LCC 56 LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and School Medical Officer for the Year 1950 Published by the London County Council, and may be purchased, either directly or through any bookseller, from Staples Press Limited, Mandeville Place, London, W.l, Agents for the sale of the publications of the London County Council. 1951. No. 3743. Price 2s. 6d By post 2s. 10½d, London County Council LONDON'S HEALTH IN 1951 Preliminary report, by the County Medical Officer of Health, Sir Allen Daley, M.D., F.R.C.P. A. VITAL STATISTICS Births after an estimated correction for residence numbered 52,800. The provisional birth rate for 1951 is 15.8 per 1,000. There has been a progressive decline from 1947, as will bo seen from the following figures:- 1951 15.8 1947 20.9 1950 15.7 1946 20.0 1949 16.7 1945 15.7 1948 17.9 1931-40 13.8 It is still too soon to suggest any level at which post-war fertility may stabilise, but the 1951 rate is not significantly different from that for 1950 and for the present the decline has ceased. Deaths numbered 4.2,360 (after the actual registrations have been adjusted by an estimated correction for residence). The provisional death rate for 1951 is 12.7 per 1,000. This compares with 1950 11.3 1949 11.7 1948 ll.l 1947 12.5 1946 12.6 1945 14.1 1931-40 12.7 The higher mortality in 1951 may be attributed in part to the influenza epidemic in the early months of the year. Apart from actual deaths assigned to influenza there wore many more deaths than usual from bronchitis and pneumonia among elderly people as a result of the prevalence of respiratory infection. In addition to this factor there was a general upward fluctuation in mortality. Infantile mortality - The provisional rate of infantile mortality for 1951 is 26 per 1,000 live births. This compares with 1950 26 1949 27 1948 31 1947 34 1946 38 1945 44 1931-40 60 The provisional rate for neo-natal mortality (i.e., of children under 4. weeks) was 17.4 per 1,000 live births and compares with 1950 16.9 1949 17.5 1948 17.5 1947 18.1 1946 22.2 1945 23.0 1931-40 24.0 Maternal mortality (excluding abortion) - The provisional rate is 0.52 per 1,000 live and stillbirths. Comparable figures are - 1950 0.53 1949 0.40 1948 0.50 1947 0.67 1946 0.92 1945 1.35 1931-40 1.91 P.T.O. It should "be "borne in mind that the number of deaths involved is now very small - only 28 in 1951 - and there are inevitably appreciable fluctuations from year to year. Epidemic diseases - Measles - incidence heavy; mortality low - only 24 deaths. Whooping cough - incidence average; mortality low - 25 deaths. Scarlet fever - incidence low; mortality low - (there were 2 deaths from scarlet fever and streptococcal sore throat). Diphtheria - incidence very low; only one death registered. Typhoid fever - incidence average; no deaths. Infantile diarrhoea - incidence below average; mortality much below average - 44 deaths. Poliomyelitis - incidence low; mortality low - 3 deaths. Diphtheria has been overcome as a killer of children, thanks to the immunisation campaign. Pre-war, there were 7,500 cases a year and 250 deaths. In 1951, there were only just over 30 cases and one death. 60 per cent. of infants under the age of 5 are immunised, and at school ages the percentage reaches 75. Continuance of this happy state of affairs depends on the maintenance of the level of immunisation. The infantile diarrhoeal death rate is the lowest ever recorded. Fortunately the incidence of poliomyelitis in 1951 was much lower than in 1949 and 1950. Tuberculosis - The notifications of new cases have again fallen, from 5,718 to 5,476, and there has been a slight further decline in the death rate. The provisional death rate for 1951 is 0.38 per 1,000 - a new low record - compared with 0.40 in 1950. Fatal road accidents caused 303 deaths (provisional figure). This is an increase on 1950 when there were 245 deaths. Cancer caused some 7,600 deaths. The provisional death rate was 2.28 per 1,000 and this can be compared with 2.20 in 1950, (an exact comparison cannot be made until precise figures of reallocation 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). B. GENERAL STATISTICS. Ante-natal, post-natal and infant clinics - Attendances at ante-natal and post-natal clinics average 4,000 a week and at infant clinics 17,600 a week. 45 per cent. of expectant mothers attend the Council's clinics and 85 per cent. of the children under 1 year of age attend. Health visitors paid about 886,000 home visits during the year. Under the Council's Domiciliary Midwifery Scheme 12,800 mothers wore attended in their confinements. During the year home helps attended 27,000 households. About 2,300 were confinement cases, the rest illness. Home nurses provided by the Council through the agency of the District Nursing Associations paid about 1,450,000 visits. The Ambulance Service during the year surpassed all previous records, the number of patients conveyed by directly provided and agency services exceeding 750,000, involving a mileage of over 5,550,000. By improved organisation more patients per mile have been conveyed than formerly. These figures include 88,000 emergency calls as against the previous year's figure of 84,000. 5th January, 1952. LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and School Medical Officer for the Year 1950 By SIR ALLEN DALEY, M.D., F.R.C.P. county medical officer of health and school medical officer THE COUNTY HALL, WESTMINSTER BRIDGE, S.E.I Foreword by the right hon. the chairman of the london county council Because of his approaching retirement, this is the last Annual Report of the County Medical Officer of Health and School Medical Officer of the Administrative County of London that will be signed by Sir Allen Daley. His annual reports have served the purpose, not only of recording progress but also of drawing attention to outstanding problems in the public health field. Sir Allen has held every professional honour open to members of his branch of the medical profession, and has contributed richly from his wisdom and experience both to the health services of the Council and to the public health work of the nation as a whole. During his years of service with the Council he has endeared himself to the Council and its staff, and has justifiably earned their profound respect for his many admirable qualities and abilities. J. W. BOWEN Chairman of the Council INTRODUCTION This report records the activities of the department for 1950. It is the half-wayyear of a century and it is not inappropriate to look back to the beginning of the present century and indicate the principal changes in the vital statistics of London since that date. For instance, the expectation of life of a baby born in 1900 was 44 years if a boy or nearly 48 years if a girl; by 1925 it had increased to 56 and 60 years, while today it is 66 and 71 years respectively. The greatest single factor contributing to this 50 per cent. increase in the expectation of life is in the reduction in the number of deaths of infants under one year of age (the Infant Mortality Kate) which fell from 158 per 1,000 live births in 1900 to 68 in 1925 and is now only 26. Similarly whereas in 1900 3.29 women died in childbirth for every 1,000 births (3.19 in 1925) now the rate is 0.70. This means that in 1900 more than one mother died for every 300 children born and in 1950 it was one death for 1,400 births. These deaths include those following abortion. Excluding those the maternal mortality rate in 1950 was 0.53 or one death for 1,880 births. Progress in the conquest of the acute infectious diseases is striking. Scarlet fever caused 329 deaths in 1900 and 4 in 1950; the numbers for diphtheria were 1,593 and 4 ; typhoid fever 767 and 3 ; smallpox 2 and nil; measles 1,946 and 4 ; whooping cough 1,957 and 30 ; enteritis under 2 years of age 3,401 and 64. Pulmonary tuberculosis killed 7,748 in 1900, 4,361 in 1925 and 1,225 in 1950 ; the non-pulmonary form of tuberculosis was responsible for 2,339 deaths in 1900, 796 in 1925 and only 122 in 1950. The crude death-rates in 1900, 1925 and 1950 were 18.6, 11.9 and 11.3. If the death-rate in 1950 had remained at the rate for 1900 and taking into account the difference in the age constitution of the population for the two years, there would have been 88,000 deaths instead of the 38,300 which actually occurred. The number of deaths of children under one year of age would have been 8,400 instead of 1,372. The population of the county of London is now three-quarters of what it was in 1900— 3,390,000 against 4,543,000. Many factors have contributed to these results. They include advances in medical knowledge both in the curative and preventive fields and what is even more important the application of that knowledge. But knowledge and its application profit not, if those whom it will benefit do not avail themselves of it at the proper time. This involves a continuous process of education of the general public as to the services available, again both curative and preventive, and the circumstances in which they should apply for them. Simple illustrations in the preventive field are immunisation against diphtheria and vaccination against smallpox. These should be started in infancy and the immunity reinforced at appropriate intervals. It is a depressing thought that there was a lag of thirty years between the discovery of the method of immunising against diphtheria and an intensive campaign to have it used. The results have been remarkable. Again the spectacular reductions in infantile mortality are largely due to the efforts over many years of health visitors, infant welfare clinics and of doctors in the public service and in individual practice to educate mothers in the principles of parentcraft. On the curative side there is no doubt that a doctor can do his best and most effective work if he is called in during the earlier, rather than the later, stages of a serious illness and dissemination of knowledge about health and disease with this objective in view is of paramount importance. It must, however, be remembered that the deaths from some diseases have declined for reasons beyond our present knowledge. The mortality from scarlet 2 fever, measles and whooping cough has declined remarkably during recent years. This decline is not wholly accounted for by improved standards of hygiene and treatment. The virulence of the infections may increase again though we now have at our disposal therapeutic measures recently discovered which should prevent a return to the mortalities of former years. Though the former great pestilences, plague, cholera and malaria have disappeared from this country, new ones may take their place of which the recent epidemics of poliomyelitis may be a forerunner. Vigilance, therefore, must be the watchword. It must also be borne in mind that indirect attack against disease has been of outstanding importance. Poverty and unemployment with their attendant anxieties, overcrowding, atmospheric pollution, bad housing, all invite disease and no effort must be spared in national and local efforts to maintain good nutrition and a healthy environment at work and at home. A result of the lowered death-rate is an increase in the number of the aged and in the incidence of the degenerative diseases from which they die. Between 1900 and 1950 the death-rate from cancer increased from 0.96 to 2.20 per 1,000 of the population and from diseases of the heart and blood vessels from 1.56 to 3.99 As will be seen from the report much attention is being given to the problem of how to improve the lot of the chronic, and aged, sick. With the stress and strain of modern life neuroses and psycho-neuroses exact a heavy toll. Little can, as yet, be done but it is a field of preventive work which is becoming of increasing importance. Although 1950 was the second full year of the working of the National Health Service Act of 1946 much time was still spent in discussions with the other bodies concerned in providing the service to ensure that the interlocking responsibilities did not cause any breakdown or delay in the provision of the facilities required by the inhabitants of London. There are still occasional difficulties which arise from time to time but every effort is made to overcome them. Brief reports of the divisional medical officers which will be found in pages 126 to 137, show that the scheme of decentralisation of the Council's principal health services is working satisfactorily. The birth-rate (15.7 per 1,000 of the population) was again lower (16.7 in 1949). The general death-rate of 11.3 per 1,000 of the population was slightly lower than that for 1949 (11.7). There were further falls in infant and maternal mortality and new low records have again been attained. The rate of infantile mortality was 26 per 1,000 live births compared with an average of 63 during the ten pre-war years and of 27 last year. The neo-natal and maternal mortalities were 16.9 and 0.53 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 service is reviewed over the last 50 years (page 81). The work of the chemical branch continued to grow and an account of its activities will be found on page 30. Attendances at the maternity and child welfare centres showed a tendency to decline, 79 per cent. of all infants born being brought to a centre in their first year of life compared with 84 per cent in 1949 (page 46). Details of an investigation into the care of all premature babies born at home during the year is given on page 49. It is very pleasing to report that 375 of the 416 premature babies born made satisfactory progress. Demands on the home help service continued to outstrip supply (page 65). The maintenance of a high level of immunisation against diphtheria suffered a slight setback probably due to the publicity given to exaggerated reports of cases of paralysis following inoculation during the poliomyelitis epidemic of 1949 (page 66). Every effort must be made to maintain a high level of immunity in the child population otherwise there will be a return to the years when thousands of cases of diphtheria occurred every year. 3 The number of vaccinations and re-vaccinations showed a welcome increase compared with 1949 (page 67). Demands on the ambulance service continued to increase and the number of patients carried and the mileage travelled were substantially in excess of those for 1949, which were themselves records (page 68). The fall in the birth-rate was reflected in the smaller number of confinements dealt with by the domiciliary midwifery service, the demands on which were also affected by the increase in the number of maternity beds available in hospitals (page 58). The work of the school health service showed another increase (page 99), Delay in the supply of spectacles was almost abolished by the end of the year but the dental scheme still suffers from the lack of a sufficient number of dental surgeons (page 119). Visitors to the Department During the year 195 visitors, apart from organised groupg, from 46 countries came to study the Council's various health services, compared with 147 from forty countries in the previous year. The numbers for each country are shown below, the figures in brackets being for 1949 Argentina 1 (-); Australia 19 (12); Austria 3 (-); Belgium 2 (-); Bhutan (1); Brazil 1(2); Burma2(-); Canada 5 (6); Ceylon 5(1); Chile 2 (—); China 1(2); Czechoslovakia - (1); Denmark 2 (4); Egypt 4 (3); Eire 1 (-); Ecuador - (1); Ethiopia 1 (-); Fijil(-); Finland 2(1); France 7(1); Germany 7 (5); Greece-(2); Holland 3 (4); Hong Kong - (3); Hungary - (1); Iceland - (1); India 22 (27); Iran 1 (4); Israel 6 (-); Italy 5 (2); Japan 1 (-); Kenya 1 (-); Korea 1 (-); Malaya - (1); Mauritius 1 (1); Mexico 1 (-); New Zealand 7 (1); Nigeria 1 (-); Northern Ireland 1 (1); Norway 4 (2); Pakistan 4 (4); Philippines 1 (-); Portugal 3 (-); Siam 4 (2); Singapore 1 (1); Spain 1 (-); Sudan 1 (6); Sweden 11 (6); Switzerland 4 (2); Tangier - (1); Turkey 2 (1); Uruguay 5 (1); U.S.A. 32 (29); Venezuela 2 (1); West Indies 3 (1); Yugoslavia - (1). These visitors included seventy-three doctors, seventeen nurses, twenty-three students, twelve journalists, eleven social workers and forty-eight administrative officers in the service of local or central government authorities. They spent periods varying from a day to four weeks in visits to all types of establishments and many had talks with senior officers of the department both at County Hall and in the divisions. Appropriate publications were supplied to the visitors when desired. At the same time, they were given advice as to suitable visits to see the services provided by other authorities, metropolitan and provincial, which would be advantageous to them in their studies of British health and allied services. In addition to the individual visitors mentioned above, several delegations and groups of visitors amounting to over 200 persons visited County Hall to obtain information on the Council's health services. They included :— 14 members of the World Study Tours Group from the United States of America, under the leadership of Dr. Harold Aaron and Dr. Milton Roemer of Yale University Medical School, who were investigating health services and medical care in Western Europe. They were addressed by several senior officers of the department and visited the ambulance service control room, an infant welfare centre and a day nursery. 5 United States medical practitioners sent by the American Medical Association to study the British National Health Service were given a similar programme of talks and visits. 75 child care workers (paediatricians, nurses and social workers) from thirty-five countries, under the leadership of Professor Bonet, Director of Studies of the Children's International Centre in Paris, attended for talks on our school health service by a senior officer of my department and by one in the school meals service, Subsequently they visited schools to see the service of school meals. 4 30 ladies accompanying delegates to the World rower Conference visited a welfare centre and a day nursery. 2 Members of Parliament and 6 officers of the Ceylon Government visited a day nursery. 4 German Press representatives visited a maternity and child welfare centre and a day nursery. 20 American visitors belonging to the " European Flying Classroom " (head masters and teachers of training colleges and persons of similar standing), under the direction of Professor Carl Horn of the Michigan State College, visited a welfare centre and a day nursery. 3 Paramount Chiefs from Sierra Leone inspected the ambulance service. 16 members of the Association of County Medical Officers of Health visited a deaf school and also attended at County Hall where they listened to a talk and saw a demonstration on audiometric work. A film on the problems of education of the deaf was also shown. 30 members of the National Association of Enrolled Assistant Nurses, who were attending a conference of that body, were received at the County Hall, where the Council's nursing service was explained by the Chief Nursing Officer and others. A programme of visits was planned for the delegates to the Annual Conference of the National Association for Maternity and Child Welfare, which included an inspection of the ambulance service and visits to occupation centres. Foreign travel Mr. B. Benjamin, the department s statistician, was enabled by the Council and the Rockefeller Foundation to spend nine weeks in the United States of America and Canada studying methods of organising the collection and treatment of public health statistics. Re.signationa There were three resignations on reaching the age for voluntary or compulsory retirement: Dr. M. Hogarth, senior medical officer (maternity and child welfare), on 30th June ; Miss R. Dreyer, chief nursing officer, on 3rd September ; and Dr. V. Wiley, senior medical officer (medical examinations), on 30th September. Dr. G. E. Breen, senior medical officer (epidemiology), who had been seconded from the South East Metropolitan Regional Board returned to duty with that Board on 14th March. Appoint ments Appointments of senior staff were : Dr. I. Taylor (seconded from the Ministry of Health) as senior medical officer (epidemiology), Dr. W. Hartston as senior medical officer (tuberculosis), Dr. D. F. Egan as senior medical officer (maternity and child welfare), Dr. C. W. J. Ingham as senior medical officer (medical examinations) and Miss J. M. Calder, chief nursing officer. This is the last report which I shall have the privilege of presenting, as before the next can be written I shall have retired under the age limit. I wish, therefore, to take this opportunity of thanking the staff of the Department in the warmest possible terms for the magnificent work which they have done, and to express my deep appreciation of their loyal and devoted service to the Council and to the people of London. VITAL STATISTICS Population The Registrar-General estimates the total home population of the county in the middle of 1950 to have been 3,389,620, compared with 3,389,850 in 1949. (The provisional census figure at April, 1951, was 3,348,336.) The corresponding estimates for metropolitan boroughs are shown in Table 2 on page 138 and the rates given in this annual report are calculated upon these figures. 5 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 in 1938, 8.5 per cent. of the population of the county was then over the age of 65. Assuming that the county population is not substantially younger than the population of the country as a whole, the percentage at mid-1950 was at least 10.9. 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 movement 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 remembered as a continuing factor. In addition it should be borne in mind that large numbers of people come into the county each day from outside to earn their living. So far as the spread of infection is concerned the Londoner has a larger field of contact than can be assessed by reference to resident population alone. Fertility The total births allocated to London for 1950 were :— Live 53,281 Still 1,054 Total 54,335 The live birth-rate was 15.7 per 1,000 total population, compared with 16.7 in 1949. 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 now amounts to about 13 per cent., i.e., some 7,000 births in 1950. The corresponding figure in 1949 was 5,800. The number of marriages registered was 34,175, or 20.2 persons married per 1,000 of the total population, compared with 21.1 in 1949. The birth-rate in London tends to follow the same trend as for the country as a whole, but at a lower level. The diagram on page 6 shows the course of the two rates since 1931. The actual rates for London are given in Table 5 (page 141). Following the return of men from overseas and the establishment of more stable conditions of family and economic life, the birth-rate in London, as elsewhere in the country, reached a very high level in 1946 and 1947, greatly exceeding the pre-war level, but the history of the period following the 1914-18 war had indicated that substantial changes could occur in a comparatively short time, and it is not surprising that a decline has taken place. The point of interest now lies in how far the decline may proceed. The 1950 rate is still well above the pre-war level, and the pace of the decline is much slower now than two years ago. 6 LIVE BIRTH RATE IN ENGLAND AND WALES AND LONDON (A.C.) 1931-1950 PER 1,000 TOTAL POPULATION Illegitimacy There were 3,705 illegitimate births (7.0 per cent. of the total live births). Percentages in recent years are :— London England and Wales 1938-42 6.6 4.7 1943 8.2 6.3 1944 9.3 7.2 1945 11.4 9.4 1946 8.0 6.7 1947 6.7 5.3 1948 7.0 5.4 1949 6.9 5.1 1950 7.0 5.1 The peak of the war-time rise occurred in 1945, with a rapid reduction after the end of hostilities. The percentage for 1950 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 38 per 1,000 illegitimate live births compared with a rate of 2.5 for legitimate births. The corresponding rates in 1949 were 41 and 26 respectively. A detailed comparison of deaths in the legitimate and illegitimate groups is given in Table 6 (page 142). Still-births There were 1,054 still-births in 1950 or 19.4 per 1,000 of all births (legitimate 18.9 illegitimate 25.5). 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 7 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; this would also contribute to reduction in foetal mortality. Mortality The total deaths in 1950 amounted to 38,352, or 11.3 per 1,000 of the population. Detailed figures are given in Tables 2, 3 and 4, on pages 138,139 and 140. 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 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. To take the extreme case, if the former classification had been used, the 2,368 deaths from bronchitis in 1950 would have been reduced to 1,319 and the rest would have been classified otherwise, e.g., to heart disease or cardiovascular conditions. 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. The effect of this factor can be judged from the following figures for England and Wales as a whole, published in the Registrar-General's Statistical Review, 1946-47, Text, Medical. The " total " rates exclude deaths abroad but are an approximation to the true rate. 1940 1941 1942 1943 1944 1945 1946 1947 Civilian death-rate per 1,000 civil population 14.4 13.5 12.3 13.0 12.7 12.6 12.1 12.3 "Total" death-rate per 1,000 total population 13.9 12.8 11.5 11.9 11.6 11.4 11.5 12.0 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 8 TREND OF MORTALITY LONDON 1936-50 DEATH RATE PER 1,000 9 TREND OF MORTALITY-LONDON 1936-50 DEATH RATE PER 1,000 10 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 1950, at 11.3, is lower than in 1949, and apart from fluctuations due mainly to sharp differences from year to year in the incidence of respiratory mortality there has been a declining trend since 1944. Another cause of the rise in the war-time death-rate, notably in 1941, was the increase in deaths from tuberculosis. The 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 (page 139). 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. Since 1948 there has been a tendency for the rate to turn upward; a reflection perhaps of an ageing population, and perhaps of changes in certification practice leading to transfers to heart disease of deaths from circulatory disease other than heart disease where the rate was 0.45 per 1,000, compared with 0.65 in 1949 and 0.55 in 1948. Cerebral haemorrhage The death-rate from vascular lesions ot the nervous system in 1950 was 1.11 per 1,000, compared with 1.07 in 1949. 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 1950 amounted to 0.11 per 1,000, compared with 0.18 in 1949 and an average of 0.36 over the decade 1931-40. 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 cardiovascularrenal 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 6.1 1950 5.99 The true effects of the war cannot be separated from the statistical influences described on page 7 (particularly the change in 1940). Rates in recent years appear to be running higher than before the war. The total death-rate is thus 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. Cancer The cancer death-rate for all ages for 1950 was 2.20 per 1,000, slightly higher than in 1949, but the increase is mainly attributable to the 1950 revision in cause of death classification which now places leukemia and aleukemia in the malignant disease group. Cancer is a disease mainly of advanced age and mortality is sensitive to change 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 11 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 smallrise for males and a small fall in females. The difference between the crude and standardised rates for London, which lost a large proportion of its population (more young than old) by evacuation would doubtless be larger but in London age group population estimates were not available between 1939 and 1946. Age specific rates since 1946 are shown below:— County of London Cancer Mortality Rates per 1,000 living (total population) Age and Sex 1946 1947 1948 1949 1950 Males 0-14 0.05 0.02 0.03 0.06 0.11 15-44 0.23 0.35 0.30 0.29 0.38 45 + 5.30 5.34 5.61 5.81 6.18 All Males 2.09 2.13 2.21 2.27 2.45 Females 0-14 0.04 0.04 0.03 0.05 0.07 15-44 0.30 0.34 0.36 0.33 0.37 45 + 4.06 4.27 4.44 4.42 4.51 All Females 1.79 1.88 1.95 1.93 1.98 All Persons 1.93 2.00 2.08 2.09 2.20 Up to 1949 for England and Wales, the comparative mortality index for females had fallen to 0.937 (1938 — 1.000) while the male index had risen to 1.063. In London, for both sexes combined, the long-term trend of cancer mortality can be seen from Table 3 (page 139). 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 1948-50 in relation to certain specific sites are summarised below:— County of London—Changes in Mortality Rates from Cancer between 1931-33 and 1948-50 (all ages) Site Males Females Mean deathrate 1948-50 per 1,000 Change between 1931-33 and 1948-50 Mean death- rate 1948-50 per 1,000 Change between 1931-33 and 1948-50 Buccal cavity 0.087 decrease 48 per cent. 0.025 increase 4 per cent. Respiratory system 0.770 increase 226 per cent. 0.138 increase 151 per cent. Digestive system 1.025 increase 10 per cent. 0.846 increase 22 per cent. Breast 0.381 increase 25 per cent. Genito-urinary organs 0.304 increase 44 per cent. 0.400 increase 6 per cent. All sites 2.35 increase 41 per cent. 1.92 increase 26 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. Since 1931 there had been until recently considerable increase in male mortality from cancer of the digestive system, but in the last four * Comparative Mortality Index. B 12 years the death-rates for males per 1,000 have been 1.063, 1.057, 1.055, 0.963; the increase now appears to be halted and, perhaps, reversed. For females the deathrates have been 0.818, 0.868, 0.860, 0.811; and the increase, which had been progressive up to 1948, has also 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 441, 433, 456, 470 and 514; the increase appears to be continuing. Digestive The mortality from digestive diseases (other than cancer) was 0.44 per 1,000. Within this group the death-rate from ulcer of the stomach or duodenum was 0.17 per 1,000, compared with 0.15 in 1949 and 0.17 in 1948. 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 four years the death-rates have been 0.07, 0.06, 0.07, 0.08, indicating an arrest in the decline. At ages under 55 where treatment is more effective, the number of deaths in 1950 was 39—which compares with recent figures of : 1936-38 (mean annual deaths) 86 1939-41 71 1942-44 42 1945-47 31 1948 27 1949 26 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 general downward trend is, however, clear and an important factor is no doubt the discovery of sulphonamide and anti-biotic therapies. The pneumonia death-rate for 1950 was 0.50 per 1,000 and the rate for " other respiratory diseases," excluding bronchitis, was 0.10. Tuberculosis Road accidents Mortality from tuberculosis is discussed on page 23. Deaths from motor vehicle accidents in 1950 amounted to 245, compared with 257 in 1949 and 248 in 1948. 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. Other violence Other violent causes accounted for 1,253 deaths, The peaks in the diagram on page 9 are due to the heavy toll of air raids. General The leading causes of death in London in 1950 were as follows Deaths Per 1,000 population 1. Diseases of the heart 12,003 3.54 2. Cancer 7,474 2.20 3. Pneumonia, bronchitis 4,332 1.28 4. Vascular lesions of nervous system 3,757 1.11 5. Other circulatory 1,527 0.45 6. Violent causes 1,498 0.44 7. Digestive diseases 1,495 0.44 8. Tuberculosis 1,347 0.40 9. Diseases of early infancy (prematurity, birth injury, congenital malformation, etc) 1,150 0.34 10. Nephritis 385 0.11 11. All other causes 3,384 1.00 38,352 11.31 13 The following chart might well be entitled " the conquest of pestilence " :— Infant mortality The infant mortality rate in 1950, 25.8 per 1,000 live births, constitutes a new low record, and is an improvement on the rate of 26.8 per 1,000 live births in 1949. The movements of the death-rates from the principal diseases at ages below one year since 1911 are shown in Table 7 (page 142). The diagram on the next page illustrates the decrease in the fatality of infants since the years 1911-14. The increase in deaths assigned to congenital malformations and birth injury is partly attributable to changes in classification following the adoption of the 5th revision of the International List of Causes of Death, which added about 12 per cent, to the deaths which would formerly have been assigned to this group and partly also to a tendency for post-mortem examination to be done more frequently resulting in increased precision in certification. For most diseases there has been a dramatic reduction in mortality over the last forty years, and, even since 1927, the improvement is substantial. The pronounced fall in the case-mortality of whooping-cough and measles has helped to bring down the infant mortality rate. Diarrhoea and respiratory infections too are now less frequently contracted, and methods of treatment are more effective. Increasing attention has been paid to the care of the premature infant and there are signs that these efforts are having a salutary effect on the mortality risk. 14 Neo-natol mortality Deaths in various periods of the first year of life are shown in detail in Table 6 (page 142). Deaths under four weeks numbered 902 or 16-9 per 1,000 live births, a new low record. Comparative rates for London and England and Wales in recent years are:— London England and Wales 1931-35 25.1 31.4 1936—10 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 1950 16.9 18.5 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 increase arising from the severe conditions but this setback was soon recovered at the end of the war. INFANT MORTALITY MORTALITY PER 1.000 LIVE BIRTHS 15 The reduction in infant mortality in the past fifty years is a result of many factors and they have mainly been effective against the causes of death (principally infections, diarrhoeal or respiratory) which do not operate until after the first few weeks of life. Deaths within the first four weeks of life, which result mainly from prematurity, congenital malformations and birth injury, have been more resistant to reduction. The distribution of causes of death in the first four weeks of life in 1950 was as ollows:— Cause No. of deaths Per cent. Total Prematurity 245 27.2 Post-natal asphyxia and atelectasis 195 21.6 Birth injury 129 14.3 Congenital malformations 136 15.1 Other diseases of early infancy 94 10.4 Pneumonia of newborn 58 6.4 Diarrhoea and Enteritis 4 0.4 All other causes 41 4.6 Total 902 100.0 Thus, deaths from prematurity, birth injury and congenital malformation account for 57 per cent, of all neo-natal 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 4.6 in 1950, 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 becomes more general. The average neo-natal rate from this cause over the period 1936-40 was 2.20 per 1,000 live births, but was 2.42 in 1950. The birth injury deathrate has in the past been understated. Now more post-mortem examinations are performed and more injuries are detected. The result is that deaths which would formerly be assigned to other causes are now assigned to birth injury and the death rate has increased without any real increase in the risk necessarily being implied. The average neo-natal death-rate from congenital malformation was 2.84 per 1,000 live births over the period 1936-40 and in 1950 the rate was 2.55. 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 1950 the neo-natal mortality rate was less than two-thirds of the average rate for 1931-35. Puerperal fever and pyrexia, maternal mortality A summary of maternal mortality statistics is given below. Detailed figures for the metropolitan boroughs are shown in Table 2 and comparative figures for England and Wales in recent years are shown in Table 8 (page 143). Year Live and still-births Deaths in pregnancy or childbirth excluding abortion Post-abortion deaths Notifications of Puerperal pyrexia No. Rate No. Rate No. Rate 1949 57,679 23 0.40 17 0.023 433 7.51 1950 54,335 29 * 0.53 9 0.012 371 6.83 Rates per 1,000 total births except for deaths following abortion where the rates are expressed per 1,000 females 15-44. The maternal mortality rate in 1950 was officially 0.53 but it is necessary to point out that the Registrar-General assigned (under international rule of classification) two deaths to maternal causes because the death certificates mentioned earlier pregnancies as the origin of hypertensive disease. One of these pregnancies was * See text for correction to this rate. 16 10 years earlier and the other 13 years earlier and neither, therefore, has any bearing on maternal risks in the year under review. The true maternal death-rate was 0-50. While the downward trend of the total maternal mortality rate in recent years 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 and individual years are liable to considerable fluctuation without any significance necessarily being attached thereto. The analysis of maternal deaths has therefore been made on the basis of numbers, not rates, and is as follows :— Cause of death Postabortion Other pregnancy and childbirth Total Sepsis 7 — 7 Other causes 2 29 31 Total maternal deaths 9 29 38 This is the second successive year in which there was not a single death from sepsis following childbirth. All the seven deaths from 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. The notification rate in 1950 was 6.83 per 1,000 total births, compared with 7.51 in 1949. The trend of the 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. 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. Since the war further considerable progress has been made. MATERNAL MORTALITY ( EXCLUDING ABORTION) MORTALITY PER 1,000 TOTAL BIRTHS 17 Infectious Diseases The attack rates and death-rates of the principal infectious diseases in London during 1950 and earlier years, and for the constituent metropolitan boroughs in 1950, are shown in Tables 2, 3 and 9. 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 9. Anthrax Two cases of anthrax were notified during the year, one was confirmed bacteriologically but the other could not be confirmed because penicillin had been administered before admission to hospital. One patient was a lime jobber employed in a tannery and handling foreign hides ; the other was a tanner handling goat skins. Appropriate precautionary action was taken by the responsible medical officers of health of the metropolitan boroughs concerned and no secondary infections occurred. Both cases made good recoveries. Meningococcal infection 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. As from 1st January, 1950, the notification regulations were amended to require the notification of all " meningococcal infection " as a single entity. There were 90 such notifications in 1950, giving an attack rate of 0.027 per 1,000. There were 21 deaths but owing to imperfect notification the case fatality from the disease is less than would appear from this figure. Mortality is greatest at the extremes of age, viz., 62 of the total of 90 cases were in infants under the age of five years and of these 47 were boys and 15 girls. The attack rates for males are consistently higher than for females at all ages. Dysentery The increase of dysentery notifications from 1940 to 1945 coincided with an increase in the available facilities for bacteriological examination and it is impossible to say how far the increase of notification was due to increased incidence and how far it was due to better recognition of the disease. The subsequent marked fall in notifications from 1946 to 1949 and the sudden rise in 1950, cannot be explained on the basis of changes in the degree of recognition, and it seems probable that they do represent changes in incidence and indicate a renewed epidemicity of the disease after an interval of 5 years. It is, however, an undoubted fact that a large number of mild infections pass unrecognised and unnotified and that the actual figures of notifications are a gross underestimate of the number of cases in the community. The wide fluctuation in incidence since notification became operative has not been accompanied by corresponding fluctuations in the number of deaths as the large epidemics have been almost entirely of the mild Sonne type. In London the death-rates from dysentery since the beginning of the century have been as follows :— Mean annual death-rale 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 1950 0.0018 In 1947, 1948, 1949 and 1950, the deaths were 11, 3, 4 and 6, respectively. 18 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 1950 there were only 81 cases or 0.024 per 1,000 living, at all ages, compared with a rate of 0.065 in 1949. 75 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 seven times as great as among those who had at some time been immunised. The effects of the immunisation campaign are illustrated by the diagram, on which the continuous lines indicate the trend of the notification rates in the three age groups 0-4, 5-14, 15+, and the broken line indicates the percentage not artificially immunised. During 1950 the rates have continued their rapid decline although the degree of artificial immunisation at school ages having reached 77 per cent, has tended to become stabilised. DIPHTHERIA — AGE INCIDENCE NOTIFICATIONS PER 1.000 LIVING IN AGE GROUPS There were four deaths from diphtheria in London in 1950. 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 19 further the rate of immunisation; great efforts must be made to ensure that there is no falling off in the existing proportion immunised. To leave children unprotected is to invite the return of those tragedies which, only a decade ago, occurred with appalling and needless frequency. In 1939 there were over 2,000 confirmed cases of diphtheria in London and 98 deaths. The mortality from diarrhoea and enteritis under two years of age (64 deaths) amounted to 1.20 per 1,000 live births, compared with 1.73 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 Diarrhoea and enteritis average for the country as a whole is small but favourable to London, and that both rates are declining. Enteritis is not a notifiable disease in London but hospital reports indicate a. much lowered in 1950. Notification of fevers of the enteric group numbered 63 compared with 58 in 1949. There were only 3 deaths. In 1900 there were 767 deaths. Enteric fevers A large part of the reduction in the incidence of typhoid fever since the middle of the 19th century 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. Much can also be expected from the increasing use of serological tests for Vi-agglutinins in convalescent typhoid patients to ascertain which patients are likely to become chronic carriers, in order that they can be diverted into suitable occupations—a matter in which there is scope for liaison between the public health and hospital authorities. There were 566 notifications of erysipelas in 1950, giving an attack rate of 0.167 per 1,000, compared with 0.173 in 1949. The incidence of this disease has been declining continuouslv since 1941. There was one death in 1950. Erysipelas There were 256 deaths (0.076 per 1,000) from influenza during the year. recent years the deaths have been :— Year Influenza deaths Year Influenza deaths 1940 569 1946 371 1941 397 1947 284 1942 198 1948 78 1943 726 1949 372 1944 206 1950 256 1945 171 During Influenza 20 Although there has frequently been laboratory evidence of the presence of the virus the last major outbreak was in 1937. At the end of 1950, however, too late to affect the statistics, influenza became prevalent first in the North West of England and later in the South. (In London 704 deaths were registered in the first 13 weeks of 1951, compared with 146 in the corresponding period of 1950. The outbreak will be recorded fully in the 1951 report.) Measles Measles became notifiable in London in 1938. Before that 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. In 1950 the annual rise in notifications did not occur until April, three or four months later than expected, and the outbreak did not develop to normal post-war magnitude before the September refractory period when the incidence of measles is usually minimal and outbreaks rarely persist. Notifications fell in late August and early September but rose rapidly again in the remaining months to begin a sharper epidemic than any which had occurred since 1938. (The peak did not occur until after the end of the year and details of the epidemic will be given in next year's report.) In total the notified cases in 1950 amounted to 22,282 giving an attack rate of 6.57 per 1,000. 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 1950 22,282 4 0.018 * 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. Ophthalmia neonatorum The incidence of ophthalmia neonatorum, which, since 1921, remained fairly constant at between 8 and 10 new cases per 1,000 live births, began to fall slightly towards the end of the 1931-1940 decade and in recent years has fallen to below 5 new cases per 1,000 live births. There were 145 cases in 1950 (2.7 per 1,000 live births), 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 Number of cases Domiciliary confinements Institutional confinements Total Notified during the year 41 104 145 Removed to hospital for special treatment 4 32 36 21 The condition at the end of the year of the 145 cases notified was :— (a) Vision unimpaired 135 (b) Vision impaired 1 (c) Vision lost — (d) Died 1 (e) Under treatment 2 (/) Removed from the county 6 Total 145 Notified cases of pneumonia in 1950 numbered 1,691, or 0.499 per 1,000, compared with 0.550 per 1,000 in 1949. Pneumonia is considerably under-notified, particularly at ages over 65, and it is believed 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 9 that the 1950 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 anti-biotics. See page 12 for comment on the deathrate. Pneumonia In 1950 poliomyelitis was again epidemic. During the year 430 cases occurred (corrected notifications) and there were 36 deaths, giving a crude case mortality of 8.4 per cent. In the 1949 outbreak there were 668 cases and 50 deaths, so the 1950 outbreak was milder than in the previous year. In 1950 34.9 per cent, of cases were of infants under 5 years of age. Poliomyelitis and polioencephalitis The variations in age distribution are interesting. Prior to 1947 the percentage of cases under 5 had been falling since 1930, and the proportion of adult cases had been rising, as will be seen from the following figures :— Cases of Poliomyelitis and Polio-encephalitis Year Total No. Under 5 years of age Year Total No. Under 5 years of age No. % No. % 1921-3 209 116 55.5 1942-4 88 41 46.6 1924-6 266 152 57.1 1945 70 22 31.4 1927-9 206 117 56.8 1946 39 14 35.9 1930-2 182 107 58.8 1947 702 196 27.9 1933-5 225 112 49.8 1948 141 47 33.3 1936-8 280 114 40.7 1949 668 356 53.3 1939-41 159 72 45.3 1950 430 150 34.9 The first serious outbreak was in 1947 when there were many adult cases and the proportion of infantile cases under 5 was only 27.9 per cent. In the next epidemic, in 1949, the possible immunising effect on the older children of the 1947 outbreak was seen in a much higher proportion, 53.3 per cent, of cases 0—4 years of age, the highest percentage since 1932. The 1950 outbreak following closely, without the interval year which intervened between 1947 and 1949, probably found a larger proportion of the two and three year olds immunised by the 1949 outbreak. It is not surprising, therefore, that the percentages were more intermediate between the extremes of 1947 and 1949. The 1950 age distribution was :— Poliomyelitis notifications (corrected), 1950 Age No. % 0-4 150 34.9 5-14 149 34.6 15-24 64 14.9 25+ 67 15.6 Total 430 100.0 22 The attack rates in the metropolitan boroughs are shown in Table 2, and the diagram on page 160 shows the location of cases (unconfirmed) reported daily from 10th June, 1950, to 30th December, 1950. It is noteworthy that in Greenwich, Woolwich and Stepney which had low incidences in 1947, and again in 1949, suffered higher than average attack rates in 1950, but Poplar has remained an area of low incidence in all three years. Rheumatic fever Deaths in London from rheumatic fever in 1950 numbered 30, of which 5 were among children under 15 years of age. Corresponding figures in 1949 were 16 and 6 respectively. Account must also be taken of all 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 years, according to age, in recent years:— Deaths from Heart Disease under 45 Years Year 0-4 5-14 15-44 Total Rate per 1,000 living 0-44 1946 1 10 376 387 0.194 1947 1 11 398 410 0.197 1948 1 9 338 348 0.167 1949 5 3 350 358 0.172 1950 _ 4 379 383 0.184 No clear post-war trend can be discovered. The 1950 figures indicate an upward fluctuation in the death-rate, but it is gratifying that there were only 4 deaths under 15. Scabies Scabies became notifiable in London in August, 1943. Notifications in 1950 numbered 823, compared with 1,311 in 1949. The effect of improved control resulting from notification may be reflected in the persistent decline in incidence shown by the figures in Table 9 (page 143). Excellent progress has been made. The attack rate (0.243 per 1,000) in 1950 was less than one-thirtieth of the rate experienced seven years earlier. Scarlet fever The incidence of scarlet lever was lower than in 1949. There were 4,157 cases (1.23 per 1,000), compared with 4,945 (1.46 per 1,000) in the previous year. There were 4 deaths only from scarlet fever or streptococcal sore throat in 1950. Fifty years ago the annual death roll in London amounted to over 300. Smallpox Whooping cough There was no notification of smallpox of London residents in 1950. There were 10,875 notifications of whooping cough during the year, compared with 5,754 in 1949 and 10,450 in 1948. As can be seen from Table 11 the incidence varies considerably from year to year. There were 30 deaths, giving a death-rate of 0.009 per 1,000 (crude case mortality 0.28 per cent.). Corresponding rates for 1949 were 0.008 per 1,000 and 0.47 per cent. It will be seen from Table 3 that the fatality from this disease which had been falling since before the turn of the century, has fallen with dramatic rapidity in more recent times. Infectious disease in schools The number of cases of infectious disease reported from schools in 1950 and other years is shown in Table 14 (page 146). 1950 was the third successive 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 lower than in 1949. Whooping-cough was more prevalent than in the previous year. The incidence of chicken-pox was normal. Measles incidence was sub-normal (see above, page 20). Cases of mumps were much more numerous than in 1949. Tuberculosis Detailed figures of new cases of tuberculosis notified in 1950 are shown in Tables 10 to 13 (pages 143 to 146). Non-civilians are included in the statistics and total populations are used. 23 The general trend of morbidity and mortality since 1921 is indicated by Table 10 (page 143), and is also illustrated by diagram below. 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 1.02 per 1,000 for pulmonary disease and 0.14 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 and they may now be regarded as having fallen below even the level to which they might have been expected to decline on the basis of pre-war trends. 24 The death-rates per 1,000 living in 1950 in London and for the whole country were:— Pulmonary Non-pulmonary London 0.361 0.036 England and Wales 0.321 0.043 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. The statistical improvement was, however, short-lived, for between 1947 and 1949 the notification rate rose slightly. It must, however, be remembered that diagnostic services are now more used than ever before and also that 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 part of the rise in the notification was due to improved case-finding and that pre-war and post-war rates are not strictly comparable. It is, therefore, all the more gratifying that the primary notification rate for pulmonary disease in 1950, 1.53 per 1,000, was considerably below the rate of 1.68 per 1,000 recorded in 1949. The war-time increase in morbidity from nonpulmonary tuberculosis was less severe than for the pulmonary form and the rates have fallen below the pre-war level and have continued to decline to a very low level. The non-pulmonary notification rate in 1950 was 0.16, the same rate as for 1949. The age distribution of new notifications of tuberculosis is shown in Tables 11(a) and (6), and age specific notification and death-rates are shown in Tables 12(a) and (6). With regard to notifications, the improvement in 1950 was common to all age groups, except at ages 0.4, where many more cases of pulmonary disease are now reported than formerly. Whether or not this increased level of reporting at infantile ages is wholly real or in part represents increased radiological detection of primary lesions is not known. In any case, if the potential infection is from adult to child, improvement in morbidity at very young ages is likely to lag behind that of adults. The non-pulmonary cases have been analysed, according to the site of the lesion, in Table 13. The incidence of abdominal tuberculosis continues to be very much lower than before the war. 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 number now survive and mortality is certainly declining. 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. The tuberculosis service over the last 50 years is reviewed on pages 81 to 93. Food poisoning Since the beginning of 1949 food poisoning has been a notifiable disease. Reports in 1949 were probably incomplete, but in 1950 863 cases were reported, an attack rate of 0.25 per 1,000. The sex and age distribution was:— Age Males Females 0-4 76 56 5-14 40 48 15-44 136 229 45-64 64 99 65+ 44 66 Age unknown 1 4 361 502 25 It appears that cases were more frequently reported in women than in men. A similar female excess is observed in dysentery. According to figures supplied by the Ministry of Health there were 50 outbreaks of food poisoning in London in 1950, covering a total of 928 subsequently ascertained cases, of which, however, only 288 had been notified before enquiries were made and are therefore included in the total notifications of 863. GENERAL PUBLIC HEALTH Housing During the year 15,680 houses and flats were erected or brought into commission after repair by the Council and/or the metropolitan borough councils. Of these 8,587 were in London (3,813 by the Council and 4,774 by the borough councils) and the remainder (7,093) were erected by the Council outside the London area. The total number of houses or flats owned by the Council at 31st December, 1950, was 136,592 (an increase in the year of 10,891) of which 68,152 are situated in London and 68,440 outside the county. At 31st December, 1950, the Council's list of applicants waiting for accommodation contained 198,955 names, 49,202 new applications having been made during the year. In this period 44,284 requests for preference in rehousing on health grounds were considered and suitable recommendations made to the Director of Housing and Valuer. This figure includes a number of applications, estimated at 10 per cent., which had been considered in previous years but which were reviewed in the light of changed medical or domestic conditions. The number of new applications was, therefore, about 40,000, which is approximately 10,000 more than were considered in 1949. The increasing number of applications on health grounds has been very significant in recent years, and no doubt is largely attributable to the natural anxiety of applicants to put forward any claims which might possibly lead to prospects of early rehousing. Inevitably, many have to be disappointed, but all applications are carefully considered and many enquiries are made to enable fair decisions to be reached. Once again, the great assistance given by medical officers of health of metropolitan boroughs and out-county authorities, of hospitals and of family doctors in providing reports is gratefully acknowledged. At the request of the Local Medical Committee for London, a standard form of medical certificate was introduced and made available to applicants whose doctors recommended special consideration of their patients' need of rehousing. In September consideration of the applications for preference, formerly done centrally, was delegated to the nine divisional medical officers. Since then, of the applications considered on general health grounds, about 9 per cent, were classified as " most urgent", and 27 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 64 per cent. Included in the 44,284 applications received during the year were 2,359 for which special preference was recommended because rehousing was urgently necessary to reduce the danger of infection arising from inadequate accommodation for persons suffering from active pulmonary tuberculosis. In 1949, the Council decided that six unfit areas, on which clearance procedure had been stopped by the war, should be resurveyed with a view to commencing clearance action under Part III of the Housing Act, 1936. The second of these six priority areas, comprising 441 houses and extending over 1½ acres, was "represented" to the Housing Committee in 1950, and another of the areas was resurveyed with a view to representation. Clearance areas 26 Notifications under section 33 of the Housing Act, 1936, of intention to deal with 211 unfit houses contained in seven areas were received from four borough councils. Surveys were made of 421 houses contained in 10 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 237 houses on which slum clearance action was contemplated under the Housing Act, 1936. Town and Country Planning Act, 1947— Declaration of Unfitness Orders The Council gave approval to the acquisition of two areas contained in that portion of the east end of London covered by the County of London (Stepney and Poplar) Declaratory Order, 1947. By the terms of the 5th schedule to the Town and Country Planning Act, 1944, as re-enacted by the 11th schedule to the Town and Country Planning Act, 1947, and the Housing (Declaration of Unfitness) Regulations, 1947, a local authority may make a " Declaration of Unfitness Order " in respect of houses in an area, which is the subject of a Declaratory Order, found to be unfit for human habitation and not capable of being rendered so fit at a reasonable expense. In the two areas referred to above, declarations were made by the Council in respect of 67 houses. The Slun Clearance Survey As a result of discussions with the metropolitan borough councils, details of the slum clearance problems in their respective districts were submitted, including 1,160 unfit areas containing 39,027 houses. A rapid survey of these areas was made, and the areas outstanding from the Council's 1937 slum clearance programme were also resurveyed to ascertain their present condition. These surveys showed that there are in the County 10,347 unfit houses which are probably suitable for immediate clearance action ; 9,066 more are considered to be suitable for possible action in about five years and a further 19,614 houses are likely to become ripe for clearance in about ten years. Before a detailed programme of slum clearance operations can be formulated, further discussions must take place and other aspects of the problem be investigated, but it is hoped that such a programme will be compiled during 1951. Draft Development Plan—1951 The information gained in the slum clearance survey has been utilised by the Council's Architect in the preparation of the programme maps which have to be submitted to the Minister of Local Government and Planning to show the stages for the fulfilment of the development plan. Much work has been done, including the plotting of 10,347 unfit houses on maps and the detailed survey of two areas containing 673 houses. Modernisation of block dwellings Consideration was given to means of securing the modernisation of block dwellings in London, many of which, while structurally sound, were built many years ago and are lacking in modern amenities. The Director of Housing reported on proposals for a programme for modernisation of such dwellings in the Council's ownership, and means of encouraging improvements to buildings in private ownership were discussed with the Metropolitan Boroughs' Standing Joint Committee. It was recommended that when possible this should be done by assistance to owners under the provisions of the Housing Act, 1949. Height of habitable rooms The Council's byelaws require a minimum height of 8 ft. 6 ins. in all new buildings, except on the top floor of multi-storey dwellings which may be 8 feet. Following a research carried out in the Applied Physiology Department of the London School of Hygiene on the height of rooms it was decided to relax this requirement for a trial period to permit the building of block dwellings with staircase access and cottages, including 3-storey terrace houses, with rooms having a minimum height of 8 ft. on all floors. This concession, which is subject to review, does not apply to flats of balcony access type below the top floor which are still subject to the minimum requirement of 8 ft. 6 ins. 27 During the year 2,951 searches were made in connection with enquiries concerning properties scheduled as dangerous structures. Dangerous structures Tuberculous Milk The following are details of the sampling for biological examination of milk coming into London in churns by road and rail and the results of the examinations:— Source of sample Designation Total Samples Percentage positive of completed samples Positive Incomplete Negative 1950 1949 (a) Supplied to Ordinary 475 13 10 452 2.8 2.5 London by Accredited 1 1 0 0 * * road and rail in churns. Tuberculin tested 13 0 0 13 — — (b) Plant at London depots. Pasteurised 11 0 0 11 — —— (c) Residential schools. Ordinary 3 0 0 3 — — Total 503 14 10 479 2.8 2.5 * A percentage would be unreliable owing to the few samples taken in 1949 and 1950. Owing to the relatively small quantities of accredited milk received in London only one sample was secured. Further samples of milk from this source were not taken during 1950 as the herd was under investigation by the Ministry of Agriculture and Fisheries. The herd was subsequently declared free from infection, one tuberculous cow having been slaughtered before the investigation was completed. As a result of investigations by the Ministry of Agriculture and Fisheries into the origin of positive samples from 8 other herds, 12 tuberculous cows were removed and slaughtered under the provisions of the Tuberculosis Order, 1938. Two other cows removed from one of these herds before investigations were complete, were also found to be tuberculous. The sources of infection of two other herds were presumed to be two cows disposed of before investigations into the origin of positive samples were complete. No sources of infection in three herds could be traced and the herds have since been declared free from infection. Sanitary inspection Reports of 289 instances of infestation were received from 249 establishments controlled by the Council, e.g., restaurants, schools, rest centres and parks. Infestation by rats, mice, cockroaches, bugs, ants, flies, fleas, mosquitoes, moths, etc., were dealt with and 212 of the disinfestations were satisfactorily completed by the end of the year. Disinfestation The disinfestation of dwelling houses owned by the Council is undertaken by the staff of the Housing and Valuation Department. Advice on the latest methods of control is given as occasion arises. 2,130 visits of inspection were made to 563 civic restaurants, kitchens and school meals centres. 34 reports of illness following meals were investigated. In one case only was contamination of food confirmed bacteriologically. This was beef and a butcher handling the meat before delivery to the kitchen concerned was found to harbour the same organism as that discovered in the meat. Restaurants & catering Regular inspections, at least once a quarter, were made of 59 homes, hostels, rest centres and other premises in connection with sanitary conditions. c. Welfareestablish ments 28 Complaints A large number of complaints of insanitary and overcrowded home conditions were received from the public. These were referred to the health departments of the appropriate boroughs. Blind and partially-sighted persons The following figures show the number of persons examined under the National Assistance Act, 1948, for certification of blindness and the results. The figures do not include children of school age, details of whom are to be found in the table on page 150. Examinations by the Council's Ophthalmologists Classification Certified blind Not blind Grand total Male Female Total Male Female Total New cases 287* 530* 817* 91 170 261 1078* Previously blind, still blind 33 30 63 — — — 63 Previously not blind, now certified 18 35 53 — — — 53 Previously hot blind, still not blind — — — 30 69 99 99 Previously blind, now not blind — — — 14 4 18 18 Total 338* 595* 933* 135 243 378 1311* * These figures include 10 boys and 9 girls under 5 years of age. 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 201 certificates were accepted from other authorities, hospitals and private ophthalmologists as follows :— Blind persons 193 (82 male, including 4 children under 5 years, 111 female) Not blind persons 8 (2 male, 6 female) The causes of blindness in the 23 children under five years of age who were certified during the year were :— Retrolental fibroplasia 11 Optic atrophy 6 Glioma 2 Microphthalmos 1 Cataract 1 Buphthalmos 1 T.B. meningitis 1 No case among these children was attributable to ophthalmia neonatorum which has practically been eliminated as a cause of blindness. Statistics relating to the incidence and effects of this disease will be found on page 20. The number of cases of retrolental fibroplasia is alarming and enquiry is being made as to its alleged association with prematurity. The number of partially-sighted persons recommended for inclusion in the Observation Register was 228 (82 male, 146 female). Blind persons examined as to suitability for training and the results were :— Male Female Total Suitable for training 19 8 27 Unsuitable for training — — — 29 Registration of nursing homes At the end of the year 54 nursing homes on the register were functioning compared with 58 registered homes open at the end of 1949. One new registration took place and 5 homes were closed during the year. In the 54 homes there were 982 beds distributed as follows :— Number of beds in home Type of patient accommodated Total  Number of homes Maternity only Maternity or others Others 25 or over 5 240 97 337 20 to 24 11 — 64 177 241 15 to 19 10 17 60 92 169 10 to 14 12 — 31 105 136 5 to 9 11 — 50 36 86 Under 5 5 1 2 10 13 Total 54 18 447 517 982 * Numbers include additional beds which can be used if the "maternity or other" beds are not used for maternity patients. 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, particularly males. Welfare Committee Establishments 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. Each of the homes is attended by a visiting medical officer whose duties include the examination of newly admitted residents and attendance in case of illness on any resident or member of the staff who is on his National Health Service list (and others in emergency). Periodic visits are also made to homes and rest centres by medical officers and by inspectors on the central office staff to supervise medical and sanitary arrangements and hygiene, and to investigate and advise on the control of infection and other social problems. Other establishments are visited for these purposes as necessary. Many residents of the homes are, owing to age and infirmity, particularly susceptible to acute illness, especially in winter and during epidemics of respiratory infections. Arrangements for suitable accommodation for such acutely sick persons and for medical and nursing attention for those who cannot be removed to hospital are under continuous review. Many problems arose in connection with the eight Homeless Families Units, attached to large welfare homes. Difficulty was experienced at times in the control of infectious disease, due to unavoidable overcrowding caused by pressure on the available accommodation, and also, during the winter months, due to the shortage of hospital beds. Advice was given to the Welfare Department on quarantine measures and on the installation of essential equipment, such as milk preparation rooms, sluices, etc. 30 Care of the chronic sick Attention has also been given to the needs of the considerable number of chronic sick persons who remain in the Council's homes because hospital beds are not at present available and to means of avoiding the deterioration of patients into a permanently bedridden condition. During the year a special survey was made of eight large welfare homes accommodating chronic sick and aged and infirm residents. Agreement was reached in principle with the Metropolitan Regional Hospital Boards for a link between each home and a hospital geriatric unit but at present this is restricted in practice by the limited number of such units. Arrangements for the care of chronic sick people in their own homes were also under review. These included the laundering of fouled linen and the provision of meals. Invalid Kitchens of London The Council's Wellare Service includes assistance in providing meals on wheels which are distributed to aged persons by the agency of voluntary Old People's Welfare Associations. Under the National Health Service, the Council may arrange for the provision of meals at home for the sick, including the aged sick. Many parts of London are covered by the service of the Invalid Kitchens of London, a voluntary organisation which provides meals for invalids at various centres or delivers them by car to the patients' homes. The Council made a grant to this organisation's funds towards the cost of meals provided by them for sick persons living in their own homes. Health, welfare & safety of employed persons & hours of employment of j uveniles Government Committees The Council gave written and oral evidence before the Interdepartmental Committee which was set up in 1946 under the chairmanship of Sir Ernest Gowers. The Committee's report, published in March 1949, recommended the introduction of legislation to improve the standard of health and welfare in non-industrial employment. In the main it was found that the practices and standards adopted by the Council conformed with those proposed by the Committee but representations were made to the Home Office on certain recommendations which were considered to be impracticable. Industrial health service Written evidence was submitted to the Committee of Enquiry which was set up in 1949 under the chairmanship of Judge Edgar T. Dale to consider the need for an industrial health service and what steps might be taken to prevent overlappng between it and the National Health Service. 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:— Particularly since the end of the recent war and as the implications of world economic conditions have become apparent, the contribution which science can make to the well-being of the community has been increasingly recognised. In government service this is exemplified by the rapid expansion of the Department of Scientific and Industrial Research and the reports of the Advisory Council on Scientific Policy set up in 1947. The undoubted success of these bodies and the realisation of the essential need for their development has done much to make evident the uses of science in local as well as national government, particularly in the case of such a large and complex organisation as that of the London County Council dealing, as it does, with all aspects of the life of the citizens of London. Of the sciences included in the government schemes it is fair to say that chemistry and physics occupy a foremost place, as indeed they must necessarily do in any comprehensive research organisation. Both these subjects are catered for by the Chemical Branch and there was much evidence during the year, as will be seen from 31 the following paragraphs, that their potential uses were increasingly recognised in all departments of the Council. Particularly was there an increase in the number of enquiries sent to the Chemical Branch for advice on problems covering a wide range of subjects. In addition to the considerable increase in the amount of this consultative and advisory work, which occupied a large proportion of the time of the senior officers of the Branch, there was also a further increase in the committee work, both of the Council itself and of government departments, British Standards Institution, etc., on which the Council was represented and its views and requirements advocated. The number of samples received for examination in 1950 also showed a continued increase on those of former years, this applying to each of the three laboratories. The total number for 1950 was 24,523 compared with 23,729 in 1949 and 21,400 in 1948. The classification was:— Air, tunnels, etc. 355 Milk, liquid, condensed, dried 206 Building materials 255 Oils, lubricating, fuel, etc. 78 Chemicals, drugs and medical supplies 40 Paints, varnishes and distempers 1,744 Petroleum and allied samples 99 Clay, subsoils and borehole waters, etc. 578 Rainwater (atmospheric pollution deposit gauges) 86 Compost (manurial use), etc. 10 Rubber and substitutes 16 Detergents and soaps 42 Scouring powders and lavatory cleansers 56 Disinfectants and insecticides 10 Fertilisers and feeding stuffs 110 Sewage and effluent 3,933 Floor oils and polishes 32 Sludge, primary, digested, and activated 3,493 Fuel (coal and coke) 49 Foods, etc 554 Sulphur gases and smoke in air 1,820 Gases, sludge digestion plant, flue, degreasing plants, etc. 486 Water, steam raising plants 2,002 Water, drinking 2,100 Grit deposits (from power stations) 132 Water, swimming bath 944 Lamps, gas detector 315 Water, river 4,248 Liquor, effluent from gas works 356 Water, miscellaneous 54 Meals 75 Miscellaneous 193 Metals 52 Total 24,523 (The water samples included both chemical analyses and bacteriological examinations) 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. The amount of work done for this service increased still further during the year and covered a very wide field. That on paints and other protective coatings included the continued revision of the lists of firms and brands of materials which shall be approved for use by the Council or for work done by contractors for the Council. Many samples from manufacturers were examined for the information and guidance of the inter-departmental committees dealing with this matter ; others were of paints as supplied to works in progress. Generally, it was found that an appreciable proportion of the paint on the market did not comply with the standard of quality required by the Council. Examples of reasons for adverse reports on samples were (a) the use of white lead and lithopone together in a pigment; (b) the inclusion of lithopone in a paint for exterior use; (c) gritty nature of the finished surface ; and (d) softness, or lack of adhesion and/or flexibility of the film produced. A few failures of surface coatings were investigated during the year, the premises being visited for examination and collection of samples for subsequent analysis in the laboratory. Examples of the reasons ascribed were (a) variation of the " suction " of the surface in the case of a flat oil paint; (6) painting on a moist wood surface of a type of timber liable to shrink (or expand) with moisture change. Long period exposure tests were carried out on Housing 32 certain types of paints and surfaces and advice was given in a number of cases as to the best types of material to use and procedure to adopt. Other building materials examined included cements of all kinds, bricks of many varieties, asphalts, synthetic stones, concretes, timber, synthetic floorings, clinker, mortar, putty, slates, bitumen sheeting, etc. The considerable number of synthetic floorings submitted for analysis as to composition and for test as to efficiency under various conditions indicated particular interest in this line. Many materials tendered as hardeners or waterproofers for concrete were examined and their probable efficiency assessed: examples were calcium chloride, mixed soap solutions, hydrated lime with chalk and soap, alkali silicates and soap, and emulsion of a urea-formaldehyde resin, etc. The possible danger of sulphates to concrete was carefully watched and many samples of soils and waters from housing sites were analysed, the use of sulphate resisting cement or high alumina cement being recommended where the sulphate content indicated the need for such precautions. Some suspected cases of dry rot were examined for the presence of the active agent Merulius Lacrymans. Other special items were :—(a) a surface hardener and skid proofer for concrete was alundum i.e..electric furnace produced aluminium oxide containing a small amount of aluminium carbide ; (6) a neutralising fluid for treating new plaster was an aqueous solution of zinc fluorosilicate ; (c) a glaze producing process for wood was based on the polymerisation of urea-formaldehvde in the presence of an organic phosphate and an organic acid. Rivers and drainage The formation, early in the year, of a separate Rivers and Drainage Committee of the Council emphasised the importance attached to the subject of river sanitation and the associated one of sewage treatment. 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. 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 on the works. The composting of sewage products with pulverised household refuse was continued, considerable quantities being made during the year from sludge screenings and subsequently transported mainly to farms at hospitals. 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. In order to improve its condition the Council approved, in principle, large additions to the present treatment works on both sides of the river and the construction of new sedimentation tanks at the Northern Outfall Works was started during the year. Two other important factors which affect the condition of the water are the freshwater flow and the water temperature. The statutory minimum for the former is 170 million gallons per day which can, by Order made by the Minister of Health,* be reduced, under certain circumstances, to 50 million gallons per day. A large proportion of London's water supply is drawn from the upper Thames by the Metropolitan Water Board and a scheme was agreed by the authorities concerned for the withdrawals to be regulated to the best mutual advantage. In regard to the temperature, a Government Committee was set up by the Minister of Health to examine the effect on the river of the admission of heated effluents and the Chemist-in-Chief was * Now Minister of Local Government and Planning. 33 appointed to be a member of this Committee. He also continued to be a member of the "Thames Survey Committee," which operates under the auspices of the Department of Scientific and Industrial Research. Close liaison was maintained with research work proceeding in this country and elsewhere, particularly in the United States of America, on the treatment of sewage and on river sanitation. 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 (a) the dewatering of sludge by a new process involving freezing after the addition of chemicals ; (b) preaeration of sewage for grease separation ; (c) modifications of operation of the present activated sludge plant; (d) cleaning of diffuser tiles. Item (a) resulted in a paper on "Sludge dewatering by freezing with added chemicals" which was presented to the Public Works Congress in November by three officers of the Chemical Branch. The question of trade discharges into sewers was investigated in a number of cases as to compliance with the appropriate sections of the Public Health (London) Act, 1936, and advice was given in many instances on whether a proposed discharge would be within the terms of the Act, sometimes with suggestions as to possible pre-treatment which would render it so. 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. 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. Public health The air in the Council's vehicular tunnels under the river Thames 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. Considerable work was done during the year on atmospheric pollution, assays being made by various methods of the polluting matter (total deposit, tarry matter, sulphur gases, smoke, etc.) in the air in various places within the county and also, for comparison, at two observation stations outside it. This work was done in conjunction with a scheme sponsored by the Department of Scientific and Industrial Research. In compliance with a Committee Order, a special survey was made in conjunction with the Public Control Department of the emission of industrial chimney grit in the vicinity of all the electricity generating stations in the county. In some instances the quantities were judged to be unduly high and the appropriate sanitary authorities (borough councils) were notified. In accordance with an official arrangement, the Chemist-in-Chief accompanied the Chief Alkali Inspector, Ministry of Health, on his periodical visits to Battersea Power Station to test the efficiency of the flue gas-washing process for the removal of sulphur compounds. At the close of the year only 70 per cent, of the flue gases were being washed at this station and no part of the gas-washing plant at Fulham Power Station has yet been reconditioned and put into operation. 34 A close watch was kept on advances in the insecticide field and the Council's specifications for these preparations were kept up to date for the various requirements; they were based mainly on the use of D.D.T. and Gammexane. Considerable attention was also given to matters concerning industrial hygiene and safety, some instances of which occur in other sections of this report; others were warnings in regard to the precautions necessary in using a caustic soda jelly for cleaning, and a paint remover. Advice was also given on disinfection problems. Public control Samples taken under the Fertilisers and Feeding stuffs Act, 1926 (under which the Chemist-in-Chief is the Official Agricultural Analyst for the County), were examined as to whether they complied with the statutory statement of ingredients which is required to be given with every sale and also (in the case of feeding stuffs) as to their freedom from deleterious substances. Several were reported upon adversely. Many samples were also examined under the Petroleum (Consolidation) Act, 1928, the London Building Act, 1930, and the Explosives Acts. The first concerned the issue of licences for the storage of petroleum, or contraventions of the provisions of the Act. One particular case was of special interest. It was a proposed large petroleum storage installation in somewhat difficult conditions from the aspect of the possible corrosion of the tanks ; a protective system of painting with red lead, coating with bitumen and subsequent installation of cathodic protection was recommended and agreed. Under the London Building Act, potentially dangerous businesses were inspected in order to express an opinion on the risks involved, e.g. fire risk. The Explosives Acts samples were concerned with the manufacture of indoor fireworks, some samples being found to contain potentially explosive ingredients. Other statutory work was in reference to the London County Council Celluloid Act, 1915, as to whether films contained cellulose nitrate and were hence inflammable. Advice was also given, when requested, in relation to the provisions of the Town and Country Planning Act, as to the possibility of objection on the grounds of amenity to the setting up of new industrial processes. 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 visited periodically and samples of the atmosphere in the machines were taken for subsequent analysis to ensure that the safety regulations regarding the limitation of inflammable gases, derived from volatile solvents, were being duly observed. School and other meals The work done in co-operation with the Restaurants and Catering Department was continued and many meals were analysed as to their nutritional value by the determination of their fat, protein, carbohydrate and mineral contents. The results generally showed a reasonable approximation to the targets aimed at for the several nutritional factors for the various age groups concerned. A few whole-day food intakes at nursery schools were also examined and found to be satisfactory. The possible purchase of peeled potatoes preserved in sulphur dioxide solution having been considered, it was advised that rigid control would be necessary to ensure that none of this was retained in the cooked potatoes. The merits of various types of insulated containers were assessed and the tarnishing of cutlery was investigated. Parks Chemical analyses and bacteriological examinations of the water of swimming baths were made and the chlorine dosage being applied for sterilisation was checked, recommendations for any necessary alteration of procedure being made as required. During the bathing season all water used in the Council's public swimming baths is chemically treated, filtered and chlorinated. As mentioned in the report for 1949, it 35 was decided to adopt, so far as possible, the breakpoint system of chlorination whereby the dosage applied is sufficient to ensure a residual of true free chlorine (as distinct from " combined " chlorine in the form of chloramines). By this procedure the polluting nitrogenous matter derived from bathers is quickly destroyed by oxidation and the water is kept chemically pure as well as bactriologically sterile. A considerable investigation was carried out as to the necessary changes at existing plants to implement this decision and the best method of operating them. Methods and demonstrations on water testing were given to bath attendants. The water of natural ponds used for bathing was also tested. Samples of soil were analysed as to their content of plant nutrient substances and new types of plant pots were examined as to their suitability for use, having regard to Dorositv. frost resistance, etc. The materials examined for this service covered a very wide field and many of them are dealt with in other paragraphs concerning the services which use them; for example, paints and building materials for housing, and insecticides for public health. Foods of all types formed a considerable proportion of the total; they were examined (a) to allocate contracts ; (6) to check the quality of deliveries ; (c) to investigate complaints ; and (d) to assess whether new preparations are of potential use in the service and are offered at a fair price. Generally a high standard of quality was maintained with but few justifiable complaints. Particular attention was again given to canned foods in regard to corrosion of the container and possible tin content of the food. Supplies A careful watch was kept on the quality of the liquid milk supplied for use by the Council in its various services and samples of condensed and dried milk were also examined in the Council's laboratories and generally found to be satisfactory. Chemicals, drugs and medical supplies of various types were submitted for analysis and report, and also lubricating and other oils, floor and other polishes, soaps, scouring powders, etc. Many of these are supplied to the Council's specifications. The position in regard to synthetic detergents was closely watched during the year and many proprietary preparations were examined. The use was continued of the type previously found by trial to be the most satisfactory for hand washing-up in kitchens. 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. In the case of the swimming baths at premises of both the Education and Children's departments the water treatment has been by a system of improvised chlorination. The Council, however, agreed in principle to a recommendation that treatment plants should be installed at these baths in order that they shall operate on the "breakpoint" chlorination system already mentioned, instead of the present less efficient improvised process. Having regard to existing circumstances, the construction of such plants will naturally have to be spread over a considerable period. Advice was also given on the treatment of swimming bath water at summer camps. Education and Children riastic articles tendered tor use as ieeding utensils tor intants were examined as to their suitability; they were tested from the utility angle, such as strength and resistance to heat, and also for the possibility of toxicity. Plastic wood suggested for use as a modelling material was considered to be unsuitable primarily because of its formaldehyde content. Instructional visits of school parties to both the Headquarters and Northern Outfall Works laboratories should also be mentioned. Work in connection with this service increased, particularly on the advisory side, for instance, in regard to the use of fire-resisting coatings and materials. A few of the special investigations made were :—(a) the cause of a fire was ascribed to steel Fire Brigade 36 wool making contact with an electric battery: the material is easily ignited, for example, by a match; (b) subsequent to a fire, a fractured oil pipe was examined as to whether the fracture had existed before the onset of the fire ; and (c) various foam producing compounds were assessed for their efficiency as fire extinguishers. Steam raising, heating, etc., plants Much consultative and advisory work was done tor both the Chief Engineers 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 hexametaphosphate for scale prevention and of soda ash and quebracho or full phosphate conditioning for boiler water was extended; the dosages were controlled by periodical analysis of the water concerned. Examples of special cases dealt with were :—(a) corrosion of condenser tubes in a sludge vessel was ascribed primarily to the effect of sulphate reducing bacteria in the river water and silt producing hydrogen sulphide ; (b) a boiler scale contained an undue proportion of oil and overhaul of the de-oiling plant was recommended. Miscellaneous Many other matters were dealt with of which may be mentioned :—(a) examinations of metal plating finishes for the thickness of the nickel and chromium films : e.g. sanitary fittings, cutlery etc.; (6) some plastic lampshades exhibited the troublesome characteristic of attracting an abnormal amount of dust; this was found to be due to the formation of electrostatic charges and a simple treatment was recommended to mitigate the trouble ; (c) a method for quick cleaning of brass finger-plates on doors, etc., was devised, using a solution of ammonia and ammonium chloride; (d) the death of fish in an ornamental pond was ascribed to a deficiency of dissolved oxygen due to its being used up by mud and debris ; and (e) certain statues, etc., were cleaned by the most suitable method for each individual case. Attention was paid to the development of new analytical methods and close liaison was maintained with many research associations. During the year many visitors, both from home and abroad, were welcomed to inspect the work of the various laboratories. 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 was also a member of the Council of the Society of Public Analysts and other Analytical Chemists. 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. A Senior Assistant Chemist (Mr. G. B. Courtier) served on a Committee of the Institution of Civil Engineers. Publications and lectures during the year were: —(a) "Atmospheric Pollution with particular reference to its measurement"by C. J.Regan ; (b) "The role of Chemistry in relation to Public Health " by C. J. Regan ; (c) "Sludge dewatering by freezing with added chemicals " by G. S. Clements, R. J. Stephenson and C. J. Regan; (d) "Some recollections of the United States of America (Sewage treatment) " by C. J. Regan in collaboration with W. P. Warlow of the Chief Engineer's Department; (e) "Disposal of Sewage Sludge by composting with household refuse" by C. J.Regan in collaboration with W. P. Warlow of the Chief Engineer's Department; and (/) " The losses of Ascorbic Acid during the large-scale cooking of green vegetables" by S. G. Burgess in collaboration with Mrs. M. A. Allen of the Restaurants and Catering Department. HEALTH SERVICE PREMISES The work of planning new clinics and day nurseries proceeded during the year in accordance with the Council's short-term programme for the provision of premises urgently required. Since much of this work had been commenced shortly after the "appointed day" under the National Health Service Act, 1946, the number of schemes reaching an advanced stage for submission to the Ministry of Health was 37 larger than in the preceding year. As indicated later, however, the Minister of Health was not able to sanction a number of schemes put forward by the Council and progress with the short-term programme is likely to continue to be hampered by the increasing financial stringency and by other demands upon the nation's resources. Concurrently with the planning of buildings on sites which had already been acquired, negotiations for the purchase of further sites proceeded in anticipation of buildings being provided at a later date when conditions become more favourable. The insecure tenure of many health service premises was noted in the report for 1949. Difficulties were again experienced in maintaining services when such buildings ceased to be available and as adequate replacements could not be provided. In three cases as indicated below day nurseries which had to be closed could not be immediatelv replaced. Maternity and child welfare premises The following day nurseries were relinquished :— Division 1. Australia Road Day Nursery, Hammersmith.—This nursery was closed on 31st January and demolished, as the site was required for the building of a school which could not be postponed. Plans were advanced for the building of a permanent replacement day nursery in Westway, Hammersmith, but work on this nursery had not been started at the end of the year. Closing of clay nurseries Division 3. The Brecknock Day Nursery, Islington.—This nursery in an old requisitioned building had to be closed permanently as it developed serious settlements and was regarded as dangerous. The considerable expenditure on underpinning, which would have been necessary to render it fit for continued use, was not considered justified. A replacement has not yet been found. Clarke's Buildings Day Nursery, Holborn.—This nursery, which was held on a short tenancy, had to be closed on 25th September, when the buildings were demolished to make way for a large block of offices. A search for alternative premises was still continuing at the end of the year. The following premises were opened during the year to replace buildings which were relinquished :— Division 1. Mulgrave Day Nursery, Fulham.—Partially completed day nursery buildings, where work had been stopped during the war, stood on a bombed site in Mulgrave Road, Fulham. The site was purchased, the shell of the building acquired from the Ministry of Health and the building completed. The new nursery was opened on 10th July to replace another in St. Andrew's Vicarage, which was required by the vicar. Replacement of day nurseries and clinics Division 2. Ampthill Square Day Nursery.—Alternative accommodation for the day nursery at 108, Hampstead Road, St. Pancras, had to be found as these premises were required urgently by the National Temperance Hospital. Accommodation at 1, Ampthill Square, which had been in use for many years as a maternity and child welfare centre, was made available after conversion works had been carried out, and the nursery was transferred there on 11th September, although with a reduced number of places. The maternity and child welfare centre continued to function in another section of the building. Division 3. East Islington Branch Welfare Centre.—This centre, in mission premises, was transferred on 5th October to a more suitable building belonging to the Highbury Quadrant Congregational Church. Division 4. Upper Clapton Maternity and Child Welfare Centre.—This centre was formerly at 2-4, Warwick Grove, in premises which were unsound structurally and due for demolition in connection with a housing estate. Premises at 186, Upper Clapton Road, which had been requisitioned for a day nursery staff hostel, were 38 purchased and converted into a maternity and child welfare centre and an office for the home help service. The transfer to the new centre took place on 11th December. Division 5. Salmon Lane Welfare Centre, Stepney.—This centre, in leasehold premises, which were considered unsatisfactory, was closed on 30th September. The welfare centre activities were combined with those of the existing Commercial Road Welfare Centre, 671-3, Commercial Road. Division 6. New Eltham Maternity and Child Welfare Centre, Rusthall Lodge, 46, Southend Crescent.—A welfare centre held in a sports pavilion in Footscray Road, Eltham, was transferred on 28th February, to better accommodation at Rusthall Lodge, a large house belonging to the Council which was converted for clinic purposes to provide more extensive facilities, including school health services. Division 7. Flower House Welfare Centre, Beckenham Hill Rise.—Bellingham welfare centre, held in a church hall, was transferred on 10th January to better accommodation at Flower House, a block of flats on a Council housing estate, where ground floor space was adapted as a maternity and child welfare centre in the course of the erection of the flats. This is regarded as a temporary measure until a health centre can be built in the vicinity. Downham Health Centre, Churchdown, Downham Estate.—This building, erected before the war to provide a maternity and child welfare centre, a school health centre, and two dental surgeries, was almost entirely demolished during the war by a bomb. The building was rebuilt substantially as originally planned and taken into use on 28th February. The temporary maternity and child welfare centre at Wesley Hall, Downham Way, was then closed. Division 8. Alford House Maternity and Child Welfare Centre.—A voluntary grant-aided maternity and child welfare centre at 156, Kennington Lane, Lambeth, was closed and a new centre brought into use on 20th November, at Alford House, Aveline Street, where the Council rents accommodation from a youth club. Provision of additional centres The following additional maternity and child welfare centres were opened during the year:— Division 2. Linnet House Welfare Centre, Charlbert Street, St. Marylebone.—The St. Marylebone metropolitan borough council prepared plans before the appointed day under the National Health Service Act, 1946, to include a specially designed maternity and child welfare centre in a block of flats on a borough council housing estate. The Council agreed that the building of the centre should be proceeded with by the borough council, and the centre was completed and brought into use on 5th April. The equipment was provided by the Council and the premises are now rented from the borough council. Bickersteth Hall, Grove Place, Hampstead.—Pending the erection of a specially designed maternity and child welfare centre to serve the New End area, where there is a growing demand for these services, a temporary centre was opened on 4th October, in Bickersteth Hall, which is being rented from the church authorities. Division 6. All Saint's Church Hall, Bercta Road, Woolwich. To meet a growing demand from the rapidly developing Coldharbour housing estate, Woolwich, an additional infant welfare centre was opened as a temporary measure in All Saint's Church Hall, Bercta Road, New Eltham. Eventually a health centre should be provided to serve this new estate, and negotiations are proceeding to acquire a site. Building works in progress At the end of the year the following schemes, for which plans had been completed and Ministry sanctions obtained, were under construction :— Division 2. Peach Street Day Nursery, Paddington.—The existing Peach Street Day Nursery consists of a prefabricated building standing on a site required for a block of flats which will complete a Paddington metropolitan borough council housing 39 scheme. Before the appointed day the borough council, in consultation with the Council, prepared plans for the replacement of the existing nursery by a permanent building on another site on the housing estate. The Council agreed that the borough council should continue as its agents with the erection of the new nursery. The nursery has been planned and its erection supervised by a firm of private architects employed by the borough council. Division 5. 69, East India Dock Road, Poplar.—The postponement by the Ministry of Health of the building of a health centre in East India Dock Road, which was mentioned in the report for 1949, raised difficulties in maintaining the services in that area, a large part of which was under development in connection with the "Live Architecture" Exhibition for the Festival of Britain, 1951. The building from which the maternity and child welfare services were provided had to be demolished to make way for a new secondary school, and arrangements were made for the transfer of the clinic to a school health centre at 69, East India Dock Road, by the conversion of a few vacant rooms. This is a temporary measure as the clinic building will have to be demolished in due course to permit the erection of a block of flats, but before this can be done it will be necessary to erect a permanent modern health centre to serve the Lansbury neighbourhood unit and another unit to the east. Although the Festival of Britain, 1951, will not be able to show an example of a modern clinic or health centre in the Lansbury neighbourhood unit, the expedients adopted to maintain the essential health services are an example of the problems which have to be solved when the reconstruction of an area is undertaken. The following schemes mentioned in the report for 1949 were abandoned :— Division 4. Ickburgh Road, Hackney.—A large permanent day nursery to replace two war-time nurseries in requisitioned premises was planned. The Minister of Health was, however, unable to approve this project and negotiations were commenced instead to purchase the requisitioned premises and continue to use them. Division 9. 23, Weir Road, Wandsworth.—The conversion of a former Civil Defence building into an additional day nursery was planned. In view of a fall in the demand for day nursery accommodation, especially among the younger age groups, it was decided that the provision of additional accommodation in that area could not be justified. Schemes abandoned Accommodation for tuberculous persons A scheme was prepared to demolish the old and derelict buildings of St. Peter's Hospital, Stepney, which was not transferred to the Minister of Health under the National Health Service Act, 1946, and to erect on the site a night sanatorium for 50 tuberculous men, together with industrial workshops for 150 persons. The workshops were to be provided in conjunction with the Disabled Persons (Employment) Corporation. It was intended, later, to build a divisional health office on another part of the site. The scheme was submitted to the Minister who stated that although the provision of hostels and night sanatoria by local health authorities was regarded as an essential part of the future development of the tuberculosis services the strict limits that the Government had been obliged to set to National Health Service expenditure did not permit the scheme to be proceeded with for the time being. The Council decided, therefore, to seek the approval of the Minister to establish hostels elsewhere for the accommodation of infective chronic tuberculous persons by utilising savings from money voted for other health service purposes. At the end of the year a scheme, approved by the Minister, to bring into use vacant premises at 20-22, Highbury Quadrant, Stoke Newington, which had been purchased by the Council as part of an area acquired for a housing estate, was being prepared. This hostel will accommodate up to 35 tuberculous men, the majority of whom would be in employment. 40 Occupation centres for the mentally defective During the year, the centre at the Metropolitan Tabernacle, Newington Butts, was closed, and new centres at Dalston Congregational Church Hall, Bay Street, and at Cecil Rooms, Chilvers Street, Greenwich, were opened. The centre at Orchard Mission, Mission Place, Camberwell, which had been closed for war damage repairs to be carried out, was reopened. A scheme was under preparation to convert vacant property belonging to the Council at 9, Spencer Park, Wandsworth, into a permanent occupation centre for junior and elder girls. This centre, when in use, will replace two other centres in rented accommodation which is not entirely satisfactory. School treatment centres replaced School health services Division 2. 210, Harrow Road, Paddington.—The voluntary committee who provided a minor ailment clinic at 84, Cirencester Street, Paddington, resigned, and the opportunity was taken of relinquishing the unsatisfactory premises. The service was transferred by the Council as from 14th April, to 210, Harrow Road. Division 5. Whitechapel School Treatment Centre.—New accommodation was brought into use, on 30th October, after the conversion of a vacant part of the building housing the Mary Hughes maternity and child welfare centre in Underwood Street had been completed. Full restoration of pre-war services, comprising minor ailments, vision and dental sessions was then complete for the first time since the former centre was destroyed by enemy action in 1941. The new Whitechapel school treatment centre was renamed "The Ida Samuel School Treatment Centre" in memory of the late secretary of the voluntary committee administering the centre. Division 6. Eltham School Treatment Centre.—This centre, which had operated from a dwelling house at 595, Westhorne Avenue, was transferred on 26th August, to the maternity and child welfare centre at Rusthall Lodge, and the house in Westhorne Avenue was released for residential purposes. New centres opened Division 2. St. Marylebone Town hall Extension.—St. Marylebone Town Hall Extension, erected before the war by the borough council, includes accommodation for a maternity and child welfare centre and chest clinic. The Council was already renting the maternity and child welfare centre and rented further accommodation for a minor ailments and dental centre. The minor ailments centre was opened in February, but the dental centre has not yet been opened owing to the shortage of dental surgeons. Division 7. Downham Health Centre.—School health activities were resumed on the completion of the rebuilding of this centre, the greater part of which was destroyed during the war. Building work in progress Division 5. Bethnal Green School Treatment Centre.—The work of adaptation of Mowlem Street former special school buildings to provide premises for the Bethnal Green school treatment centre, which was destroyed by enemy action in 1944, was approaching completion at the end of the year. Schemes in preparation Division 1. Chelsea School Treatment Centre, 31-33, Brammerton Street.—The Council decided to purchase these buildings which had been held previously on a short tenancy and to draw up a scheme to improve the accommodation. Division 2. Westminster School Treatment Centre.—The Council was informed that accommodation, which had been used for many years at the Western Dispensary, Rochester Row, and at 41, Greencoat Place, would cease to be available. The Council decided, therefore, to purchase a house at 40, Alderney Street, and to convert it into a school health centre. 41 Child guidance units To provide better facilities the following child guidance units were established or planned:— Division 1. 25, Stratford Road, Kensington.—The building was acquired by the Council and opened on 24th August. The existing unit in Bishop Creighton House, Fulham, which had worked in very restricted quarters, was transferred to the new premises. Division 8. Water Lane, Brixton.—Work was commenced on the conversion of the former Brixton Provident Dispensary premises, which the Council had purchased, to provide a large unit which, in association with the Maudsley Hospital, will be used for postgraduate teaching purposes. Division 9. 6, Cambridge Road, Battersea.—Vacant accommodation in the possession of the Council was brought into use on 3rd October, and the unit accommodated at Putney Health Centre transferred there. Office accommodation The following changes in office accommodation were made during the year :— Division 1.—Sub-office accommodation at 94, Kensington High St., was vacated at the request of the Kensington borough council, and an annual tenancy taken of accommodation at the Red House, Hornton Street, W.8. Division 2.—In anticipation of the vacation of 33-35, Lancaster Grove, Hampstead, at the expiration of the lease in September, 1951, negotiations were entered into for the taking of a seven-year lease of accommodation at 251-253, Finchley Road, Hampstead, for use as a sub-office. The head-lease is held by the Restaurants and Catering Committee, the ground and first floors being used as a civic restaurant. Division 5.—The sub-office at 2, Salmon Lane, Stepney, long regarded as unsatisfactory, was vacated and a suite of three modern offices taken at 532-534, Commercial Road. Division 6.—At the request of the Woolwich borough council, alternative accommodation to that held at Woolwich Town Hall was sought, and arrangements were made for domestic help staff to be housed partly in Rusthall Lodge and partly at the Health Centre, Market Street, Woolwich. Division 8.—Shop premises at 376, Brixton Road were leased for a period of 21 years, and brought into use as a sub-office. Division 9.—Shop premises at 52, Fairfield Street, Wandsworth, were taken into use and negotiations begun for the leasing of 50, Fairfield St., to relieve overcrowding at the main divisional offices. Schemes in preparation The recommendations made by the Local Government Manpower Committee to simplify the means of obtaining the sanction of the Ministry of Health to local authorities' capital building projects led to the introduction of a revised procedure for the submission of schemes to the Ministry. The new procedure will normally obviate, except in the case of health centres, the submission of plans, bills of quantities, etc. and instead of the details of each project being submitted individually, particulars of all work proposed for a year's programme will be submitted at one time with a view to approval being given for the work to commence in the following financial year. The annual programme will normally be submitted in November but, 42 in order that the new arrangements could be started as soon as possible, an interim programme was invited in July for works to be commenced before 31st March, 1951. The Council accordingly submitted two programmes in 1950, one in July and a second in November. The July programme comprised the following projects :— Ref. No. Division Scheme 1 1 Provision of a replacement day nursery and a maternity and child welfare centre at Clareville Grove and Gloucester Road, Kensington. 2 2 The building of a combined maternity and child welfare centre and school health centre in Daleham Gardens, Hampstead. 3 2 The completion of a day nursery in Westbourne Park Road, Paddington. 4 4 The building of a replacement day nursery in the grounds of St. John's Rectory, Hackney. 5 4 The building of a replacement day nursery in Springdale Road, Stoke Newington. 6 8 The execution of substantial maintenance works at the day nursery at 210, Knight's Hill, Lambeth. 7 5 The building of a maternity and child welfare centre at Peel Grove, Bethnal Green. 8 5 The building of an extension to University House day nursery, Sugar Loaf Walk, Bethnal Green. 9 — The erection of a new accident ambulance station in West Smithfield, City of London, to replace a temporary structure. 10 — The erection of a new additional accident ambulance station adjacent to the North Western Hospital, Hampstead. 11 — The provision of additional vehicle accommodation by adaptation of existing premises at the Eastern Ambulance Station. 12 9 The execution of conversion works at 102, Earlsfield Road, Wandsworth, to bring the building into use as a maternity and child welfare centre. 13 5 Conversion of vacant accommodation at the school health centre at 69, East India Dock Road into a maternity and child welfare centre. 14 2 The erection of a permanent replacement nursery at Peach Street, Paddington. Of these the Minister had approved Nos. 6, 9, 11, 12, 13 and 14 when the time came to prepare the November programme, the remainder, including the larger schemes, having been deferred for further consideration. Work on the latter could not, therefore, be begun as intended before 31st March, 1951, and they were carried forward as part of the November programme. The November programme consisted of the following projects in addition to those carried forward from July :— Ref. No. Division Scheme 1 9 The erection of a replacement maternity and child welfare centre in Stormont Road, Battersea, designed so that it could be extended in due course to form part of a comprehensive health centre. 2 7 The conversion of a part of the former Pioneer Health Centre, Peckham, to provide a day nursery as the first stage of the conversion of the building into a health centre. 3 — The erection of a new accident ambulance station in West Hill, Wandsworth. 4 *— The erection of a garage and new offices at the South Western General Ambulance Station. 5 1 The erection of a permanent replacement day nursery at Westway, Hammersmith. 6 4 The extension of the day nursery at Victorian Grove, Stoke Newington. 7 — The conversion of a surplus fire station at Foxley Road, Lambeth, into an accident ambulance station. 43 Ref. No. Division Scheme 8 5 The erection of a permanent replacement day nursery in Brewhouse Lane, Stepney. 9 1 The erection of a maternity and child welfare centre in Highlever Road, Kensington, to replace a centre destroyed during the war. 10 1 Alterations to premises in use as the main Divisional Health Office at 129, Fulham Palace Road, Fulham. 11 — Provision of accommodation for Civil Defence personnel and the formation of a new petroleum store at Fulham Ambulance Station. 12 — The conversion of premises at 9, Spencer Park, Wandsworth, into an occupation centre for mentally deficient children. 13 7 Substantial repairs to the main Divisional Health Office at 29, Peckham Road, Camberwell. 14 8 Substantial repairs to a maternity and child welfare centre at 12, Hannen Road, Lambeth. 15 7 Enlargement of the doctor's and ante-natal rooms, etc., at the maternity and child welfare centre at Amott Road, Camberwell. At the end of the year the minister had come to the following further decisions:— Daleham Gardens maternity and child welfare and school treatment centre, Hampstead.—The Minister was unable to approve this project for the time being owing to the need for stringent economy in expenditure on the health services. The former Pioneer Health Centre— Stage I of the schemes of adaptation was approved. Decisions on the other schemes were still awaited. Woodberry Down Health centres The building of the first comprehensive health centre at Woodberry Down was continued during the year and it is expected that the centre will be ready for use in the spring of 1952. The Pioneer Health Centre The Pioneer Health Centre, Peckham, was forced to close in March, 1950 owing to insufficient financial support. For some years the Centre had difficulty in obtaining adequate funds, and early in 1949 the Council was approached for financial assistance. This request was sympathetically considered by representatives of the Council. The facilities provided by the Centre were available only to its members and the Council's representatives pointed out that if the Council were to grant financial assistance under any of its statutory powers it would probably consider it essential for the facilities to be generally available to residents of the district and not restricted to members only. With this qualification in mind, certain aspects of the work of the Centre were considered which could be integrated into the services provided by the Council under both the National Health Service and the Education Acts. The Centre authorities, however, were unanimous that the Centre must continue to concentrate on research and therefore limit its membership to family groups, and that there appeared to be no alternative but to defer for the time being the prospect of financial help from the Council. The difficulties of the Centre subsequently became more acute and in March, 1950, the authorities opened negotiations for continuing and developing the Centre on the basis of the report of a scientific advisory committee convened by the Sir Halley Stewart Trust, from which the Centre received a substantial part of its income. This report recommended that the Centre should be (i) developed as a health centre under section 21 of the National Health Service Act, 1946 ; (ii) developed as a research institute under section 16 of that Act; and (iii) continued as a family club. If the Centre had been developed on these lines it would have been possible for the Council to give financial assistance under (i) and, to a limited extent, under (iii), and for the Minister of Health to do so under (ii). The Centre could also, of course, have sought D 44 assistance from voluntary sources. This scheme was carefully considered by the Council but it came to the conclusion that the development of the Centre broadly on the lines recommended by the scientific advisory committee could best be achieved if the Council itself acquired the Centre. The Centre authorities finally abandoned hope of continuing the Centre on its original lines and decided to realise their assets on the best terms possible with the proviso that the property should be disposed of to some authority or body who would use it for purposes related as closely as possible to the aims and objects which the Centre formerly carried out. The Council was given the first offer of the property before it was placed in the open market, subject to the condition that the building, if acquired by the Council, should bear a name other than the Pioneer Health Centre or the Peckham Health Centre and the Council decided on 12th December, 1950 to acquire it. A scheme was prepared to use the Centre for the establishment of a day nursery and ante-natal clinic under the Health Committee and the use of the swimming bath, gymnasium and lecture hall by the Education Committee. The Education Committee will also provide in the building during the afternoons and evenings a wide range of classes to which will be attached a family club. It is also proposed that medical practitioner and dental group practices will be started when general medical and dental practitioners desire to use the accommodation. The establishment of a research unit with financial assistance from the Ministry of Health, University grants, medico-educational foundations, or other sources is under active • consideration. When the building comes into full use the facilities provided, although employed on different lines, will, it is hoped, perpetuate to some extent the aims and objects for which the Pioneer Health Centre has become renowned. Group practices Twenty-nine groups of doctors having expressed a desire, through the Local Medical Committee, to undertake group practice in buildings provided by the Council as health centres under section 21 of the National Health Service Act, 1946, efforts were continued to find suitable accommodation for them. Owing, however, to the shortage of buildings suitable for conversion for group practice, little success was attained, only one suitable building being found. A scheme to establish a group practice there was the subject of consideration by the Ministry of Health at the end of the year. Acquisition and reservation of sites for health centres The arrangements for acquiring and reserving sites for health centres described in my report for 1949, were carried a stage further when the Council decided that six sites should be designated under the Town and Country Planning Act, 1947 and included in the County Development Plan. It was also decided that a further 17 sites should be reserved on housing estates and in reconstruction areas, etc. These do not require designation since they are on land which has been or will be acquired by the Council for larger schemes. The concurrence of the Executive Council to the designation and reservat on of these sites was sought. Equipment The departmental committee set up in 1949 to prepare a standard of equipment for day nurseries, maternity and child welfare centres and other health service buildings continued to meet regularly. Ten meetings were held during the year and consideration of the equipment for the day nursery and the maternity and child welfare section of the Woodberry Down Health Centre was completed. Subcommittees were appointed to deal with the furniture and equipment of the general practitioner wing and with the dental suites of the Centre. The Executive Council nominated two general practitioners, Dr. A. P. McEldowney and Dr. M. Sorsby and a dental surgeon, Mr. Seymour Robinson, to serve on these sub-committees of which each held one meeting during the year. 45 Transfer of Premises under the National Health Service Act, 1946 The transfer of hospitals from the Council to the Minister of Health and of maternity and child welfare premises from the metropolitan borough councils to the Council raised a number of complex problems concerning the future ownership and allocation of buildings which had not previously been used entirely for functions assumed under the Act by one authority. Certain portions of hospitals, for example, remained with the Council while some borough council buildings had previously provided accommodation for (1) maternity and child welfare services which passed to the Council, (2) clinic services which became the responsibility of the hospital authorities and (3) some of the borough council's own services. Since problems concerning hospitals involved the four metropolitan regional hospital boards, the Ministry decided, in order to maintain a common policy and to expedite the matter, that negotiations should be conducted between officers of the Ministry and the Council with a view to finding a solution which the Council and the Minister could be recommended to approve. Conferences were held during the year with a view to a scheme of exchanges of property being devised which would meet the needs as far as possible of the parties concerned. It was considered that joint ownership should be avoided wherever possible since it presented so many administrative difficulties and that a building should eventually pass entirely into the ownership of the Minister or the Council. At the end of the year these negotiations were nearing completion. Negotiations were also conducted with the metropolitan borough councils concerned with a view to formulating agreements in respect of buildings used by both the Council and the borough councils. CARE OF MOTHERS AND YOUNG CHILDREN Administration During 1950 the task of maintaining, reorganising and improving the personal health service was continued. After a further year's experience this new service has solved many of the difficulties that confronted it at the beginning but, none the less, new problems continually call for attention. The day-to-day administration of the services has been continued by the nine divisional health committees. Elected and co-opted members of these committees have regularly visited health establishments in their areas. The divisional medical officer is responsible, through his administrative staff, for the co-ordination of the personal services in his area. Expansion of services The following table shows the number of attendances at infant welfare and antenatal and post-natal centres which were held during 1947, 1949 and 1950. The figures for 1947 are taken from the annual reports of the metropolitan boroughs who up to July, 1948, were responsible for the administration of the maternity and child welfare service in the county, and to ensure comparability it has been necessary to exclude foot and light treatment sessions. The decline since 1947 in the number of attendances at clinics is partly due to the decline in the birth rate, which in 1947 reached its highest level for many years. This may have been accentuated in the ante-natal clinics by an inclination on the part of expectant mothers to seek ante-natal care from general practitioners or to book for confinement, including ante-natal care, in hospital. In the infant welfare centres, a factor in decreasing attendance may have been a tendency to take children to the family doctor for minor ailments rather than to the centre. The reductions in some areas have been greater than in others. 46 Attendances at Maternity and Child Welfare Clinics 1947 1949 1950 Health Divisions Ante-natal and Post-natal Infants Ante-natal and Post-natal Infants Ante-natal and Post-natal Infants 1 47,331 130,497 36,428 116,204 33,074 107,888 2 44,047 119,043 39,844 145,689 34,379 140,137 3 18,506 85,812 15,460 84,840 15,583 78,642 4 15,259 81,367 13,416 74,197 13,411 67,037 5 11,944 71,139 6,580 67,091 8.150 67,106 6 51,272 122,522 26,046 124,016 27,725 115,615 7 33,880 150,574 30,319 147,159 29,757 136,056 8 46,836 170,899 39,367 141,503 35,991 134,421 9 15,591 108,332 10,583 100,092 16,643 90,382 Total 284,666 1,040,185 218,043 1,000,791 214,713 937,284 Early records are not available of attendances at different types of sessions but the following table gives a comparison between 1949 and 1950 :— Attendances 1949 1950 First Total First Total Infant Welfare Under 1 year 48,489 683,089 43,916 649,983 Over 1 year 6,641 282,202 5,496 245,484 Special toddlers — 35,500 — 41,817 Ante-natal 29,917 184,018 26,979 176,993 Post-natal 5,839 7,486 5,934 7,255 Breast feeding 1,559 2,851 1,240 2,555 Education and advisory — 23,688 — 27,910 Total 92,445 1,218,834 83,565 1,151,997 Foot 9,964 128,055 10,165 153,687 Light and massage 6,440 108,545 6,903 109,013 Grand Total 108,849 1,455,434 100,633 1,414,697 With regard to the age incidence of infant attendance and the extent to which local populations are covered, the following table shows, for each Division, attendances and children attending per 1,000 population in the age groups under 1 and 1-4 years. It will be seen that 79 per cent. of infants attended a centre at least once in their first year of life. This compares with 84 per cent. in 1949 and confirms the suggestion that attendances have been falling off to a small extent. Those infants who attend in their first year do so about fifteen times ; it is general experience that for eight or nine months the mother's anxiety about the progress of the infant brings her regularly to the clinic for weighing, medical advice and mothercraft guidance, but that, with normal progress, attendances thereafter fall off rapidly. It will be seen that 37 per cent. of the infant population (between 1 and 5) attend after the first year for three or four further visits. Special toddlers' clinics are arranged and attractive birthday cards are sent to mothers to remind them of the facilities for preventive advice. Onefifth of the infants who attend in response to these invitations are referred for treatment for ailments which the parents might not otherwise have recognised or have taken any action about. 47 Child Welfare Centres in London, 1950 Health Division Number per 1,000 child population per year* Number of attendances per child per year Sessions Attendances Children Under 1 1-4 Under 1 1-4 Under 1 1-4 1 84 10,915 652 791 379 14 1.7 2 93 11,675 1,386 800 514 15 2.7 3 87 11,574 1,004 796 318 15 3.2 4 79 10,948 1,055 798 379 14 2.8 5 81 11,370 1,243 823 280 14 4.4 6 107 15,424 1,713 905 442 17 3.9 7 67 13,481 1,564 816 452 17 3.5 8 77 13,429 1,327 626 336 21 2.9 9 45 10.546 719 774 227 14 3.2 County 79 12,124 1,185 786 373 i15 3.2 * Within the specified age group. First attendances at ante-natal clinics amounted to 50 per cent. of all women needing ante-natal care during the year (as estimated from confinements over a corresponding later period) compared with 52 per cent. in 1949. Nowadays almost every expectant mother has ante-natal care. The balance of 50 per cent. receive it from the hospitals where they will be confined, or from the doctor who has been booked. Many hospitals refer their booked cases to the Council's ante-natal clinics for intermediate supervision. The mothers attend the hospitals to book and later in pregnancy, at the thirty-fourth to thirty-sixth week according to local practice, they are referred for final examination at the hospital where confinement is to take place. 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 was to be expected that they would tend more and more to avail themselves of the general practitioner obstetrician service, and towards the end of 1949 there was a slight 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. In 1950 the decline persisted, though not rapidly, and total attendances were reduced. The decline in attendance at the special sessions to redevelop breast feeding is probably the result of increased attention to breast feeding during the post-natal period and on the part of clinic medical officers at infant welfare sessions. There was a satisfactory expansion in attendances at educational and advisory sessions, increases in such attendances having been noted in the previous year. Attendances were well maintained at the light and massage and foot clinics. Comments on the work of the dental clinics will be found in the report of the Chief Dental Surgeon (page(19). Joint arrangements with other Local Health Authorities Reciprocal arrangements were continued with the Kent county council whereby expectant mothers and those with young children living in the Mottingham area may attend either the Kent or London maternity and child welfare centre whichever may be nearer to their homes. There has been a temporary withdrawal of some of the reciprocal facilities for the attendance at the Council's 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. 48 Voluntary organisations Nineteen voluntary organisations have provided 22 maternity and child welfare centres under agreements with the Council in accordance with section 22 of the National Health Service Act. The centres are managed by voluntary committees. The Council is represented on the committees and has power of inspection of the premises. During the year, two centres (the Downham Infant Welfare Centre and the Moffat Institute Child and Infant Welfare Centre) transferred to more suitable accommodation in the Council's premises, the voluntary committees continuing to administer them. The West Norwood Maternity and Babies' Welfare Centre was taken over by the Council at the request of the voluntary committee. For infant welfare clinics provided by arrangement with medical schools, see pace 52. rroviamg day nurseries and creches Arrangements with the six voluntary associations providing day nursery facilities continued satisfactorily during the year. Financial assistance was granted towards the maintenance cost of two nursery play groups. Applications for financial assistance were received from a further two voluntary bodies, and negotiations were still proceeding at the end of the year. Providing residential accommodation By arrangement with the two bodies 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. Patients recommended for admission pay at an agreed rate. Children under six months old accompanied by their mothers are admitted free. 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 46. The areas served by the various centres are 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. Tests 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 has a specimen of her blood taken in order that tests may be made for the Rhesus factor and the Wassermann reaction. The necessary laboratory services, including those needed in connection with outbreaks or suspected outbreaks of active infectious disease, are carried out in hospital laboratories free of charge to the Council until such time as these services can be made available by the public health laboratory service. Pregnancy diagnosis tests are carried out for the Council at the Ministry of Health's laboratory in Shrodell's Hospital, Watford. Health education An investigation is being undertaken at a few clinics to ascertain the age at which children become sensitised to tuberculin. Every opportunity has been taken to make full use of the educational activities in the centres. These are mainly talks on mothercraft by health visitors and sewing classes for expectant and nursing mothers. A working party has considered the possibility of extending these activities. Health visitors have co-operated with school nursing sisters and nursery staff in giving courses of lectures in parent-craft for schools and polytechnics and for nursery students for the Nursery Nurses' Examination Board and in allied subjects. Family planning The family Planning Association holds clinics in premises transferred to the Council under the National Health Service Act, and some extension of the facilities 49 has been necessary. A payment of 12s. 6d. is made for every woman referred by the Council's medical staff; 1,031 cases were so referred during the year. There are now 27 weekly sessions held by the Association in Council and other premises and in addition 5 sessions a week are held by the Council at which family planning advice is given. Letting of premises The policy of letting rooms in health service premises has been considered. It is desired to restrict such lettings to bodies akin to the health service. Within this limitation a scale of charges and conditions of letting have been laid down. Care of premature babies Special equipment is provided for use when a premature infant is being nursed at home. Three sets of equipment are held in each of the nine divisions and are available on request. A deposit is 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 1950. The specially heated cots carried on the ambulances were used on 68 occasions for premature infants. Premature babies bora at home: special report on 416 Every domiciliary midwife is asked to report immediately to the supervisor if she delivers a baby of 5½ lb. or under whether or not it is premature. For the purpose of this report all still-births have been excluded. 416 babies of this weight were born alive to 385 mothers. In each case the supervisor visited the home to make sure that medical aid had been called where necessary, that all facilities for the proper care of the baby were available, to arrange for loan of premature baby equipment where necessary and to arrange the midwife's other work so that she would be able to devote sufficient time to the premature baby. This supervision often necessitated several visits. In their reports the supervisors have followed up the case for 28 days or until the child was well established. Medical aid By the rules of the Central Midwives Board a midwife must call medical aid for any abnormality. A low weight by itself is not regarded as abnormal, but if the infant is feeble, a doctor must be called. In the 385 confinements, 189 were attended by a doctor, either because he was already in charge or because he was called in by a midwife. Hospital care It is the duty of the doctor to decide whether or not the baby should remain at home. 100 of the 416 babies were removed to hospital as soon as possible after birth either on account of their poor condition or because the home conditions were unsuitable for the proper care of a premature baby. Babies under 4 lb. and any over that weight who required oxygen were removed. In all cases they were transported to hospital by the ambulance service in a specially heated cot. Not a single baby died during the ambulance journey. Where possible the mother was admitted to hospital with the baby, but unfortunately several of the premature baby units have no accommodation for mothers. It is appropriate here to pay tribute to the excellent judgment shown by midwives and doctors on this point. In only 4 cases where the child died during the first 4 weeks is it at all possible that earlier removal to hospital, might have made any difference. Causes of prematurity This is a selected group of cases. As so many primiparae are booked for hospital, the ratio of them to multiparae was 1 : 4. There were 76 primiparae and 309 multiparae. 69 of all infants were not premature according to estimated gestation period and were 5 lb. or over in weight. 15 of the multiparous mothers had had a small baby before. Cases of severe toxaemia and placenta praevia were transferred to hospital during pregnancy so that, the fact, that, these disorders did not appear as 50 major causes of prematurity is not surprising. In spite of the tendency for all twins to.be delivered in hospital, there were 38 in this total series—some were undiagnosed, and in some cases the mothers refused hospital confinement. Age and parity do not appear to have any effect on the gestation period. Only one mother was over 45, and one under 16 : 21 had had 5 or more nrevious confinements and one had had 15. Details as to concurrent conditions are given below :— Primiparae Multiparae Total Twins 4 34 38 Toxaemia 8 14 22 Ante-partum haemorrhage 1 9 10 Influenza or other general — 9 9 ness. Wassermann reaction positive 1 1 2 Moving house — 2 2 Hopping 1 1 2 Fall — 1 1 Fibroids 1 — 1 Double uterus — 1 1 Pyelitis — 1 1 External version — 3 3 No special possible causal 60 233 293 feature observed. Ante-natal care A few of the cases were unbooked emergencies, some had booked so late in pregnancy that only one or two attendances at the clinic were possible and others had failed to attend for ante-natal examination. 10 primiparae and 38 multiparae had inadequate or no ante-natal care. Gestation period Dates as given by the mothers are never regarded as being very reliable. According to these :— 22 of the pregnancies were under 32 weeks 67 „ „ „ „ between 32 and 36 weeks 296 „ „ „ „ over 36 weeks Primiparae Multiparae Total Under 3£ lb 6 23 29 3½-4½lb 52 64 4½-5 lb 13 86 99 5-5½ lb 48 176 224 416 Weights Domiciliary care The management of each individual case was left to the discretion of the doctor or midwife. Generally premature babies were not bathed at birth or for some days afterwards. They were not fed for the first 24 hours, after that time feeds of glucose water or expressed breast milk were given. Most of the larger babies were able to suck and could be put on to 3 hourly breast feeding. The midwife continued to attend each case for 28 days, or until the infant was well established. Breast feeding It is satisfactory to find that it appears to be as easy to establish breast feeding in the premature as in the normal baby. In 1950 94 per cent. of all domiciliary midwives' cases were discharged entirely breast fed. Out of 300 premature babies who survived 269 (90 per cent.) were entirely breast fed. In the cases which were transferred to hospital, out of 75 infants who survived 56 (75 per cent.) were entirely breast fed. These babies included the smaller, feebler and most immature. There was also the added difficulty that the mothers were often not admitted and had to exnress their milk and take or send it to hospital dailv. Neo-natal mortality The following table shows the maturity and weights of the 192 infants under 5 lb. As might be expected the chance of survival of a small baby is related to the 51 length of the gestation period : under 32 weeks the chance of survival is poor and 7 of these immature babies died before their removal to hospital could be arranged. Most of them were 2 lb. or less and not really viable. Survived Died Hospital Home Hospital Home Under 3½ lb. less than 32 weeks 2 — 10 7 32-36 weeks 6 — 3 — Over 36 weeks 1 — — — lb. less than 32 weeks 2 1 3 1 32-36 weeks 12 5 3 — Over 36 weeks 19 17 — 1 4½-5 lb. less than 32 weeks 2 — — — 32-36 weeks 6 16 — 2 Over 36 weeks 11 57 1 4 61 96 20 15 Of 316 babies of all weights nursed at home, 16 died within the first month, a neonatal mortality rate of 50 per 1,000. As post-mortem examinations were not always obtained the causes of death cannot be regarded as strictly accurate. Seven were very small immature babies who only survived for minutes or at most an hour or two. The causes of death in the remainder were :— Birth weights 3½ to 4½ lb. 1 asphyxia 15th day 1 bronchitis 25th day Birth weights 4½ to 5 lb. 2 pneumonia 8th day 1 cerebral haemorrhage 5th day 1 cerebral oedema 9th day 1 gastro-enterit-is 19th day 1 congenital heart 4th day Birth weights over 5 lb. 1 "prematurity" 5th day In these 9 cases the infants appeared to make satisfactory progress at first and then suddenly became cyanosed, and either died within a few hours at home or shortly after removal to hospital. Of the 100 infants transferred to hospital within 12 hours of birth, 25 died, a neo-natal mortality rate of 250 per 1,000. Considering that few of those removed to hospital exceeded 4i lb. this result may be regarded as not unsatisfactorv. Congenital abnormalities In only four of these babies were there obvious congenital abnormalities and apart from one case of congenital heart disease, all survived the first month. This is not an abnormal experience and congenital abnormality does not appear to be a cause of premature birth. Summary Provided that housing and social conditions reach a reasonable standard, babies over 4 lb. and not more than 6 weeks premature can be satisfactorily nursed at home, and breast feeding is established in nearly all cases without any difficulty. The smaller and more immature infants have a better chance of survival in a special premature baby unit ; their transfer should be arranged as early as possible. Out of a total of 416 babies, 375 made satisfactory progress for 28 days or until their discharge by the midwife or hospital. This excellent result reflects great credit on the care given by the midwives and doctors in the patients' homes and in the hospital premature babies' units. Specialist clinics Progress was made in the discussions with the metropolitan regional hospital boards with a view to their taking over full responsibility for the administration of gynaecological clinics and providing and paying specialists for consultative infant 52 welfare sessions. These clinics were provided by the metropolitan borough councils as part of their general provision for the care of expectant and nursing mothers and young children ; but, it has now been determined that they are specialist services not proper to the local health authority under the National Health Service Act. Maternity and Child Welfare Centres provided by Hospitals Consultations were held with representatives of the teaching hospitals and of the metropolitan regional hospital boards on the continuance of the maternity and child welfare services (ante-natal and post-natal clinics, infant welfare clinics, health visiting services) provided by some of the hospitals before the " appointed day." The consultations arose from the need of applying the ruling of the Ministry of Health that it is not legal for a hospital as such to provide a service for healthy babies or to employ health visitors. The Ministry suggested, however, that it would be possible for the committee of the medical school of a teaching hospital to be regarded as a voluntary body and to act as the Council's agent in providing these services. Also the Council could continue a clinic on hospital premises, paying a rent for the accommodation. The Ministry's ruling did not apply to ante-natal and post-natal clinics as the hospitals may provide these for their own patients. Infant welfare, however, provided a more complex problem. It was ascertained that ten hospitals were providing only consultative clinics or clinics for sick children which were within their powers under Part II of the Act. The Council has no concern with these, and incidentally no question arose of continuing any grants made for these services by the metropolitan borough councils before 5th July, 1948. There were three infant welfare clinics in hospitals of the metropolitan regional hospital boards but, although the Council was willing to continue these clinics, the hospital management committees concerned decided to discontinue them. The children attending them were transferred to the Council's nearby centres. There remained four teaching hospitals with infant welfare clinics for consideration under the Ministry's ruling. As a result of consultations and with the agreement of all parties concerned it was finally decided that at one hospital the Council should take over the services hitherto provided and run the clinic in the hospital premises as a municipal centre, paying rent to the hospital authorities. In order to preserve continuity and to provide teaching facilities, a member of the hospital medical staff who previously conducted the clinic holds a part-time appointment as a medical officer in the Council's service and continues his work there. The Council may not pay specialist rates for work of this nature but pays the non-specialist rate, the balance being made up by the medical school. At the other three teaching hospitals the medical schools preferred to run the services as voluntary bodies grant aided by the Council. This was agreed in consultation with the medical schools and hospitals. Broadly the arrangement is that the medical school pay a rent agreed by the Council to the hospital authorities for use of the clinic premises. The medical school also provide and pay all staff, except health visitors. The Council reimburses the medical schools at the rate of ninety per cent. of the approved net expenditure, subject to the payment by the Council of the full non-specialist rate for the pediatricians. The other ten per cent. of the expenditure, with the balance of any specialist rates paid to medical staff, is found by the medical school and is regarded as a fair return for the teaching facilities which they enjoy at the clinic. The arrangements will be confirmed by agreements between the Council and the hospital or the medical schools. 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 are preserved, e.g., in such matters as the appointment of medical staff to conduct the clinics attended by medical undergraduates. Any grants made by the borough councils prior to 5th July, 1948, were paid by the Council up to the date of operation of the new agreement. 53 As a result these clinics will be brought into the closest association with the Council's divisional organisations, liaison with each hospital and medical school being maintained through the appropriate divisional medical officer. The same close association has operated for health visiting services required for the infant welfare clinics at hospitals. The Council's health visitors attend the clinics, where they work to the paediatrician in charge, although for the general direction of their work outside the clinic they remain under the divisional medical officer. At one clinic the medical school continues to employ a health visitor, subject to the refund of ninety per cent. of her salary under the agreement with the Council, and there is close co-operation in her work with the Council's health visitors. At one of the teaching hospitals a training school for health visitors which had been in existence for some years has been taken over by the Council. Four students are trained annually, receiving their practical experience and tutorial instruction at the hospital and taking systematic lectures at the Royal College of Nursing. The student health visitors have been taken on to the Council's establishment and the superintendent of the centre receives from the Council a personal allowance for her tutorial duties. There has been an extension of the arrangements under which the Council's full-time assistant medical officers from infant welfare centres exchange with medical officers working in the children's departments of hospitals. Exchanges are for periods of not less than six months and enable the Council's medical officers to keep abreast of developments in the care of sick children and the hospital medical officers to watch the growth and development of healthy ones. An exchange of four medical officers from either side has commenced satisfactorily with the Hospital for Sick Children, Great Ormond Street. Similar arrangements have been continued with other hospitals. There are no financial adjustments between the two sides. Institute of Child Health The Council has entered upon a scheme of co-operation with the Institute of Child Health for the erection of a model welfare centre in the neighbourhood of the Hospital for Sick Children, Great Ormond Street. The Institute, which is part of the British Postgraduate Medical Federation of the University of London, provides educational and research facilities both preventive and curative in the field of child health. Through it the Council has the opportunity of co-operation with the University and with the hospital to secure for child health the prominent place which it should have in the National Health Service. The proposed model welfare centre would serve the purpose of teaching postgraduate students and conducting research as well as meeting the needs of the neighbourhood. Its functions would include an infant welfare centre, an ante-natal clinic, a school treatment centre, a nutrition clinic, a minor ailment clinic, a dental clinic, together with lecture and demonstration rooms. Allied specialist clinics such as enuresis and child guidance would be held in the hospital nearby. The scheme is being worked out in close co-operation between the Council's officers and those of the Institute. Generally, the capital expenses would be met by the Institute and the Council would contribute a ninety per cent, grant on the approved expenditure on services proper to it as the local health authority. The cost of teaching and research would fall on the Institute. Dental care Details of the priority services for expectant and nursing mothers and children will be found on page 122 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 remained in force subject to minor amendments 54 from time to time. 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 Mothers and children at maternity and child welfare centres and day nurseries have enjoyed amenities, e.g., Christmas parties, seaside and country excursions provided out of allocations made from contributions received by the Council from Sunday cinema entertainments. The funds are administered by voluntary committees set up in each division. Marriage guidance The report of the Departmental Committee on Marriage Guidance set up by the Secretary of State for Home Affairs (the " Harris Report"—Cmd. 7566), recommended that financial assistance in this field should be made by local authorities to the London Marriage Guidance Council, the Catholic Marriage Advisory Council and the Family Discussion Bureaux organisation of the Family Welfare Association. The Council, after consulting the Metropolitan Boroughs' Standing Joint Committee, made an interim grant to each body pending a decision on future policy. Home visiting and after-care : co-operation with hospital almoners Negotiations took place with the hospital authorities and the Institute of Almoners on the question of the after-care arrangements for persons discharged from hospitals. The Ministry of Health, in Circular 160/48 on the respective spheres of the almoner and the local health authority, state that when a patient who needs care and after-care is about to leave the hospital, the almoner should ensure that as far as possible the local health authority's Part III Services would be brought into play. There has been longstanding and widespread co-operation between the almoners and the Council's field workers, such as the health visitors and the child care organisers. It is proposed to provide, through the divisional medical officers, a regular channel of approach for the almoners whereby the divisional medical officers will put the Council's Part III Services at the full disposal of the almoners. The Council will encourage direct approach by almoners to its field workers for mutual discussion and exchange of information. Provision is also made for close co-operation in this field of work with voluntary agencies, such as the Invalid Children's Aid Association and the Family Welfare Association. Notification of births Notifications were received during the year of 60,685 live and 1,236 still-births. 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 5). It is interesting to note that 6,754 of the births notified were to women residing outside the county. Quadruplets Quadruplets were born to a London mother in Westminster Hospital on 12th September, 1950. The mother had previously attended one of the Council's ante-natal clinics and been referred to the hospital. The Council's health visitor kept in close touch with the hospital staff to prepare for the homecoming of the quadruplets on discharge from hospital. The Council and borough housing departments also co-operated in providing a larger flat for the family. On the advice of the hospital medical attendant, special provision was made for the home nursing of the babies, when they were discharged on 20th November, 1950, whereby the hospital would provide a night nurse for four weeks and a day nurse for about three months and the Council refund the nurses' salaries. A full-time home help was also sent by the Council. 55 Enquiry into virus infection during pregnancy The Council is participating in an investigation sponsored by the Ministry of Health to estimate the frequency with which virus diseases during pregnancy are followed by congenital abnormalities. The investigation was undertaken by the Ministry following information obtained by doctors in this country and abroad which suggested that maternal virus infections, i.e., rubella, measles, chickenpox, mumps and poliomyelitis were liable to produce congenital defects in the child. The approach planned is for a dual investigation to be carried out to compare the risk among children born of women who had some virus infection during pregnancy with that among children born of other women. The enquiry is in the hands of the medical officers of ante-natal clinics and covers all expectant mothers except those who have booked a doctor for delivery. There are two categories, viz., Category I, which includes those who on first coming under ante-natal supervision have already had a virus infection during pregnancy or who suffer an attack during the subsequent course of pregnancy, and Category II, which consists of a control series of expectant mothers whose date of birth is on the 31st of a month. Provision is made for women whose category changes from II to I. This enquiry differs from others in that the enquiry is being conducted forward from the expectant mother to the child and not backward from an affected child to a mother who claims to have had a virus infection during pregnancy. Care is taken not to let the mother know before her confinement that she has been selected for special observation, nor to focus her attention on virus infection. Routine health enquiries are made during visits to the ante-natal clinic. After delivery there are three special examinations of the child— (i) at birth or as soon as possible afterwards ; (ii) on the child's first birthday ; (iii) on the child's second birthday. It is realised that certain abnormalities do not become evident until after the second birthday, but it was decided to confine the investigation in the first place to children up to the age of two years. The plan calls for co-operation between the Council's maternity and child welfare clinics, the domiciliary midwifery service and the hospital maternity service. Each case is registered with the Registrar-General and provision is made for transfers in and out of the county. Child guidance The problem of child guidance for children under five has been under consideration during the year. It has a bearing on juvenile delinquency which has come to the fore with the Report of the Committee on Juvenile Delinquency. There are two child guidance clinics for the pre-school child which were taken over from the metropolitan borough councils on 5th July, 1948. At these, psychiatrists see children, and their parents, referred from local infant welfare centres because of various behaviour disorders. The two clinics do valuable experimental work, but serve a necessarily limited number of centres. Experience will show what is the appropriate method of meeting the needs of other infant welfare centres. One immediate step is the training of the centre doctors and health visitors to select children for reference to the child guidance units and lectures in mental health are being arranged with this purpose in mind. Children neglected or ill-treated in their own homes A Joint Circular issued by the Home Office, the Ministry of Health and the Ministry of Education in July, 1950, invited local authorities to consider what might be done to prevent the neglect or ill-treatment of children in their own homes. Attention was drawn to the Government's policy that the present need is not for an extension of statutory power or for enquiry by a departmental committee but the fully co-ordinated use of the local authority and other statutory and voluntary services available. The Circular referred to contributory causes ranging from the 56 poor health of *an affectionate mother to dislike of the child and brutality, and embracing other contributory factors, such as lack of help in the home, bad housing, ignorance of home management, subnormality of parent or child, frequent pregnancies, laziness and unhappy relations between parents. While in some cases prosecution and the removal of the child from home may be the only possible course, in many it will be feasible to remove or mitigate the causes of neglect by bringing into action the various social services available. The Joint Circular is being considered by the Council in relation to its many functions that bring it into touch with the homes of the people of London through its health and other services. Day nurseries, creches and nursery play centres During the year five day nurseries were closed because the premises were no longer available for day nursery purposes and two replacement day nurseries were opened. The number of places provided in the Council's maintained and grant aided day nurseries, including creches, was 6,462 on 31st December, 1950, compared with 6,615 on 31st December, 1949. The charges for meals supplied in day nurseries were revised and a sliding scale, varying with the number of children from each family attending a nursery, was introduced. The charges were also made subject to abatement according to financial needs, as opposed to the previous fixed charge. The priorities for admission were reviewed during the year and were applied to all children in attendance in the day nurseries, including those admitted before January, 1949, when the priorities were first approved. Provision was also made for a six-monthly review of the circumstances of parents whose children were attending day nurseries, and parents are required to withdraw their children from nurseries as and when the cases no longer fall within the approved priority classes. Reasonable notice of withdrawal is given and, where possible, assistance is offered to the parent concerned in providing alternative means of looking after the child, generally through a child-minder. As a result of the first review in August, 1950, some 400 places were made available for children on the priority waiting list, which, at the end of the year, stood at 1,932 compared with 4,797 on 31st December, 1949. The comparatively high cost of maintaining a child in a day nursery continued to cause concern and a detailed survey of the day nursery service was carried out during the latter part of the year. It is hoped that as a result of the findings some saving in the cost of the service will be effected during next year. Measures were taken to improve the precautions made in day nurseries against burglaries and the number of unlawful entries, although still considerable, was lower than in the previous year. There was a small increase in nursery play centre facilities during the year. Nurseries and Child-Minders Regulation Act, 1948 There was an increase in the number of private day nurseries statutorily registered under the Nurseries and Child-Minders Regulation Act, 1948. The number of these nurseries and the places provided on 31st December, 1950, compared with 31st December, 1949, were as follow :— At 31.12.49 At 31.12.50 Number of private day nurseries statutorily registered 28 41 Number of places provided 972 1,294 Child minders service This service increased during the year, both as regards child-minders who are statutorily registrable under the Nurseries and Child-Minders Regulation Act, 1948 (i.e., 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), and women 57 looking after one or two children who voluntarily register with the Council and receive a weekly registration fee in return for which they are subject to inspection by the Council. The numbers of child-minders, both statutorily and voluntarily registered on 31st December, 1950, 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 31.12.49 On 31.12.50 Number of child-minders statutorily registered 73 96 Number of children minded 501 570 Number of child-minders voluntarily registered 584 766 Number of children minded 579 834 Residential nurseries The management of the residential nurseries (apart from that at Queen Mary's Hospital, Carshalton), including the filling of vacancies, is now under the control of the Children's Officer. The residential nursery at New Cross General Hospital was closed in March, 1950, and the children transferred elsewhere. The children in the residential nurseries are under the medical care of the visiting medical officers, who examine them periodically, as well as on admission and discharge, and as may be required. Close co-operation is maintained with the Children's Officer in regard to questions affecting the children's health. With this in view the residential nurseries are visited at regular and frequent intervals by senior members of the Council's central medical and nursing staff. Adoption and boarding-out of children Special records kept since 1st March, 1950, show that during the last ten months of the year 517 children were referred to me by the Children's Officer for opinion as to their suitability on medical grounds for adoption or boarding-out in accordance with the duties placed upon the Council by the Children Act, 1948. Of these, 119 were found fit for adoption, 390 fit for boarding-out and 8 unfit for various reasons. 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 Voluntary homes take expectant mothers during the later stages of pregnancy and for several weeks after confinement. With the exception of two homes, the mothers are transferred to a hospital for the confinement. The Council as local health authority has continued to pay grants under section 22 of the National Health Service Act, 1946, 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 structural alterations to the premises are necessary. Standards of staffing, space and management which have been recommended by the Ministry of Health are carefully applied to the running of the homes. The grants paid are subject to the carrying out by the voluntary bodies of any improvement suggested by the Council. The homes are registered or exempted from registration as nursing homes 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 58 Act, 1948. There are 22 grant-aided homes and the approximate total grant for the financial year was £13,023. Denominations responsible for the management of the homes are Church of England 8, Roman Catholic 4, Church Army 2, Salvation Army 2, Jewish 1, Methodist 1, undenominational 4, 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 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 amounting 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. Participation of health visitors There is close 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 are 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. L.C.C. Midwives DOMICILIARY MIDWIFERY SERVICE The birth-rate continued to fall during the year and so, consequently, did the number of confinements attended by the Council's midwives, as shown in the following table :— Year Maternity Midwifery Total nursing cases cases 1946 805 10,834 11,639 1947 899 12,025 12,924 1948 630 9,533 10,163 1949 749 7,831 8,580 1950 649 6,659 7,308 The attraction of hospital confinement, owing to the lower cost to the patient, and the increase in the number of maternity beds available were other factors in reducing the number of home confinements. As regards the higher cost of a home confinement, representations have been made to the National Insurance Advisory Committee with a view to possible adjustments in maternity benefit and/or allowances. Of the 7,308 confinements during 1950, 915 were primi-gravidae and 6,393 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 average number of midwives employed during the year was 128 and the number of midwives employed at the end of the year was 121, compared with 140, at the end of 1949 and 155 at the end of 1948. The average number of confinements taken by each midwife, including her sick and holiday reliefs, was approximately 57 compared with 58 in 1949 and 65 in 1948. It was a constant problem during the year to adjust the number of midwives to the reduced number of bookings. In many cases this involved adjustment of practising areas of the 27 district nursing associations and hospitals providing district midwifery services under agreement with the Council. Part-time midwives were occasionally employed for various periods during the year to assist in the nursing of mothers 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 4,703 miles were run on the service during the year. 59 Housing of midwives Accommodation for domiciliary midwives, as recommended by the Midwives Salaries (Rushcliffe) Committee, continued to be provided by the Council. On 31st December, 1950, 63 midwives were housed in 57 houses or flats, of which 36 were provided by the Council and 21 taken on lease or on licence from either borough councils or direct from private owners. The metropolitan regional hospital boards continued to co-operate, when requested, in arranging for temporary accommodation to be provided for midwives in hospital staff quarters. Drugs and iressings Up to 31st March, 1950, drugs and dressings for the Council's midwives were by arrangement with the metropolitan hospital regional boards supplied from hospital dispensaries. Since then, drugs and dressings required have been supplied to the Council's midwives and to some district nursing associations direct through the chief officer of supplies. Agency organisations There was also a decrease during the year in the number of confinements undertaken on behalf of the Council by district nursing associations and hospital district midwives Year Maternity M idwifery Total nursing cases cases 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 1950 Hospital district service 131 3,881 4,012 District nursing associations 219 2,213 2,432 6,444 The number of midwives employed by these agencies on 31st December, 1950, was :— Supervisory Midwives staff Hospital district service 16 58 (including 2 part-time midwives) District nursing associations 9 28 (including 14 part-time midwives and supervisory staff) Payments to District Nursing Associations and Hospitals In addition, a small number of part-time midwives and some full-time staff of the district nursing associations did part-time midwifery and part-time home nursing. Payments to district nursing associations under section 23 of the National Health Service Act, 1946 continued to be merged in the grants made to them for home nursing services provided under section 25 of the Act. The rate of payment to hospitals providing midwifery services on behalf of the Council has continued throughout the year at £7 13s. 4d. a confinement, but in December a request was received for an increase in the case rate. This was under consideration at the end of the year. E 60 Ante-natal sessions Midwives' sessions for booking patients and for ante-natal examinations at maternity and child welfare centres continued to be developed as necessary. A midwives, however, still book and examine their patients at home. Confinements attended by Maternal Still- Neo-natal Deaths Births Deaths London County Council midwives 63 23 Hospital district midwives 21 9 District nursing association midwives 29 6 Total 1 113 38 Mortality Emergency Obstetric Service During the year 74 calls were made to hospitals for the emergency obstetric service ; 37 of the calls were made by doctors and 37 by midwives. The time between the call being made and the arrival of the service was:— Less than 30 minutes 36 cases Between 30-45 minutes 30 cases Over 45 minutes 8 cases In no case was the delay really serious. The conditions for which the service was called were as follow :— Retained placenta 28 Post-partum haemorrhage (after delivery of placenta) 31 Malpresentation and/or obstructed labour 8 Prolapsed cord 1 Obstetric shock 3 Failed forceps 2 Abortion 1 54 of the cases were multigravidae, 15 primigravidae and 5 not known. In 4 cases the mother had had 6 or more previous pregnancies. Two of these had post-partum haemorrhage and two malpresentations. The action taken by emergency obstetric service was as follows :— Blood transfusion 44 cases Saline drip 4 „ Expression of placenta 4 „ Manual removal of placenta 8 „ Forceps delivery 1 case Internal version and delivery 1 „ Episiotomy 1 „ Drugs administered 6 cases In the remaining 5 cases no treatment was given before removal to hospital. 38 patients were removed to hospital either after blood transfusion or, if their condition was satisfactory, without treatment; 36 patients were treated satisfactorily at home. In all cases to which service was called the mother made a good recovery. Comments—During the year the emergency obstetric service was mainly called for true obstetric emergencies, i.e., 59 cases of retained placenta and/or post-partum haemorrhage. In the majority of cases a transfusion was given in the house and then the patient was removed to hospital. On 11 occasions the emergency obstetric service was called for difficult deliveries either by a doctor unable to deal with the case himself or by a midwife unable to obtain a doctor. Pupil midwives At the end of 1950, 74 of the Council's domiciliary midwives had been approved by the Central Midwives Board as district teachers. During the year 140 pupil midwives from part II midwifery training schools received their district training with 61 midwife-teachers employed by the Council. Some hospitals and district nursing associations which were part II training schools also gave pupil midwives district experience with their own district midwives. Gas and air analgesia The following table sets out the numbers receiving analgesia throughout the year and the percentage which they represent of all confinements attended. In addition there were some mothers whom the midwives attended as maternity nurses under the direction of doctors who themselves administered anaesthesia or analgesia and in respect of which no figures are available. Confinements attended by 1950 1949 London County Council midwives 5,027(68%) 5,479(64%) Hospital district midwives 2,783 (69%) 3,033 (65%) District nursing association midwives 1,400(57%) 1,571(55%) There are still mothers who decline analgesia. Some are not considered medically suitable to receive it and in other cases the midwife is not summoned early enough. Developments in 1950 The chief development during this year was the extension to midwives of permission to administer pethidine on their own responsibility. The Ministry of Health have also initiated an enquiry into the relationship of virus infections to congenital defects in which the domiciliary midwifery service is participating. Premature airth Details of the premature babies born at home will be found on page 49. Change in law relating to midwives Midwives Acts, 1902-1950 During the year the Midwives (Amendment) Act, 1950, became law. The main effects of this Act concerning the work of local supervising authorities are :— (1) Administrative changes are made in the procedure for notifying the Central Midwives Board of the names of midwives who have notified intention to practise (2) Local supervising authorities are empowered to provide residential accommodation for pupil midwives (3) Practising midwives are exempt from serving on a jury (4) Provisions relating to a national uniform for midwives. Notifications of intention to practise The number of notifications of intention to practise compared with previous years was:— 1948 1949 1950 As midwives 1,213 1,252 1,275 As maternity nurses 289 242 241 An analysis of the notifications shows :— Midwives Maternity nurses Practising in hospitals 898 — Practising in nursing homes 23 67 London County Council domiciliary 145 — District nursing associations 107 — Hospital districts 91 — Nursing co-operations — 153 Independent 11 21 1,275 241 It should be borne in mind that notification to practise 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. 62 The supervisors of midwives investigate all cases of puerperal pyrexia and of children with skin and eye affections. On two occasions midwives were suspended from practice for varying periods to prevent the spread of infection. Lectures etc., to mid wives Two courses each of six post-certificate lectures and three all-day intensive courses each consisting of four ante- and post-natal demonstrations at hospitals were arranged in conjunction with Middlesex and Surrey County Councils. The number of tickets issued to midwives for the lectures was 389 and for the demonstrations 45. Dangerous Drugs Regulations Statutory Instrument 1950, No. 380, The Dangerous Drugs Regulations, 1950, came into operation on 1st April, 1950, and authorised certified midwives who had notified intention to practise to the local supervising authority to be in possession of and to administer medicinal opium, tincture of opium and pethidine so far as is necessary for the practice of their profession or employment as midwives. Conditions were laid down which provided that midwives could only obtain supplies of these dangerous drugs by the production of a drug book and their personal registers of cases. Records of supplies and administrations of the drugs have to be kept in the drug books. The rules of the Central Midwives Board provide that practising midwives must not on their own responsibility use any drugs unless in the course of their obstetric training they have been thoroughly instructed in their use and are familiar with the dosage and methods of administration or application. To ensure that all practising domiciliary midwives in London were qualified to administer pethidine, lectures on this subject were arranged at the County Hall. Midwives who commence to practise in London in the future and who are not qualified to use these dangerous drugs, will be given the opportunity to attend similar lectures. Summoning of medical aid, doctors fees, etc. The number of medical aid notices issued by midwives during the year, under section 14 (1) of the Midwives Act, 1918, was :— By domiciliary midwives 7,070 By midwives in institutions with less than 15 beds and/or no R.M.O. 124 7,194 Some of the notices were for assistance for more than one condition. A classification of the conditions for which aid was summoned appears in the appendix (Table 16) and the following is a summary :— (1) (2) Number of calls for Col. (1) repressed as a medical aid for percentage of the 13,828 tions as indicated midwifery cases attended during the year by iciliary midwives and midwives in small institutions (i) Conditions of pregnancy 1,636 11.83% (ii) Conditions during and mediately following labour 3,259 23.56% (iii) Conditions during puerperium 824 5.95% (iv) Conditions of the child 1,880 13.59% Fees paid under the Midwives Acts to medical practitioners called in by midwives in emergency were as follow :— 1948 1949 1950 No. of claims 6,354 5,368 4,216 Amount £15,594 £15,829 £12,682 63 The reduction in the number of claims received in 1950 is attributed partly tc the fall of 4.8 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. Maternity medical service At the end of the year there were 507 (compared with 480 at the end of 1949) 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 1950 for maternity medical services. doctors during the year 1950 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. Claims from Claims from General General Service provided Quarter Practitioner Medical Totals Obstetricians Practitioners 1949 1950 1949 1950 1949 1950 Full March 482 671 89 100 571 771 June 428 573 73 93 501 666 • September 582 649 72 92 654 741 December 990 587 51 73 1,041 660 2,482 2,480 285 358 2,767 2,838 Partial March 203 513 201 305 404 818 June 500 670 243 322 743 992 September 700 756 259 366 959 1,122 December 745 406 448 227 1,193 633 2,148 2,345 1,151 1,220 3,299 3,565 Emergency March 5 31 1 19 6 50 June 14 17 2 22 16 39 September 24 20 2 6 26 26 December 45 17 5 10 50 27 88 85 10 57 98 142 Full maternity medical service, for which a fee of £7 7s. Od. is paid to general practitioner obstetricians or £5 5s. Od. 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 Greater fluidity between health visiting, tuberculosis visiting and school nursing staffs has enabled the health visitor to give more time to problems which concern the family as a whole and is a step further in the direction of her wider duties as envisaged in section 24 of the National Health Service Act, 1946. She plays a large part in the various services referred to in detail elsewhere in this report, viz., maternity and child welfare centres (page 46), educational and advisory sessions (page 48) infant, 64 welfare centres at hospitals (page 52), home visiting and after care for almoners (page 54), selection of children for child guidance clinics (page 55), children neglected or ill-treated in their own homes (page 55). By arrangement with the Children's Officer I have continued responsibility for duties in 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 the children are living have continued to be undertaken by health visitors designated as " child protection officers." Towards the end of the year 618 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. Owing to the continued shortage of hospital beds for tuberculous persons and for the aged and chronic sick, necessitating their being nursed at home, the service has been subject to considerable pressure throughout the year. The district nurses made 1,291,887 visits in 1950 compared with 1,087,226 in 1949, and there were 7,318 patients still in nursing care at the end of the year. An analysis of the completed treatments is given in Table 15 (page 147) but the principal details of the work done during 1950 were :— Mid-year population Treatments No. of treatments completed per 1,000 population Total number of visits Total visits per 1,000 population Commenced Completed 3,389,620 44,431 43,048 12.7 1,291,887 381.1 The number of nurses employed at the end of the year was 281 full-time and 111 part-time, being a whole time equivalent of 340 nurses. This gave an average case load per nurse at any one time of 21 patients and each nurse made an average of 14 visits per day. The main conditions treated were :— Number Per cent. of total Infectious and parasitic disease 1,733 4.0 Tuberculosis 1,515 3.5 Cancer (and other neoplasms) 2,198 5.1 Diabetes 1,334 3.1 Mental and other nervous diseases 472 1.1 Ear and eye and other sense organs 2,347 5.5 Cerebral lesions of vascular origin 1,892 4.4 Heart and arteries 3,969 9.2 Veins and other circulatory diseases 525 1.2 Respiratory diseases 6,394 14.9 Digestive diseases 5,209 12.1 Genito-urinary 3,547 8.2 Pregnancy 699 1.6 Skin 3,912 9.1 Bones and organs of movement (mainly rheumatism) 1,059 2.5 Injuries 1,197 2.8 Other diseases or ill-defined 5,046 11.7 43,048 100.0 65 Patients were referred to the nursing associations as follows :— Per cent. Number of total By general practitioners 32,744 76.0 hospitals 7,685 18.0 public health authority 918 2.1 direct application 1,171 2.7 tuberculosis clinic 530 1.2 43,048 100.0 Duration of treatment The length of time and the frequency of visits involved in any treatment vary considerably with the nature of the disease. Diabetic patients, in respect of whom the treatment is mainly the administration of insulin, are on the average attended for six months and the visits are daily in most cases. On the average the rheumatic patients are nursed for four months at a time with two or more visits a week. Respiratory conditions are nursed on the average for less than three weeks but with almost daily visits. Digestive diseases (other than cancer) are normally of short duration. Tuberculous patients, as might be expected, require prolonged nursing (about seven weeks) as also do patients with heart disease (about eleven weeks). Cancer cases extend over about seven weeks and cerebral haemorrhage cases over eight weeks. The reasons given for cessation of treatment were :— Number Per cent. Recovered, relieved or convalescent 29,908 69.4 Admitted to hospital 7,451 17.3 Transferred to private nurse 111 0.3 Gone away or lapsed 645 1.5 Died 4,933 11.5 43,048 100.0 A high proportion of the tuberculosis, cancer, cerebral-haemorrhage and heart disease patients are ultimately removed to hospital or die at home, while for the other disease groups, where the conditions are less severe, the recovery rate is high. Equipment required for nursing patients at home has continued to be supplied by the Council, either direct (in a few special cases) and through the agency of the district nursing associations and the British Red Cross Society. DOMESTIC HELP SERVICE Domestic assistance is provided by the Council under section 29 of the National Health Service Act, 1946, which extended the powers previously granted so as to provide such service to any person who was ill, lying-in, an expectant mother, mentally defective, aged, or a child not over compulsory school age. The demand was greater than the supply but every endeavour was made to provide some service for all those in urgent need, priority being given to maternity patients. The following table shows the progressive growth of the service :— 1947 1948 1949 1950 (6 months) Cases assisted 7,389 11,302 25,933 25,805 Hours worked 703,000 (o) 1,211,000 (a) 2,783,000 3,159,728 Home helps (whole-time) or part- time employed at end of year 826 1,932 2,310 2,525 Equivalent in whole-time staff 490 (a) 1,101 1,265 1,402 (a) Estimated • 66 The demand on the service increased steadily and the extent to which it could be met is shown in the following figures for the year :— Maternity Other Applications received 3,960 16,763 Households attended (a) Completed periods of assistance 2,537 12,986 (b) Service incompleted at end of year 92 10,190 IMMUNISATION AND VACCINATION Diphtheria Immunisation Diphtheria immunisation is carried out at infant welfare centres at special immunisation sessions, at day schools and at children's residential establishments in London. When parents prefer the family doctor to immunise their children, general practitioners undertake the duties and are paid a fee of 5s. for each completed record of immunisation. The material is supplied free of charge through the Ministry of Health's Public Health laboratory service. The total number of children immunised against diphtheria under all these arrangements during the year was 46,689 and in addition 27,579 " boosting " doses were given. The comparative figures for 1949 were 56,030 and 38,312 respectively. Some part of the reduction in immunisat ion in 1950 was undoubtedly due to publicity given to exaggerated reports of cases of paralysis following inoculation during the poliomyelitis epidemic of 1949. The reduction in the demand for immunisation is also associated with the present low incidence of diphtheria, itself a result of the Ihe disparity between the number of applications received and those provided with assistance in the maternity cases was due in many instances to the applicants either obtaining alternative assistance, or having obtained a bed in a hospital for the confinement. Of the non-maternity cases, about 1,560 applications had to be refused owing to inability to supply home helps ; the excess of households attended over the number of applications received in 1950 is due to the carry over of cases already being serviced at the commencement of the year. Service for the maternity patients is normally provided for two 44 hour weeks. In other cases the average number of hours of service per week is 6 continued over an average period of 33 weeks. These cases cover a wide range of short and long duration and many chronic sick and aged patients receive continuous service for periods considerably over 33 weeks. There has been a tendency for maternity cases to decline and for chronic sickness cases to increase ; as the latter are of long duration this means that the number of households assisted has not increased in proportion to the expansion in hours of service. Home helps are encouraged to obtaih the certificate of the National Institute of Houseworkers, Ltd., upon obtaining which they receive an addition of Id. an hour to their rate of pay. Facilities are granted to those desirous of taking the examination. Where recipients of the service can pay it they are charged the full rate of 2s. 6d. an hour, but in other cases an abatement is made in accordance with a scale approved by the Ministry of Health. For this purpose, particulars of income are required to be stated on the form of application for domestic help, and assessment is based on the information supplied. An impression that incorrect information was being given led to an investigation of the details supplied by 36 per cent. of the applicants. This disclosed that in 48 per cent. of the cases investigated, understatements of income and allowances were made. In some cases the understatement was substantial and apparently deliberate. Since a large loss of income was likely as the result of a large number of mis-statements of income, a 100 per cent. check is now being undertaken. 67 immunisation campaign, and every effort must be made to maintain a high level of immunity in the child population, otherwise there will be a return to the years when many thousands of cases of diphtheria occurred every year. Residentia establishments for children in London 1 he visiting medical officer usually undertakes the immunisation of the chi in the Council's residential establishments in London and the following details the position at 31st December, 1950. Number of children fully immunised 527 Number of children in course of being immunised 42 Number of children awaiting immunisation 53 Number of children awaiting parental consent 70 Number of children for whom parental consent was refused 24 Number of children not immunised for various other reasons 68 Total number of children on the roll 784 It will be seen that at the end of the year 73 per cent. of all the children then in residence had been, or were in the process of being immunised. Residential establishments for children outside London The local health authority of the area in which the residential establishment is situated is responsible for making arrangements for the 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 each completed record. At the end of the year, of a total roll of 4,363, the number of children fully immunised was 3,642 ; 85 were in course of being immunised. 118 were awaiting immunisation and 321 were awaiting parental consent. Parents had refused consent in respect of 67 children and the remaining 130 children had not beer immunised for various reasons. The percentage of children immunised or in process of being immunised was 85.4 and a further 2.7 per cent. had received parental consent Whooping Cough Immunisation As the value of inoculation against whooping cough has not yet been fully established, there is no comprehensive scheme in the County for this service although a considerable amount of immunisation against whooping cough is done on request in immunisation clinics. The total number of children inoculated at these clinics during the year was 17,338. In addition 60 children in the Council's residential nurseries in London and 633 in out-county establishments had been fully immunised by the end of the year. Experience gained in 1949 confirmed the findings of other published reports that there was an association in certain cases between the site of paralysis in an attack of poliomyelitis and the site of an inoculation given during the previous month, and this association was noticed particularly with the combined diphtheria and whooping cough antigen. When poliomyelitis reappeared in 1950, therefore, this antigen was stopped, immunisation against diphtheria and whooping cough being carried out separately. In areas that were heavily attacked by poliomyelitis, whooping cough immunisation was in most cases postponed to a more favourable time. These means appear to have been successful. Vaccination. Special sessions are held at infant welfare centres for vaccination. In addition, general practitioners who so wish carry out vaccination on the Council's behalf, a fee of 5s. being paid for completion of the medical record. Lymph is supplied free of charge by the Ministry of Health through the Public Health Laboratory Service. 68 The following table gives particulars of the number of persons who were vaccinated either at infant welfare centres or by general practitioners during the year. The comparative figures for 1949 are shown in brackets. Age at date of vaccination Under 1 year 1 to 4 years 5 to 14 years 15 or over Total Vaccination 16,836 7,960 1,290 1,491 27,577 (13,896) (6,197) (508) (906) (21,507) Re-vaccination 8 125 382 4,818 5,333 (320) (79) (208) (2,305) (2,912) One case of post-vaccinal encephalomyelitis occurred but no death from complications arising from vaccination was reported. It was intimated in my last report that the significant drop in the number of infants vaccinated in 1949 might be only temporary. This forecast appears to be substantially true, as both vaccinations and revaccinations for 1950 show a considerable increase over those for 1949 although the increase was largely confined to the second quarter of the year when smallpox occurred in Glasgow. Residential establishments for children in London On 31st December, 1950, the number of children in the Council's residential establishments who had been vaccinated was 397. Those awaiting vaccination numbered 100, and of the remainder, 50 were awaiting parental consent, 121 were not vaccinated for various reasons and parental consent was refused in respect of 116 children. The vaccinated children constituted approximately 50 per cent. of the total in residence. Residential establishments for children out side London The responsibility for the vaccination of the children in the Council's out-county residential establishments rests with the local health authority where the institution is situated, the arrangements being similar to those for diphtheria immunisation. Of a total of 4,363 children in residence at the end of the year, 2,203 had been vaccinated, 162 were awaiting vaccination, 721 were awaiting parental consent, 1,133 were not vaccinated for various reasons and the parents of 144 children had refused consent. Here again the proportion of vaccinated children in residence was approximately 50 per cent. LONDON AMBULANCE SERVICE This service operates under the immediate supervision of Mr. A. G. Hellman, O.B.E., the Officer-in-Charge. Continued increase in demand for ambulance service As stated in the report for 1949, an immediate and substantial increase in the demand for ambulance transport followed the introduction of the National Health Service and during 1950 this upward trend continued and showed no sign of levelling out. The statistical tables on page 72 show that, with the exception of work carried out on an agency basis by 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 patients carried and the mileage travelled were substantially in excess of those for 1949 which themselves were " records." By the end of the year, directly provided service vehicles alone were carrying out an average of over 1,500 removals a day and great credit is due to the staff of the service generally and to the ambulance control clerks and operative staff in particular for the manner in which they have carried out their duties during this period of unprecedented stress and strain. 69 Home ambulance service The steady reduction in the number of orders 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, which was noted in the report for 1949, was continued during 1950 and, as last year, this was due in the main to the greater use of the railways for lone distance removals. Hospital car service The number of patients conveyed by the County of London Hospital Car Service during 1950 was 37,000 more than in 1949 and comparison with the 1948 figures shows an increase of over 84,000 patients and more than 900,000 miles. It is a matter for serious concern that if this rate of increase is not substantially abated the demand may shortly outstrip the available resources of the service. Short of requiring a medical certificate of need in respect of each patient conveyed, every effort is made to ensure that cars are provided only in cases of medical necessity and, following recent discussions between the Officer-in-Charge, London Ambulance Service, and the County of London Organiser of the Hospital Car Service, further measures have been taken to effect economies and to increase the efficiency of the Service. As an experiment, the car service work of a few selected hospitals has been " decentralised," i.e., cars are stationed at the hospitals during the day and the drivers work to the direct order of the hospital transport officer, as is done in the case of decentralised ambulances. There is good reason for supposing that this may result in an appreciable reduction in the average mileage travelled per patient carried. A still greater economy is looked for from an arrangement recently made whereby all orders received by the Hospital Car Service for the removal of patients beyond a radius of 40 miles from London are referred to the headquarters control room of the London Ambulance Service with a view to the substitution in all suitable cases of rail for road transport over the major portion of the journey. In a circular letter dated 20th November, 1950, addressed to all hospitals using the County of London Hospital Car Service, I gave details of this arrangement and again appealed for co-operation in ensuring that ambulance or car transport, whether for short or long journeys, is ordered only in cases in which it is essential. West Ham county borough council 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 river Thames. Staff There has been no effective change in the authorised establishment of drivers and attendants during the year although, in consequence of the adoption in March, 1950, of revised shift rotas based upon a working week reduced from 48 to 44 hours, the number of positions was increased from 514 (temporarily 574 to meet the additional demands resulting from the National Health Service) to 560 (temporarily 626). It has proved increasingly difficult to recruit suitable men into the service although applications have been invited by advertisement in the press and by other means. Towards the end of the year, it became difficult even to fill the vacancies resulting from normal wastage as existing drivers left the Service. It has been the Council's practice for some years to require all newly recruited drivers, who are not already in possession of a recognised elementary qualification in first aid to the injured, to obtain such a qualification within six months of engagement. They then undergo an oral examination by a medical officer to ensure that they are competent to apply their knowledge. It is gratifying to record that many members of the staff maintain a keen interest in the subject of first aid to the injured and pursue their studies either by obtaining the Council's " Advance " or " Teacher's " certificate or by membership of one of the voluntary first-aid organisations. An additional 6s. a week is paid to a holder of any of the recognised elementary 70 tions and this, together with an increase of 5s. 6d. a week, which was authorised by the Council with effect from 23rd November, 1950, in accordance with an agreement reached in the National Joint Council for Local Authorities Services (Manual Workers), results in a wage of 130s. 6d. a week to a qualified driver/attendant. Additional payments are granted for certain other duties, such as shift duty, Sunday duty and stand-by duty. At the end of the year the staff comprised (in addition to headquarters administrative and clerical staff):— 1 chief superintendent. 7 superintendents. 7 assistant superintendents. 19 station officers (including one for Civil Defence training). 628 operative staff (drivers and attendants—including 2 temporary reliefs). 1 stores assistant. Civil Defence The ambulance section will form an essential part of the Civil Defence Corps and, in accordance with the policy of H.M. Government that in the event of war the Council's expanded ambulance service shall function as a single integrated service for the conveyance of both war casualties and the ordinary sick, arrangements were put in train for the staff of the London Ambulance Service to undergo basic Civil Defence training. Vehicles Reference was made in the 1949 report to the two 3-year programmes (1947-50 and 1950-53) approved by the Council for the replacement of vehicles in the London Ambulance Service fleet and to the fact that, although the first programme provided for the supply of 120 new ambulances by 31st March, 1950, only 39 had been taken into commission by the end of 1949. I am happy to report that during 1950, not only were the arrears of deliveries quickly overtaken but substantial progress was made towards the completion of the first stage of the second programme. Altogether, during the year, 139 new vehicles were taken into commission (126 ambulances, 3 single stretcher ambulances and 10 ambulance-omnibuses) while 115 vehicles (91 ambulances, 19 ambulance-omnibuses and 5 sitting-case cars) were withdrawn from Service. The vehicle strength at the end of the year was :— 310 ambulances of various types. 14 ambulance omnibuses. 21 sitting-case cars. 2 emergency tenders. Decentralisation Measures to relieve pressure on ambulance service As will be seen from the foregoing paragraphs, the recruitment of additional staff and the expansion of the ambulanoe fleet has not been in any way commensurate with the heavy increase in demand on the service and considerable ingenuity has been called for in the devising of new methods for dealing with the demand so as to ensure that the most economical and efficient use is made of available resources. During the year ambidance transport arrangements for 14 more hospitals (making 28 in all) were " decentralised," i.e., arrangements were made for one or more ambulances, according to need, to be stationed at the hospitals during the day for the purpose of conveying local out-patients to and from the hospital at the direct order of a transport officer appointed by the hospital to co-ordinate ambulance orders from their various departments, 71 Train journeys The number of "ambulance-train-ambulance" journeys arranged during 1950 reached the record figure of 1,975, the monthly total rising from 84 in January to 285 in December, and I would again pay tribute to the Railway Executive Staffs for their co-operation in making these arrangements and providing reserved accommodation, special rolling stock, etc., often at unavoidably short notice. It is confidently expected that still greater use wdl be made of the railways for long distance removals as full knowledge of the facilities offered becomes more widely disseminated and that, in time, hospitals, etc., will agree without question to accept this means of conveyance in all cases where there is no medical contra-indication to it. Quite apart from the fact that it is considerably cheaper to send patients by rail over long distance, it is more comfortable, very much quicker and consequently less fatiguing for the patients than a long journey by road, especially in winter when the additional hazards of fog, ice, snow and flood are likely to be encountered. Moreover, it is to the advantage of users of the service generally that the difficulties which are being experienced in dealing with the present overwhelming demand for ambulance transport should not be aggravated by the depletion of the ambulance fleet for extended periods which results from sending ambulances on long distance removals. Major accidents Major accidents were, unfortunately, more numerous during 1950 than in recent years and the following are only a few examples of the many multiple calls answered by the Accident Section of the Service:— April 7 Fire at Bernard Street, W.C.I—three ambulances sent. Nine residents (one fatally injured) and one fireman removed to hospital. July 22 Coach conveying children in collision with a lamp standard in Holloway Road—two ambulances sent. Twenty-four casualties removed. Aug. 14 Two trams in collision Glenbow Road—Downham Way— two ambulances sent. Seventeen injured persons taken to hospital. Nov. 18 Two trams in collision in Kingsway subway—three ambulances sent. Twelve casualties removed to hospital. Nov. 20 Coach in collision with obelisk—Ebury Bridge Road— Chelsea Bridge Road—three ambulances sent. Fifteen casualties removed to hospital. Visitors to the London Ambulance Service Headquarters Many of the overseas visitors referred to in the introduction to this report who came during the year to obtain first-hand information about the Council's Health Services were shown over the Headquarters Control room of the London Ambulance Service and the Headquarters Ambulance Station. In addition, a total of nearly 150 persons visited the Headquarters Control room during the year and were given a practical demonstration of the Council's organisation for dealing with the receipt and allocation of calls for ambulance transport. These included delegations of students, representatives of other local health authorities and a number of hospital transport officers and almoners responsible for the ordering of ambulance transport. The visits of the latter have proved of great value in establishing close and cordial relations between the staffs of hospitals and of 72 the London Ambulance Service and have resulted in a fuller understanding of the problems and difficulties with which both are beset at the present time. A full account of the history of the service was given in the report for 1949. National agreement on ambulance charges In October, 1950, a further conference of representatives of the County Councils Association, the Association of Municipal Corporations and the London County Council was convened to consider a revision of the basis of charges and allocation of cost between local health authorities in respect of the provision of ambulance transport and to discuss the possibility of agreement among local health authorities as to the interpretation of (a) certain recommendations contained in the published report of the Conferences held in 1949, and (b) the provisions of section 24 of the National Health (Amendment) Act, 1949. General agreement was reached on all matters discussed and it was referred to the financial advisers of the respective bodies to submit recommendations for a revised standard rate of charge and for a uniform system of accounting procedure. Statistics (i) Directly Provided Service Under this head the Service is divided into two sections—Accident and General. The Accident Section, as is shown in the analysis of calls below, deals not only with street accidents and other emergencies but also with the bulk of maternity removals, including the conveyance of analgesia apparatus to women being confined at home. All other removals, including the conveyance of persons suffering from infectious diseases are dealt with by the General Section. 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 subsequent years:— Accident Section No. of calls No. of cases (patients conveyed) 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 1950 83,791 85,376 437,416 A detailed classification of all calls received by this section is recorded on punched cards, an analysis of which reveals the following items of general interest:— The average time taken to reach street accidents was 7.2 minutes, the same as in 1949. The period of greatest pressure commenced between 10 and 11 a.m. and continued until 6 p.m.; after that there was a sharp rise in the number of calls received between 10 p.m. and midnight and the lowest number of calls was received between 6 a.m. and 7 a.m. The number of calls (404) dealt with by the Accident Section on Friday, 22nd December, 1950, was the greatest in any one day since the inception of the service in 1915—with the exception of Coronation Day, 12th May, 1937, when the number was 457. 73 The nature of the calls answered with comparative figures for 1949 were:— 1949 1950 Increase or decrease Street accidents 10,379 12,287 + 1,908 Other accidents 14,588 16,761 + 2,173 Assault cases 1,216 1,395 + 179 Attempted suicide 590 739 + 149 Mental 443 541 + 98 Epilepsy 1,349 1,373 + 24 Other sudden illness 14,155 16,865 + 2,710 Maternity 23,187 23,788 + 601 Analgesis apparatus delivered to women being confined at home 6,972 6,311 – 661 *Special cases 220 298 + 78 Ambulance not required 4,281 5,018 + 737 77,380 85,376 + 7,996 *Including transfer of accident cases taken to hospital within previous 24 hours. General Section Persons conveyed and mileage Patients Others Total Mileage 1938 217,908 102,520 320,428 1,930,172 1947 182,206 129,599 311,805 1,768,550 1948 239,157 130,335 369,492 2,072,545 1949 362,963 189,468 552,431 2,808,550 1950 480,048 220,017 700,065 3,041,569 (ii) Agency and Supplementary Services Except for the West Ham Ambulance Service which by agreement carries out removals on behalf of the Council in those parts of the Borough of Woolwich north of the river Thames, the following agency arrangements have been in force only since 5th July, 1948 (the " appointed day " under the National Health Service Act, 1946). Comparative statistics for 1949 and 1950 were:— 1949 1950 Patients carried Mileage Patients carried Mileage Home Service Ambulance Department 9,557 376,564 7,966 281,183 County of London Hospital Car Service 107,667 1,496,090 144,669 1,787,434 *City of London Police Ambulance Service 835 2,619 — — West Ham Ambulance Service 113 1,468 246 4,373 118,172 1,876,741 152,881 2,072,990 * Agency terminated 5th July, 1949. PREVENTION OF ILLNESS : CARE AND AFTER-CARE Health education The main health education effort continued to be that of the health visitors to individual mothers and to small groups, either in the maternity and child welfare centres or in the homes. More organised talks to larger groups in the centres were arranged by several of the divisions and visual aids (films and film-strips) were used to advantage. 74 The exhibition stands and topics of the Central Council for Health Education were displayed throughout the year and, with posters and leaflets, formed the basis of our " silent " health education effort. There were 1,400 attendances at 16 courses of lectures on sex education arranged for youth clubs. Five of the courses were illustrated 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 asking and answering of the more intimate questions. Four talks, mainly dealing with the way in which sex should be taught to children, were given to parent-teacher associations (2) and mothers' meetings (2). The attendances at these four talks totalled 110. Exhibitions The Council co-operated in three exhibitions during the year:— In May the accident section of the ambulance service was featured in New Scotland Yard's exhibition "Whitehall 1212" held in an Oxford St. store. At the beginning of November the Fulham borough council held their Golden Jubilee exhibition and a stand was allocated to the Council to show the growth of the maternity and child welfare services. For a fortnight in November, we again (as in 1949) had a stand in the Mothercraft Exhibition at the Central Hall, Westminster on which the Council's services for mothers and babies were depicted. Health visitors attended at the stand by rota to answer questions and to distribute health education leaflets. Foot clinics The Council continued to administer the twenty-six foot clinics which had been established by the metropolitan borough councils before 5th July, 1948. During the year the clinic at Charlton Lane, S.E.7, was closed, the sessions being transferred to Fairfield House, Fairfield Grove, S.E.7, and a clinic which had been approved in principle by the Minister of Health before 5th July, 1948, was opened at 48, Glenthorne Road, W.6. No other steps were taken to extend the service pending a decision by the Minister of Health as to whether chiropody is a form of treatment which should be provided by local health authorities. The following are particulars of sessions, attendances, etc., for the year:— *Clinic Sessions New Cases Attendances Staff (In terms of wholetime units) 9,811 10,165 153,687 44 *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. Recuperative holidays The demand for recuperative holidays continued to grow during the year and further recuperative holiday home accommodation was approved for the reception of persons of all categories medically recommended for a recuperative holiday. Unaccompanied children The services of voluntary organisations such as the Invalid Children's Aid Association, Women's Voluntary Services, Jewish Board of Guardians and the Children's Country Holiday Fund, continued to be used in connection with the provision of recuperative holidays for unaccompanied children and the Council's experiment by which selected children over the age of 7 years are sent to a private hotel at the seaside in the care of holiday organising staff appointed by the Council was extended and approved as an integral part of the Council's provision for 75 tive holidays. Full use was made of the Council's own recuperative holiday home for children at Mayfield, Sussex, and a second home at Littlehampton was opened in April for the reception of children aged 5 to 8 years. Expectant and nursing mothers and accompanied young children and other adults The majority of placings in recuperative holiday homes for adults and accompanied young children was carried out by direct arrangements made by the Council but the services of the Family Welfare Association were used as a placing agency for specially difficult cases. Additional holiday home accommodation was approved for expectant and nursing mothers and young children and increased facilities for recuperative holidays for persons suffering from various disabilities were provided. Such special categories include blind, tuberculous and epileptic persons and adults suffering from infantile paralysis. The following is a statement of admissions to recuperative holiday homes in 1950. The comparable figures for the year 1949 are also given. Unaccompanied children Expectant and nursing mothers and accompanied young children Other adults Under 5 yrs. School children Mothers Children 1950 1548 4255 340 566 3439 1949 1517 3121 379 671 2779 Venereal Disease A summary of work done in 1950 at the London V.D. clinics will be found in Table 33, p. 156. Approximately 73 per cent. of the patients were resident in the County of London. The figures show a continued decline in the number of patients suffering from syphilis and gonorrhoea. The number of patients attending the clinics for treatment of non-venereal conditions is again very large, there being a substantial increase in the number of male patients. Graphs showing the incidence of early syphilis in London among persons attending V.D. clinics are again reproduced below. They do not include patients treated by general practitioners, of whom no statistics are available, but the figures for clinic patients are probably indicative of the general trend. The continued decline in the number of new cases of early syphilis attending the clinics is gratifying, as also is the reduction in the numbers of new patients suffering from early latent syphilis, i.e., those showing no clinical signs but considered by blood test, etc., to have contracted the disease within the preceding twelve months. The rate of decline of early latent syphilis was, however, only about 45 per cent. in the last two years compared with a rate of about 61 per cent. for all new early cases. The generally falling trend should not give rise to over optimistic hopes that the disease may cease to be a serious menace to public health. Modern methods of treatment may provide more rapid cures than formerly and in many cases provide a speedy means of removing infectivity but these alone will not eliminate venereal disease. It is disquieting to note the number of new patients attending clinics who were found to have late stage syphilis of long standing. These and new congenital syphilis cases, happily decreasing, may be taken as an indication of the great number of early cases of the disease which must still be escaping effective treatment. The fact that at some clinics new patients with late stage syphilis are as numerous as new patients with recently acquired syphilis in the primary and secondary stages emphasises that great efforts will be necessary in many directions before there can be any real prospect of bringing the disease under fuller control. F 76 There was again some improvement in the defaulter rate, except for male patients who completed treatment for gonorrhoea but ceased to attend before final tests for cure. The table below gives the number of patients completing treatment and of defaulters as shown by analysis of the returns from the clinics for 1950 Syphilis Gonorrhoea Male Female Male Female Number of patients discharged after completion of treatment and final tests of cure 1016 763 2730 623 Number of patients who ceased to attend after completion of treatment but before final tests of cure 769 366 2319 371 Number of patients who ceased to attend before completion of treatment 327 204 290 70 Number of patients who died from the disease while still undergoing treatment 12 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. At the request of the Prison Commissioners the part-time services of a welfare officer have been made available for attendance at clinics at Holloway Prison and for following-up contacts and prisoners on discharge. The initial trial period has shown that there is great scope for this work and permanent arrangements on a larger scale are under consideration. Twenty-one notifications were received from the Service authorities 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. INCIDENCE OF V.D. IN LONDON — EARLY SYPHILIS — CIVILIANS MP OF CASES OF EARLY SYPHILIS (HALF YEA PL Y FIGURES ) 77 Tuberculosis Throughout the year the Council continued to provide its share of the National Health Tuberculosis Service, the diagnostic and therapeutic aspect of which is dealt with by the hospital boards. Considerable and sometimes complex and delicate integration and liaison with the Metropolitan Regional Hospital Boards, the Boards of Governors of Teaching Hospitals and Hospital Management Committees is necessary in order to ensure that the available resources are used to the best advantage for tuberculous persons and their families. Chest clinics There are 29 chest clinics in the county, with two in some of the larger boroughs and with occasional combinations of boroughs covered by one clinic. The medical staff, the radiographer and the physicians' clerks are provided by the hospital boards, who also provide the premises and equipment. The Council rents accommodation for the staff it provides, which includes an after-care organiser, a clerk for the latter, a handicraft instructor, and a varying number of tuberculosis health visitors who spend part of their time assisting the physicians in clinic work and rather more of their time visiting patients in their homes so as to ascertain and, where needed, endeavour to improve, the domiciliary, social and economic conditions under which the patients live. The after-care organiser at the clinic is concerned with the patient's needs other than medical and nursing; she also acts as secretary to the local tuberculosis care committee. These clinics had on their books on 31st December, 1950, 32,301 patients, of whom 28,623 were suffering from the pulmonary form of the disease. Home care and treatment At the end of September, 1950, there were 3,076 tuberculous Londoners undergoing hospital treatment mainly in regional hospital board institutions, and 2,035 patients awaiting admission to hospital. There were also at that time 1,287 patients under special treatment in their own homes ; many of these were awaiting vacant hospital beds, a wait usually stretching to about six months so that anxious chest clinic physicians, where housing circumstances permitted, increasingly introduced and extended home treatment by rest, chemotherapy, collapse therapy or combinations of such therapies. This multiplied the need for health visitor, home nurse and home help services and increased the demand for facilities to " board-out" susceptible home contacts to avoid the risks of infection or to reduce the burden of domestic labour from an ill mother for whom rest in bed at home was prescribed. By the end of the year the number of patients under special domiciliary treatment had risen to 1,678 and the waiting list for admissions to hospital had fallen to 1,513. In the last quarter of the year 662 patients received attention by the Council's home nursing service. Consideration was given to the desirability of extending the clinic service of diversional therapy to patients bedfast or "homefast" but for various reasons the introduction of such a service has had to be postponed. The Council's ambulance service was also taxed by this increase in home treatment inasmuch as many of the patients so treated had to be brought repeatedly by car or ambulance from home to clinic or hospital for X-ray examination or for lung collapse therapy or minor surgical procedures associated therewith. Many chest clinic physicians have expressed their satisfaction at the full and convenient arrangements made to this end by the officers of the ambulance service. After-caro organisers and local Care Committees Increasing awareness of the importance to tuberculous patients of relieving them of domestic, social, industrial and financial anxieties has led to an increase in the activities of local Care Committees and of after-care organisers. In the last quarter of 1950 these officers made first investigations in respect of 1,574 patients. During these three months 160 newly assisted patients received extra nourishment; 731 received the services of home helps; 190 were provided with beds and bedding; 213 were lent nursing apparatus; 284 were provided with clothing and 89 with 78 other commodities. At the end of the year 499 tuberculous persons were receiving extra nourishment from Council or care committee resources. In addition to providing food, clothing, etc., as outlined above, the Council's after-care organisers also arranged or tried to arrange for patients, better housing, more suitable employment, foster homes for child contacts, diversional therapy and gave help or guidance in numberless other problems of personal or family concern. It may be mentioned here that necessitous tuberculous persons receive higher financial grants from the National Assistance Board than do other necessitous persons. The following extracts from a number of current annual reports of care committees illustrate the activities, difficulties and value of these voluntary organisations:— "Members of the Tuberculosis Care Committee represent local bodies or interests which already have to deal with the problems of the tuberculous. They bring to the Committee's meetings, special knowledge of a particular field of public or voluntary service, as well as their individual concern for those who suffer from the disease." "The increasing cost of living has made life more difficult for our families during the year, and although National Assistance Board scale rates were raised slightly in July, it is undoubtedly true that many families who receive only the bare statutory allowances are having a hard struggle." "For many years the Committee has given Christmas presents to needy families. In 1950 thirty-two gifts and twenty-six grocery vouchers were distributed." "In order that patients may not suffer, we are obliged to spend more now on pyjamas, dressing-gowns and bedroom slippers. The rise in cost of bed linen, blankets and night apparel is alarming and a serious drain on our resources." "During the year 17 men and 11 women have had recuperative holidays we are indeed grateful to those who have made it possible for these patients to get rest and change, away from their drab surroundings." Divisional Tuberculosis Care Committees A Divisional Care Committee has been appointed by each Divisional Health Committee to co-ordinate the activities of the Tuberculosis Care Committees, SubCommittees or other groups of persons authorised by the Divisional Care Committee to deal with tuberculosis care work in the division. Boarding-out of child contacts As in previous years, children were boarded-out under the Council's tuberculosis contact scheme when they were exposed to infection at home or when their parent or parents were receiving institutional or home treatment for tuberculosis with consequent difficulties in the care of the children. In addition, boarding-out was arranged in connection with B.C.G. (Bacillus Calmette-Guerin) vaccination when it was thought necessary to segregate children from known cases. The arrangements for boarding-out were made on behalf of the Council by the Invalid Children's Aid Association, who experienced a continued shortage of suitable foster homes. A few child tuberculosis contacts were admitted during the year to accommodation provided by the Council in its residential schools, homes and nurseries, but greater use was made of private nurseries and homes. At the end of the year 318 children remained accommodated with foster mothers and in private nurseries and homes and 115 in the Council's establishments for deprived children. The average number boarded-out at any one time during the year was 405 compared with between 130 and 140 before 1939, 180 in 1946, 230 in 1947, 257 in 1948 and 326 in 1949. The total number of children accommodated during the year was 759 of whom 448 were new cases and 311 were children whose stay extended from 1949. 79 Residential open-air schools Certain children with a history of early or incipient or healed tuberculous infection were admitted to residential open-air schools for delicate children. No child with known "open" or infectious tuberculosis was, however, taken. The schools maintained by the Council in use at the beginning of 1950 were:— Burrow Hill Colony School, Frimley ; George Rainey School, St. Leonards-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. The total number of places in them is 441. In addition some were accommodated in private residential open-air schools. At the end of the year 38 children with a history of primary tuberculosis were in residential open-air schools. This is a service which provides suitable convalescence in good surroundings and with educational facilities for children who need "building up "for several months to tide them over a "primary" infection. B.C.G. vaccination By September, arrangements were completed to provide, through chest clinics facilities for B.C.G. vaccination of susceptible (tuberculin negative) contacts of knowr cases and the newborn children of tuberculous mothers. The procedure involves getting parental consent after full explanation of the purpose; ordering a special supply of the fresh living vaccine; making skin tests on the children concerned both before, and after, vaccination, the former to ensure that the child is not already infected with the disease and the latter to test whether or not the vaccination has been effective. All this, added to the work of already very busy and often understaffed chest clinics, inevitably delayed full application of this preventive measure, but by the end of the year 271 contacts were known to have been vaccinated in London under the Council's scheme. Arrangements were also completed with other county medical officers of health for suitable children boarded-out under the Council's tuberculosis contact scheme, to be vaccinated with B.C.G. by the chest physician of the clinic in the district where they are staying. Children boarded-out solely for vaccination during segregation are also included in this arrangement. The very willing co-operation of the medical officers of health and chest physicians in many places as far apart as Northumberland and Cornwall, has been invaluable. The number of children known to have been vaccinated under this arrangement by the end of the year was 43. It is likely to take another year before B.C.G. vaccination of London contacts gathers full momentum and takes an established place in our tuberculosis control measures. Tuberculin survey The survey, undertaken in two metropolitan boroughs by a special team of the staff of the Medical Research Council and referred to in my last annual report, was completed in March. It revealed that allergy (i.e., acquired special sensitivity to the toxins of the Tubercle Bacillus due to previous contact with infection, but not necessarily indicating actual disease) was present to a greater extent among Southwark than among Fulham children. The percentage of positive tuberculin reactors among those tested was 8.7 for Fulham 5 year olds (10.7 in Southwark) rising to 16.4 for 8 year olds (23.3 in Southwark), to 25.6 for 11 year olds (32.2 in Southwark) and to 32*1 for children aged 15 (44'7 in Southwark). These findings suggest that there is somewhat greater exposure to infection among children in Southwark than among those in Fulham and point to the desirability of arranging more widespread periodic tuberculin surveys among children (separately 80 from those vaccinated with B.C.G.) throughout the county preferably in association with chest X-ray examination of the positive reactors. Mass Miniature Radiography I am indebted to the 4 Metropolitan Regional Hospital Boards for the subjoined figures showing the number of persons (mostly working adults) examined during the year by the Boards' mass X-ray units operating in London and the number of cases of tuberculosis whose diagnosis was established during 1950. It will be seen that many of the persons X-rayed were not London residents and that a number of the diagnoses completed during 1950 related to persons X-rayed in 1949. Likewise a number of those persons X-rayed during 1950 will remain under surveillance until a firm diagnosis becomes established in 1951. Men Women Total number of persons X-rayed on miniature film during 1950 138,918 110,137 Diagnostic classifications completed during 1950 of persons who were X-rayed in London during parts of 1949 and of 1950:— (1) Active Tuberculosis London residents 259 217 Non-London residents 127 82 (2) Inactive Tuberculosis Primary lesions 472 381 Other inactive lesions 1,543 856 Rehabilitation Patients who have sufficiently recovered to be able to undertake work, either return to their previous employment or start in other employment if their former work is no longer available or is now considered too arduous, are assisted to obtain new and more suitable employment, sometimes by the local Disablement Rehabilitation Officer of the Ministry of Labour, sometimes by their own efforts and sometimes through the local Tuberculosis Care Committee. Some selected patients are sent by the Council to "village settlements" where they undertake courses of instruction in work suited to their capacity and temperament. At the end of 1950 the Council was financially responsible for 28 men and women at the British Legion Village, Preston Hall, near Maidstone; for 11 men and women at Papworth Village Settlement near Cambridge; and for 2 men at East Lanes. Tuberculosis Colony, Barrowmore Hall, near Chester. Considerable difficulty is experienced in finding suitable employment or training for severely disabled potentially infective tuberculous patients (the "stable" chronics) and for these special " sheltered " workshops are urgently needed. Schemes to build workshops of this kind in Paddington and in Stepney are under consideration. The homeless infective ambulant tuberculous man Throughout the year the Council was seriously exercised by the problem of providing suitable accommodation for this type of patient for whom treatment is unlikely to do much good. A scheme to build in Stepney a "night sanatorium" for such men, in association with a proposed sheltered workshop for disabled tuberculous workers, was submitted by the Council to the Minister of Health but in the existing national circumstances further progress has had to be suspended. Towards the end of the year, however, the Council was able to plan the provision of residential hostel accommodation for 35 working tuberculous men in a house in Islington and for 40 more severely disabled tuberculous men, unfit to work, in a private hostel near St. Albans. Both these hostels were expected to be ready for occupation early in 1951. Discussions were also started with the Welfare Department of the Council with a view to providing special facilities and precautions for tuberculous men residing in the Council's common lodging houses. From enquiries at chest clinics and sanatoria there appeared to be no call for the provision of special accommodation for homeless infective tuberculous women in London. 81 Housing of tuberculous families The Council's policy of giving a measure of priority to applicants for rehousing who have tuberculosis in the family was continued. During 1950, the Council provided houses or flats for 870 families or individuals who had been granted priority on account of tuberculosis. HALF A CENTURY OF TUBERCULOSIS IN LONDON A REVIEW OF CHANGES AND TRENDS SINCE 1900* "Comparisons with the past are absolutely necessary to the comprehension of all that exists to-day; without them we cannot penetrate to the heart of things." Chas. Booth—" Life and Labour in London," Vol. IX, 1897. Before 1900 In reviewing what has transpired in the past half century in relation to tuberculosis in London, it will be well, first, to look back a little at the state of affairs before 1900. The rapid expansion of industry, commerce and shipping which took place in London in the second half of the nineteenth century was largely responsible for the increase in population from 1½ millions in 1830, 2½ millions in 1850, to 4½ millions in 1900. For the past 25 years the figure has been gradually decreasing, The social and sanitary conditions of London during that half century were only just emerging from the condition Sir Edwin Chadwick had described in his 1842 Report to the Poor Law Commissioners in these words :—"The various forms of epidemic, endemic and other disease caused or propagated chiefly among the labouring classes by atmospheric impurities produced by decomposing animal and vegetable substances, by damp and filth, and close and overcrowded dwellings prevail among the population in every part of the kingdom as they have been found to prevail in the lowest districts of the metropolis." In 1838 the average age at death of the London "gentleman" and professional person was 44 years while that of a tradesman was 26 years and a London mechanic, servant or labourer 24 years. In 1840 the City of London's one square mile was so crowded with dwellings occupied by a population of 128,000 that there was no further room for building. In 1848 no less than 14,000 persons died in the metropolis from typhus and cholera. In 1891 the general mortality rate from all causes of death in London was 21.1 per thousand of the populace; by 1921 this had fallen to 12.5 per thousand. In 1850 it was computed that 80,000 (of the total of 300,000) London dwellings housing 640,000 persons had no water supply. The influence of bad housing conditions and low wages in inducing and aggravating tuberculosis has long been established. Sir John Simon, who was Medical Officer to H.M. Privy Council, and before that, the first Medical Officer of Health to the Corporation of London, a great pioneer of sanitary administration and reform, wrote in 1890 of poverty in London:— "As the largest and most miscellaneous labour market in the country, it has drawn competitors for the various chances of employment from all parts of England and from elsewhere. So far as the innumerable immigrants have not found employment in adequately paid industries, they of course have added to the poverty of their new settling place. The London labour market has been distinguished by a terribly large 'casual' department in which the workers, apparently next door to destitution, are perhaps for two-thirds of their time idle. The above-mentioned two facts as to London—the fact of its so largely attracting industrial immigration and the fact that in its lower-class industries a large proportion of working power is left unemployed—are facts of cardinal importance in the case; for the distresses, domestic and industrial, which have * This retrospect (pages 81 to 93) is mainly the work of Dr. W. Hartston, Senior Medical Officer (Tuberculosis). 82 been most brought under notice as attaching to London poverty are facts of over-competition for employment and for house room." In a survey of London life and labour undertaken in 1889, Chas. Booth and his associates found that 30.7 per cent. of the population were living in financial poverty and that 31 per cent. lived in overcrowded conditions. A survey on similar lines in 1929 by a group of investigators from the London School of Economics estimated the London population below the "poverty line" to be 9.6 per cent. of the total, while 16 per cent. of the people were overcrowded. And in this pre-1900 setting, what of tuberculosis? Accurate measures of incidence and prevalence of this disease in London's population are not available for the years before 1911, when the disease was first generally and compulsorily notifiable. Mortality figures, however, are reasonably accurate and offer a sufficiently reliable guide for secular comparison. The earliest measures of tuberculosis mortality for London are to be found recorded as deaths from consumption, in the "Bills of Mortality," but there are no accurate estimates of the population at risk in the area of the London to which the Bills of Mortality apply. However, the ratio of recorded deaths from phthisis to the total of deaths from all causes is of value, within limits, for investigating conditions in the seventeenth century. This mortality ratio rose continuously from 12 per cent. in 1700 to 26 per cent. at the end of that century and thereafter lessened steadily to 8 per cent. in 1900. It may be postulated that a long epidemic wave of phthisis spread steadily over London in the eighteenth century, reached a peak about 1800 and then declined. In 1850 the tuberculosis mortality rate (pulmonary) for London was nearly three per 1,000 of the population, in 1880 it was 2.2 and by 1900 it had fallen to 1.7 per 1,000 though remaining higher than the corresponding rate for the whole of England and Wales, and in fact London's phthisis death rate was higher than that for any other county or town in the kingdom. In this connection it is well to recall that the causative organism of tuberculosis was discovered by Robert Koch in 1882. This discovery had a very considerable influence on medical thought and practice in relation to the disease, which was now more widely acknowledged to be an infectious condition. Diagnosis became more accurate and surgical intervention for the non-pulmonary forms now gave way to rest as the cardinal treatment. In 1890 Dr. Koch first devised the tuberculin skin reaction, then used mainly as a diagnostic agent in veterinary practice. In the next ten years a Royal Commission investigated bovine tuberculosis and showed how widespread was tuberculous infection of dairy herds and raw milk in England. The turn of the century In 1901 the hygienic evolution of London advanced a further step with the passing of the Factory and Workshop Act which provided for inspection and reports by the Medical Officer of Health on workshops and the homes of outworkers. In 1907 routine medical examination of school children was started. A year earlier the Provision of Meals Act had been passed, enabling local authorities to provide meals for needy children at elementary schools. In 1908 the Public Health (Tuberculosis) Regulations placed on all sanitary authorities and boards of guardians the duty of making provision for tuberculous patients who came under the care of poor law medical officers either at home or in poor law institutions. Sanitary authorities were enjoined to make by-laws to prohibit spitting in public places. Further social legislation included the Old Age Pensions Act in 1908 and in the following year the Labour Exchanges Act and the Trades Boards Act, the latter establishing machinery to ensure reasonable minimum wages in industries which had hitherto yielded a competitive, uncertain and insufficient return. 83 This spate of social welfare legislation laid the foundations for better conditions to lessen the ravages of tuberculosis and indeed of other diseases too. In 1909 the first London tuberculosis "Dispensary" was established in Paddington by a local voluntary committee; rebuilt in 1940 it is one of the best equipped and most attractive clinics in the country. The National Health Insurance Act passed in 1911 was the first important legal measure to make statutory provision for the treatment of tuberculosis, albeit limited to the insured working population ; to provide for financial payments to patients during sickness; and to lay the foundations of the Medical Research Council. At this time more than 3,000 hospital beds were available in London, provided by the poor law authorities, for the treatment of pulmonary and "surgical" tuberculosis. In addition, the Metropolitan Asylums Board provided hospital beds for the treatment of tuberculous children. Compulsory notification of tuberculous sufferers had applied to inmates of poor law institutions since 1908, and by Regulation in October, 1911 such notification was extended to all cases of tuberculosis coming under the care of a medical practitioner whether in a hospital or otherwise. Concern at the prevalence of tuberculosis disclosed by notification and at the variable provisions for treatment and control led to the appointment by the Chancellor of the Exchequer in 1912 of a committee to report on general policy in tuberculosis in its "preventive, curative and other aspects which should guide the Government and local bodies in making or aiding provision for the treatment of tuberculosis." The improvement in mortality from pulmonary tuberculosis, already manifest by 1900, led Sir Shirley Murphy, first Medical Officer of Health to the London County Council, to report in 1905:— "I know that if the sanitary areas of London are arranged, first in order according to the amount of overcrowding, i.e., the proportion of their population overcrowded; and second, according to their rate of mortality from phthisis, you will find much parallelism between the two. That demonstrates pretty clearly that the phthisis death rate of a district stands in close relation to the proportion of its population which is overcrowded—and overcrowding is, after all, only an expression for poverty." In the clinical field shortly after this time, sanatorium treatment by graduated exercise and rest was established and the Out-patient "Dispensary" became accepted as the community centre for diagnosis and supervision. The Brompton Hospital "for Consumption," the first of its kind in England, had been founded in London in 1840. Rontgen discovered X-rays in 1893, and in the same year Nils Finsen began treating lupus (tuberculosis of the skin) in Denmark with ultra-violet light focused on to the lesion by a system of lenses fitted into special lamps. The first clinic in England for the treatment of lupus by heliotherapy was established at the London Hospital in 1900. It is still the largest known of its kind. Some indication of the prevalence of skin tuberculosis at that time may be gauged from the statement of E. W. Morris in his "History of the London Hospital " that "within a month or two of the opening of the department, the lamps were booked forward for two years and no more patients could be treated." The merits of improved hygienic conditions in the prevention of tuberculosis were becoming sufficiently recognised to draw the following remarks from Dr. Theodore Williams at the Harveian Oration delivered before the Royal College of Physicians of London in 1911—"What are the prospects of the crusade against tuberculosis in this country, and how can we further them ? We must bear in mind the blessed agencies of prevention which, when set in motion, go on pursuing their beneficent course independently of fashion and caprice. Such are improved drainage, more cubic space and less overcrowding, better food and more of it, more air and sunlight, cleanliness of house and person and greater opportunities for play and 84 exercise. It is probable that a large proportion of the two-thirds reduction in our phthisis mortality during the last fifty years is due to such agencies. What a splendid effect a good town-planning scheme ought to exercise on the public health." Prevalence and Mortality From 1931 to 1939, the number of known tuberculous persons on the registers of Tuberculosis Clinics in London fell from 40,000 to 30,000, but rose to 40,000 again during the war and post-war years though the ratio of lung cases to nonpulmonary cases has changed considerably. Pulmonary cases have increased from '29,560 in 1931, to 34,120 in 1950. Tuberculosis in other sites has fallen from 11,000 cases in 1931 to 5,600 in 1950. This reflects two separate trends ; first, better casefinding and increased chronicity of lung tuberculosis, and secondly, as many nonpulmonary cases were milk infections, a considerable improvement in the purity of milk supplies of London. There is little doubt that improved medical supervision of children and adults, at school, at home and at work; better diagnostic facilities including X-ray and tuberculin surveys, and a determined drive to examine the contacts of known cases of tuberculosis, have contributed most to the increased registered numbers by eliciting new cases of lung disease—even though the population has been decreasing in size and even allowing for a considerable rehousing of tuberculous families out of London. The reduced death-rate from the disease with its corollary, a longer life during which others can be infected; the increasing daily contact between members of London's population in streets, shops, crowds, transport vehicles and other public places; and the housing shortage of the last 10 years has each played a part in spreading infection and producing new cases. Since the advent in 1911 of compulsory notification of newly discovered cases of tuberculosis, the annual recorded incidence of these in London, both for pulmonary and for other forms, has, apart from the war years, fallen steadily. New notifications of lung cases had been decreasing until 1939 when the rate rose and remained raised until 1945 when it began to fall again and it has not yet returned to the 1939 level. New notifications among males, hitherto always higher, are tending in some age groups to approximate to, and in the age group 5—14 years, even to fall below, the rates for females. The slower pace of decline in the incidence of tubercle in females is not a new problem but a serious one, the trend of which has been underlined by recent statistical approach. Not only does this represent a gradual change in the sex, age and other characteristics of the tuberculous population, but it may be taken to reflect changes in the reasons and sources of recruitment to that demographic group . The epidemiology of tuberculosis is not static; it is sensitive to all the intricate, subtle and pervading social influences manifest in modern human populations especially those living in big cities. The tables and graphs at the end of this conspectus illustrate these trends in full detail. Tuberculous meningitis which occurs mainly in young children might reasonably be taken as a measure of infective hazard, human and bovine, in the home. In London, since 1904, mortality from tuberculous meningitis which, until streptomycin became available late in 1947, was uninfluenced by treatment, has, apart from the war years, fallen steadily. The figures for meningitis incidence and mortality appear, therefore, to be less a measure of infection in the whole community than one of exposure hazard in the immediate family circle of the young children concerned. This indicates that young children are now better protected against infection in the home. Eleven per thousand of London's population are known at the present time to have active or quiescent tuberculosis. To this may be added four per thousand presumed to be "at large" and as yet unrecognised. With a total tuberculosis prevalence of 1.5 per cent. among the population and of these about a quarter capable 85 of producing identifiable tubercle bacilli, it is disturbing at tuberculin surveys to find that 10 per cent, of London children at their fifth birthday have already met sufficient infection to develop allergy and a positive tuberculin reaction. There is evidence that the "minimal" and the "sputum negative "lesions are more infective than we have hitherto believed. Mortality from tuberculosis at all ages has fallen steadily during the past century. This reduction has been most manifest in infancy and among nonpulmonary infections. The age group 5-14 years has always in lung cases shown a higher mortality rate among girls than among boys and this preponderance has also become manifest in recent years in non-pulmonary cases. London's cfiaracteristics affecting its tuberculosis epidemiology The fact that it is the largest conurbation in the country exposes London to a special disadvantage in sickness mortality. More than that, the daily working population is considerably greater than the resident population so that the working Londoner is exposed to tuberculosis infection not only from his fellow citizens but also from an almost equal number of non-Londoners who come into town to work or shop by day or to be amused in the evenings. Migration into and out of London, and between its boroughs, goes on to a much larger extent than in most other towns, especially as the result of housing programmes. War-time "evacuation" and deaths of Londoners, many in air-raids, decreased the civil population from over 4 million in 1938 to less than million during 1941-45. By 1950, the population had risen to 3,389,620. A large number of London dwellings, hospitals and other buildings were very severely damaged as a result of war-time bombing. A post-war housing survey undertaken in Holborn in 1947 disclosed that nearly one-third of the inhabitants of that Borough were living under conditions of gross overcrowding. There has been a steady growth of industrial and commercial buildings in London at the expense of dwellings which tend now to extend upwards, thereby increasing the population per acre of built-up areas and the occasions on which they meet and pass and exchange bacterial exhalations. London is unique in its richness in hospitals of all kinds. These better facilities make for more accurate diagnosis and contribute to a higher incidence of discovered cases of tuberculosis, especially of the non-pulmonary types. There is a growing "coloured" population with a rising incidence of tuberculosis among them. There appear to be greater opportunities in London for social mobility between classes, particularly in an upward direction. The children of unskilled labourers tend to become semi-skilled assemblers or machine operatives with better wages and standards of living. The children of artisans and shopkeepers strive to enter the professions. This "upgrading" of social classes must have a beneficial effect on the mortality rates of diseases which reflect social class influences. The 1951 Census will show to what extent such social class change has happened. Rising living costs and the opportunities offered by increases in the numbers employed in distributive trades, light engineering, wireless assembly and in restaurants and " snack bars," attracts much larger numbers of women into industry with consequent increased exposure to infection. It has been suggested that married women who are gainfully employed (in addition to housekeeping) have a higher risk of tuberculosis than single women of the same age, though married women who are not working have a lower incidence than single women. There have also been suggestions that sacrifices made by mothers to make the rations "go round" have had their effect on tuberculosis mortality in women of the older age groups. Whatever force there may or may not be in these suggestions it is certain that the differential tuberculosis mortality and morbidity of men in comparison with those of women (at least in the industrial age 86 groups) is not now so marked as even a decade or so ago; female mortality and morbidity have declined more slowly. This is a serious matter in so far as the mother is in closer contact with the family than the father and therefore within the family is potentially more infectious. Shorter working hours, higher wages, better canteen and restaurant facilities, better appreciation of nutritive food values and cleanliness, better clothing, regular holidays, more transport to the country, improved ventilation at home and at work and increased popularity of holiday camps, swimming pools, etc., have all made for better health and lower mortality. The better-off younger families tend to move out of the Metropolis (though they may continue to work in it), while the poorer and the disabled have to remain in London to be nearer to their places of work. Temporary residents and students of the industrial age group (18-45) which carries the highest tuberculosis incidence, live in the Metropolis in large numbers. The London population in this respect is not a random sample of the United Kingdom population, and for the reasons suggested has always shown greater prevalence of tuberculous infection. L.C.C. schemes for the treatment of Tuberculosis, 1914, 1922 and 1936 In 1912, the Government Departmental Committee on Tuberculosis already referred to, recommended that local authorities should be made responsible for providing facilities to deal with tuberculosis. The Council prepared and submitted its first scheme in May, 1914. This was approved by the Local Government Board and included the following provisions:— Domiciliary treatment of persons insured under the 1911 National Health Insurance Act to be provided by the panel practitioner. Home treatment of uninsured persons to be provided by private practitioners, by District Medical Officers (Poor Law), by voluntary institutions or by the tuberculosis dispensary physician. Dispensaries for diagnosis and treatment to be provided by, or arranged by, each local sanitary authority or by combinations of these, such provisions to be to the satisfaction of the Council who would contribute a grant for maintenance. Hospital accommodation for insured persons to be provided by arrangement with the Metropolitan Asylums Board, with voluntary institutions or by the Council itself. The Council to make arrangements, if and when required and subject to the approval of the Local Government Board, for residential accommodation for uninsured tuberculous patients who may be asked to contribute towards the cost of their treatment. The Council to make arrangements for accommodation in open-air residential schools for medical and surgical cases of tuberculosis in children. In 1922, following on the requirements of the Public Health (Tuberculosis) Act, 1921, the Council revised its 1914 Scheme, mainly in the following respects:— Dispensary service—Emphasis laid on early diagnosis, services made available to Ministry of Pensions, appointment of dispensary nurses or visitors; Each clinic to be linked to a hospital for consultation purposes. Facilities to be provided by the Council for pneumothorax, dental and sunlight treatment, X-ray examination and other special diagnostic measures or treatment and for sending patients to village settlements ; Tuberculosis Officers to visit patients' homes and examine contacts, Appointment of Tuberculosis Care Committees. 87 The National Health Insurance Act, 1920, withdrew sanatorium benefits from N.H.I, patients and the Council's scheme from then applied equally to the insured and uninsured. The Local Government Act, 1929, transferred to the Council the hospital functions and properties of the Metropolitan Asylums Board and metropolitan boards of guardians. The Council thus, in April, 1930, became the owners of the World's largest group of hospitals under local authority management and found itself possessed of 1,700 beds in sanatoria and surgical tuberculosis hospitals, apart from beds for chronic tuberculous cases in general hospitals, in asylums and mental deficiency colonies, as well as special groups of hospital beds for children ; there were provided subsequently units for tuberculous maternity cases and a pleural effusion unit; while day and residential open-air schools, were part of the Council's education service. In his Annual Report for 1932, the County Medical Officer proudly announced that "the development of the Council's tuberculosis scheme over a period of approximately twenty years has been gradual and may now be regarded as comprehensive." By a revised consolidating scheme—dated 1936—following on the County of London (Tuberculosis) Regulations, 1930, the Council also provided additional facilities for the maintenance of children exposed to tuberculosis when one or both parents were undergoing hospital treatment for tuberculosis and therefore unable to look after the child. This provided an extension of the existing boarding-out scheme for child contacts. The 1936 treatment of Tuberculosis scheme continued the existing arrangements with borough councils for dispensaries and voluntary care committees and made all treatment and services for the tuberculous free of charge. The Council continued to make use of voluntary colonies and village settlements for the industrial rehabilitation of suitable patients. The effects of two major wars The half century under review includes ten years of devastating war. The first, from 1914 to 1918, was accompanied by an increase in mortality from tuberculosis, mainly due to severe food rationing, and was followed by a wave of widespread and prolonged unemployment. In 1918, the last year of the first World War, 160,545 London men who were examined for military service included 5,238 rejected or deferred on account of tuberculosis (911 of them non-pulmonary) an incidence of 3.2 per cent. These figures, however, do not refer to a random sample of the population and only to the last year of war when it might be presumed that the healthier male residents had mostly already been recruited into the Forces. Nevertheless it denotes an appalling prevalence. The second World War, from 1939 to 1945, was more severe than its predecessor in its involvement of the civil population in physical danger from bombing, severe anxieties, food rationing, "black-out," the considerable employment of women in industry, serious crowding in homes, workplaces and shelters, and evacuation into country districts of many women and children. This war, soon after its onset, showed a sudden and sharp rise in tuberculosis incidence and mortality. Recognised health hazards from bad ventilation in darkened, crowded factories led, in 1943, to the use by the Council of mobile miniature mass X-ray units to examine volunteers in factories, in the hope of discovering and removing infective, previously unknown cases of tuberculosis. Many cases of active and of very early tuberculosis were brought to light in this way, and the use of such mobile mass X-ray units was continued and extended when the war ended. 88 As an incentive to treatment, Government allowances were introduced for tuberculous persons in need, who gave up work in order to undertake institutional treatment as recoverable cases of pulmonary tuberculosis. Considerable bomb damage was done to hospital buildings, and this, combined with serious post-war nursing and domestic staff shortages, has seriously restricted hospital treatment provision. Between 1945 and 1950 the waiting period was often nine months or more for a patient recommended by his physician for sanatorium treatment compared with 2 to 3 weeks before the war. This led to an increasing interest in the home treatment of the tuberculous involving special arrangements by the Council for the nursing of patients undergoing new drug or lung collapse treatment in bed at home. In conjunction with Mr. B. Benjamin, I wrote in the British Medical Journal in 1942:— "The experience of London has been less favourable than in the country as a whole. A probable effect of evacuation has been to increase the proportion of tuberculous persons in the population remaining. Part of the increases in the numbers of notifications of, and deaths from, tuberculosis can be attributed to reduced resistance to the disease and increased numbers of new cases among London patients in mental hospitals. The statistics of non-pulmonary tuberculosis throw light on the type of infection and on the efficacy of pasteurisation of milk. Most of the milk consumed in the Metropolis is pasteurised and therefore the fact that abdominal infections have not increased in proportion to infections at other sites is of special significance. The disproportionate rise in non-abdominal infections indicates that the principal infecting source is human. The increase in the incidence of tuberculosis is greater in respect of children than in respect of adults, and new cases of pulmonary tuberculosis increased more in adults than new cases of non-pulmonary disease. As compared with 1938, there was in 1941 an increase of 43 per cent. in the rate of occurrence of new cases of pulmonary and of 15 per cent. in new cases of non-pulmonary tuberculosis. The pulmonary tuberculosis death-rates increased over the same period by 72 per cent. and the non-pulmonary rate by 67 per cent. These increases are much greater than for England and Wales as a whole." The increased mortality rates associated with both wars were transient and after each war the steady fall which had begun in 1860 continued. The 1946 National Health Service Act and after The provisions of this Act came into force in July, 1948, and had the following effects on tuberculosis control:— All clinics, hospitals, sanatoria and mass radiography units came under the control of the Ministry of Health; those previously owned by the Council were handed over to the newly formed Regional Hospital Boards, who admitted into the hospitals, without charge, patients from a much larger area than London. A free General Practitioner service was made available to everybody. Diagnosis and treatment became a Hospital Board responsibility, the Council's interests being now confined to prevention; home nursing; boarding of child contacts; providing domestic "home helps"; industrial rehabilitation; diversional therapy; providing hostels for homeless infective cases; providing a free ambulance service; arranging health education of the public; providing better housing accommodation, extra nutriment, clothing, and other personal needs. The Council arranged to share with the Hospital Boards and Boards of Governors of certain London Teaching Hospitals the services of the senior physician at each 89 dispensary—now called a "chest clinic" and to provide an appropriate number of tuberculosis visitors and an almoner (who also acted as secretary to her local tuberculosis care committee) and clerk at each chest clinic. A diversional therapy instructor was also provided at almost all the clinics. The Council also provided "recuperative holidays" for those patients who needed a holiday after illness but without medical or nursing requirements. Considerable misgiving was felt about this dichotomy of the tuberculosis control services and the closest, most patient liaison with Hospital Boards was required to promote smooth and efficient working. In 1947 streptomycin and in 1948 para-amino salicylic acid became widely available as the new active therapeutic agents in tuberculosis. Their great value in the treatment of miliary and meningeal disease and to reduce patients' infectivity soon became recognised. Pneumoperitoneum was added to measures of collapse therapy while bold surgery to excise affected lung lobes or to collapse a chest wall by thoracoplasty became commonplace. Injections of large doses of Vitamin D proved a quicker and better treatment for skin lupus than the older local treatments. In 1950 a scheme was completed for the preventive inoculation with B.C.G. vaccine of the healthy contacts of known tuberculous persons. Prospects Tuberculosis in closely aggregated, long standing, urban industrial communities has become a chronic disabling infectious disease of widespread incidence and heavy though decreasing mortality. The new antibiotic and chemotherapeutic agents show prospects of reducing the infectivity of a proportion of advanced cases and of curing early or localised ones, while B.C.G. and other vaccines offer possibilities of increased immunity for the young susceptible members of the population. The post-war emphasis on "social medicine" has introduced clinicians to a renewed interest in the domestic, financial, psychological and industrial background of the tuberculous patient. Mass radiography and tuberculin surveys are new and useful weapons in epidemiological control. Bovine type tuberculosis has faded steadily in the last half century both in incidence and severity. Massive scrofulous glands of neck or abdomen, large patches of lupus, wards full of spinal cases fixed to frames, or of children with "hip disease," common at the beginning of the century, are rare conditions now. The newer pathology envisages the "primary lesion" as a small lung focus in childhood with gross intrathoracic glandular enlargement, usually healing and leaving a partial immunity by allergy which can subsequently break down to produce active phthisis under abnormal nutritional, psychological, traumatic or other injurious tissue influences. The hazards of exposure to infection once a primary lesion has appeared and healed are, by one current school of thought, no longer considered to have serious implication. In tuberculosis, as in other diseases, treatment of the individual makes greater appeal, on the short-term view, than does the application of preventive measures. It may be necessary to emphasise the paramount importance of never losing sight of the fact that tuberculosis is an infectious and preventable disease. It may well be that the second half of the century calls for a review of the "set-up" of tuberculosis control and a careful consideration of what further steps can be taken in an attempt to eradicate this great national scourge. This stocktaking may assist in focusing attention on what has been done and what still remains to be done. 90 TUBERCULOSIS TRENDS IN LONDON, 1900-1950 (ALL RATES ARE PER 1,000 TOTAL POPULATION) 91 County of London cases of tuberculosis on notification registers (a) Year Total population Pulmonary Non-Pulmonary Cases on Register Rate per 1,000 Cases on Register Rate per 1,000 1925 4,612,000 39,551 8.58 15,074 3.27 1926 4,615,400 40,205 8.71 15,762 3.42 1927 4,550,000 39,633 8.71 15,867 3.49 1928 4,469,000 33,117 7.41 13,623 3.05 1929 4,430,000 32,117 7.25 12,730 2.87 1930 4,399,000 31,008 7.05 11,879 2.70 1931 4,374,300 29,565 6.76 11,060 2.53 1932 4,357,800 28,399 6.52 10,596 2.43 1933 4,298,600 27,363 6.37 10,144 2.36 1934 4,230,200 27,094 6.40 9,862 2.33 1935 4,185,200 25,656 6.13 9,010 2.15 1936 4,141,100 24,696 5.96 8,248 1.99 1937 4,094,500 23,591 5.76 7,462 1.82 1938 4,062,800 23,201 5.71 6,890 1.70 1939 3,800,300 23,041 6.06 6,737 1.77 1940 3,236,600 22,356 6.91 6,536 2.02 1941 2,507,800 21,796 8.69 5,960 2.38 1942 2,634,800 22,335 8.48 5,748 2.18 1943 2,794,200 23,840 8.53 5,921 2.12 1944 2,753,600 25,330 9.20 6,051 2.20 1945 2,906,900 26,514 9.12 5,936 2.04 1946 3,272,500 27,957 8.54 5,920 1.81 1947 3,409,300 29,236 8.58 5,841 1.71 1948 3,397,900 30,773 9 .06 6,036 1.78 1949 3,389,850 32,426 9.57 5,767 1.70 1950 3,389,620 34,121 10.07 5,659 1.67 (a) From returns made under the Public Health (Tuberculosis) Regulations, 1924, by Medical Officers of Health of the Metropolitan Boroughs. The contribution of tuberculosis to mortality County of London tuberculosis deaths and deaths from other respiratory diseases (excluding cancer) as a percentage of deaths from all causes in the specified age group. Period Age group 0-14 15-44 45 + Tuberculosis Other respiratory Tuberculosis Other respiratory Tuberculosis Other respiratory 1901-05 8.7 19.8 34.4 10.8 7.9 22.2 1906-10 8.0 18.8 34.6 10.9 7.3 20.8 1911-15 8.1 20.3 34.9 11.2 6.8 20.6 1916-20 8.2 22.6 32.0 11.0 6.4 19.9 1921-25 5.8 23.1 34.7 10.3 5.0 19.3 1926-30 5.2 22.5 32.9 9.4 4.0 14.9 1931-35 4.5 20.1 31.6 8.7 3.6 11.3 1936-40 3.8 18.8 27.5 7.1 3.0 11.8 1941-45 4.8 16.6 28.3 6.6 3.3 14.5 1946-50 4.0 16.9 30.3 6.5 2.8 14.2 The figures show the persistent high toll of tuberculosis deaths during the adult working ages and the steady decline in the tuberculosis proportion of all deaths in the young and the "over 45's." Proportionate mortality from "other respiratory " causes shows a marked fall mainly in the older age groups. G 92 County of London—Age and Sex—Specific death and notification rates per 1,000 living, in selected years Year Males Females Persons all ages 0-1 1-4 5-14 15-44 45 + All males 0-1 1-4 5-14 15-44 45 + All females Pulmonary Tuberculosis—Deaths (per 1,000)— 1900 0.62 0.42 0.18 2.70 4.46 2.26 0.48 0.36 0.28 1.51 1.74 1.22 1.71 1910 0.67 0.33 0.13 1.90 3.01 1.62 0.56 0.34 0.20 1.02 1.29 0.87 1.22 1920 0.38 0.28 0.13 1.52 2.24 1.32 0.53 0.25 0.25 1.13 0.86 0.85 1.07 1930 0.27 0.08 0.06 1.23 1.94 1.14 0.18 0.08 0.11 0.96 0.51 0.65 0.87 1939 0.18 0.05 0.01 0.88 1.61 0.92 0.11 0.02 0.05 0.60 0.35 0.42 0.65 (a) 1950 0.15 0.03 0.01 0.34 0.99 0.51 — — 0.01 0.32 0.22 0.22 0.36 Pulmonary Tuberculosis—Primary notifications (per 1,000)— 1900 Not notifiable 1910 1920 0.32 0.40 1.15 3.35 2.68 2.48 0.33 0.43 1.14 2.26 1.08 1.63 2.02 1930 0.09 0.21 0.37 2.44 2.20 1.83 0.03 0.16 0.46 1.89 0.66 1.20 1.49 1939 0.14 0.30 0.27 1.84 1.72 1.48 0.26 0.32 0.32 1.41 0.39 0.87 1.15 1950 0.47 1.31 0.75 2.46 1.59 1.83 0.49 0.95 0.77 2.34 0.33 1.26 1.53 Non-Pulmonary Tuberculosis—Deaths (per 1,000)— 1900 6.19 2.60 0.48 0.15 0.18 0.60 4.83 2.22 0.39 0.11 0.11 0.44 0.52 1910 4.90 1.95 0.43 0.18 0.20 0.50 3.67 1.67 0.45 0.11 0.12 0.36 0.43 1920 1 .62 0.77 0.31 0.14 0.12 0.24 1.42 0.74 0.27 0.09 0.10 0.19 0.21 1930 0.68 0.42 0.14 0.10 0.08 0.13 0.52 0.45 0.15 0.08 0.05 0.11 0.12 1939 0.29 0.28 0.05 0.07 0.05 0.08 0.26 0.22 0.09 0.07 0.04 0.07 0.07 (a) 1950 0.04 0.04 0.03 0.04 0.04 0.04 0.15 0.06 0.04 0.02 0.04 0.03 0.04 Non-Pulmonary Tuberculosis—Primary notifications (per 1,000)— 1900 Not notifiable 1910 1920 0.98 1.41 1.46 0.33 0.13 0.59 0.79 1.00 119 0.28 0.10 0.44 0.51 1930 0.59 0.87 0.80 0.30 0.12 0.38 0.31 0.73 0.70 0.29 0.05 0.30 0.34 1939 0.18 0.50 0.37 0.21 0.09 0.21 011 0.38 0.36 0.21 0.05 0.18 0.20 1950 0.07 0.28 0.26 0.16 0 05 0.14 015 0.33 0.27 0.25 0.04 0.17 0.16 (a) These rates are slightly lower than those published by the Registrar-General because the 1938 estimates of the population by ago and sex have been used without any allowance for evacuation at the end of 1939; this is a more realistic method as the tuberculous were evacuated to a much less extent than healthy persons. 93 Tuberculosis (all forms)—Notifications and deaths in Metropolitan Boroughs, 1913-1950—Rates per 1,000 living. Borough 1913 1921 1931 1950 Population Notifications Deaths Notifications Deaths Notifications Deaths Notifications Deaths Population Division 1 No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate Chelsea ... 64,598 244 3.78 96 1.49 1.23 1.91 74 1.15 115 2.01 52 0.91 78 1.49 16 0.30 52,490 Fulham 157,117 1,131 7.20 258 1.64 561 3.52 190 1.19 353 2.33 170 1.12 228 1.85 42 0.34 123,400 Hammersmith 123,745 688 5.56 181 1.46 378 2.94 175 1.36 239 1.77 127 0.94 187 1.57 39 0.33 119,200 Kensington 171,284 982 5.73 241 1.41 492 2.77 187 1.05 245 1.40 148 0.85 278 1.57 59 0.33 177,400 Division 2 Hampstead 86,346 322 3.73 61 0.71 178 2.05 71 0.82 109 1.24 48 0.55 105 1.08 27 0.28 97,400 Paddington 142,210 750 5.27 185 1.30 325 2.23 126 0.87 300 2.14 138 0.98 279 2.14 55 0.42 130,600 St. Marylebone 114,532 646 5.64 197 1.72 275 2.61 123 1.17 162 1.73 92 0.98 88 1.12 21 0.27 78,260 St. Pancras 214,330 1,065 4.97 398 1.86 428 2.01 301 1.41 328 1.68 208 1.06 263 1.86 76 0.54 141,300 Westminster, City of 154,810 737 4.76 245 1.58 324 2.32 140 1.00 201 1.69 120 1.01 168 1.60 39 0.37 105,100 Division 3 Finsbury 84,679 595 7.03 229 2.70 279 3.64 133 1.73 162 2.31 94 1.34 76 2.12 14 0.39 35,810 Holborn 46,949 186 3.96 100 2.13 97 2.23 48 1.10 66 1.91 38 1.10 44 1.70 11 0.42 25,930 Islington 325,585 1,661 5.10 554 1.70 973 2.92 417 1.25 588 1.81 333 1.03 471 1.98 96 0.40 238,200 Division 4 Hackney 223,353 993 4.45 334 1.50 338 1.51 274 1.22 299 1.38 184 0.85 242 1.41 63 0.37 172,100 Shoreditch 109,654 893 8.14 254 2.32 397 3.77 177 1.68 200 2.04 106 1.08 69 1.54 20 0.45 44,800 Stoke Newington 50,518 184 3.64 62 1.23 59 1.12 50 0.95 87 1.69 59 1.15 67 1.38 15 0.31 48,510 Division 5 Bethnal Green 127,824 901 7.05 268 2.10 385 3.25 183 1.55 171 1.57 132 1.21 86 1.46 20 0.34 58,730 City of London 17,916 54 3.01 30 1.67 33 2.39 16 1.16 23 2.37 7 0.72 13 2.67 4 0.82 4,870 Poplar 160,913 1,383 8.59 314 1.95 738 4.50 221 1.35 308 1.97 170 1.09 82 1.11 32 0.43 74,050 Stepney 275,300 2,195 7.97 581 2.11 570 2.26 367 1.46 484 2.14 259 1.14 176 1.76 56 0.56 99,730 Division 6 Deptford 109,280 533 4.88 190 1.74 289 2.55 152 1.34 198 1.85 114 1.06 258 3.37 29 0.38 76,580 Greenwich 96,015 418 4.35 136 1.42 345 3.40 140 1.38 158 1.57 114 1.13 135 1.51 44 0.49 89,570 Woolwich 122,382 601 4.91 218 1.78 363 2.64 207 1.50 280 1.90 168 1.14 205 1.38 58 0.39 149,000 Division 7 Camberwell 261,805 1,833 7.00 376 1.44 791 2.93 366 1.36 414 1.64 268 1.06 325 1.82 64 0.36 178,900 Lewisham 168,822 463 2.74 181 1.07 265 1.51 172 0.98 359 1.63 176 0.80 406 1.78 72 0.32 228,300 Division 8 Bermondsey 124,739 881 7.06 278 2.23 550 4.56 185 1.54 215 1.91 130 1.16 115 1.92 28 0.47 59,810 Lambeth 297,139 2,045 6.88 491 1.65 802 2.62 362 1.18 561 1.90 287 0.97 431 1.87 100 0.43 231,000 Southwark 188,487 1,285 6.82 415 2.20 613 3.30 311 1.67 338 1.95 236 1.36 206 2.12 56 0.58 97,080 Division 9 Battersea 167,464 708 4.23 248 1.48 418 2.47 216 1.28 257 1.61 173 1.08 149 1 .27 45 0.38 117,700 Wandsworth 330,395 1,277 3.87 353 1.07 825 2.49 393 1.19 512 1.45 308 0.87 488 1.46 146 0.44 333,800 London County 4,518,191 25,654 5.68 7,474 1.65 12,214 2.71 5,777 1.28 7,732 1.77 4,459 1.02 5,718 1.69 1,347 0.40 3,389,620 94 Provision of care and treatment for the mentally ill MENTAL HEALTH SERVICES Lunacy and Mental Treatment Acts, 1890.1930 A staff of fifteen mental welfare officers and five assistants, under the supervision of a senior mental welfare officer, operating centrally from the County Hall, continued to carry out the work of taking initial steps to provide care and treatment for persons suffering from mental illness. The difficulties caused by the shortage of accommodation in observation wards, particularly for female patients, continued and many patients had to be admitted direct to mental hospitals from their own homes under sections 14 and 16 of the Lunacy Act, 1890, or on urgency orders under section 11 of that Act, instead of being admitted first to an observation ward as envisaged in the Council's scheme under section 51 of the National Health Service Act, 1946. The proposal to decentralise the work had to be further postponed, principally for manpower reasons as decentralisation would require additional staff. The following table shows the number of persons dealt with by the mental welfare officers during the year, together with the action taken:— 1950 1949 Male Female Total Number admitted to hospitals designated under section 20 of the Lunacy Act, 1890 (i.e. for observation) 2,377 2,917 5,294 5,326 Number dealt with in their homes etc. under sections 14 and 16 of the Lunacy Act, 1890 13 210 223* 16t Number admitted direct to mental hospitals under section 11 of the Lunacy Act, 1890 9 36 45 8 Number dealt with under section 24 of the Criminal Justice Act, 1948 3 — 3 — Number in which no action under the Lunacy Acts was found necessary 722 1,105 1,827 1,614 Total 1950 3,124 4,268 7,392 — Total 1949 2,977 3,987 — 6,964 * Of these 9 male and 110 female patients were certified and removed to mental hospitals. † Of these 6 male and 8 female patients were certified and removed to mental hospitals. The following table shows the ultimate disposal of the patients admitted to observation wards:— Male Female Total Certified and sent to mental hospitals 664 1,215 1,879 Admitted to mental hospitals as voluntary patients 469 544 1,013 Admitted to mental hospitals as "temporary "patients 12 23 35 Discharged to care of relatives (sec. 22) 19 37 56 No order made by Justice and discharged 15 12 27 Transferred to general wards 120 90 210 Transferred to Tooting Bec Hospital 210 253 463 Transferred to Mental After Care Association Homes 3 1 4 Died 143 112 255 Discharged by Medical Officer 641 516 1,157 Dealt with privately 6 11 17 Dealt with under Mental Deficiency Acts — 7 7 In ward on 31.12.50 75 96 171 Total 2,377 2,917 5,294 95 Recuperative holidays and long-term residential care During the year recuperative holidays of four to eight weeks duration were provided, mostly in Mental After Care Association homes, for 59 persons suffering from some form of mental illness. The number of persons receiving these holidays was unfortunately restricted owing to lack of accommodation, but it is hoped that this difficulty will be overcome. Responsibility for the maintenance, in homes of the Mental After Care Association, of mentally sick persons needing long-term residential care, but not requiring skilled nursing or medical treatment, was transferred from the Welfare Committee to the Health Committee. This was contemplated in the Council's scheme under section 51 of the National Health Service Act, 1946. The weekly charge made by the Mental After Care Association for maintenance in their homes was increased from 44s. 11d. to 54s. 10d. a head during the year. At the end of the year 55 persons were being boarded out under this arrangement. After care The Mental After Care Association and the National Association for Mental Health continued to provide a domiciliary after care service on the Council's behalf for persons living in London suffering from mental illness and requiring help and advice. The Council contributed 90 per cent, of the approved cost of this service. 260 new cases were visited, 145 by the National Association for Mental Health and 115 by the Mental After Care Association, making a total of 727 cases dealt with since the scheme was started in 1949. The Council continued to contribute 90 per cent. of the approved cost of six psychotherapeutic social clubs and a rehabilitation centre run by the Institute of Social Psychiatry for various types of patient needing social readjustment. In December, 1950, the Council agreed to make a payment of £200 to the National Association for Mental Health in consideration of the services of the Association in the field of mental health from which the Council, in common with other local health authorities, has benefited, but in respect of which the Association receives no direct reimbursement of the cost involved. Prior to the operation of the National Health Service Act, 1946, a contribution was made by the Council to the Association by deduction from the Exchequer grant under the Local Government Act, 1929, in respect of such services and its cessation resulted in the Association being unable to cover all the costs of its services and activities. Medical adviser Dr. A. A. W. Petrie, C.B.E., acted as medical adviser on mental health to the Council throughout the year on a part-time basis. 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 Source of information 1949 1950 Totals from 1st April, 1914, to 31st Dec., 1950 Supervision section 8 12 1,553 Local education authority 357 439 14,530 Police authority (section 8) 28 39 1,910 Transfers from prison (section 9) 1 1 229 Transfers from approved schools (section 9) 5 2 563' From hospitals and institutions 111 89 287 Miscellaneous 168 157 10,113 Total 678 739 29,185 96 Position as at 31st December, 1950, with regard to the cases referred to in the last column of the preceding table:— Detained in institutions 7,767* Discharged from institutional care 2,738 Removed to mental hospitals under the Lunacy Acts 522 Ascertained not subject for action 9,403 Died 4,380 Total removed from active list — 24,810 Under guardianship 229 In places of safety awaiting the presentation of a petition for an order 5 Under supervision 4,092 † In institutions awaiting the presentation of a petition for an order 45 Still under consideration 4 Total remaining on active list 4,375‡ Total 29,185 Summary of cases dealt with during 1950:— Placed in institutions 330 Placed under guardianship 9 Placed in places of safety pending the presentation of a a petition 37 Placed under supervision 591 Discharged from institutional care or guardianship 192 Removed to a mental hospital under the Lunacy Acts 19 Ascertained not subject for action 360 Died 128 Total 1,666 * This figure includes 366 cases on licence who are visited at regular intervals by the officers of the Council on behalf of the Regional Hospital Boards. † In addition to the 4,092 under supervision, 968 persons known to the local authority to be mentally deficient but not subject to be dealt with are visited on a voluntary basis. ‡ Of these 139 were awaiting the provision of institutional care. Employment service On 1st April, 1950, the Education Committee undertook, through its Youth Employment Service responsibility (formerly undertaken by the Health Committee as the paid agent of the Ministry of Labour and National Service) for the placing in employment of mentally defective children leaving schools for the educationally sub-normal. Students Facilities were given during the year for students taking courses of training in social science and in occupation centre work to spend short periods in the district offices of the Council's supervision section and in the occupation centres as part of their practical training. Accommodation in institutions The shortage of beds available in institutions for the mentally defective continued throughout the year. The position remained most serious in respect of infants and young children of the type suitable for admission to the Fountain Hospital, the majority of whom are of low mental grade and in addition are suffering from some physical disability. Many of them are living in inadequate and unsuitable 97 tion and others are in acute hospitals, nurseries or similar establishments where they are occupying beds urgently needed for the admission of children of the type for whom the accommodation was intended. Of the 139 patients awaiting admission on 31st December, 1950, 103 were children awaiting admission to the Fountain Hospital and 45 of them were regarded as being cases of outstanding urgency. In an attempt to provide more vacancies at the Fountain Hospital, the South West Metropolitan Regional Hospital Board in July decided that no patients from the other three metropolitan hospital regions would in future be admitted unless the regional hospital board concerned arranged for the transfer from the Fountain Hospital of an older patient to another hospital. The immediate effect of this decision has been to expedite admissions from the South West Metropolitan Region, in some cases out of proportion to their apparent urgency, and to slow up admissions from the other three regions. It is hoped, however, that when the initial difficulties have been overcome admissions will again be at a uniform rate from all four regions. Some relief during the year was provided by the admission of seven children from the Fountain Hospital waiting list to approved homes with which the South West Metropolitan Regional Hospital Board have contractual arrangements. Three patients were admitted to the care of nominees of the Guardianship Society, Brighton, pending the provision of suitable vacancies for them in the Fountain Hospital. In addition, during the year 14 patients awaiting admission to that hospital were admitted to the holiday home (Lynsted) at Walmer, Kent, administered by the National Association for Mental Health, for periods not exceeding six weeks, to relieve parents during domestic emergencies. In each of the cases sent to Lynsted and placed by the Guardianship Society, admission was under section 15 of the Mental Deficiency Act, 1913, as to a place of safety, and the cost of maintenance was defrayed by the appropriate metropolitan regional hospital board. Provision of medical certificates The Council agreed to provide free of charge, medical certificates required to secure the admission to mental deficiency institutions of private patients residing in the County of London. Guardianshi p Patients under guardianship in London were visited by the Council's officers at least once a quarter, every third quarterly visit being made by one of the Council's medical staff. Each London patient placed under guardianship through the agency of the Guardianship Society, Brighton, was visited at least once during the year by an inspector of the Public Health Department in addition to the visits made by the Society's officers. Generally the conditions of guardianship were found to be satisfactory, but in a few cases a change of guardian was thought to be in the patient's interest and this was arranged. A marked feature of the care of patients under guardianship was the rise in maintenance costs, and, where necessary, the amount paid to the guardian was increased. During the year holidays for patients under guardianship were provided where it was considered desirable on medical grounds. An allowance of 10s. a head was granted, where necessary, to patients under the guardianship of the Council's inspectors for the provision of extra fare at Christmas. Occupation centres Two additional occupation centres (one in Greenwich for children and another in Hackney for elder boys) were opened during the year, bringing the total to eighteen, the number approved by the Minister of Health. The accommodation now provided is considered adequate to meet the present needs of the County. The following is a list 98 of the occupation centres for mentally deficient persons under guardianship, supervision or on licence from institutions Address No. on roll (Dec. 1950) Average daily attendance (Dec. 1950) Address No. on roll (Dec. 1950) Average daily attendance (Dec. 1950) Centres for children Branstone St., 56 49 Centres for elder girls Fellowship Hall, 28 22 N. Kensington, W.10 (also takes elder girls) 182, Hammersmith Rd., W.6 Old Gravel Pit Hall, 26 21 Cecil Rooms Woolwich Road, S.E.10 29 22 Valette St., E.9 St. Chrysostom's Hall, 37 32 Christ Church Hall, Mowell St. S.W.9 26 19 Goldsmith Rd., S.E.15 Claremont Central Mission, White Lion St., N.l. 44 32 Centres for elder boys All Saint's Hall, 40 30 Lewisham Methodist Hall, Albion St., S.E.13 24 19 Blenheim Grove, S.E.15 19, Compton Terrace, N.l 25 17 London Mission Methodist Hall, Shepherds Bush Rd., W.6 25 19 Dalston Congregational Hall, Bay St., E.8 31 26 Orchard Mission, Mission Place, S.E.15 25 19 St. Michael's Hall, Darley Rd., S.VV.ll 32 25 (replacing Metropolitan Tabernacle) Total 553 439 Oxford House, Mape St., E.2 25 21 St. Margaret's House, 19, Old Ford Rd., E.2 18 16 St. Peter's Hall, Clapham Manor St., S.W.4 34 29 Unity Hall, 56, East India Dock Rd., E.14 28 21 The Council decided to erect a building in the playground of Branstone Street Occupation Centre, which accommodates children and a small number of elder girls, to provide accommodation for about 10 to 15 elder boys living in N.W. London for whom there are no suitable facilities at present. Outings and holidays As the centres are with one exception (Branstone Street), conducted in hired premises (mainly church halls) with little or no outdoor recreation space, those attending were taken by school bus to nearby parks or open spaces approximately once a fortnight during the summer months when the weather proved suitable. During the year four parties (one of children only, two of children and elder girls and one of elder boys—93 in all) spent a week's holiday at seaside holiday homes belonging to the National Association for Mental Health. The expenses of 15 necessitous children were paid wholly or partly by the Council. 145 children and young persons were also taken for a day's outing. Rules were drawn up for the guidance of staff conducting day outings for parties from the centres with a view to safeguarding the patients against the risk of accident. Christmas parties Refresher courses for staff Christmas parties and entertainments were arranged for all centres during December. The fees and expenses of six of the supervisory staff who attended a residential refresher course in occupation centre work conducted by the National Association for Mental Health were borne by the Council, as were the fees of 12 staff who attended a similar non-residential course conducted by the same body. During the first three days of the summer holiday a refresher course for the Council's occupation centre supervisory staff was conducted by the Organiser of Occupation Centres, at the Branstone Street Centre. Lectures were given by medical 99 and lay staff of the department and by others on a number of subjects. 12 persons from the staff of other authorities in the home counties attended the course. Open days Parents and friends were invited to displays of work and sales of articles made at the centres. Sales realised £40.2.6 at junior centres, £170.10.3 at elder boys' centres and £75.1.2 at elder girls' centres. At the elder boys' centres some apparatus and toys for junior centres were also made. Conveyances for children The release of vehicles from the education service for the conveyance of children to the Branstone Street centre, for which the authority was given during the previous year, has not yet become possible. Payment of fares The Council agreed to pay the fares of pupils attending the centres under the same conditions as apply to children attending special schools for the educationally subnormal, viz. if they are over twelve years of age and have to travel two miles or one and a half miles if under that age, or for shorter journeys if a certificate is given by one of the Council's medical officers that conveyance is necessary on medical grounds. Parents' Associations Permission was given for the parents of pupils attending the centres to use a room at the centres, free of charge, for the holding of parents' meetings, on the understanding that, except in the case of Branstone Street Centre, (which is situated on Council premises and where meetings may be held after Centre hours,) the meetings are restricted to one a term at each centre and take place during the last period of centre hours in the afternoon, and provided that no charge is made for the admission of any person to the meeting. Provision of cod liver oil and malt The Council agreed to provide, free of charge, cod liver oil and malt (or halibut oil) to children under the age of sixteen years attending the centres, when recommended bv a medical officer of the Council. Establishment of staff The fixed establishment of staff at occupation centres was determined on the following basis:— (i) 1 supervisor for each centre and 1 assistant supervisor for each 15, or substantial part of 15, pupils on roll (except the first 15). (ii) Women attendants at the discretion of the medical officer of health, provided that at no centre shall the ratio of the total number of staff (i.e. supervisors and attendants) to pupils exceed 1 to 10, except at St. Margarets' House Centre for junior mixed children where, since the accommodation is for 20 children only, an attendant may be employed in excess of this ratio. (iii) Two boot repairing and two woodwork instructors for duty at the four elder boys' centres. SCHOOL HEALTH SERVICE Organisation The school health service for the County of London (117 square miles—approximate school population 380,000) continued with other health services to be organised in nine divisions each with a divisional office and each division being in charge of a Divisional Medical Officer assisted by a Divisional Administrative Officer, a Divisional Nursing Officer and a Divisional Treatment Organiser. The arrangements for the medical inspection and treatment of school children continued as before and special examinations were held with a view to placing handicapped children in schools catering for their special needs. At County Hall there are Senior Medical Officers, one giving his whole time to the school health service, a Chief Nursing Officer, a Principal Treatment Organiser, and a Chief Dental Surgeon. They are advisory and supervisory and deal with questions of policy. There are also consultants who advise the School Medical Officer on ophthalmology, ear, nose and throat conditions, orthopaedics, child psychiatry and juvenile rheumatism. Apart from the School Medical Officer and his deputy there is also a Principal Medical Officer whose responsibilities cover both the school health and the maternity and child welfare services. 100 The School Care Committees established in 1907 continued to play their valuable part. The Council relied on this large voluntary organisation (to which a new constitution was given this year) to follow up the medical recommendations and was justified in the results, treatment being obtained in 92 per cent. of cases. Over 90 per cent. of the medical inspections were attended by care committee workers. The number of voluntary workers had risen steadily after the war years and this year rose from 1,600 to over 2,000. The social work in connection with the treatment centres continued to be carried out by the children's care organisation and enabled the care committees to do their valuable and constructive case work, which brought them into close contact with the families needing their help and guidance. Pupils on school rolls At the end of 1950 there were 283,878 children of primary and secondary school age in county schools and 97,007 children in voluntary or associated schools making a total of 380,885 pupils. Medical Inspections The following table summarises the medical inspections made during the year compared with the three previous years :■— Routine (detailed) Inspections 1947 1948 1949 1950 No. % No. % No. % No. % Nursery 7,074 4.9 8,953 5.7 10,021 6.2 11,294 6.5 Entrants 33,439 23.3 37,793 23.8 40,287 24.8 41,598 24.1 7 years old 26,046 18.2 26,222 16.5 29,541 18.2 32,607 18.9 11 years old 28,556 19.9 32,961 20.8 31,725 19.6 33,037 19.2 Leavers 6.433(a) 4.5 26,817 16.9 26,382 16.3 27,464 15.9 Other ages 40,516 28.2 23,558 14.9 22,115 13.6 23,742 13.8 Special schools 1,203 0.8 1,581 1.0 1,633 1.0 2,143 1.3 Training colleges 268 0.2 648 0.4 465 0.3 543 0.3 Total 143,535 1000 158,533 1000 162,169 1000 172,428 100 0 Other Inspections Special inspections† 101,707 — 107,844 — 110,026 — 119,901 Re-inspections 84,227 — 88,243 — 87,915 — 106,350 — Residential schools (b) — 7,920 — 9,845 — 10,441 — Total 185,934 — 204,007 — 207,786 — 236,692 — Grand Total 329.469 — 362,540 — 369,955 — 409,120 — (a) School leaving age raised. (b) Not recorded prior to 1948. tThese 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. The volume of work carried out by the school health service on medical inspections in 1950 showed an increase on the other post-war years. Comparison of routine and other inspections with the school populations for these years is shown below. Although duplication between routine and special examinations and re-inspections of children 101 subjected to routine inspections earlier in the year is common, the element of duplication is constant and comparisons from year to year are valid. The percentages show a rising trend:—: 1947 1948 1949 1950 School population 353,000 373,000 373,000 380,885 Routine inspections 143,535 158,533 162,169 172,428 Percentages 40.7 42.5 42.7 45.3 Other inspections 185,934 204,007 207,786 236,692 Percentages 52.7 54.7 55.7 62.1 The percentages of children seen at routine inspections, who were referred for treatment (other than for infestation or teeth) compared with the preceding years were:— Pupils referred for treatment at routine examinations Age Group and sex 1947 1948 1949 1950 Nursery Boys 16.1 16.2 16.5 15.1 Girls 14.8 14.4 14.5 13.0 Entrants Boys 18.0 191 18.7 17.8 Girls 15.6 16.5 17.2 16.5 7 years old Boys 19.4 21.8 21.6 20.4 Girls 21.2 21.2 20.6 19.7 11 years old Boys 18.5 19.0 18.8 17.5 Girls 20.1 21.4 20.4 18.8 Leavers Boys 14.0 14.8 14.4 13.6 Girls 16.6 20.3 18.9 16.0 Other ages Boys 17.6 19.6 18.0 17.1 Girls 22.4 23.3 23.6 21.5 Total Boys and Girls* 18.7 19.3 18.9 17.6 * Excluding special schools and training colleges. Despite rising standards the 1950 rates show reductions in every age group. 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 1947, 1948 and 1949:— Defects found on medical inspection to require treatment or observation 1947 1948 1949 1950 •Numbers examined 142,064 156,304 160,071 169,742 Percentages Skin diseases 1.20 1.22 1.22 0.97 External eye diseases 0.67 0.61 0.58 0.57 Defective hearing 0.32 0.39 0.41 0.44 Otitis media 0.47 0.70 0.75 0.69 Enlarged tonsils and adenoids 7.61 8.16 8.91 8.98 Defective speech 0.43 0.53 0.62 0.60 Enlarged cervical glands 0.99 10.1 1 33 1 38 Heart and circulation 0.62 0.73 0.68 0.69 Lung disease (not T.B.) 1.32 1.30 1.44 1.62 Orthopaedic defects 4.02 4.67 4.66 4.84 Defects of nervous system 0.33 0.30 0.34 0.33 Psychological defects 0.42 0.72 0.75 0.70 Anaemia 0.31 0.29 0.31 0.36 *Excluding special schools and training colleges. Comparing 1950 with 1949 the decrease in skin diseases was most marked in entrant girls, 11 year old and leaver boys ; for psychological defects the decrease was mainly in the entrant age groups ; reduced incidence of otitis media was seen in the 102 older age groups ; increased incidence in the younger age groups accounted in the main for increases in the figures for lung disease (not tuberculous), orthopaedic defects and anaemia. Nutrition The classification of general condition as found at routine medical inspections was:— 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 1950 46.3 50.9 2.8 The percentages of children referred for treatment or observation on account of nutrition were :— 1947 1948 1949 1950 % % % % Referred for (1) Treatment 1.1 1.0 1.0 1.0 (2) Observation 0.5 0.5 0.7 0.7 Total 1.6 1.5 1.7 1.7 These figures show a fairly stable fraction. An analysis of height and weight measurements made during the year showed no significant deviations from those of the 1949 survey, (Council publication No. 3692/1950) which revealed substantial improvement on pre-war figures, and was summarised in the 1949 Annual Report. Cleanliness Percentages of children found to have vermin in the hair at routine inspections during 1950, with corresponding figures for 1947, 1948 and 1949, follow :— Routine Medical inspections—Percentage with Verminous Heads 1947 1948 1949 1950 Entrants Boys 0.7 0.3 0.2 0.2 Girls 1.5 0.7 0.4 0.2 7 years old Boys 0.9 0.4 0.3 0.1 Girls 2.1 1.2 0.4 0.3 11 years old Boys 0.9 0.4 0.2 0.2 Girls 2.3 1.0 0.7 0.4 All ages Boys 0.7 0.3 0.2 0.1 Girls 1.8 0.9 0.5 0.3 The improvement noted in 1949 was maintained in 1950. Naturally, the personal hygiene of pupils is shown at its best at routine inspections as parents are 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 medical inspections :— Routine personal hygiene inspections by nurses Total number of inspections Number found to be verminous Percentage found to be verminous 1947 1948 1949 1950 Infants 480,925 13,121 4.7 3.9 3.4 2.7 Boys (aged 7 yrs. and over) 446,680 7,740 2.5 21 1.9 1.7 Girls (aged 7 yrs. and over) 501,178 25,151 7.5 6.4 6.1 5.0 Total 1,428,783 46,012 4.9 4.2 3.8 3.2 103 As in former years many pupils were found to be verminous at more than one inspection. The number of individual verminous children found during the year was 22,159 (26,063 in 1949, 29,970 in 1948 and 37,978 in 1947). The number of "advice" cards issued during the year compared with 1949 was 29,305 (32,422). The number of children who attended cleansing centres after the issue of advice cards was 20,269 (22,032); the number of statutory notices served was 4,759 (5,133); 1,405 (1,564) of the children concerned attended voluntarily and 2,567 (3,182) were cleansed compulsorily. Of the 4,759 statutory notices served, 4,437 were issued under the powers conferred by sec. 126 of the Public Health (London) Act, 1936, and 322 under sec. 54 of the Education Act, 1944. The former Act is used in respect of children of compulsory school age as the procedure is more expeditious than that of the 1944 Act. The latter Act is only used in respect of pupils above compulsory school age. Only 6 of 169,742 pupils inspected at routine medical examinations had body vermin. Vaccination The upward trend in the proportion of pupils vaccinated against smallpox noted in the past three years continued with a rise from 54.9 per cent. in 1949 to 56.5 per cent. in 1950. Diphtheria immunisation For diphtheria immunisation the percentages of pupils stated to have been immunised followed closely those of 1949 ; the figure for 1950 was 85.9 per cent. compared with 84.4 per cent. in 1949, 83.1 per cent. in 1948 and 82.7 per cent in 1947. The former borough records were incomplete owing to children in older age groups having been immunised whilst evacuees and because general practitioners had not until recently 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 leads to the conclusion that the true figure is at least 77 per cent. Dental standard The percentages of pupils in the different age groups (disregarding the nursery group) found at routine medical inspections to have defective teeth are given below. Whilst these figures are not as reliable an index as the more exacting inspections of the school dental surgeons they may be used for comparative purposes :— Routine Medical Inspections—percentages with defective teeth 1947 1948 1949 1950 Entrants 28.9 27.6 26.7 27.3 7 years old 27.2 26.3 25.6 26.3 11 years old 17.5 16.7 16.3 18.5 Leavers 11.9 12.7 12.8 11.3 Other ages 17.7 17.4 17.6 17.4 It will be seen that the downward trend of earlier years has been reversed. A more detailed commentary will be found in the report of the Chief Dental Surgeon (page 119). The next table contains statistics of the standard of visual acuity of pupils whose Vision sight was tested at routine inspections. Routine Medical Inspection—Visual acuity—Percentage with normal vision 6/6 (With glasses if worn) 1947 1948 1949 1950 °/ /o °/ /o °/ /o °/ /o 7 years old Boys 80.0 79.2 78.2 78.3 Girls 77.4 78.2 76.5 76.3 11 years old Boys 80.7 81.7 80.1 80.9 Girls 76.7 78.1 76.9 77.9 Leavers Boys 80.7 80.9 79.7 80.1 Girls 77.3 76.7 76 0 76.5 Other ages Boys 80.8 81.2 77.4 78.8 Girls 76.8 76.4 73.4 75.2 104 A further table shows the percentages of cases of visual defect referred for treatment. 1947 % 1948 % 1949 % Already wearing spectacles 1950 Percentage Not wearing spectacles Total 7 years old Boys 6.0 7.4 6.8 0.7 6.5 7.2 Girls 7.9 7.4 7.6 0.8 6.7 7.5 11 years old Boys 9.1 8.9 9.3 1.9 6.5 8.4 Girls 10.9 111 10.4 2.2 7.8 10.0 Leavers Boys 9.1 9.5 9.3 2.6 6.6 9.2 Girls 10.6 12.2 12.4 3.3 7.5 10.8 Other ages Boys 9.2 9.8 9.3 2.1 6.4 8.5 Girls 11.5 12.0 12.0 3.0 7.8 10.8 As can be seen a proportion of those referred for treatment of defective vision were wearing spectacles already. This proportion rose from one-tenth at age 7 to about one-third at age 15. The higher total percentages of children referred for treatment at older ages is thus almost wholly due to children needing adjustment of their lenses with the passage of time. The two tables above show that, in 1950, the incidence of defective vision and the percentage of pupils referred for treatment of defective vision remained fairly stable compared with the preceding years. In accordance with experience over many years the incidence of defective vision was greater among girls than boys. Squint was most prevalent in the entrant group falling to an insignificant level in the leaver group. The overall figure for pupils referred for treatment of squint was 0.9 per cent, compared with 1.1 in 1949 and 1.0 in 1948 and 1947. Co-operation of parents and care committee The percentage attendance of parents at routine inspections showed that their co-operation, especially for the earlier age groups, was quite good. The average attendance of parents at all routine medical inspections was 65 per cent., varying from 92 per cent. in the entrants group and 84 per cent. in the 7 year old group to only 19 per cent. in the leavers group. The attendance of members of the Children's Care Organisation was around 92 per cent. in the schools which they attend ; this does not include the grammar and technical schools. Choice of employment Compared with 1949, the number of both sexes together advised against particular forms of employment showed a reduction from 15.8 per cent. to 15.3 per cent. Work involving eye strain followed by work involving strenuous physical exertion, headed for both sexes the list of contra-indications. Exposure to bad weather in the case of girls, and prolonged standing, much walking or quick movement from place to place for both sexes were next in order of magnitude. The introduction of the extended list of contra-indications to conform with the Ministry of Labour Disabled Persons certificate led to no increase in the level of contra-indications or individuals concerned. Details are given in Table 17 (page 149). Following-up and reinspection The following-up at their homes of children referred by the school doctors for observation or treatment, which is an essential part of the school health service, is carried out by members of the children's care organisation. Each referred child is re-inspected in school by the school doctor a few months after medical inspection, to allow time for treatment to be carried out, and further medical re-inspections are made if necessary, to ensure that as far as possible every child gets adequate treatment. 105 During the year 106,350 re-inspections were made. The number of defects for which children were re-inspected were :—• Medical re-inspections No. of medical defects No. of dental defects Total defects First re-inspections 25,763 23,831 49,594 Second and subsequent re-inspections 27,457 16,975 44,432 Total 53,220 40,806 94,026 Treatment was obtained or commenced as follows:— 1947 1948 1949 1950 Excluding dental defects 90.5 89.4 90.2 90.3 Including dental defects 87.1 87.0 87.3 87.5 Medical Treatment Treatment centres At the end of 1950 there were 94 school treatment centres; 60 of them were directly run by the Council and 34 by voluntary school treatment centre committees. Some provide only one type of clinic, others several. The defects treated and the number of clinics available for the treatment of each defect are shown in the following table:— No. of Clinics Defect L.C.C. Voluntary Total Minor ailments 50 29 79 Dental 34 16 50 Vision 24 16 40 Orthoptic 6 1 7 Ear, nose and throat 8 5 13 Speech therapy 15 3 18 Enuresis 3 - 3 Nutrition 22 6 28 Rheumatism (supervisory) 10 5 15 Special sessions at hospitals In addition 27 hospitals continued to provide special sessions for the medical and dental treatment of school children. At these hospitals treatment organisers attended at the following special sessions to which children were referred by the school health service and were greatly helped in their work by the co-operation of the almoner's department and nursing and administrative staff. Belgrave Hospital for Children Aural Bermondsey Medical Mission Minor ailments Children's Hospital, Sydenham Eyes, aural and nutrition Eastern Hospital Aural Evelina Hospital Eyes Guy's Hospital Eyes, aural, skin and orthopaedic Hampstead General Hospital Rheumatism King's College Hospital Eyes and rheumatism London Hospital Eyes Moorfields, Westminster and Central Eye (1) City Road—Eyes and orthoptic Hospital (2) High Holborn—Eyes and orthoptic Paddington Hospital Aural Princess Louise Hospital Aural and rheumatism Queen Elizabeth Hospital, Hackney Eyes, aural and rheumatism „ „ „ Shadwell Rheumatism, eyes and enuresis Royal Eye Hospital Eyes Royal Free Hospital Rheumatism Royal National Throat, Nose and Ear Hospital Aural 106 St. George's Hospital Rheumatism St. George's in the East Hospital Aural St. Mary's Hospital Eyes and aural St. Mary Abbott's Hospital Aural St. Marylebone General Dispensary Rheumatism St. Thomas' Hospital Rheumatism University College Hospital Enuresis Western Ophthalmic Hospital Eyes Westminster (All Saints Genito-Urinary) Enuresis Co-operation with hospitals Arrangements were continued with some of the former voluntary hospitals whereby one or more of the Council's treatment organisers attended 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 were 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. There were in addition several hospitals where the treatment organiser undertook the making of appointments for the dental and tonsil and adenoid departments although she was not present at the sessions. She also did the following-up of school children in co-operation with the almoner. In addition, the Council referred children for child guidance to twenty-two hospitals and clinics within the national health service ; but Council organisers did not attend these clinics. As an example, the following table indicates the scope of the work of the organisers, who acted as the link between Guy's hospital children's out-patient department, the special clinics, the school health service doctors and the child care organisation. In not a single instance did the child cease to attend before the completion of the case. Summary of work of Child Care organisers attached to Guy's Hospital in the year 1950 Children's Dept. Ear, nose and throat Eyes Orthopaedic Skin General Orthoptic New school children seen 368 530 289 65 180 189 Attendances of current cases 1,266 945 — 826 306 501 Discharged—treatment completed 170 227 105 16 88 27 Referred to other departments 74 — — — 34 — Lapsed through non-attendance — — — — — Referred for operation — 258 — — 31 — Glasses ordered — — 274 — — — Glasses obtained — — 327* — — — No glasses needed — — 162 — — — Re-tested—no change of glasses — — 224 — — — Referred to Child Guidance Clinic 32 — — — — — * Includes spectacles ordered in 1949 the delivery of which was delayed until 1950. The total number of attendances of L.C.C. children in departments covered by the organisers was 6,684. Similar arrangements operated at the Evelina Hospital for Children, in the same hospital group, where the total number of attendances in departments covered by the organisers was 1,382. Treatment statistics The following statistics of school treatment centres and the clinics held in hospitals in association with the Council's treatment scheme show that there was a continued increase in the volume of work in 1950, except at dental centres and rheumatism 107 supervisory centres. The reasons for the decline in the amount of dental work in 1950 are set forth in the report of the Chief Dental Surgeon (page 119), while the rheumatism scheme is treated in some detail on page 121. Type of centre 1948 1949 1950 Vision and orthoptic New Cases 31,377 32,292 33,404 Attendances 77,517 79,777 98,109 Ear, nose and throat New Cases 4,972 5,843 6,974 Attendances 11,922 14,815 15,138 Minor ailments New Cases 170,181 171,731 163,658 Attendances 1,052,081 1,002,051 1,014,155 Dental New Cases 118,439 102,495 82,650 Attendances 236,175 203,523 166,874 Rheumatism New Cases 1,468 1,375 1,224 Attendances 10,505 10,887 10,088 Enuresis New Cases 86 830 911 Attendances 441 3,977 5,110 Nutrition New Cases 1,178 1,222 1,350 Attendances 8,452 9,420 10,067 Scabies, Impetigo and Ringworm The number of individuals treated for scabies etc. in 1950 was 916, compared with 2,173 in 1949. Although the number of verminous individuals (19,401) treated at bathing centres was much smaller than in 1949 (34,700) the number of treatments needed did not decrease in the same proportion. This illustrates the fact that, as might be expected, progress is easier among those who are not being constantly reinfected in verminous homes while the volume of attendance is maintained by the " hard core " cases. Children treated for impetigo at minor ailment and bathing centres numbered 2,607 against 2,954 in 1949. The incidence of scalp ringworm has almost been eliminated ; it fell to a new low level of 27 cases compared with 77 in 1949. Vision Spectacles for school children prescribed at school treatment centres continued to be supplied under the supplementary ophthalmic service, pending the development of the hospital eye service. The arrangements provided for the continuance of eye sessions at the Council's school treatment centres. By agreement with the Ophthalmic Services Committee of the London Executive Council the attendance at each session of an optician for the convenience of parents was continued, but it was made clear to them that they had freedom of choice of optician for the child. The vast majority of the parents, however, availed themselves of the services of the optician attending the centre. There was a gradual improvement during the year in the delivery time for spectacles, and at the end of the year there was no undue delay except for those requiring high power lenses. 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. The number of new cases attending the clinic rose to a rate of over 500 a year and the total attendances to a rate of over 3,000 a year. The analysis of results obtained is shown below :— Group A.—542 children who attended the clinic for periods of 2 months and over:— Per cent. Average of dry beds on admission 9 Average of dry beds after treatment 56 Average improvement in group 47 Complete cures, discharged 16 H 108 Group B.—306 children who attended for periods of under 2 months:— Per cent. Average of dry beds on admission 8 Average of dry beds after treatment 37 Average improvement in group 29 Complete cures, discharged 4½ Boys formed 63 per cent. of the total of 848 cases analysed in the two groups. At the clinics established by the Council at the Clapham Park, Tooting, and Wandsworth School Treatment Centres, 269 pupils attended regularly during the year; of these 70 (26 per cent.) were cured, 154 (57 per cent.) improved and 45 (17 per cent.) did not respond to treatment. Many of the children 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 for 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. Towards the end of the year additional clinics were opened at Queenstown and Streatham School Treatment Centres and at the University College Hospital. Enlarged tonsils and adenoids Negotiations were resumed with the four metropolitan regional hospital boards for the purpose of setting up special units in hospitals to deal with the long waiting lists of children referred for operative treatment for enlarged tonsils and adenoids. During the year four units were opened (one in each of the metropolitan regional hospital boards areas). At the beginning of September the two units which were then open were suspended owing to the incidence of poliomyelitis. At the end of the year two units were functioning. The numbers dealt with in this way were:— By operation 992 Operative treatment not advised 670 Total 1662 Medical treatment was recommended for 316 children. Artificial limbs and surgical appliances Artificial limbs were supplied free and were made and fitted at Queen Mary's Hospital, Roehampton, to which children were admitted, if necessary, for training in the use of the limb. Because recent changes had sometimes caused delay in the repair of surgical appliances, arrangements were made with the Governors of the Royal National Orthopaedic Hospital to repair at short notice the surgical appliances (except artificial limbs) of children in London schools for the physically handicapped who had difficulty in getting repairs. Specialist clinics Negotiations were entered into with the four metropolitan regional hospital boards for the transfer of responsibility, under the provisions of the National Health Service Act, 1946, for specialist clinics provided up to now by the Council under the Education Act, 1944 (i.e., refraction, orthoptic, ear, nose and throat, rheumatism, and enuresis). Travelling expenses of pupils, etc. An extension was authorised of the scheme for the payment of travelling expenses of pupils and their parents or escorts when attending 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), to include attendances at out-patient departments of hospitals in London. Recuperative holidays abroad Through the courtesy of the International Help for Children, twenty-four London children, aged 8-13 years, suffering from asthma, were selected and sent in the summer to La Bourboule, France, for a six weeks' recuperative holiday. Later in the year twelve London children, aged 8-14 years, also suffering from 109 asthma, were selected and sent to Malix, Switzerland, for a six months' stay, through the generosity of the Swiss Mountain Cure Aid for British Children. Special investigations A new vitamin, B.12, was recently used in the United States of America and found to be of value to debilitated children. Sufficient of this vitamin was made available to the Council for a trial at some of the residential open-air schools. The results were not conclusive, and a further investigation of its value will be made in dav open-air schools in 1951. Follow-up by school health service 01 children discharged from hospital Arrangements for the transmission of information on the discharge of child in-patients from the former Council hospitals were continued. Special arrangements are being made with the Hospital for Sick Children for the transmission to the divisional medical officers of copies of the discharge summaries which are also sent to the family doctor responsible for the patient; and co-operation has been secured with certain other hospitals for the trial use of a new "follow-up" card, devised and first used in the county borough of West Ham. Discharge reports from hospitals are of value to the Council's staff who consider whether any special action is needed by the Council, e.g., special visits, home nursing, recuperative holidays, special education, and advice concerning employment. Co-operation with family doctor The school health service is fully aware of the importance of team work with the family doctor as well as with the hospitals in the care of the school child. Arrangements are made at the school medical inspections and at school treatment centres for the family doctor to be informed of any defect deemed to require hospital investigation or treatment and he is given the opportunity of arranging this himself if he prefers to do so. There are, also, many direct references of children by the school doctor to the family doctor. Speech therapy At the end of 1950 there were 19 speech-therapy centres for children attending ordinary schools, 1 experimental clinic for children attending E.S.N, schools, and a clinic at Banstead Residential School; this will be expanded in the coming year. The staff consisted of one senior speech therapist, one whole-time and four part-time speech therapists, all under the supervision of a senior assistant medical officer. The children attended the centres once or twice a week and the average number treated at each session was 16. The number of children attending the centres for the first time during the year was 194, and the total number of pupils in attendance was 864 ; 148 children were discharged as cured, and 54, most of whom were improved, left for various reasons. The remainder were still under treatment at the end of the year. Classes for foot defects Special classes to correct foot defects, before they develop into permanent disabilities, were started in 1948 in 78 schools. These classes were under the supervision of a part-time specialist in physical medicine, who selected suitable children and of teachers, selected and instructed by the Council's organisers of physical training. By the end of 1950 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 co-operation of the head teachers and staff concerned. Handicapped children 6,804 examinations of children were made during the year with a view to ascertaining the need for either special educational treatment or its continuance. The number of examinations in each category was as follows :— Vision 252 Hearing 263 Epilepsy 93 Educational subnormality 2,608 Delicate (i.e. suitable for open-air education) 2,377 Physically handicapped 609 Dual defects 67 Speech defects 535 no In addition 391 children were considered with regard to maladjustment and 18 with regard to diabetes. Accommodation Tables 18 to 28 in the appendix show the results of the above examinations. Day Special Schools Defect No. of schools Roll Partially sighted 6 407 Deaf 4 331 *Partially deaf 4 88 Physically handicapped 19 1,535 Delicate 10 1,239 Educationally subnormal 24 2,858 *Maladjusted (in day classes) 11 161 *Speech defectives (in day classes) 21 662 Total 99 7,281 * Special classes held in normal schools. Residential Special Schools No. of schools Accommodation Defect Residential Day Roll Blind 2 80 30 78 * Deaf and partially deaf 3 152 62 152 Physically handicapped 2 119 — 107 Delicate 7 431 — 400 Educationally subnormal 6 498 — 480 Diabetic 1 63 — 53 Maladjusted 3 94 — 93 24 1,437 92 1,363 * Including Rayners for dual defects. In addition to the handicapped children in the Council's own residential special schools there were at the end of the year 863 of the Council's children in non-Council residential special schools catering for the following defects :— Blind 48 Partially sighted 7 Deaf and partially deaf 36 Physically handicapped 54 Delicate 248 Educationally subnormal 88 Epileptic 65 Maladjusted 312 Speech defect (Moor House) 5 Total 863 Hospital schools and groups The Council provided education for children in the following seven hospitals, the first four of which are recognised as hospital special schools. Tuition was given to groups in the remainder under section 56 of the Education Act, 1944 :— Average roll Goldie Leigh 79 Guy's (and Evelina) 93 St. Mary's, Paddington 18 Maudsley and Bethlem Royal 41 Victoria Hospital for Children 16 Hammersmith 10 Whittington 19 In addition there are many London children in hospital schools outside the County particularly in the long-stay children's hospitals taken over from the Council by regional hospital boards in 1948. 1ll Residential schools There were seven residential schools with accommodation for about 2,802 children committed to the care of the Council under the Children Acts. A visiting medical officer attended each day and was available for emergency calls. He examined all children on entry, before discharge and at such other times as are prescribed by the Council. Arrangements were made for the dental treatment of the children resident in the schools. At each school there were at least two resident school nurses. Periodical visits were made by senior medical and nursing officers from the County Hall. There were also 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 officers of the local maternity and child welfare authority, and a medical officer from County Hall visited each term. There were three reception homes providing accommodation for 160 children, 4 approved schools with a total accommodation of 482 and 2 remand homes with accommodation for 145 children. Each of these establishments had the services of a visiting medical officer and periodical visits were made by medical staff from County Hall. During the year the Council's psychiatrist made a survey of the psychiatric needs of these establishments. In the development of one of the reception homes, Langley House, on the lines suggested by the Home Office, approval was given to the appointment of a psychiatric social worker, who will work with the psychiatrist in advising on the proper placement of each child. Infectious diseases in schools The number of infectious cases reported from the day schools during the year is shown in Table 14, page 146. The number of visits to schools made during 1950 by school nursing sisters in connection with outbreaks of the principal infectious diseases was :— Diphtheria Scarlet Fever Whooping Measles j Cough Chickenpox Mumps Poliomyelitis Other diseases Total 29 248 266 141 226 221 109 405 1645 When necessary, special visits were made by assistant school medical officers. During the year eleven cases of scalp ringworm and 78 of body ringworm were reported among children in residential schools and children's homes. All practicable steps were taken to prevent the spread of infection. Provision of meals The following information was supplied by the Chief Officer of the Restaurants and Catering Department:— The number of kitchens of all kinds producing school meals increased from 578 (including 471 school kitchens) to 579 (including 504 school kitchens) and dining centres from 829 to 854 between October, 1949 and October, 1950. 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 850-950 112 Meals for children in Group III are planned to contain 20-25 grammes of firstclass protein ; 25-30 grammes of fat; and 400 milligrammes of calcium. The diet of the children taking meals was under the supervision of the Council's honorary nutritional consultant, Dr. T. F. Macrae, O.B.E., D.Sc. To provide a close check on the quantities and qualities of served meals, random samples were analysed by the Council's chemist-in-chief from time to time (see page 34). School buildings and furniture In considering the plans for the new comprehensive high schools, it was found necessary to make considerable modifications to the standards laid down in the Building Regulations 1945. It was hoped, however, that, by careful design, the reduction in the size and number of rooms available for medical purposes would not lead to any reduction in efficiency. It was more difficult to provide an efficient medical unit in the smaller schools, as the rooms needed to be as large as those in larger schools but would not be in such continuous use. Arrangements were completed for the design and manufacture of bins for the disposal of sanitary towels. These bins will be placed in closets of all secondary girls' schools. Sanitary towels are kept in each school and are available on application. Audiometric testing After new electric gramophone audiometers and modified portable gramophone audiometers were supplied it was possible to extend the tests of the hearing of pupils over seven years of age to schools in five of the nine divisions. It is hoped that it will be possible to provide a service in all divisions in 1951, which may entail the purchase of an additional audiometer. When this position has been reached it is proposed to change the present scheme, which is a hearing test of all pupils in a school, to a test of all new entrants as soon as possible after their admission into a junior school. 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 causes. A number of children who failed the second gramophone audiometer test were given a further test with a pure tone audiometer with a view to obviating the reference for treatment to special ear, nose and throat centres of those not in need of it. The total number of children tested by a gramophone audiometer was 21,843 of whom 6,320 failed the first test and 1,446 failed in the second. It was possible to arrange for 854 of the latter to be tested by a pure tone audiometer and of these 405 failed. These last together with the remaining 592 of those who failed the second gramophone test were referred to special ear, nose and throat centres. A total number of 571 children completed treatment at these centres during the year and, of this number, 212 again failed the audiometer test and were referred to aurists for consideration as to further treatment. Rheumatism Scheme The number of beds provided for institutional treatment of children at Queen Mary's Hospital, Carshalton, is now 250 and the average number of beds occupied in 1950 was 185. In 1938 there were 900 beds provided in five hospitals, including two for mild and convalescent cases (200 beds). The average number of beds occupied was 794. The decrease in the number of children nominated for institutional treatment mentioned in last year's report continued in 1950 but the fall was considerably less, viz. from 348 to 274 compared with 638 to 348. The reasons for the fall are by no means certain but it is probable that juvenile rheumatism is less prevalent 113 than it was. It is interesting to note that the weather in 1950 was inclement. Whereas 1949 was characterised by long spells of fine weather, the summer and autumn of 1950 were damp and the humidity high. Changes in methods of disposal of convalescent cases is probably a more potent factor and a tendency for hospitals to keep their rheumatism cases and not inform the school health service has been noted. But improvements in treatment of acute infections of the upper respiratory tract must also be borne in mind. In the days before sulphonamide therapy became prevalent (and with the advent of more elegant and less toxic forms of the drug, this prevalence has been enhanced) acute sinusitis and acute tonsillitis were severe diseases ushered in by fever, tachycardia, toxaemia and fall of blood pressure in addition to the local signs. The acute phase lasted for a week or ten days and was then followed by resolution or sequelae such as peritonsillar abscess, antral empyema, otitis media or mastoiditis or more remotely by articular rheumatic fever or carditis. Of latter years, however, the picture has altered. Under sulphonamide and penicillin therapy the period of convalescence begins within twenty-four to fortyeight hours and the untoward effects mentioned above are now comparatively rare. Admittedly during the last two decades scarlet fever has become a more benign disease and the streptococcus haemolyticus is no longer so dangerous, so the decrease in the number of nominations for institutional treatment may in part be a measure of a real decrease in the prevalence of j uvenile rheumatism also. Certainly the number of cases of rheumatic carditis applying for admission to schools for physically handicapped children is also decreasing, and gradually the importance of congenital heart disease is overshadowing that of rheumatic carditis. The drop in nominations in 1949 which was maintained in 1950 seems to have been too sudden, however, to be explained solely by improved treatment or reduced incidence or virulence of streptococcal infection and we come back, therefore, to the conclusion that alterations in the administrative activity and disposal of the cases must have played a substantial part in its causation. By far the most serious complication of rheumatic infection in children is carditis. It is responsible for much crippling heart disease in later life, and preventive work in this direction is bound to have a beneficial effect upon the health and efficiency of the community at large. It is interesting to record that the Council's rheumatism scheme started some 25 years ago with clinics for juvenile rheumatism and developed therefrom hospital and clinic provision for carditis, whereas our American colleagues, starting with the care of heart disease in children, have come to treat juvenile rheumatism, so that working from opposite ends the schemes have eventually covered much the same ground. The preventive aspect of the juvenile rheumatism scheme is one that cannot too often be stressed, for although many people regard recurrence of this disease as something different from a first attack, yet time after time the same clinical features are reproduced and, if the complete history of every case could be obtained, many so-called first attacks would be found to be recurrences of infection. Many, of course, are so mild that they go unrecognised. Sub-acute rheumatism can often be overlooked, as it is in the nature of this disease to recur. If it is a smouldering chronic infection, what causes it suddenly to light up ? Is it the sudden exaltation of virulence on the part of the infecting organism ? Is there a diminished resistance on the part of the host ? Does a change of environment stimulate or unmask a latent toxaemia, or is it caused by an allergic response on the part of the child ? Wherein lies this latent trigger action ? These are all questions which the physician in charge of the rheumatism supervisory centre must bear in mind, and perhaps one or two key discoveries in immunity may well uncover the tissue reaction involved in rheumatic fever. We all await the results of further research in the use of A.C.T.H. and Cortisone in the treatment of this symptom-complex. 114 The work of the care committees in following up and reporting upon home conditions has again been of great assistance and the active co-operation of the Borough Medical Officers of Health in endeavouring to improve and correct some of the deplorable housing conditions in which some of our cases are to be found has been greatly appreciated. During the latter end of the year an alteration in staff took place. Dr. C. E. Thornton, who for so many years had combined the supervisory and administrative work at the County Hall, together with care of the in-patients at Queen Mary's Hospital, Carshalton, decided to concentrate on his hospital work under the SouthWest Metropolitan Regional Hospital Board, and Dr. R. Cove Smith was appointed to deal with the administrative side, to undertake visits to rheumatism supervisory centres and to supervise the cardiac cases at schools for physically handicapped children. In the near future it is probable that these cardiac cases will come under the care of cardiovascular clinics attached to hospitals as a part of the hospital organisation of the national health scheme, but it will be necessary to ensure that the better facilities for diagnosis and treatment which may result from this will not lead to any fall in the attention paid to the preventive aspects of the work. Tables 29 to 32 (page 155) give details of this service. Psychiatric service in remand homes Dr. P. D. Scott, M.A., M.D., D.P.M. reports : The psychiatric work was carried out by one psychiatrist (two-thirds full-time), two educational psychologists (one of them part-time), and a psychiatric social worker. Assistance was also given by psychiatrists, from County Hall when pressure of work was high. The junior girls were transferred from Stamford House in May, 1950, and since their numbers had been kept as low as possible almost all the psychiatric work was with boys. The number of psychiatric reports requested by the Courts was 783, of which 17 were for girls. This represented a reduction on the previous years: 1948—800 psychiatric reports and 1949—902. In addition 17 cases were referred for psychiatric examination while remanded on bail. The team was also used for the selection of cases for the Henderson Trust establishment for pre-delinquent children at Seer Green, and cases referred by probation officers were seen when the case load permitted. Recommendations to the Juvenile Courts made on 213 consecutive cases from 1st March, 1950. Probation and Supervision Order 80 Approved school or hostel 47 Special school for maladjusted children 27 Special school for educationally subnormal children 5 Special school for physically handicapped children 1 Agricultural or nautical training 5 Boarding schools 19 Foster homes 3 Psychological treatment 20 No specific recommendation 6 213 Problem children The Council's scheme, established in 1944, to co-ordinate the local arrangements for special children's case work was continued in 1950. Particulars of school children 115 presenting difficulties in behaviour or of educability were referred to a case conference of senior officers of the Education Officer's and School Medical Officer's departments in each of the nine divisions into which London is divided for education and health purposes. Suitable cases were referred by the conferences to child guidance clinics provided by hospitals, by voluntary associations, and by the Council. Treatment was free. The number of children referred for the first time to case conferences during the year 1949-50 was 1,558. An analysis of the new cases showed that the main methods of initial action taken were as follow :— Referred to child guidance units (this included those children referred to units privately and subsequently reported to the conferences) 1,026 Placed under supervision of Care Committee 108 Referred for medical examination and/or treatment 98 Referred for admission to special day classes for the maladjusted 90 Referred for statutory educationally subnormal examination 52 Deferred for further enquiry 59 Miscellaneous (included juvenile court cases, and cases referred to N.S.P.C.C., moral welfare workers, voluntary societies for residential placement and others, for example, the Children's Officer) 125 1,558 The total number of the children considered (i.e. new and old cases) represented 0.78 per cent. of the primary and secondary school population. The most encouraging feature of the figures, indicating the progress in dealing with current and previous cases, was that 702 children were no longer considered as problems and this represented an increase of 129 over the figure of the previous year. Other children were dealt with as follows :— 157 were placed in boarding accommodation as maladjusted 75 were on the waiting list for such accommodation 868 were under treatment at child guidance units 196 were on the waiting list to attend the units 136 were placed in special classes for the maladjusted 933 were dealt with in a variety of ways, e.g., given supervision by Care Committee, referred for medical treatment, statutory E.S.N, examination, N.S.P.C.C. moral welfare workers, etc., At the end of the year there were 11 special day classes for the maladjusted operating in eight divisions. Although 33 more maladjusted children were placed in boarding establishments than during the previous year, the numbers on the waiting list did not decrease. Vacancies were delayed in many instances as great difficulty was experienced in improving home conditions and this prolonged the length of stay away from home of those in the boarding establishments. During the year two new boarding schools for the maladjusted were established at Dromenagh and Buckshaw House. The Council's boarding accommodation for maladjusted children was as follows:— (1) Bredinghurst School, Peckham Rye, S.E.15.—45 boys most of whom attend local schools, some of the younger children being educated on the premises. (2) Dromenagh School (opened April, 1950), Iver Heath, Bucks.—17 boys and girls educated on the premises. (3) Buckshaw House, Holwell, Dorset (opened September, 1950).—32 boys and girls; some of the senior children educated in local schools. There were 312 maladjusted children in residence at other schools belonging to the Council or in non-Council schools or hostels or boarded out with foster parents. Use was made of 73 establishments not maintained by the Council. 116 Group psychotherapy at Bredinghurst The following report was made jointly by the Headmaster of Bredinghurst and the psychotherapist who undertook the group psychotherapy at the school:— " We are of the opinion that the method we have used has served a very real purpose and deserves further experiment. It must be borne in mind that this method has been developed to suit " Bredinghurst " where many of the boys are of low intelligence and where it is also possible to observe and have contact with them outside the analytical situation. The group method is of advantage where it is necessary to treat a large number of children, and where the therapists' time is severely limited. The increase in numbers dealt with is not so great as might at first be hoped since each child has to be seen in private session at least once a week. Nevertheless since four or five boys are taken together for an hour it has, in fact, meant that we have been able to raise the number of children receiving treatment by 40 per cent. As a result of the past year's work we have good reason to believe that certain types of children who may not need, or who may have too low an Intelligence Quotient to benefit from, deep analysis, may make a satisfactory adjustment through the group alone. At the moment we have not felt justified in taking this risk with any of the present children. It is wise, however, to bear in mind that there are forces at work in the group which, if rightly used, may be sufficient for the cure of many repressed and introverted children whose conflicts are comparatively near the surface. It has been for long realised that analyses are more difficult with children and adults who have a low I.Q. A number of those whom we are at present treating have I.Q.'s well below 90. Here the group is of great service. The child is able to respond to the group situation more easily than he is able to assimilate material disclosed in individual sessions with the therapist. We have, for instance, two of the present group whose progress has been remarkable, and we are satisfied that had it not been for this method of treatment their development would have been much slower. In both cases the I.Q. is about 80. Further, the group serves to reveal specific conflicts and tensions among the children and points thus observed can be taken up again by the therapist when seeing the child alone. It is as though the child were able to observe his own difficulties re-enacted and we have remarked upon the ability of some of them to criticise their own behaviour in a way which shows genuine understanding of their problems. The group is of service in the solution of disorders of this nature and assists the child in the development of new relationships and behaviour patterns. Within the group the boy learns in a secure and protected situation the reasons lying behind his conflicting feelings, releases repressed aggression and, with the assistance of the group, experiments with new patterns which automatically include his relationship with the other members. One of the most useful functions of the group is that it gives ample opportunity for getting rid of repressed emotion. The discussions and drama, plus the enactment of infantile fantasies brings to the surface fears and anxieties. The ability to give vent to these feelings within the safe milieu of the group is of great value to the child, particularly to the repressed and introverted boy who has previously been too afraid of his unconscious desires and now finds himself able to express them without calling down the wrath of the adult world on his head. Many children are incapable of satisfactory relationships with adults, but are able, to a limited extent, to fit into a small group of children. They cannot understand adult reasoning and are puzzled by rules and punishments previously meted out to them. They are, however, prepared to accept rules of behaviour which they themselves have helped to frame and gradually become conscious of belonging in a unique way to a small group of which they are an integral part. They are aware 117 that certain lines of behaviour or certain attitudes on their part can sever them from the group and their main desire, therefore, is to learn those patterns which give them freedom of expression and yet at the same time do not cut them off from the other members. It is surprising how quickly this group sense can be achieved. The admission of a new member is immediately recognised as a threat to the group and it takes a week or two before he is fully accepted and integrated into the group. Once a child has learnt how to become a useful member of the small therapeutic group he is the more able to fit into a larger group such as the school and the community. Much of the analytical process depends upon the ability of the child to express his fantasies outwardly and we have found the group to be a useful method by which this can be done. Some children are able to do this almost from the start, but with others, who are unconsciously aware of the aggressive and anti-social content of their fantasies, it takes some months before they will make their first experiments. Once this has been done, however, useful material is almost immediately discovered and can be used both in the group and individual session. The therapist must keep a close watch upon the changing character of such fantasies and must also prevent those boys who have no difficulty in this from blocking the expression of the other members. Group Observations and Discussion.—Observation by the children of their own behaviour or that of others is of very real value. It serves an educational purpose which is barred to the therapist who cannot combine therapy with education since this would have the undesirable result of slowing down analysis, the child seeking only to please the therapist rather than take his own analysis deeper. The group is able to exercise a strong educative pressure without, given the safeguards which we have earlier mentioned, any untoward results. The advantages which we have enumerated indicate that we place considerable faith in the group method, particularly in a school of this nature. In this school there is no marked line of demarcation between the educational and psychiatric approach, and each member of the staff seeks to co-operate with those who approach the child's problem from another angle. The therapist makes contact with the teachers and cottage staff, sees the child in school, in the woodwork group, in the playground, and tries to get an all round picture of the child. There is a free exchange of information among the staff and the value placed upon the psychiatric approach is indicated by the recent requests made to the headmaster by both the cottage staff and the teachers that discussions with the psychiatric social workers and the therapist might be initiated. We are satisfied that the group method will repay further attention and experiment." Psychiatric social workers During the year a psychiatric social worker was appointed to the Council's staff. Most of her time was spent preparing the families of the boys at Bredinghurst for their eventual return to their own homes. The social workers at the child guidance units were already too busy to be able to undertake this extra work. The Council agreed during the year to appoint a second psychiatric social worker for the two other schools for maladjusted children. Child guidance units At the end of the year the Council was responsible for child guidance units as under:— (1) Earls Court Child Guidance Unit, 25, Stratford Road, Kensington, W.8, which was opened in new premises on 4th September, 1950, to replace the unit which had previously operated at Bishop Creighton House. (2) Battersea Child Guidance Unit, 6, Cambridge Road, Battersea, S.W.ll, which was opened on 3rd October, 1950, to replace the unit at Putney Health Centre. 118 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. Work on the premises at 19, Brixton Water Lane, Brixton, S.W.2, which it is proposed should be opened as a child guidance unit in co-operation with the Governors of the Maudsley Hospital, has proceeded. During the year 392 attendances were made at the Battersea Unit and 953 at Earls Court. The following statement gives details of the disposal of cases which had been closed by the end of the year:— Battersea Child. Guidance Unit Earls Court Child Guidance Unit Total Seen but not treated (diagnosis & advice) 14 11 25 Recovered 3 — 3 Much improved — 8 8 Improved 5 31 36 Not improved — 7 7 Unco-operative 6 10 16 Placed in residential ments, etc 12 6 18 Removed to another district — 1 1 40 74 114 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 and to guard against the accidents of a diabetic life. 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 five years of age An inspector of the Education Officer's department continued to visit primary schools with accommodation available for nursery classes after the needs of the children over five had been met, and in those cases where she was prepared to approve a nursery class, the Divisional Medical Officer was consulted, and arrangements were made to introduce some approximation to nursery school conditions. At the end of 1950 there were 128 nursery classes with accommodation for approximately 3,900 children over three years of age and upwards. In addition to a midday meal, these children had one-third of a pint of milk daily and cod liver oil and other vitamin preparations ; for those who required them medicaments containing iron were also prescribed. Nursery class children attend during the ordinary school hours of primary schools, but 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. 119 At the end of the year there were 19 maintained day nursery schools with accommodation for 1,145 children from two years upwards and five aided day nursery schools with accommodation for 230 nursery school children. School nurses attended nursery classes and schools daily and each child was examined every term by a school doctor. There was a total of 13,339 children under five years of age on the day school rolls, 11,603 being in the Council's schools and 1,736 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. DENTAL SERVICES The Council's Chief Dental Surgeon, Mr. Wm. Ritchie Young, V.R.D., F.D.S., R.C.S.(Eng.), reports as follows:— Inability to recruit a sufficient number of suitable dental surgeons to maintain an adequate " priority " dental service continued. The entanglement of the three dental services under Parts II (Hospital), III (Local Health Authority) and IV (General Dental service) of the National Health Service Act, 1946, continued. There was, however, during the year some clarification of the position. The Hospital (Part II) dental service was, during 1950, separated from the Council's dental service with the exception of a small number (185) of orthodontic patients treated in certain teaching hospitals for the Council's school dental service, and the provision by the Council's Central Dental Laboratory of the hospital requirements of considerable numbers of dental appliances (2,643). In addition, at three centres dental treatment of tuberculous patients was continued by the Council's dental officers at the request of the hospital authorities. The hospital service continued to carry out considerable dental treatment for expectant and nursing mothers. There were discussions with the Executive Council about the opportionment of cost and responsibility for the General Dental service in health centres (Part IV). At each of two centres (Shoreditch and Finsbury) a full-time general dental service dental surgeon continued to serve temporarily under the aegis of the Council on behalf of the responsible authority—the London Executive Council. For a third year the Council's policy to develop the maternity and child welfare dental service (Part III) and to integrate it with the school dental service had to be held in abeyance owing to staffing difficulties. As the two dental fields in which the Council has statutory obligations remained unchanged it is convenient to present details of the work carried out and the staff position during 1950 under two headings—" School Dental Service " and " Maternity and Child Welfare Dental Service." School Dental Service Staff Full-time Part-Time Total Full-time Establishment Full-time Number Equivalent to Full-time At end of 1947 43 19 6 49 66 At 5.7.48 51 21 10 61 66 At end of 1948 43 21 10 53 66 At end of 1949 31 27 14 45 66 At end of 1950 26 25 14 40 66 120 Statistics 1947 1948 1949 1950 Number of inspection sessions held at schools 1,588 1,230 946 544 Number of children inspected at schools by Dentists 163,528 158,063 96,201 52,931 Number found to require treatment 109,169 102,344 61,445 32,733 Percentage requiring treatment 66.8% 64.7% 63.9% 60.8% Additional number inspected at centres * 44,068 65,380 63,583 Total number found to require treatment * 146,412 126,825 96,316 Total cases treated 104,305 118,438 102,495 82,650 Attendances 199,840 236,175 203,523 166,874 Ordinary treatment sessions 19,737 22,619 19,133 15,890 General anaesthetic sessions 1,679 1,774 1,685 1,559 Temporary teeth extracted 116,795 116,664 109,467 101,066 Permanent teeth extracted 18,716 20,641 18,103 16.247 Temporary teeth restored by fillings 39,685 43,033 34,506 23,960 Permanent teeth restored by fillings 82,309 94,561 67,395 53,388 Fillings in temporary teeth 42,222 45,617 36,341 25,191 Fillings in permanent teeth 92,335 104,913 73,740 58,000 Other operations—temporary teeth * 28,406† 38,649 33,489 Other operations—permanent teeth * 25,602† 32,888 25,485 Local anaesthetics for extraction 24,857 24,859 24,328 20,557 Local anaesthetics for conservative treatment 5,582 5,372 2,926 1,577 General anaesthetics 38,036 41,292 39,455 35,102 Cases completed 86,166 98,474 85,755 74.443 * Figures not available, † Figures for April-December only. Routine dental inspections in schools for the third consecutive year were greatly curtailed to prevent congestion at the remaining treatment centres. (See graph). Ratio of permanent teeth restored to permanent teeth extracted 1945 4.04 to 1 1946 4.2 to 1 1947 4.93 to 1 1948 4.58 to 1 1949 3.72 to 1 1950 3.29 to 1 Residential establishments There were few changes in the numbers of attendances and treatments in residential schools during the year but the trend, as in other dental returns, was mainlv downwards compared with 1949. These statistics are additional to those in the proceeding table. 1947 1948 1949 1950 Ordinary treatment sessions 643 645 572 524 General anaesthetic sessions 9 11 12 10 Number of children inspected 6,523 6,781 5,648 5,783 Number found to require treatment 3,329 2,996 2,333 2,355 Percentage requiring treatment 51% 44.2% 41.3% 40.7% Attendances for treatment 3,792 4,688 4,179 3,791 Temporary teeth extracted 1,033 1,097 1,128 920 Permanent teeth extracted 336 390 271 172 Temporary teeth restored by fillings 855 1,202 1,058 854 Permanent teeth restored by fillings 1,967 1,916 1,555 1,547 Fillings in temporary teeth 1,048 1,354 1,116 976 Fillings in permanent teeth 2,166 2,128 1,715 1,708 Completed scalings 706 914 700 583 Temporary dressings, etc 631 709 745 511 Local anaesthetics for extraction 793 830 832 666 Local anaesthetics for conservative treatment 61 133 71 53 General anaesthetics 163 183 163 272 Cases completed 2,284 2,524 2,357 2,363 121 It is of interest to note the impact of the war, the recovery therefrom, and the impact of the National Health Service Act. 122 Sodium Fluoride treatment and Dental Hygienists The investigation of the efficacy of sodium fluoride treatment in the prevention .of dental caries which was started in September 1949 continued throughout 1950. The re-examination of treated dentitions began before the close of the year but sufficient time had not elapsed at the end of 1950 to warrant reliable conclusions. lhe three experimental dental hygiemsts engaged on the work treated considerable numbers of patients throughout the year and assisted the dental surgeons under whose supervision they operated. Dental Hygienists—Attendances and Treatments, 1950 Sessions 1,370 Number invited to attend for first treatment 2,389 Number invited to attend for subsequent treatment 2,851 Attended—first treatment 2,109 Attended—subsequent treatment 2,662 Treated—first treatment 2,104 Treated—subsequent treatment 2,660 Discharged—completed 1,834 Gum treatments 365 Scalings (cleanings) 3,122 Polishings (of artificial restorations) 1,823 Oral hygiene instruction 2,562 Sodium Fluoride: First application 658 Second „ 597 Third „ 559 Fourth „ 494 Orthodontic treatment Orthodontic treatment continued, as in 1949. to be given by the dental staff generally with specific reference to specialist orthodontists in certain cases. Of the four part-time orthodontists employed at the commencement of the year, one resigned in May another in July. Summary of Work Completed by Orthodontists in 1950 Sessions 425 New cases 266 Attendances 5,339 Unsuitable for treatment 84 Still under treatment (at 31.12.50) 491 Fixed appliances fitted 199 Removable appliances fitted 452 Discharged, treatment completed 424 In addition 247 new cases were treated in the course of the normal treatment sessions by clinicians, and a further 185 were accepted for treatment in hospitals ; in all a total of 698 new cases and a reduction of 436 on the proceeding year. Maternity and Child Welfare Dental Service During 1950, an unknown volume of dental treatment for expectant and nursing mothers (Part III priority service responsibility) continued to be carried out in the Hospitals (Part II service) and in the General Dental service (Part IV schemes). The number of maternity and child welfare dental sessions in operation per week by the Council at the end of 1950 was sixty-one compared with seventy at the end of 1949, and sixty-eight at the end of 1948. The number was, to a large extent, maintained by utilising the services of some of the Council's " school " dental officers. A tabulation of attendance and treatment figures for the year is given below with comparative figures for 1949 and (where available) for 1948. 123 1948 1949 1950 Number of ordinary sessions 4,982† 2,682 2,238 Number of general anaesthetic sessions 288 † 364 368 Number of appointments offered * 31,338 26,308 Failed to attend * 6,477 5,876 Attendances—By appointment 36,710 24,861 20,432 Other 5,392 3,891 Examinations • 12,057 8,579 Treated—first treatment 10,959 7,032 5,116 others * 13,447 11,851 Silver nitrate treatment 416 2,938 2,180 Scalings 1,324 1,364 859 Prolonged gum treatment 135 212 210 Fillings 8,549 8,564 8,255 Inlays * 23 22 Crowns 1 5 11 Number of teeth conserved * 7,988 7,841 Extractions 17,255 16,560 11,257 Dressings 598 2,236 2,077 Anaesthetics—local 349 1,784 1,457 general. 3,645 4,563 3,372 Number of patients prepared for dentures * 3,359 2,518 Number of patients supplied with dentures 960 918 Dentures supplied—new full 2,176 652 655 new partial 795 782 Remakes 8 7 19 Repairs 235 126 84 Number of patients X-rayed * 56 23 Number made dentally fit * 5,283 5,057 † 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. Throughout the year efforts were continued to find a solution to halt the steady deterioration of the Council's dental services. It is most disappointing that no real solution has been found. STAFF Salaries and wages— Whitley Council and other national awards Revised rates of pay and conditions of service tor a number ot grades of statt in local authorities' health services were announced by the Whitley Councils for the Health Services (Great Britain) and implemented by the Council during 1950. The grades of staff affected in the public health department were (1) health visitors, tuberculosis visitors, school nursing sisters and domiciliary midwives and (2) dental technicians. The majority of manual workers in the department also received increases in pay following the publication of an agreement by the National Joint Council for Local Authorities' Services (Manual Workers). Nursing staff at residential establishments The application by the Council to nurses at welfare institutions of the revised scales of pay for hospital nurses, as recommended by the Nurses' and Midwives' Whitley Council in 1949, and mentioned in my report for last year, led to a marked improvement in the recruitment of ward sisters for welfare establishments and there are now few vacancies. It remained difficult, however, to recruit other grades of nurses for these establishments presumably because the work is not so attractive as nursing in hospitals. There was also an acute shortage of nurses at residential nurseries. At both types of establishments it was occasionally necessary at times to engage nurses through nursing co-operations. The shortage of residential school nurses also remained acute and to maintain the service a number of non-resident school nursing sisters and health visitors were asked to take a turn of duty at residential schools. I 124 Health visitors The improvement in the recruitment of health visitors and tuberculosis visitors, referred to in my last report, was maintained during 1950, though not to such a significant extent. At the end of the year 346 were employed compared with 330 in January. The main single source of recruitment continued to be from health visitors who had obtained their qualification as a result of the training facilities offered by the Council in conjunction with the King's College of Household and Social Science. Dental surgeons Recruitment of dental surgeons, which had iallen short ot requirements since 1948, still failed to meet the severe shortage caused by resignations and the staffing of the Council's priority dental services continued to give rise to deep anxiety. Holiday organisers and assistants Two new grades of stan, viz., holiday organisers and holiday assistants, were introduced in 1950. Their duties involve the supervision of children sent for recuperative holidays at seaside hotels. Training of postgraduate medical students Following a new requirement tnat candidates for tne Diploma in Child Health must "have had not less than 20 attendances at welfare centres and school medical service clinics, including evidence of having attended at a child guidance clinic, special schools and residential or day nurseries," an extension was made of the scheme described in my report for 1949 whereby the Council co-operated with the Institute of Child Health in the training of postgraduate students. Twice a year, about 60 students from the Institute of Child Health, and twelve from other hospitals for children, will be making visits to the Council's clinics and other establishments and attending lectures given by the Council's medical officers. Co-operation with borough councils There were two noteworthy instances ot progress in implementation ot the policy of co-operation between the Council and the metropolitan borough councils in the administration of London's public health services. Two of the Council's assistant medical officers were seconded for permanent part-time duty as deputy medical officers of health, the boroughs concerned being in the first case, Finsbury, and in the second case, Hampstead and St Pancras, who now share a joint medical officer of health and deputy. Staff of the department The following statement shows the number of staff employed in the Public Health Department in December, 1950 (part-time staff being expressed as whole-time equivalents). Type of staff Location Staff employed at other establishments (a) Total 1950 Total 1949 Head office staff Divisional staff Administrative and clerical (including ambulance control clerks) 200 610 77 887 881 Medical staff 18 168 (b) 186 179 Dental staff 2 46 (c) 48 66 Chemists 16 — 7 23 23 Inspectors 15 — 15 15 Nursing staff 10 2,462 311 2,773 3,066 Medical auxiliaries (d) - 111 21 132 144 Social worker grades (including mental health) 31 145 72 248 254 Supervisory staff (London Ambulance Service) 3 - 14 17 16 Manual workers, operative staff (L.A.S.), domestic grades, etc. 3 2,185 726 2,914 2,647 Totals 298 5,717 1,228 7,243 7,291 (a) These establisnmenls 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 60 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 8 visiting dental surgeons employed in a similar manner as the medical staff referred to in note (ft) above who have been omitted from the statement. (d) Including physiotherapists, chiropodists, speech therapists, orthoptists, dental attendants and dental hygienists. 125 Medical examinations 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 12,361 compared with 12,184 in 1949. Reciprocal arrangements with provincial authorities for the examination locally of new entrants were continued. Provincial medical officers of health arranged examination for 13 entrants to the Council's service and the Council's medical officers examined 18 persons for provincial appointments. The Council's staff medical examiners made 74 home visits to examine members of the staff who were unable to travel, compared with 81 during 1949. Sewer workers Arrangements made for the ascertainment and treatment of leptospirosis among the Council's sewer workers have been continued. There was a reduction in the incidence of the disease among London sewer workers during the war years, possibly associated with the cessation of building operations in the sewers. Since the war there have been two or three cases a year and despite a slight increase in the last two years the incidence remains reasonably low. Capital FINANCE The total capital expenditure on the health services of the Council in the year ended 31st March, 1950, was £240,126 of which by far the largest amount was spent on the purchase of ambulances. This was part of a replacement programme expected to cost £280,000 in all. £8,686 was spent on the commencement of building operations on the Health Centre and Day Nursery at Woodberry Down, estimated to cost in total £163,000. Details of the year s capital expenditure were as follow £ Ambulances 187,060 Children's Holiday Home, Littlehampton 9,176 Day Nurseries—acquisition and adaptations 23,657 Health centres 9,202 Maternity and child welfare centres—acquisition and adaptations 11,031 240,126 Maintenance After allowing for Government Grant the services administered by the Public Health department cost the London ratepayer a rate of 8.U1. in the £. This was divided as follows:— d. London ambulance service 1.14 Domiciliary midwifery service .49 Mental health .26 Maternity and child welfare 1.19 Day nurseries 1.81 School health 1.14 Clinics, centres and divisional offices .40 After care and other preventive services (home nursing, domestic help, care of tuberculous, etc.) 1.53 General health services .72 8.68 The gross cost of the various services in 1949-50—including central administrative and loan charges and contributions to the Superannuation Fund—and the 126 contributions recovered from recipients of the services were:— Service Cost Amount recovered in charges £ £ London ambulance service 506.946 Domiciliary midwifery service 214,953 — Maternity and child welfare 615,349 60,467 Mental health 122,926 — Day nurseries 928,562 71,324 Medical inspection and treatment of school children 665,513 11,868 Clinics and divisional office maintenance 184,828 - Prevention of illness— Home nursing 168,370* — Domestic help 340,008* 44,137 Other preventive services 258,245 18,340 General health service (including £140,729 contribution to metropolitan borough councils for salaries of sanitary officers) 161,504 - 4,167,204 206,136 * Excluding central administration. REPORTS BY THE DIVISIONAL MEDICAL OFFICERS Division 1, comprising the boroughs of Chelsea, Fulliam, Hammersmith, and Kensington. Dr. Violet Russell reports:— General The year 1950 showed a continued expansion in the health services in the division. Excellent work was carried out among mothers and children in the sixteen infant welfare centres and in the schools. Extra facilities had to be provided for vaccination, chiropody, orthoptics and nutrition sessions. The number of vaccinations carried out in the division rose from 4,348 in 1949 to 5,216 in 1950. The home help service was considerably extended during the year; in 1949 the number of households attended was 4,022 and in 1950 it rose to 6,210. Another service showing a marked increase was the registered " child-minders " for the daily care of children whose mothers are working : these increased from 81 in 1949 to 178 in 1950. Day nurseries The demand for places in the day nurseries continued to exceed the accommodation. At the beginning of the year the Australia Road Nursery in Hammersmith was closed, the site being needed for other purposes. The new nursery in Westway which will ultimately replace it had not passed the plan stage by the end of the year. In Fulham some relief was furnished by the opening of the Mulgrave Day Nursery, on September 7th, 1950; this is a larger nursery than the St. Andrew's Nursery, which it replaced, the net gain in accommodation being 21 places. By a rearrangement of the rooms at the Fulham Babies' Day Nursery the accommodation was raised from 22 to 28 places. Unfortunately severe dry rot was discovered in Eridge House Nursery, Fulham, which had in consequence to be closed for drastic repairs from August 4th, 1950, and had not reopened at the end of the year. Tuberculosis Care Committee The first meeting of the Divisional Tuberculosis Care Committee was held in October, 1950. The Committee noted that an active voluntary care committee existed in each of the four boroughs of the division and were satisfied that the social work, so important in connection with tuberculosis, was being adequately carried out. They decided to meet twice a year when reports on the work accomplished by each of the four local committees would receive careful consideration. 127 Welfare of old people The Divisional Health Committee have taken an active interest in the organisations in the division which exist for the provision and co-ordination of welfare measures for old people. An old people's welfare committee now exists in each of the four boroughs and each committee includes at least one member and an officer of the Divisional Health Committee. This link is proving very helpful in ensuring that the services provided by the Council (home helps, home nursing, etc.,) are properly co-ordinated with others for the benefit of this class of the community. Health services— publicity Representanons were made by one of the borough councils in the division in favour of improving the facilities for obtaining information about the divisional health services. The Council decided to authorise the issue of statements to the press indicating decisions of the Divisional Health Committee or information received by the committee. A conference was held with representatives of newspapers circulating in the division and arrangements were made to issue statements after each committee meeting. As a result a steady flow of material relating to the health services has been published. Conclusion In conclusion I wish to express my appreciation of the very high standard of < work carried out during the year by all my colleagues in the division. Division 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and Westminster. Bremises Dr. H. L. Oldershaw reports:— During the year accommodation planned for health purposes became available and increased the provision of health services in areas within the division which had been inadequately served. The main changes in accommodation were as follow:— Maternity and Child Welfare (1) Linnet House Maternity and Child Welfare Centre, planned and built by the St. Marylebone Borough Council, was handed over to the Council and opened in April. This modern, well-equipped centre completes an equable distribution of maternity and child welfare services in the area. (2) Accommodation at Barnes House, previously occupied by the chest clinic, was taken over to improve and augment the welfare centre already situated in that building. (3) Owing to extensive structural repairs becoming necessary the work of the West End Lane centre was temporarily transferred to Dynham Road, where accommodation had become vacant when the chest clinic was transferred to Eton Avenue. (4) The day nursery at 108 Hampstead Road was closed in September as the Regional Hospital Board, who own the building, required the premises for hospital services. The loss was partly offset by conversion of a portion of the Centre premises at Ampthill Square to provide a nursery of thirty places. School Health Service (1) A Minor Ailments Centre was opened at the St. Marylebone Town Hall Extension in premises specially designed for the purpose but previously occupied by the Ministry of Food. (2) Further accommodation was rented from the Hampstead Borough Council at Lithos Road, which enabled dental services to be provided for school children in addition to the existing dental services for maternity and child welfare. (3) The Minor Ailments Centre at Cirencester Street, which was housed in a most unsuitable building, was transferred to the Bathing Centre premises at 210, Harrow Road, where, after appropriate alterations, accommodation for both activities became available. 128 Maternity and child welfare services Health Visiting.—The past year has shown a substantial increase in the number of visits made by health visitors. A total of 138,901 visits was made compared with 120,490 for the year 1949. Sessions.—Additional maternity and child welfare sessions have been provided at various centres during the year, including special toddlers' clinics, play centres, mothercraft classes, cookery and sewing classes. Day nurseries Medical Staff.—The opportunity has been taken for the interchange, on a sessional basis, of assistant medical officers with Registrars of hospitals in the division. (a) Accommodation.—The 23 Council day nurseries in the division provide accommodation for 1,348 children, and despite application of the priorities for admission as laid down by the Health Committee, the waiting list of children at the end of the year totalled 1,378, of which 1,068 were priority cases. (b) Nurseries and Child-Minders Regulation Act.—The Divisional Health Committee have registered 15 child-minders and 15 private day nurseries since the operation of the Act until the end of 1950. Three of the child-minders have ceased to operate as such since registration. Regular periodical supervision of both premises and child-minders is maintained by the Council's medical officers and health visitors. (c) Child-minders.— The number of child-minders on the Council's voluntary list increased from 72 at the end of 1949 to 101. School health services The work of school medical inspection has proceeded smoothly, and eight assistant medical officers are now combining this work with maternity and child welfare. Additional vision sessions and an orthoDtic clinic have been arranged. Home help service The service, already well established before 5th July, 1948, has been considerably extended, and a total of 3,111 applications for home helps was received during the year. The average number of households receiving assistance each week was approximately 1,000. Tuberculosis lhere has been close liaison tor care and after-care with the chest consultants and almoners at the chest clinics, and plans are in hand for extension of the arrangements for care and after-care during the forthcoming year. Vaccination and immunisation In addition to the service provided by the general practitioners, the Council has provided in the division centres at which vaccination and immunisation can be carried out. During the year 6,727 people, mostly children, were vaccinated and 12,170 immunised against diphtheria. Health education One of the assistant medical officers plans and co-ordinates the health education activities of the division. Liaison with hospitals Liaison with the hospitals in the area has advanced during the year. An enuresis clinic has been established at University College Hospital for school children on the recommendation of the divisional treatment organisation, and beds at St. Charles' Hospital have been allocated for urgent tonsil and adenoid cases. Divisional co-ordination Periodic meetings of certain of the assistant medical officers with the divisional staff for discussion on medical and administrative matters has proved of great advantage. Conclusion I would again like to express my sincere appreciation to all those operating the health services in the division, and in particular to the help and encouragement given by the Divisional Health Committee. Division 3, comprising the boroughs of Finsbury, Holborn and Islington. Dr. A. B. Stewart reports:— Care of mothers and young children Places for 609 children were provided at the eleven day nurseries in the division. In addition, there were three private day nurseries registered under the Nurseries and Child-Minders Regulation Act, providing up to a maximum of 185 places, and at the end of the year 166 children were being cared for during the day by childminders. The number of priority cases awaiting admission to the Council's day 129 nurseries on the 31st December, 1950 was 302, no appreciable variation of the position as it existed at the end of 1949. Fifteen maternity and child welfare centres (including branch clinics) were operating in the division throughout the year. Full use was made of the two Family Planning Clinics, to which 282 women were referred for advice, and continued use was made of the Mothercraft Training Centre for babies with dietetic upsets and mothers with breast feeding difficulties. Four maternal deaths occurred in the division, one of which was of a non-resident. The home help service was utilised to assist in 228 home confinement cases. Recuperative holidays lhere was an increased demand tor recuperative holiday placmgs, and 12 per cent, more cases were dealt with compared with 1949. Home help service Demands for this service continued to increase and the staff of home helps was, as a result, expanded by about 25 per cent. Vaccination and immunisation Approximately 28 per cent. of babies under twelve months were successfully vaccinated during the year, and there was an increase of 44 per cent, in the total number of vaccinations in all age groups. Vaccination sessions were started in the day nurseries. Smallpox in Scotland during April, May and June with resulting newspaper publicity caused the number of vaccinations to increase by about 50 per cent, above the number for the corresponding period in 1949. It is estimated that at the end of the year 57 per cent, of children 0^4 years and 85 per cent. 5-14 years had been immunised against diphtheria. Twenty-two cases of diphtheria were confirmed during the year, but only one death occurred; the child had never been immunised. Tuberculosis after-care Health education A Divisional Tuberculosis Care Committee was appointed during the year, and a review was made of the activities of the three local Tuberculosis Care Committees. A programme of health publicity was followed in the division, by which the same topics were concentrated upon at each centre. The various establishments exhibited posters and distributed leaflets according to this programme, the topic being changed once a month. The exhibition stand provided by the Central Council for Health Education was on display at various premises throughout the division. Short articles on health matters were published from time to time in the Bulletin of the Islington Public Library. Foot clinic The clinic in the Finsbury Health Centre, employing the equivalent of five full-time chiropodists, continued to provide a service much in demand. The attendances increased to approximately 20 per cent.above the previous year's level. Premises Considerable progress was made in the carrying out of essential cleaning and painting works in the various establishments and full use was made by the Divisional Health Committee of their delegated powers to incur expenditure on such work by the employment of local contractors to supplement the Architect's programme. More suitable premises were found at the Highbury Quadrant Church for a branch welfare clinic, formerly held at the Highbury Vale Mission Hall, Hurlock Street. A building re-development scheme necessitated the closure of the Holborn Day Nursery, but a project for its replacement is under consideration. School health service There was an increase in the number of sessions to meet a growing demand for appointments at nutrition clinics. Extra sessions were provided occasionally at vision clinics in order to reduce waiting lists. The delay in obtaining spectacles was considerably reduced. Doctors at the nutrition and rheumatism supervisory clinics utilised the services of a physiotherapist employed in the division. Two speech therapy clinics held in school premises were found inadequate, and it is intended to replace these by establishing three speech therapy clinics in school treatment centres, thereby reducing waiting lists, and providing better accommodation. Following a new arrangement with the North-East Metropolitan Regional 130 Hospital Board, the lists of children referred for tonsillectomy were reduced to manageable proportions. Assistant medical officers have been glad to avail themselves of paediatric seminars at the Whittington Hospital to refresh their clinical knowledge. Division 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports:— Day nurseries The priority waiting list for day nursery places which stood at the beginning of the year at 600 to 700 was reduced to about one-fifth of this figure by the end of the year. This fall was brought about largely by a careful check of the financial circumstances of all applicants, which resulted in the exclusion of a number who were found to fall outside the priority limits, and to the lapse of an even greater number of applications. At the same time, the scheme for the voluntary registration of child-minders which had been introduced in the division during the previous year was considerably developed and the number of registered child-minders increased during the year from 32 to 69. One additional private day nursery was registered under the Nurseries and Child-Minders Regulation Act, 1948, and one nursery previously registered was closed. At the end of the year, there were 6 nurseries providing 192 places registered under the Act. The number of statutorily registered child-minders at the end of the year was 3, approved for the care of 15 children. Recuperative holidays . The demand for recuperative holidays has continued to increase, and the number of holidays provided during the year reached a total of over 1,200 compared with nearly 1,000 in the previous year. Of those sent away, approximately 60 per cent, were children. Domestic help The number of applications for home help received during the year was approximately 1,800 and, with the carry-over from 1949, service was provided to over 1,500 households each week. Maternity and child welfare Following the closure of 186, Upper Clapton Road as a day nursery staff hostel, the premises were, after suitable alterations, brought into use as a maternity and child welfare centre in place of 2-4, Warwick Grove, which was an unsatisfactory building and was scheduled for demolition on its release by the Council. Special toddlers' sessions at which children receive a thorough medical examination at about their 2nd, 3rd, 4th and 5th birthdays, were commenced at three Hackney welfare centres, bringing the total weekly sessions of this type in the division to 6. Approximately one-third of the children attending these sessions were found to require treatment. As a measure of economy, the holding of separate sessions for vaccination and diphtheria immunisation was discontinued, and combined sessions were substituted throughout the division. In addition to their talks with individual mothers who attend welfare centres medical officers and health visitors have been encouraged to give group talks of 5-10 minutes' duration during infant welfare sessions on specific topics including "Food," "The basis of good health," "Common infectious diseases," and "Protection against diphtheria." Shortage of health visitors has, however, limited the development of this important activity. Postural exercises for day nursery children and school children, and ante-natal exercises for expectant mothers, were given by a qualified physiotherapist. The special scheme for the supervision and care of premature infants which was introduced in the division in September, 1949, was continued with satisfactory results. In addition to attendances at the special weekly clinics at which babies are seen by a doctor, an average of 4.9 visits was made to the home of each premature infant within the scheme. 131 Special breast feeding clinics for nursing mothers were continued in Shoreditch. Mothers attend these clinics for test-feeds two or three times in a day, and receive advice regarding feeding difficulties; 800 attendances were made during the year. The weekly marriage advisory evening clinic was continued. An average of between three and four attendances was made at each session. Permission was given to the Family Planning Association to hold a second weekly clinic in the division at Barton House welfare centre, in addition to that already held at 28, Lower-Clapton Road. After-care of tuberculous patients Handicratt classes were formeriy organised by each of the three chest clinics in the division, but all except one, serving part of the borough of Hackney, had lapsed during the war. To remedy this deficiency, suitable accommodation reasonably accessible from all parts of the division was rented by the Council, and a class was started on one afternoon a week, under the control of the local Tuberculosis Care Committees. It is proposed in due course to extend these activities. Housing Over 130 applications for housing preference on medical grounds were dealt with each week. School health service Nutrition and rheumatism clinics were well attended during the year. The scheme introduced during 1949 under arrangements between the Council and the North-East Metropolitan Regional Hospital Board to provide operative treatment for enlarged tonsils and adenoids for school children, which was suspended in August owing to the incidence of poliomyelitis, was restarted in November and was extended to include children under five. Under this scheme 461 operations were carried out during the year. The expansion of the various services has placed a heavy burden on the staff, and the success achieved is due in large measure to their zeal and efficiency, and to the help and co-operation of the medical officers of health of Hackney, of Shoreditch, and of Stoke Newington. Division 5, comprising the boroughs of Bethnal Green, Poplar, Stepney and the City of London. Dr. G. 0. Mitchell reports:— During 1950 we were able to begin to implement the Council's policy of providing office accommodation for health visitors in the areas in which they work, rather than at central points. The opportunity arose when it was decided to transfer the ante-natal clinic from very unsuitable premises in Salmon Lane to the Limehouse maternity and child welfare centre in Commercial Road. By some minor adaptations at the latter premises we were able to accommodate not only this ante-natal clinic, but also some health visitors hitherto housed at the offices of the Stepney public he&lth department. Plans were approved by the Divisional Health Committee for similarly decentralising other health visitors early in 1951. Domestic help The domestic help service continued to be much in demand, particularly in the case of the aged and infirm. This is a very real contribution to the solution )f the problem of the aged, and such requests for help will almost certainly continue to increase. Difficulty, however, was still experienced in recruiting home helps, and it the end of the year we were still somewhat below our permitted numbers. Some reorganisation of this service was achieved by redefining the three districts, which tvere hitherto conterminous with the boroughs of Bethnal Green, Poplar and Stepney, rhe three new districts, now called Northern, Southern and Eastern, cut across aorough boundaries and are more manageable administratively because of their comparative equality in terms of demand for domestic help. While the Northern listrict office remains in Cornwall Avenue, Bethnal Green, the Southern district jffice, covering most of the borough of Stepney, has been transferred from Salmon Lane to a modern office suite more centrally situated in Commercial Road. The Eastern district office will be transferred early in 1951 from Poplar Town Hall to 132 the combined maternity and child welfare and school treatment centre in East India Dock Road. School treatment centres Towards the end of the year the work of adapting a self-contained suite of rooms in the Mary Hughes Building, Underwood Road, as a school treatment centre was completed. This was designed to replace the Whitechapel school treatment centre which had suffered many vicissitudes since its premises were demolished by enemy action in 1941, but which had continued to function in temporary accommodation. The new centre was formally opened on 20th November, and was renamed "The Ida Samuel School Treatment Centre "as a memorial to the late Miss Ida Samuel, who founded the original centre in 1917 and acted as hon. secretary of its voluntary committee throughout. The rheumatism and nutrition sessions which had been held temporarily at the Rochelle Street centre were transferred to the new centre. Premises From time to time the Divisional Health Committee have been concerned about burglaries at various clinics and day-nurseries. These unlawful entries have not usually involved serious loss, but the places are left in disorder, and many small articles, often including staff property, have been taken. During the year, therefore, a comprehensive survey of all clinic buildings and day nurseries was undertaken, and measures instituted, depending upon local circumstances, to make these premises more burglar-proof than hitherto; so far, at any rate, with some apparent success. Nursery classes The programme for redecoration of premises continued steadily throughout the year, and by the end of 1950 we were within sight of its completion. As an ancillary to day nurseries, it is interesting to note that during the year five new nursery classes have been opened by the Education department; this brings the total of nursery classes attached to primary schools in this division to 23. Division 6, comprising the boroughs of Deptford, Greenwich and Woolwich. Dr. F. R. Waldron reports:— Economic circumstances have not choked all progress, as the following brief references to developments indicate. The site of 41, Fairfield Grove, Charlton, adjoining Fairfield House maternity and child welfare centre, was purchased with the object of eventually developing the whole site for comprehensive health services. New centres for integrated child welfare services In place of rented accommodation in a borough council house and sports pavilion, a large detached property known as Rusthall Lodge, Eltham, was brought into use progressively so as to provide the following services:—ante-natal clinic, ante-natal and post-natal exercise class, infant welfare clinic, light treatment and exercise classes for pre-school children; minor ailments, dental, vision, rheumatism and nutrition clinics, and speech therapy classes. In addition accommodation was provided for the home help organiser for the Eltham area. In smaller ways also the ideal of treating child health as a whole has been fostered. Nutrition clinics for school children were introduced into Amersham Road and Chevening Road welfare centres. Light treatment clinics at infant welfare centres were made available to school children referred by school doctors. Maternity and child welfare Increasing attendances made necessary four additional infant welfare or toddlers sessions at various centres. Ante-natal and post-natal exercise classes taken by physiotherapists or health visitors were introduced at four centres. Prophylaxis In place of separate sessions for smallpox vaccination and immunisation against diphtheria and whooping cough, combined sessions were provided. Economy to the extent of eleven sessions a month resulted from this arrangement. The incidence of poliomyelitis in 1950 was greater in this division than in other parts of the County and the following precautionary measures were "taken at the Council's clinics, viz., diphtheria immunisation by sub-cutaneous administration of 133 P.T.A.P. and Formol Toxoid (as it became available), and discontinuance of the use of the combined diphtheria and whooping cough antigen. School health services An improved service was provided by the opening of half-time clinics as follows:—Woolwich and Charlton—Maryon Park School; Plumstead—Garland Road maternity and child welfare centre; Eltham—Rusthall Lodge Centre and Ealdham Square School. At the Reginald Square school treatment centre (Deptford Voluntary Committee), four orthoptic sessions a week were established, two to run concurrently with refraction clinics. There is close liaison in this work with the Eye Department of the Miller General Hosnital. Chiropody Better accommodation for chiropody was provided (1) at the Health Centre, Amersham Road (5 chairs), by transfer from Deptford Chest Clinic and (2) at 105, Shooter's Hill Road. Greenwich. The number of treatments increased from 54,000 to 65,141 a year. The special Saturday morning sessions for the treatment of warts on the feet and other foot conditions in school children proved of great value. Home help service This service continued to expand although at a slackening pace. Over the year the number of persons attended increased from 875 on 1st January to 1,200 on 31st December and home helps from the equivalent of 150 whole-time staff to 190. Approximately 75 per cent. of the people assisted were elderly, many in circumstances which provide scope for voluntary help in neighbourly tasks: the fetching of library books is instanced. A scheme was accordingly introduced, with the cooperation of voluntary agencies, whereby the home help organisers pass the names of such persons to the secretary of the nearest voluntary body participating in the sohemp Medical research In addition to working on national surveys, the staff of the division have assisted with 264 cases included in the County investigation into the causes of still-births and neo-natal deaths. Premises Amenities were increased by minor alterations to buildings, the redecoration of four centres, and the improvement of grounds. Division 7, comprising the boroughs of Camberwell and Lewisham. Dr. H. D. Chalke reports:— • Premises Early in the year the Downham Health Centre (rebuilt after destruction by enemy action) and premises on the Flower House Estate became available. The former, which is managed by a voluntary committee, provides school treatment, dental services, infant welfare clinics (also under the direction of a voluntary committee) and ante-natal and exercise sessions. Both these centres have proved welcome additions to the personal health service amenities available in this part of Lewisham. A number of infant welfare clinics continue to be held in church halls, many of which are ill adapted for this purpose. It has not been possible to obtain more suitable accommodation : this is regrettable. The general condition of the premises housing the Council's day nurseries and maternity and child welfare centres has been much improved. Many have been redecorated internally and externally and the ravages of the war years—when maintenance was kept low— removed. The Council's Parks Department has given a good deal of assistance in improving the appearance of a number of centres and nurseries. Refrigerators, drying cabinets and supplementary electric heating have been installed in many of the day nurseries. The Restaurants and Catering Department gave invaluable assistance in providing meals in one of the nurseries during an emergency period when the kitchen was not available. Clinics A number of additional ''toddlers'' and ante-natal clinics were opened. The ante-natal clinics include those attended by midwives of the Salvation Army and of the postgraduate school of the General Lying-in Hospital. Close contact was 134 maintained with the obstetric departments of hospitals in the division, and the cordial relationship established was a prime factor in the efficient running of this important part of the service. Unfortunately, resignations of dental officers necessitated further curtailment of the school dental service. One dental hygienist is employed in this division. "Open Days" Upen days started at tour 01 tne largest weiiare centres tne aim oeing to give local workers in the various branches of the health service an opportunity of meeting the staff and of getting a closer insight into the work of the centres. Invitations were accepted by general practitioners, hospital medical officers, matrons, almoners and sisters, head teachers, and a large number of social workers— a most encouraging response. Welfare of old people A statistical survey was maae ot tne circumstances of 1,050 old persons wno were receiving home help. This brought to light many interesting facts. (The Report has been published in a Medical Journal.*) In view of the increasing number of old people who live alone and who do not receive adequate care and attention, it is essential that there be the fullest co-operation between everyone concerned, and it is particularly important that, for example, the services of home helps, district nurses and voluntary workers are sought early—this is, unfortunately, sometimes never sought and often left until the old person has become permanently bedridden. The greatest problem of all is that of the aged sick who are left entirely alone at night and at weekends. With the object of discussing these problems and bringing about better co-ordination of effort a conference was called which was attended by representatives of the various statutory and voluntary bodies interested in the subject. The results of the meeting were encouraging. Male home helps are proving very useful, particularly in homes which have become dirty through neglect. The initial prejudice to the visit of a male worker is being overcome. Health education New film strips have been purchased: the subjects include ante-natal care, accidents in the home and problem families. This useful adjunct to health teaching in welfare centres is becoming increasingly popular. Regular weekly mothercraft classes were held in four welfare centres, at which the attendances increased. A lending library was started at one welfare centre as an experiment. It is well patronised, and the books are read by fathers as well as mothers. In view of its popularity the scheme has been extended to other centres. The books cover a wide range of health subjects such as child care and management, home making, marriage guidance and simple physiology. There is no charge for borrowing, and it is gratifying to note that the books are returned promptly and in good condition. An approach was made to the borough councils regarding the availability in public libraries of books on mothercraft and child welfare. It was a pleasure to find that a number of suitable books were available. Additional books—recommended by the divisional staff—are being purchased, and in many libraries appropriate publicity is being given to books of this nature. School health service The number of attendances at school treatment centres rose. I he special clinics were continued, including those held at King's College Hospital and the Children's Hospital, Sydenham, which are attended by school treatment, organisers, who also visit St. Giles and Dulwich hospitals. Health visiting There was again a slight increase in staff, which lightened the case-load, but it is still above an average of over 1,000 children under 5 years of age to each health visitor. These numbers, combined with the increased number of reports on home visits required by hospitals and other social agencies, mean that there had to be a reduction in the number of routine visits paid to certain age-groups. The health visitors are now concentrating on those families where there are special difficulties or where there is a low standard of home care. A considerable amount of time is given to these families, which, it is hoped, is time well spent in the interest of preven*Chalke, H. D. and Benjamin, B. (1951). The Medical Officer, 85, 65. 135 General tion of illness and distress. The divisional staff have worked at high pressure but have responded admirably to the increasing duties devolving upon them. Excellent co-operation has been received from the medical officers of health of Camberwell and Lewisham and relationships with the staffs of hospitals, the general practitioners and the many voluntary organisations in the division have been most cordial. Division 8, comprising the boroughs of Bermondsey, Lambeth and Southwark. Dr. W. H. S. Wallace reports:— Premises The administration of the services in the division was continued from the divisional offices with sub-offices in each of the boroughs. A new sub-office was opened in Lambeth as the accommodation at the Lambeth Town Hall was no longer available. The new sub-office has proved very satisfactory and it has the advantage of having a shop window where arrangements are being made for displays of health education material. The maternity and child welfare services continued to function smoothly. The voluntary committee at the Norwood centre gave up control of the centre and its administration was handed over to the Council. The Moffat welfare centre was moved to new premises at Alford House. The old premises were unsatisfactory and the rooms rented in the Alford House Youth Club, which is situated nearby, afford a considerable improvement. Ante-natal clinics There was a decline in the number of mothers attending the ante-natal clinics throughout the division. This was in part due to a decline in the birth-rate and in part to the fact that hospitals encouraged mothers to attend the hospital ante-natal clinics. The number of ante-natal sessions at which medical officers attend was therefore reduced. Midwives' sessions are now held at nearly all centres in the division. Medical officers Arrangements were made with hospitals in the division for exchange of medical officers at welfare clinics with medical officers in the hospitals. The clinic medical officers on the Council's staff are undertaking out-patient sessions at Guy's and King's College hospitals and in-patient sessions at St. Olave's Hospital and in exchange hospital medical officers are undertaking infant welfare sessions. This gives most valuable experience to both sides, keeping clinic medical officers in touch with recent medical treatment and giving the hospital medical officers experience in the work of the Council's preventive services. School health service In the school health service there was an increase in the number of children requiring refractions and a new eye clinic was opened at Page's Walk School and one extra session in every four week period became necessary at the Norwood school treatment centre. The Royal Eye Hospital continued to provide 10 ophthalmic surgeon's sessions and 20 orthoptist's sessions a week for school children but there was still a waiting list involving a wait of approximately six weeks. The number of children recommended for tonsil and adenoid operations remained high. "T & A" operations had to be cancelled twice during the year on account of the prevalence of poliomyelitis. In spite of this 240 operations were performed at St. George's Dispensary during the year. The year showed a decline in the number of children attending minor ailment centres and both doctors' and nursing treatment hours were reduced accordingly. Day nurseries There were still long waiting lists lor admission to the day nurseries although there was some decline in the number especially in the Norwood area. The policy of applying the Council's priority rules to children who had been in the nurseries before the priorities were adopted was carried out. As a result many children were excluded. Child-minders were available to meet the needs of children so excluded in the Lambeth area but there was difficulty in obtaining child-minders in Bermondsey and Southwark. The Divisional Health Committee directed that all but two of the 136 day nurseries in the division (Bishop's House and Coldharbour Lane) should be closed on Saturday mornings. Repairs and redecorations continued to the nursery buildings; Coral Street, Cowley, Gipsy Hill, Knight's Hill, Tenda Road and Tulse Hill nurseries and also North Brixton welfare centre were completely redecorated during the year. Housing The transfer to the division of the scheme for recommending re-housing priorities on medical grounds was carried out smoothly. The medical officers on the whole-time staff assess the priorities. The administration of this scheme by the divisions has the advantage that all concerned with the housing conditions of the applicants, health visitors, after-care workers, and almoners are in close touch with each other and the medical officers can readily obtain full information regarding the families. Many requests for housing reports have been received from almoners as doctors at the hospitals wish to have full information regarding home conditions before giving medical recommendations for re-housing. The other personal health services provided, including home helps, home nursing and recuperative holidays continued to be in great demand. Division 9, comprising the boroughs of Battersea and Wandsworth. Dr. Bertha E. A. Sharpe reports:— The difficulty in administration referred to in my report of two years ago still exists, owing to the fact that there is not a centralised office. Every effort has been made to overcome this handicap. The number of births in the division this year was 621 less than in 1949, i.e., a drop of 8"6 per cent. This is naturally reflected in much of the work of the division. The number of women attending the ante-natal clinics fell and the total attendances dropped. The attendances at child welfare clinics also fell in proportion to the decline in the birth-rate. Aged chronic sick The problem of dealing adequately with the aged chronic sick is unsolved. The fact that this division has the lowest birth-rate and the highest death-rate suggests that the average age is high. The shortage of hospital beds causes long delays in admission and the best that the local personal health service can do is to alleviate home conditions. As an example of the kind of help given, one of the Samaritan Funds provided hot water bottles for all the aged sick known to be short of fuel during the cold spell in the latter part of the year. It is not without significance that the number of visits made by the district nursing associations has increased by over 11,000 compared with 1949, i.e., '210 a week. Tuberculosis The Balham chest clinic shared premises with a child welfare clinic. In the autumn it proved possible to end this unsatisfactory occupation and the chest clinic was transferred to the Weir Hospital. The home visits to tuberculous patients which I stated last year to be too infrequent still fell short of what is desirable, despite the appointment of an additional tuberculosis health visitor. This was due to an increase in the number of clinic sessions. A diversional therapy scheme for patients who are "homebound" was organised towards the end of the year. Voluntary instructors visit the patients' homes and the working material is provided by the Tuberculosis Care Committees. The finished articles will be sold and the patient will be allowed to receive up to £1 a week without imperilling his benefits under the National Insurance Act. It is hoped to develop this scheme which is only in its infancy. Recuperative holidays A qualified teacher was appointed to the Wandswortn Handicraft Class in October. The applications for holidays remained stead)' but the percentage placed through the division increased:— from 25 per cent. to 62 per cent. for mothers and accompanied children, from 25 per cent. to 51 per cent. for unaccompanied children, from 31 per cent. to 42 per cent. for adults. 137 Vaccinations Many expressions of gratitude for careful placings were received. There were 3,924 vaccinations, tl at is an increase of 40 per cent, on the figures for 1949. Consultation ?linics This division has in recent years made a special feature of consultations on bed-wetting. The number of sessions held this year was 152 and the number of attendances 1,683, showing an increase of 34 per cent, and 29 per cent, respectively. This implies that the facilities provided are meeting an increasing demand. Day nurseries The revised scheme for admission to day nurseries made little difference in this division as it had been the policy to admit only children in the priority classes. The parents of the few children who, as the result of the review, were discharged from the nurseries were given all possible assistance in making alternative arrangements Housing In August 1950 the duty of determining the priority to be given on medical grounds to applicants for housing accommodation was decentralised. During the ensuing 4 months 1,200 applications were assessed. Staff It has always been the practice in this division for health visitors to give health talks at the child welfare clinics. This practice was extended this year to include talks by the clinic medical officers. There is evidence that these talks are much appreciated. This report would not be complete without a tribute from me to the medical, nursing and administrative staff working in the division. STATISTICS Table 1—Papulation of the County of London, 1921-1950 Year Mid-year estimate of population Average age Total 0-4 6-14 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 3.800,300 211,900 457,500 3,130,900 1940 ... 3,236,600 141,300 232,500 2,862.800 1941 2,507,800 79,200 142,1(1(1 2,286,500 1942 ... 2,634,800 137,700 234,500 2,262,600 1943 ... 2,794,200 179,500 282,000 2,332,700 1944 ... 2,753,600 172,000 302,300 2,279,300 1945 ... 2,906,900 189.720 311,440 2,405,740 1946 ... 3,272,500 227,470 353,050 2,691,980 1947 ... 3,409,300 259,000 364,600 2,785,700 1948 ... 3,397,900 269,900 359,500 2,768,500 1949 ... 3,389,850 276,200 367,000 2,746,650 1950 ... 3,389,620 276,200 370,000 1,437,960 1.305,460 138 Table 2—Vital statistics for the metropolitan boroughs and the County of London in the year 1950 (6) Metropolitan boroughs arranged in divisional order Estimated home population 1950 Lire births Death.Rates Notifications of infectious disease Deaths Infant mortality (per 1,000 live births) Heart disease Other circulatory Cerebral vascular lesions Peptic ulcer Pulmonary tuberculosis Pneumonia Other respiratory diseases Cancer Violence Scarlet fever Diphtheria Poliomyelitis Meningococcal infection Acute pneumonia Measles Whooping cough Tuberculosis Paralytic Non Paralytic Pulmonary NonPul monary Division 1 Chelsea 52,490 15.8 12.2 25 3.66 0.59 1.45 0.08 0.27 0.69 0.76 2.44 0.55 1.05 — 0.02 0.04 — 0.48 6.06 3.24 1.43 0.06 Fulham 123,400 14.4 11.5 25 3.69 0.45 0.92 0.18 0.28 0.62 1.12 2.27 0.43 1.02 — 0.05 0.04 0.02 0.26 4.27 3.47 1.69 0.15 Hammersmith 119,200 16.7 10.9 17 3.17 0.43 1.34 0.10 0.32 0.45 0.94 2.19 0.44 1 .21 0.03 0.04 0.07 0.01 0.49 6.33 3.39 1.39 0.18 Kensington 177,400 15.5 10.4 28 2.89 0.50' 1.19 0.15 0.29 0.46 0.64 2.03 0.55 0.56 0.01 0.04 0.04 0.03 0.39 3.92 1.78 1.40 0.17 Division 2 Hampstead 97,400 15.5 10.0 19 3.08 0.52 1.06 012 0.25 0.41 0.53 2.00 0.52 0.79 — 0.09 0.05 0.01 0.45 6.04 1.94 0.98 0.10 Paddington 130,600 16.5 10.7 29 3.25 0.44 1.05 0.15 0.41 0.48 0.68 2.08 0.48 1.20 — 0.05 0.05 0.02 0.40 7.20 1.94 1.96 0.18 St. Marylebone 78,260 11.0 11.6 22 4.09 0.54 1.24 0.18 0.26 0.41 0.56 2.29 0.65 0.83 — 0.05 0.04 0.01 0.52 4.13 2.17 105 0.08 St. Pancras 141,300 15.5 11.5 31 3 41 0.46 0.96 0.25 0.49 0.62 0 85 2.46 0.55 1.27 — 0.08 0.06 0.04 0.67 7.46 2.99 1.70 0.16 Westminster, City of 105,100 11.9 10.2 35 2.92 0.35 0.94 0.14 0.35 0.43 0.59 2.39 0.62 0.71 0.03 0.08 0.05 0.04 0.11 3.39 2.30 1.47 0.12 Division 3 Finsbury 35,810 17.3 11.7 19 3.38 0.64 1.03 0.20 0.34 0.75 0.87 2.54 0.50 1.34 0.03 0.14 — 0.03 1.20 8.32 5.11 2.01 0.11 Holborn 25,930 11.6 11.0 23 3.16 0.46 1.04 0.15 0.39 0.81 0.58 2.28 0.66 0.62 0.08 0.08 — — 0.23 5.28 3.47 1.50 0.19 Islington 238,200 17.2 11.6 29 3 43 0.58 1.10 0.18 0.37 0.61 1.00 2.25 0.45 1.13 0.08 0.07 0.04 0.04 0.55 10.34 3.16 1.80 0.18 Division 4 Hackney 172,100 15.0 11.0 23 3.46 0.34 1.11 0.18 0.32 0.64 0.85 2.07 0.31 1.60 0.05 008 0.06 — 0.37 6.35 3.24 1 .22 0.19 Shoreditch 44,800 17.7 12.4 30 3.12 0.54 1.23 0.16 0.38 0.62 1.58 2.19 0.38 1 .21 0.45 0.07 0.02 0.04 0.67 7.21 5.11 1 .36 0.18 Stoke 48,510 17.6 10.5 25 2.91 0.31 0.87 0.25 0.31 0.68 1.11 2.02 0.41 2.10 0.06 0.08 0.14 — 0.54 8.06 2.39 1.30 0.08 Newington Division 5 Bethnal Green 58,730 16.7 12.3 28 3.87 0.44 1.11 0.17 0.31 0.77 1 .28 2.21 0.32 1.07 0.02 0.05 0.05 0.02 0.49 4.04 3.44 1.35 0.12 City of London (a) 4,870 7.8 12.7 26 4.72 — 0.41 — 0.62 0 41 1.03 3.49 — 0.41 — 0.21 — — — 0.41 0.41 2.67 — Poplr 74,050 16.7 10.8 28 2.93 0.43 1.08 0.16 0.42 0.42 1.05 2.19 0.47 1.34 0.03 0.03 0.03 0.05 1.34 5.66 6.48 1.00 0.11 Stepney 99,730 18.5 12.6 27 4.00 0.46 0.98 0.20 0.50 0.46 1.14 2.56 0.55 1.06 0.06 0.09 0.09 0.04 0.61 5.04 2.94 1.60 0.16 Division 6 Deptford 76,580 16.4 11.8 29 3.49 0.59 1.07 0.17 0.34 0.67 1.10 2.29 0.46 1.18 0.01 0.10 0.01 — 0.57 11.57 3.64 3.15 0.22 Greenwich 89,570 16.7 10.4 27 3.27 0.59 0.90 0.12 0.46 0.36 0.76 1.92 0.33 1.79 0.01 0.17 0.09 0.01 0.33 10.44 3.45 1.32 0.19 Woolwich 149,000 14.6 11.2 24 3.70 0.40 1.14 0.21 0.36 0.44 0.64 2.27 0.33 1.24 — 0.25 0.10 0.06 0.81 5.06 3.37 1.23 0.15 Division 7 Camberwell 178,900 16.2 11.3 27 3.94 0.34 1.04 0.16 0.32 0.42 1.07 2.08 0.33 1.13 0.04 0.07 0.03 0.02 0.45 8.04 3.92 1.62 0.20 Lewisham 228,300 15.3 10.6 26 3.50 0.35 1.09 0.14 0.29 0.37 0.72 2.07 0.35 1.53 — 0.11 0.05 0.03 0.47 9.13 3.56 1.58 0.20 Division 8 Bermondsey 59,810 19.2 12.0 20 3.51 0.42 1.25 0.23 0.37 0.59 1.37 2.36 0.33 1.22 — 002 0.02 0.02 0.27 6.12 4.43 1.76 0.17 Lambeth 231,000 16.8 11.8 29 3.97 0.37 1.19 0.16 0.38 0.47 0.94 2.10 0.40 0.96 — 0.07 0.03 0.03 0.32 7.10 3.13 1.73 0.13 Southwark 97,080 18.6 12. 3 20 3.85 0.36 1.04 0.23 0.53 0.59 1.16 2.28 0.58 1.53 0.10 0.04 0.08 0.24 8.30 3.65 1.84 0.28 Division 9 Battersea 117,700 16.1 11.2 27 3.88 0.39 1.26 0.14 0.37 0.42 0.76 2.07 0.35 1.29 — 0 04 0.02 0.03 0.69 1.96 2.87 1.14 0.13 Wandsworth 333,800 13.8 12.0 22 3.88 0.55 1.20 0.16 0.41 0.40 0.87 2.32 0.46 1.69 0.00 0.06 0.05 0.02 0.59 5.16 3.26 1.36 0.10 London, 1950 3,389,620 15.7 11.3 26 3.54 0.45 1.11 0.17 0.36 0.50 0.88 2.20 0 44 1.23 0.02 0.08 0.05 0.03 0.50 6.57 3.21 1.53 0.16 London, 1949 1 3,389.850 16.7 11.7 27 3.31 0.65 1.07 0.17 0.47 0.61 1.05 2.10 0.46 1.46 0.07 0.20 0.02 0.55 8.54 1.70 1.68 0.16 (o) Including Inner and Middle Temple. (6) Rates are per 1,000 home population. 139 Table 3—County of London—Principal vital statistics, 1891.1950 Period Annuo t 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) Meningococcal infection Diphtheria Enteric fever Scarlet lever Smallpox Whooping cough Measles Influenza Tuberculosis Infants 0—1 Diarrhoea and enteritis 0—2 Puerperal fever Other child.birth. Pulmonary Non.pulmonary Pneumonia (all forms) Bronchitis Other resp. diseases Heart disease Cancer Diabetes 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 1.04 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 .04 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 0.99 1.38 (d) 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 0.49 0.97 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 0.28 1.08 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 0.12 0.80 1947 20.9 23.2 12.5 0.02 0.01 0.00 0.00 — 0.03 0.01 0.09 0.62 0.03 0.75 1.03 0.15 3.37 2.06 0.07 34 4.5 0.12 0.55 1948 17.9 22.7 11.1 0.01 0.01 000 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 0.13 0.37 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 0.02 0.38 1950 15.7 20.2 11.3 0.01 0.00 0. 00 0.00 — 0.01 0 00 0.08 0.36 0.04 0.50 0.78 0.10 3.54 2.20 0.08 26 1.2 — 0.53 Table 4—County of London—Civilian deaths in 1950 by cause Cause Sex 0— 1 — 5— 15— 25— 45— 65— 75+ Total 1950 1949 1. Tuberculosis—respiratory M 4 3 1 27 209 381 163 41 829 1,046 F — — 2 51 187 105 42 9 396 539 2. Tuberculosis—other M 1 5 6 7 18 11 11 3 62 95 P 4 6 7 6 10 17 7 3 60 61 3. Syphilitic disease M — — — — 7 65 54 17 143 182 F — — — — 1 22 26 18 67 88 4. Diphtheria M — 2 2 - - - - - 4 5 F - - - - - - - - - 4 5. Whooping-cough M 13 3 - - - - - - 16 11 F 8 6 - - - - - - 14 16 6. Meningococcal infection M 6 5 1 — 1 — — — 13 7 F 3 1 — — — 4 — — 8 12 7. Acute poliomyelitis M — 3 5 6 8 2 — — 24 26 F — 1 1 4 4 2 — — 12 24 8. Measles M — 3 1 - - - - - 4 7 F - - - - - - - - - 9 9. Other infective, &c. diseases M 1 2 3 1 8 18 8 3 44 32 F 3 5 1 1 10 17 6 8 51 32 10. Malignant neoplasm: stomach M — — — — 36 210 232 104 582 598 F — — — — 28 126 142 162 458 508 11. „ „ Lung, bronchus M — — — — 71 693 364 110 1,238 1,104 F — — - — 20 86 69 45 220 240 12. „ „ Breast M — — — — 1 — 2 — 3 6 F - — — — 69 301 158 162 690 672 13. „ „ Uterus F — — — — 31 165 78 50 324 318 14. Other malignant and Lymphatic neoplasms M — 12 11 12 116 636 671 595 2,053 1,967 F 3 8 5 10 106 568 552 486 1,738 1,677 15. Leukemia, aleukemia and Hodgkins disease M — 8 5 6 20 23 21 8 91 115 F — 4 3 4 8 29 18 11 77 92 16. Diabetes M — — — 2 5 17 31 31 86 85 F — 2 — 2 9 43 57 57 170 163 17. Vascular lesions, nervous system M 2 — 1 1 21 336 560 604 1,525 1,480 F — — — 2 23 375 714 1,118 2,232 2, 122 18. Coronary disease, angina M — — — — 91 970 915 645 2,621 2,251 F — — — — 13 301 576 733 1,623 1,302 19. Hypertension with heart disease M — — — 1 6 179 267 262 715 F — — — 1 4 127 232 414 778 1 3,090 20. Other heart disease M — — 1 14 107 354 650 1,322 2,448 4,514 F — — 3 9 133 410 733 2,530 3,818 21. Other circulatory disease M — — 2 2 18 141 196 343 702 1,011 F — — — — 15 113 193 504 825 1,168 22. Influenza M 5 4 1 — 3 33 34 37 117 191 F 4 3 — 1 9 27 32 63 139 181 23. Pneumonia M 68 18 6 5 26 187 225 301 836 1,051 F 58 20 1 6 25 117 181 450 858 999 24. Bronchitis M 30 5 — — 29 469 551 574 1,658 1,890 F 14 4 3 — 8 108 243 600 980 1,152 25. Other diseases of respiratory system M 5 2 1 1 22 98 62 49 240 294 F 4 1 2 — 5 22 32 48 114 198 26. Ulcer of stomach and duodenum M — — — 1 37 165 153 80 436 423 F — — — — 6 28 47 50 131 137 27. Gastritis, enteritis and Diarrhœa M 40 4 1 2 10 17 14 19 107 104 F 22 2 — 1 4 17 25 23 94 96 28. Nephritis and nephrosis M 1 2 3 9 37 61 45 48 206 308 F — 1 5 7 16 49 49 52 179 315 29. Hyperplasia, prostate M - - - - - 26 121 193 340 384 30. Pregnancy, childb. : abortn. F — — — 9 26 3 — — 38 40 31. Congenital malformations M 128 12 5 7 13 24 9 2 200 208 F 93 12 14 12 23 40 14 7 205 179 141 Table 4—County of London—Civilian deaths in 1950 by cause—continued Cause Sex 0— 1— 5— 15— 25— 45— 65— 75+ Total 1950 1949 32. Other defined and ill-defined diseases M 489 21 14 34 124 313 288 302 1,585 1,426 F 314 9 13 21 124 341 311 494 1,627 1,615 33. Motor-vehicle accidents M — 8 21 22 31 31 23 15 151 193 F — 8 6 5 9 15 17 34 94 64 34. All other accidents M 29 13 13 22 87 90 52 100 406 433 F 16 9 9 7 16 54 78 225 414 401 35. Suicide M — — 1 11 84 110 55 17 278 309 F — — — 5 36 61 24 9 135 160 36. Homicide, operations of war M 2 — — — 3 — 4 1 10 7 F 2 1 — 2 2 2 — 1 10 18 ALL CAUSES M 824 135 105 193 1,249 5,660 5,781 5,826 19,773 20,339 F 548 103 65 166 980 3,695 4,656 8,366 18,579 19,116 Table 5—Live births and Still-births—-County of London Year Live births Still-births No. Rate per 1,000 total population No. Rate per 1,000 live and still-births 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 34.0 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 33.0 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 16.1 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 20.0 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 1950 53,281 15.7 1,054 19.4 142 Table 6—County of London—Infant mortality, 1950 Cause of death Age at death Total Rates per 1,000 live birtha Under 1 day 1 to 7 days 1 to 4 wks. 4 wks. to 1 yr. No. Male Female Total Male Female Measles Leg. - - - - - - Illeg. — — — Whooping-cough Leg. — — - 21 21 13 8 0.39 0.47 0.31 Illeg. — — — Influenza Leg. - — — 9 9 5 4 0.17 0.18 0.15 Illeg. — — — Tuberculosis Leg. — — l 8 9 5 4 0.17 0.18 0.15 Illeg. - _ Bronchitis o Leg. _ 43 44 30 14 0.83 1.09 0.54 Illeg. — — 1 Pneumonia .Leg. 2 21 29 68 126 68 58 2.36 2.48 2.24 Illeg. - 2 4 Diarrhoea Leg. - 3 58 62 40 22 1.16 1.46 0.85 Illeg. - 1 Premature birth Leg. 107 97 14 3 248 146 102 4.65 5.32 3.95 Illeg. 15 11 1 Congenital malformation Birth injury Leg. 24 60 44 86 222 129 93 4.17 4.70 3.60 Illeg. 3 3 2 Leg. 56 52 6 1 130 89 41 2.44 3.24 1.59 Illeg. 11 2 2 Other diseases of early fancy Leg. 122 125 l8 6 305 187 118 5.72 6.82 4.57 Illeg. 12 11 1 Other causes Leg. 5 8 10 157 196 112 84 3.68 4.08 3.25 Illeg. 14 — 2 All causes Leg. M. 193 228 70 225 1,230 746 484 24.81 29.21 20.13 F. 123 135 55 171 Illeg. M. 29 18 7 24 142 78 64 38.33 41.03 35.48 F. 26 11 7 20 Total, 1950 ... ... 371 392 139 470 1,372 824 548 25.75 30.03 21.20 Total 1949 ... ... 438 403 147 529 1,517 899 618 26.83 30.58 22.77 1949 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 Table 7—Infant mortality in London by cause 1915-1950 (Rates per 1,000 live births) Cause of death 1915 to 1918 1919 to 1922 1923 to 1920 1927 to 1930 1931 to 1934 1935 to 1938 1939 to 1942 1943 to 1946 1946 1947 1948 1949 1950 Measles 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 4.45 2.50 2.60 3.14 2.27 2.01 1.43 1.07 0.52 0.76 0.67 0.35 0.39 Influenza 1.10 0.81 0.38 0.48 0.40 0.24 0.39 0.29 0.27 0.17 0.07 0.27 0.17 Tuberculosis 3.20 1.52 1.26 0.89 0.77 0.56 0.63 0.36 0.36 0.35 0.28 0.09 0.17 Bronchitis 6.72 4.42 2.91 2.30 2.16 1 .97 1.81 1.36 1.08 0.94 1.03 0.64 0.83 Pneumonia . 14.96 12.60 11.51 12.10 ] 11.45 10.39 7.64 6.74 5.60 5.61 4.37 3.31 2.36 Diarrhoea 16.10 12.16 9.36 8.87 10.86 12.10 6.96 6.93 3.96 4.30 2.54 1.54 1.16 Premature birth 17.42 17.00 14.74 14.17 14.91 13.41 12.51 10.38 9.15 7.21 6.76 6.31 4.65 Congenital mal., etc. 14.66 11.26 8.39 7.38 7.22 6.35 10.08 11.96 12.52 10.75 11.27 11.30 12.33 Other causes 20.55 15.09 11.83 12.60 13.52 12.30 8.14 5.83 4.77 4.21 3.56 2.97 3.68 All causes 103 79 65 64 65 60 50 45 38 34 31 27 26 Table 9—County of London—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population 1931.1950 Year Anthrax Meningococcal infection Continued fever Diphtheria Dysentery Acute Encephalitis (?) Enteric fever Erysipelas Malaria Measles Ophthalmia neonatorum Pneumonia Poliomyelitis Puerperal pyrexia Soabies Scarlet fever Smallpox Typhus Whooping cough Cages Rate Cases Bate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate###] 1931 2 0.0005 175 0.040 3 0.0007 8,384 1.90 58 0.013 40 0.009 186 0.042 2,294 0.521 32 0.007 (b) (b) 629 (/) 9.60 6,880 1.562 56 0.013 828 (a 12.20 (b) (b) 12,025 2.73 1,452 0.330 . . (b) (b) 1032 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 89 0.020 741 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 66 0.015 838 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 74 0.018 758 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 85 0.020 652 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 38 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 91.6 0.224 8 0.002 216 0.053 1,764 0.432 42 0.010 (b) (b) 453 8.26 4,798 1.175 108 0.026 793 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 0.978 134 0.033 853 15.18 (b) (b) 8,093 2.00 1,891 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 98 0.026 704 13.05 (b) (b) 5,677 1.51 (c) 10,537 2.80 1940 3 0.001 839 0.274 6 0.002 1,844 0.601 161 0.052 8 0.003 158 0.052 1,076 0.351 16 0.005 5,447 1.78 303 7.10 2,688 0.876 20 0.007 472 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 41 0.017 340 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 25 0.010 505 12.06 (6) (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 43 0.017 471 10.20 9,689 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 17 0.006 399 8.73 (d) 16,450 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 63 0.024 515 11.05 14,753 5.69 4,079 1.57 3 0.001 3 0.001 3,264 1.25 1946 (c) - - 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 29 0.009 553 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 0.638 702 0.212 441 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 0.566 141 0.042 460 7.40 2,484 0.74 4.568 1.37 — 10.450 313 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 8.54 186 3.29 1,858 0.550 668 0.198 433 7.51 1,311 0.39 4,945 1.46 3 0.001 - — 5,754 1.70 Paralytic Non.par. Cases Rate Cases Rate 1950 (e) 2 0.0006 90 0.027 — — 81 0.024 960 0.283 18 0.005 63 0.019 566 0.167 20 0.006 22,282 6.57 145 2.72 1,691 0.499 267 0.079 163 0.048 371 6.83 823 0.24 4,157 1.23 - - - - 10,875 3.21 (a) Kate per 1,000 total births. (6) Comparable figures not available for this period, (c) Oases relate to last quarter only — Rates are adjusted on an annual basis, (d) Cases relate to last 22 weeks only—Rates are adjusted on au 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 bv the following factors:—Cerebro.spinal fever (Meningococcal lufection) 0.730, Diphtheria 0.599, Dysentery 0.908, Encephalitis lethargica 0.545, Enteric fever 0.721, Erysipelas 0.977, Measles 1.001, Ophthalmia neonatorum 1.004, Pneumonia 0.964. Poliomyelitis including polioencephalitis 0.845, 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. (/) Rate per 1,000 live births. iff) Up to 1949 the figures relate to encephalitis lethargica. 143 Table 8—Maternal mortality (excluding abortion) — London and England & Wales 1941.50 (Rates per 1,000 total births) 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 Puerperal sepsis:— London 0.46 0.29 0.24 0.17 0.26 0.12 0.12 0.13 0.02 — England and Wales 0.48 0.42 0.39 0.28 0.24 0.18 0.16 013 0.11 0.12 Other causes :— London 113 1 .27 1.06 0.85 1.09 0.80 0.55 0.37 0.38 0.53 England and Wales 1.77 1.60 1.44 1.24 1.23 1.06 0.86 0.73 0.71 0.60 Table 10—Primary notifications (a) of and deaths from tuberculosis in the 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 (6) 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) 12,358 2.76 5,197 1.16 (b) 3,231 0.72 1,127 0.25 1920 9,202 2.06 4,675 1.04 2,461 0.55 1,070 0.24 1921.25 38,807 1.71 22,980 1.01 10,881 0.48 4,383 0.19 1926.30 34,353 1.53 20,247 0.90 8,971 0.40 3,080 0.14 1931.35 29,569 1.38 17,075 0.79 6,322 0.29 2,354 0.11 1936 5,176 1.25 2,849 0.69 1,056 0.26 363 0.09 1937 5,455 1.33 2,888 0.71 1,014 0.25 351 0.09 1938 5,200 1.28 2,590 0.64 982 0.24 347 0.09 1939 4,691 1.24 2,650 0.70 805 0.21 302 0.08 1940 4,326 1.34 2,687 0.83 653 0.20 318 0.10 1941 4,577 1.83 2,552 1.02 675 0.27 343 0.14 1942 4,734 1.80 2,164 0.82 796 0.30 283 0.11 1943 5,066 1.82 2,204 0.79 782 0.28 256 0.09 1944 5,056 1.84 2,073 0.75 673 0.24 237 0.09 1945 4,893 1.68 2,033 0.70 614 0.21 224 0.08 1946 5,137 1.57 1,940 0.59 611 0.19 243 0.07 1947 5,421 1.58 2,044 0.60 662 0.19 252 0.07 1948 5,473 1.61 1,900 0.56 600 0.18 202 0.06 1949 5,699 1.68 1,585 0.47 553 0.16 156 0 .05 1950 5,189 1.53 1,225 0.36 I 529 0.16 122 0.04 (a) Excluding posthumous cases. (b) Not chocked for duplicates. 144 Table 11(a)—Tuberculosis—Primary notifications in London during the year 1950 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- 05 + Pulmonary tuberculosis m. 13 149 84 57 265 350 683 413 408 356 181 2,959 F. 13 103 68 72 311 506 644 279 120 71 43 2,230 Other forms of tuberculosis m. 2 32 34 16 24 32 39 19 12 11 6 227 F. 4 36 25 24 25 44 69 45 18 5 7 302 All forms of tuberculosis M. 15 181 118 73 289 382 722 432 420 367 187 3,186 F. 17 139 93 96 336 550 713 324 138 76 50 2,532 Table 11(6)—New cases of tuberculosis in London recorded by means other than notification, 1950 Form of tuberculosis Sex New cases of tuberculosis coming to knowledge otherwise than by formal notification Total 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Pulmonary tuberculosis M. 3 31 21 17 37 168 361 155 133 93 95 1,114 F. 1 23 21 8 49 201 362 115 54 31 32 897 Other forms of tuberculosis M. 3 4 5 6 4 8 17 8 5 3 3 66 F. 4 4 4 4 9 20 25 8 5 2 6 91 All forms of tuberculosis m. 6 35 26 23 41 176 378 163 138 96 98 1,180 F. 5 27 25 12 58 221 387 123 59 33 38 988 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 registers 138 9 1 transferable deaths from Registrar-General 100 34 44 8 "Transfers" from other areas 1,688 97 Other sources 41 9 Table ll(c)—Numbers on the registers, for the whole county, 1942-1950 1942 1943 1944 1945 1940 1947 1948 1949 1950 Cases on the register at the end of the year— Pulmonary— Males 12,894 13,608 14,340 15,018 15,695 16,374 17,224 18,203 19,090 Females 9,441 10,232 10,990 11,496 12,262 12.862 13,549 14,223 15,031 Other forms— Males 2,785 2,847 2,866 2,813 2,821 2,699 2,889 2,752 2,591 Females 2,963 3,074 3,185 3,123 3,099 3,142 3,147 3,015 3,068 Total 28,083 29,761 31,381 32,450 33,877 35,077 36,809 38,193 39,780 No. per 1,000 of population 11.7 11.9 12.7 12.5 10.9 10.6 11.0 11.3 11.7 145 Table 12(a)—Primary notifications of tuberculosis in the County of London by age and sex. Rates per 1,000 living (i) Pulmonary Sex Age 1946 1947 1948 1949 1950 Malm No. Rate No. Rate No. Rate No. Rate No. Rate 0—4 105 0-90 108 0.81 149 1.08 153 1.08 162 1.15 5—14 175 0-98 187 1.01 158 0.87 153 0.82 141 0.75 15—44 1,787 2-61 1,809 2.56 1,873 2.66 1,886 2.70 1,711 2.46 45+ 849 1-45 973 1.61 957 1.60 1,093 1.84 945 1.59 All males 2,916 1.87 3,077 1.89 3,137 1.93 3,285 2.03 2,959 1.83 Females 0—4 81 0.73 96 0.76 124 0.94 126 0.94 116 0.86 5—14 177 1.01 174 0.96 171 0.96 188 1.04 140 0.77 15—44 1,682 2.32 1,811 2.41 1,797 2.40 1,821 2.45 1,740 2.34 45+ 281 0.40 263 0.36 244 0.34 279 0.39 234 0.33 All females 2,221 1.30 2,344 1.32 2,336 1.32 2,414 1.36 2,230 1.26 Total 5,137 1-57 5,421 1.59 5,473 1 .61 5,699 1.68 5,189 .153 (ii) Non-Pulmonary Males 0—4 43 0.369 69 0.520 55 0.398 39 0.275 34 0.241 5—14 89 0.499 87 0.472 87 0.479 75 0.404 50 0.265 15—44 143 0.209 118 0.167 116 0.165 109 0.156 114 0.164 45+ 24 0.041 36 0.060 29 0.048 32 0.054 29 0.049 All males 299 0.191 310 0.190 287 0.177 255 0.157 227 0.140 Females 0—4 44 0.397 56 0.444 38 0.289 42 0.312 40 0.296 5—14 96 0.550 71 0.394 69 0.388 68 0.375 49 0.271 15—44 144 0.198 190 0.253 171 0.229 159 0.214 183 0.247 45+ 28 0.040 35 0.048 35 0.049 29 0.041 30 0.042 All females 312 0-183 352 0.198 313 0.176 298 0.168 302 0.171 Total 611 0187 662 0.194 600 0.177 553 0.163 529 0.156 Table 12(6)—Deaths from tuberculosis in the County of London by age and sex (i) Pulmonary Male* 0—4 16 0.14 12 0.09 8 0.06 3 0.02 7 0.05 5—14 7 0.04 9 0.05 2 0.01 1 0.01 1 0.01 15—44 484 0.71 495 0.70 463 0.66 323 0.46 236 0.34 45+ 731 1.25 748 1.24 762 1.27 719 1.21 585 0.99 All males 1,238 0.79 1,264 0.78 1,235 0.76 1,046 0-65 829 0.51 Females 0-4 9 0.08 13 0.10 7 0.05 4 0.03 — — 5—14 5 0.03 8 0.04 6 0.03 4 0.02 2 0.01 15—44 498 0.68 527 0.70 487 0.65 342 0.46 238 0.32 45+ 190 0.27 232 0.32 165 0.23 189 0.26 156 0.22 All females 702 0.41 780 0.44 665 0.37 539 0.30 396 0.22 Total 1,940 0.59 2,044 0.60 1,900 0.56 1,585 0.47 1,225 0.30 146 Table 12(6)—Deaths from tuberculosis in the County of London by age and sex— continued Sex Age (ii) Non.Pulmonary 1946 1947 1948 1949 1950 No. Rate No. Rate No. Rate No. Rate No. Rate Males 0.-t 31 0.266 30 0.226 26 0.188 13 0.092 6 0.043 5—14 25 0.140 20 0.109 10 0.055 12 0.065 6 0.032 15—44 38 0.056 44 0.062 38 0.054 36 0 052 25 0.036 45+ 22 0.048 38 0.063 29 0.048 34 0.057 25 0.042 All males 116 0.074 132 0.081 103 0.063 95 0.059 62 0.038 Females 0—4 33 0.298 19 0.151 23 0.175 16 0.119 10 0.074 5—14 20 0.115 16 0.089 11 0.062 7 0.039 7 0.039 15—44 44 0.061 48 0.064 35 0.047 20 0.027 16 0.022 45+ 30 0.043 37 0.051 30 0.042 18 0.025 27 0.038 All females 127 0.074 120 0.067 99 0.056 61 0.034 60 0.034 Total 243 0.074 252 0.074 202 0.059 156 0.046 122 0.036 Table 13—Primary notifications of non.pulmonary tuberculosis in the County of London. Distribution according to site Rates per 1,000 living are shown in parenthesis against the number of cases ###] group Year Site of tuberculosis lesion Bones and Joints Abdomen Peripheral glands Meninges Other sites (o) Total 1. Under 15 1946 58 (0.100) 25 (0.043) 110 (0.189) 44 (0.076) 35 (0.060) 272 (0.468) 1947 53 (0.085) 26 (0.042) 115 (0.184) 63 (0.101) 26 (0.042) 283 (0.454) 1948 54 (0.086) 17 (0.027) 97 (0.154) 50 (0.079) 31 (0.049) 249 (0.395) 1949 56 (0.087) 13 (0.020) 68 (0.106) 63 (0.098) 26 (0.040) 226 (0.351) 1950 51 (0.079) 15 (0.023) 54 (0.084) 36 (0.056) 17 (0.026) 173 (0.268) 2. Over 15 years of age. 1946 103 (0.038) 38 (0.014) 83 (0.031) 20 (0.008) 95 (0.035) 339 (0.126) 1947 110 (0.040) 53 (0.019) 87 (0.031) 15 (0.005) 114 (0.041) 379 (0.136) 1948 111 (0.040) 36 (0.013) 82 (0.030) 22 (0.008) 100 (0.036) 351 (0.127) 1949 107 (0.039) 42 (0.015) 77 (0.028) 13 (0.005) 88 (0.032) 327 (0.119) 1950 94 (0.034) 43 (0.016) 91 (0.033) 22 (0.008) 106 (0.039) 356 (0.130) (a) Includes miliary and genito.urinary. Table 14—Cases of infectious illness reported from schools in 1950 and preceding years Year Chicken.pox Diphtheria German measles Impetigo Measles Mumps Ophthalmia and conjunctivitis Poliomyelitis Ringworm Scabies Scarlet fever Whooping cough 1938 11,018 3,576 2,383 1,018 31,852 4,805 342 - 278 2,718 3,988 4,067 1946 5,602 290 349 381 8,291 5,296 251 5 245 1,488 1,654 2,421 1947 7,423 263 1,571 264 6,684 2,845 233 153 180 650 1,974 3,660 1948 7,745 187 491 243 11,545 9,162 297 34 119 323 2,078 3,691 1949 5,528 135 313 178 7,651 2.113 361 132 71 120 2,359 1,814 1950 7,773 63 312 151 7,495 7,638 275 91 79 106 1,925 4,039 147 Table 15—District Nursing Associations—Completed Treatments by Diagnosis— Year Ended 31st December, 1950 Disease Total Cases Males Total Males Females Total Females 0-39 40-59 60 + 0-39 40-59 60 + No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. Infectious and parasitic diseases 1,733 4.02 543 1.26 27 0.06 29 0.07 599 1.39 965 2.24 64 0.15 105 0.24 1,134 2.63 Tuberculosis (all forms) 1,515 3.52 365 0.85 314 0.73 126 0.29 805 1.87 490 1.14 168 0.39 52 0.12 710 1.65 Cancer and other neoplasms 2,198 5.10 37 0.08 251 0.58 620 1.44 908 2.10 67 0.16 350 0.81 873 2.03 1,290 3.00 Diabetes 1,334 3.11 19 0.04 50 0.12 179 0.42 248 0.58 48 0.11 239 0.56 799 1.86 1,086 2.53 Mental and other nervous diseases 472 1.10 28 0.07 48 0.11 79 0.18 155 0.36 49 0.12 94 0.22 174 0.40 317 0.74 Diseases of ear and eye and other sense organs 2,347 5.45 925 2.15 59 0.14 74 0.17 1,058 2.46 972 2.26 127 0.29 190 0.44 1,289 2.99 Cerebral haemorrhage 1,892 4.39 2 — 47 0.11 594 1.38 643 1.49 25 0.06 113 0.26 1,111 2.58 1,249 2.90 Heart and arteries 3,969 9.22 42 0.10 246 0.57 1,210 2.81 1,498 3.48 134 0.31 432 1.00 1,905 4.43 2,471 5.74 Veins and other circulatory 525 1.22 11 0.03 39 0.09 83 0.19 133 0.31 44 0.10 112 0.26 236 0.55 392 0.91 Respiratory disease 6,394 14.85 1,117 2.59 513 1.19 861 2.00 2,491 5.78 1,553 3.61 777 1.81 1,573 3.65 3,903 9.07 Digestive disease 5,209 12.10 503 1.18 418 0.97 959 2.23 1,883 4.38 874 2.03 725 1.68 1,727 4.01 3,326 7.72 Genito.urinary disease 3,547 8.24 747 1.74 68 0.16 382 0.88 1,197 2.78 1,133 2.63 408 0.95 809 1.88 2,350 5.46 Pregnancy 699 1.62 — — — — — — — — 665 1.54 34 0.08 — — 699 1.62 Skin 3,912 9 09 752 1.75 336 0.78 445 1.03 1,533 3.56 845 1.96 576 1.34 958 2.23 2,379 5.53 Bones and joints 1,059 2.47 48 0.11 59 0.14 102 0.24 209 0.49 96 0.22 166 0.39 588 1.37 850 1.98 Injury 1,197 2.78 156 0.36 57 0.13 126 0.30 339 0.79 128 0.30 127 0.29 603 1.40 858 1.99 Other diseases or ill.defined 5,046 11.72 574 1.33 313 0.73 823 1.91 1,710 3.97 811 1.88 618 144 1,907 4.43 3,336 7.75 Totals 43,048 100.00 5,872 13.64 2,845 6.61 6,692 15.54 15,409 35.79 8,899 20.67 5,130 11.92 13,610 31.62 27,639 64.21 N.B.—All percentages arc of the total cases—43,048. 148 Table 16—Analysis of conditions for which Medical Aid was summoned by midwives During pregnancy Toxaemia 620 Presentation 21 Condition of veins 20 Mental condition 14 Pyrexia 8 Insomnia 14 Pyelitis 11 Fits 5 Bronchitis 6 Unusual home conditions 3 Pains 62 Threatened abortion 113 Abscess 9 Abortion 61 Anæmia 10 Incomplete abortion 7 Fainting attacks 9 Ante-partum haemorrhage 304 Vomiting 20 Early rupture of membranes 108 Hydramnios 5 Premature labour 48 Post-maturity 41 False pains 4 Fœtal heart conditions or no foetal Other abnormal conditions 85 movements 24 Height of fundus 4 1,636 During and immediately following labour Malpresentations Delayed labour Breech 91 Delayed 332 High head 41 Protracted 142 Face 15 Uterine inertia 100 Transverse 13 Occipito Posterior 49 Miscellaneous Footling 6 Post-partum haemorrhage 342 Shoulder 2 Adherent or retained placenta 138 Hand 7 Retained membranes 12 Prolapsed cord 21 Maternal distress 46 Twin 2 Sedation 13 Disproportion 14 Foetal distress 100 ? Malpresentation 15 Ruptured perineum 1,696 Episiotomy 24 Obstructed labour Other abnormal conditions 2 Contracted pelvis 1 3,259 Rigid cervix 10 Obstructed 25 During puerperium Pyrexia 320 Pain 20 Condition of veins 148 Sub-involution 10 Condition of breasts 132 Heavy or offensive lochia 4 Respiratory 15 Oedema 17 Pyelitis 1 Heart disease 2 Rheumatism 1 Anaemia 5 Jaundice 1 Hypertension 2 Conjunctivitis 1 Albuminuria 2 Vomiting 1 Mental condition 4 Constipation 1 Other abnormal conditions 105 Rash 20 824 Collapse and shook 12 149 Table 16—continued Condition of the child Prematurity 165 Cleft palate 9 Cyanosis 75 Hare lip 10 Asphyxia 57 Tongue tie 5 Feebleness 23 Imperforate anus 4 Convulsions 3 Fistula 1 Shock 4 Inguinal hernia 2 Atelectasis 4 Feeding difficulties 11 Still-birth 15 Vomiting 37 Dead baby 6 Loss of weight 9 Birth injury 6 Condition of stools 6 Inflammation of eyes 929 Malaena 7 Skin affection 114 Bleeding P.R 2 Mastitis 3 Hæmateraesis 6 Whitlow 2 Oedema 2 Exomphalos 1 Respiratory condition 96 Discharging ear 2 Jaundice 61 Phimosis 29 Other abnormal conditions 110 Malformation 32 1,880 Talipes 22 Spina bifida 10 Table 17—School leavers contra-indications for employment Contra-indications Boys Girls No. Per cent. of inspected pupils (13,605) (a) No. Per cent. of inspected pupils (13,859) (a) Heavy manual work 413 3.0 384 2.8 Sedentary work 35 0.3 36 0.3 Indoor work 18 0.1 11 0.1 Exposure to bad weather 184 1.4 288 2.1 Wide changes of temperature 50 0.4 74 0.5 Work in damp atmosphere 88 0.6 116 0.8 Work in dusty atmosphere 150 1.1 105 0.8 Much stooping 33 0.2 37 0.3 Climbing 100 0.7 102 0.7 Work near moving machinery or moving vehicles 74 0.5 67 0.5 Prolonged standing, much walking or quick movement from place to place 212 1.6 242 1.7 Eye strain 979 7.2 1,059 7.6 Normally acute vision 855 6.3 784 5.7 Normal use of hands 8 0.1 3 (0.02) Work requiring freedom from damp hands or skin defects 16 0.1 17 0.1 Handling or preparation of food 58 0.4 88 0.6 Normal hearing 52 0.4 42 0.3 Any other work which would be unsuitable 17 0.1 8 0.1 No. of pupils with contra-indications (b) 2,067 15.2 2,139 15.4 (а) Excluding special schools and certain grammar schools at which the leaver contra-indication slip is not in use. (b) The total number of contra-indications is greater than the number of pupils since an individual may be noted for two or more contra-indications. 150 Ascertainment of handicapped children Table 18—Vision cases A. Children not in special schools :— Boys Girls Total Found to be blind 9 4 13 Found to be partially sighted 41 27 68 Found to be fit for ordinary school with "care " 32 53 85 Found to be fit for ordinary school 19 17 36 B. Children already in attendance at special schools :— Found to be no longer blind — — — Found to be no longer partially sighted 12 15 27 Recommended to continue blind school 1 1 2 Recommended to continue partially sighted school 7 3 10 Recommended for transfer from blind school to partially sighted school 1 1 2 Recommended for transfer from partially sighted school to blind school 5 1 6 Recommended for treatment before decision 3 — 3 130 122 252 Table 19—Hearing cases A. Children not in special schools:— Boys Girls Total Found to be deaf 60 25 85 Found to be partially deaf 22 17 39 Found to be suitable for ordinary school with individual hearing aid and/or to sit in front row, etc 31 24 55 Found to be suitable for ordinary school 33 18 51 Recommended for treatment before decision made 2 — 2 B. Children in special schools:— Found to be no longer deaf — 2 2 Found to be no longer partially deaf 10 2 12 Recommended to continue deaf school 4 1 5 Recommended to continue partially deaf school 2 1 3 Recommended for transfer from deaf school to partially deaf school 1 1 2 Recommended for transfer from partially deaf school to deaf school 3 4 7 168 95 263 Table 20—Epilepsy cases A. Children not in special schools. Boys Girls Total Found suitable for residential special schools for epileptics ... 30 17 47 Found suitable for ordinary school 14 9 23 Found suitable for E.S.N. school 1 1 2 Found to be ineducable 4 4 8 Recommendation postponed 4 4 8 53 35 88 B. One boy and two girls from residential special schools for epileptics were examined and found to be fit to attend ordinary schools and one boy and one girl were recommended for transfer to E.S.N. school. 151 Table 21—Educationally subnormal A. Children not in special schools:— Boys Girls Total Found suitable for day E.S.N. schools Over 11 117 80 197 Under 11 337 188 525 Found suitable for residential E.S.N. schools Over 11 30 30 60 Under 11 49 22 71 Found suitable for special E.S.N. classes in ordinary schools Over 11 83 40 123 Under 11 236 129 365 Found to have no disability of mind Over 11 70 32 102 Under 11 304 95 399 Found to be unsuitable for school (e.g., ineducable) Over 11 4 3 7 Under 11 49 43 92 Decision postponed Over 11 — — — Under 11 13 5 18 1.292 667 1,959 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 13 4 17 Found to be suitable for transfer to special E.S.N. classes in ordinary schools 7 3 10 Found to be unsuitable for retention because ineducable, etc. 55 35 90 Found to be suitable to continue in special E.S.N. school 60 24 84 Recommended for transfer to residential special E.S.N. school 18 11 29 Examined with a view to considering whether supervision required after leaving school 187 116 303 340 193 533 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 25 8 33 Found to be suitable for transfer to special E.S.N. schools 26 17 43 Found to be suitable to continue in E.S.N. class 29 11 40 80 36 116 In addition 13 children who had been reported as incapable on the ground of mental disability of receiving education at school, were examined in accordance with section 8 of the Education (Miscellaneous Provisions) Act, 1948, with a view to reconsidering the previous decisions; 8 boys and 3 girls were found to be still ineducable. In the cases of 2 boys it was recommended that the report should be withdrawn. Table 22—Delicate children 1,600 children (930 boys and 670 girls) were recommended for admission to residential schools for delicate children. 470 children (280 boys and 190 girls) were recommended for admission to day schools for delicate children. 307 (181 boys and 126 girls) were found to be no longer in need of special educational treatment in day schools for delicate children. 152 Table 23—Physically handicapped children A. Children not in special schools:— Boys Girls Total Found to be suitable for day special schools for physically handicapped (see (i) below) 152 141 293 Found to be suitable for residential special schools for physically handicapped (see (i) below) 7 3 10 Found to be suitable for ordinary schools (see (ii) below) 23 25 48 Found to be unsuitable for education at school but suitable for home tuition or tuition in hospital 12 17 29 194 186 380 (i) Number of these children recommended for physically handicapped schools:— Morbid condition Day Residential Grand Total Boys Girls Total Boys Girls Total Infantile paralysis 28 26 54 1 1 2 56 Cerebral palsy 15 13 28 2 1 3 31 Various paralyses 6 4 10 1 — 1 11 T.B. bones and joints 15 12 27 — — — 27 Osteomyelitis 2 1 3 — — — 3 Perthes disease 9 5 14 1 — 1 15 Congenital deformities 15 8 23 1 1 2 25 Spinal deformities, including scoliosis 2 2 4 — — — 4 Traumata and amputations 10 4 14 — — — 14 Non-T.B. arthritis and synovitis 4 — 4 — — — 4 Rheumatism and chorea 4 5 9 — — — 9 Heart disease, congenital 9 16 25 — — — 25 Heart disease, other 11 25 36 — — — 36 Other diseases 22 20 42 1 — 1 43 152 141 293 7 3 10 303 (ii) Number of these children recommended for ordinary school:— Morbid condition Boys Girls Total Infantile paralysis 1 3 4 Cerebral palsy — 1 1 Various paralyses — 1 1 T.B. bones and joints 1 — 1 Osteomyelitis 3 — 3 Perthes disease 1 2 3 Congenital deformities 2 2 4 Traumata and amputations 2 — 2 Non-T.B. arthritis and synovitis — 2 2 Heart disease, congenital 2 — 2 Heart disease, other 5 1 6 Other diseases 6 13 19 Total 23 25 48 153 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) 96 65 161 Found to be medically unfit to remain in special school 2 5 7 Other recommendations (see (ii) below) 40 21 61 138 91 229 (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 Total Boys Girls Total Boys Girls Infantile paralysis 10 6 16 — — — Cerebral palsy — 2 2 1 — 1 T.B. of bones and joints 12 10 22 2 1 3 Osteomyelitis 3 2 5 2 — 2 Perthes disease 9 5 14 — — — Congenital deformities 9 7 16 1 — 1 Spinal deformities, including scoliosis 1 — 1 1 — 1 Traumata and amputations 11 3 14 — — — Non-T.B. arthritis and synovitis 2 — 2 — — — Rheumatism and chorea 3 5 8 — — — Heart disease, congenital 7 4 11 — — — Heart disease, other 11 11 22 1 1 Other diseases 10 9 19 — — 88 64 152 8 1 9 (ii) Other recommendations:— Morbid condition Day P.H. Schools Residential P.H. Schools Continue day Transfer to res. Continue res. Transfer to day Grand Total B. G. T. B. G. T. B. G. T. B. G. T. Infantile paralysis 1 – 1 – – – 1 1 2 – – – 3 Cerebral paralysis 2 – 2 – – – 5 – 5 – – – 7 Various paralyses 3 – 3 – – – – 1 1 – – – 4 T.B. of bones and joints 6 4 10 1 – 1 4 – 4 – – – 15 Perthes disease – 3 3 – – – – – – – – – 3 Congenital deformities 2 – 2 – – – – 1 1 – – – 3 Traumata and amputations 1 – 1 – – – 1 – 1 – – – 2 Rheumatism and chorea – 1 1 – – – – – – – – – 1 Heart disease, congenital 1 2 3 – – – – – – – – – 3 Heart disease, other 2 6 8 – – – 1 – 1 – – – 9 Other diseases 5 2 7 1 – 1 3 – 3 – – – 11 23 18 41 2 – 2 15 3 18 – – – 61 154 Table 24—Dual defects The following children were found on examination to suffer from more than one handicap:— Boys Girls  Recommended for Hayners Residential School 7 8 15 „ „ other schools for dual defects 8 4 12 „ „ E.S.N. schools 3 2 5 „ „ P.H. schools 8 5 13 „ „ blind schools – 1 1 „ „ partially sighted schools 3 2 5 „ „ partially deaf schools – 3 3 Recommended to stay at home pending the provision of a suitable school 3 3 6 Found to be blind and ineducable 1 – 1 „ „ deaf, P.H. and ineducable – 1 1 „ ., blind, epileptic and ineducable – 2 2 „ suitable for home tuition (excluding P.H.) 1 2 3 34 33 67 Table 25—Speech defects Boys Girls Total Recommended for speech therapy because of stammer 128 26 154 Recommended for speech therapy because of speech defect 212 92 304 Found to be unsuitable for speech therapy 57 20 77 397 138 535 Table 26—Maladjusted children Boys Girls Total Deemed to be maladjusted and suitable for residential placement 183 86 269 Deemed to be maladjusted and suitable for special classes 69 22 91 Deemed to be no longer in need of special educational treatment as maladjusted 24 7 31 276 115 391 In addition, the Consultant Psychiatrist examined 61 children and the Council's Psychiatrist examined 69 children and made special reports on them. Table 27—Diabetic children Number of children found to be diabetic and suitable for residential treatment:— Boys Girls Total London children 2 – 2 Out-county children 10 3 13 Three out-county boys were considered unsuitable for admission to the unit. 155 Table 28—Reclassification The following table shows the number of children reclassified (i.e. found upon examination to be in need of different special educational treatment):— Boys Girls Total From physically handicapped to E.S.N. 3 3 „ E.S.N. to dual defect 1 2 3 „ P.H. to dual defect 1 1 2 „ deaf to dual defect * 1 1 2 „ partially deaf to dual defect — 1 1 „ partially sighted to E.S.N. 1 1 2 „ delicate to partially deaf — 1 1 „ partially deaf to E.S.N. — 1 1 „ E.S.N. to partially sighted 1 — 1 8 8 16 Table 29—Nominations for in-patient treatment under the Rheumatism Scheme, 1948-1950 1948 1949 1950 Received from hospitals 528 238 185 „ „ rheumatism supervisory centres 64 78 66 „ „ school doctors 10 17 8 „ „ other sources (private practitioners, welfare organisations, etc.) 12 11 11 614 344 270 Number outstanding from previous year 35 4 5 649 348 275 Number withdrawn before consideration 11 – 1 638 348 274 Found unsuitable for admission to unit 27 6 7 Died before admission 2 – – Parents' consent to admission refused 17 – 2 Accepted nominations subsequently withdrawn 65 5 8 Admitted to rheumatism unit 523 331 250 Removed from scheme (not rheumatic) – 1 3 Awaiting admission on 31st December 4 5 4 638 348 274 Supervision 1948 1949 1950 Number of children under supervision of school doctors on 31st December 382 375 306 Number of children under supervision at rheumatism supervisory centres on 31st December 3,216 3,021 2,790 Number of supervisory centres 23 24 24 Number of sessions at supervisory centres 893 988 930 Number of children attending for first time 1,468 1,394 1,224 Total number of attendances at centres 10,505 10,929 10,088 k 156 Table 30 —Condition on discharge in 1950 of London children treated in Queen Mary's Hospital, Carshalton Sex Fit for ordinary school or ordinary employment Fit for P.H. school or light employment Unfit for school or work Died Total No. Percentage No. Percentage No. Percentage No. Percentage Boys 112 91.1 7 5.7 4 3.2 — — 123 Girls 140 85.4 17 10.4 7 4.2 — — 164 Total 252 87.8 24 8.4 11 3.8 — — 287 Table 31—Percentage number of children with cardiac involvement admitted to the special rheumatism units, 1936-1950 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 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 60.8 The percentage of children with cardiac involvement admitted to the rheumatism units has risen during the last ten years and the figure for 1950 (6.8) was nearly double that for 1940 (32.1). The main rise, however, occurred in the early part of the decade and was a sudden not a progressive one, being probably due to the fact that with only a limited number of beds available, the milder cases were being treated elsewhere and consequently the more severe cases with cardiac complications formed a larger proportion of the whole. Table 33—Treatment of venereal disease at London clinics Year New Cases Total venereal cases Total non-venereal cases Total attendances Syphilis S. Chancre Gonorrhoea M F. 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 1,348 169,485 1928 3,433 1,837 229 6 8,249 2,647 11,911 4,490 6,369 3,226 544,969 218,566 1938 1,799 1,065 235 9 7,120 2,151 9,154 3,225 8,249 5,269 588,815 263,908 1939 1,573 904 164 5 5,982 1,652 7,719 2,561 7,468 5,008 412,067 189,355 1940 1,493 709 146 9 4,591 1,319 6,230 2,037 5,383 3,515 305,693 131,375 1941 1,381 773 205 12 3,862 1,425 5,448 2,210 4,675 3,709 224,954 122,492 1942 1,369 917 148 9 3,082 1,444 4,599 2,370 4,960 5,177 222,864 155,559 1943 1,362 1,107 104 15 2,839 1,442 4,305 2,564 7,627 8,867 219,014 177,859 1944 1,176 967 89 13 2,929 1,363 4,194 2,343 6,568 8,234 188,450 156,332 1945 1,417 1,176 102 3 3,962 1,738 5,481 2,917 9,517 9,849 196,074 160,697 1946 2,371 1,354 154 11 7,718 1,785 10,243 3,150 17,153 8,654 284,108 161,839 1947 2,207 1,301 128 6 7,236 1,408 9,571 2,715 13,847 7,132 269,435 147,717 1948 1,949 1,155 102 6 7,008 1,346 9,059 2,507 16,349 6,821 268,203 148,212 1949 1,572 790 62 5 6,463 1,207 8,097 2,002 16,140 6,533 245,250 134,897 1950 1,278 664 90 3 5,740 1,127 7,108 1,794 17,385 6,180 238,986 122,482 157 Table 32—Admissions of London children to Queen Mary's Hospital, Carshalton, in 1950 Sex Articular rheumatism Chorea Articular rheumatism and chorea No. admitted Percentage with No cardiac involvement No. admitted Percentage with No cardiac involvement No. admitted Percentage with No cardiac involvement Carditis Pericarditis only Valvular damage Carditis Pericarditis only Valvular damage Carditis Pericarditis only Valvular damage Mitral Mitral and aortic and pericarditis Mitral Mitral and aortic and pericarditis Mitral Mitral and aortic and pericarditis Boys 86 34.9 – 30.2 6.9 1.2 26.8 19 26.3 – 21.1 – – 52.6 5 20.0 – 20.0 – – 60.0 Girls 100 24.0 – 35.0 1.0 2.0 38.0 32 15.6 – 18.8 – – 65.6 8 37.5 – 25.0 – – 37.5 Total 186 29.0 – 32.8 3.8 1.6 32.8 51 19.6 – 19.6 – – 60.8 13 30.8 – 23.0 – – 46.2 158 Table 34 Statistics of the administrative work carried out by the Metropolitan Borough Councils since 1950 Borough No. of houses in borough Public Health Act Housing Acts, 1936 No. of houses inspected on account of complaints or illn.'ss 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 Section 11 Voluntarily No. made No. determined By owners L.A. City of London 1,100 13 1 10 21 – – 8 – – – 3 – – – – 5 – 19 7 – – Battersea 27,541 4,644 2,075 10,716 – – – 11 3 1 – 2 – 268 92 64 * 2 * * * * Bermondsey 15,707 4,817 1,434 3,521 876 – – – – 12 – 6 2 144 126 60 857 2 418 548 – 5 Bethnal Green 15,763 4,182 4,309 2,897 232 – – – – 4 – – – 203 279 190 * 3 184 581 2 – Camberwell 41,925 8,322 2,426 4,276 – – 9 19 6 7 – 7 – 332 250 215 * 26 * * * * Chelsea 15,471 2,123 427 466 66 – – 42 36 – – 1 – 46 15 12 – – 575 * – – Deptford 16,123 3,644 935 2,657 22 – 2 – – – 20 – 125 58 138 – – – – – – Finsbury 9,890 2,303 90 1,116 27 – – – – – – – – 65 176 109 1,200 – 456 – – – Fulham 30,744 4,723 2,493 4,902 293 – – 1 2 1 – 5 – 264 125 24 – 255 – – – – Greenwich 21,947 2,451 316 1,723 70 – – – – – 4 1 1 148 132 71 65 2 6 25 – – Hackney 39,154 8,436 2,607 6,296 366 – – 41 10 2 – 1 – 400 336 267 7 – – – – – Hammersmith 25,440 4,125 2,232 2,889 – – – 5 3 2 2 15 3 439 203 26 * – 9,600 – – – Hampstead 20,086 2,336 436 2,140 45 – – 11 1 – – – – 135 95 57 512 10 1,573 1,070 – 960 Holborn 5,742 594 47 543 9 – – – – – 31 1 – 48 39 – 499 2 294 287 – 42 Islington 43,519 11,132 7,921 9,084 2,671 – – – – 1 127 2 1 883 712 390 * 39 * + + 16 – Kensington 36,399 5,955 1,747 3,172 877 67 – 98 18 7 11 9 33 445 128 186 3,910 75 4,026 3,254 Lambeth 51,434 12,643 2,340 6,335 – – – – – 6 * – – 173 201 311 * 9 * * * * Lewisham 61,350 6,781 1,214 5,264 613 – – 29 1 5 – 2 2 478 277 409 – – * – – – Paddington 22,819 5,932 1,199 8,946 – – 15 14 1 7 5 5 7 421 315 193 * 190 5,879 942 18 381 Poplar 17,135 4,224 1,818 3,724 123 9 – – – 5 – 13 – 258 200 216 1,850 9 141 85 2 – St. Marlebone 22,579 2,327 268 966 343 136 79 – – – 14 2 – 1,300 155 240 2,447 26 1,932 7,409 2 39 St. Pancras 26,529 7,334 2,957 5,401 66 – – – – – – 2 – 647 768 239 1,000 100 5,000 – 117 – Shoreditch 10,920 4,994 431 5,274 3,452 32 – 2 – 6 – – – 384 177 206 282 14 * * * * Southwark 23,749 5,314 1,129 2,725 – – – – – 13 – – 45 316 164 110 – 12 * * * * Stepney 28,114 9,458 1,504 6,486 44 – – – – 2 – 11 – 351 555 232 3,880 33 1,887 795 – 48 Stoke Newington 8,500 1,908 16,276 75 146 – – 35 – – – – – 103 53 166 – 6 10 – – – Wandsworth 94,776 12,913 6,429 5,967 91 80 – – – 2 – – – 244 110 281 12 9 3 10 – – Westminster, C. of 22,695 1.935 74 1,121 – – – – – – – 1 11 124 47 141 2,540 60 3,350 4,166 8 4 Woolwich 38,424 5,627 1,866 17,110 83 – – – – 4 – 1 – 198 76 341 * – – – – – Total 795,575 151,190 67,001 125,802 10,514 346 103 318 81 87 194 110 105 8,942 5,864 4,894 19,066 884 35,353 19,179 165 1,479 159 Table 34 (continued) Borough Cowsheds Slaughterhouses Offensive trades Smoke nuisances Common lodging houses Cleansing of persons and rooms Water supply Dairies 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 – – – – – – 112 – 15 – 1 2 271 2,237 46 86 – 51 76 71 150 582 1,620 Battersea – – 1 35 2 3 165 2 7 – – – 226 2,238 729 392 5 126 288 111 193 173 341 Bermondsey – – – – 9 63 260 – 12 – 2 86 292 1,363 29 451 – 109 315 131 97 110 464 Bethnal Green – – 5 70 1 2 3 – – – 1 6 53 11 29 970 – 18 24 130 334 131 460 Camberwell 1 – 3 24 5 5 58 – 30 – 1 39 125 1,964 1,108 1,079 12 184 213 358 642 279 486 Chelsea – – – – – – 27 – 13 – – – 158 452 121 225 22 11 87 57 181 140 353 Deptford – – 2 – 2 3 20 – – – 1 5 469 1,123 276 533 – 112 208 168 418 95 100 Finsbury – – – – 3 86 138 – 14 – 1 27 158 1,168 220 451 9 12 112 105 172 169 221 Fulham – – – – – – 479 – 25 – – – – – 353 856 10 48 502 177 559 153 620 Greenwich – – – – \– – 53 – 7 – – – 52 714 413 32 – 8 20 188 196 163 492 Hackney – – – – 5 10 1,245 7 19 2 1 10 173 1,083 783 548 – 32 390 281 517 236 254 Hammersmith – – 2 2 – – 163 9 3 1 – – 311 1,667 115 893 14 71 425 153 314 199 468 Hampstead – – – – – – 19 – – – – – 27 17 509 162 21 • 195 * 255 * 440 Holborn – – – – – – 143 – 10 – 2 6 133 42 65 178 19 3 17 65 88 535 1,872 Islington – – 6 16 10 318 103 9 39 – – – 230 1,246 517 910 87 394 1,072 474 922 592 1,898 Kensington – – – – – – 15 – – – – – 256 1,908 418 954 34 162 370 245 256 213 505 Lambeth – – 1 7 2 8 74 2 23 1 – – 165 66 899 2,581 18 28 39 563 117 218 444 Lewisham – – 2 7 – – 5 – 5 – – – 76 1,215 757 254 – 159 222 333 848 296 421 Paddington – – – – 1 1 4 – 1 – 1 20 299 37 375 1,574 71 9 278 160 219 139 791 Poplar – – 3 – 3 5 219 5 21 1 3 39 78 785 339 730 1 13 108 149 296 109 225 St. Marylebone – – 1 10 – – 152 3 24 – 2 51 506 856 325 517 34 160 189 148 192 852 1,109 St. Pancras – – 2 – – – 57 – 22 – – – 833 2,016 775 598 29 310 589 316 769 850 1,107 Shoreditch – – – – 1 4 424 – 9 – – – 17 14 210 842 27 84 248 117 397 302 898 Southwark – – 1 4 7 14 83 1 19 – 6 30 1,208 3,033 313 2,307 – 171 409 175 285 360 748 Stepney 1 1 – – 16 339 228 3 42 – 4 103 435 18 371 1,096 – 206 356 240 372 913 924 Stoke Newington – – – – – – – – – – – – 20 739 196 286 – 38 208 63 127 50 198 Wandsworth – – 3 38 – – 59 5 10 – – – 224 121 1,405 336 8 228 1,508 623 1,879 494 1,452 Westminster, C. of – – – – – – 1,374 34 85 3 3 55 464 468 524 1,212 14 114 282 173 119 3,000 3,652 Woolwich – – 2 † 2 15 450 4 10 4 2 14 147 1,532 467 1,052 – 108 354 284 461 546 697 Total 2 1 34 213 69 876 6,132 84 465 12 31 493 7,406 28,133 12,687 22,105 435 3,058 9,104 6,302 11,375 12,125 23,260 Note:—In the columns above a dash signifies a NIL return ; * information not available; † daily supervision (one slaughterhouse not in use); and ‡ included in inspections under Public Health Act. Seamen's Lodging Houses: Total 7—Poplar 2 (48 inspections), Stepney 5 (65 inspections). Prosecutions: Dairies—St. Marylebone 1, St. Pancras 3, Westminster 1; Smoke Nuisance—Poplar 1; Restaurants—St. Marylebone 3, Stepney 37 (involving 7 premises), Westminster I; Water Supply—Paddington 3, St. Marylebone 1, St. Pancras 4 ; Ice-cream Premises'— Islington 1. 160 161 INDEX Aged persons 30, 127, 134 Ambulance service 68 Analgesia 61 Anthrax 17 Audiometry 112 Births 5, 54 Blind persons 28 Bronchitis 10 Cancer 10 Care of mothers and young children 45, 128, 130, 132, 134, 135 Chemical branch 30 Child guidance 41, 55 Child-minders 56 Chronic sick 30,136 Deaths 7 Dental services 103,119 Diabetes 12, 118 Diarrhoea and enteritis 19 Diphtheria 18,66 Domestic help service 65, 128, 129, 130, 131, 133 Domiciliary midwifery service 58 Dysentery 17 Emergency obstetric service 60 Enteric fevers 19 Enuresis 107, 137 Erysipelas 19 Fertility 5 Finance 125 Food poisoning 24 Foot defects 74, 109, 129, 133 Government Committees 30, 36 Handicapped children 109 Health centres 43 Health education 73, 128, 129 Health service premises 36, 127, 129, 132, 133, 134, 135, 137 Health visiting 54, 63, 134 Heart disease 10 Home nursing 64 Housing 25, 131, 136, 137 Illegitimacy 6, 57 Immunisation 66, 103, 128, 129, 132 Infant mortality 13 Infectious diseases 17 Do. in schools 22,111 Influenza 19 Introduction 1 Marriage guidance 54 Mass miniature radiography 80 Maternal mortality 15 Meals for children 111 Measles 20 162 Medical inspection of school children 100 Medical treatment of school children 105 Meningococcal infection 17 Mental health services 94 Midwifery service 58 Milk sampling 27 Mortality 7 Notification of births 54 Nurseries, day 56, 126, 128, 130, 135, 137 Do. residential 57 Nursing home registration 29 Occupation centres 40, 97 Ophthalmia neonatorum 20 Peckham Pioneer Health Centre 43 Pneumonia 12,21 Poliomyelitis 21 Population 4 Premature babies 49 Prevention of illness 73 Problem children 114 Psychiatry 114 Puerperal fever and pyrexia 15 Quadruplets 54 Recuperative holidays 74, 108, 129, 130, 136 Remand homes114 Reports of Divisional Medical Officers 126 Rheumatic fever 22 Rheumatism scheme 112 Ringworm 107 Road accidents 12 Sanitary inspection 27 Scabies 22, 107 Scarlet fever 22 School health service 99, 128, 129, 131, 132, 133, 134, 135 School children under 5 years 118 Smallpox 22 Specialist clinics 51,108 Special schools 110 Speech therapy 109 Staff 4,123 Statistical tables 137 Still-births 6 Sunday cinema grants 54 Tuberculosis 22, 39, 77, 126, 128, 129, 131, 136 Tuberculous milk 27 Unmarried mothers 57 Vaccination 67, 103, 128, 129, 132, 137 Venereal diseases 75 Virus infection enquiry 55 Visitors 3 Vital statistics 4 Voluntary organisations 48 Welfare Committee establishments 29 Whooping cough 22, 67 Woodberry Down Health Centre 43 750. (M°0. 54314) 5.11.51.