the personal health service depends on the work of the Health Visitor, and the importance of these home visits cannot be over-estimated. There has been an increase of 11 maternity and child welfare sessions a week (62 in 1948, 73 in 1949). Although there are 1,398 places in the Day Nurseries, there is still a waiting list of over 2,000 priority applications. The Divisional Committee approved the registration of 9 child-minders caring for 78 children, and of 9 private nurseries providing 274 places. Holiday Homes. — No less than 1,739 applications were received for recuperative holidays for adults, expectant mothers, nursing mothers and children. Owing to the lack of suitable holiday homes, most patients for whom applications were made during the summer and autumn had to wait up to three months for a vacancy. Conclusion.—I would like to express my sincere appreciation to all my colleagues in the Division who throughout the year have given of their best to ensure an ever increasing and improving Personal Health Service. Division 3, comprising the boroughs of Finsbury, Holborn and Islington. Dr. A. B. Stewart reports:— During 1949 the Division had 12 day nurseries, with places for 651 children and six main and five branch maternity and child welfare centres. In addition, 110 voluntary organisations having grants in aid from the Council operated two welfare clinics, two branches, and two nursery creches, one of which, however, was closed during the year. Day Nurseries.—Two private nurseries, associated with industrial premises, were established and registered during the year. Fourteen women were registered also under the appropriate Act to mind a maximum of 45 children. In addition to these registered compulsorily a further 129 women were voluntarily registered to care for 132 children and received the Council's weekly registration fee. Forty registered foster mothers caring for sixty children also reside in the Division. The great demand for day nursery places continued. With the restricted accommodation only urgent priority cases were considered. At the end of the year 562 applicants were waiting of whom 308 were in the priority groups. Considerable progress was made towards equipping the nurseries up to the standard laid down by the Council, and the more urgent renovation work was started, use being made of the Divisional Committee's delegated powers to supplement the work of the Architect's programme. The Divisional Committee, in view of sparse attendances and in the interests of economy closed all but one of the Divisional day nurseries on Saturdays. It became necessary to close one day nursery owing to structural defects. The children were absorbed elsewhere and the staff transferred to duty at other nurseries. An outbreak of Sonne dysentery in a nursery resulted in the diagnosis of 15 cases. Suitable measures were taken, and all the children recovered. The facilities for medical inspection of day nursery children have been extended. The medical staff now visit weekly. Midday Meals.—The scheme for the provision of meals to expectant and nursing mothers and children under 5 on a selective basis on medical recommendation at two welfare centres was altered during the year so as to operate through the Council's restaurant service on a voucher system. Home Helps. — The expansion of this service was considerable. By the end of the year the number of households attended was 90 per cent, more than the corresponding 1948 figure. The available service was equitably distributed throughout the division. Eleven Home Helps were successful in obtaining the diploma of the National Institute of Houseworkers during the year. Vaccination and Immunisation. — 43 per cent. of babies under 12 months were successfully vaccinated during the year. Seven vaccination sessions were held each week at welfare centres. The mobile clinic continued its propaganda work for diphtheria immunisation during May, June and July; 1,555 injections were given in the mobile clinic. The immunisation sessions were increased from five to eight partly to cater for increased work in connection with whooping cough immunisation. Tuberculosis After Care. This work was carried out at the four chest clinics in the Division. There are three voluntary committees. The scale of issue of extra nourishment, which had varied from borough to borough, was standardised at an improved level and grants were made to 50 cases during the year. School Health Service. Additional nutrition clinics were commenced at two centres in the Division to cope with the number of children requiring attention. The other work of the department continued as before. Publicity. The co-operation of local newspaper editors and the borough librarians has resulted in the appearance of short reports and articles on public health topics of general interest and newspaper reports of the activities of the Divisional Health Committee. 1ll Foot Clinic. The clinic in Finsbury Health Centre, employing four full-time and also part-time chiropodists as required, continued to provide a service much in demand. Our thanks are due to the staffs of the various local organisations for their help during the year. Division 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports:— Day Nurseries. The heavy pressure on day nursery accommodation has continued, and the waiting list increased during the year to nearly 700, so that there is now approximately one child awaiting admission for each place provided. Owing to the lack of open spaces in Shoreditch, no facilities in the vicinity of the two day nurseries in that borough could be provided for the outdoor recreation of the nursery children. Arrangements were accordingly made for the children to be taken daily during fine weather to parks in adjoining boroughs. Seven private day nurseries, providing 217 places, have been registered under the Nurseries and Child-Minders Regulation Act, 1948. Child-minders. Three child-minders have also been registered under the Act for the daily care of 31 children. At the commencement of the year the Council's scheme for the voluntary registration of child-minders was put into operation in the Division ; 32 women were registered by the end of the year and the number was increasing. Domestic Help Service. This service was already well developed in the three boroughs of the Division before 5th July, 1948, and had considerably increased by the end of that year. It was necessary constantly to review the cases being assisted in order to ensure that the available help was spread over the maximum number of households. Over 1,800 applications for home help were received during the year, and assistance was provided each week in approximately 1,500 households. Of the home helps employed in the Division, 26 qualified during the year for the diploma of the National Institute of Houseworkers. Premature Baby Scheme. An experimental scheme for securing the proper care and supervision of premature babies has been introduced in the Division. Advice and instruction are given in the home by health visitors specially trained in the care of premature infants, and mothers are asked to bring these infants to a premature baby session held weekly for examination at ages 4, 8 and 12 months. A special statistical investigation is being conducted in conjunction with the scheme. Premises and Equipment. Considerable improvements have been made in the various premises, such as the provision of additional sinks in day nursery kitchens where only one sink previously existed, provision of refrigerators and sandpits where necessary, replacement of outworn linoleum, redecoration of kitchens and milkrooms, and the supply of additional educational play equipment. The annual programme provided for the internal and external redecoration of 3 day nurseries, a maternity and child welfare centre and a bathing centre, but this work had not been completed by the end of the year. Child Welfare Sessions at School Treatment Centres. The child welfare facilities in the Hackney Wick area were improved by transferring the work from a church hall to the unused first floor of the Wick school treatment centre, and in Shoreditch by commencing a weekly half-day session in the Hoxton school treatment centre. The latter arrangement helps to satisfy temporarily a need for additional centre 112 facilities in Shoreditch which arises from the bombing of centre premises in that borough. School Health Service. At the end of the year the Divisional Health Committee took over from the former voluntary committee responsibility for the administration of the Hackney school treatment centre. Thus there are now 3 centres under direct control and 2 managed by voluntary committees. The medical inspection and treatment of schoolchildren continued smoothly. An additional rheumatism supervisory clinic, and two additional vision clinics were started during the year. Under an arrangement between the Council and the North-East Metropolitan Regional Hospital Board a three-months' campaign was started in July to deal with the considerable number of schoolchildren in Divisions 3, 4 and 5 who had been recommended for operative treatment of enlarged tonsils and adenoids. This scheme had to be suspended after only one month, owing to the incidence of poliomyelitis. The nutrition clinics have been very fully attended, and the minor ailment treatment given daily in the school treatment centres has been supplemented by school nursing sisters who hold daily sessions in two schools. Division 5, comprising the boroughs of Bethnal Green, Poplar, Stepney and the City of London. Dr. G. O. Mitchell reports:— There are no startling developments of the service in the Division during the year to be recorded. Many of our clinics are held in buildings which leave a good deal to be desired, and we had hoped to have a comprehensive health centre in Poplar, but this project 'has been postponed for the present, and our plans for the future were further frustrated when the former centre of the Royal College of St. Katherine in Brunswick Road, Poplar, was denied us by reason of its having become derelict and decayed. We had hoped to rehabilitate it and transfer to it some of our neighbouring clinics, and so restore it to its pre-blitz condition of a flourishing maternity and child welfare centre. These disappointments have necessitated some reorientation in planning, and the immediate future is still a little hazy. The remoter outlook is necessarily wrapped in obscurity, and the longed-for materialisation of health centres seems, and quite likely is, very far away. However, the services continue to function satisfactorily; but in the direction of development and improvement we are forced to proceed, in the felicitous translation of the author of "Religio Medici," with "celerity tempered with cunctation." The educational needs of maladjusted and backward children have been recognised, and we have three classes for maladjusted children. The teachers of these classes work in co-operation with the Child Guidance Clinic and the School Doctor. In addition, we hope to have six classes for backward children as soon as the supply of teachers in the East London area will permit. During the year we have concentrated upon diphtheria immunisation in the schools and have given special attention to the immunisation records in the school registers. As a result of these efforts it would seem that in the majority of schools in the Division the percentage of immunised children is relatively high; but the need for a close watch on the immunisation of school children will continue. The incidence of scabies among school children continued to decline, the number of children treated at bathing centres being 106 in 1949 compared with 237 in 1948, and there has been further improvement in the cleanliness of the school child. For a short time during the year a number of beds for tonsillectomy cases was made 113 available at the Eastern Hospital, and five school nursing sisters from this Division volunteered to help in staffing them. There was a steady decline during the year of attendance at ante-natal clinics. The great majority of confinements in the Division take place in hospitals, due, in many cases, to the unsuitability of the home, and in many other cases to the wish of the mother, and there seems to be an increasing tendency for the hospitals to take over the complete ante-natal care of cases booked with them. The home help service continued in popularity and we managed to expand it slightly during the year. We have still room for further expansion within our financial limits, but recruitment is not now so brisk as it had been. In July a pleasant little ceremony was held at the new Christian Street day nursery to mark its formal opening. This project for a day nursery was initiated and well advanced by the Stepney Borough Council before the appointed day, and its completion enabled us to transfer the children from the rather cramped temporary accommodation at the Queen Elizabeth Hospital for Children, Shadwell, and so release much needed hospital space for normal ward purposes. During the year a useful link was forged between the local health and hospital services. By arrangement with the Queen Elizabeth Hospital for Children an assistant medical officer from the divisional staff visits the hospital for one session weekly in the capacity of clinical assistant in the out-patient department, while the Hospital, in return, supplies the services of a Registrar for one infant welfare clinic weekly. This liaison could be usefully extended if more full-time medical officers were available on the divisional staff. Division 6, comprising the boroughs of Deptford, Greenwich and Woolwich. Dr. F. R. Waldron reports:— During this, the first complete year of the Council's administration of the personal health services, the twin features of continued consolidation and limited progress were each apparent. The Divisional Health Committee have fostered this policy and besides attending regular meetings the members have systematically visited all centres. Administration was aided by three changes. Divisional headquarters, which had occupied accommodation in Greenwich Town Hall, was transferred in June to St. Paul's House, Deptford High Street. Although this location at the western extremity of the Division is less convenient than a central site, it is well served by public transport and is close to other local offices concerned with the health services. Moreover, this large modern clergy house on three storeys was usable as offices without extensive alteration. A Greenwich sub-office was opened at the same time at the welfare centre, 105 Shooter's Hill Road. By stages stores of all kinds, which previously had been held separately in the three boroughs comprising the Division, were concentrated in a central store at the Greenwich sub-office. The third administrative measure, namely the absorption of the school health service sub-office at 19 Breakspears Road into Divisional headquarters in September, promoted the integration of the school health and maternity and child welfare services. A second assistant to the divisional nursing officer was appointed, but otherwise it was a matter of improving the services within existing resources of staff. The following are instances of developments achieved:— (i) In July responsibility was accepted for personal health services in the Woolwich Garrison area, including the maternity and child welfare clinic provided by the military authorities for the families of serving men. These services are now also available to the civilian population and the weekly sessions have been increased from five to six. 114 (ii) Two weekly ante-natal and post-natal exercise classes, under a physiotherapist, commenced at the Amersham Road Centre, Deptford, in November, a facility which it is hoped to extend throughout the Division as opportunity arises. (iii) The arrangement with the Seamen's Hospital for the conduct of two immunisation sessions weekly was discontinued in October and replaced by facilities at the Council's Chevening Road Centre. (iv) Arrangements were made for improved spreadover of the Divisional chiropody service by the re-arrangement of sessions at Chevening Road Centre and by the transfer of sessions from Charlton Lane Centre to the nearby Fairfield House Centre, thereby ensuring the availability of treatment in those areas throughout the week. (v) In association with the Voluntary Committee, the Deptford School Treatment Centre was reopened in the rebuilt and excellently equipped centre at Reginald Square, and arrangements were made for the facilities to be extended. (vi) A weekly nutrition session was commenced at Westhorne Avenue (Eltham) School Treatment Centre. The paramount development was, however, that of the home help service. The number of persons attended increased from 300 on 5th July, 1948, to 600 on 1st January, and to 875 on 31st December, 1949. The wages bill amounted to £48,000 for the year 1949 and in the latter part thereof was running at £1,000 a week. Charges for the service produced an income of £7,300, or fifteen per cent, of the wages bill. At the end of the year 390 home helps were employed part-time, the equivalent of 150 whole-time units. In many instances more than domestic help and home nursing were called for ; and there is no doubt that the inability of hospitals to cope fully with the chronic sick was a material factor in the mounting demand for the home help service. What this service has meant not only in the care and prevention of physical illness, but in lifting anxieties and mitigating distress is shown by the following expression of appreciation by the manager of a housing estate within the Division:— "Your staff have not only completed their work most efficiently but have shewn those little off-duty kindnesses, by calling on the occupants who may have been sick, with little gifts of flowers, which have delighted the recipients beyond words. Thank you again for your most humane efforts to assist the aged." Division 7, comprising the boroughs of Camberwell and Lewisham. Dr. H. D. Chalke reports:— Premises Every effort was made to find improved accommodation for certain of the welfare centres in the Division. New centres were acquired at Consort Road and on the Flower House Estate. Church buildings at Townley Road, Dulwich, and Trewsbury Road, Sydenham, were also brought into use. Extension of the Louise House Centre, Forest Hill, has resulted in a big improvement in the maternity and child welfare facilities in this neighbourhood. Minor adaptations, alterations and repairs were carried out and additional equipment provided at many of the centres. A number of the premises in use—particularly church halls—are ill adapted for clinic work; it is gratifying to record, however, the splendid way in which the Council's and the voluntary staffs of these Centres coped with difficult working conditions. A new school treatment centre was opened at Gordon Road, whilst another was transferred from the Children's Hospital, Sydenham, to Adamsrill Road School. Sessions Ante-natal sessions additional to those attended by doctors and health visitors were arranged so that midwives of the Council, of the Camberwell District Nursing Association and of the Salvation Army (Downham) could see their patients at the 115 centres. All expectant mothers attending an ante-natal clinic are given a blood test which includes the Rhesus Factor. Three midwives of the Camden Grove District Home of the General Lying-in Hospital also operate in this Division. A post-natal clinic was opened in Camberwell and a further educational and ante-natal exercises session commenced at Forest Hill. Close contact was maintained with the obstetric and gynaecological departments of local hospitals, and a number of conferences took place during the year. Extra child welfare sessions were arranged at some of the centres where the attendances were large. In some instances, this could not be done as the accommodation was unavailable. An increase in the number of Schick testing and diphtheria and whooping cough immunisation clinics was found to be necessary. Authority was given for the holding of an evening Family Planning Clinic at the Sumner welfare centre ; the morning session formerly held there was transferred to the Consort Road welfare centre. A high standard of visiting was maintained, despite the continued shortage of health visitors which necessitated the carrying of a much heavier "case-load" than is desirable. In addition to their responsibilities in connection with mothers, and children under five years of age, many visits were paid to elderly folk, and to patients discharged from hospital. As this important aspect of their work develops, the need for more health visitors becomes increasingly urgent. Health visiting The home help service has been expanded to its fullest extent. Male home helps have been engaged primarily to work in the homes of aged males but it may take a little time for this development to become generally acceptable. A conference of home helps was held with the object of showing them how best to fill the important role they occupy in the personal health services scheme, and particular reference was made to aged persons. The conference was very successful and will be repeated. Home helps Much attention was given during the year to this increasingly important problem. More than half of the work of home helps was in connection with the aged, whilst district nurses also devoted a large proportion of their time to these cases. It was found possible to arrange recuperative holidays for a number of old folk. The visits paid by health visitors and the employment of male home helps have already been mentioned. There are a number of agencies—statutory and voluntary —concerned with the welfare of the aged and the aim has been to maintain the closest contact with them with regard to such matters as meals, suitable accommodation and general care and attention. Fuller co-ordination is, however, essential in order to prevent the aged from becoming bedfast unnecessarily and to free hospital beds so that those who are fit to return home may be enabled to do so. Welfare of old people The heavy demand on this service continued, but requests for admission of very young babies showed, fortunately, some decrease. The priorities for admission laid down by the Council were closely adhered to but every effort was made to secure temporary admission during the illness of a mother. The use of child-minders would reduce the demand for day nursery admission, but the number available is very limited. A number of private day nurseries have been registered by the Council, under the Nursery and Child-Minders Regulations Act, 1948. Day nurseries Attendances at the school treatment centres showed a steady increase. Extra nutrition and vision clinics were started, and regular audiometer sessions commenced. An orthodontic session was opened at King's College Hospital. Arrangements were made for certain rheumatic children to receive physiotherapy and special cases were seen by the consulting cardiologist at King's College Hospital. A school treatment organiser was attached to the medical out-patient department at the Children's Hospital, Sydenham, at the request of the physician. School Health Service 116 Care and after-care Close liaison continued with the chest physicians at the two chest clinics in the Division regarding the care and after-care of the tuberculous. A Tuberculosis Care Committee functioned in each borough. Where necessary, the Council provided home helps, extra nourishment, and beds and bedding, to the tuberculous. Occupational therapy in the form of handicraft classes was also provided. Health education Much attention was given to health propaganda. A film strip projector and suitable film-strips provided a popular adjunct to the health teaching given at the welfare centres. Mothercraft classes were held by nursing staff in schools. Numerous talks on general health topics were given by the medical and nursing staff of the Division. General The demands on the divisional staff have been very heavy and it is a pleasure to record the splendid way in which they have played their part during this very difficult period. The co-operation of the medical officers of health of Camberwell and Lewisham has proved invaluable, as has also that of the staffs of the hospitals, the medical practitioners and the members of voluntary organisations in the Division. Division 8, comprising the boroughs of Bermondsey, Lambeth and Southwark. Dr. W. H. S. Wallace reports:— Administration The administration of the health services in the Division was carried out from the Divisional Health Office at 128 Brook Drive, S.E.ll, with a sub-office in each borough. The work ran smoothly once the initial difficulties of the transfer had been overcome. Maternity and child welfare A new welfare centre situated on the ground floor of a new block of flats, Purser House, Tulse Hill, was opened by the Chairman of the Health Committee (Mr. Reginald A. Stamp) on 16th September. Ante-natal, post-natal, infant, toddlers, immunisation, artificial sunlight and massage clinics are held at the centre. The Family Planning Association also hold a clinic on one evening a week. A re-arrangement of the districts served by centres made possible the closing in September of the centre at 56 Lambeth Road. The policy of providing special ante-natal sessions for domiciliary midwives has been continued and new sessions are started at Gomm House, at St. Anne's and at Tulse Hill centres. Where possible these sessions are held at the same time as a doctor's session so that mothers can be referred to the doctor if any difficulty arises. Infectious diseases The outbreak of diphtheria which occurred in Bermondsey in June and July (see p. 22) led to a great demand for immunisation. From the time of the epidemic to the end of the year 2,500 children were immunised and over 4,000 schoolchildren received "booster" doses. School clinics New agreements are being made with the voluntary bodies who are still carrying on the administration of the school treatment centres in the Division. The committees of the Stockwell Centre in Lambeth and the Dockhead Centre in Bermondsey decided to give up their work and these centres are now administered directly from the divisional office. Home nursing The District Nursing Associations continued to administer the Home Nursing Service and there is still a great need for more district nurses. Some male district nurses have been appointed and their work has been most valuable in the special cases in which their services are required. Day nurseries and childminders Large numbers of applications for admission of children to day nurseries are still being received. Priorities were given in accordance with the Health Committee instructions but there were still waiting lists even for priority cases. The position was helped by an increase in the number of child-minders. It was possible to place a large number of children with child-minders in the Brixton area of Lambeth, but in North Lambeth and Southwark there was difficulty in meeting the demand. 117 The demand for home helps continued and the service was increased to the maximum that the financial limitations allowed. Home helps The difficulties in making adequate provision for the aged and chronic sick continued, and every effort was made to improve the facilities available. Most active efforts were made in Lambeth where there is an active Old People's Welfare Association and meals are supplied in the homes by the Women's Voluntary Services. The Lambeth Group Hospital Management Committee set up a sub-committee on which the Divisional Medical and Nursing Officers and the Borough Medical Officers of Health are represented, to discuss problems of the aged and chronic sick. Geriatric wards were opened at the South Western Hospital and a part-time medical officer appointed to be in charge of the patients in the wards and also to visit old persons in their homes. This has made a most valuable link between the hospital and personal health services. Old people Division 9, comprising the boroughs of Battersea and Wandsworth. Dr. Bertha E. A. Sharpe reports :— The second year under the National Health Service Act in this Division has been a year of exploration and development. The last report covered the first six months of the new regime and could be little more than an account of the take over from the previous authorities. The result of experience and co-ordination is shown in the succeeding paragraphs, where it will be seen that some services were increased considerably, whereas economies were effected in others. The number of people helped weekly under this scheme increased by 40 per cent. during the last nine months of the year and the position has now been reached when no application for assistance is refused. Payments for this service continue to be satisfactory. In order to improve the service still further the Division is to be divided into three areas, earh under a separate organiser. Home helps The number of maintained nurseries in the Division is 16. The number on the priority waiting list fell from 304 to 178 and the total number waiting from 1,423 to 1,258. All these nurseries are recognised for training purposes as a result of inspection by the Ministry of Health and Ministry of Education. The nurseries benefited by the engagement of a full-time carpenter to repair the broken toys and equipment. There is also one errant-aided nursery, for over two's only. Day nurseries The number of attendances fell slightly during the year owing to the fall in the birth-rate and the tendency to go to hospital or to doctors for confinement. The number of sessions at clinics was reduced accordingly. Blood tests are now taken of all patients at all the clinics. Ante-natal clinics Under the Nurseries and Child-Minders Regulation Act, 1948, two applications were received for registration of nurseries and two for child-minders. The Divisional Health Committee declined one of the latter applications. The applicant subsequently appealed successfully to a Magistrate's Court against this decision, and certain conditions to the registration were imposed by the Court. Child- minders and private nurseries The Wandsworth Peace Memorial Committee kindly placed their holiday home at Whitstable at the disposal of the Council during the Winter months, when it had previously been closed. Recuperative holidays Wherever possible it was the practice to hold vaccination and immunisation clinics in conjunction with infant welfare clinics. This was of great convenience to the parents and may have contributed to the increase in vaccinations of nearly 60 per cent, over the comparable figure for 1948. Another cause of this increase may be the intensive work of the health visitors in the course of their routine visits. Vaccination A staff appointments sub-committee was set up by the Divisional Health Committee to deal with the grades of staff they appoint. During the year a large staff 118 number of those engaged in nurseries were placed on the permanent staff and were medically examined by the Council's medical staff in the division. The latter now do this work for all staff appointed by the Divisional Health Committee. The permanent assistant medical officers are now given the opportunity of working both in the maternity and child welfare service and in the school health service. Steps have been taken to allow health visitors the same opportunity and school nurses with the requisite qualifications are encouraged to undertake health visiting. The results have proved satisfactory and there is to be a further extension of this interchange of duties. Unfortunately there is a shortage of tuberculosis visitors with the result that the tuberculous are not visited as frequently as is desirable. STATISTICS Table 1—Population* of the administrative County of London, 1921-19-19 Year Mid-year estimate of population ' i ge 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 1949 3,389,850 276,200 367,000 2,746,650 *Civilian population only from 1939 to 1948. Table 2— Vital statistics for the metropolitan boroughs and the County of London in the year 1949 (b) Metropolitan boroughs arranged in divisional order Estimated civilian population 1949 Live births Death.Rates Notifications of infectious disease Deaths Infant mortality (per 1,000 live births) Measles Diphtheria Whooping cough Diarrhoea & enteritis age 0.2(per 1,000 live births) Pulmonary tuberculosis Pneumonia Other resp. dis. Cancer Maternal mortality (per 1,000 total births Scarlet fever Diphtheria Typhoid fever Erysipelas Cerebro spinal fever Acute pneumonia Measles Whooping cough Tuberculosis Pulmonary Non. Pulmonary Division 1 Chelsea 51,990 16.8 11.3 26 — — 0.02 1.1 0.27 0.58 0.69 1.98 — 0.71 0.02 0.02 0.17 0.04 0.58 5.81 2.37 1.25 0.04 Fulham 124,040 16.4 12.1 26 0.02 — 0.02 2.5 0.42 0.80 1.04 2.10 0.96 2.64 0.05 0.08 0.16 0.03 0.26 8.86 1.55 1.97 0.19 Hammersmith 118,440 16.6 11.1 28 — — 0.01 1.0 0.38 0.63 1.00 2.01 0.99 1.42 0.07 0.01 0.16 0.03 0.42 7.29 2.04 1.63 0.12 Kensington 174,220 15.3 10.4 24 — — 0.01 2.2 0.32 0.57 0.63 1.81 — 0.65 0.02 0.04 0.09 0.05 0.69 4.25 1.74 1.34 0.18 Division 2 Hampstead 97,000 14.7 10.5 29 — — 0.02 1.4 0.28 0.45 0.77 1.81 2.06 0.82 — 0.01 0.15 0.02 0.61 6.44 2.13 1.08 0.08 Paddington 130,640 17.1 11.4 26 0.02 — 0.01 0.9 0.60 0.73 0.94 2.05 0.87 0.94 0.05 0.01 0.09 0.01 0.66 4.34 1.00 2.33 0.21 St. Marylebone 78,050 11.2 12.0 22 — — — 2.2 0.36 0.69 1.00 2.23 — 1.36 — 0.01 0.18 0.01 0.60 4.05 1.43 1.08 0.16 St. Pancras 141,330 16.2 12.5 31 0.01 — 0.01 0.9 0.70 0.83 1.04 2.43 2.14 1.22 0.01 — 0.25 0.04 0.79 8.07 2.24 1.64 0.23 Westminster, City of 102,160 11.9 10.9 34 0.01 — 0.02 4.8 0.46 0.48 0.81 2.25 1.58 0.47 0.02 0.02 0.06 0.01 0.15 6.22 0.89 1.69 0.11 Division 3 Finsbury 36,010 18.6 13.7 25 — — — 1.5 0.56 0.92 1.28 2.55 2.92 1.17 — — 0.11 — 1.22 5.19 2.05 2.52 0.28 Holborn 25,440 12.8 11.2 37 — — — 3.1 0.55 0.51 1.26 2.12 — 0.59 0.04 — 0.20 — 0.35 6.68 0.20 1.65 0.24 Islington 239,580 18.3 12.3 27 — 0.01 0.00 1.8 0.52 0.79 1.25 2.23 0.67 1.41 0.07 0.02 0.22 0.03 0.60 11.81 2.21 1.92 0.15 Division 4 Hackney 173,020 15.6 11.3 23 0.01 — 0.01 1.5 0.50 0.73 1.02 1.93 — 1.54 0.10 0.07 0.14 0.02 0.30 11.61 2.10 1.42 0.12 Shoreditch 45,200 19.1 13.1 38 — — 0.02 4.6 0.73 0.58 1.42 2.46 1.14 1.02 0.58 — 0.31 0.02 0.29 10.88 0.91 1.28 0.29 Stoke Newington 46,510 20.4 10.8 16 0.02 — — 1.1 0.52 0.92 1.27 1.96 — 0.62 — 0.02 0.22 0.04 0.39 13.76 1.55 1.29 0.11 Division 5 Bethnal Green 59,120 17.4 12.7 32 0.02 0.02 — 1.0 0.29 0.59 1.39 2.54 0.95 1.66 0.34 — 0.20 0.02 0.71 8.46 1.74 1.47 0.12 City of London a 4,830 6.0 8.3 103 — — — — 0.41 0.83 0.83 1.45 — 1.04 — — 0.41 — — 1.66 0.21 2.28 — Poplar 74,570 18.2 12.8 37 0.01 — — 3.7 0.58 0.44 1.48 2.17 2.87 2.04 0.07 — 0.15 0.05 1.14 16.19 4.73 1.81 0.24 Stepney 100,550 18.2 13.3 32 — —. — 2.2 0.66 0.78 1.06 2.54 0.53 1.65 0.04 0.01 0.16 0.02 0.82 11.24 1.28 1.57 0.12 Division 6 Deptford 76,370 18.7 12.1 29 0.01 — 0.01 1.4 0.52 0.63 1.13 1.81 — 2.12 0.04 0.01 0.17 — 0.60 8.92 0.88 2.47 0.24 Greenwich 87,680 17.5 10.8 23 — — 0.01 0.6 0.47 0.56 1.04 1.96 0.63 1.46 0.03 0.02 0.23 — 0.34 9.00 2.21 1.31 0.11 Woolwich 144,000 16.8 10.9 28 0.01 — 0.01 2.0 0.38 0.35 0.87 2.08 0.39 1.41 0.06 0.01 0.18 0.07 0.93 9.12 1.85 1.51 0.20 Division 7 Camberwell 178,110 17.9 12.0 24 0.01 0.01 0.01 1.6 0.44 0.58 1.25 2.09 1.24 1.92 0.07 0.01 0.17 0.02 0.43 6.74 1.29 2.41 0.27 Lewisham 227,700 16.8 10.2 19 0.00 — 0.00 1.0 0.40 0.35 0.85 1.80 0.26 2.28 0.01 0.01 0.16 0.01 0.37 8.52 1.59 1.46 0.17 Division 8 Bermondsey 60,440 18.8 12.0 29 — 0.08 — 1.8 0.66 0.74 1.52 2.02 — 1.31 0.65 — 0.12 — 0.71 12.77 0.66 1.98 0.20 Lambeth 229,400 17.9 11.9 29 — — 0.01 3.2 0.52 0.55 1.05 2.06 — 1.07 0.03 0.00 0.12 0.00 0.41 6.70 1.02 1.89 0.13 Southwark 96,720 19.6 13.0 30 0.01 — 0.01 1.6 0.62 0.78 1.23 2.39 1.03 2.16 0.14 — 0.17 0.02 0.42 9.80 1.35 1.90 0.11 Division 9 Battersea 117,510 17.2 12.1 25 — — 0.01 1.5 0.41 0.56 1.23 2.29 0.97 2.24 0.04 0.01 0.26 0.02 0.67 10.24 1.93 1.48 0.17 Wandsworth 334,840 15.1 11.9 26 — — 0.01 0.6 0.40 0.49 1.01 2.11 0.19 1.38 0.02 0.01 0.23 0.02 0.57 8.87 1.84 1.50 0.13 London, 1949 3,375,470 16.7 11.7 27 0.00 0.00 0.01 1.7 0.47 0.61 1.05 2.10 0.69 1.46 0.07 0.02 0.17 0.02 0.55 8.54 1.70 1.68 0.16 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 (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. 120 Table 3—County of London—Principal vital statistics, 1891.1949 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 Whooping. cough Measles Influenza Tuberculosis Pneumonia (all forms) Bronchitis Other resp. diseases Heart disease Cancer Diabetes Infants 0—1 Diarrhoea and enteritis 0—2 Puerperal fever Other child.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 4.1 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 1949 16.7 21.1 11.7 0.01 0.00 0.00 0.00 0.00 0.01 0.00 0.11 0.47 0.05 0.61 0.90 0.15 3.31 2.10 0.07 27 1.7 0.24 0.45 (а) 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. 121 Table 4—Administrative County of London—Civilian deaths in 1949 by cause Cause Sex 0— 1 — 5— 15— 45— 65+ Total 1949 1948 1. Typhoid and paratyphoid M — — — — — — — 1 F — — 1 — — 1 2 — 2. Cerebro-spinal fever M 4 2 — — 1 7 16 F 4 4 — 1 1 2 12 20 3. Scarlet fever M — — — — — — — 1 F — — 1 — — 1 1 4. Whooping.cough M 9 2 — — — — 11 34 F 11 5 — — — — 16 21 5. Diphtheria M — 1 4 — — — 5 12 F — 2 2 — — — 4 7 6. Tuberculosis—respiratory M 1 2 1 323 489 230 1,046 1,235 F 1 3 4 342 134 55 539 665 7. Tuberculosis—other forms M — 13 12 36 23 11 95 103 F 3 13 7 20 14 4 61 99 8. Syphilitic disease M 1 — — 6 91 84 182 168 F 1 — — 4 32 51 88 86 9. Influenza M 8 2 2 14 57 108 191 42 F 7 3 1 13 38 119 181 36 10. Measles M 1 5 — 1 — — 7 16 F 2 6 1 — — — 9 10 11. Acute poliomyelitis and polioencephalitis M 1 6 7 11 1 — 26 8 F — 5 4 15 — — 24 6 12. Acute infectious encephalitis M — — — 6 3 — 9 11 F — — — 5 3 2 10 13 Cancer of— 13. Mouth and oesophagus M — — 2 14 68 206 290 269 14. Uterus F — 1 — 31 138 148 318 347 15. Stomach and duodenum M — — — 34 233 331 598 597 F — — — 20 134 354 508 522 16. Breast M — — — — 3 3 6 10 F — — — 64 287 321 672 681 17. All other sites M 1 7 10 153 1,123 1,487 2,781 2,713 F 2 8 6 133 638 1,130 1,917 1,915 18. Diabetes M — 1 — 4 22 58 85 52 F — — 1 6 29 127 163 132 19. Intra-cranial vasc. lesions M 1 1 — 22 360 1,096 1,480 1,388 F 1 — 1 28 370 1,722 2,122 1,974 20. Heart disease M — 4 2 195 1,331 3,809 5,341 4,953 F — 1 1 155 719 4,940 5,816 4,953 21. Other circulatory diseases M 1 1 1 22 201 785 1,011 926 F — — — 23 199 946 1,168 923 22. Bronchitis M 23 1 — 36 544 1,286 1,890 1,593 F 13 4 — 22 150 963 1,152 842 23. Pneumonia M 109 21 2 42 242 635 1,051 961 F 78 17 5 39 133 727 999 846 24. Other respiratory diseases M 5 4 1 22 113 149 294 229 F — — — 24 59 115 198 172 25. Ulcer of stomach or duodenum M — — — 35 198 190 423 383 F — — — 10 33 94 137 120 26. Diarrhoea under 2 years M 55 7 — — — — 62 94 F 32 4 — — — — 36 70 27. Appendicitis M — 1 — 11 25 23 60 57 F — 3 5 6 12 21 47 53 28. Other digestive diseases M 3 8 5 25 105 171 317 369 F 5 2 — 31 117 265 420 418 29. Nephritis M 1 — 4 43 92 168 308 338 F — 1 3 41 85 185 315 369 30. Maternal sepsis F — — — 14 — — 14 22 31. Other maternal F — — — 24 2 — 26 26 122 Table 4—Administrative County of London—Civilian deaths in 1949 by cause—continued Cause Sex 0— 1— 5— 15— 45— 65+ Total 1949 1948 32. Premature birth m 214 — — — — — 214 237 f 143 — — — — — 143 175 33. Congenital malformation, birth injury, other infant diseases m 381 13 7 20 20 6 447 467 f 258 9 5 22 25 21 340 341 34. Suicide m — — — 107 133 69 309 271 f — — — 53 74 33 160 165 35. Road traffic accidents m — 16 28 65 35 49 193 153 f — 5 8 12 9 30 64 95 36. Other violent causes m 50 18 30 115 77 143 433 474 f 38 15 9 35 51 253 401 465 37. All other causes m 30 21 28 150 221 717 1.167 1,117 f 19 16 20 131 236 611 1,033 1,040 All causes m 899 157 146 1,512 5,811 11,814 20,339 19,298 f 618 127 85 1,324 3,722 13,240 19,116 17,630 Table 5.—Live births and Stillbirths—Administrative County of London Year Live births Stillbirths No. Rate per 1,000 total population No. Rate per 1,000 live and stillbirths 1928 72,352 16.2 2,417 32.3 1929 70,089 15.8 2,335 32.2 1930 69,447 15.8 2,448 340 1931 65,684 14.9 2,205 32.5 1932 62,233 14.3 1,987 30.9 1933 56,743 13.2 1,934 330 1934 56,853 13.4 1,844 31.4 1935 55,780 13.3 1,854 32.2 1936 56,273 13.6 1,857 31.9 1937 55,011 13.4 1,864 32.8 1938 54,495 13.4 1,711 30.4 1939 52,366 13.4 1,579 29.3 1940 46,213 14.3 1,405 29.5 1941 33,944 13.5 1,046 29.9 1942 40,654 15.4 1,225 29.3 1943 45,030 161 1,137 24.6 1944 44,554 16.2 1,138 24.9 1945 45,532 15.7 1,095 23.5 1946 65,883 200 1,598 23.7 1947 71,323 20.9 1,554 21.3 1948 60,934 17.9 1,191 19.2 1949 56,545 16.7 1,134 19.7 123 Table 6—County of London—Infant mortality, 1949 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 wks. to 1 yr. No. Males Females Total Males Females Measles Leg. - - - 3 3 1 2 0.05 0.03 0.07 llleg. - — — Whooping-cough Leg. - — — 20 20 9 11 0.35 0.31 0.41 Illeg. - — — Influenza Leg. - 1 — 14 15 8 7 0.27 0.27 0.26 Illeg. - — — Tuberculosis Leg. - — — 5 5 1 4 0.09 0.03 0.15 Illeg. - — — Bronchitis Leg. - — — 36 36 23 13 0.64 0.78 0.48 Illeg. - — — Pneumonia Leg. 1 21 29 134 187 109 78 3.31 3.71 2.87 Illeg. - 2 — Diarrhoea Leg. - — 1 85 87 55 32 1.54 1.87 1.18 Illeg. - — 1 Premature birth Leg. 152 126 33 2 357 214 143 6.31 7.28 5.27 Illeg. 25 13 6 Congenital malformation, birth injury and other diseases of early infancy Leg. 206 225 62 101 639 381 258 11.30 12.96 9.51 Illeg. 28 11 6 Other causes Leg. 4 3 9 129 168 98 70 2.97 3.33 2.58 Illeg. 22 1 - All causes Leg. M. 219 219 88 288 1,358 814 544 25.79 29.76 21.49 F. 144 157 46 197 Illeg. M. 38 16 6 25 159 85 74 40.96 41.38 40.48 F. 37 11 7 19 Total 1949 438 403 147 529 1,517 899 618 26.83 30.58 22.77 Total 1948 436 447 184 802 1,869 1,082 787 30.67 34.39 26.70 1948 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 34.02 F. 23 14 4 30 Table 7—Infant mortality in London by cause 1911-1949 (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 1949 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 0.05 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 0.35 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 0.27 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 0.09 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 0.64 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 3.31 Diarrhoea 24.28 16.10 12.16 9.36 8.87 10.86 12.10 6.96 6.93 3.96 4.30 2.54 1.54 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 6.31 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 11.30 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 2.97 All causes 108 103 79 65 64 65 60 50 45 38 34 31 27 124 Table 8—Maternal mortality—London and England and Wales 1940.49 (Rates per 1,000 total births) 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 Puerperal fever:— London 0.95 1.42 1.10 0.93 0.74 0.69 0.33 0.32 0.35 0.24 England and Wales 0.81 0.83 0.77 0.73 0.60 0.49 0.31 0.26 0.23 0.22 Other causes:— London 0.97 1.52 1.34 1.15 0.92 1.20 0.90 0.64 0.42 0.45 England and Wales 1.87 1.97 1.71 1.56 1.33 1.31 1.12 0.91 0.78 0.76 Table 9—Maternal mortality in London 1931-49 Metropolitan boroughs arranged in divisional order Childbirth deaths (a) per 1,000 total-births Number of deaths (b) in childbirth 1949 1931-40 1941-49 Puerperal fever Other causes Total Puerperal fever Other causes Total Puerperal fever Other causes Total Division 1. Chelsea 1.5 1.8 3.3 0.5 1.1 1.6 - - - Fulham 1.1 1.6 2.7 0.5 0.9 1.4 1 1 2 Hammersmith 1.0 1.1 2.1 0.5 0.8 1.3 — 2 2 Kensington 1.5 1.5 3.0 0.6 0.9 1.5 — — — Division 2. Hampstead 0.8 1.3 2.1 0.3 1.4 1.7 - 3 3 Paddington 1.8 2.1 3.9 1.0 0.8 1.8 2 — 2 St. Marylebone 1.4 2.0 3.4 1.1 1.1 2.2 — — — St. Pancras 1.4 1.6 3.0 1.1 0.8 1.9 4 1 5 Westminster, City of 1.9 1.4 3.3 1.2 0.9 2.1 1 1 2 Division 3. Finsbury 0.8 0.7 1.5 1.2 1.0 2.2 1 1 2 Holborn 2.0 1.3 3.3 1.6 0.4 2.0 — — — Islington 1.1 1.4 2.5 0.6 0.8 1.4 — 3 3 Division 4. Hackney 0.8 1.3 2.1 0.3 0.6 0.9 - - - Shoreditch 0.7 1.4 2.1 1.0 0.7 1.7 1 — 1 Stoke Newington 0.6 2.8 3.4 0.4 1.1 1.5 — — — Division 5. Bethnal Green 1.1 1.0 2.1 0.6 0.6 1.2 - 1 1 City of London 3.1 — 3.1 — — — - — — Poplar 1.3 1.1 2.4 0.7 1.0 1.7 - 4 4 Stepney 0.9 1.6 2.5 0.5 1.0 1.5 - 1 1 Division 6. Deptford 1.0 1.3 2.3 0.5 0.8 1.3 - - - Greenwich 1.2 1.5 2.7 0.4 0.9 1.3 1 — 1 Woolwich 0.8 1.1 1.9 0.3 0.8 1.1 1 — 1 Division 7. Camberwell 1.2 1.6 2.7 0.8 1.0 1.8 2 2 4 Lewisham 1.1 1.5 2.6 0.4 1.0 1.4 — 1 1 Division 8. Bermondsey 1.3 1.5 2.8 0.6 1.5 2.1 - - - Lambeth 0.9 1.0 1.9 0.5 0.8 1.3 — — — Southwark 0.9 1.6 2.5 0.4 1.1 1.5 — 2 2 Division 9. Battersea 1.1 1.5 2.6 0.4 0.7 1.1 - 2 2 Wandsworth 1.4 1.3 2.7 0.6 0.8 1.4 — 1 1 London County 1.1 1.4 2.5 0.6 0.9 1.5 14 26 40 (а) 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 1949 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 1949 and for London as a whole are, however, set out in Table 2. 125 Table 10—Death-rates from certain infectious diseases—London and England and Wales—1931.49 Rates are per 1,000 living except for diarrhoea and enteritis where it is expressed per 1,000 live births Year Measles Whooping-cough Scarlet fever Diphtheria Diarrhoea and 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 1949 0.005 0.007 0.008 0.012 0.0003 0.0004 0.003 0.002 1.73 2.85 126 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 8,97 1 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 1949 5,699 1.68 1,585 (c) 0.47 553 0.16 156 (c) 0.05 (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 on London during the year 1949 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— 55- 65+ Pulmonary tuberculosis M. 12 141 95 58 292 391 680 523 484 423 186 3,285 F. 19 107 89 99 352 477 671 321 143 80 56 2,414 Other forms of tuberculosis M. 2 37 41 34 19 33 36 21 18 7 7 255 F. 7 35 39 29 28 46 60 25 12 9 8 298 All froms of tuberculosis M. 14 178 136 92 311 424 716 544 502 430 193 3,540 F. 26 142 128 128 380 523 731 346 155 89 64 2,712 Table 11—County of London—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—1931-1949 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 Whoopingcough Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Kate 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 (f) 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 2.63 — — — — (b) (b) 1936 — — 113 0.027 4 0.001 7,030 1.68 304 0.072 12 0.003 255 0.061 1,815 0.432 35 0.008 (b) (b) 462 8.10 4,141 0.986 2 0.0005 36 0.009 635 10.92 (b) (b) 10,705 2.55 — — — — (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 2.07 — — — — (b) (b) 1938 4 0.001 182 0.045 1 0.0002 7,611 1.88 1,049 0.259 5 0.001 191 0.047 1,829 0.451 16 0.004 282 (c) 0.28 489 9.00 3,962 0.978 12 0.003 122 0.030 853 15.18 (b) (b) 8,093 2.00 — — — — 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 1.00 — — — — 7,944 3.36 1942 1 0.0004 341 0.142 1 0.0004 1,813 0.756 749 0.312 3 0.001 67 0.028 1,034 0.431 16 0.007 19,987 8.33 210 5.18 2,246 0.936 1 0.0004 24 0.010 505 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 1949 (e) 3 0.0009 76 0.023 — — 221 0.065 440 0.130 4 0.001 58 0.017 583 0.173 21 0.006 28,816 8.54 180 3.29 1.858 0.550 46 0.014 622 0.184 433 7.51 1,311 0.39 4,945 1.46 3 0.001 — — 5,754 1.70 (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) Cases 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 0.545, Enteric fever 0.721, Erysipelas 0 977, Measles 1.001, Ophthalmia neonatorum 1004, 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. (f) Rate per 1,000 live births. 127 Table 13(b)—New cases of tuberculosis in London found by other means than notification, 1949 Form of tuberculosis Sex New cases of tuberculosis coming to knowledge otherwise than by formal notification 0. 1. 5. 10. 15. 20. 25. 35. 45. 55. 65 + Total Pulmonary tuberculosis m. 3 19 26 6 29 139 340 174 130 95 99 1,060 f. 2 18 18 7 62 184 329 118 40 28 22 828 Other forms of tuberculosis m. — 10 2 12 5 10 11 8 14 3 4 79 f. 1 7 14 12 4 8 22 9 7 3 1 88 All forms of tuberculosis M. 3 29 28 18 34 149 351 182 144 98 103 1,139 f. 3 25 32 19 66 192 351 127 47 31 23 916 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 138 9 transferable deaths from Registrar-General 120 32 Posthumous notifications 41 6 "Transfers" from other areas 1,516 110 Other sources 73 10 Table 13(c)—Numbers on the registers, for the whole county, 1941-1949 Cases on the register at the end of the year— 1941 1942 1943 1944 1945 1946 1947 1948 1949 Pulmonary— Males 12,677 12,894 13,608 14,340 15,018 15,695 16,374 17,224 18,203 Females 9,119 9,441 10,232 10,990 11,496 12,262 12,862 13,549 14,223 Other forms Males 2,916 2,785 2,847 2,866 2,813 2,821 2,699 2,889 2,752 Females 3,044 2,963 3,074 3,185 3,123 3,099 3,142 3,147 3,015 Total 27,756 28,083 29,761 31,381 32,450 33,877 35,077 36,809 38,193 No. per 1,000 of population 11.9 11.7 11.9 12.7 12.5 10.9 10.6 11.0 11.3 128 Table 14(a)—New cases (a) of tuberculosis in London (A.C.) by age 1938-39 and 1946-49 Morbidity rates (i) Pulmonary Age. Group 1938 1939 1946 1947 1948 1949 No. Rate per 1,000 No. Kate per 1,000 No. Rate per 1,000 No. Rate per 1,000 No. Rate Per 1,000 No. Rate per 1,000 0- 4 105 0.42 76 0.35 199 0.94 223 1.04 282 1.01 285 0.97 5-14 228 161 349 384 351 337 15-24 1,484 1 1.52 1,353 1.46 1,482 1.76 1,545 1.75 1,551 1.82 1,490 1.88 25-64 3,262 2,917 2,982 3,111 3,149 3,341 65+ 224 236 244 262 290 276 Not stated 2 24 30 49 41 50 Total 5,305 1.31 4,767 1.26 5,286 1.62 5,574 1.63 5,664 1.67 5,779 1.70 Ratio to 1938 per cent. 100 96 124 124 127 130 (ii) Non Pulmonary Age Group 1938 1939 1946 1947 1948 1949 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 No. Rate per 1,000 0- 4 142 0.50 112 0.47 99 0.49 121 0.46 99 0.41 81 0.35 5.14 253 200 187 147 156 143 15.24 272 0.20 217 0.18 142 0.13 137 0.14 154 0.13 126 0.12 25.64 346 302 201 241 181 188 65+ 40 26 15 18 20 15 Not known - 2 3 6 — — Total 1,053 0.26 859 0.23 647 0.20 670 0.20 610 0.18 553 0.16 Ratio to 1938 per cent. 100 88 77 77 69 62 (a) Including posthumous notifications and new cases reported otherwise than by primary notification but excluding transfer of cases already notified. 129 Table 14(b)—Tuberculosis deaths in London (A.C.) by age 1938.39 and 1946.49 (i) Pulmonary Age Group 1938 1939 1946 1947 1948 1949 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 No. Rate per 1,000 0- 4 30 0.07 15 0.05 25 0.06 25 0.07 15 0.04 7 0. 02 5-14 25 16 12 17 8 5 15-24 459 0.77 447 0.84 278 0.75 266 0.75 228 0.69 154 0.58 25.64 1,863 1,922 1,383 1,487 1,392 1,134 65+ 213 250 242 249 257 285 Total 2,590 0.64 2,650 0.70 1,940 0.62 2,044 0.62 1,900 0.57 1,585 0.47 Ratio to 1938 per cent. 100 102 75 79 73 61 (ii) Non Pulmonary Age Group 1938 1939 1946 1947 1948 1949 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 No. Rate per 1,000 0- 4 88 0.19 64 0.15 64 0.19 49 0.14 49 0.11 29 0.07 5-14 59 38 45 36 21 19 15.25 66 0.06 75 0.06 39 0.05 38 0.06 24 0.05 17 0.04 25.64 113 103 79 107 90 76 65+ 21 22 16 22 18 15 Total 347 0.09 302 0.08 243 0.08 252 0.08 202 0.06 156 0.05 Ratio to 1938 per cent. 100 87 70 73 58 45 130 Table 15—New cases of non-pulmonary Tuberculosis in London (A.C.) 1938-1939 and 1946-1949. Distribution according to site Rates for 1,000 living are shown in parenthesis against the number of cases Age group Year Site of tuberculosis lesion Bones and Joints Abdomen Peripheral glands Meninges Other sites (a) Total 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) 1949 56 (0.087) 13 (0.020) 68 (0.106) 63 (0.098) 24 (0.037) 224 (0.348) 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 1949 69 36 68 87 91 69 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) 1949 107 (0.039) 42 (0.015) 77 (0.028) 13 (0.005) 90 (0.033) 329 (0.120) Rates expressed per cent. of 1938. 1938 100 100 100 100 100 100 1939 97 65 102 93 77 88 1946 69 54 74 50 67 67 1947 69 73 77 36 73 70 1948 69 50 70 57 62 64 1949 67 58 65 36 55 60 (a) Includes miliary and genito-urinary. Table 16—Cases of infectious illness reported from schools in 1949 and preceding years Year Chicken-pox Diphtheria German measles Impetigo Measles Mumps Ophthalmia and conjunctivitis Poliomyelitis Ringworm Scabies Scarlet fever Whoopingcough 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 1949 5,528 135 313 178 7,651 2,113 361 132 71 120 2,359 1,814 131 Table 17—Diphtheria Immunisation—Year ended 31-12-49 Immunisation in relation to Child population Divisions Totals Age at 31-12-49 1 2 3 4 5 6 7 8 9 Under 5 years (born 1945-1949) Child population 34,501 35,565 25,532 22,848 21,228 28,752 36,550 34,314 37,110 276,200 Immunised 18,943 19,905 15,047 13,631 11,257 16,458 18,642 16.099 21,110 151,092 Per cent. 54.9 56.0 58.9 59.7 53. 0 57.2 51.0 46.9 56.9 54.7 5-14 years (born 19351944— Child population 46,199 44,120 33,985 30,911 30,139 38,090 48,330 45,806 49,420 367,000 Immunised 36,446 28,682 27,939 24,660 17,121 29,175 36,383 25,732 277,17 253,855 Per cent. 78.9 65.0 82.2 79.8 56.8 76.6 75.3 56.2 56.1 69.2 0-14years (born 1935. 1949)— Child population 80,700 79,485 59,517 53,759 51,367 66,842 84,880 80,120 86,530 643,200 Immunised 55,389 48,587 42,986 38,291 28,378 45,633 55,025 41,831 48,827 404,947 Per cent. 68.6 61.1 72.2 71.2 55.2 68.3 64.8 52.2 56.4 63.0 Diphtheria Notifications and Deaths in relation to immunisation during 1949 Cases notified— Immunised 2 3 3 4 7 4 3 7 2 35 Not immunised 7 3 12 32 16 2 7 65 4 148 Deaths— Immunised - - - - - - - - - - Not immunised - - 2 — 1 — 1 5 — 9 Table 18—Prophylaxis with Pertussis Vaccines—Year ended 31-12-49 Division Age at Date of Final Injection Total Under 1 year 1-4 years 5-14 years 1 130 442 10 582 2 1,451 1,083 44 2,578 3 11 1,537 131 1,679 4 1 2,781 169 2,951 5 687 1,249 63 1,999 6 617 2,155 155 2,927 7 154 2,814 139 3,107 8 1,087 3,210 216 4,513 9 852 3,348 269 4,469 Totals 4,990 18,619 1,196 24,805 132 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 9,164 3,225 8,249 6.269 1939 1,573 904 164 5 5,982 1,662 7,719 2,561 7,468 5,008 1940 1,493 709 146 9 4,691 1,319 6,230 2,037 5,383 3,515 1941 1,381 773 205 12 3,862 1,426 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 1949 1,572 790 62 5 6,463 1,207 8,097 2,002 16,140 6,533 Year Total attendances In-patient days Pathological examinations for M. F. M. F. Clinic Practitioners. tioners 1918 169,485 66,095 25,973 6,380 1928 544,969 218,566 23,821 41,285 107,410 29,785 1938 588,815 263,908 20,608 32,303 263,710 48,763 1939 112,067 189,355 13,030 22,715 223,696 40,176 1940 306,693 181,376 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 284,108 161,8351 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 1949 245,250 134,897 not known not known not known not known 133 Table 20—School leavers contra-indications for employment Contra.indications Boys Girls Number Per cent. of inspected pupils (11,606) (a) Number Per cent. of inspected pupils (11,389) (a) Heavy manual work 367 3.2 256 2.2 Sedentary confined work 47 0.4 44 0.4 Exposure to bad weather 189 1.6 238 2.1 Dusty atmosphere 154 1.3 99 0.9 Climbing 70 0.7 86 0.8 Proximity to moving machinery 51 0.4 49 0.4 Prolonged standing 202 1.7 210 1.8 Eyestrain 881 7.6 1,048 9.2 Acute distant vision 751 6.5 837 7.3 Acute hearing 60 0.5 65 0.6 Handling of confectionery 71 0.6 78 0.7 Food preparation 82 0.7 71 0.6 Number of pupils with tions (6) 1,781 15.3 1,841 16.2 (а) Excluding special schools and certain grammar schools at which the Leaver contra.indication slip is not in use. (б) The total number of contra.indications is greater than the number of pupils for the reason that an individual pupil may be noted for two or more contra.indications. Table 21—"Ascertainment" of handicapped children—Vision A. Children not in special schools:— Boys Girls Total Found to be blind 7 12 19 Found to be partilly sighted 45 37 82 Found to be fit for ordinary schools with "care" 22 37 59 Found to be fit for ordinary schools 17 19 36 91 105 196 B. Children already in attendance at special schools Boys Girls Total Found to be no longer blind 1 — 1 Found to be no longer partially sighted 10 13 23 Recommended to continue blind school 1 1 2 Recommended to continue partially.sighted school 6 8 14 Recommended for transfer from blind school to partially.sighted school 1 1 2 Recommended for transfer from partially.sighted school to blind school 4 1 5 23 24 47 134 Table 22—"Ascertainment" of handicapped children—Hearing A. Children not in special schools:— Boys Girls Total Found to be deaf 32 31 63 Found to be partially-deaf 24 23 47 Found to be suitable for hearing school with individual hearing aid and/or to sit in front row, etc. 28 13 41 Found to be suitable for hearing school. 13 10 23 Recommended for treatment before decision made 4 1 5 101 78 179 B. Children in special schools:— Found to be no longer deaf 1 1 2 Found to be no longer partially-deaf 5 5 10 Recommended to continue deaf school 4 3 7 Recommended to continue partially-deaf school 1 — 1 Recommended for transfer from deaf school to partially-deaf school 4 2 6 Recommended for transfer from partially-deaf school to deaf school — — 2 17 11 28 Table 23—"Ascertainment" of handicapped children—Epilepsy A. Children not in special schools:— Boys Girts Total Found suitable for residential special schools for epileptics 20 15 35 Found suitable for ordinary school 11 7 18 Found suitable for E.S.N, school 3 4 7 Found to be ineducable 1 2 3 Recommendation postponed 7 6 13 42 34 76 B. Three boys and one girl from residential special schools for epileptics were examined and found to be fit to attend ordinary schools. 135 Table 24—"Ascertainment" of handicapped children—Educationally sub-normal A. Children not in special schools:— Boys Girls Total Found suitable for day E.S.N, schools Over 11 109 75 184 Under 11 263 181 444 Found suitable for residential E.S.N, schools Over 1 1 21 20 41 Under 11 40 29 69 Found suitable for special E.S.N, class in ordinary school Over 11 108 62 170 Under 11 414 187 601 Found to have no disability of mind Over 11 45 22 67 Under 11 270 96 366 Found to be unsuitable for school (e.g., ineducable) Over 11 4 3 7 Under 11 46 55 101 Decision postponed Over 11 — 1 1 Under 11 8 8 16 1,328 739 2,067 B(i). Children in attendance at Special E.S.N. Schools:— Boys Girls Total Found to be no longer in need of special educational treatment 17 18 35 Found to be suitable for transfer to special E.S.N, classes in ordinary schools 18 4 22 Found to be unsuitable for retention because ineducable, etc. 40 34 74 Found to be suitable to continue in special E.S.N, school 51 25 76 Recommended for transfer to residential special E.S.N, school 18 10 28 Examined with a view to considering action under Section 57 (5) 134 82 216 278 173 451 B(ii). Children in attendance at special E.S.N, classes in ordinary schools:— Boys Girls Total Found to be no longer in need of special educational treatment 10 5 15 Found to be suitable for transfer to special E.S.N, schools 17 12 29 Found to be suitable to continue in E.S.N, class 12 5 17 39 22 61 In addition, 23 children were considered for action under Section 8 of the Education (Miscellaneous Provisions) Act, 1948: 9 boys and 9 girls were found to be still ineducable; in the cases of 3 boys and 2 girls it was recommended that the report should be withdrawn. Table 25—"Ascertainment" of handicapped children—Delicate 1,662 children (985 boys and 677 girls) were recommended for admission to residential schools for delicate children. 518 children (296 boys and 222 girls) were recommended for admission to day schools for delicate children. 399 (227 boys and 172 girls) were found to be no longer in need of special educational treatment in day schools for delicate children, 136 Table 26—"Ascertainment" of handicapped children—Physical A. Children not in special schools:— Boys Girls Total Found to be suitable for day special schools for physically handicapped (see (i) below) 169 154 323 Found to be suitable for residential special schools for physically handicapped (see (i) below) 9 4 13 Found to be suitable for ordinary schools (see (ii) below) 38 20 58 Found to be unsuitable for education at school but suitable for home tuition or tuition in hospital 20 25 45 Decision postponed 7 3 10 243 206 449 (i) Number of these children recommended for physically handicapped schools Morbid condition Day school Residential school Grand total Boys Girls Total Boys Girls Total Infantile paralysis 20 15 35 1 — 1 36 Cerebral paralysis 13 25 38 1 1 2 40 Various paralyses 1 1 2 — — — 2 T.B. bones and joints 21 16 37 — — — 37 Osteomyelitis 4 2 6 1 — 1 7 Perthes disease 14 4 18 — — — 18 Rickets and resultant deformities 1 1 2 — — — 2 Congenital deformities 12 17 29 1 — 1 30 Spinal deformities, including scoliosis — 4 4 — — — 4 Traumata and amputations 15 1 16 — — — 16 Non.T.B. arthritis and synovitis 1 1 2 — 2 2 4 Rheumatism and chorea 1 3 4 — — — 4 Congenital heart disease 19 20 39 1 — 1 40 Heart disease (acquired valvular) with matism 17 22 39 1 1 2 41 Heart disease (acquired valvular) without rheumatism 4 8 12 — — — 12 Other diseases 26 14 40 3 — 3 43 169 154 323 9 4 13 336 (ii) Number of these children recommended for ordinary school Morbid condition Boys Girls Total Infantile paralysis 5 3 8 Cerebral paralysis 2 2 4 Various paralyses 1 — 1 T.B. bones and joints — — — Osteomyelitis 3 — 3 Perthes disease 3 — 3 Rickets and resultant deformities — — — Congenital deformities 5 5 10 Spinal deformities, including scoliosis — — — Traumata and amputations 2 — 2 Non.T.B. arthritis and synovitis 1 — I Rheumatism and chorea 2 — 2 Congenital heart disease 1 1 2 Heart disease (acquired valvular) with rheumatism 3 5 8 Heart disease (acquired valvular) without rheumatism 2 2 4 Other diseases 8 2 10 Total 38 20 58 137 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) 112 76 188 Found to be medically unfit to remain in special school 3 1 4 Other recommendations (see (ii) below) 35 41 76 Total 150 118 268 (i) Number of these children found to be no longer in need of special educational treatment Morbid condition Day P.H. Schools Residential P.H. Schools Boys Girls Total Boys Girls Infantile paralysis 3 11 14 — — Cerebral paralysis 2 1 3 — — Various paralyses 2 — 2 — — T.B. of bones and joints 8 12 20 1 — Osteomyelitis 15 1 16 1 — Perthes disease 7 4 11 — — Rickets and resultant deformities 4 1 5 — — Congenital deformities 20 4 24 1 — Spinal deformities, including scoliosis — 2 2 — — Traumata and amputations 8 3 11 — — Non.T.B. arthritis and synovitis 2 1 3 — — Rheumatism and chorea — 3 3 — — Congenital heart disease 4 7 11 — — Heart disease(acquired valvular)with rheumatism 21 18 39 — — Heart disease (acquired valvular) without rheumatism 1 2 3 — — Other diseases 10 6 16 2 — 107 76 183 5 — (ii) Other recommendations Morbid condition Day P.H. Schools Residential P.H. Schools Grand Total Continue Day Transfer to Res. Continue Res. Transfer to Day B. G. T. B. G. T. B. G. T. B. G. T. Infantile paralysis 2 3 5 — 1 1 — — — — 1 1 7 Cerebral paralysis 2 3 5 2 8 10 — — — — 2 2 17 Various paralyses I — 1 1 1 2 — — — 1 — 1 4 T.B. of bones and joints 3 1 4 1 — 1 1 — 1 — — — 6 Osteomyelitis 3 1 4 — — — — — — — — — 4 Perthes disease 1 — 1 — — — — 1 1 — — — 2 Rickets, etc. — — — — — — — — — — — — — Congenital deformities 2 4 6 — 1 1 — — — — — — 7 Spinal deformities — — — — — — — — — — — — — Traumata and amputations — i 1 1 — 1 — — — — — — 2 Non.T.B. arthritis and synovitis — — — — — — — — — — — — — Rheumatism and chorea — 2 2 1 — 1 — — — — — — 3 Congenital heart disease 3 2 5 2 2 4 — — — — — — 9 Heart disease (acquired valvular) with rheumatism 2 5 7 — — — — — — — — — 7 Heart disease (acquired valvular) without rheumatism — 1 1 — — — — — — — — — 1 Other diseases 4 — 4 2 1 3 7 23 23 46 10 14 24 1 1 2 1 3 4 76 138 Table 27—"Ascertainment" of handicapped, children—Dual defects The following children were found on examination to suffer from more than one handicap:— Boys Girls Total Recommended for Rayners Residential School 8 7 16 „ ,, other schools for dual defects 2 3 5 „ ,, E.S.N, schools 5 4 9 „ „ P.H. schools 9 10 19 ,, „ Partially-sighted schools 3 3 6 ,, „ Epileptic colony 1 — 1 ,, ,, Day open-air school — 1 1 invalid pending the provision of a suitable school 2 2 4 Found to be blind and ineducable — 2 2 30 32 62 Table 28—"Ascertainment" of handicapped children—Speech Boys Girls Total Recommended for speech therapy because of stammer 144 31 175 ,, „ „ ,, ,, speech defect 165 90 255 Found to be unsuitable for speech therapy 65 24 89 374 145 519 Table 29—"Ascertainment" of handicapped children—Maladjustment Boys Girls Total Deemed to be maladjusted and suitable for residential placement 160 57 217 „ „ ,, „ „ „ special classes 50 16 66 Deemed to be no longer in need of special educational treatment as maladjusted 30 4 34 240 70 317 In addition the psychiatrist examined 52 special cases and made reports on them. Table 30—"Ascertainment" of handicapped children—Diabetes Number of children found to be diabetic and suitable for residential treatment: Boys Girls Total London children 4 2 6 Out-Countv children 1 2 3 One out-county boy was considered unsuitable for admission to the unit. Table 31—"Ascertainment" of handicapped children—Reclassification 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. 1 — 1 „ E.S.N, to epileptic colony 1 — 1 „ epileptic colony to E.S.N. 1 1 2 ,, Rayners (dual defect) to E.S.N. 1 — 1 „ Rayners (dual defect) to deaf 1 2 3 5 3 8 139 Table 32—Nominations for treatment under the Rheumatism Scheme, 1947-1949 1947 1948 1949 Received from hospitals 538 528 238 ,, „ rheumatism supervisory centres 90 64 78 „ „ school doctors 41 10 17 „ „ other sources (private practitioners, welfare organisations, etc.) 23 12 11 692 614 344 Number outstanding from previous year 3 35 4 695 649 348 Number withdrawn before consideration 5 11 — 690 638 348 Found unsuitable for admission to unit 45 27 6 Died before admission 1 2 — Parents'consent to admission refused 19 17 — Accepted nominations subsequently withdrawn 27 65 5 Admitted to Rheumatism Unit 563 523 331 Removed from Scheme (not rheumatic) — — 1 Awaiting admission on 31st December, 35 4 5 690 638 348 Supervision Number of children under supervision of school doctors (G.P.H. 449) on 31st December 268 382 375 Number of children under supervision at rheumatism supervisory centres, 31st December 2,890 3,216 3,021 Number of supervisory centres 22 23 24 Number of sessions at supervisory centres 849 893 988 Number of children attending for first time 1,508 1,468 1,394 Total number of attendances at centres 9,333 10,505 10,929 Nominal accommodation at Rheumatism Unit (i.e., number of beds) 250 250 250 140 Table 33—Admissions of London children to Queen Mary's Hospital, Carshalton, in 1949 Sex Articular Rheumatism Chorea Articular Rheumatism and Chorea Number admitted Percentage with Number admitted Percentage with Number admitted Percentage with Carditis Pericarditis only Valvular damage No cardiac involvement Carditis Valvular damage, Mitral No cardiac involvement Carditis Valvular damage, Mitral No cardiac involvement Mitral Mitral and Aortic and pericarditis Boys 108 33.3 1.7 24.4 3.6 1.8 35.2 28 7.1 17.9 75.0 7 14.3 42.9 42.8 Girls 133 18.8 — 25.6 1.5 2.2 51.9 41 19.5 22.1 58.4 14 28.6 35.7 35.7 Total 241 25.3 0.8 24.5 2.9 2.1 44.4 69 14.5 20.3 65.2 21 23.8 38.1 38.1 141 Table 34—Condition on discharge in 1949 of London children treated in Queen Mary's Hospital, Carshalton 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 131 81.9 17 10.6 11 6.9 1 0.6 160 Girls 187 87.8 16 7.5 10 4.7 — — 213 Total 318 85.3 33 8.8 21 5.6 1 0.3 373 Table 35—Percentage number of children with cardiac involvement admitted to the special rheumatism units, 1935.1949 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 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 51.7 142 Table 36 County of London—Statistics of the administrative work carried out by the Metropolitan Borough Councils during the year 1949 Sanitary authority Cowsheds Slaughterhouses Offensive trades Smoke nuisances Common lodging houses Cleansing of persons and rooms Water supply Milkshops 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 — — — — — — 7 — 2 — 1 1 204 2,528 41 100 — 44 61 70 164 576 1,655 Battersea — — 1 49 2 2 133 — 11 — 1‡ 10 286 2,773 827 334 1 133 333 86 272 158 311 Bermondsey — — — — 11 61 246 — — — 2 49 211 1,335 68 396 11 104 266 93 108 56 379 Bethnal Green — — — — 1 1 1 — — — 1 8 75 11 51 947 — 123 537 121 361 96 301 Camberwell 1 5 3 13 5 1 83 11 19 4 1 16 232 2,238 1,220 1,319 26 174 307 323 499 251 452 Chelsea — — — — — — 53 — 19 — — — 47 516 117 320 19 38 55 38 98 88 234 Deptford — — 2 2 2 5 3 — 3 — 1 4 261 1,259 330 526 — 66 163 121 324 90 369 Finsbury — — — — 3 60 70 — 10 — 1 19 * * * * 18 74 212 99 159 159 285 Fulham — — — — — — 210 2 15 — — — — — 535 1,050 57 50 487 139 836 159 582 Greenwich — — — — — — 120 — 19 — — — 204 1,098 342 29 3 58 186 163 297 162 725 Hackney — — 1 — 5 3 1,387 17 17 4 1 1 240 1,411 810 584 12 32 631 262 509 248 383 Hammersmith — — 3 4 — — 86 6 12 1 — — 490 1,595 94 643 5 80 280 207 375 217 159 Hampstead — — — — — — 19 — 9 — — — 37 18 541 162 18 61 159 141 301 193 455 Holborn — — — — — — 146 — 13 — 2 6 98 106 93 153 8 53 64 50 234 652 1,965 Islington — — 6 56 12 148 102 4 54 — — — 365 1,427 595 737 107 408 1,098 457 1,021 560 1,299 Kensington — — — — — — 12 — — — — — 354 2,660 450 1,401 22 157 429 207 224 213 439 Lambeth — — 1 19 3 6 54 3 21 — — — 260 91 784 2,718 10 201 160 534 131 212 398 Lewisham — — 2 8 — — 19 — 7 — — — 163 1,649 943 326 — 185 174 279 280 233 335 Paddington — — — — 1 15 21 — — — 1 45 228 63 369 1,640 46 116 375 149 275 141 707 Poplar — — 3 — 3 11 123 7 32 3 2 45 91 1,110 281 687 — 122 310 108 114 71 148 St. Marylebone — — 1 16 — — 152 16 20 1 2 117 484 1,148 814 575 34 159 246 139 275 845 1,099 St. Pancras — — 2 — — — 121 — 29 — — — 883 2,316 771 887 18 296 814 276 1,028 839 973 Shoreditch — — — — 1 3 398 3 4 1 — — 43 42 277 1,087 24 80 402 117 367 176 757 Southwark — — 1 4 7 30 34 — 14 — 6 39 1,120 3,375 382 2,079 — 179 487 145 423 284 355 Stepney 1 9 — — 16 161 193 5 18 — 4 96 338 43 426 1,200 778 211 479 215 489 426 685 Stoke Newington — — — — — — 36 — 6 — — — 45 985 157 269 36 127 64 132 50 192 Wandsworth — — 3 56 — — 64 2 9 2 — — 281 97 945 242 11 196 2,225 556 1,846 477 1,623 Westminster — — — — — — 720 4 80 — 3 45 374 630 636 1,398 8 114 416 151 162 3,000 3,873 Woolwich — — 2 t 2 10 36 2 9 — 2 16 183 1,826 400 369 — 105 421 238 596 309 823 Total 2 14 31 227 74 517 4,649 82 452 16 31 517 7,597 32,330 13,299 22,178 1,236 3,655 11,904 5,548 11,900 10,941 21.961 Note : In the columns above a dash signifies a nil return ; †daily supervision; *information not available and ‡closed in June, 1949. Seamen's Lodging Houses, 8—Bermondsey 1 (1 inspection); Poplar 3 (54 inspections); Stepney 4 (76 inspections). Prosecutions : Ice Cream—Lewisham 1, Westminster 1 ; Milkskops— Lewisham 2; Smoke Nuisances—Camberwell 1, St. Marylebone I. Restaurants—St. Marylebone 6, Stepney 21, Westminster 6 ; Water Supply—Camberwell 2, Hackney 4, St. Marylebone 3. 143 Table 37 Statistics of the administrative work carried out by the Metropolitan Borough Councils during 1949 Borough Public Health Act Housing Acts, 1936 No. of houses in borough 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 Section 9 and 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 No. made No. determined By owners By l.a. Section 11 Voluntarily City of London 1,100 9 — 5 25 2 — 10 — — — 2 — 14 4 — 5 — 25 4 — — Battersea 25,479 5,900 2,457 9,423 46 — — 22 — — — 1 — 459 76 51 * 9 — — — — Bermondsey 15,652 5,815 1,677 4,469 659 — — — — 3 — 6 1 130 105 54 859 — 419 675 — 3 Bethnal Green 15,229 7,465 1,457 2,877 — — — 1 — — 4 6 — 224 246 — — — 183 679 — — Camberwell 39,296 7,962 2,305 3,502 — — — 2 1 1 — 2 — 378 196 130 * 5 ‡29,000 — — — Chelsea 15,251 2,012 629 648 141 — — 20 — 1 — — — 28 27 150 — — 575 — — — Deptford 16,948 3,567 1,043 2,574 — 19 3 1 — 3 — 24 1 150 42 55 3 3 — — — — Finsbury 9,890 2,618 77 1,315 163 — — — — — — 5 — 66 ‡145 95 1,390 — 456 510 — — Fulham 30,714 5,055 2,246 4,987 48 13 — — 1 2 — 6 — 316 85 71 — 250 — — — — Greenwich 21,736 2,688 350 1,838 133 — — — 1 — 61 9 1 168 121 60 67 2 3 59 — — Hackney 38,607 9,338 2,824 5,860 307 — — — — — — 1 — 517 345 225 * * * * * * Hammersmith ‡24,600 4,391 1,689 2,536 — — — 18 1 — 11 2 — 358 132 380 * 6 ‡9,600 — — — Hampstead 19,813 2,311 701 1,997 69 — — 1 — — 1 — 309 42 122 516 19 1,600 836 — 1,811 Holborn 5,770 637 44 583 8 — — — — — 13 5 — 58 57 112 501 22 311 417 — 30 Islington 40,564 10,991 9,371 6,442 749 — — — — 2 37 33 — 877 610 252 * 37 • * * * Kensington 35,816 8,271 1,872 3,309 741 41 — 65 33 — 10 2 39 474 147 24 ‡4,000 101 4,015 2,890 — 366 Lambeth 51,235 13,082 2,354 12,390 — — — — — — — 2 — 460 347 302 * 2 * ♦ * ♦ Lewisham 60,889 8,353 1,229 3,262 148 — 36 7 — 3 — 5 — 937 876 175 1 — ‡255 — — — Paddington 22,663 7,611 1,157 902 — — — 8 2 1 8 8 377 275 — • 207 5,800 * 9 * Poplar 15,732 4,668 1.716 3,403 109 22 — — — — — 1 4 226 135 58 12 6 141 494 — — St. Marylebone 22,635 3,309 276 966 343 136 79 — — — — — 3 1,145 110 118 2,473 23 1,932 7,409 15 39 St. Pancras 26,094 8,209 2,848 5,486 — — — — — — — 2 — ‡894 683 375 ‡1,000 114 ‡5,000 — 137 — Shoreditch 11,140 4,452 639 5,098 2,834 25 — 4 12 — — 1 — 502 109 214 29 11 * * — — Southwark 23,473 0,181 1,414 3,397 261 — — — — 5 — 2 — 236 206 185 * 4 * * * * Stepney 26,681 11,194 1,700 5,604 72 — — — — 2 — — — 404 626 575 4,000 17 1,678 965 — 6 StokeNewington {8,500 6,891 318 1,363 — — — — — — — — — 86 65 149 — — 10 — — — Wandsworth 95,000 15,460 1,624 6,530 — — 21 — — 3 — 2 2 198 60 281 15 11 1 12 — 2 Westminster,C.of 22,536 2,191 96 1,475 409 — — — — — — 4 7 135 66 — 2,574 70 3,350 5,239 2 4 Woolwich 37,929 6,885 1,201 2,321 397 — — — — 4 — — — 261 87 380 • 2 — — — — Total 780,972 177,516 45,314 104,562 7,162 258 139 158 50 31 137 132 66 10,387 6,025 4,593 17,445 921 64,354 20,189 163 2,261 *Information not available. ‡Estimated. Table 38—District Nursing Associations—Completed Treatments—Year ended 31st December, 1949 Diseases Total cases Males Sub-total Females Sub-total All females 0-39 40-59 60+ All males 0-39 40-59 60+ No. % No. % No. % No. % No. % No. % No. % No. % No. % Infectious and parasitic diseases 1,823 4.8 607 1 .6 21 — 31 01 659 1.7 1,035 2.7 55 0.2 74 0.2 1,164 3.1 Tuberculosis 783 2.1 143 0.4 133 0.3 115 0.3 391 1.0 248 0.7 91 0.2 53 0.2 392 1.1 Cancer (and other neoplasms) 1,938 5.1 26 0.1 191 0.5 510 1.3 727 1.9 69 0.2 312 0.8 830 2.2 1,211 3.2 Diabetes 2,080 5.5 27 0.1 45 0.1 263 0.7 335 0.9 70 0.2 339 0.9 1,336 3.5 1,745 4.6 Mental and nervous diseasesanddiseases of the sense organs 2,061 5.4 642 1.7 93 0.2 141 0.4 876 2.3 627 1.7 213 0.5 345 0.9 1,185 3.1 Heart and arteries 3,171 8.4 39 0.1 156 0.4 927 2.5 1,122 3.0 121 0.3 325 0.9 1,603 4.2 2,049 5.4 Cerebral lesions of vascular origin 1,733 4. 6 10 — 46 0.1 487 1.3 543 1.4 29 0.1 119 0.3 1,042 2.8 1,190 3.2 Veins and other circulatory 546 1.4 12 — 28 0.1 60 0.2 100 0.3 55 0.1 111 0.3 280 0.7 446 1.1 Respiratory system 4,060 10.7 598 1.5 283 0.8 685 1.8 1,566 4.1 881 2.3 384 1.1 1,229 3.2 2,494 6.6 Digestive system 4,304 11.4 440 1.2 320 0.8 830 2.2 1,590 4.2 819 2.2 539 1 .4 1,356 3.6 2,714 7.2 Genito-urinary system 3,873 10.2 972 2.6 46 0.1 466 1.2 1,484 3.9 892 2.4 407 1.1 1,090 2.8 2,389 6.3 Pregnancy 1,053 2.8 — — — — — — — — 993 2.6 60 0.2 — — 1,053 2.8 Skin 3,108 8.2 539 1.4 213 0.6 375 10 1,127 3.0 622 1. 6 424 1.1 935 2.5 1,981 5.2 Bones and organs of movement 1,127 3.0 33 0.1 32 0.1 100 0.2 165 0.4 71 0.2 189 0.5 702 1.9 962 2.6 Injury 1,054 2.8 131 0.3 42 0.2 118 0.3 291 0.8 134 0.4 104 0.2 525 1.4 763 2.0 Other diseases or ill. defined 5,141 13.6 568 1. 5 253 0.7 827 2.2 1,648 4.4 736 1.9 557 1.5 2,200 5.8 3,493 9.2 Total completed treatments 37,855 100 0 4,787 12.6 1,902 5.0 5,935 15.7 12,624 33.3 7,402 19.6 4,229 11.2 13,600 35.9 25,231 66.7 N.B.—All percentages are of the total cases—37,855. 144 •Part period only. til months only. 145 Atmospheric Pollution Table 39 Deposit Gauge Yearly averages and, period averages of monthly deposits expressed in English tons per square mile Place and period Rainfall, mm. Insoluble matter Total soluble matter Total solids Included in soluble matter pH value Tar Carbonaceous other than tar Ash Sulphates so4 Chorions Cl1 Archbishops Park 1949 37.2 0.32 6.97 11.68 7.58 26.55 2.54 0.86 5.6 1948 45.7 0.35 8.61 13.03 6.35 28.34 2.55 0.71 5.4 1947 44.5 0.36 6.99 10.78 6.40 24.53 2.66 0.79 5.4 1946 58.5 0.43 7.34 10.67 7.69 26.13 3.08 1.00 5.3 1945 42.7 0.37 7.34 10.99 6.11 24.81 2.18 0.77 5 . 4 1945-49 45.7 0.36 7.45 11 43 6.83 26.08 2.60 0.83 5.4 1940-44 48.4 0.32 5 .26 8.06 7.01 20.65 2.77 0.82 5.5 1930-39 46.2 0.44 6.65 10.22 10.09 27.40 3.88 0.99 5. 6 1920-29 47.9 0.36 6.37 10.40 11.12 28.25 4.37 1.30 - Battersea Park 1949 38.0 0.40 11.92 13.46 7.18 32.96 2.63 1.00 5.6 1948 43 4 0.48 14.93 14.95 7.41 37.77 2.94 0.94 5 . 6 1947 43.8 0.77 14.85 17.61 7.89 41.12 3.14 0.99 5 . 5 1946 58.5 0.53 12.10 14 11 7.52 34.26 2.93 0.88 5.8 1945 39.6 0.39 8.97 11.22 7 . 56 28.14 2.70 0.83 5.5 1945-49 44.7 0.51 12.56 14.27 7.51 34.85 2.87 0.93 8 . 6 1940-44 48.3 0.36 7.62 10.63 7.56 26.17 2.78 1.15 5.7 1930-39* 520 0.43 4.93 6.86 7.81 20.03 3.04 0.45 5.2 1920-29 — — — — — — — — — Finsburv Park 1949 27.0 0.27 3.71 6.97 4.58 15.54 1.93 0.55 5.1 1948 50.3 0.29 3.84 6.41 5.64 16.18 2.53 101 5.2 1947 44.1 0.29 3.49 5.45 6.67 15.90 2.34 0.74 5.2 1946 59 .3 0.29 3.30 5.45 9.47 18.51 3.47 1.14 5.3 1945 46.1 0.24 2 43 4.02 7.82 14.51 3.01 0.84 4.9 1945-49 45.4 0.28 3.35 5 .66 6.84 16 13 2.66 0.86 5.1 1940-44 53.4 0.28 2.44 4.37 6.91 14.00 2.57 0.80 5.2 1930-39 48.8 0.38 3.10 6.71 12.50 22.69 4.74 1.02 5.5 1920-29 49.1 0.30 3.50 8.25 9.18 21.23 2.80 1.35 — South Kensington ( Science Museum) 1949 33.9 0.32 4.92 8.00 6.09 19.33 2 . 55 0.75 5.3 1948 44.7 0.29 6.86 8.57 5.69 21.41 2.69 0.80 4.9 1947 41.5 0.56 4.65 10.11 5.97 21.29 2.66 0.69 5.5 1946 63.4 0.29 4.87 8.50 6.39 20.05 2.54 0.99 5.5 1945 — 1940-44 — 1930-39 47.6 0.42 3.76 6.38 8.05 18 .59 2.30 1.07 5.2 1920-29 44.2 0.46 4.82 9.26 9.44 23.98 2.50 1.60 — 146 Table 39 (continued) Place and period Rainfall, mm. Insoluble matter Total soluble matter Total solids Included in soluble matter pH value Tar Carbonaceous other than tar Ash Sulphates SO4 Chlorions Cl1 Victoria P ark 1949 39.7 018 3.98 7.14 5.75 17.05 2.25 0.74 5.2 1948 48.4 0.24* 3.92* 6.94* 5.81* 16.91* 2.50 0.76 5.3 1947 43.8 0.22 3.66 7.34 6.01 17.23 2.68 0.65 5.4 1946 58.2 0.20 3.73 6.36 6.01 16.30 2.51 0.82 5.4 1945 42.5 0.22 3.70 6.45 6.44 16.81 2.40 0.73 5.3 1945-49 38.6 0.21 3.80 6.85 6.00 16.86 2.47 0.74 5.3 1940-44 48.5 0.23 3.26 5.52 6.79 15.80 2.76 0.77 5.2 1930-39 47.4 0.29 3.77 6.98 6.56 17.60 2.55 0.73 5.1 1920-29 50.1 0.21 3 79 7.30 7.87 19.17 2.92 1.20 — Kew Observatory, N orth 1949 37.8 0.17 2.23 3.47 3.62 9.49 1.37 0.54 5.3 1948 42.6 0.13 1.72 2.63 3.65 8.13 1.60 0.59 5.2 1947 39.2 0.16 2.21 3.75 3.68 9.80 1.45 0.51 5.6 1946 64.6 0.13 2.36 3.32 4 .23 10.04 1.61 0.62 5.6 1945 41.8 0.12 1.95 2.80 3.24 8.11 1.06 0.48 5.4 1945-49 45.2 0.14 2.09 3.19 3.68 9.10 1.42 0.55 5.4 1940-44 51.6 0.15 2.49 3.08 5.53 11.25 1.91 0.56 5.1 1930-39 50.3 0.25 1.86 2.76 5.04 9.91 1.75 0.60 5.2 1920-29 — — — — — — — — — Godalming, King George V Sanatori um 1949 39.9 0.08 0.85 1.18 2.51 4.62 0.74 0.56 4.9 1948 60.0 0.06 0.74 0.89 2.84 4.53 1 .01 0.60 5.2 1947 42.8 0.10 1.37 1.12 4.53 7 12 1.09 0.49 5.5 1946 66.2 0.08 0.84 0.87 4.37 6.16 1.29 0.72 5.3 1945 61.9 0.05 0.92 1.08 3.95 6.00 1.16 0.62 5.2 1945-49 54.2 0.07 0.94 1.03 3.64 5.68 1.06 0.60 5.2 1940-44 59.0 0.06 0.72 1.43 3.69 5.90 1.14 0.54 5.8 1930-39* 67.0 0.09 1.00 0.85 4.55 6.49 1 .31 0.77 5.5 1920-29 — — — — — — — — *Part period only 147 Table 40 Sulphur Gases in Air Lead, Peroxide Method Yearly averages expressed as S0} milligrammes per 100 square centimetres per day Year average Battersea Park (South East) * Clissold Park Peckham Rye Park * Ravenscourt Park * Victoria Park * Average of 5 selected stations in L.C.C. area County Hall Beckton Crossness Godalming N.E. S.W. laboratory roof 1949 1.66 1.58 1.17 1.66 2.05 1.52 3.63 2.75 3.63 4.74 2.52 0.39 1948 1.83 1.84 1.24 1.68 2 .04 1.73 4.11 2.81 4.24 6.24 2.20 0.27 1947 1.77 1.52 1.30 1.89 1.91 1.68 3.04 3.24 3 . 49 4.18 2.01 0.40 1946 1.72 1.78 1.33 1.79 2.03 1 . 73 3.53 2.93 3. 85 4.39 1.88 0.38 1945 1.73 1.90 1.24 1 .89 2.24 1.80 3.83 2 . 65 3.92 6 .58 — 0.63 1944 1.85 1.93 1.30 1.79 2.25 1 . 82 3.66 — 3.82 6.46 — 0.43 Averages 1945.49 1.74 1 . 72 1 . 26 1.78 2.05 1.69 3.63 2.88 3.83 5.23 — 0.41 1940-44 1.75 1 .67 1.06 1.68 1.99 1.63 3.15 — 3.63 — — 0.37 1935.39 2.32 1.85 1.26 1.88 2 .09 1.89 3.52 3.01 4.36 — — 0.31 * Stations included in column of averages Table 41 Sulphur Dioxide in Air, Volumetric Method Yearly Averages SO2 Parts per Million by Volume Year Beckton County Hall Crossness 1949 0.110 0.112 0 .031 1948 0.128 0.136 0 .030 1947 0.102 0.111 0 .028 1946 0.104 0 .104 0 .021 1945 0.141 0 .106 0 .022 1944 0.140 0 .104 0 .038 5 years' average— 1945-49 0.117 0.114 0 .026 1940-44 0.116 — 0.035 7 years' average— 1932-38 0.131 0.146 0 .056 148 Table 42 Sulphur Dioxide in Air, Volumetric Method Yearly averages (frequencies) Percentages of total readings of S02 above 0.2 part and below 0:1 parts per million by volume Year Beckton County Hall Roof Crossness Percentage Percentage Percentage Above 0.2 p.p.m. Below 0.1 p.p.m. Above 0.2 p.p.m. Below 0.1 p.p.m. Above 0.2 p.p.m. Below 0.1 p.p.m. 1949 15 61 10 55 0 97 1948 19 51 19 46 0.3 96 1947 12 59 18 51 0 94 1946 15 57 11 58 1 98 1945 25 48 9 52 0 97 1944 25 50 9 60 1 95 1943 28 42 — — 1 93 1942 12 56 — 0 92 1941 14 66 — 0 97 1940 11 66 — — 1 98 1939 14 61 — — 0 96 Average— 1945-49 17 55 13 52 0.3 96 1940-44 18 56 — — 1 95 Table 43 Smoke Concentration in Air Monthly Averages Black Suspended matter : Milligrammes per cubic metre 1949 Beckton County Hall Crossness January 0.49 0.51 0.22 February 0.53 0.67 0.23 March 0.24 0.23 0.35 April 0.19 0.20 0.09 May 0.20 0.20 0.12 June 0. 09 0.17 0.11 July 0.09 0.17 0.10 August 0.17 0.14 0.10 September 0.12 0.18 0.11 October 0.37 0.29 0.15 November 0.67 0.53 0.25 December 0.60 0.37 0.19 Yearly average— 1949 0.31 0.31 0.17 1948 0.30 0.36 0.10 1947 0.36 0.35 0.13 1946 0.48 032 0.09 149 INDEX Page Ambulance service 63 Analgesia 53 Anthrax 16 Atmospheric pollution 33 Audiometry 98 Births 4,49 Blind persons 26 Bronchitis 7 Cancer 10 Care of mothers and young children 44 Cerebro-spinal fever16 Chemical branch 28 Child life protection 56 Child-minders 49 Deaths 6 Dental services 102 Diabetes 10, 100 Diarrhoea and enteritis 17 Diphtheria 16 Diphtheria immunisation 59, 87 Domestic help service 57 Domiciliary midwifery service 52 Dysentery 16 Enteric fevers 18 Enuresis 91 Erysipelas 18 Fertility 4 Foot defects 76, 91 Handicapped children 92 Health Centres 43 Health education 78 Health Service premises 40 Health visiting 55 Heart disease 7,21 Holiday homes 51 Home nursing 56 Housing 24 Illegitimacy 6,50 Immunisation 59 Infant Mortality 12 Infectious diseases 16 Do. in schools 21,93 Influenza 18 Introduction 1 Laboratory work 28 Marriage guidance 48 Mass miniature radiography 76 Maternal mortality 14 Meals for children 93 Measles 18 Page Medical inspection of school children 84 Medical treatment of school children 89 Mental health services 79 Midwifery service 52 Migration 4 Milk sampling 26 Mortality 6 Nurseries, day 49 Do. residential 50 Nursing home registration 27 Occupation centres 82 Ophthalmia Neonatorum19 Pneumonia 10,19 Poliomyelitis 20 Population 4 Premature infants 47 Prevention of illness 74 Problem children 99 Psychiatry 94 Puerperal fever and pyrexia 14,21 Recuperative holidays 51 Remand homes 94 Reports of Divisional Medical Officers 107 Rheumatic fever 21 Rheumatism scheme 97 Ringworm 90 Road accidents 11 Sanitary inspection 26 Scabies 21,90 Scarlet fever 21 School health service 83 School children under 5 years 100 Smallpox 21 Specialist clinics 47 Special schools 92 Staff 106 Statistical tables 118 Stillbirths 6 Sunday cinema grants 48 Tuberculosis 7,22,74 Tuberculous milk 26 Typhus fever 21 Vaccination 61,87 Venereal diseases 76 Visitors 3 Vital statistics 4 Voluntary organisations 45 Welfare foods 48 Whooping cough 21 Whooping cough immunisation 61 756 (C & S 24529) II-I-50