LCC 57 LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and School Medical Officer for the Year 1951 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. 1952 No. 3794 Price 2s. 6d. Postage extra. LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and School Medical Officer for the Year 1951 By J. A. SCOTT, O.B.E., M.D., M.R.C.P. COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER THE COUNTY HALL WESTMINSTER BRIDGE, S.E.1 INTRODUCTION Throughout the year 1951, with which this report deals, Sir Allen Daley was County Medical Officer. He retired some seven weeks later, on reaching the age of 65 years, and it is fitting that the first words in this volume should refer to his distinguished service to London and to the public health. Allen Daley was appointed medical officer of health of the County Borough of Bootle in 1911 and in due course held similar appointments at Blackburn and Hull, where he served until October 1929. These years saw the consolidation of the environmental health services and the growth of the personal health services, in particular of those concerned with maternity and child welfare, school health, tuberculosis and mental deficiency. From Hull, with a vast experience of all branches of public health, he took up his duties as a principal medical officer in the Council's service. In immediate charge of the general public health branch of the department, he also played a leading part in the taking over of the hospital services of the former Guardians of the Poor and of the Metropolitan Asylums Board. Appointed Deputy Medical Officer of Health in due course, he succeeded Sir Frederick Menzies as County Medical Officer at the end of 1939 and faced the many war-time problems of London's health and hospital services with courage and distinction. The end of the war saw no respite. The National Health Service Act of 1946 was to become operative in July, 1948. The greatest municipal hospital service in the world, comprising nearly 100 hospitals with many thousands of medical, nursing, technical and clerical staff was to be transferred, not to one, but to four metropolitan regional hospital boards, and the great personal health services of the metropolitan boroughs had, per contra, to be absorbed. Both tasks were successfully completed with astonishing smoothness and efficiency, and perhaps only those working close to Sir Allen (as he had become in 1944) know how much of that success was due to his administrative flair, abounding energy and tact. The years since 1948 have seen the consolidation of the health service in London in its new form and already the new structure is firmly rooted. In addition to the distinguished handling of these manifold burdens of a great office, Sir Allen found time to play an active part in many spheres connected with medicine and public health. The Rushcliffe Committee, the Central Midwives Board, the Central ? Health Services Council and several of its standing tees, the Royal College of Physicians, the Society of Medical Officers of Health, the boards of governors of several teaching hospitals, the London Executive Council and the London Local Medical Committee, amongst other bodies, have engaged his active interest over many years, with consequent benefit to the Council's own service. Readily accessible to his staff, his luminous intellect, unflagging energies, unrivalled experience and unfailing good humour, resolved the complexities of many a knotty problem. Still full of energy and good health, he takes with him into a nominal retirement, the good wishes not only of a department to which he has added fresh lustre, but of a very wide circle of colleagues all over the world. Two special contributions have been included this year—a sample survey on family accommodation, carried out for the Council's architect in connection with the development plan for the County (page 136), and one on the day time migration of London as disclosed by the London Travel Survey of 1949 (page 132). As usual brief reports by the divisional medical officers are included (pages 119 to 132). There was a slight fall in the birth-rate, 15.6 compared with 15.7, but the rate is still well above the pre-war level and the pace of the decline since the peak of 1947 is much slower than at first (page 6). (1) 2 The general death-rate at 12.6 is appreciably higher than the previous year (11.3), probably due to the influenza epidemic, concerning which a note appears on page 19 ; and to the increasing number of deaths from cancer, heart disease, and respiratory diseases due to the gradual ageing of the population (page 8). Deaths from motor vehicle accidents amounted to 282, an increase of 37 compared with 1950 (page 13); each year there are more deaths from this cause than from poliomyelitis. The infant mortality rate was again lower at 25.4 per 1,000 live births (25.8 in 1950). The neo-natal rate (deaths in the first four weeks of life) rose from 16.9 to 17.3 per 1,000 live births, but the 1950 figure was the lowest on record in London ; the average for the past ten years was 20.4 (page 13). A note on the relative importance of school, home and other forms of contact in the spread of whooping cough appears on page 24. The attendances of children at the welfare centres during the first year of life was higher than in 1950, but the total attendances were lower; 82 per cent. of children attended a centre during their first year of life, compared with 79 per cent. in 1950 (page 50). First attendances at ante-natal clinics amounted to 45 per cent. of all women requiring such care during the year, compared with 50 per cent. in 1950; an increasing number of mothers receive ante-natal care from hospitals, or from their family doctors (page 50). A report is given on page 53 of the 296 premature babies who were born at home, and it is satisfactory to note that 272 of the 296 made satisfactory progress. There was a continuation of the fall in the number of domiciliary confinements, due in part to the fall in the birth-rate, but mainly to the larger number of maternity beds now available in hospitals (page 60). The demand on the home help service continued, 26,542 families being assisted, compared with 25,805 the previous year (page 68). There has been a steady decline since 1949 in the number of children receiving primary immunisation against diphtheria, probably due in part to the publicity given to reports of cases of paralysis following inoculation in 1949 and partly to the low incidence of diphtheria (page 68). The risk of an attack of paralysis following an immunising injection against diphtheria is slight. The risk of a recrudescence of diphtheria, which is both a killing and crippling disease, should there be any substantial falling off in the number of children immunised, is a real one. The relationship between immunisation and infantile paralysis is being closely studied and new immunising agents are being tested. In the meantime, it may prove to be desirable to concentrate immunisation work, in the years when poliomyelitis is prevalent, into the late autumn, winter and spring months. The number of vaccinations and re-vaccinations again showed a welcome increase (page 70). The demand on the ambulance service, both for accidents and for general work again increased, as it has done in every year since 1948 (page 71). The work of the school health service is reflected in the increased number of medical inspections, 418,558 compared with 409,120 in 1950 (page 90). Deaths I regret to record the deaths on 17th January, 1951, of Mr. P. Gerrard, a principal clerk, and on 21st December, 1951, of Mr. F. D. Manners, L.D.S., R.C.S., the assistant chief dental officer. Facts and figures from the census Publication of the one per cent. sample tables of the results of the 1951 census provides an opportunity to review the facts and figures that form the bases of so many of the rates and indices which appear in the annual report of a Medical Officer of Health. It is twenty years since there was a stocktaking of the people and their manifold social characteristics ; twenty turbulent years of social history and national upheaval in a world war. 3 The following table is a summary of the age and sex constitution of London's population :— Age and sex constitution of the population in 1931 and 1951 (numbers in thousands) Age (years) 1931 1951 Male Female Male Female No. % No. O/ /O No. % No. % 0- 4 150 7.3 147 6.2 141 9.1 136 7.6 5-14 327 16.0 323 13.7 197 12.7 188 10.5 15-34 735 36.0 837 35.6 458 29.4 523 29.2 35-64 702 34.3 854 36.3 619 39.8 712 39.7 65 and over 130 6.4 192 8.2 140 9.0 232 13.0 Total 2,044 100.0 2,353 100.0 1,555 100.0 1,791 100.0 There has been an overall decline in population over the twenty years of just over one million persons, or 24 per cent. of the 1931 population. The decrease is greatest in the East London boroughs where there has been a fall of over 50 per cent. in population; on the other hand the population of the Borough of Hampstead increased by seven per cent. and there were very small increases in the boroughs of Woolwich and Lewisham. Slum clearance, migration into outer London, change in class of user of residential accommodation and bomb damage have been the prime factors in the cause of this change. The higher fertility of earlier years in inflating the present middle age-groups by the increase in the proportions at ages 35-64 years is demonstrated by the above figures which also reflect the improved survival rates, especially of women. In brief the population is an ageing one, and as the bulge in the age pyramid at ages 35-64 years passes into old age the general death-rate, which has been declining and has now reached what appears to be a stable level, may be expected to rise again. The increased proportions of children under 5 years is the effect of the temporary postwar boom in births. The build-up of London's population corresponds to the national experience, as instanced by the figures for England and Wales, except that there are rather fewer school children and more young adults (about two per cent.) in the London proportions for both census years. A vital constituent of the population is the proportion of married women at ages 15-44 years—the child-bearing years. Proportion of women ever married (Percentage of all women in the age groups specified) Age (years) London England and Wales 1931 1951 1931 1951 15-19 1.6 3.2 1.8 4.5 20-24 23.1 44.2 25.8 48.4 25-34 61.3 76.6 67.0 81.9 35-44 76.3 81.9 80.6 86.6 During and after the war there was a tendency for spinsters to marry earlier, thus increasing the average period of exposure of married women to the risk of childbearing. This suggests the maintenance of the fertility rates at a level somewhat above the experience of the nineteen-thirties. The London proportions of married women are lower than the corresponding national figures for both census years. Congenial employment is a contributory factor to good health and certain kinds of employment present a direct hazard to health. Table 31 in the Appendix shows the pattern of change in occupation between 1931 and 1951. Although changes in the 4 classification of occupations between 1931 and 1951 render it impossible to make precise comparisons without lengthy explanation, an attempt has been made in Table 31 to adapt the 1931 figures to the 1951 classification; the adaptation is approximate only but the general nature of the changes may be accepted as reliable. There are proportionately fewer men employed in London in 1951 compared with 1931 in textile and dressmaking trades, transport and communications, commercial trades (mainly shopkeeping) and in other and unskilled occupations with proportionately more employed in engineering and allied metal trades, building, the professions, the defence services and the non-occupied group (excluding unemployed). Most of the last increase will be due to the greater proportion of retired persons. For women the changes are not spread over such a variety of occupations, there are proportionately fewer women employed in the textile and dressmaking trades and in personal service. To counter-balance these decreases there are more women in the professions and many more (almost double the 1931 proportion) employed as clerks and typists. The non-occupied proportion for women, which shows a decline of 2 per cent. from 1931, is a composite figure which will be made up of an increase in the number of retired persons, probably an increase in the number of students, with a very much greater decline in the proportion whose sole occupation is that of a housewife, i.e. there are probably more married women at work in 1951 compared with 1931 than is indicated by the overall decline of 2 per cent. in this group. The actual details will not be available until publication of the full census results. The figures for Greater London show very similar changes which, on the face of it, negatives any suggestion of a differential migration according to occupation as being the cause of the changes in London. There is no possible analogy between London and the national figures in respect of occupation, since so much of industry and trade has a geographical basis. The final aspect of social conditions dealt with in part I of the present volume of census tabulations concerns housing. The following figures give a comparison of the essential details for the years 1931 and 1951. Particulars of London housing 1931 1951 Number of private households 1,190,030 1,114,400 „ „ structurally separate dwellings 730,628 761,600 Proportion of families sharing accommodation 63% 52% Number of rooms in these households 4,197,123 3,781,900 „ „ persons „ „ 4,122,639 3,129,100 „ „ „ per room 0.98 0.83 It is important that the definitions attaching to these statements be clearly understood before arriving at any conclusions from these figures. Thus by private household is meant a person living alone or persons living together under a single menage in the sense of sharing the same living-room or eating at the same table, but a lodger or group of lodgers hiring or sharing separate accommodation to themselves are treated as a separate household. Similarly, by dwelling is meant a room or suite of rooms used for habitation having separate access to the street or to a common landing or staircase to which the public has access. The number of households has not declined in the same ratio as the population for the reason that there has been a tendency for families to become smaller as instanced by the following figures :— Size of family 1931 1951 % % Single person families 13.0 19.3 2 persons in family 23.6 30.4 3 „ ,, ,, 22.0 22.6 4 ,, ,, ,, 16.7 15.3 5 „ „ „ 10.6 7.0 Over 5 „ „ ,, 14.1 5.4 100.0 100.0 5 The number of structurally separate dwellings has increased slightly in spite of the heavy damage sustained by residential property during the war, although conversion of premises to " structurally separate dwellings " within the terms of the definition referred to above will be a factor in this as well as new building. The overall density of population has declined from 0.98 to 0.83 persons per room in the twenty years, but the improvement varies with size of family as shown below. Housing density by size of family Persons per household No. of households Persons per room Reduction in average No. of persons per room 1951 1951* 1931 1 214,800 0.47 0.54 -0.07 2 338,600 0.63 0.66 -0.03 3 252,400 0.83 0.85 -0.02 4 170,300 1.00 1.01 -0.01 5 77,600 1.11 1.17 -0.06 Over 5 60,700 1.34 1.48 -0.14 Total 1,114,400 0.83 0.98 -0.15 * Estimated from the frequency distribution of Table IV—4 of the One Per Cent. Sample Tables. The considerable reduction in the overall average density is not matched by an equivalent reduction of the average density ratio for all sizes of family. It is in the main the reflection of a transfer of population from families of the larger size housed at the higher density rates, to smaller sized families housed at the lower densities. So far as the reduction in the overall average density is due to a transfer of population from the larger to the smaller families the reduction only partially reflects a real improvement in housing conditions. Nevertheless, the near correspondence of the improvement in the density ratio of the over 5 in family with the overall average indicates that the improvement has been greatest where the need was greatest. The overall density figures for London boroughs and for the groups of boroughs comprising the nine health divisions of the County are shown in the last two columns of Table 32. The improvement has been greatest in the eastern and central boroughs of London, closely followed by the boroughs of Bermondsey and Southwark south of the river. The proportion of families sharing accommodation is important from a health view, as the more people share household arrangements the greater is the risk of spread of disease. From the figures quoted above, about 50 per cent. of people are shown to be living in shared accommodation. For the first time the 1951 census gives some details of all household arrangements. It is noteworthy that in the Metropolis 28 per cent. of all households are without exclusive use of piped water (0.7 per cent. entirely without), 8 per cent. are without exclusive use of a cooking stove (3 per cent. entirely without), 16 per cent. are without exclusive use of a kitchen sink (6 per cent. entirely without), 35 per cent. are without exclusive use of a water closet (0.1 per cent. entirely without) and 62 per cent. are without exclusive use of a bath (44 per cent. entirely without). These proportions in modified form are shown in the detail of boroughs and health divisions of the County in Table 32. The proportions are somewhat higher for people living in shared accommodation. In respect of non-provision of these services, commonly accepted as essential, or having to share these facilities, with the consequent increased risk to health, London is not alone. Other large centres of population in the Country show somewhat lower proportions for all dwellings, with very much higher proportions for shared dwellings, but the total number of such dwellings in what the Registrar-General terms " Conurbations " in England, excluding London, is less than half that for the County of London. The problem of families having to share domestic arrangements may be more acute outside London but it is not so extensive. 6 VITAL STATISTICS Population The total home population of the County in the middle of 1951, according to the Registrar-General, was 3,358,000, compared with 3,389,620 in 1950. The provisional census figure in April, 1951, was 3,348,336. Corresponding estimates for metropolitan boroughs are shown in Table 2 on page 141, and the rates given in this annual report are calculated upon these figures. Table 1 shows the age distribution of the population at the middle of each year from 1921, as estimated by the Registrar-General. Though exact figures have not been available since the census of 1931, 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 Registrar-General in 1938, 8.5 per cent. of the population of the County was then over the age of 65. Based on the 1951 Census (one per cent.) figures, this percentage in mid 1951 was 11 .0. Migration Reference has been made in previous reports to the trend towards centrifugal housing that has been in process for many years, and which continues. It has been pointed out that such migration to dormitory areas outside the County might be selective in so far as those leaving the central areas will tend to be younger and healthier than average, this being a factor that would increase the ratio between mortality in London and that in the outer ring. The heavy concentration of industry and commerce in the central area continues, with the result that those moving to the outer ring have to travel to London to work, and from the epidemiological standpoint the resident London population is daily exposed to a correspondingly increased field of contact. Observations on a recent estimate (1949) of the day-time population of London appear on page 132. Fertility The total births allocated to London for 1951 were :— Live 52,387 Still 1,073 Total 53,460 The live birth-rate in 1951 was 15.6 per 1,000 total population, compared with 15.7 in 1950. 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 London to be confined in hospitals and nursing homes. This excess of registered over allocated births now amounts to about 11 per cent., i.e., some 6,800 births in 1951. The corresponding figure in 1950 was 7,000. The number of marriages registered in London in 1951 was 34,514, or 20.6 persons married per 1,000 of the total population, compared with 20.2 in 1950. 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 below shows the course of the two rates since 1931. The actual rates for London are given in Table 5 (page 142). 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 that of prewar, but the history of the period following the 1914-18 war had shown that substantial changes could occur in a comparatively short time, and it is not surprising that a decline in the birth-rate has taken place. The chief point of interest now lies in how far this decline will continue. The 1951 rate is still well above the pre-war level, and the pace of the decline is much slower now than two years ago. 7 LIVE BIRTH RATE IN ENGLAND AND WALES AND LONDON (A.C.) 1931-1951 PER 1,000 TOTAL POPULATION ENGLAND AND WALES LONDON (A.C.) There were 3,597 illegitimate live births (6.9 per cent. of the total live births). Illegitimacy The percentages in recent years are :— Year 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 1951 6.9 4.7 The peak of the war-time rise occurred in 1945, with a rapid reduction after the end of hostilities. The percentage for 1951 taken together with those for the two preceding years indicates that the rate is now fairly stable. Still-births Deaths under one year among illegitimate infants amounted to 35 per 1,000 illegitimate live births compared with a rate of 25 for legitimate births. The corresponding rates in 1950 were 38 and 25 respectively. A detailed comparison of deaths in the legitimate and illegitimate groups is given in Table 6 (page 145). There were 1,073 still-births in 1951 or 20.1 per 1,000 of all births (legitimate 19.3, illegitimate 29.9). The number of still-births and the rate per 1,000 total births in each year since 1931 is shown in Table 5 (page 144), from which it will be seen that after remaining stable for many years the still-birth rate fell sharply in 1943 and 8 although it has since followed a downward trend there has been in no year an improvement comparable with that between the years 1942 and 1943. Mortality The total deaths in 1951 amounted to 42,338, or 12.6 per 1,000 of the population. Detailed figures are given in Tables 2,3 and 4 (pages 141 to 143). Mortality from infectious diseases is discussed below under that heading and tuberculosis is dealt with separately (see p. 25). For the latter and other principal causes of death the trend is indicated by the diagram on p. 10. The sharp changes that occurred between 1939 and 1940 are attributable to two causes. In the first place, the Registrar-General abandoned the rates 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 general 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 diseases - 10 ,, Other circulatory diseases - 6 ,, Bronchitis + 100 ,, Pneumonia + 5 ,, Other respiratory diseases + 50 ,, Nephritis + 12 ,, Diseases of pregnancy, etc. + 10 ,, * Based on the dual classification of deaths for England and Wales, 1939. The second cause affecting the statistics was the outbreak of war. The young and healthy section of the population was, from September, 1939, excluded from the mortality statistics, which henceforth related only to civilians. This selective factor was bound to inflate the death-rates, since the population in respect of which they were calculated was now on the average older and less healthy. To 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, again rose sharply in 1940. This increase was partly due to the war-time statistical basis as explained above, but the heavy toll of air raids was an important contributory factor. Between 1944 and 1950 there was, however, a decline in trend. The rate of 12.6 in 1951 is appreciably higher than that of the previous year (11.3) due to increasing number of deaths from cancer, heart disease and respiratory diseases, resulting from the gradual ageing of the population, and to the influenza epidemic. Bronchitis and heart disease The death-rate for the bronchitic and heart disease group which was 5.01 in 1951 compared with 4.32 in 1950 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 142). Cerebral haemorrhage The death-rate from vascular lesions of the nervous system in 1951 was 1.22 per 1,000, compared with 1.11 in 1950. The average for 1941-45 was 1.15, but a 9 Nephritis large proportion of the apparent reduction in the interval was due to the increase in the civil population upon demobilisation, a purely " statistical " effect. For nephritis the death-rate in 1951 amounted to 0.12 per 1,000, compared with 0.11 in 1950 and an average of 0.36 over the years 1931-40. Degenerative diseases If, as an indication of mortality from degenerative diseases, heart disease, other circulatory diseases, cerebral vascular lesions, nephritis and bronchitis are combined, the following trend becomes apparent:— Mortality (per 1,000) from cardiovascular—renal disease and bronchitis 1931-40 (average) 5.33 1946 6.11 1941 7.93 1947 6.27 1942 6.93 1948 5.47 1943 7.23 1949 6.11 1944 7.12 1950 5.99 1945 6.67 1951 6.82 The true effects of the war cannot be separated from the statistical influences described on page 8 (particularly the change in 1940). The rates in recent years appear to be running higher than pre-war. Degenerative diseases thus continue to attain greater importance, and are responsible for over half the death-rate. Cancer The cancer death-rate for all ages in 1951 was 2.27 per 1,000, slightly higher than in 1950. The death-rate from cancer, which is largely a disease of the latter half of life, can be substantially changed by variations in the age constitution of the population. Some form of standardisation of the crude rate is therefore essential for true comparative purposes. Thus in England and Wales the crude cancer mortality rates between 1938 and 1945 rose 37 per cent. for males and 7 per cent. for females, but the " standardised " mortality rates (C.M.I.*) were almost stationary, a small rise for males and a small fall for females. The difference between the crude and standard rates for London, which lost a large proportion of the population (more young than old) by evacuation during the war, would doubtless be larger, but in London age group population estimates were not available between 1939 and 1946. Age specific rates since 1947 are shown below:— Administrative County of London Cancer Mortality Rates per 1,000 living (total population) Age and Sex 1947 1948 1949 1950 1951 Males 0-14 0.02 0.03 0.06 0.11 0.10 15-14 0.35 0.30 0.29 0.38 0.35 45 + 5.34 5.61 5.81 6.18 7.45 All Males 2.13 2.21 2.27 2.45 2.60 Females 0-14 0.04 0.03 0.05 0.07 0.09 15-44 0.34 0.36 0.33 0.37 0.35 45 + 4.27 4.44 4.42 4.51 4.83 All Females 1.88 1.95 1.93 1.98 1.99 All Persons 2.00 2.08 2.09 2.20 2.27 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 142). 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 doubtless attributable to increased incidence, particularly cancer of the lung. The important changes in mortality in London between 1931-33 * Comparative Mortality Index. 10 TREND OF MORTALITY LONDON 1936-51 DEATH RATE PER 1,000 11 TREND OF MORTALITY-LONDON 1936-51 DEATH RATE PER 1,000 12 and 1949-51 in relation to certain specific sites are summarised below :— County of London—Changes in Mortality Rates from Cancer between 1931-33 and 1949-51 (all ages) Site Males Females Mean deathrate 1949-51 per 1,000 Change between 1931-33 and 1949-51 Mean deathrate 1949-51 per 1,000 Change between 1931-33 and 1949-51 Buccal cavity 0.093 decrease 47 per cent. 0.026 increase 8 per cent. Respiratory system 0.829 increase 251 per cent. 0.145 increase 164 per cent. Digestive system 1.016 increase 9 per cent. 0.831 increase 19 per cent. Breast — 0.386 increase 27 per cent. Genito-urinary organs 0.312 increase 48 per cent. 0.382 increase 1 per cent. All sites 2.45 increase 47 per cent. 1.94 increase 28 per cent. The outstanding fact is the increase in cancer of the lung. The male rate is more than five times the female rate, and during the last 20 years male mortality has increased to a figure three and a half times the original rate, while the female rate is two and half times its 1931-33 level. Buccal cancer in males has improved during the same period. An increase in cancer of the digestive system in both sexes was arrested five years ago, and figures have been steady since then. A slight diminution occurred in 1951 in the number of male deaths from cancer of the genitourinary system, but it is too early to say if this represents anything more than a temporary check in the steadily increasing figures of the last few years. Digestive Mortality from digestive diseases (other than cancer) in 1951 was 0.45 per 1,000. Within this group the death-rate from ulcer of the stomach or duodenum was 0.19 per 1,000 compared with 0.17 in 1950 and 0.15 in 1949. Diabetes Diabetes mortality fell steadily between 1939 and 1947, but in the last four years the death-rates have been 0.06, 0.07, 0.08, 0.09, indicating an arrest in the decline which supports the impression that the previous decline had been connected with the dietary stringency of the war and post-war years. At ages under 55, where treatment is more effective, the number of deaths in 1951 was 34, 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 1950 39 1951 34 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 1946 a level lower than the average of the intermediate and pre-war years. The rate for " other respiratory diseases " was distorted in 1940 by the statistical revision of cause of death, 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 diseases. 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 in 1951 was 0.64 per 1,000 compared with 0.50 in 1950, and the rate for " other respiratory diseases," excluding bronchitis, was 0.12 compared with 0.10 in 1950. these slight rises being probably due to the influenza epidemic. Road accidents Deaths from motor vehicle accidents in 1951 amounted to 282 compared with 245 in 1950 and 257 in 1949. Although the addition to the death-rate due to road 13 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. Other violence Other violent causes of death accounted for 1,252 deaths. The corresponding figure for 1950 was 1,253. The peaks in the diagram on page 11 are due to the heavy toll of air raids. General The leading causes of death in London in 1951 were as follows:— Deaths Rate per 1,000 population Diseases of the heart 12,991 3.87 Cancer 7,639 2.27 ♦Pneumonia, bronchitis 5,969 1.78 Vascular lesions of the nervous system 4,110 1.22 Other circulatory 1,558 0.46 Violent causes 1.534 0.46 Digestive diseases 1,520 0.45 Tuberculosis 1,279 0.38 Diseases of early infancy (prematurity, birth injury, congenital malformation, etc.) 1,129 0.34 Nephritis 407 0.12 All other causes 4,202 1.25 Total 42,338 12.61 Infant mortality *Now includes pneumonia of the newborn. The infant mortality rate in 1951 was 25.4 per 1,000 live births, which is an improvement on the rate of 25.8 for 1950. The movements of the death-rates from the principal diseases at ages below one year since 1911 are shown in Table 7 (page 145). The diagram (page 15) illustrates the decrease in the fatality of infants since the years 1911-14. The increase in deaths assigned to congenital malformations and injury at birth is partly attributable to changes in classification following the adoption of the fifth 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 made more frequently, thus resulting in increased precision in certification. In most diseases there has been a dramatic reduction in mortality over the past forty years, and even since 1927 the improvement is substantial. The pronounced fall in case mortality of whoopingcough and measles has also 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. Increased attention has been given to the care of the premature infant, and there are signs that these efforts are having a salutary effect on the mortality risk. Neo-natal mortality Deaths in various periods of the first year of life during 1951 are shown in detail in Table 6 (p.145). Deaths under four weeks numbered 907 or 17.3 per 1,000 live births. Comparative rates for London and England and Wales in recent years are :— Year London England and Wales 1931-35 25.1 31.4 1936-40 22.9 29.0 1941-15 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 1951 17.3 18.9 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 wartime increase arising B 14 from the severe conditions, but this setback was soon recovered at the end of the war. The reduction in infant mortality in the past fifty years 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 injury at birth, have been more resistant to reduction. The distribution of causes of death in the first four weeks of life in 1951 was as follows :— Cause No. of deaths Per cent. Total Prematurity 242 26.7 Post-natal asphyxia and atelectasis 198 21.8 Birth injury 154 17.0 Congenital malformations 112 12.3 Other diseases of early infancy 88 9.7 Pneumonia of newborn 58 6.4 Diarrhoea and Enteritis 6 0.7 All other causes 49 5.4 Total 907 100.0 It is seen that deaths from prematurity, injury at birth and congenital malformations account for 56 per cent. of 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 could be reduced by specialised treatment of the infant. An analysis of the 296 premature babies born at home will be found on page 53. 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 during the war the rate has been further reduced from 11.6 in 1944 to 4.6 in 1951, 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 1936-10 was 2.20 per 1,000 live births, but was 2.94 in 1951. The birth injury death-rate has, in the past, been understated. Now more post-mortem examinations are performed and more injuries are thus detected. The result is that deaths which would formerly have been assigned to other causes are now assigned to birth injury, and the deathrate has thus increased, without any real increase in the risk necessarily being implied. The average neo-natal death-rate from congenital malformations was 2.84 per 1,000 live births over the period 1936-40, and in 1951 the rate was 2.14. 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 1951 the neo-natal mortality rate was about two-thirds of the average rate for 1931-35. Puerperal fever and pyrexia— Maternal mortality A summary of maternal mortality statistics is given below. Comparative figures for England and Wales in recent years are shown in Table 8 (page 146). 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 1951 53,460 24 0.45 18 0 .023 911 17. 04 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 1951 was officially 0.45 as compared with 0.53 in the previous year. It is, however, necessary to point out that in three cases assigned 15 by the Registrar-General (under international rule of classification) to pregnancy or childbirth the last pregnancy occurred in previous years, so that the true maternal death-rate for 1951 was therefore 0.39. 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 in individual years are liable to considerable fluctuation without any significance necessarily being attached thereto. INFANT MORTALITY MORTALITY PER 1,000 LIVE BIRTHS The analysis of maternal deaths in 1951 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 13 3 16 Other causes 5 21 26 Total maternal deaths 18 24 42 16 There were 16 deaths from sepsis, of which 13 were post-abortive and 3 followed childbirth. 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 1951 was 17.04 per 1,000 total births, compared with 6.83 in 1950. This large increase in notifications since the previous year is misleading and is due to the Puerperal Regulations of 1951 which now require the inclusion of cases notified in the hospitals. Many of these relate to maternity patients residing outside the County. The trend of maternal mortality in the Administrative County of London from 1891 is shown in Table 3. It will be observed from this Table that maternal mortality fell very slowly until the introduction of the sulphonamides in the middle '30s, 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 in pregnancy and has been displaced by toxaemia, haemorrhage and other accidents (trauma of the pelvic organs, etc.), which now contribute the greater part of the total mortality, though the risk of death from this cause 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 this can be attributed to the effect of the air bombardment, which reached its peak intensity in that year, and the subsequent 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 ENGLAND &. WALES LONDON Infectious Diseases The attack rates and death-rates of the principal infectious diseases in London during 1951 and earlier years, and for the constituent metropolitan boroughs in 1951, 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.) 17 Anthrax One case of anthrax was notified during the year and was confirmed bacteriologically. The patient was a stevedore at a wharf handling hides, bonemeal and such-like articles. The medical reports showed that satisfactory progress was made. Meningococcal infection Prior to the war the attack rate of 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 incidental with military and industrial mobilisation. Subsequently the rate fell rapidly. In 1949 the incidence was only 0.023 per 1,000, 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. In 1951 there were 108 such notifications giving an attack rate of 0.032 per thousand. There were 25 deaths of which 20 were under 5 years but owing to imperfect notification the case fatality from this disease is less than would appear from this figure. Incidence is greatest in infants, e.g., 63 of the total of 108 cases were infants under the age of 5 years and of these 40 were boys and 23 girls. The attack rates for males are consistently higher than for females at all ages. Dysentery During 1951 London in common with the rest of the country experienced the highest incidence of dysentery since the disease became notifiable, the total of 4,069 notifications representing a fourfold increase over that of 1950 which had itself been higher than usual. Deaths rose only from 6 in 1950 to 9 in 1951, the disease being almost entirely of the mild Sonne type. The increased incidence of the disease has presented two features calling for special mention. The first, of particular importance to London, is that this disease which previously showed its highest attack rates in rural areas now has the higher incidence in urban areas. The second is that in London as elsewhere the increased incidence was more marked in the 5-14 age group than in the 0-4 group. During the year this disease which has always shown a special predilection for day nurseries became epidemic also in certain of the infants' departments of day schools. There is scope for further investigation into the dynamics of Sonne dysentery epidemics in order to elucidate the part played by school and nursery outbreaks in the dissemination of infection in the general population. Diphtheria The campaign to encourage immunisation against diphtheria began in 1941 and the results have been very encouraging. The fall in incidence since that date has been far in excess of any downward fluctuation observed in the previous fifty years. In 1951 there were only 30 cases or 0.009 per thousand living at all ages compared with a rate of 0.024 in 1950 ; 69 per cent. of the cases under the age of 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 nearly 5½ A 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. Attention is drawn to the fact that there was an immediate acceleration in the rate of decline in incidence at ages under 15 years from 1942 onwards, but that this did not take place in the rate for those over 15 years of age until 1947. It cannot be without significance that in the early days of the immunisation campaign both infants and school children were artificially protected, and that five years later a substantial number of those immunised in the schools had passed into the over 15 age group with obvious results on the curve of incidence in this age group. During 1951 the rates have continued their rapid decline. The degree of immunisation at school ages has risen from 77 per cent. in 1950 to 82 per cent. in 1951. 18 According to the Registrar-General's classification there were two deaths from diphtheria in London during the year. One was a male child age 7 who died of faucial diphtheria and had not been previously immunised ; the other was a female adult age 60 who died from suppurative thyroditis and stenosis of the trachea following tracheotomy performed at age 7. Since the initiating disease for which the operation was performed was diphtheria according to the certifying practitioner this death has by international agreement been assigned to this disease. DIPHTHERIA — AGE INCIDENCE NOTIFICATIONS PER 1.000 LIVING IN AGE GROUPS It cannot be too strongly emphasised that the maintenance of this good progress depends upon the co-operation of the public in sustaining and even increasing still further the rate of immunisation ; great efforts must be made 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. Diarrhoea and enteritis The mortality from diarrhoea and enteritis under two years of age (44 deaths) amounted to 0.84 per 1,000 live births, a figure that is less than half that in 1949. Enteritis is not a notifiable disease so it is not possible to say whether this is due to a decrease in incidence or severity or both. There has been a steady decline in mortality for some years, and during the last ten years the London rate has fallen more rapidly than the national rate. It is the opinion of some hospital workers that during the last two or three years there has been a decrease in the incidence of the severe forms of gastro-enteritis, which may be a reflection of changes in the prevalence 19 of particular micro-organisms. During the last ten years there has been a great improvement in the treatment of the dehydration associated with this disease ; and a further hopeful sign is that the specific types of B. coli that are being increasingly found in outbreaks of this infection are susceptible to the newer anti-biotics. DIARRHCEA AND ENTERITIS (UNDER TWO YEARS) MORTALITY PER 1,000 LIVE BIRTHS Enteric fevers Notifications of fevers of the enteric group numbered 66 in 1951 compared with 63 in 1950 ; there were only 4 deaths. In 1900 there were 767 deaths. A number of the London cases represent infections acquired while the persons were abroad on the Continent; most of the remainder were the result of infection from healthy unrecognised carriers. This fact indicates that further reduction in the present low incidence of these diseases can only result from energetic enquiries in the environment of known cases with a view to detection of the carrier source. Recent advances in the methods of detection of enteric organisms in sewage have opened up new possibilities in the search for carriers. The present interest in the improvement of hygiene in food premises may be expected to reduce the likelihood of outbreaks of enteric fever. Erysipelas There were 496 notifications of erysipelas in 1951, giving an attack rate of 0.148 per 1,000, compared with 0.167 in 1950. The incidence of this disease has been declining continuously since 1941. There was one death in 1951. Influenza There were 809 deaths (0.24 per 1,000) from influenza during the year. During recent years the deaths have been :— Year Influenza deaths Year Influenza deaths 1941 397 1947 284 1942 198 1948 78 1943 726 1949 372 1944 206 1950 256 1945 171 1951 809 1946 371 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, influenza became prevalent first in the north-west of England and later in the south. In London 704 deaths were registered in the first thirteen weeks of 1951 compared with 146 in the corresponding period in 1950, indicating that an epidemic was occurring. Epidemic of 1950-51* Since influenza is not notifiable its incidence must be studied by the weekly notifications of the various forms of pneumonia and registrations of deaths. A study of weekly deaths in the great towns of England and Wales, e.g., London, Birmingham and Manchester in successive winters from 1920 onwards shows sharp seasonal rises in influenza deaths during most of the winters and since 1919 these periods of high mortality have not persisted beyond the twentieth week of the year, the deaths rising rapidly to a peak and then falling away again. The disease does * Based on a contribution by Mr. B. Benjamin, Statistician of the Council's public health department' to a discussion at the Royal Society of Medicine. Acknowledgement is made to the Royal Society of Medicine for permission to use the diagram from page 797 of their " Proceedings " (Vol. 44) 1951. 20 not behave in different local areas in the same way at the same time and the epidemic curve for the whole country is compounded of those of different localities subject to variations in timing and operation of spread as between one district and another. WEEKLY DEATHS FROM INELUENZA , LONDON 1950-51 AND WEEKLY AVERAGE IN N0N-EPIDEMIC YEARS 1944-48 Thus the 1923/24, 1926/27 curves for the Great Towns were much influenced by an earlier rise in London than occurred in Birmingham and Manchester. A much sharper peak was evident in 1921/22 and 1928/29 when there was less difference in timing. Since 1931 there has been a tendency for the widely separated towns of London, Birmingham and Manchester to give mortality peaks closer in time and thus tend to produce sharper curves for the Great Towns. In the most recent epidemic the mortality in London, Manchester and Birmingham exceeded that for 21 1943-44 but the 1936-37 level was not attained in London. The highest weekly mortality rates per million reached during the year were :— London Manchester 41.6 102.2 Birmingham Great Towns 67.3 60.0 In the diagram the 1950-51 weekly deaths for London are shown in greater detail. The continuous line at the top relates to deaths over 55 years of age; the lower continuous line with the circled points relates to deaths under 55. The broken lines denote the averages for the corresponding weeks in non-epidemic years 1945-48. Temperature, rainfall and fog are also shown. It will be seen that most of the deaths occurred at very advanced ages. For the weeks ended 23rd December, 1950, to 24th February, 1951, the age distribution of influenza deaths in London was :— Age Per cent. Age Per cent. 0-4 1.3 10.5 55-64 16.51 89.5 5-14 — 65-74 32.0 15-24 0.3 75 + 41.0 25-44 2.5 45-54 6.4 Deaths under 55 attained a peak in spite of higher temperature and absence of fog. Deaths over 55 peaked at minimum temperature and maximum fog. The effect of low temperature and fog in increasing the death rate from non-specific chronic respiratory disease has been previously noted, and it appears that many of the deaths in this epidemic at ages over 55 were in those already suffering from chronic respiratory infection. It is to be noted that the rise in deaths over 55 attained a maximum somewhat later than the younger age groups; also that the incidence of influenza in younger persons as measured by the deaths rose to five times and in older persons to ten times the average non-epidemic level of 1945-48. Measles Measles became notifiable in London in 1938. Before that year records of incidence were built up from reports of school absences, hospital admissions and death records. Until 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 war years disturbed this rhythm and since 1940 the outbreaks have been annual and of about the same order of magnitude each year. In 1950 there was a delayed sub-normal outbreak of measles which did not reach peak until mid-summer. This was followed by a marked rise in cases again in the autumn heralding a major epidemic which finally reached a peak of 3,754 cases in the eighth week of 1951 with a sub-peak in the first week of that year (2,730 cases). The total cases notified during the year 1951 were 49,148. After the peak was attained there was a steady fall in weekly cases and the epidemic gradually petered out—in the twenty-sixth week the cases numbered only 229 and during the last week of the year only 19 cases were notified. Ignoring the small outbreak in 1950, which can now be seen to be the beginning of the 1951 epidemic later temporarily interrupted by the autumn refractory period, the interval between the peak of the 1949 outbreak and that of 1951 was 96 weeks so it would seem that owing to the decrease in susceptibles with the fall in the birth rate since 1947 the rhythm of measles epidemics is now moving towards a biennial period as existed in the pre-war period 1923-38. The attack rate of 14.64 per thousand in 1951 was the highest incidence known since notification became compulsory in 1938. 22 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 1951 49,148 25 0.051 *Actual notifications since 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. Ophthalmia neonatorum The incidence of ophthalmia neonatorum which since 1921 has remained fairly constant between 8 and 10 new cases per thousand live births commenced to fall slightly towards the end of the period 1931-40 and in recent years has fallen to below 5 per thousand live births. There were 93 cases in 1951 (1.8 per thousand live births) full details of which are shown below. Ophthalmia Neonatorum Number of cases Domiciliary confinements Institutional confinements Total Notified during the year 40 53 93 Removed to hospital for special treatment 4 10 14 The condition at the end of the year of the 93 cases notified was:— (a) Vision unimpaired 87 (b) Vision impaired — (c) Vision lost — (d) Died — (e) Under treatment 1 (/) Removed from the county 5 Total 93 Pneumonia Notified cases of pneumonia in 1951 numbered 2,409 or 0.717 per thousand, compared with 0.499 per thousand in 1950. This disease is considerably undernotified 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 believe that this fraction varies from year to year so that the notifications may still be used as a relative index of incidence. It will be seen from Table 9 that the 1951 notification rate is lower than either war-time or pre-war rates. See page 12 for comment on the death-rate. Poliomyelitis and polioencephalitis During the year 112 cases of poliomyelitis occurred according to corrected notifications and there were 2 deaths giving a crude case mortality of 1.8 per cent. In the 1950 outbreak there were 430 cases and 36 deaths so that the 1951 incidence was much lower than that of the previous year. In 1951 24.1 per cent. of the cases were infants under 5 years of age compared with 34.9 per cent. in 1950. The variations in age distribution are interesting. Before 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 in the following table. The rise and subsequent fall in this percentage from 1947 onwards will be noted. 23 Cases of Poliomyelitis and Polio-encephalitis Year Total No. Under 5 years of age Year Total No. Under 5 years of age No. °/ /o No. % 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 1942-4 88 41 46.6 1951 112 27 24.1 The 1951 age distribution was:— Poliomyelitis notifications (corrected), 1951 Age No. 0/ /o 0- 4 27 24.1 5-14 45 40.2 15-24 15 13.4 25+ 25 22.3 Total 112 100.0 The attack rates in the metropolitan boroughs are shown in Table 2. Rheumatic fever Deaths in London from rheumatic fever in 1951 numbered 25, of which 7 were among children under 15 years of age. Corresponding figures in 1950 were 30 and 5 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 Rale 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 1951 1 1 338 340 0.156 No clear post-war trend can be discovered. The 1951 figures indicate a downward fluctuation in the death-rate and there were only two deaths under the age of 15 Scabies Scabies became notifiable in London in August, 1943. Notifications in 1951 numbered 572 compared with 823 in 1950. The effect of improved control resulting from notification is shown in the persistent decline in incidence. (See Table 9, page 144.) It is seen that excellent progress has been made. The attack rate (0.170 per 1,000) in 1951 was about 1 /40th of the rate experienced seven years earlier. Scarlet fever Scarlet fever incidence was lower than in 1950. There were 3,705 cases (1.10 per 1,000) compared with 4,157 (1.23 per 1,000) in the previous year. Only 3 deaths from scarlet fever or streptococcal sore throat occurred in 1951. Fifty years ago the annual death roll in London was over 500. There were no notifications of smallpox in London during the year. Smallpox Typhus There was one case of typhus during 1951. The case occurred in St. Pancras. The patient was a resident of the Gold Coast and was sent to the Hospital for Tropical Diseases from the airport. Whooping cough There were 10,448 notifications of whooping cough during the year compared with 10,875 in 1950 and 5,754 in 1949. As can be seen from Table 9 the incidence varies considerably from year to year. The roughly equal incidence in 1950 and 24 1951 represents the rising and falling stages of one continuous epidemic with its peak at the turn of the year. During 1951 there were 21 deaths giving a death-rate of 0-006 per 1,000 (crude case mortality 0.20 per cent.). The corresponding rates for 1950 were 0.009 per 1,000 and 0.28 per cent. It is seen from Table 3 that the fatality from this disease which has been declining since the end of the last century has fallen with dramatic rapidity in more recent times. The relative importance of school, home arid other forms of contact in the spread of whooping cough An investigation was carried out with the assistance of health visitors in Division 9 to estimate the relative importance of school contact, home contact, and other forms of contact in the spread of whooping cough. The sample investigated included 272 children in three age groups (Table A). Table A Age Total July-Dec. 1950 Jan.-July 1951 The Sample 0-4 162 60% 92 57% 70 63% 5-14 104 38% 65 40% 39 35% over 15 6 2% 4 3% 2 2% Total 272 161 111 Notifications—London 0-4 65% 63% 67% 5-14 33% 35% 31% over 15 1% 1% 2% Table B School Infection Age Patient at infected school Sibling at infected school Total possible attributable to school All cases 0-4 2 37 39 24% 162 5-14 61 10 71 68% 104 over 15 1 — 1 6 Age Patient at infected school Sibling at infected school develop'd wh.c. Total attributable to school All cases 0-4 2 13 15 9% 162 5-14 61 3 64 61% 104 0-4 July-December, 1950 8% 0-4 January-July, 1951 11% 5-14 July-December, 1950 58% 5-14 January-July, 1951 66% Compared with the total notifications from the whole of London during the same period the sample contained a slightly smaller proportion of children under five. The percentage of under-fives was higher in the latter half of the epidemic than in the first half, and this was found in both the total notifications and the sample. Table B shows the possible effect of school contact in the infection of the cases in the sample. If transmission of infection from school to home by healthy intermediaries were excluded it would be seen that school infection could not have been responsible for more than 9 per cent. of the cases in children under the age of 25 5 years. As might have been expected the corresponding figure in respect of children of school age was higher, viz., 61 per cent. The influence of school as a source of infection appeared to become slightly greater as the epidemic progressed. All types of direct contact that were brought to light during the survey are detailed in Table C. A possible origin for about half the cases was discovered. Table C Types of known direct contact 0-4 yrs. 5-14 yrs. Over 15 Total Relative living at home 19 7 2 28 Relative living at home plus school contact — 1 (included in above) — — Cousin living elsewhere 14 — — 14 Other known contact 24 9 1 34 Other known contact plus school contact — 6 (included in above) — — School contact 2 55 1 58 TOTAL KNOWN CONTACT 59 71 4 134 Total cases 162 104 6 272 Percentage known contact 37% 69% 48% It was noteworthy that school and home contact accounted for only 37 per cent. of the infections in children under five. The major risk to this group appeared to be the unknown and presumably casual type of contact. This might perhaps be partly explained by the fact that children of this age tended to spend most of the day with the mother and therefore encounter a wide variety of casual and unknown contacts. Infectious disease in schools The number of cases of infectious disease reported from schools in 1951 and in other years is shown in Table 14 (page 148). The year 1951 was an epidemic year for German measles. A rise occurred in the incidence of ringworm. The downward trend of scabies already noted is shown in the school figures. There was, however, a slight rise in the incidence of impetigo. The incidence of scarlet fever was lower than in 1950. Whooping cough was also less prevalent in the schools than in the previous year. The incidence of chicken-pox was abnormal. There was a very heavy epidemic of measles during the year (see above, page 21). Cases of mumps were less numerous than in 1950. The rise in ophthalmia and conjunctivitis prevalence was confined to a few schools in one division. Tuberculosis Detailed figures of new cases of tuberculosis notified in 1951 are shown in Tables 10 to 13 (pages 146 to 149). Non-civilians are included in the statistics and total (home) populations are used. The general trend of morbidity and mortality since 1921 is indicated in Table 10 (page 146) and is also illustrated by the 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 only 1.3 per 1,000 in 1938, a fall of about 40 per cent. in just under 20 years. During 1938 the death-rate from pulmonary disease was 0.64 per 1,000, i.e., about 40 per cent. lower than in 1920; a saving of some 1,600 deaths annually at the 1938 population level. In the earlier 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 26 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 TUBERCULOSIS MORTALITY & MORBIDITY 1923-1950 ANNUAL DEATHS PER 1,000 LIVING ANNUAL NOTIFICATIONS PER 1,000 LIVING mortality and by 1941 the ground gained in 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 mortality quickly began to decline again as the war proceeded. 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 the pre-war trends. Ihe death-rates per 1,000 living in 1951 in London and for the whole country were:— Pulmonary Non-pulmonary London 0.344 0.037 England and Wales 0.275 0.041 With regard to morbidity the rate of occurrence of new cases of pulmonary tuberculosis rose by nearly 50 per cent. between 1938 and 1941, remaining at the higher level until the end of the war, when a decline took place, at first quite rapidly. The statistical improvement, however, was short-lived, for between 1947 and 1949 the notification rate rose slightly. It must, however, be remembered that diagnostic 27 services are now more used than ever before and also that new methods such as mass miniature radiography now discover early cases which normally 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 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 of pulmonary disease in 1951, 1.46 per 1,000, was less than the rate of 1.53 per 1,000 recorded in 195???. A 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 1951 was 0.15. The age distribution of new notifications of tuberculosis is shown in Tables 11(a) and (b) and specific notification and death-rates are shown in Tables 12 (a) and (b). As regards pulmonary tuberculosis notifications there were signs of improvement in the rates for all age groups in males except ages 45+ and for females except in the age groups 0-4 and 45+. In non-pulmonary there was a fall in the rate for males except at ages 5-14 and 45+ and for females in all age groups excepting 45+. The death-rate for males 45+ does not seem to show signs of decreasing, there being an increase on that of the previous year. That of females 45+, however, seems more or less stable. The rates under 45 appear to be falling for both sexes. 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 of diagnosis. A few years ago the death figures sufficed to measure incidence, but since the introduction of streptomycin a number of cases now survive and mortality is certainly declining. The incidence of tuberculosis of bones and joints seems satisfactory. Tuberculosis of the peripheral glands, which showed in children a large war-time increase, is now steadily becoming rarer. Food poisoning Since the beginning of 1949 food poisoning has been a notifiable disease in London. In 1951 787 cases were reported giving an attack rate of 0.23 per 1,000 compared with 863 cases (0.25) in 1950. The sex and age distribution was:— Age Males Females 0-4 70 47 5-14 48 46 15—44 132 250 45-64 49 88 65+ 16 40 Age unknown 1 — 316 471 From the above it would appear that cases are more frequently reported in women than in men. A female excess is also observed in dysentery. GENERAL PUBLIC HEALTH Housing During the year 13,364 houses and flats were erected or brought into commission after repair by the Council and/or the metropolitan borough councils. Of these 7,375 were in London (3,291 by the Council and 4,084 by the borough councils) and the remainder (5,989) were erected by the Council outside the London area. The total number of houses or flats owned by the Council at 31st December, 1951, was 145,801 (an increase in the year of over 9,000) of which 71.448 are situated in London and 74,353 outside the county. 28 The number of applications registered on the Council's housing waiting list on 31st December, 1951, was 171,567, compared with 198,955 in 1950. Approximately 34,000 new applications were registered during the year. The overall reduction in the number of names remaining on the list was due to applications having been allowed to lapse. The housing waiting list is divided into three categories in accordance with urgency on the basis of the total number of points awarded under the Council's Points Scheme as follows:— Category A—Urgent cases Category B—Cases with some housing need, but not of an urgent character Category C—No basic housing need. During the year 40,613 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 which had been considered in previous years but were reviewed in the light of changed medical or domestic conditions. The number of new applications considered was some 4,000 less than in 1950. The continuing large number of applications on health grounds is no doubt 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. Of the applications considered on general health grounds, 4 per cent. (1,704) were recommended for special preference because rehousing was urgently necessary to reduce the danger of infection arising from inadequate accommodation for persons suffering from active pulmonary tuberculosis, 11 per cent. were classified as "most urgent," and 30 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 doctors' certificates did not warrant additional preference for the remaining 55 per cent. Clearance areas 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. Of these priority areas, one was represented to the Council in 1949, a second in 1950, and a further two areas were resurveyed and represented to the Housing Committee during the year under review. These latter two areas extended over 7 acres and contained 341 houses. The remaining two of the six areas were also resurveyed with a view to early representation in 1952. Representations in respect of three areas situated within the Stepney and Poplar Reconstruction Area, covering over 2 acres and containing 146 houses, were also made during the year. A further representation was made in respect of an area in south London extending over approximately 1| acres and comprising 51 unfit houses. Four public local inquiries were held by the Minister of Health and confirmation of three of the Council's Orders was received. The result of the remaining inquiry is awaited. Notifications under section 33 of the Housing Act, 1936, of intention to deal with 292 unfit houses contained in seventeen areas were received from eight borough councils. Surveys were made of 364 houses contained in seven areas, apart from those mentioned above, in connection with proposals for their acquisition by the Council. The Slum Clearance Survey As mentioned in my report for 1950, the metropolitan borough councils submitted details of all areas regarded as suitable for clearance. Discussions were held with individual borough councils during the year and a detailed draft programme of slum clearance to be undertaken during the years 1951-55 by both the Council and 29 the borough councils has been submitted to the Housing Committee. This programme provides for the demolition of 10,131 unfit houses within the County. Improvement Grants Surveys were made in respect of four applications for improvement grants under section 20 of the Housing Act, 1949, and recommendations as to the suitability of the properties made to the Director of Housing and Valuer. Three other properties were surveyed in connection with applications for loans. Dangerous structures During the year 2,874 searches were made in connection with enquiries concerning properties scheduled as 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:— 8ource of sample Designation Samples Percentage positive of completed samples Total Positive Incomplete Negative 1951 1950 (a) Supplied to London by road and rail in churns. Ordinary 451 8 23 420 1.8 2.8 Accredited 13 1 — 12 * * Tuberculin tested 20 — 1 19 — — (b) Plant at London depots. Pasteurised 14 — — 14 — — (c) Residential schools. Ordinary 2 — — 2 — — Total 500 9 24 467 1.8 2.8 *percentage would be unreliable owing to the few samples taken in 1950 and 1951. There has been a considerable increase in the amount of tuberculin-tested milk sent to London. As a result of investigations by the Ministry of Agriculture and Fisheries into the origin of positive samples in 5 herds, 4 tuberculous cows were removed and slaughtered under the provisions of the Tuberculosis Order, 1938. One other cow, removed from one of the herds before investigations were complete, was also found to be tuberculous. The source of infection in one other herd was presumed to be two cows disposed of before investigations into the origin of positive samples were complete. No sources of infection in two herds could be traced, and investigation is still proceeding in the case of one other herd. Sanitary inspection Disinfestation Reports of 307 instances of infestation were received from 280 establishments controlled by the Council, e.g., restaurants, schools, rest centres and parks. Infestation by rats, mice, cockroaches, bugs, ants, flies, fleas, mosquitoes and moths were dealt with and 266 of the disinfestations satisfactorily completed by the end of the year. 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. Restaurants and Catering The routine inspection of civic restaurants was discontinued during the year, the inspection being undertaken by the metropolitan borough councils as part of their activities under the Food and Drugs Act, 1938. 1,947 visits of inspection were made to school meals centres, dining centres and kitchens. Nineteen reports of illness following consumption of school meals were investigated. In no case was contamination of food confirmed bacteriologically. c 30 Welfare establishments Regular inspections, at least once a quarter, were made of 67 homes, hostels, rest centres and other premises in connection with sanitary conditions. 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. Appeals Under Part II of the London County Council (General Powers) Act, 1951, appeals by persons aggrieved by acts and decisions of sanitary authorities under the Public Health (London) Act, 1936, formerly heard by the Appeals Committee, will in future be heard by courts of summary jurisdiction. The Council has, however, retained the right to determine appeals in respect of certain matters relating to sewers. Representation on committees of outside bodies The Chief Inspector represents the Council on a number of committees of the British Standards Institution, and is chairman of two committees and two subcommittees appointed to consider standards in relation to sanitary appliances, dustbins, traps and flushing cisterns. He is also a member of the Plumbing Research Committee of the Building Research Board of the Department of Scientific and Industrial Research. 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 those relating to children of school age, details of which are to be found in the table on page 149. Examinations by the Council's Ophthalmologists Classification Certified blind Not blind Grand total Male Female Total Male Female Total New cases 265* 636* 801* 109 214 323 1124* Previously blind, still blind 36 49 85 — — — 85 Previously not blind, now certified 22 24 46 — — — 46 Previously not blind, still not blind — — — 61 125 186 186 Previously blind, now not blind — — — 9 18 27 27 Total 323* 609* 932* 179 357 536 1468* *These figures include 11 boys and 9 girls under 6 years of age. The standards used are those prescribed by the Ministry of Health (Circular 1353-5.10.33). The cases "previously blind, now not blind" are mainly those in which catarac ts have been removed surgically. 207 certificates were accepted from other authorities, hospitals and private ophthalmologists as follows:— Blind persons 190 (73 male, including 2 children under 5 years, 117 female including 4 children under 5 years) Not blind per Bons 17 (6 male, 11 female) 31 The causes of blindness in the 26 children under five years of age who wen certified during the year were as follows:— Retrolental fibroplasia 8 Congenital, hereditary and development defects 6 Optic atrophy 4 Microcephalia 2 Microphthalmia 1 Ophthalmia neonatorum 1 Cataract 1 Non-industrial trauma 1 Cerebral haemorrhage 1 Bilateral anophthalmos 1 The number of partially-sighted persons recommended for inclusion in the Observation Register was 308 (100 male, 208 female). Blind persons examined as to suitability for training and the results were:— Male Female Total Suitable for training 18 3 21 Unsuitable for training 2 — 2 Registration of nursing homes At the end of the year 53 nursing homes on the register were functioning compared with 54 at the end of 1950. In the 53 homes there were 946 beds distributed as follows:— Number of beds in home Number of homes Patients accommodated All types † Medical and surgical only* Total 25 or over 5 240 89 329 20 to 24 10 63 157 220 15 to 19 9 58 97 155 10 to 14 11 34 88 122 5 to 9 14 48 60 108 Under 5 4 2 10 12 Total 53 445 501 946 *Numbers include beds for medical and surgical patients which cannot be used if a maternity patient is accommodated in the same room. †Each bed is registered for a medical, surgical or maternity case. The number of maternity patients admitted to nursing homes during the year was 1,243, compared with 1,117 in 1950. Thirty-nine exemptions from the operation of Part XI of the Public Health (London) Act, 1936, were granted. Visits of inspection to the homes were undertaken at regular intervals by medical officers (111 inspections) and public health inspectors (128 inspections). A tendency during the year towards a lowered standard of maintenance and cleanliness in some homes due to the employment of less efficient staff, coupled with difficulty in securing early compliance with essential health requirements as a result of high costs and building delays, has called for closer overall supervision of the homes and more frequent inspection of a number of them. W elf are Committee Establishments The arrangements in regard to the medical supervision of all types of establishments under the control of the Welfare Department, i.e., large homes, mother and baby homes, rest centres, reception centres for persons without a settled way of 32 living, lodging houses, small homes for the aged and infirm, homes for the blind and hostels for persons in employment, to which reference was made in my report for 1950, were continued during the year under review. Homeless famities units At the end of the year 339 mothers and 792 children (of whom approximately 50 per cent. were under 5 years of age and 15 per cent, under 1 year of age) were accommodated in the nine homeless families units attached to large homes. The unavoidable overcrowding of these units due to pressure on the available accommodation, coupled with the wide variation in the standard of living among the large groups of mothers and children, continued to give rise to many difficulties. Regular inspection of the units was undertaken by medical officers on the central staff to supervise medical arrangements and hygiene, and in particular to advise on the control of infection which, among communities of this type, demands constant vigilance. Advice was also given to the Welfare Department in regard to special diets for children under 5 years of age, and regular weekly visits made by health visitors to advise mothers and to give talks on mothercraft. Mothers were also encouraged to attend sessions at neighbouring maternity and child welfare centres and preliminary arrangements were made to open an infant welfare centre at one of the larger units early in 1952. A nursery class for 22 children aged between 3 and 5 years has been opened by the Education Department in one welfare home. Care of the Chronic Sick Attention has continued to be given to the needs of the considerable number of chronic sick persons who remain in the Council's homes because of the present shortage of suitable hospital beds and, as a result of discussions between the Welfare Department and the Regional Hospital Boards, arrangements were made for a number of them to be exchanged for suitable recovered infirm persons in hospital who could not be discharged to their own homes. There were, however, 603 chronic sick persons (187 men and 416 women) accommodated in the homes at the end of the year and, as a large proportion were either permanently bedridden or in need of treatment in varying degree, their continued care has presented many varied and difficult problems. Sick bays have been provided in some homes for the care of the aged suffering from temporary illnesses for whom hospital beds were not available. A conference of visiting medical officers was held at County Hall during the year to discuss problems arising from the care of the chronic sick and the aged, and similar meetings will be held in future at six-monthly intervals. Invalid Kitchens of London Reference was made in my report for 1950 to the activities of the Invalid Kitchens of London. During the year the Council increased its grant to this organisation's funds towards the cost of meals provided by them for sick persons living in their own homes. CHEMICAL BRANCH The work of the branch was carried on during the year at the three laboratories at County Hall and the Northern and Southern Outfall Works, and Mr. C. J. Regan, the Chemist-in-Chief, has submitted the following report:— The year 1951 will be remembered as "Festival of Britain Year" and it should be recalled that it was timed to celebrate the centenary of the Great Exhibition of 1851. Both events, although planned to have a popular appeal, were designed to demonstrate the progress made at their periods in the general standards of life. To this intent science figured largely in the exhibits and the advances made in the intervening century indicate the outstanding triumphs which have been achieved by its use and development. For example, radio communication, television and the aeroplane are now commonplaces of everyday life, but, in 1851, they had not even been invented. 33 In the more restricted chemical and physical field with which this report is primarily concerned similar remarks apply, for example, to rayon and nylon for clothing, to the vast range of plastics for constructional use for many purposes, to the aluminium alloys for aviation, etc., to the great variety of new drugs, antibiotics, etc., such as the sulphonamides and penicillin, to synthetic insecticides like D.D.T. and Gammexane, to synthetic rubber, etc. Such a list of achievements could be extended almost indefinitely. These developments have succeeded one another through the century at an ever increasing rate and their effect on the many ramifications of the Council's service has been increasingly evident in the enquiries made of the Chemical Branch for advice and assistance in the scientific field. The volume of work thus accruing to the branch has considerably increased during the year now under review and has occupied much of the time of the senior officers. Committee duties, too, both on Council work and on Government and British Standards Institution Committees to which officers have been appointed to express the Council's views, have also increased and undoubtedly form a most valuable feature of the work of the branch. The number of samples received for examination in 1951 also showed an appreciable increase on those of former years. The total number was 25,666 as compared with 24,523 in 1950. The classification was:— Air, tunnels, etc. 347 Building materials 313 Chemicals, drugs and medical supplies 39 Clay, subsoils and borehole waters, etc. 1,264 Compost (manurial use), etc. 4 Detergents and soaps 29 Disinfectants and insecticides 7 Fertilisers and feeding stuffs 96 Floor oils and polishes 37 Foods, etc. 656 Gases, sludge digestion plant, flue, degreasing plants, etc. 479 Grit deposits (from Power Stations) 232 Insulating coverings for hot water systems 18 Lamps, gas detector 314 Liquor, effluent from gas works 358 Meals 41 Metals 28 Milk, liquid, condensed, dried 216 Miscellaneous 241 Oils, lubricating, fuel, etc. 57 Paints, varnishes and distempers 1,658 Petroleum and allied samples 88 Rainwater (atmospheric pollution deposit gauges) 84 Rubber and substitutes 15 Scouring powders and lavatory cleansers 12 Sewage and effluent 4,560 Sludge, primary, digested and activated 3,485 Sulphur gases and smoke in air 1,928 Water, steam-raising plants 1,609 Water, drinking 1,710 Water, swimming bath 1,148 Water, river 4,539 Water, miscellaneous 54 Total 25,666 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. Rivers and Drainage Throughout 1951 the whole of the sewage flow to the Northern Outfall Works was treated by sedimentation and approximately one-third of it subsequently by the activated sludge process. At the Southern Outfall Works the whole of the flow continued to be treated by primary sedimentation only. Regular sampling and examination were done to assess the results of the treatment. In the case of both outfall works, the plants functioned satisfactorily throughout the year and achieved as large a saving of B.O.D. (biochemical oxygen demand) load on the water of the River Thames as could be expected. The sludge digestion plant at the N orthern Outfall W orks was sub j ect to analytical control, the rate of charge being decided accordingly, and it functioned satisfactorily, the gas produced (containing about 70 per cent. methane) being used for power production at the works. The composting of sewage products (mainly screenings) with household refuse was continued and a large amount of the finished product was available for transport to farms, mostly those at hospitals. 34 As mentioned in a previous annual report, in an endeavour to improve the condition of the water of the River Thames a programme of additions to the existing sewage treatment works has been agreed by the Council. At the end of the year the completion of the new detritus pits at the Northern Outfall Works was approaching, and progress had been made there on the construction of the new sedimentation tanks. Progress continued, too, with the construction of the "old reservoir" sludge digestion plant. The other works approved in principle by the Council comprise additional 60 million gallons per day diffused air activated sludge plants at both the Northern and the Southern Outfall Works and, also at both works, sludge digestion plants to deal with the whole of the sludge produced. None of these had been started at the end of the year owing to the fact that they had not been licensed for the supply of materials by the Ministry of Housing and Local Government. In view of the delay in the construction of these works and the bad condition of the water of the River Thames in the previous summer, consideration was given to any temporary palliative measures which could be adopted to prevent a still further deterioration in the state of the river. It appeared that the chlorination of some of the sewage effluent was the only practicable course and it was decided to chlorinate that part of the primary sedimentation effluent from the Northern Outfall Works which was not subsequently submitted to secondary treatment. The first necessary action was to divert the waste gas effluent liquor to flow through the existing activated sludge plant in order to prevent it preferentially utilising the chlorine which was to be added to the rest of the flow. The average chlorine demand of the latter was then determined, it being about 40 parts per million for a flow of about 140 million gallons per day. Treating this to about one-third of its demand thus required about 50 tons of chlorine per week. This full degree of treatment was not attained until the latter part of the summer. Natural oxidation by the dissolved oxygen in the river water is the final process in the purification of the effluents from the sewage treatment works. In this process, the dissolved oxygen in the water is used up and, in order to prevent the water, after admixture with the sewage effluent, becoming putrescent, the rate of this using-up of dissolved oxygen must be less than the rate of reabsorption of oxygen from the air at the surface or air/water interface, so that there is at all times some oxygen present in the water. Hence the most important single test to indicate the condition of a river water is the dissolved oxygen content; similarly, the B.O.D. (biochemical oxygen demand) of an effluent is of significance as indicating the "oxygen load" imposed on the river by that effluent. It follows that, for the river to be maintained in a satisfactory condition, sewage must be subjected to a sufficient amount of treatment to ensure that the oxygen demand of the effluent will be of such magnitude that it will not exhaust the dissolved oxygen in the receiving water. The chemical state of the water of the river is thus of great concern to the Council and a weekly examination of it is therefore made at 25 points between Teddington Weir and the sludge dumping area in the estuary. In addition, the water off the two outfall works is sampled daily at both high and low tide. An important factor in determining the pollution load with which the water of a river will deal satisfactorily is the fresh water flow; in the case of the River Thames, this is the amount coming over Teddington Weir after the Metropolitan Water Board has, above that point, abstracted the quantity required for water supply. The statutory minimum flow is 170 million gallons per day, but the appropriate Minister can, by Order, permit the reduction of this to 50 million gallons per day. The summer of 1951, particularly the latter part of it, was wet and the rainfall maintained the flow at a higher level than that of 1950 and of the dry year of 1949. In spite of this fact and the chlorination of part of the effluent as already described, the condition of the water of the river, particularly in the area between London Bridge and Gravesend, 35 was extremely poor in the summer months. It was difficult to assess the ma gnitude of the effect of the chlorination of effluent for, although an equivalent reduction of chlorine demand was proved, the variation in fresh water flow to the river also came into question, as did also the progressive deterioration which has occurred i n recent years. There was, however, evidence on a few occasions of a very slight improvement in the neighbourhood of the Northern Outfall Works which could presumably be attributed to the chlorination. There are now two Government Committees considering and investigating the condition of the River Thames; the Thames Survey Committee of the Department of Scientific and Industrial Research set up at the request of the Port of London Authority in June, 1949, and the Heated and Other Effluents Committee of the Ministry of Housing and Local Government set up early in 1951 with wider terms of reference. The Chemist-in-Chief is a member of both these Committees. Close liaison was maintained with other research work both in this country and in the United States on the problems of sewage treatment and 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 the dewatering of sludge by a new process involving freezing after the addition of chemicals. This was deemed to be of sufficient importance for the Council to apply for patents both in this country and in the United States and for the construction of a pilot plant to be authorised for larger scale investigations at the Northern Outfall Works. The question of trade discharges into sewers was investigated in a number of cases as to compliance with the appropriate sections of the Public Henlth (London) Act, 1936; one occurrence which caused the death of a sewer worker was proved to have been due to a sulphide waste from one outlet coming into contact with an acid waste from another; both discharges contravened a section of the Act. Advice was also given in many instances as to 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-inChief and their senior officers have been of the utmost value in this respect. Housing 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 information and guidance of the interdepartmental 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;(&) 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. Special questions investigated included the treatment of wooden structures to reduce inflammability, the priming of hardboard, and the efficiency of the protection of iron and steel with calcium plumbate (red lead has hitherto been used). Paint failures were examined and reasons postulated with advice as to remedial measures. 36 Other building materials examined included cements, asphalts, tiles, plywood panels and synthetic materials, flooring of all types and floor sealers, hessian based bituman sheeting for various purposes, material for expansion joints, cement waterproofers, clinkers, mortars and concretes, rust removers, fireproofing and insulating materials, etc. Many types of flooring were examined which varied considerably in composition from coloured Portland cement to those mainly organic in nature, such as polyvinyl chloride. In some cases, polyvinyl chloride plasticised with tricresyl phosphate was filled with clay and asbestos and backed with hessian; magnesium oxychloride is a usual constituent for some types with a variety of added components such as wood dust, rubber powder and bitumen; various bitumen bound products were examined. Important aspects of the examination of these products are their resistance to staining and abrasion, fire resistance, water absorption and general durability, as well as their thermal conductivity. Woods were examined as to fungal or other attack and appropriate treatment was recommended. The causes of structural failure were investigated as required and the possible danger of sulphates to concrete was carefully watched, Samples of clay and subsoil water were examined in many cases and the use of sulphate resisting cement or high alumina cement advised where it was considered desirable. Pablic Health An important part of the work ot the Uhemical Branch irom the standpoint of Public Health is that of ensuring the satisfactory quality of the drinking water used in Council establishments. Where water is obtained from a mains supply no trouble is experienced, provided care is taken to avoid contamination between the end of the main and the service taps; but in a number of schools and institutions the supply is drawn from private wells and, in these cases, continuous treatment and supervision is given to ensure that the high standard appropriate to drinking water is maintained. As a general principle, all such private supplies are chlorinated before use by means of automatic dosing apparatus. The Chemical Branch carries out regular monthly inspections and samples are taken of both the untreated and treated water for chemical and bacteriological examination in the laboratory; chlorine tests are made on the spot to confirm the adequacy of the dosage, which is also determined daily by the resident engineer at each establishment. Certain former L.C.C. hospitals have private wells and these have continued to be included in the regular programme of water examinations at the request of the Hospital Management Committees. 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 at 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 accordance with an official arrangement, the Chemist-in-Chief accompanied the Chief Alkali Inspector, Ministry of Housing and Local Government, on his periodical visits to Battersea Power Station to test the efficiency of the flue gaswashing 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 had been reconditioned and put into operation. Other fields of public health work which have been closely watched are those dealing with insecticides and disinfectants and assistance and advice have been given as required. The relation of the fluoride content of drinking water to the incidence of dental caries has been kept under review. This is a matter which has been the subject 37 of much investigation in recent times both in this country and in the United States and it appears that about 1 part per million is the optimum quantity. Problems and work on industrial hygiene and safety ranged over a wide field and included (a) the inadvisability of using a drawing ink containing a large proportion of aniline; also a marking ink; (b) dust prevention in sack emptying; (c) the importance of washing the hands in the case of food handlers; (d) sterilisation of ambulance instruments and hyperdermic syringes; (e) the breaking strength of glass panels; and (f) disposal of broken fluorescent tubes (mercury and beryllium hazard). 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, and the London Building Act, 1930; other Acts with which the Chemical Branch was concerned were the L.C.C. (Celluloid, etc.) Act, 1915, and the Town and Country Planning Act, 1947. In connection with the former, the setting-up of a Committee by the British Standards Institution on the "Inflammability of Films" should be noted; the Deputy Chemist (Dr. S. G. Burgess) was appointed Chairman of this Committee. In a number of cases the Chemical Branch was asked to advise in regard to the last mentioned Act as to the category in which businesses should be considered to fall, consent to their being allowed to operate in certain areas depending on this classification. Many samples of bread were analysed under the Bread Order, 1951, 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, court 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. Parks Chemical analyses and bacteriological examinations ot the water ot 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. In co-operation with the Chief Engineer's Department and the Parks Department a detailed survey was made of all the baths, and research work was conducted at two of them working on somewhat different lines. Useful conclusions were reached whereby improvements can be made in operation at a comparatively low cost; in particular, were studied the neutralisation of the acidity produced by chlorination, the significance of the albuminoid nitrogen content of the water, the advantage of adding sodium hexametaphosphate to the soda dosing plant, and the loss of chlorine due to the action of sunlight, etc. Fertilisers and soils were examined for this service and also plant pots as to resistance to fracture by frost and other causes. School meals education and children The work done in co-operation with the Restaurants and Catering Department was continued and many meals were analysed as to their nutritional value by the determination of their fat, protein, carbohydrate and mineral contents and their calorific value. The results generally showed a reasonable approximation to the standards aimed at for the several nutritional factors for the various age groups concerned. In connection with this work, there should be mentioned a report on the loss of fat in cooking made to a Working Party of the Ministry of Food, of which the Deputy Chemist is a member. 38 Swimming bath waters and drinking waters at residential schools were examined. Pending the authorisation by the appropriate Ministry of the expenditure for installing automatic treatment plants at these baths, they continued to be treated by an improvised chlorination system. Instructional visits of school parties to both the County Hall and the Northern Outfall Works laboratories should be mentioned. Supplies 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. Many foodstuffs of all types were examined, the main purposes being (a) to allocate contracts to the tenderers of the cheapest satisfactory material, (b) to check the quality of deliveries, (c) to investigate complaints and (d) to assess whether new preparations could be of potential use in the service. Generally, a high standard of quality was maintained for the foodstuffs in use and there were only a very few justifiable complaints. A careful watch was kept on the quality of the liquid milk supplied and condensed and dried milks were examined as required. Other materials which might be mentioned included chemicals, drugs and medical supplies, lubricating and other oils, floor and other polishes, soaps, etc. Careful attention was given to the use of synthetic detergents and an alteration was made in the formulation of the Council's specification for washing-up powder which increased its efficiency and decreased the cost. Fire Brigade Much of the work in this field was of a consultative and advisory nature, including the discussions of the British Standards Institution's Technical Committees on Inflammability of Films and Definitions of Fire Resistance and Incombustibility. Investigations and laboratory tests were undertaken in a number of cases including:— (a) the cause of a fire attributed to smouldering in the groove of a board after the use of a blow lamp: (b) in another case the theory of spontaneous combustion could not be supported; (c) rubber fire hose, foam producing compounds, fire resisting paints and protective coatings were examined. Steamraising, heating, etc., plants Much consultative and advisory work was done for both the Chief Engineer's and Architect's departments involving examinations in situ and subsequent analysis of samples in the laboratory regarding scale formation, scale removal and corrosion problems. The use of sodium 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 some elements of a gas fired heating boiler was ascribed to the action of steam on red hot iron and faulty circulation of the water in the boiler; (b) 85 per cent. magnesia plastic and hard setting compounds were examined as to compliance with the Council's specification. Other suggested materials for heat insulation purposes containing slag wool and diatomaceous earth were also tested for comparison. Miscellaneous Many other matters were dealt with of which a few examples can be given:— (a) plastic materials for use in lampshades, etc., were examined as to the temperature at which deformation occurred under varying degrees of stress, and the discoloration produced by light; (b) comparison of different types of tracing paper used for plans as to dimensional changes occurring with varying temperature and humidity; (c) a number of inleakages of water into basements were examined as to the source from which the water was derived (e.g., mains, sewer, or ground); (d) electric cable sheathing was examined for rubber content, etc., and also for traces of metals which accelerate deterioration of the rubber; (e) a commercial "drain tester" was examined and considered to have an element of danger associated with its use; (f) air conditions in show cases at an exhibition were examined to prevent deterioration of valuable documents. 39 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 from abroad, weje 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 four committees of the Ministry of Housing and Local Government, four of the Department of Scientific and Industiial Research, and eight 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 three 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) "The Sanitary Engineer and Reports on Chemical Analyses" by C. J. Regan; (b) "Early developments in London's sewage disposal with particular reference to the work of W. J. Dibdin", by C. J. Regan; and (c) "Cleaning of Porous Air Diffusers" by R. J. Stephenson in collaboration with A. Bruce of the Chief Engineer's Department. HEALTH SERVICE PREMISES Building Programmes The planning of new clinics and day nurseries and the adaptation and improvement where necessary of existing premises was continued. The number of schemes reaching the stage for submission to the Minister of Health was smaller than in the two previous programmes. Nevertheless, when added to projects from former programmes which had already been approved but which had not reached the construction stage, and to those for which approval was awaited, the whole would have constituted a very large building programme for the year 1952-53. Increasing restrictions on expenditure and on the use of steel was however, by the end of the year, leading to the curtailment of building programmes and will no doubt delay the carrying ont of many of the Council's schemes. Schemes in preparation Under the procedure introduced on the recommendation of the Local Government Manpower Committee the Council submits an annual capital building programme to the Minister of Health in November each year with a view to approval by the Minister of schemes to be commenced in the following financial year. This programme comprises all works costing more than £1,000, except cleaning and painting. Since the inception of the scheme three programmes for the years 1950-51, 1951-52 and 1952-53 together with five other special schemes, comprising in all 41 projects, have been submitted to the Minister. One scheme (Victorian Grove day nursery extension) was cancelled by the Health Committee and two others were withdrawn because they were adaptations of office accommodation which had become matters for reference to the Ministry of Housing and Local Government. Of the remaining 38 schemes, eleven were under consideration by the Minister at the end of the year, two had failed to receive the approval of the Minister and twentyfive had been approved in principle. The particulars of these 38 schemes are:— Schemes for which approval was refused Division 2—Daleham Gardens, Hampstead.—Combined maternity and child welfare and school health centre. As stated in the report for 1950 the Minister was unable to approve this project owing to the need for economy in expenditure on the health service. Further representations to the Minister were unsuccessful. In view of this the general position regarding clinics in the Metropolitan Borough of Hampstead was under review at the end of the year. Division 5—Brewhouse Lane, Stepney.—Permanent day nursery and child welfare centre. The Minister did not consider there was need for a nursery to serve the 40 "island" of Wapping and did not feel justified in approving the scheme in view of the pressure on labour and materials. The implications of the Minister's decision were under consideration at the close of the year. Schemes still under consideration by the Minister Division 1—Gloucester Road and Clareville Grove, Kensington.—Conversion of premises to form a maternity and child welfare centre and staff hostel and the erection of replacement day nursery. Westway, Hammersmith.—Erection of a permanent replacement day nursery. The Minister asked for a more economical scheme to be prepared. Fleet Road, Hampstead.—Erection of new accident ambulance station. Foxley Road, Lambeth.—Conversion of former fire station into an accident ambulance station. Schemes approved in principle, works completed Division Premises Service Work involved 2 Katherine Bruce Day Nursery, Peach Street, Paddington. Day nursery Erection of new building (replacement). 3 20/2, Highbury Quadrant. Islington. Tuberculosis hostel Conversion of existing building. 5 69, East India Dock Road. Poplar. Maternity and child welfare centre. Conversion of portion ot existing school treatment centre. 8 Knight's Hill, Lambeth Day nursery Substantial maintenance works. 9 Earlsfield Road, Wandsworth Maternity and child welfare centre. Conversion of existing building Starting dates awarded and works in hand at end of year. 2 Westbourne Park Road, Paddington. Day nursery Completion of a partly erected building. 3 Springdale Road, Stoke Newington. Day nursery Erection of new building. 4 St. John's Rectory, Hackney Day nursery Erection of new building (replacement). 7 Queen's Road Centre, Camberwell. Stage (1)—day sery Conversion of existing building. 8 Hannon Road, Lambeth Maternity and child welfare centre. War damage and substantial maintenance repairs. - Roland House, Littlehampton Holiday home Conversion of existing building (1st stage). Branstone Street, Kensington Occupation centre Building or an additional classroom. Eastern Ambulance Station, Hackney. Ambulance station Adaptations to provide additional vehicle accommodation. Starting dates not yet awarded 1 Highlever Road, Kensington Maternity and child welfare centre. Erection of new building (replacement). 5 Christian Street, Stepney Day nursery Provision of play space. 5 Peel Grove, Bethnal Green Maternity and child welfare centre. Erection of new building. 5 University House, Bethnal Green. Day nursery Extension. 7 Amott Road, Camberwell Maternity and child welfare centre. Extension. 7 Queen's Road Centre, Camberwell. Stage (2)—Maternity and child welfare centre and evening institute. Final stages of adaptation and repairs. 9 Stormont Road, Battersea Maternity and child welfare centre. Erection of new building (replacement designed to be extended to form part of a comprehensive health centre). - Roland House, Littlehampton Holiday home Conversion ot existing building (2nd stage). 41 Division Premises Service Work involved - Fulham Ambulance station, Fulham. Ambulance station Extension for new petroleum store and accommodation for Civil Defence personnel. - London H.Q. Ambulance Station. Waterloo Road. H.Q. of ambulance service. Conversion of fire station. - Putney Ambulance Station, West Hill, Wandsworth. Accident ambulance station. Erection of new building. - South West General Ambulance Station, Lambeth. Ambulance station Extension to provide garage and new offices - West Smithheld Ambulance Station. Accident ambulance station. Extension of new building to replace temporary structure. Programme for 1952-53 The building programme for 1952-53, which was under consideration by the Minister of Health at the end of the year consisted of six projects as follows:— Division Premises Work involved 3 Muriel Street, Islington Erection of new day nursery to replace Pembroke Street Nursery, the site of which is required for housing purposes. 3 St. Alban's C. of E. School, Holborn Conversion of old school buildings to form a replacement day nursery for Holborn. 5 Galbraith Street, Poplar Conversion of first-aid post as a maternity and child welfare and school treatment centre. 5 Mary Hughes Maternity and Child Adaptation of first floor to form an infant Welfare Centre, Stepney. welfare centre in association with the London Hospital. 7 Merton Place, Greenwich Erection of a temporary building for maternity and child welfare purposes. - South-Eastern Ambulance Station, Deptford. Extension. The acquisition and reservation of sites suitable for future building was continued, and as opportunity arose better terms of tenancy were obtained for health service premises which were likely to be required for long periods but were held on insecure tenancies. Maternity and child welfare premises Closing of day nurseries Following a survey of the day nursery provision in the County it was decided early in the year that while the total day nursery provision should remain substantially at its existing level and every effort should be made to obtain the maximum beneficial use of the accommodation, any indication of redundancy in the light of prescribed priorities for admission was to be kept constantly under review and steps taken to deal with it by closing or amalgamating nurseries. As a result of this policy the following five nurseries were closed :— Division 4—St. Anne's Day Nursery, Stoke Newington.—This nursery was in requisitioned accommodation on the ground floor of a home for aged persons owned by the Little Sisters of the Poor. The nursery was closed and de-requisitioned on 28th June. Division 5—Nursery Creche, White Horse Road,, Stepney.—This nursery, in unsatisfactory accommodation, was closed on 30th June as a result of a considerable falling off in attendances and the Council's tenancy was terminated. Division 6—Conley Street Day Nursery, Greenivich.—This was a prefabricated building owned by the Ministry of Health, standing on requisitioned land near the Conley Street Nursery School. The day nursery was closed on 31st March and the premises were placed at the disposal of the Education Committee for use as a nursery school. Division 9—Roehampton Day Nursery, Wandsworth.—This nursery in requisitioned premises was closed on 18th May, and the accommodation was transferred to the Education Committee for use as a nursery school. Streatham Vale Day Nursery, Wandsworth.—A. prefabricated nursery building on a requisitioned site, was closed on 28th September and the site was de-requisitioned. Sites 42 Replacement of a day nursery In addition to the above, the following day nursery was relinquished:— Division 2—Peach Street Day Nursery, Paddington.—This prefabricated building stood on a site required for a block of flats forming part of a Paddington Borough Council housing scheme. The day nursery was closed on 16th April and demolished. It was replaced by the new permanent Katherine Bruce Day Nursery. The Metropolitan Borough of Paddington acting as the Council's agent erected the nursery which was planned by the private architect employed by the borough council for the housing scheme. Reduction of day nursery accommodation Division 8—Fulford St. Day Nursery, Bermonasey.—The west wing of this day nursery was demolished to make part of the site available to the Metropolitan Borough of Bermondsey for housing. The accommodation was reduced from 58 to 35 places and having regard to local requirements it was decided not to replace the 23 places lost. The following maternity and child welfare centre was relinquished:— Closing of M. & C. W. centre Division 4—Maternity and Child Welfare Centre, Britannia Walk, Shoreditch.—This centre, situated in unsatisfactory accommodation in a Boys' Club, was transferred to the Hoxton Bathing Centre, Crondall Street, where spare accommodation was available. Replacement of centres The following premises were opened during the year to replace buildings which were relinquished:— Division 5—69, East India Dock Road.—The conversion of vacant rooms at the school health centre at 69, East India Dock Road, referred to in the report for 1950, was completed, and the maternity and child welfare centre was transferred there on 5th February, from Trinity Hall, Upper North Street, which was required for demolition in connection with the development of the Lansbury Reconstruction Area. Division 7—Salvation Army Hall, Romer Avenue, Lewisham.—Alternative accommodation had to be found to replace the accommodation at St. John's Hospital, Morden Hill, Lewisham, which was inadequate for the increasing demand for child welfare facilities in the locality and was required by the hospital authorities for other purposes. The use of the Salvation Army Hall is a temporary expedient until satisfactory alternative accommodation can be found. The St. John's Hospital clinic was closed on 20th June. 28, Sangley Road, Lewisham.—This accommodation replaced the chiropody clinic at the Central Lewisham Welfare Centre, which was overcrowded, and temporary office accommodation at Rushey Green Day Nursery, which was not entirely suitable. Division 9-—102, Earlsjield Road, Wandsworth.—These premises, which belong to the Council, were converted for clinic purposes and were opened on 1st September. They replaced accommodation at Earlsfield Congregational Church Hall, Earlsfield Road, Wandsworth, the tenancy of which was terminated. Provision of additional centres The following additional maternity and child welfare centres were opened during the year:— Division 2—Church House Infant Welfare Centre, Paddington.—A centre was opened in these premises on 10th January, to serve a growing need for infant welfare services in the Lancaster Gate area of Paddington. Division 7—Queen's Road Centre, Camberwell.—In accordance with the Council's proposals for the use of these premises under the National Health Service and the Education Acts, an ante-natal clinic was opened at the centre on 1st November. 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—Westbourne Park Road, Paddington.—Prefabricated nursery buildings erected towards the end of the war were never finished and brought into use. The work of completing the buildings was commenced to provide a day nursery which will replace an existing nursery in a requisitioned dwelling-house. 43 Division 3—Springdale Road, Stoke Neivington.—A hutted nursery was being erected at Springdale Road. This nursery was originally planned as a partial replacement for the day nursery in St. Anne's Home, referred to earlier. It is situated near the boundary between Divisions 3 and 4 and will be administered by Division 3. Some children from Division 4 may be admitted. Division 4—St. John's Rectory, Hackney.—A hutted nursery was being erected in the grounds of St. John's Rectory to replace the existing nursery in Ram's Episcopal School, in order that the accommodation at the school might be used again for educational purposes. scheme abandoned The following scheme mentioned in the report for 1950 was abandoned:— Division 4—Victorian Grove, Hackney.—An extension of the existing day nursery was planned to replace, together with the Springdale Road Nursery, the St. Anne's Home Nursery. Owing to the reduction in the demand for day nursery accommodation as a result of the Health Committee's review, it was found possible to abandon this proposal. Transfer of property Division 8—Lyntnia Mosley Day Nursery.—Although the maintenance ot this day nursery passed to the Council under the National Health Service Act, the building was vested in the Cynthia Mosley Memorial Trust Fund. Under a ruling of the Charity Commission the Council accepted the trusteeship of the property which was transferred to the Council on 15th June. Accommodation for tuberculous persons The adaptation of 20-22, Highbury Quadrant, Islington, as a hostel for 35 infective chronic tuberculous men was completed and the hostel was opened on 29th October. Recuperative Holiday Homes The Mayfield Recuperative Holiday Home, Mayfield, Sussex, was uneconomical to maintain owing to the small number of children (15) which could be accommodated. Difficulty in staffing it was also experienced due to its isolated position. It was closed on 30th April. The loss of accommodation was largely offset by the use of Roland House Holiday Home, Littlehampton, which had been opened on 13th April, 1950. Occupation centres for the mentally defective Details regarding premises used for occupation centres will be found on page 88. School Health Service School treatment centres replaced Division 3—Neivington breen school Ireatrnent Centre.—This centre was transferred on 14th May from 59, King Henry's Walk, Islington, where the tenure was insecure, to accommodation adapted for the purpose at St. Jude's Church Hall, King Henry Street, where a three year's tenancy was obtained. Division 4—Northwold School Treatment Centre, 8 and 9, Rossendale House, Rossendale Street, Hackney.—The two L.C.C. flats occupied by the centre were released for housing purposes, and the school health activities were transferred to existing centres in the neighbourhood. No. 9, Rossendale House was relinquished in March when the dental and vision clinics moved to 13, Goulton Road, and No. 8 was given up in December when the minor ailments centre transferred to 186, Upper Clapton Road. Division 5—Bethnal Green School Treatment Centre.—The adaptation of the former Mowlem Street Special School was completed, and the centre opened on 29th January, with accommodation for dental and vision clinics and the treatment of minor ailments. Owing to the lack of dental surgeons it was not possible to provide dental sessions, and the dental accommodation was temporarily allocated for use as a foot clinic. The new premises replaced the centre premises which were destroyed in 1944 and a temporary minor ailments clinic which had been held in school premises. Division 6—54-56, Ormiston Road, Greenwich.—The minor ailments centre from Glenister Road School was transferred to these premises on 9th January, and the accommodation at the school was surrendered to education purposes. 44 Centre closed Division 9—Queenslown School Treatment Centre, 65, Queenstoum Road, Battersea.— It was decided to close this centre on 30th June as the facilities could be provided as effectively at other centres in the neighbourhood. Schemes in preparation Division 1—Chelsea School Treatment Centre, 31-33, Bramerton Street.—The purchase of these premises was completed, and a scheme of improvements and alterations was approved by the Council on 3rd July. The Minister of Education approved the proposed work but it was not possible to start this before the year ended. Division 2—Westminster School Treatment Centre.—The purchase of 40, Alderney Street, Westminster, was completed, and a scheme for converting the premises was approved by the Council on 4th December. When the adaptations have been carried out, the premises will replace the accommodation rented for the centre at 38, Rochester Row, and 41, Greencoat Place, which must be given up. Division 7—East Dulwich School Treatment Centre, 29, Amott Road, Camberivell.— It was decided to transfer this centre to 475, Lordship Lane, where a maternity and child welfare centre will also be established, and to dispose of the premises which are unsatisfactory for health service purposes. The transfer will be effected when adaptations have been carried out at 475, Lordship Lane. Division 8—St. George's Dispensary, 86, Blackfriars Road, Southwark.—For many years medical treatment for school children was provided at this dispensary by the St. George's Dispensary Trust which received financial aid from the Council. On the National Health Service Act coming into force in 1948 the dispensary remained vested in the Trust, but subsequently the sole surviving trustee, Lord Haden Guest, offered the Trust to the Council. This offer was accepted and application was made to the Charity Commission for a scheme to be drawn up for transfer of the property. This was still in preparation at the end of the year. Child guidance units Division 8—Brixton Child Guidance Unit, 19, Brixton Water Lane, Lambeth.—The conversion of the former Brixton Provident Dispensary premises, which the Council had purchased, was completed, and the unit opened on 1st October. Office accommodation The following changes in office accommodation were made during the year:— Division 4—The domestic help office was transferred from 28, Lower Clapton Road, to the Hackney School Treatment Centre, 13, Goulton Road. Division 5—It was possible to reduce the office accommodation at 43, White Horse Road, rented from Stepney Metropolitan Borough Council, and at Poplar Town Hall, rented from Poplar Metropolitan Borough Council. Reduced rentals were negotiated by the Director of Housing and Valuer. The domestic help office was transferred from Poplar Town Hall to the clinic building at 69, East India Dock Road. Division 9—The sub-office at Electric House, Lavender Hill, Battersea, was vacated on 14th July, at the request of the Battersea Metropolitan Borough Council, and arrangements were made for the staff to be accommodated in other offices in the Division. To relieve overcrowding at the main divisional office a lease was taken on premises at 50, Fairfield Street, Wandsworth, which were occupied on the 1st June. Health centres Woodberry Down Health Centre. The building of the first comprehensive health centre at Woodberry Down, Stoke Newington, was continued during the year, but progress was retarded by unavoidable delays and it was expected that the centre would not be ready for use until the summer of 1952. Staffing Staffing proposals drawn up after consultation with representatives of the London Executive Council were submitted to the Minister of Health for approval. 45 Consultations took place between the Council and representatives of the British Medical Association and the London Executive Council, in association with the Ministry of Health, regarding the general practitioner services to be provided at the health centre, and a draft model contract between a general practitioner and an executive council, defining the conditions under which a general practitioner would practise at a health centre, was drawn up, the intention being that, when agreed by all concerned, this would be the form of agreement between the general practitioners providing general medical services at Woodberry Down Health Centre and the London Executive Council and also serve as a model for similar arrangements elsewhere. A complementary agreement between the Executive Council and the Council covering the conditions under which the Council will make available accommodation for general practitioners at the health centre will also be necessary and a draft agreement was drawn up. Both documents were still under consideration at the end of the year. Equipment The departmental committee set up in 1949 completed their work of compiling schedules of the equipment required for Woodberry Down Health Centre. These included equipment for the school treatment section, the child guidance unit, the foot clinic and the portions of the building designed for common use. The task of a special sub-committee appointed to consider the equipment of the general medical practitioner suites of the centre was made very much easier by the valuable help and advice of the two general practitioners, Dr. A. P. McEldowney and Dr. M. Sorsby, nominated by the London Executive Council to serve on the sub-committee. The services of Mr. Seymour Robinson, the dental surgeon nominated by the Executive Council, were also of great assistance in the preparation of the schedule of equipment for the dental suites. The schedules of furniture and equipment required for the centre were approved by the Ministry of Health, and, as regards the school health services, by the Ministry of Education. The equipment of the general medical practitioner suites was also agreed by the Local Medical Committee for the County of London and of the dental suites by the Local Dental Committee. Orders were placed for the supply of the equipment in readiness for the opening of the centre. Queen's Road Centre. The Council's decision to acquire the former Pioneer Health Centre, Peckham, was mentioned in my report for 1950, in which a scheme for the use of the centre was also described. The Council took possession of the premises, now known as the Queen's Road Centre, on 27th April. It was planned to carry out the necessary works of repair and adaptation in two stages. The first stage, designed to enable partial use of the premises to begin as soon as possible, included the provision of a day nursery for forty children over one year of age to replace the nearby St. Mary's Road Day Nursery in a requisitioned house. The second stage, comprising water, electricity, heating works and the provision of a lift, will enable the whole building to be brought into full use. The first stage works were put in hand and partial use of the building for health and education purposes was begun. A maternity and child welfare (ante-natal) clinic was opened and health education lectures were arranged. The swimming bath and gymnasium were brought into use for shools and afternoon and evening classes were held in the lecture hall. More extensive use of the premises depends on completion of the second stage work, when it is intended that in addition to extended educational evening institute activities, a family club and a medico-sociological research unit shall be established. It seemed likely, however, at the end of the year that increasing restrictions on capital expenditure and the use of steel would call for modification of the second stage works. At a later date, if general medical and dental practitioners desire the provision of accommodation for group practice, this could be arranged. D 46 Discussions were held with the Peckham Health Centre Members' Association with a view to the formation of a family club and the association of their activities with the health and educational facilities. Before the closure of the Pioneer Health Centre one of its chief objects was research into human health and the biological observation of the family as a unit. This research was largely supported by the Sir Halley Stewart Trust which was latterly guided by a scientific advisory committee. In giving further consideration to the formation of a medical research unit at the Queen's Road Centre, the Council has had the benefit of the valuable advice of members of the former scientific advisory committee. It is hoped to establish a medico-sociological research unit with an independent governing body on which the Council would be represented. The Council has no direct powers under the National Health Service Acts to carry out the type of research contemplated, but it is hoped that funds will become available from other sources. Details of the scheme were still under consideration at the end of the year. Future developments. In April, 1951, the Council reviewed the possibilities of providing health centres following discussions with the Ministry of Health from which it had become clear that under existing circumstances proposals for the erection of general practitioner health centres would be considered only for areas where there was exceptional urgency, e.g., in certain redevelopment areas where a considerable increase in the population was imminent and general medical services would be needed in excess of those already available. In general this would not apply to redevelopment and reconstruction areas being planned in London, since in most cases the population will tend to decrease slightly when rebuilding is completed, while other areas, where the population will increase, are too small or too widely scattered to justify a substantial increase in the general medical services. It was understood that in cases of exceptional urgency it might be possible to consider the building of maternity and child welfare and/or school health centres on health centre sites as first instalments of health centres, or to undertake the adaptation of existing buildings as comprehensive health centres if an immediate need for maternity and child welfare, school health and general medical services were established. With regard to group practices it was thought that the building or adaptation of premises would be undertaken only where a group of general practitioners wished to co-operate in such a scheme and existing general medical services in the district were very inadequate. Accordingly the Council decided that the planning of health centres should for the time being be limited to:— (i) The provision of a group practice at the Queen's Road Centre if a group of doctors wished to practise there. (ii) The reservation of suitable sites on housing estates, etc., where the future provision of health centres would be difficult if this action were not taken. (iii) The building, in cases of exceptional urgency, of maternity and child welfare centres and/or school health centres on health centre sites as first instalments of health centres. (iv) The provision of a limited number of premises for group practices as first instalments of health centres or otherwise in areas where there is, or will be, a deficiency in the general medical services. Reservation of sites for health centres Reference was made in my report tor 1950, to the Council s decision that six sites should be designated under the Town and Country Planning Act, 1947, for acquisition and development as health centres. With the approval of the Executive 47 Council these sites, listed below, were included in the County Development Plan, 1951, submitted to the Minister of Housing and Local Government:— Walmer Road, Threshers Place, Kensington. Southend Lane, Lewisham. 10, St. Alban's Villas, St. Pancras. St. Philip's Church and Vicarage, Richmond Road, Hackney. Burney Street, Greenwich. 21, Weir Road, Wandsworth. Six other sites in areas of comprehensive development were included in the Development Plan, 1951. Meetings were held with officers of the Executive Council to discuss problems relating to the selection and reservation of sites for health centres and the suitability of sites to be submitted to the Executive Council for approval. In addition to the six designated sites referred to above, the Executive Council agreed, during the year, to the Council's proposals for the use of sixteen sites for health centres. The Local Medical Committee again asked general practitioners in London whether they desired to undertake practice in buildings provided by the Council as health centres and nine groups of doctors expressed a wish to do so. No premises suitable for immediate conversion for group practice, however, became available during the year. Group practices The proposal mentioned in my report for 1950 to convert the Hampstead Health Institute to provide accommodation for a group of five doctors was not approved by the Minister of Health on the ground that the area was already adequately supplied with doctors and doctors' surgeries. Transfer of premises under the National Health Service Act, 1946 Negotiations were continued with the Minister of Health and metropolitan borough councils concerning the future ownership and allocation of buildings which, prior to 5th July, 1948, had not been used entirely for functions assumed under the Act by one authority. The Minister agreed in principle to a settlement for the transfer of property between the Council and the Minister, in accordance with the details set out below. Detailed settlements with the appropriate Regional Hospital Boards were still being negotiated by the Council's Director of Housing and Valuer at the end of the year. (1) Properties to be conveyed by the Minister of Health to the Council. (i) Norivood Children's Hospital, Lambeth.—Home for old people. (ii) New Cross Hospital, Deptford.—A strip of land required for improvement of adjoining ambulance station. (iii) South Western Hospital, Lambeth.—Small portions of land required for improvement of adjoining ambulance station. (iv) " Southlands," Battersea.—Minister's apportionable interest in a former chest clinic. (v) Eltham Hill Health Centre, Woolwich.—Minister's apportionable interest in property used by the Council for health purposes. (2) Properties to be conveyed by the Minister of Health to the Council at some future date, when the existing users are able to vacate. (i) Finsbury Health Centre, Finsbury.—The Minister will convey his apportionable interest to the Council to enable a general practitioner health centre to be established. (ii) Parsons Green Maternity Hospital, Fulham.—The Minister will convoy his apportionable interest to the Council to enable the premises to be converted into a health centre. 48 (3) Property to be conveyed by the Council to the Minister of Health. (i) Belmont Hospital, Sutton, Surrey.—A former social welfare establishment used as an emergency hospital since 1939. (ii) 2, Kenworthy Road, Hackney.—Former guardians' boardroom and offices within the curtilage of Hackney Hospital. (iii) 275, Bancroft Road, Stepney.—Former relief office within the curtilage of Mile End Hospital. (iv) 2A, Woolwich Road, Woolwich.—The Council's apportionable interest in a former relief station, partly used by regional hospital board for offices. (v) 28, Marloes Road, Kensington.—The Council's apportionable interest in a former relief station required by regional hospital board for out-patient use. (vi) Western Ambulance Station, Fulham.—Land at rear required for improvements to the Western Hospital. (vii) Horton Street Foot Clinic, Deptford.—The Council's apportionable interest in a former clinic building required for extension of chest clinic facilities. (viii) 394, Lewisham High Street, Lewisham.—Former relief offices within the curtilage of Lewisham Hospital. (ix) South Western Ambulance Station, Lambeth.—Land to south, surrendered to regional hospital board in exchange for land conveyed to the Council (see 1 (iii) above). (4) Properties to be conveyed by the Council to the Minister of Health at some future dale, when existing users are able to vacate. (i) 128, Brook Drive, Lambeth.—Former guardians' office within the curtilage of Lambeth Hospital now used as divisional health office and area children's office. (ii) 275, Bancroft Road, Stepney.—Former relief offices within the curtilage of Mile End Hospital, now used as divisional health office. (iii) Fulham Road Institution, Fulham.—Part of the institution which is Welfare Committee property required by the regional hospital board for the extension of St. Stephen's Hospital. (5) Other agreements. (i) Fulham Babies' Hospital, 23, Broomhouse Lane, Fulham.—The Minister will agree to a lease to the Council for 7 years of part of building used for day nursery. (ii) St. George's Dispensary, Southwark.—The Minister disclaimed interest in dispensary formerly provided by a voluntary body. Negotiations proceeding for vesting the property in the Council. (iii) 91, Bedford Hill, Wandsworth.—Chest clinic removed from premises which were also used for maternity and child welfare purposes. (iv) Woolwich Central Health Centre, Woolwich.—Premises to vest entirely in the Council. (v) 129, Fulham Palace Road, Fulham.—Former relief station within curtilage of Fulham Hospital to be vested in the Council, and used as divisional health offices. (vi) Barnes Home, St. Pancras.—Accommodation formerly used as chest clinic made available to the Council for maternity and child welfare purposes. (vii) St. Alfege's Hospital, Greenwich.—The Council relinquished accommodation on ground floor used as a dental clinic. , (viii) White Oak Hospital, Swanley, Kent.—A short tenancy of part of premises granted to the Council for an open-air school. (ix) British Dental Hospital, Lewisham.—The Council acquired leasehold of premises for which regional hospital board had no need. (x) Gasworks Cottage, Friern Hospital.—It was agreed that this property passed to the Minister. 49 Acquisitions and leases Many of the premises used by the Council for health service purposes have been held on insecure tenancies. All possible opportunities have therefore been taken to acquire properties and sites, when suitable, or to secure long-term leasehold tenancies. The following acquisitions and leasehold tenancies were completed during the year:— Property Interest obtained. Service Division 1. 31 and 33, Bramerton Street, Chelsea. Leasehold School treatment and dental centre. Grove House, Bagley's Lane, Fulham. Leasehold Day nursery. 90, Highlever Road, Kensington... Freehold Day nursery and site for maternity and child welfare centre. 468, Uxbridge Road, Hammersmith. Leasehold Day nursery. Division 2. Solent Road, Hampstead Freehold Site for maternity and child welfare centre as first instalment of health centre Sumatra Road, Hampstead Freehold 38 and 42 to 46, Westbourne Park Road, Paddington. Freehold Site and partially constructed buildings for day nursery. 40, Westbourne Park Road, Paddington. Leasehold 42, Phoenix Road and 63, Chalton Street, St. Pancras. Freehold Day nursery. 40, Alderney Street, Westminster Freehold School treatment centre. Division 3. 10, John Street, Holborn Leasehold Maternity and child welfare and dental centre. Division 4. 1, Fountayne Road, Hackney Freehold Day nursery. 186, Upper Clapton Road, Hackney. Freehold Maternity and child welfare and school treatment centre. 235, Albion Road, Stoke Newington. Freehold Maternity and child welfare and dental centre, and foot clinic. | Division 5. 54, Westferry Road, Poplar Leasehold Maternity and child welfare centre. Queen Mary D.N., Tidey Street, Poplar. Leasehold Day nursery. 532/4, Commercial Road, Stepney Leasehold Divisional sub-office. Division 6. St. Paul's House, High Street, Deptford. Freehold Divisional office. 10, 20, 22 and 24, Garland Road, Woolwich. Freehold Maternity and child welfare and minor ailments centre. Lionel Road First Aid Post, Woolwich. Leasehold Maternity and child welfare centre. Division 7. Queen's Road Centre, St. Mary's Road, Camberwell. Freehold Health centre and day nursery. 81-93, Peckham Park Road, Camberwell. Freehold Day nursery. 103-111 (odd), and 113-117, Brockley Rise, Lewisham. Freehold Site for health centre. Division 8. Cynthia Mosley Day Nursery, Oval Way, Lambeth. Leasehold Day nursery. 2 and 4, Barston Road, Lambeth Freehold Day nursery. 44, 46 and 48, West Hill, Wandsworth. Freehold Site for ambulance station. 50 CARE OF MOTHERS AND YOUNG CHILDREN Administration During the year the task of maintaining and improving the personal health service was continued. The day to day administration of these 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 divisions. The divisional medical officer is responsible through his administrative staff for the co-ordination of the personal services in his area. Maternity and child welfare centres Details of changes in centres and of the commencement of maternity and child welfare services at the Queens Road Centre, Peckham, will be found in the section on Health Service Premises, page 39. Maternity and child welfare services The following table shows the number of attendances at child welfare and anteand post-natal sessions which were held during 1949, 1950 and 1951. It will be noted that attendances at ante-natal sessions have continued to decline. There has been an increase in first attendances at child welfare sessions compared with 1950, but the total attendances have declined. With regard to the age incidence of child 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 one and one to four years. It will be seen that 82 per cent. of children attended a centre at least once in their first year of life; this compares with 79 per cent. in 1950. Those children who attend in their first year do so about 14 times. It will be realised that for eight or nine months the mother is anxious about the progress of the child, and so she brings the baby regularly to the centre for weighing, medical advice and mothercraft guidance. With normal progress of the child, however, attendances thereafter tend to fall off rapidly. It will be noted that 37 per cent, of the child Attendances 1949 1950 1951 First Total First Total First Total Child Welfare under 1 year 48,489 683,089 43,916 649,983 45,534 626,164 over 1 year 6,641 282,202 5,496 245,484 4,540 235,942 Special toddlers - 35,500 - 41,817 - 43,145 Ante-natal 29,917 184,018 26,979 176,993 24,819 162,667 Post-natal 5,839 7,486 5.934 7,255 5,662 6,860 Breast feeding 1,559 2,851 1,240 2,555 1,201 2,467 Education and Advisory - 23,688 - 27,910 - 34,925 Total 92,445 1,218,834 83,565 1,151,997 81,756 1,112,170 Foot 9,964 128,055 10,165 153,687 10,348 162,163 Light and massage 6,440 108,545 6,903 109,013 6,533 102,692 Grand Total 108,849 1,455,434 100,633 1,414,697 98,637 1,377,025 population between one and five years attend after the first year for three or four further visits. Special toddlers' clinics are held and special birthday postcards are sent to mothers to remind them of the facilities for preventive advice. One fifth of the infants who attend in response to these invitations are referred for treatment for ailments which the parents might not otherwise have recognised. 51 Child Welfare Centres in London, 1951 Health Division No. per 1,000 child population per year* No. of attendances per child per year Attendances Children Under 1 1-4 Under 1 1-4 Under 1 1-4 1 11,093 954 835 353 13 2.7 2 12,152 1,601 881 481 14 3.3 3 12,540 940 991 258 13 3.6 4 10,102 918 815 458 12 2.0 5 10,252 1,227 819 252 13 4.9 6 14,207 1,654 919 479 15 3.5 7 13,907 1,269 751 336 18 3.8 8 12,048 1,558 673 463 18 3.4 9 9,950 673 771 201 13 3.3 County 11,847 1,206 822 366 14 3.3 * Within the specified age group. First attendances at ante-natal sessions amounted to 45 per cent. of all women requiring ante-natal care during the year (as estimated from confinements over a corresponding later period) compared with 50 per cent. in 1950. An increasing percentage of mothers receive their ante-natal care from hospitals where they have booked for confinement or from their family doctor who has been booked to undertake the delivery. A number of hospitals refer their booked cases to the Council antenatal sessions for intermediate supervision. The general practice is for mothers to attend the hospitals to book, and later in pregnancy at the 34th to 36th week, according to local practice, they are referred for final examination at the hospital to which they are being admitted for their confinement. There was a corresponding decline in post-natal attendances and in attendances at breast feeding clinics. Educational and advisory sessions have been given increased support. There was increased pressure on foot clinics. 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. The arrangements whereby mothers and young children living in that part of the county borough of West Ham adjacent to North Woolwich may, if they so wish, attend the Council's North Woolwich Welfare Centre, Fernhill Street, E.16, were continued. Providing M. and C.W. Services Voluntary organisations Throughout the year, 18 voluntary organisations have provided maternity and child welfare centres under agreement with the Council in accordance with Section 22 of the National Health Service Act. The centres are administered by voluntary committees on which the Council is represented and the premises are inspected from time to time. During the year, the Council took over the Moffat Institute Welfare Centre at the request of the voluntary committee. The Mothercraft Training Society decided to end its activities at the end of July. As a result, their child welfare centres in Kensington and at Cromwell House. Highgate. and, at the latter premises, an in-patient department for mothers and 52 babies with breast feeding or dietetic upsets, closed down. The society, which was founded in 1918 by the late Sir Truby King, was one of the pioneers in child welfare. The Council had long been associated with it in its work and had given financial help towards the care given to London women and children at its centres. Children from the London area attending the child welfare sessions were referred to neighbouring Council centres. Mothers and children who would have gone into the in-patient department at Cromwell House were referred to the residential unit at the Violet Melchett Centre, where treatment is provided for mothers and babies experiencing breast feeding difficulties and for babies with dietetic upsets. Providing Day Nurseries and Creches Arrangements with the six voluntary associations providing day nurseries continued satisfactorily during the year. Financial assistance was granted towards the maintenance costs of two nursery play groups and one part-time day nursery. 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 50. 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 they can keep in touch with the health visitor of their area. Any mother is, however, free to choose which centre she wishes to attend. The practice continued of allocating clinic medical officers to child welfare or ante-natal and post-natal work, according to preference. Many of them are general practitioners holding part-time appointments with the Council. Tests 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 or Kahn reaction. The necessary laboratory services, including those needed in connection with outbreaks or suspected outbreaks of active infectious diseases, have continued to be carried out at hospital laboratories free of charge to the Council, pending the facilities being made available through the public health laboratory services. Pregnancy diagnosis tests are carried out for the Council at certain hospital laboratories or at the Ministry of Health's laboratory in Shrodell's Hosnital. Watford. Health Education Full use has been made of the educational activities at the centres. Health visitors have given talks on mothercraft, etc., and with the co-operation of the Council's Education Officer, sewing, dressmaking and cookery classes have been provided for expectant and nursing mothers at many centres. Family Planning Accommodation at certain of the Council's welfare centres is let free of charge to the Family Planning Association for the purpose of holding family planning clinics. There are now 31 weekly sessions held by the Association in Council or other premises, and, in addition, 6 sessions a week are held by the Council at which family planning advice is given. 989 women were referred by the Council to the Family Planning Association for birth control advice when further pregnancy would be detrimental to health. Care of premature babies Special equipment is provided, if required, 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 this is refunded in full when the equipment is returned. The arrangements outlined in my report in 1948 with respect to special transport facilities when these infants have to be removed to hospital have operated throughout 1951. The specially heated cots carried on the ambulances were used on sixty-five occasions for premature infants. 53 Premature babies, bom at home: special report on 296. Domiciliary midwives are asked to inform the supervisor immediately if she delivers a baby of 5½ lb. or less, whether or not it is premature. In this report still-births are excluded. During 1951, 296 babies of this weight were born alive to 269 mothers, 207 multigravidae and 62 primigravidae. Each baby was visited at least once by the supervisors of midwives and this summary is based on their reports. 15 of the cases (11 primigravidae) were unbooked emergencies when no preparations whatever had been made. 52 mothers (19 primigravidae) had received inadequate or no ante-natal care, owing to late booking and non-attendance at clinics. 112 cases were attended bv a doctor, either because he was already in charge, or because he was called in by the midwife. Causes of prematurity As patients with abnormalities during the ante-natal period are usually transferred to hospital, well-known causes such as toxaemia and twins are not common. 39 babies were not premature according to the dates and although weighing 5½ lb. or just under appeared to be normal mature infants. In 28 cases either the parents were very small or the mother had had previous small babies. The causal factors may be summarised as follows:— Twin pregnancy 30 Toxaemia 24 A.P.H 7 Anaemia and malnutrition 4 Trauma 4 Multi-parae 2 External version 2 Excessive physical work 2 Cough, influenza 2 No cause found 152 The following table shows the weights and maturity of the infants :— Under 3½ lb. Survived Died Total Hospital Home Hospital Home Less than 32 weeks 2 - 11 2 15 32-36 weeks 3 - 1 - 4 36+ 5 1 - - 6 3½-4½ lb. Less than 32 weeks 2 1 1 - 4 32-36 weeks 9 7 - - 16 36+ 7 12 1 1 21 4½-5 lb. Less than 32 weeks - - - - - 32-36 weeks 6 7 1 - 14 36+ 1 27 2 - 30 5-5½ lb. 32-36 weeks 1 7 - 1 9 36+ 14 160 - 3 177 Total 50 222 17 7 296 Babies were transferred to hospital on account of unsuitable home conditions, i.e., unbooked emergency, or on account of cyanosis or some other unsatisfactory state. The usual practice is for babies under 4 lbs. or more than 8 weeks premature to be removed to hospital as soon after birth as possible, in a specially heated cot. 57 infants were transferred within a few hours, 7 between 12 and 24 hours and 6 at a later date, usually on account of some infection or abnormality. Breast feeding Of the 219 babies nursed at home, 199 were entirely breast fed when discharged by the midwife. 54 Neo-natal deaths 24 infants died within 28 days, 7 at home and 17 in hospital. 10 deaths occurred within the first 12 hours, the remaining 14 within 28 days. 13 deaths were in infants of less than 32 weeks gestation and under 3½ lbs., several of which were not really viable. In the majority no cause of death was found other than prematurity. Two infants died from cerebral haemorrhage at 1 day and 28 days respectively, and one from pneumonia at 7 days. Four had congenital malformations. Comments It is evident that the chance of survival depends on the period of gestation as much as on the weight. Only two infants of less than 32 weeks gestation and under 3½ lbs. in weight survived. These were twins who were removed to hospital immediately after birth and made excellent progress in a premature-baby unit. Ten infants of 32-36 weeks gestation and under 3½ lbs. survived, nine in hospital and one at home. Where the gestation period is over 36 weeks and the weight 4½ lbs. or more, the baby can be adequately nursed in its own home by the domiciliary midwife. Out of 190 infants in this group only three died (2 from cerebral hæmorrhage and 1 from pneumonia), the rest were making good progress when discharged by the midwife. Maternity and child welfare services provided by hospitals The Council runs a child welfare clinic, as a municipal centre, in the premises of two teaching hospitals. To provide teaching facilities, a member of the hospital medical staff conducts the sessions, but as the Council may not pay specialist rates for work of this nature, only the non-specialist rate is paid, the balance being made up, if necessary, by the medical school. By arrangement with four teaching hospitals, their medical schools, acting as voluntary bodies grant-aided by the Council, provide child welfare services on its behalf. The medical schools pay a rent to the hospital authority for the use of the clinic premises, and also provide and pay all staff except health visiting staff. The Council reimburses the medical school at the rate of 90 per cent. of the approved netexpenditure, subject to the payment by the Council of the full non-specialist rate for the paediatricians conducting the child welfare sessions. The remaining 10 per cent. of the expenditure, with the balance of any specialist rate paid to the medical staff, is found by the medical school and is regarded as a fair return for the teaching facilities at the clinic. Provided the interests of the Council and of the children for whose welfare it is responsible are safeguarded, the special requirements of the teaching hospital are preserved, e.g., in such matters as appointment of the medical staff to conduct the clinics which are attended by medical students. These clinics are closely associated with the Council's divisional organisation, 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 child welfare clinics at hospitals. The Council's health visitors attend the clinics, where they are under 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 has continued to employ a health visitor, subject to the refund of 90 per cent. of her salary by the Council. At this same clinic, the Council maintains a training school for health visitors, four students being trained annually. The students receive their practical experience and tutorial instruction at the hospital, and take systematic lectures at the Royal College of Nursing. The arrangements whereby the Council's full-time assistant medical officers at child welfare centres exchange with medical officers working in the children's departments of certain hospitals have continued, and there has been some expansion of this exchange system. This system enables the Council's medical officers to keep 55 abreast of developments in paediatrics, and the hospital medical officers to watch the growth and development of healthy children. Institute of Child Health As outlined in my report for 1950, the Council is co-operating with the Institute of Child Health in 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 the Institute, the Council has the opportunity of co-operating 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 will serve the purpose of teaching post-graduate students and conducting research as well as meeting the needs of the neighbourhood. The capital expenses of the scheme are being met by the Institute but the Council will contribute a 90 per cent. grant on the approved expenditure on services proper to it as the local Health Authority. The cost of teaching and research will fall on the institute. Negotiations with the Institute Authorities and their architects have taken place during the year with regard to the erection of the centre and my department has been given the opportunity of commenting on the plans for the centre. Dental care Details of the priority services for expectant and nursing mothers and children will be found on page 110 in the report of the Council's Chief Dental Officer. Drugs, medicaments, welfare foods, etc. Simple drugs, medicaments and vitamin products (supplied free of charge) and welfare foods and nutrients (at fixed charges) subject to abatement, are available at welfare centres and to a limited extent at day nurseries. The lists of drugs and welfare foods are revised from time to time to keep abreast of modern medical developments. Ministry of Food national dried milk, concentrated orange juice, cod liver oil compound and vitamin A and D tablets were also made available at the welfare centres for the convenience of mothers attending. Sunday cinema grants The Council continued to receive contributions from Sunday cinema entertainments out of which an allocation was made to each of the nine divisions for the purpose of providing amenities for mothers and children attending maternity and child welfare centres and day nurseries. The funds are administered by voluntary committees set up in each division. Marriage guidance The Council agreed in principle to give financial aid over a period of five years (commencing in April) to the London Marriage Guidance Council, the Catholic Marriage Advisory Council and the Family Discussion Bureaux of the Family Welfare Association, and made a grant to each of these three bodies for the year ending March, 1952. In addition, the Council also authorised the London Marriage Guidance Council to hold marriage guidance sessions in available accommodation in a number of its maternity and child welfare premises. Home visiting and after care on behalf on almoners As a result of the negotiations with hospital authorities and the Institute of Almoners, reported in 1950, a scheme was introduced whereby the Council undertook, through its divisional organisation, to carry out home visiting and provide after care for patients referred by hospital almoners. Under this scheme, the direct approach 56 of almoners to the Council's field workers for mutual discussion and exchange of information is still encouraged but all correspondence on arrangements for home visiting and after care is conducted through the divisional medical officers. The large majority of hospitals agreed to participate in this scheme, which will be reviewed early next year. Children neglected or ill treated in their own homes In the report for 1950, reference was made to the joint circular issued by the Home Office, the Ministry of Health and the Ministry of Education inviting local authorities to consider what might be done to prevent the neglect or ill-treatment of children in their homes. The Council decided that the main objects of the joint circular were being achieved under the Council's existing organisation. Measures were taken in each division to bring together the Council's officers and the officers of other official and voluntary bodies interested in the welfare of children in their own homes. The aim of these measures was to co-ordinate the efforts of all concerned so that neglect and ill-treatment might be prevented, or, if it had come to light too late, suitably remedied. Neglect and ill-treatment often arise from the same conditions of health and environment which produce juvenile delinquency and maladjustment and form part of one great problem. An attempt to face the problem as a whole has been planned in two divisions by the setting up of experimental conferences, to be attended by all organisations, whether voluntary or statutory, who are interested in, or can help, the children who live under these conditions. The conferences were due to meet early in 1952, and their results are awaited with interest. Day nurseries, creches and nursery play centres The results of the comprehensive enquiry into the high costs of the day nursery service carried out in the latter part of 1950 were examined in detail, and the following action taken during 1951 (i) Weighting of registers.—In an endeavour to secure maximum occupation, extra children were allowed on the registers up to 25 per cent, above the number of approved places. This was done to offset absences due to illness, etc. (ii) Introduction of a revised ratio of non-domestic staff to children.—A new ratio was adopted of non-domestic staff to children of 1 : 3 and 1 : 8 for children aged 0-2 and 2-5 years, respectively. This ratio was based on the number of approved places in each of these age groups, with a relaxation of the standard in day nurseries catering for children aged 2-5 years only. The ratio was subject to the overriding consideration that in no day nursery should there be fewer than five places for children of all ages to one unit of non-domestic staff. (Hi) Institution of a revised ratio of nursery students to staff places.—The former ratio of three nursery students to one staff place was replaced by a ratio of 2 :1. (iv) Reduction of the number of training nurseries.—The number of training nurseries has been gradually reduced during the year by approximately one-third, and the position will be reviewed early in 1952. (v) Non-issue of children's overalls as a routine.—It was decided that overalls or dungarees should be provided, washed and kept in good repair by the mothers of children attending the day nurseries. A small stock of a simple type apron is held in each day nursery for use in emergency or in cases of genuine hardship. (vi) Hours of opening of day nurseries.—The hours of day nurseries generally were fixed as 7.30 a.m. to 5.30 p.m. on Mondays to Fridays, with provision for remaining open until 6 p.m. when local conditions so required. Nurseries which were previously opening later than 7.30 a.m. have continued to do so as far as practicable. Approval was given, in principle, to all day nurseries being closed 57 on Saturdays as soon as this could be achieved, and, by the end of 1951, only three were open on Saturday mornings. (vii) Priorities for admission.—The priorities for admission of children to day nurseries were revised, and the new rules brought into operation on 1st April, 1951. The rules were applicable to children already in the nurseries, and the provision for a six-monthly review of the circumstances of parents of children attending day nurseries was continued. (viii) Provisions and laundry services.—Experiments were instituted during the year in selected day nurseries with a view to determining whether economies could be effected in the relatively high expenditure on provisions and in the method of laundering day nursery articles. The results of these experiments were awaited at the end of the year. (ix) Future day nursery provision.—The total day nursery provision for the County was to remain substantially at its January, 1951, level. Any indication of redundancy was to be kept under review, and steps taken to deal with it by closing or amalgamating nurseries. During 1951, four full-time day nurseries and one part time nursery creche were closed, and one day nursery transferred to new premises. The number of places provided in the Council's maintained (106) and grant aided (6) day nurseries was 6,216 on 31st December, 1951, as compared with 6,462 in 117 day nurseries on 31st December, 1950. The priority waiting lists for admission to day nurseries stood at 977 at the end of the year, compared with 1,932 on 31st December, 1950. Nursery play centre facilities remained unaltered during the year. Nutritional Investigation at day nurseries Facilities were granted to professor John Yudkin, Department of Physiology, King's College of Household and Social Science (University of London) to carry out a nutritional investigation at four day nurseries in one of the divisions. The main purpose of the investigation was to determine whether the present day diet contains all the nutritional factors necessary for the best growth and development of childen and was designed to ascertain the effect on the height and weight of young children of the daily administration (in chocolate) of a Vitamin B preparation. The results of the investigation are still awaited. Nurseries and Child-Minders Regulation Act, 1948 There was a small 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 were:— At 31.12.50 At 31.12.51 Number of private day nurseries statutorily registered 41 49 Number of places provided 1,294 1,583 Child- minders service There were small decreases in the number of child-minders statutorily and voluntarily registered but the reductions are, however, so small as to suggest that the service has now found its level, and that supply keeps pace with demand. The childminders who are statutorily registered under the Act are 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. Voluntarily registered child-minders are women who look after one or two children and voluntarily register with the Council, receiving a weekly registration fee in return for which they are subject to inspection by the Council. 58 The number of child-minders, both statutorily and voluntarily registered, together with the number of children looked after, are shown in the following table At 31.12.50 At 31.12.51 Number of child-minders statutorily registered 96 93 Number of children minded 570 604 Number of child-minders voluntarily registered 766 749 Number of children minded 834 840 Residential nurseries One of the consequences of the children Act, 1948, was that the residential nurseries previously administered by the Public Health and Welfare Departments were transferred to the Children's Department. The Health Department, however, is still concerned with the health of the children and staff in the nurseries. The importance of this associat ion was recognised by the Home Office in the memorandum accompanying their Circular No. 124/1950, in which it is laid down that "the advice of the Medical Officer of Health should be sought on all medical matters affecting nurseries provided by a local authority, including the appointment of the medical officer and, where it arises, the allocation of duties between two doctors, and on the medical aspects of the planning of accommodation and staffing of nurseries." 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. Medical and dental staff for the Council's residential nurseries are appointed to the staff of the Public Health Department, and the Medical Officer of Health is associated also with the appointment of nursing staff at nurseries where there is a large proportion of children under 2 years of age, such children being particularly prone to sudden changes of condition between health and sickness. Adoption and boarding-out of children During the year 794 children were referred 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, 95 were passed fit for adoption, 687 fit for boarding-out, and 12 unfit for various reasons. It is regarded as being of the utmost importance, both for the child and for the adoptive parents, that any adverse medical condition which may arise as the child grows older should be fully appreciated before adoption is finally undertaken, and every case is most carefully scrutinised with this in mind. The care of unmarried mothers and their children As hitherto, "the problem of illegitimacy still remains and still needs all the skill, patience and effort which statutory authorities and voluntary organisations can bring to its solution," and the Council has, since undertaking this responsibility in 1948, done everything in its power to co-operate with and reinforce the work of the moral welfare associations in aiding and rehabilitating the unmarried mother. 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 hospital for the confinement. The Council, as local health authority, pays grants under section 22 (1) of the National Health Service Act, 1946, to voluntary organisations maintaining mother and baby homes, the homes being visited by medical 59 officers of the department at least twice a year, and by sanitary inspectors when any structural alterations to the premises are necessary. Some of the homes are also registered under Section 29 of the Children Act. 1948. There are 20 grant-aided homes and the approximate total grant for the financial year was £12,405. The denominations responsible for the management of the homes are Church of England 7, Roman Catholic 4, Salvation Army 2, Church Army 2, Methodist 1, undenominational 4, but all the 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. Valuable assistance is given by the voluntary committees of the mother and baby homes. The primary object is to re-establish the mother in her own life, together with her baby if possible. In London 35 moral welfare workers are employed by five associations which received grants amounting to £9,110 during the financial year. Participation of health visitors There is the closest co-operation between the health visitors and the moral welfare workers. Unmarried mothers are put into touch with the moral welfare workers, and the health visitors see that the maternity and child welfare services 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. Annual Moral Welfare Conference A conference is held once a year with representatives of the voluntary moral welfare organisations at which outstanding problems are freely discussed and personal contacts established between those organisations and the local supervisory authority. L.C.C. Midwives DOMICILIARY MIDWIFERY SERVICE The number of domiciliary confinements attended by the Council's midwives has continued to fall during the year as the following table will show:— Year Maternity nursing cases Midwifery cases Total 1947 899 12,025 12,924 1948 630 9,533 10,163 1949 749 7,831 8,580 1950 649 6,659 7.308 1951 679 6,361 7,040 There was a slight fall in the birth-rate, but the attraction of hospital confinement and the number of maternity beds available were the main factors in reducing the number of home confinements. Of the confinements during 1951, 753 were primi-gravidae and 6,287 multigravidae. The figures do not include women booked by the Council's midwives who were subsequently taken to hospital before confinement . The number of midwives employed at the end of the year was 111 compared with 121 at the end of 1950 and 140 at the end of 1949. The average number of confinements attended by each midwife, including sick and holiday reliefs, was approximately 62 as compared with 57 in 1950 and 58 in 1949. Transport Transport by ambulance cars continued to be available for the use of midwives in emergency, particularly at night time and when undertaking additional relief duties, and 3,133 miles were run on the service during the year. Housing of midwives Accommodation for domiciliary midwives continued to be provided by the Council. On 31st December, 1951, 56 midwives were housed in 54 houses and flats, of which 30 were provided by the Council and 24 taken on lease or on licence. 60 Drugs and dressings Agency organisations Drugs and dressings were supplied to the midwives and also to some district nursing associations through the Council's supply organisation. There was a decrease during the year in the number of connnements undertaken on behalf of the Council by district nursing associations and hospital district midwives. Year Maternity nursing cases Midwifery cases Total 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 1951 Hospital district service 102 3,144 3,246 District nursing associations 161 1,912 2,073 5,319 The number of midwives employed by these agencies on 31st December, 1951 was as follows:— Staff Hospital district service 70 (including supervisory staff) District nursing associations 36 (including supervisory and Dart-time staff) Payments to District Nursing Associations and hospitals 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 was increased from £7 13s. 4d. a confinement to £10 10s. a confinement on 1st April, 1951. The rate of payment for one hospital (the Mothers' Hospital—Salvation Army) is £9 15s. as some of the district midwives employed by that hospital are members of the Salvation Army and do not receive the full Whitley Council rates of pay. Ante-natal sessions The midwives' sessions for booking patients and ante-natal examinations at the maternity and child welfare centres were adjusted as necessary. There are now only a very few midwives who still continue to book and examine their patients at home. Mortality Patients attended by Maternal deaths Stillbirths Neo-natal deaths London County Council midwives 1 73 15 Hospital district midwives — 33 2 District nursing association midwives — 23 6 1 129 23 Emergency Obstetric Service During the year, 79 calls were made to hospitals for the emergency obstetric service. Thirty-seven of these calls were made by doctors and 42 by midwives. The time intervals between the calling and arrival of service were:— 15 minutes 12 cases 15 to 30 minutes 57 cases 30 to 45 minutes 8 cases 60 minutes 1 case 95 minutes 1 case (delay due to fog) 61 The conditions necessitating the use of the service were:— Primi- para Multiparae Parity unknown Total Obstetric shock with post-partum haemorrhage 1 4 1 6 Retained placenta with post-partum haemorrhage 5 10 1 16 Post-partum haemorrhage (following delivery of placenta) 9 27 1 37 Retained placenta 2 4 — 6 Post-partum eclampsia 1 — — 1 Intra-partum haemorrhage 1 1 — 2 Ante-partum haemorrhage — 2 — 2 Malpresentations 2 1 — 3 Obstructed labour — 2 — 2 Abortion 1 1 — 2 Prematurity — 1 — 1 Haemolytic disease of the newborn — 1 — 1 22 54 3 79 The action taken by the emergency obstetric service was :— Treatment given Removed to Hospital Remained at Home Total OBSTETRIC SHOCK WITH POST-PARTUM HAEMORRHAGE Blood transfusion 1 3 4 Administration of drugs 2 — 2 RETAINED PLACENTA WITH POST-PARTUM HAEMORRHAGE Blood transfusion 5 2 7 Saline transfusion 2 — 2 Manual removal with blood transfusion 1 1 2 Placenta expressed with blood transfusion 2 3 5 POST-PARTUM HAEMORRHAGE (FOLLOWING DELIVERY OF PLACENTA) Blood transfusion 14 14 28 Saline transfusion 1 1 2 Administration of drugs 3 2 5 No treatment 1 1 2 RETAINED PLACENTA Manual removal with blood transfusion — 2 2 Placenta expressed following administration of drugs 1 1 Placenta expressed — 2 2 No treatment 1 — 1 POST-PARTUM ECLAMPSIA Administration of drugs 1 — 1 INTRA-PARTUM HAEMORRHAGE Blood transfusion 2 — 2 ANTE-PARTUM HAEMORRHAGE Blood transfusion 2 — 2 OBSTRUCTED LABOUR Delivery of impacted shoulders — 1 1 Attempted delivery of impacted shoulders 1 1 MALPRESENTATIONS External version and rupture of membranes — 1 1 No treatment 2 — 2 ABORTIONS Blood transfusion 1 — 1 Administration of drugs 1 — 1 PREMATURITY No treatment — 1 1 HAEMOLYTIC DISEASE OF THE NEWBORN No treatment 1 — 1 44 35 79 E 62 Comments.—During the year the obstetric emergency service was called mainly for true obstetric emergencies, i.e., sixty-five cases of retained placenta and/or post-partum haemorrhage and/or obstetric shock. In five cases of malpresentation or obstructed labour three calls were made by doctors unable to deal with the case themselves and two calls by midwives unable to obtain medical aid. In only two cases was the service called for conditions in the infant. In all cases to which the service was called the mother made a good recovery. There were three stillbirths and one infant death. Pupil midwives At the end of 1951, 73 of the Council's domiciliary midwives had been approved by the Central Midwives' Board as district teachers and during the year 196 pupil midwives from Part II midwifery training schools received their district training with Midwife teachers employed by the Council. Some hospitals and district nursing associations which are Part II training schools also provided district experience for pupil midwives with their own district midwives. Analgesia (a) Gas and Air.—The following table sets out the number of women receiving gas and air analgesia during the year and the percentage which they represent of the total confinements attended. There were also some women whom the midwives attended as maternity nurses under the direction of medical practitioners who themselves administered anaesthesia or analgesia; for them no figures are available. Confinements attended by Total London County Council midwives 5,338 (75.8%) Hospital district midwives 2,323 (72.5%) District nursing association midwives 1,443(68.0%) The comparable figures for the year 1950 were as follows:— London County Council midwives 5,027(68%) Hospital district midwives 2,783 (69%) District nursing association midwives 1,400 (57%) There are still some mothers who decline analgesia and some who are not considered medically suitable to receive it. There are also a number of cases where the midwife is not summoned early enough. (b) Pethidine.-—The number of women given Pethidine by midwives in the Domiciliary Service during the year was:— Administered by As midwives As maternity nurses London County Council domiciliary midwives 1,442 175 Hospital district midwives 158 43 District nursing association midwives 205 52 Developments in 1951 The Minister of Health asked the Council to co-operate with the hospital authorities in the policy which he had laid down for the selection of maternity cases for admission to hospital. Broadly speaking, his object was to introduce a greater discrimination in selecting patients for hospital confinements and so reduce the demand for maternity beds. He suggested that priority for hospital beds should be given for (i) medical or obstetric reasons, including a large proportion of primigravidae and multiparae with four or more children, and (ii) adverse social conditions, especially bad housing. Hospitals were asked always to consult the Council on social conditions and always to consult the Council on the question of need whenever it is proposed to increase the number of maternity beds. The Council, through the divisional medical officers, is co-operating to the full. The effectiveness of the Minister's advice and the extent to which the hospital authorities consult the divisional medical officers will be assessed after the scheme has been working for a few months. 63 Midwives Act, 1951 During the year the Midwives Act, 1951, which consolidated, without amendment, the law contained in the Midwives Acts, 1902 to 1950, and repealed (with the exception of certain provisions of the 1936 Act) the previous legislation on this subject, became law. Notifications of intention to practise The number of notifications of intention to practise compared with previous years was:— 1948 1949 1950 1951 As midwives 1,213 1,252 1,275 1,337 As maternity nurses 289 242 241 205 An analysis of the notifications shows:— Midwives Maternity nurses Practising in hospitals 997 — Practising in nursing homes 18 47 London County Council domiciliary 124 — District nursing associations 95 — Hospital districts 91 — Nursing co-operations — 138 Independent 12 20 1,337 205 Notification to practise as a midwife includes practice as a maternity nurse. The Council, as local supervising authority under the Midwives Act, continued to inspect midwives and maternity nurses in accordance with the rules of the Central Midwives Board. The supervisors of midwives investigate all cases of puerperal pyrexia and of children with skin and eye affections. On five occasions midwives were suspended from practice for varying periods to prevent the spread of infection. Lectures, etc. to midwives Two courses each of six post-certificate lectures and 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 340 and for the demonstrations 41. Dangerous Drugs Regulations The Dangerous Drugs Regulations, 1950, provide that midwives can obtain supplies of medicinal opium, tincture of opium and pethidine only by 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 book. The Central Midwives Board requires that "a drug should not be used by a midwife on her own responsibility unless in the course of her obstetric training, whether before or after enrolment, she has been thoroughly instructed in its use and is familiar with its dosage and methods of administration or application." During the year two further lectures for midwives on the use of dangerous drugs were held at County Hall. 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, 1951, was:— By domiciliary midwives 6,324 By midwives in institutions with less than 15 beds and/or no R.M.O. 145 6,469 64 Some of the notices were for assistance for more than one condition. The following is a summary of the conditions for which aid was summoned:— (1) (2) Number of calls for medical aid for conditions as indicated Col. (1) expressed as a percentage of the 13,564 midwifery cases attended during the year by domiciliary midwives and midwives in small institutions (i) Conditions of pregnancy 1,533 11.30% (ii) Conditions during and immediately following labour 2,853 21.03% (iii) Conditions during puerperium 814 6.00% (iv) Conditions of the child 1,628 12.00% Fees paid under the Midwives Acts to medical practitioners called in by midwives in emergency were as follow:— 1948 1949 1950 1951 No. of claims 6,354 5,368 4,216 3,932 Amount £15,594 £15,829 £12,682 £12,042 The continued reduction in the number of claims received during the year may be attributed to the effect of the maternity medical services provided under the National Health Service Act, 1946, and, to a small degree, to a slight decline in the birth rate. Maternity medical service At the end of the year there were 501 (compared with 570 at the end of 1950) 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 1951 for maternity medical services. The figures quoted do not represent the total number of cases attended during the year as there is no time limit for the submission of claims for fees on maternity medical services and some claims were therefore received too late for inclusion in these figures. Maternity Medical Services Service provided Quarter Claims from general practitioner obstetricians Claims from genoral medical practitioners Totals Full 1949 1950 1951 1949 1950 1951 1949 1950 1951 March 482 671 612 89 100 99 571 771 711 June 428 573 553 73 93 85 501 666 638 September 582 649 493 72 92 44 654 741 537 December 990 587 603 51 73 52 1,041 660 655 2,482 2,480 2,261 285 358 280 2,767 2,838 2,541 Partial March 203 513 621 201 305 410 404 818 1,031 June 500 670 622 243 322 400 743 992 1,022 September 700 756 550 259 366 320 959 1,122 870 December 745 406 782 448 227 500 1,193 633 1,282 2,148 2,345 2,575 1,151 1,220 1,630 3,299 3,565 4,205 Emergency March 5 31 28 1 19 24 6 50 52 June 14 17 35 2 22 19 6 39 54 September 24 20 37 2 6 22 16 26 59 December 45 17 28 5 10 31 50 27 59 88 85 128 10 57 96 98 142 224 63 Full maternity medical service, for which a fee of £7 7s. 0d. is paid to general practitioner obstetricians or £5 5s. 0d. to other medical practitioners, entails the carrying-out of two ante-natal examinations, attendance at the confinement if necessary and availability for emergencies, together with the care of mother and child for fourteen days after confinement and a post-natal examination of the mother at about six weeks after the birth. Payment is also made, according to approved rates, for partial services, i.e., when the full maternity medical service is not given. The London Executive Council also pay for attendances by medical practitioners in emergency on unbooked maternity patients, where the practitioner is not called in by a midwife. HEALTH VISITING Each year more school nursing sisters obtain the health visitor's certificate and progress has been made in the gradual introduction of a combined health visiting and school nursing service. During the year, thirty-one health visitors have attended the routine refresher courses arranged by the Royal College of Nursing and the Women Public Health Officers' Association. Some health visitors attended a course on the teaching of parentcraft, arranged by these bodies. A large number of the health visiting staff also attended lectures arranged by the Council on the care of premature infants, and on marriage guidance and the family. Divisional nursing or assistant divisional nursing officers attended the summer school held by the Central Council for Health Education, the annual conference of the Women Public Health Officers' Association, the conference on Expert Committee on Nursing of the World Health Organisation and the conference for Superintendent Public Health Nurses, both arranged by the Royal College of Nursing. 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 these children are living have continued to be undertaken by health visitors designated as "child protection visitors." Towards the end of the year 616 foster-children were being supervised under these arrangements. HOME NURSING The home nursing service is provided on the Council's behalf by the voluntary district nursing organisations in the County, the Central Council for District Nursing in London acting as the liaison and advisory body. There are 24 District Nursing Associations, 2 religious denominational societies and the Ranyard Nurses acting in this capacity, and the number of nurses employed by them at the end of the year was 341 whole-time and 114 part-time, being the equivalent of 397 whole-time nurses, compared with 281 whole-time and 111 part-time at the end of 1950 (equivalent to 340 whole-time nurses). The district nurses made 1,452,410 visits in 1951 compared with 1,291,887 in 1950, and there were 8,284 patients still in nursing care at the end of the year. The average case-load of a nurse at any one time was 21 patients, and each nurse made an average of 13 visits daily. The chief details of the work done by the organisations on behalf of the Council during the year were:— Mid-year population (estimated) 3,358,000 Treatments commenced 53,008 Treatments completed 52,025 Treatments completed per 1,000 population 15.5 Total number of visits 1,452,410 Total visits per 1,000 population 432.5 66 The main conditions treated were:— Number Per cent. of total Infectious and parasitic diseases 1,824 3.5 Tuberculosis 2,034 3.9 Cancer and other neoplasms 2,346 4.5 Diabetes 1,376 2.6 Mental and other nervous diseases 597 1.1 Ear, and eye and other sense organs 3,169 6.1 Cerebral lesions of vascular origin 1,873 3.6 Heart and arteries 5,132 9.9 Veins and other circulatory diseases 618 1.2 Respiratory diseases 10,951 21.1 Digestive diseases 5,040 9.7 Genito-urinary 3,428 6.6 Pregnancy 669 1.3 Skin 4,855 9.3 Bones and organs of movement 1,136 2.2 Injuries 1,317 2.5 Other diseases or ill-defined 5,660 10.9 Patients were referred to the nursing organisations by various agencies as follows:— Number Per cent. of total By General practitioners 40,947 78.7 Hospitals 8,250 15.9 Public health authority. 690 1.3 Direct application 1,213 2.3 Chest clinics 925 1.8 The nursing of patients in their own homes is often made easier if special equipment and surgical appliances can be supplied, and there are also cases where, in order to ease the pressure on hospital beds, patients are discharged to their homes whilst still requiring the use of such equipment to assist their recovery. These patients are all referred to the district nursing service, and the equipment can be supplied by arrangement with the District Nursing Associations and the British Red Cross Society. A few large and expensive items are supplied direct by the Council. Experience has shown that the work of a district nurse can be more speedily carried out if instead of relying on public transport or a pedal cycle she can use a car to travel between cases. Most associations are not able to purchase a car from thenown resources, nor could those in better financial position obtain delivery of cars ordered. The Council therefore agreed to provide up to 25 cars to those associations whose work justified it, seven to be delivered during each of the financial years 1951-2, 1952-3 and 1953-4, and the balance in 1954-5. Any association obtaining a car under this scheme and subsequently acquiring one from its own resources will return the Council's car for use by another association. Up to the end of the year five cars had been provided, and they have proved of gre£t value to the associations concerned. The cars remain the Council's property. The associations pay only running costs, which rank for grant from the Council. In October, the Central Council for District Nursing in London organised an exhibition for the purpose of recruiting nurses to the district nursing service. The exhibition was held for a period of four days and was financially assisted by the Council to the extent of half the cost. Assistance was also given by way of the loan of equipment and by other services. Enquiries subsequently received indicate that the main object of the exhibition may to a large extent have been achieved. Several of the district nursing associations have found that the increased demands on their services, with consequent need to employ more staff, have rendered their existing nurses' homes no longer adequate for their purpose. The building of an 67 sion to one such home, and the adaptation of larger premises to replace another, have been approved and loans have been granted to the associations concerned, repayment of capital and interest ranking for grant from the Council. For another association the Duchy of Cornwall Estate have agreed to erect a building which can be used as a nurses' home to replace the scattered and inadequate premises now in use, and the Council will take a 60 years' lease of the new home and sub-let to the association. The Queen's Institute of District Nursing asked the Council to examine the possibility of establishing a block training scheme for student district nurses in London, whereby all lectures would be taken during the second month of training instead of being spread over six months as at present. It was felt, however, that since district nursing training is affected by discussions being held at national level it would not be opportune to embark on a reorganisation of such magnitude. Means are being considered of preventing the overcrowding at lecture centres which has been an unsatisfactory feature of the existing system. DOMESTIC HELP SERVICE Domestic assistance is provided by the Council under Sec. 29 of the National Health Service Act, 1946, which extended the powers previously exercised by the metropolitan borough councils and transferred them to the Council. Such service can be provided wherever it may be required owing to the presence of any person who is ill, lying-in, an expectant mother, mentally defective, aged, or a child not over school age. The growth of the service is shown by the following table:— 1949 1950 1951 Cases assisted 25,933 25,805 26,542 Hours worked 2,783,000 3,159,728 3,441,152 Home helps employed at end of year 2,310 2,525 2,663 Equivalent of whole-time staff 1,265 1,381 1,562 The service includes a small number of male home helps who are sent to selected homes, e.g., elderly men living alone who cannot wholly fend for themselves. The demand on the service and the extent to which it was met in 1951 is shown by the following. Maternity Other Applications received 2,992 15,837 Households attended:— (a) Completed periods of help 2,194 12,171 (b) Service incomplete at end of year 125 12,052 Some of the maternity patients were able to obtain other help and others who had anticipated a home confinement were in the event removed to hospital: there is therefore some disparity between the applications received and the cases helped which is not attributable to any failure of the home help service. Whilst every endeavour was made to provide some service to all the non-maternity patients, it was not possible to meet the whole demand even by a policy of "spreading the butter," and about 385 applications had to be refused because of inability to supply. Service for maternity patients is usually provided for two weeks of 44 hours : the average number of hours weekly for other patients was 5¼, which continued over an average period of 42 weeks. A charge is made for the service, varying from the full rate of 2s. 6d. an hour to free attendance. Assessments are based on a scale approved by the Council and the Ministry of Health. In November a short experimental course of instruction for home helps was organised by the National Institute of Houseworkers, Ltd., with assistance from the Council and on the recommendation of the Ministry of Health. From the experience 68 gained, it was felt that the practical work of the course was inappropriate for the housewives employed in the Council's domestic help service, and no decision to hold any further courses has been taken pending a further approach from the National Institute. IMMUNISATION AND VACCINATION Diphtheria Immunisation Diphtheria immunisation is carried out at child welfare centres, special immunisation clinics, day schools and residential establishments in London. When parents prefer their family doctor to immunise their children, general practitioners undertake the work and are paid a fee of 5s. for each completed record of immunisation sent to the Council. Material is supplied free of charge through the Ministry of Health's Public Health Laboratory Service. The total number of children immunised against diphtheria for the first time in 1951 under all these arrangements was 40,656, and in addition 22,908 "boosting" doses were given. The corresponding figures for 1950 were 46,689 and 27,579. There has been a steady decline since 1949 in the number of children receiving primary immunisation. This is most regrettable and methods of reversing the trend are under consideration. One reason for the decline is undoubtedly the publicity given to exaggerated reports of cases of paralysis following inoculation in 1949 and 1950: another is the low incidence of diphtheria, which, whilst itself resulting from the successful measures of immunisation, tends to produce apathy in parents to whom the old days of the diphtheria scourge were unknown. The attainment and maintenance of a high level of immunity in the child population is most urgent and essential. Residential establishments for children in London The visiting medical officer usually undertakes the immunisation of children in the Council's residential establishments in London, and the following table shows the position at the end of 1951:— Number Percentage of total Children fully immunised 596 73.6 Children in course of being immunised 28 3.5 Children awaiting immunisation 20 2.5 Parental consents awaited 75 9.2 Parental consents refused 44 5.4 Children not immunised for other reasons 47 5.8 Number of children on the roll 810 100 Residential establishments for children outside London The local health authority of the area in which the establishment is situated is responsible for making arrangements for the immunisation of children in the Council's residential establishments outside the County and for paying the fee of 5s. for each completed record received. record received. The position at 31st December, 1951, was:— Number Percentage of total Children fully immunised 3,557 82.0 Children in course of being immunised 114 2.6 Children awaiting immunisation 54 1.2 Parental consents awaited 257 5.9 Parental consents refused 128 3.0 Children not immunised for other reasons 227 5.3 Number of children on the roll 4,337 100 69 Whooping Cough Immunisation There is no comprehensive scheme in the County for this service, although a considerable amount of immunisation against whooping cough is carried out on request in immunisation clinics. Immunisation against whooping cough was carried out in some ot the Council s residential establishments by the visiting medical officers, and the following statement shows the position at the end of the year:— Establishments in London Out-County Establishments Children fully immunised 66 654 Children in course of being immunised 3 4 Children awaiting immunisation 122 11 Parental consents awaited 13 111 Parental consents refused 34 378 Children not immunised for other reasons 572 3,179 Number of children on the rolls 810 4,337 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 which 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, and the use of the combined antigen was not resumed in 1951. Vaccination Special sessions are held at child welfare centres for vaccination as for diphtheria immunisation. In addition, general practitioners carry out vaccination under the Council's arrangements, a fee of 5s. being paid for each completed record received. Lymph is supplied free of charge by the Ministry of Health through the Public Health Laboratory Service. The following table gives particulars of the number of persons who were vaccinated under these arrangements during 1951; corresponding figures for 1950 are shown in brackets:— Age at date of vaccination Under 1 year 1 to 4 years 5 to 14 years 15 or over Total Vaccinations 19,700 8,614 2,712 4,444 35,470 (16.768) (8,002) (1,314) (1,499) (27.583) Re-vaccinations 35 254 1,330 15,641 17.260 (281) (125) (382) (4,856) (5,644) One cast of generalised vaccinia occurred. One fatal case of post-vaccinal encephalomyelitis was reported, but the autopsy findings were not consistent with this diagnosis. Residential establishments for children in London The vaccinal state of the children in the Council's residential establishments London at 31st December, 1951. was:— Number Percentage of total Children vaccinated 400 49.4 Children awaiting vaccination 58 7.2 Parental consents awaited 104 12.8 Parental consents refused 95 11.7 Children not vaccinated for other reasons 153 18.9 Number of children on the roll 810 100 70 Residential establishments for children outside London The responsibility for the vaccination of children in the Council's residential establishments outside the County rests with the local health authority of the area in which the establishment is situated, the arrangements being similar to those for diphtheria immunisation. The position at 31st December, 1951, was:— Number Percentage of total Children vaccinated 2,487 57.4 Children awaiting vaccination 126 3.0 Parental consents awaited 268 6.1 Parental consents refused 178 4.1 Children not vaccinated for other reasons 1,278 29.4 Number of children on the roll 4,337 100 Fees to general practitioners The Brighton smallpox epidemic in January, 1951, resulted in a greatly increased number of vaccinations taking place not only in that area but also in London, where, in addition to a steady stream of adults and children presenting themselves for vaccination in the clinics, many of the hospitals vaccinated patients and members of the staff. An interesting outcome of the increased number of record cards received was the realisation that in times of epidemic a small authority might well be faced with a substantial bill in respect of 5s. record fees, many of which might relate to the vaccination of persons normally resident in other areas. This led in turn to consideration of the whole basis of payment for records by local health authorities, as a result of which discussions have been held with the County Councils Association and the Association of Municipal Corporations as a preliminary to further discussions with the Ministry of Health. Publicity A note on the publicity undertaken to encourage parents to have their children immunised and vaccinated will be found on page 81. LONDON AMBULANCE SERVICE This Service operates under the immediate supervision of Mr. A. G. Hellman, O.B.E., the Officer-in-Charge. Increase in demand As will be seen from the statistics on page 74, there was, during 1951, a further substantial increase in the demand for ambulance transport, the number of patients conveyed by the General Section of the Service rising to 550,621, against 480,048 in 1950, an increase of over 70,000 or nearly 15 per cent. Relatively, however, the increase in the number of journeys and the mileage—20,000 and 50,000, respectively—was not nearly so great, a fact which reflects the success of the efforts made, by decentralisation and other arrangements referred to below, to increase the efficiency of the Service and to make the most economic use possible of available resources. The upward trend of the number of calls on the Accident Section of the Service continued, also, the 1950 "record" of 83,791 calls being exceeded by more than 3,000. Decentralisation Reference was made in the reports for 1949 and 1950 to the substantial economies which had been affected by the "decentralisation" of the ambulance transport arrangements at a number of hospitals, i.e., by arranging 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 the various departments. These arrangements were extended during 1951 and they are now in operation at 32 hospitals and clinics throughout the County. 71 Train journeys The number of "ambulance-train-ambulance" journeys arranged during 1951 was 3,998—more than double the previous record figure of 1,975 for 1950. The arranging of journeys by these means adds greatly to the administrative work of the Service but against this must be set the very considerable economies effected in vehicle and man hours, to say nothing of the financial saving. I would again place on record my deep appreciation of the co-operation of the Railway Executive staffs who are invariably most helpful in making these arrangements and always most solicitous for the comfort and well-being of sick persons travelling bv rail. P.L.A. Police Ambulance Service During the year discussions were held and visits exchanged between officers of the Council and representatives of the Port of London Authority Police Ambulance Service to review and bring up to date the existing measures for co-operation between the two services. Festival of Britain By arrangement with the British Red Cross Society and the St. John Ambulance Brigade, direct telephone communication was established for the duration of the Festival between London Ambulance Service Headquarters Control Room and FirstAid Posts at the South Bank Exhibition and the Festival Gardens, Battersea Park. During the Festival 724 emergency ambulance calls were received on these telephone lines—416 to South Bank and 308 to Battersea Park. Major Accidents Of the many multiple calls answered by the Accident Section of the Service during 1951, the most serious was to an outbreak of fire in a warehouse adjoining Broad Street Railway Station on the night of 21st December, in which three firemen lost their lives and a number of others, including the Deputy Chief Officer of the London Fire Brigade, were seriously injured. Altogether 24 injured firemen were taken to hospital and very many more were given first-aid treatment in the standingby ambulances, after which they were able to resume their duties. Among other major accidents were:— July 11th—Derailment of train on "Peter Pan" railway at the festival Pleasure Gardens, Battersea Park. Seven casualties—one fatal—taken to hospital. August 26th—Bus and tram in collision outside Lambeth North Underground Railway Station—nineteen casualties taken to hospital. August 28th—Two buses in collision in Walworth Road. Thirty-one casualties taken to hospital. September 21st—Following the derailment of a train near Daventry, thirteen injured persons were met at Euston Station and conveyed to hospital. Recovery of Costs under the National Health Service (Amendment) Act, 1949 During the year discussions took place with representatives of the Middlesex and Surrey County Councils at which it was agreed, in principle, that claims as between those two authorities and the Council under section 24 of the National Health Service (Amendment) Act, 1949, should be settled by an annual lump sum payment. The payment was to be based on the difference between the mileage travelled by ambulances and sitting-case cars on work done for Middlesex and Surrey by London and vice versa and calculated at the nationally agreed rate per mile for each type of vehicle. Home Servic Ambulance Department Agency Arrangements Due, in the main, to the greater use made of the railways, the 1951 mileage figures for the Home Service Ambulance Department of the Joint Committee of the Order of St. John of Jerusalem and the British Red Cross Society, which mainly undertakes long distance journeys, again show a reduction—nearly 18,000 miles less 72 than in 1950. There was, however, a very appreciable increase in the number of patients conveyed (over 2,000 more than in 1950) due to the fact that towards the end of the year the department took over a proportion of the work at the Limb-fitting Centre of the Ministry of Pensions at Roehampton, which had previously been carried out by the Council's own vehicles. Hospital Car Service The statistics of work done by the County of London Hospital Car Service during 1951 also show a decrease in mileage but an increase in the number of patients conveyed and again this reflects the economy and increased efficiency achieved by the "decentralised" arrangements referred to earlier. The Hospital Car Service work of four of the London Teaching Hospitals was decentralised and the cars stationed at these hospitals conveyed on an average a total of more than 4,000 patients and travelled over 40,000 miles a month. West Ham County Borough Council The West Ham County Borough Council continued to provide ambulance services on behalf of the Council in the two parts of the Metropolitan Borough of Woolwich which lie north of the River Thames. Staff Owing to the continued difficulty experienced in obtaining suitable male ambulance drivers to fill vacancies in the Service, the Health Committee, in July, 1951, authorised the recruitment, in a temporary capacity, of women ambulance drivers and, by the end of the year 30 women had been so engaged. This has, in the main, accounted for the increase in the numbers of operative staff from 628 to 669. It has been decided that the duties of women shall normally be restricted to sitting-case removals although only those who are capable of assisting in lifting a stretcher patient, if called upon in an emergency, have been engaged. Women are particularly suitable for the type of work arising at hospitals with large out-patient departments, at which ambulances are stationed daily, because the majority of patients attending are able to travel sitting up and can assist themselves in and out of the ambulances. In accordance with the existing practice applied to male entrants to the Service, women are required to obtain within six months of engagement a recognised qualification in first-aid to the injured—London County Council certificate in first-aid to the injured, St. John Ambulance Association first-aid certificate or medallion, British Red Cross Society certificate, or St. Andrew's Ambulance Association certificate—and, before being allowed to act as attendants, must satisfy a medical officer of the department that they are competant to do so. All staff holding such a certificate are paid an additional 6s. a week, in accordance with a recommendation of the London District Council of the National Joint Council for Local Authorities' Services (Manual Workers). Following a recommendation of the Joint Council the Council authorised, with effect from 30th August, 1951, an increase of 7s. 4d. a week to members of the operative staff, thus bringing the wage of a driver/attendant, qualified in first-aid, to 137s. 10d. a week, apart from additional payment for such duties 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. 8 Superintendents (including one seconded for Civil Defence training). 7 Assistant Superintendents. 21 Station Officers (including two seconded as Civil Defence instructors). 669 Operative Staff (drivers and attendants). 73 Vehicles Altogether during the year 70 new vehicles were taken into commission (54 ambulances, 14 single-stretcher ambulances [used mainly for sitting patients] and 2 emergency tenders), while 57 vehicles (55 ambulances and 2 emergency tenders) were withdrawn from service. The programme of replacements for 1952/53 (the final stage of the second 3-year programme referred to in the report for 1949) has been amended in the light of experience gained of the need for more carrying capacity for sitting patients and, instead of the 40 new ambulances originally included in that programme, the Council has approved the acquisition of 15 small ambulances suitable mainly for sitting patients. In addition, 25 existing ambulances are to be adapted to accommodate either eight sitting or two recumbent patients. The vehicle strength at the end of the year was:— 320 ambulances of various types, 14 ambulance buses, 21 sitting-case cars, 2 emergency tenders. Publicity The work of the service and particularly that of the Accident Section was included in the "London Town" television programme on 31st March, 1951, on some aspects of the Council's activities. Road-safety Campaigns Facilities were given to the Press to photograph and describe some of the work of the Service in connection with articles designed to draw public attention to the mounting toll of road accidents. Introduction Civil Defence The Ministry of Health has stated that, in the event of war, the Council's expanded ambulance service would operate as a single integrated service for the conveyance of both war casualties and the ordinary sick. The peace-time establishment would form a nucleus around which expansion would take place in an emergency and it is considered that it is necessary to train 4,000 volunteers as members of the Ambulance Section in the County of London Division of the Civil Defence Corps in order to be prepared to meet an emergency. The strength of the Ambulance Section on 31st December, 1951, was 1,244 representing an increase of just over 300 volunteers since 31st December, 1950. The response to appeals for volunteers has been disappointing having regard to the heavy responsibilities of the ambulance service in war. Basic training All volunteers in the Ambulance Section receive training in basic general Civil Defence subjects which provides a background for them later when they are transferred to the County Council for Ambulance Section training. This basic training, which includes instruction on such general subjects as Civil Defence organisation and atomic, chemical and biological warfare, is given at local training centres by the Metropolitan borough councils, acting, so far as Ambulance Section volunteers are concerned, on behalf of the Council. The length of the basic general Civil Defence course is twentytwo hours and volunteers are generally able to complete this initial stage in their traininig in six months or less. Section training After completing their basic general training with the metropolitan borough councils, volunteers in the Ambulance Section are then transferred to the County Council for Special Ambulance Section training. This is given at one of the following six training centres:— North Western Ambulance Station, Lawn Road, Hampstead. Eastern Ambulance Station, Brooksby's Walk, Hackney. Brook Ambulance Station, Shooter's Hill Road, Greenwich. South Eastern Ambulance Station, New Cross Road, Deptford. "A" (Fulham) Accident Ambulance Station, Seagrave Road, Fulham. "E" (Kennington) Accident Ambulance Station, Foxley Road, Lambeth. 74 Courses are also held at Headquarters Ambulance Station, 142, Waterloo Road, Lambeth, and at County Hall. Ambulance Section training is classified under two main headings (1) First-aid training (2) Ambulance training. Ten first-aid courses have been completed and a further six have been arranged. 120 volunteers have passed the first-aid examination held at the end of each course and, when the six courses mentioned are completed in May, 1952, this figure should approach 200. After completing the ten weeks full firstaid course, volunteers then take a short (four weeks) practical first-aid revision course. Four of these courses have been arranged. One short course of Ambulance Section training has been completed and others are being arranged but the emphasis so far has been upon ensuring that, as far as possible, volunteers are fully trained in first-aid before progressing to ambulance work proper. Training of peace-time staff The first course of basic Civil Defence training for the peace-time operative staff of the Service was commenced on 19th February, 1951, when ten members of the operative staff attended a week's course. Forty-two courses have now been held and 386 members of the operative staff have been fully trained. Lectures are given by two Ambulance Station Officers who have been seconded for Civil Defence duties and who have attended one of the Home Office Civil Defence Schools and qualified as instructors. Conclusions Thus it will be seen that, while the peace-time operative staff who are fully qualified in first-aid and general ambulance work are undergoing basic general Civil Defence training, volunteers who have already completed their basic training with the metropolitan borough councils are receiving instruction in first-aid and ambulance duties so that, in the event of an emergency, both would be fully trained in the many and varied duties which the staff of an integrated ambulance service would be called upon to carry out. 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 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 are given in the following tables: Accident Section No. of calls No. of cases* Mileage 1938 56,318 58,196 293,166 1947 64,560 66,143 362,880 1948 66,373 67,676 367,627 1949 75,901 77,380 410,917 1950 83,791 85,376 437,416 1951 87,012 89,149 443,683 * No. of patients conveyed plus non-patient-oarrying journeys. An analysis of the calls reveals that the average time taken to reach the scene of a street accident was 7.2 minutes, the same as in 1950. 75 The numbers of patients conveyed, with comparative figures for 1950, were 1950 1951 Increase or decrease Street accidents 12.287 13,631 + 1,344 Other accidents 16,761 17,858 + 1,097 Assault cases 1,395 1,559 + 164 Attempted suicide 739 381 - 358 Mental 541 602 + 61 Epilepsy 1,373 1,379 + 6 Other sudden illness 16,865 17,873 + 1,008 Maternity 23,788 24,249 + 461 Analgesia apparatus delivered to women being confined at home 6,311 5,848 - 463 Special cases 298 363 + 65 Ambulance not required 5,018 5,406 + 388 85,376 89,149 + 3,773 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 1951 550,621 231,540 782,161 3,092,902 (ii) Agency and Supplementary Services Comparative statistics for 1948 and subsequent years are: Hospital Car Service Patients conveyed Mileage 1948 30,052 430,121 1949 107,667 1,496,090 1950 144,669 1,787,434 1951 149,046 1,740,930 Home Service Ambulance Department Patients conveyed Mileage 1948 5,454 204,048 1949 9,557 376,564 1950 7,966 281,223 1951 10,111 263,087 West Ham Ambulance Service Patients conveyed Mileage 1948 6 41 1949 113 1,468 1950 246 4,373 1951 208 3,338 The agreements with these bodies have been in operation only since 5th July, 1948 (the "appointed day" under the National Health Service Act, 1946). 76 PREVENTION OF ILLNESS: CARE AND AFTER-CARE Tuberculosis Throughout the year the Council has continued to provide facilities for the care and after-care of tuberculous patients and the prevention of tuberculosis as part of the National Health tuberculosis service, the diagnostic and therapeutic aspects of which are dealt with by the metropolitan regional hospital boards. Considerable, and sometimes complex, arrangements for integration of the services and liaison with the metropolitan regional hospital boards, the boards of governors of teaching hospitals, and hospital management committees have been necessary 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. In some of the larger boroughs there are two clinics, but some combinations of boroughs are served by one. These clinics had on their books on 31st December, 1951, 34,043 patients, of whom 30,459 were suffering from pulmonary tuberculosis. The medical staff, the radiographer and the physician's clerks are provided by the metropolitan regional hospital boards, which also maintain the premises and equipment. The Council rents from the hospital management committees the accommodation used by the staff it provides, which includes care organisers and their clerks, handicraft instructors and a number of tuberculosis health visitors who spend part of their time assisting the physicians in clinic work. The majority of the health visitors' time is spent in visiting patients in their homes to ascertain the domiciliary, social, and economic conditions under which the patients live, and where necessary, to endeavour to improve them. The aftercare organisers at the clinics are concerned with the patients' needs other than medical and nursing; they also act as the secretaries to the local tuberculosis care committees. Care committees The Divisional Tuberculosis Care Committees appointed by the Divisional Health Committees have continued their work of co-ordinating the activities of the Tuberculosis Care Committees, sub-committees or other groups of persons authorised by them to deal with tuberculosis care work in the divisions. Care organisers and local care committees The importance of relieving tuberculous patients of domestic, social, industrial and financial anxieties has always to be borne in mind, notwithstanding that necessitous tuberculous persons receive higher financial grants from the National Assistance Board than do other necessitous persons. This is the special province of the tuberculosis care committees and care organisers. In 1951, these officers made first investigations in respect of 6,383 patients; 2,343 newly assisted patients received extra nourishment; 553 were provided with beds and bedding; 687 were provided with nursing requisites; 1,019 were provided with clothing and 291 with other commodities. At the end of the year 1,537 tuberculous patients were receiving extra nourishment from the Council or care committee resources and 536 were receiving the services of home helps. In addition to arranging for the provision of food, clothing, etc., as outlined above, the Council's after-care organisers made arrangements, where possible, for better housing, more suitable employment, foster homes for child contacts, diversional therapy, and gave help or guidance in many other problems of personal or familv concern. Home care and treatment At the end of 1951, there were 773 tuberculous persons in London awaiting admission to hospital, compared with 1,513 at the end of the previous year. 658 patients (compared with 1,678 at the end of the previous year) were under special treatment in their own homes. Many of these were awaiting admission to hospital, but where the patient's domestic and home conditions permitted, chest clinic physicians introduced home treatment by rest, chemo-therapy, collapse therapy, or combinations of these forms of treatment. This involved the services of health visitors, home nurses and home helps, and the boarding-out of susceptible children from the homes to avoid the risk of infection or to reduce the domestic work while mothers were undergoing treatment at home. At the end of the year 408 patients were receiving attention by the Council's home nursing service. 77 The Council's ambulance service also rendered valuable assistance to the home treatment scheme by conveying many patients by car or ambulance from homes to clinics or hospitals for X-ray examinations, for lung collapse therapy, or associated minor surgical treatment. Homeless infective ambulant tuberculous men Towards the end of 1950 the Council made arrangements for the opening of a residential hostel for 35 working tuberculous men at premises which it owned at 20/22, Highbury Quadrant, Islington, N.5. Arrangements were also made for 40 homeless and severely disabled tuberculous men, unfit for work, to be accommodated in a private establishment, St. Catherine's Hostel, Sopwell House, St. Albans. On 26th February, 1951, the first 16 men were admitted to the St. Catherine's Hostel and at the end of the year there were 37 in residence. On 29th October, 1951, the Council's hostel at 20/22, Highbury Quadrant, N.5. was ready and the first men were admitted. At the end of the year 17 men were in residence. A charge in respect of accommodation in these hostels is made by the Council to the residents according to their means. Rehahihtation 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 considered too arduous. They may, however, be assisted to obtain new and more suitable employment by the local Disablement Resettlement Officer of the Ministry of Labour or by the local tuberculosis care committee. Selected patients are sent by the Council to "village settlements" where they undertake courses of instruction in work suitable to their capacity and temperament. At the end of 1951 the Council was financially responsible for 28 men and 2 women at the British Legion Village, Preston Hall, Nr. Maidstone; 14 men at Papworth Village Settlement, Nr. Cambridge; 5 men at the Enham Alamein Village Centre, Andover, Hants; and 2 men at East Lanes. Tuberculosis Colony, Barrowmore Hall, Nr. Chester. Considerable difficulty is experienced in finding suitable employment or training for severely disabled and potentially infective tuberculous patients (the "stable" chronics) and for these special "sheltered" workshops are urgently needed Boarding open-air schools Certain children with a history of early, incipient or healed tuberculous infection were admitted to boarding open-air schools for delicate children. No child with known "open" or infectious tuberculosis was, however, admitted. The schools maintained by the Council's Education Committee at the beginning of 1951 were:— Burrow Hill Colony School, Frimley. George Rainey School, St. Leonards-on-Sea. Swanley Residential School, White Oak Hospital, Swanley. Kathleen Schlesinger School, Nr. Henley. Wanstead House, Cliftonville, Margate. Bowden House School, Seaford. Wainwright Residential School, Broadstairs. These Schools provide 441 places for delicate children. In addition some children were accommodated in private boarding open-air schools. The total number of children with a history of primary tuberculosis accommodated in boarding open-air schools during 1951 was 57 (24 boys and 33 girls). At the end of the year 34 such children, (18 boys and 16 girls) were still in these schools. This is a service which provides suitable convalescence and educational facilities, in good surroundings, for children who need "building up" for several months to tide them over a "primary" infection. 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 because a parent or parents were receiving treatment for tuberculosis difficulties arose in arranging for the care of the children. In addition, boarding out was arranged in 78 connection with B.C.G. vaccination when it was thought necessary to segregate children from known cases of tuberculosis. The arrangements for boarding out were made on behalf of the Council by the Invalid Children's Aid Association. The average number boarded out at any one time during the year was 448. compared with between 130 and 140 before 1939, 180 in 1946, 230 in 1947, 257 in 1948, 326 in 1949, and 405 in 1950. The total number of children boarded out during the year was 949, of whom 556 were new cases and 393 were children whose stay extended from 1950. The number of children, included in these figures, who were segregated for the purpose of B.C.G. vaccination was 81. B.C.G. vaccination At the end of the year 445 children remained boarded out. The Council's scheme, which was initiated in September, 1950, for the B.C.G. (Bacillus Calmette-Guerin) vaccination of tuberculin negative contacts of a known case of tuberculosis, continued successfully throughout 1951. The number of contacts reported as having been vaccinated by London chest physicians during the year is 2,287, which, with the 271 vaccinations in the last quarter of 1950, gives a total of 2,558 dealt with since the commencement of the scheme. The continued co-operation in this scheme of out-county medical officers of health and chest physicians is gratefully acknowledged. 220 London child contacts boarded away from home were reported during 1951 as having been vaccinated with B.C.G., and the total to the end of 1951 was 262. Also 65 children, the majority of whom were new-born babies, were vaccinated in hospital prior to boarding out. During 1951, 81 children were boarded-out solely for segregation during vaccination, but it has been found that many of these could not return home after convert ing to Mantoux positive owing to adverse home conditions or to the mother becoming unfit to undertake the care of the child. Mass miniature radiography I am indebted to the four metropolitan regional hospital boards for the following 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 1951. It will be seen that a number of the diagnoses completed during 1951 related to persons X-rayed in 1950. Likewise a number of persons X-rayed during 1951 will remain under surveillance until a firm diagnosis becomes established in 1952. Men Women (1) Total number of persons X-rayed on miniature film during 1951 154,095 129,907 (2) Diagnostic classification of active tuberculosis pleted during 1951 of persons who were X-rayed in London during 1950 and 1951:— London residents 394 315 Non-London residents 156 99 In 1951, 57,794 civil service employees working in London were examined by the Ministry of Health's London mass X-ray unit; 240 (4.15 per thousand) had active lung tuberculosis requiring treatment or surveillance. Chest X-rays of 50,000 youths aged 18 years living in and around London called for medical examination before admission to the Armed Forces yielded 529 cases (10.6 per thousand) of apparently active lung tuberculosis. Foot Clinics The Council continued to administer twenty-six foot clinics which had been established by the metropolitan borough councils before 5th July, 1948. During 1951 the clinic at Ridgebrook Road, S.E.3 was closed, the sessions being transferred to the clinic at 105, Shooters Hill Road, S.E.3. In April, 1951, the committee set up by the Minister of Health under the chairmanship of Mr. V. Zachary Cope, M.D., M.S., F.R.C.S., published their report which recommended, inter alia, that "local 79 authorities should be enabled to provide chiropody in the National Health Service, possibly in the exercise of the powers of section 28 of the National Health Service Act, 1946." In view of this recommendation and of the continued pressure on the chiropody service, and the need for its extension to areas where no service is at present provided by the Council, the Minister was approached with a view to permission being given for a limited expansion to mitigate the hardship in certain parts of the County. He replied, however, that he could not see his way in the existing financial circumstances to authorise any extension of the service. The following are particulars of sessions, attendances, etc., for the year:— *Clinic Sessions New Cases Attendances Staff (In terms of wholetime units) 9,759 10,348 162,163 43.5 *Some sessions are attended by more than one chiropodist. The majority of treatments provided at the clinics are for superficial excrescences (corns, callosities, etc.) and malformed nails. Advice is given on shoe fitting, foot hygiene and exercises. Venereal Disease A summary of the work done in 1951 at the London V.D. clinics will be found in Table 29, page 156. Approximately 74 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. A large number of persons who were not suffering from venereal disease again attended the clinics. There was no appreciable change in the defaulter rate. The table below gives the number of patients completing treatment and of defaulters as shown by analysis of the returns from the clinics for 1951. Syphilis Gonorrhoea Male Female Male Female Number of patients discharged after completion of treatment and final tests of cure 840 721 2177 623 Number of patients who ceased to attend after completion of treatment but before final tests of cure 711 320 2088 414 Number of patients who ceased to attend before completion of treatment 235 208 316 63 Number of patients who died from the disease while still undergoing treatment 10 4 — — 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 were made available during 1950 for attendance at clinics at Holloway Prison and for following up contacts and prisoners on discharge. Good results were achieved during the initial trial period and, as it was apparent that there was scope for much more valuable work in this direction, arrangements were made for the appointment of a whole-time welfare officer to undertake the work. Ten 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. 80 Recuperative holidays The demand for recuperative holidays continued steadily hut the number of persons provided with such holidays were fewer than in the previous year, mainly due to the need of economy and the acceptance of only those where a recuperative holiday was really essential. Unaccompanied children Increased accommodation was made available at the Council's recuperative holiday home at Littlehampton for children between the ages of four and eight years, and parties of 30 children aged between seven and 15 years were sent during the year to private hotel accommodation under the Council's private hotel scheme. The services of voluntary organisations, such as the Invalid Children's Aid Association, Women's Voluntary Services, Jewish Board of Guardians, Children's Country Holiday Fund and the Wandsworth Peace Memorial, continued to be used for the provision of recuperative holidays for unaccompanied children. Special arrangements were made to send a limited number of educationally subnormal boys for a recuperative holiday. The Council's recuperative holiday home for children under the age of five years at Mavfield. Sussex, was closed on 30th April. 1951. Expectant and nursing mothers and accompanied young children and other adults The Council placed direct in recuperative holiday homes the majority of adults and accompanied young children, but the Family Welfare Association was used as a placing agency in a few especially difficult cases. The services of the St. Henry Convalescent Fund were also used for the provision of recuperative holidays for a small number of adults and accompanied children. The co-operation of the Spero Fund for the Welfare of Tuberculous Workers was continued in the placing of tuberculous persons in recuperative holiday homes. Further recuperative holiday home accommodation was approved during the year, particularly of the small private hotel type where suitable facilities were available. Two additional homes were approved for the reception of tuberculous persons recommended for recuperative holidays. The following is a statement of admissions to recuperative holiday homes during the year:— Unaccompanied children Expectant and nursing mothers and accompanied young children Other adults Under 5 years School children Mothers Children 1950 1548 4255 340 566 3439 1951 1309 8001 219 386 3154 Health Education The main health education effort continued to be that addressed to individuals and to small groups by the medical and health visiting staffs in the course of their normal duties. In addition, some maternity and child welfare centres have formed parents' clubs, and health talks, illustrated by films or film-strips, have been given to them in the evenings. The "silent" side of the work has continued with the use of the exhibition stands and topics of the Central Council for Health Education and of the posters and leaflets published by the several associations connected with the promotion of positive health. The various subjects, vaccination, accidents in the home, infectious diseases, etc., etc., are selected to suit local circumstances, and no attempt, apart from the intensive campaign against diphtheria, is made to synchronise displays in the county. This method allows elasticity and local initiative. 81 Diphtheria immunisation In May an intensive campaign to encourage parents to have their children immunised against diphtheria was carried out in conjunction with the Ministry of Health national campaign. There were special displays of posters, leaflets, slides in cinemas (by the co-operation of the owners), and advertisements in the local newspapers throughout the country. It is not possible to evaluate the results of these annual campaigns, but the need to maintain a high level of immunity amongst the child population is so essential, if we are to avoid a recurrence of diphtheria epidemics, that any increase in the numbers immunised is worthwhile. The mobile van in one division, which, during part of the summer, accompanied by a car fitted with a loudspeaker, tours busy streets and immunises children brought forward by their parents, does good work. The van has been made available to other divisions, but because of the "open air" waiting for parents and children its use is necessarilv restricted to fine weather. Exhibitions The department co-operated with the following metropolitan boroughs by the provision of exhibition material: Fulham: Health week (June 18th to 23rd) in the Lillie Road Recreation Ground. Woolwich: Civic exhibition at the Town Hall (Oct. 20th to 27th). Shoreditch: Civic week (August 7th to 11th). Facilities were granted to the B.B.C. for sound and television programmes dealing with the Council's work. Sex education The demand for talks to youth clubs, etc., on this subject was not so pronounced as in previous years, probably due to a smaller "turnover" in their memberships. There were 403 attendances at seven courses. Provision of care and treatment for the mentally ill MENTAL HEALTH SERVICES Lunacy and Mental Treatment Acts, 1890-1930. During the year the shortage of accommodation in observation wards continued to be the most disturbing feature of the work of placing under care persons suffering from mental illness. Before the war there were, in London, 353 beds in observation wards. Owing to bomb damage and other circumstances arising from the war there were 203 at the time of the transfer of the hospitals to the Minister of Health in July, 1948, At the end of 1951 there were 217. distributed as follows:— Observation ward accommodation Metropolitan Region Hospital Ntimber of beds Male Female Total South-East St. Francis 41 41 82 North-West St. Pancras 38 38 76 South-West St. John's 8 8 35 Fulham — 19 North-East St. Clement's 12 12 24 99 118 217 The following table shows the number of patients admitted to observation wards during 1931 and various years since:— Year Number of admissions Male Female. Total 1931 2,452 2,948 5,400 1939 2,462 2,936 5,398 1945 1,634 2,136 3,770 1946 1,980 2,545 4,525 1947 2,049 2,603 4,652 1950 2,399 3,163 5,562* 1951 2,488 3,303 5,791* *Includes 208 cases dealt with in 1950 and 911 in 1951 under sections 11 and 14 ot the Lunacy Act, 1890, elsewhere than in an observation ward. As will be seen, the number of admissions dropped very considerably during the war but has since progressively increased, and in 1950 was almost 50 per cent. higher than at the end of the war and a little higher than the pre-war figure. 82 The existing observation ward accommodation is quite inadequate, and since July, 1948, it has frequently not been possible for all patients who would in normal circumstances have been admitted to an observation ward to be so dealt with. In order to deal with the patients for whom no accommodation was available, it has been necessary, contrary to the Council's scheme under section 51 of the National Health Service Act, 1946, either to admit them direct to mental hospitals by urgency orders under section 11 of the Lunacy Act, 1890, or to bring them before a Justice in their own homes or in general hospitals under section 14 and then, if the orders were made, to admit them direct to mental hospitals. During the past year 261 male and 669 female patients were dealt with by these means. A large percentage (about 45 per cent.) of the patients admitted to observation wards are found not to require subsequent admission to a mental hospital under the Lunacy or Mental Treatment Acts. It would seem not unlikely, therefore, that some of the patients admitted direct to mental hospitals might have been found not to need mental hospital treatment if they had been admitted to an observation ward. In such cases, the patients and their relatives are caused pain and anxiety which might have been avoided. The shortage of accommodation at Tooting Bec hospital was a considerable contributory factor in the shortage of accommodation in observation wards, since beds in these wards were blocked by senile patients waiting admission to that hospital. Some relief was afforded, however, towards the end of the year by the provision of additional accommodation for elderly mental patients at Abbots Langley hospital by the North West Metropolitan Regional Hospital Board for patients residing in that Region. In view of the serious shortage of beds in observation wards, the Minister of Health was asked to receive a deputation from the Council to hear their views on the question. This was arranged on 12th December, 1951. All aspects of the problem of the shortage of accommodation for mental patients were discussed with the Minister, who undertook to investigate all the points made by the deputation and see what could be done. (See also page 86.) Two additional mental welfare officers were appointed during the year making a total of 17 mental welfare officers and five assistants under the supervision of a senior mental welfare officer. The service, which operates on a 24 hour day basis continuously throughout the year, has continued to work centrally from the County Hall. The following table shows the number of persons dealt with by the mental welfare officers during the year, together with the action taken:— 1951 1950 Male Female Total Admitted to hospitals designated under Section 20 of the Lunacy Act, 1890 (i.e., for observation) 2,205 2,675 4,880 5,294 Dealt with in their own homes, etc., under sections 14 and 16 of the Lunacy Act, 1890 273 617 890* 223† Admitted direct to mental hospitals under Section II of the Lunacy Act, 1890 10 11 21 45 Dealt with under Section 24 of the Criminal Justice Act, 1948 3 No action under the Lunacy Acts found necessary 662 940 1,602 1,827 Total 3,150 4,243 7,393 7,392 * Of these 144 male and 323 female patients were certified and removed to mental hospitals. † Of these 9 male and 110 female patients were certified and removed to mental hospitals. 83 The following table shows the ultimate disposal of the patients admitted to observation wards (including 171 patients in wards on 1.1.51):— 1951 1950 Male Female Total Certified and sent to mental hospitals Admitted to mental hospitals as voluntary patients 558 455 1,204 554 1,762 1,009 1,879 1,013 Admitted to mental hospitals as temporary patients 7 21 28 35 Discharged to care of relatives (Section 22) 19 24 43 56 No order made by Justice and discharged 80 38 118 27 Transferred to general wards 82 66 148 210 Transferred to Tooting Bec. Hospital 137 140 277 463 Transferred to Abbots Langley hospital 6 21 27 — Transferred to Mental After Care Association homes 2 1 3 4 Died 121 87 208 255 Discharged by Medical Officer 701 537 1,238 1,157 Dealt with privately 3 10 13 17 Dealt with under Mental Deficiency Acts 5 5 10 7 In ward on 31.12.51 72 95 167 171 Total 2,248 2,803 5,051 5,294 Recuperative holidays and long-term residential care Recuperative holidays of an average duration of 3 weeks 4 days were provided for 93 persons suffering or recovering from psychiatric illness, compared with the provision of holidays for 59 such persons during 1950. Most of the holidays were provided in homes sponsored or maintained by the Mental After Care Association but in 35 cases this special accommodation was not needed and the holidays were provided in other selected holiday homes. The average weekly cost of maintenance was approximately £3 a head. During the year the number of persons placed in Mental After Care Association homes for long term care had risen from 55 to 65. Most of these are elderly persons needing residential care on account of comparatively mild psychiatric illness and not requiring skilled nursing attention or medical treatment. The weekly charge made by the Mental After Care Association in respect of all persons maintained in the Association's homes has remained at 54s. 10d. a head throughout the year. Visits have been made by a psychiatric social worker employed by the Council to all the homes sponsored and maintained by the Mental After Care Association and in addition several of the homes have been visited by the Council's Medical Adviser on mental health. Conditions generally were found to be satisfactory and the patients well-cared for and happy. After care The scheme for the domiciliary visitation of mentally sick persons resident in London requiring help and advice continued to be carried out on the Council's behalf, by social workers of the Mental After Care Association and the National Association for Mental Health and a grant of 90 per cent. of the cost of the service was paid to each Association. 230 new cases were visited during the year making a total of 957 persons visited since the scheme began in May, 1949. During the year the scheme made by the Charity Commissioners for the regulation of Queen Adelaide's Fund, a charity administered in two branches, one for London and one for Middlesex, for the benefit of certain persons who have suffered from mental illness, was revised. The Hospital Management Committees responsible for the administration of mental hospitals in the four Metropolitan Hospital Regions have nominated persons to disburse the income of the fund (on the imprest system) on behalf of the Trustees, two of whom are appointed by the Council. As the National Association for Mental Health and the Mental After Care Association at present carry out the Council's after care scheme, they have been asked to refer 84 eligible cases direct to the nominated persons, but in fact no eligible persons needing assistance were brought to notice during the year. The Council made a further contribution of £200 to the National Association for Mental Health in recognition of the Association's various general services in the field of mental health for which the Association receives no specific payment from local health authorities. The Institute of Social Psychiatry again received a grant of 90 per cent. of the cost of the occupation centre and the five psychotherapeutic social clubs administered by the Institute to benefit mentally sick persons living in the community and needing social readjustment. Medical Adviser on mental health Dr. A. A. W. Petrie, C.B.E., retired on 31st March, 1951, and was succeeded by Dr. J. A. Herd, M.D., Ch.B., D.P.M., D.I.H., as part-time medical adviser on mental health. His duties with the Council include advice on all matters relating to mental health (except those relating to child guidance and mental deficiency), the medical supervision of the work of the mental welfare officers and of the care and after care services for persons suffering from psychiatric illness. 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:— Sources of information 1948 1949 1950 1951 Totals from 1.4.14 to 31.12.51 Supervision section 15 8 12 8 1,561 Local education authority 389 357 439 453 14,983 Police Authority (Section 8) 32 28 39 31 1,941 Transfers from Prison (Section 9) 1 1 1 229 Transfers from approved school (Section 9) 3 5 2 2 565 From hospitals and institutions 87 111 89 103 390 Miscellaneous 140 168 157 187 10,300 Total 667 678 739 784 29,969 Position at 31st December, 1951, with regard to the cases referred to in the last column of the preceding table, together with the position on the same date in the three preceding years:— 1948 1949 1950 1951 Detained in institutions 7,671* 7,720* 7,767* 7,809* Discharged from institutional care 2,393 2,584 2,738 2,902 Removed to Mental Hospitals 495 509 522 543 Not subject for action 8,818 9,098 9,403 9,668 Died 4,119 4,251 4,380 4,523 Total removed from active list 23,496 24,162 24,810 25,445 Under guardianship 330 246 229 221 In places of safety awaiting the presentation of a petition 6 11 5 8 Under supervision 3,853† 3.964† 4.092† 4,222† In institutions awaiting the presentation of a petition 21 54 45 52 Still under consideration 62 9 4 21 Total remaining on active list 4,272‡ 4,284‡ 4,375‡ 4,524‡ Grand Total 27,768 28,446 29,185 29,969 * This figure includes cases on licence who are visited at regular intervals by officers of the Council on behalf of the Regional hospital boards as follows:— 1948 1949 1950 1951 353 338 366 352 † In addition to the cases under supervision persons known to the local authority to be mentally defective but not subject to bo dealt with, are visited on a voluntary basis. 1948 1949 1950 1951 999 970 968 1,020 ‡ Of these the following were awaiting institutional care. 1948 1949 1950 1951 70 135 139 154 85 Summary of cases dealt with during 1951, with the comparable figures for the three preceding years:— 1948 1949 1950 1951 Placed in institutions 341 293 330 303 Placed under guardianship 44 12 9 10 Placed in places of safety pending the presentation of a petition 29 23 37 56 Placed under supervision 420 453 591 618 Discharged from institutional care or guardianship 173 212 192 182 Removed to mental hospital under the Lunacy Acts 17 22 19 27 Ascertained not subject for action 262 51 58 68 Withdrawn from supervision — 238 258 217 Removed to other areas — 40 44 49 Died 122 111 128 140 Total 1,408 1,455 1,666 1,670 Students During the year facilities were given for 10 students taking courses of training in social science to spend periods up to four weeks in the district offices of the supervision section to enable them to gain practical experience in social work. Supervision The work of supervising mentally defective persons in their own homes has continued to be carried out from four district offices. On 31st December, 1951, there were 4,221 persons under statutory supervision and 352 patients on licence from institutions whom it had been arranged for the Council's officers to visit on behalf of the hospitals. A total of 18,941 visits were paid in these cases. The success of supervision depends to a great extent on the atmosphere in a patient's home and the attitude of the parents and other members of the family. It is necessary to gain the confidence of the family and the patient if supervision is to be. effective. The Mental Deficiency Acts, whilst imposing the duty of providing supervision upon the local health authority, do not provide any specific means for enforcing it against parental wishes, perhaps because in any case where this becomes necessary supervision may be considered to have already failed in its purpose. In addition to seeing that the patient is well cared for and under suitable control, help and advice are given when necessary on medical treatment, employment and occupation, insurance and pension problems, enrolment on the Register of Disabled Persons and other matters. Mentally defective persons under statutory supervision are debarred from holding motor driving licences. During the year a number of cases have been brought to notice where defectives have obtained provisional or permanent driving licences. Several of these have surrendered their licences when the position has been explained to them or their parents. Others have been specially re-examined with a view to ascertaining their present mental condition and, where the circumstances have justified it, the licensing department has been advised to take steps to withdraw the licence. Mental defectives under supervision are exempt from compulsory National Service and action is taken to prevent their call up. During the year the father of a severely mentally defective child under statutory supervision received a calling up notice as a "Z" reservist. Considerable hardship would have been caused by the father's absence from home and he was given documentary evidence that he was providing an essential part of the care necessary for his child. The calling up notice was cancelled. In other similar cases it was found possible to arrange for the child to be temporarily accommodated in an institution during the period of the father's military service. In addition to the cases under statutory supervision 1,020 cases were visited on a voluntary basis normally about once a year, but more often if necessary, and given any necessary help and advice. 1,959 visits were paid on behalf of hospital management committees and other local health authorities to ascertain the home circumstances of patients in connection with the statutory re-consideration of orders and the consideration of applications for leave of absence or discharge from orders under the Mental Deficiency Acts. 86 Farm training In July, 1951, approval was given to a scheme whereby suitable boys under supervision could receive training on farms under the Y.M.C.A.'s "British Boys for British Farms" arrangements. Under the scheme boys leaving special schools who are keen to undertake farm work and are mentally and physically fit to do so may be given training in elementary agricultural work and subsequently found employment. When necessary, assistance can be given in the provision of clothing to enable the boy to undergo the training. Unfortunately no boys suitable for placing under the scheme have been found up to the end of the year. Accommodation During the year, the list of patients waiting admission to institutions continued to increase. Before the war 9,476 beds were available in the Council's own mental deficiency institutions for London patients. Owing to war damage and other causes, the number was reduced to 8,519 by July, 1948. In consequence of the re-allocation of the accommodation by the four Metropolitan Regional Hospital Boards, 25 per cent. of the vacancies arising in these institutions was allocated to other local health authorities and London's allocation was correspondingly reduced. The number of London cases waiting admission increased from 40 in July, 1948, to 154 at the end of December, 1951; of these 117 were infants and young children of the type suitable for admission to the Fountain Hospital. The present resources of the Fountain Hospital, which serves a part of Surrey as well as the whole of London, are quite inadequate to meet the needs. If more accommodation for infants and young children could be provided, London's problem of accommodating mentally defective patients would be largely solved, since the waiting time for other types is not very long and vacancies for really urgent cases can usually be obtained without undue delay. Opportunity was taken when the deputation from the Council waited on the Minister of Health on 12th December. 1951, (see page 82). to impress these difficulties upon him. The decision of the South West Metropolitan Regional Hospital Board, referred to in the report for 1950, that patients from other Metropolitan Regions should not be admitted to the Fountain Hospital unless the Regional Board concerned arranged for the transfer of an older patient from the Fountain Hospital to another hospital in exchange, resulted at first in the proportion of admissions from the South West Metropolitan Region being higher than from the other Metropolitan Regions, but after the initial stages admissions from the four Metropolitan Regions became more nearly uniform as had been anticipated. During the year some relief has been afforded by the admission of ten children (three from St. Lawrence's Hospital and seven from the Fountain Hospital waiting lists) to approved homes. As in the previous year it was possible to secure the admission of a number of children to the holiday home (Lynsted) at Walmer provided by the National Association for Mental Health for periods generally not exceeding six weeks, to provide some relief to the parents. The cost of maintenance of the children was defrayed by the appropriate Metropolitan Regional Hospital Board. During the year the Management Committee of the Fountain Hospital agreed to admit a number of patients awaiting permanent admission to that hospital for short periods without formality to assist parents during periods of particular difficulty, e.g., whilst the mother was in hospital or to enable parents to have a much needed holiday. The attendance of children at the Council's occupation centres has undoubtedly helped to relieve the pressure on institutional accommodation. Three children awaiting admission did so well at the centres that their parents withdrew requests for their admission to institutions and there is no doubt that in many other cases attendance at an occupation centre has provided much relief to parents. Guardianship Of the 221 cases remaining under guardianship on 31st December, 1951, 34 were under the personal guardianship of the Council's Inspectors, 69 under the guardianship 87 of nominees of the Guardianship Society, Brighton, 104 under the guardianship of relatives and friends, and 14 under the guardianship of superintendents of voluntary homes. Patients under guardianship in London (including 19 for whom other local health authorities were responsible), continued to be visted not less frequently than once a quarter, every third quarterly visit being made by one of the Council's medical officers. In addition to the statutory visits and reports made by the officers of the Guardianship Society each London patient in the care of a nominee of that organisation was visited, unannounced, by an inspector of the Public Health Department at least once during the year. The conditions of guardianship were found generally to be satisfactory. Maintenance costs have continued to increase during the year. As in previous years, holidays have been provided for patients for whom it has been considered necessary 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 extras at Christmas. Occupation centres During the year two occupation centres for children (St. Margaret's House, Bethnal Green and Unity Hall, Poplar), were closed and the children from both centres were transferred to larger and more convenient premises at St. Michael and All Angels' Hall, Clapton, thus reducing the total number of centres to 17. The centre at St. Peter's Hall, Wandsworth, was transferred to larger premises at Earlsfield Congregational Hall, Wandsworth. It is expected that the building of the additional classroom at the Branstone Street centre referred to in the last report, will be completed early in 1952. Further increases in accommodation will probably be required in 1952 which may necessitate the replacement of centres in inadequate premises and possibly the opening of additional ones. The following is a list of the existing occupation centres for mentally deficient persons living in the community under .guardianship or under supervision or on licence from institutions:— Address No. on roll (Dec. 1951) Average daily attendance {Dec. 1951) Address No. on roll (Dec. 1951) Average daily attendance (Dec. 1951) Ventres for children Branstone St., 62 53 N. Kensington, W.10 (also takes elder girls) Cecil Rooms 35 25 Woolwich Road, S.E.10 Christ Church Hall, 41 27 Mowll St. S.W.9 Claremont Central Mission, 52 44 White Lion St., N.l. Earlsfield Congregational Hall, 51 43 Earlsfield Road, S.W.18 (replacing St Peter's Hall) Lewisham Methodist Hall, 25 19 Albion Way, S.E.13 London Mission Methodist Hall, 27 22 Shepherds Bush Rd., W.6 Orchard Mission, 29 22 Mission Place. S.E.15 Oxford House, 27 21 Mape St., E.2 St. Michael's and All Angel's 59 47 Hall, Northwold Road, E.5 (replacing St. Margaret's House and Unity Hall) Centres for elder girls Fellowship Hall, 27 25 182, Hammersmith Rd., W.6 Old Gravel Pit Hall, 29 24 Valette St., E.9 St. Chrysostom's Hall, 42 36 Goldsmith Rd., S.E.15 Centres for elder boys All Saints' Hall, 45 41 Blenheim Grove, S.E.15 19, Compton Terrace, N.l 28 22 Dalston Congregational Hall, 36 28 Bay St., E.8 St. Michael's Hall, 28 25 Darley Rd., S.W.11 Total 643 524 88 In December, 1950, there were 553 on roll and the average daily attendance was 439. Permanent Centre The Minister of Health approved a proposal to adapt a large house, No. 9, Spencer Park, Wandsworth Common, for use as an occupation centre for juniors to replace the centre now at Earlsfield Congregational Hall, but shortage of materials will probably delay the execution of the work. Students Eight students (5 women and 3 men) attending the full-time course of training for occupation centre staff organised by the National Association for Mental Health each spent six weeks in a London centre as part of their practical training. Centre and students both benefit from the facilities given. Inspections Visits by Inspectors of the Board of Control were paid to all centres during the year and their reports were generally satifactory. Members of the Health (Mental Health Sub-) Committee also visited centres in their areas. Rules for sales Rules governing the sale of articles made in the centres were approved. Open days Parents and friends were invited to displays of work and sales of articles made at the centres. Sales realised £37 2s. 4d. at junior centres, £297 10s. 9d. at elder boys' centres and £84 11s. 4d. at elder girls' centres. At the elder boys' centres some apparatus, furniture and toys were also made for the occupation centre service. Outings and holidays Owing to the absence of adequate outdoor recreation space at the centres, those attending were again taken by school bus to nearby parks or open spaces approximately once a fortnight during the summer months when the weather was suitable. During May a party of 185 children and adults attending the centres, accompanied by staff, spent two weeks at a holiday camp at Dymchurch, Kent. The Council bore the expenses of the staff and wholly or partly those of 29 necessitous children. The holiday was a great success. Letters of thanks were received from parents and the Director of the Camp expressed his appreciation of the way the party was organised, and the behaviour of the children. A similar holidav is to take nlace in 1952. Conveyances for children By the release of two redundant vehicles from another branch of the Council's service, it was possible to commence in September the conveyance of children to the Branstone Street centre. Gifts Several gifts, including toys and games from America and food parcels from Australia, were received and distributed to the centres. Christmas Parties Christmas parties and entertainments were arranged for all centres during December. SCHOOL HEALTH SERVICE Organisation The school health service for the County of London is, with other health services, for purposes of routine administration, organised on a divisional basis. 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. The School Care Committees took their share in the work of supervising the health and general well-being of the school children. Care Committee representatives were present at 94 per cent. of the medical inspections and 92 per cent. of the children needing treatment received it. The number of voluntary care workers is still rising and has now reached 2,150. During the year an officer of the Special Services Branch of the Ministry of Education inspected the school health service and in September the Minister of Education, having studied the report, sent his congratulations on the good work that was being done for the health and welfare of London's children through the Council's school health service. As the service had had time to recover from the effects of the war and the National Health Service had been established for three years, the Minister made a number of suggestions which were still under consideration at the end of the year. 89 Pupils on school rolls At the end of 1951 there were 290,335 children of primary and secondary school age in County schools, 98.545 in voluntary or assisted schools, 10,196 in nursery schools or classes and (5,471 in day special schools ; a total of 405,547 pupils. Medical Inspections Medical inspections made during the year, with comparable figures for the three previous years, are summarised in the following table:— Routine (detailed) Inspections 1948 1949 1950 1951 No. % No. % No. % No. % Nursery 8.953 5.7 10,021 6.2 11,294 6.5 12,320 7.1 Entrants 37,793 23.8 40,287 24.8 41,598 24.1 45,324 26.1 7 year old 26,222 16.5 29,541 18.2 32,607 18.9 34,597 10.9 11 year old 32,961 20.8 31,725 19.6 33,037 19.2 31,415 18.1 Leavers 26,817 16.9 26,382 16.3 27,464 15.9 27,272 15.7 Other ages 23,558 14.9 22,115 13.6 23,742 13.8 19,952 11.5 Special schools 1,581 1.0 1,633 1.0 2.143 1.3 2,215 1.3 Training colleges 648 0.4 465 0.3 543 0.3 533 0.3 Total 158,533 100.0 162,169 100.0 172,428 100.0 173,628 100.0 Other Inspections Speoial inspections* 107,844 — 110,026 — 119,901 — 122,302 — Re-inspections 88,243 — 87,915 — 106,350 — 112,667 — Residential schools 7,920 — 9,845 — 10,44! — 9,961 — Total 204,007 — 207,786 — 236,692 — 244,930 — Grand Total 362.540 — 369,955 — 409,120 — 418,558 — * These are non-routine inspections of a miscellaneous nature and include pupils urgently brought to the attention of the school doctor, inspections for employment certificates, for school journeys and holiday camps, admissions to special schools, periodical inspections of handicapped pupils (for their special defect), etc. The school population is still expanding under the influence of the post-war rise in the birth-rate and as a result medical inspections in 1951 reached the highest total since the war. Children seen at routine inspections formed 42.8 per cent. of the total of 405,547 on school rolls. The percentages of these children who were referred for treatment (other than for infestation or teeth) compared with the preceding years were:— Pupils referred for treatment Age Group and Sex 1948 1949 1950 1951 Nursory Boys 16.2 16.5 15.1 16.4 Girls 14.4 14.5 13.0 14.4 Entrants Boys 19.1 18.7 17.8 17.4 Girls 16.5 17.2 16.5 15.3 7 years old Boys 21.8 21.6 20.4 19.8 Girls 21.2 20.6 19.7 18.6 11 years old Boys 19.0 18.8 17.5 16.5 Girls 21.4 20.4 18.8 18.2 Leavers Boys 14.8 14.4 13.6 12.2 Girls 20.3 18.9 16.0 16.6 Other ages Boys 19.6 18.0 17.1 16.1 Girls 23.3 23.6 21.5 21.7 Total Boys and Girls* 19.3 18.9 17.6 17.0 * Exclusive of special schools and training colleges. 90 Referral rates in 1951 were generally lower in all age groups except nursery boys and girls. The following table shows the percentages of the principal defects found in children of all age groups inspected at routine inspections and referred for treatment or observation, with comparable figures for 1948, 1949 and 1950:— *Numbers examined 1948 1949 1950 1951 156,304 160,071 169,742 170,880 Percentages Skin diseases 1.22 1.22 0.97 1.13 External eye diseases 0.61 0.58 0.57 0.71 Defective hearing 0.39 0.41 0.44 0.51 Otitis media 0.70 0.75 0.69 0.87 Enlarged tonsils and adenoids ... 816 8.91 8.98 8.44 Defective speech 0.53 0.62 0.60 0.63 Enlarged cervical glands 1.01 1.33 1.38 1.67 Heart and circulation 0.73 0.68 0.69 0.80 Lung disease (not T.B.) 1.30 1.44 1.62 1.95 Orthopædic defects 4.67 4.66 4.84 4.52 Defects of nervous system 0.30 0.34 0.33 0.31 Psychological defects 0.72 0.75 0.70 0.72 Anaemia 0.29 0.31 0.36 0.33 * Excluding special schools and training colleges. Increased incidence in nursery, entrant and 7 year old groups was mainly responsible for higher rates for skin and external eye diseases, enlarged cervical glands, lung disease (not T.B.) and heart disease. Higher rates for otitis media were found in all age groups except " leavers," and defective hearing rates were higher among nursery children of each sex and slightly higher in entrant and 7 year old girls. The decrease in the incidence of enlarged tonsils and adenoids was common to all groups except nursery children. The reduced figure for orthopaedic defects was due to lower rates for all groups of boys and for nursery and leaver girls. Nutrition Classification of general condition as found at routine medical inspections A—Good B—Fair C—Poor 1948 40.8 56.0 3.2 1949 41.8 55.1 3.1 1950 46.3 50.9 2.8 1951 47.6 49.8 2.6 The percentages of children referred for treatment or observation on account of nutrition were:— 1948 % 1949 % 1950 % 1951 % Referred for (1) Treatment 1.0 1.0 1.0 0.9 (2) Observation 0.5 0.7 0.7 0.8 Total 1.5 1.7 1.7 1.7 Although the proportion of children classified as of "poor" general condition has diminished gradually in the years under review, it must be remembered that this assessment is subjective and the apparent improvement is not paralleled by a corresponding reduction in the percentage of children referred for treatment or observation on account of nutritional defects. Cleanliness Percentages of children found to have vermin in the hair at routine inspections during 1951, with corresponding figures for 1948, 1949 and 1950, follow:— 91 Percentage with Verminous Heads 1948 1949 1950 1951 Entrants Boys 0.3 0.2 0.2 0.1 Girls 0.7 0.4 0.2 0.1 7 year old Boys 0.4 0.3 0.1 0.1 Girls 1.2 0.4 0.3 0.2 11 year old Boys 0.4 0.2 0.2 0.1 Girls 10 0.7 0.4 0.3 All ages Boys 0.3 0.2 0.1 01 Girls 0.9 0.5 0.3 0.2 Improvement in personal hygiene continued in 1951. As parents are warned in advance, the personal hygiene of pupils as shown by the result of routine inspection is inevitably better than would be shown by surprise inspections, although it would be difficult for parents to remove all traces of persistent neglect at very short notice. Confirmation of this improvement is given by the percentage of verminous children found at nurses' rota visits:— Rota Visits Total number of inspections Number found to be verminous Percentage found to be verminous 1948 1949 1950 1951 Boys 478,648 6,589 2.1 1.9 1.7 1.4 Girls 515,541 21,113 6.4 6.1 5.0 4.1 Infants 537,229 11,797 3.9 3.4 2.7 2.2 Total 1,531,418 39,499 4.2 3.8 3.2 2.6 During the year the number of children found to be verminous at these inspections as distinct from the number of occasions on which vermin was found (in which one child might appear more than once) was 18,503 (22,159 in 1950, 22,063 in 1949 and 29,970 in 1948). Children who attended a cleansing centre after the issue of advice cards numbered 16,938 (20,269 in 1950) and the number of advice cards issued during the year was 25,177 compared with 29,305 in 1950. The number of statutory notices served was 3,848 (4,759); 1,084 (1,405) of the children concerned attended voluntarily and 2,089 (2,567) were cleansed compulsorily. Only 7 of 170,880 pupils inspected at routine medical inspections had body vermin. Vaccination The upward trend in the proportion of pupils vaccinated against smallpox noted in the past four years was interrupted, the percentage falling from 56.5 per cent. in 1950 to 55.8 per cent. in 1951. Diphtheria immunisation Pupils stated to have been immunised against diphtheria formed 85.5 per cent. of those seen at routine inspections in 1951; 85.9 per cent. in 1950, 84.4 per cent. in 1949 and 83.1 per cent. in 1948. Dental standard With the omission of nursery children, the percentages of pupils in the different age groups found at routine medical inspections to have defective teeth are shown below:— 1948 % 1949 % 1950 % 1951 % Entrants 27.6 26.7 27.3 27.8 7 year old 26.3 25.6 26.3 26.6 11 year old 16.7 10.3 18.5 20.4 Leavers 12.7 12.8 11.3 12.2 Other ages 17.4 17.6 17.4 17.2 Although these figures do not provide as reliable an index as the more exacting inspections by school dental surgeons, they can be used for comparative purposes. For entrants and seven and eleven year old groups, the percentages of children with 92 defective teeth continued the upward trend noted last year. A more detailed commentary will be found in the report of the Chief Dental Officer (page 110). Vision Statistics of the standard of visual acuity of pupils tested at routine inspections are contained in the table below:— Visual acuity—Percentage with normal vision (6/6) (with glasses, if worn) 1948 % 1949 % 1950 % 1951 % 7 year old Boys 79.2 78.2 78.3 77.8 Girls 78.2 76.5 76.3 76.7 11 year old Boys 81.7 80.1 80.9 80.3 Girls 78.1 76.9 77.9 77.0 1948 % 1949 % 1950 % 1951 % Leavers Boys 80°9 79.7 80.1 80.7 Girls 76.7 76 0 76.5 761 Other ages Boys 81.2 77.4 78.8 79.8 Girls 76.4 73.4 75.2 75.0 A further table shows the percentage of children referred for treatment of defective vision:— 1948 % 1949 % 1950 % Already wearing spectacles 1951 Percentage not wearing spectacles Total 7 year old Boys 7.4 6.8 7.2 0.7 6.3 7.0 Girls 7.4 7.5 7.5 0.8 6.7 7.5 11 year old Boys 8.9 9.3 8.4 2.1 6.5 8.6 Girls 11.1 10.4 10.0 2.6 7.4 10.0 Leavers Boys 9.5 9.3 9.2 2.8 5.8 8.6 Girls 12.2 12.4 10.8 3.8 7.5 11.3 Other ages Boys 9.8 9.3 8.5 2.0 5.3 7.3 Girls 12.0 12.0 10.8 3.4 7.8 11.2 A proportion of those referred for treatment of defective vision were already wearing spectacles. 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 were thus almost wholly due to the need for adjustment of lenses with the passage of time. The two tables above show that, in 1951, the incidence of defective vision and the percentage of pupils referred for treatment of defective vision remained fairly stable compared with the preceding years. As experienced over many years the recorded 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 percentage of pupils of all ages referred for treatment of squint was 0.5 per cent. compared with 0.9 per cent. in 1950, 1.1 per cent. in 1949 and 1.0 per cent. in 1948. 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. Care committee representatives attended about 94 per cent. of the routine inspections, except for the "leaver" and "other ages" groups. These latter include the grammar and technical schools where the committees do not function. Choice of employment Children advised against particular forms of employment formed 17.6 per cent. of both sexes examined, the highest proportion recorded in the last few years. This increased figure is due apparently to the more closely defined categories of contraindications, as comparison of separate classifications does not support the view that there has been a real deterioration in the standard of school leavers. 93 Eye strain and defective vision, followed by heavy manual work, again headed the list of contra-indications for both sexes. Next came exposure to bad weather and prolonged standing or quick movement for boys, while for girls this order was reversed. Details are given in Table 15 (page 150). Following-up and re-inspection The following-up 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 by the school doctor a few months after medical inspection, to allow time for treatment to be carried out, and further re-inspections are made, if necessary, to ensure that as far as possible every child gets adequate treatment. During the year, 112,667 re-inspections were made. The number of defects for which children were re-insnected were:— No. of medical defects No. of dental defects Total defects First re-inspections 23,602 23,996 47,598 Second and subsequent re-inspections 30,339 18,796 49,135 53,941 42,792 96,733 At the time of re-inspection, treatment had either already been obtained, or had been started, in the following percentages of cases:— 1948 1949 1950 1951 Excluding dental defects 89.4 90.2 90.3 92.1 Including dental defects 87.0 87.3 87.5 88.7 Treatment centres Medical treatment At the end of 1951 there were 96 school treatment centres; 66 of them were directly run by the Council and 30 by voluntary 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:— Defect L.C.C. No. of Clinics Voluntary Total Minor ailments 53 26 79 Dental 30 16 46 Vision 23 16 39 Orthoptic 8 — 8 Ear, nose and throat 8 5 13 Audiology 9 — 9 Speech therapy 20 3 23 Consultative 8 — 8 Nutrition 21 8 29 Rheumatism (supervisory) 11 5 16 Special sessions at hospitals In addition, 27 hospitals continued to provide special sessions for the medical and dental treatment of school children. (See page 98 concerning hospital authorities and specialist services.) 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 ailment* 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 Hospital (1) City Road—Eyes and orthoptic (2) High Holborn—Eyes and orthoptic G 94 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 St. George's Hospital Rheumatism St. George's in the East Hospital Aural St. Mary's Hospital Aural St. Mary Abbott's Hospital Aural St. Thomas's Hospital Rheumatism University College Hospital Enuresis Western Ophthalmic Hospital Eyes Westminster (All-Saints Genito Urinary) Enuresis Whittington Aural 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, Evelina, Paddington, 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. There were in addition several hospitals where the treatment organiser undertook the making of appointments for the dental and the 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. 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 children's care organisation:— Summary of work of Care organisers attached to Guy's Hospital in the year 1951 Eyes Children's Dept. Ear, nose and throat General Orthoptic Orthopaedic Skin New school children seen 332 566 215 86 152 224 Attendances of current cases 1,096 984 — 704 274 567 Discharged—treatment completed 130 254 59 43 86 66 Referred to other departments 101 24 — — 21 3 Lapsed through non-attendance — — — — — — Referred for operation — 256 — — 23 — Glasses ordered — — 337 — — — Glasses obtained — — 348* — — — No glasses needed — — 141 — — — Re-tested—no change of glasses — — 224 — — — Referred to Child Guidance Clinic 42 — — — — — * Includes spectacles ordered in 1950 the delivery of which was delayed until 1951. The total number of attendances of L.C.C. children in departments of this hospital covered by the organisers was 6,591. 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 2,172, and at the Queen Elizabeth Hospital, where the total number of attendances was 5,913. 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 1951, except at minor ailment centres, dental centres and rheumatism supervisory centres. A more detailed account of 95 Treatment statistics dental work in 1951 is given in the report of the Chief Dental Officer; and the rheumatism scheme is treated in some detail in a later part of this report. Type of Centre 1948 1949 1950 1951 Vision and orthoptic New cases 31,377 32,292 33,404 35,666 Attendances 77,517 79,777 98,109 102,143 Ear, nose and throat New cases 4,972 5,843 6,974 7,289 Attendances 11,922 14,815 15,138 16,565 Minor ailments New cases 170,181 171,731 163,658 155,080 Attendances 1,052,081 1,002,051 1,014,155 1,005,549 Dental New cases 118,439 102,495 82,650 82,564 Attendances 236,175 203,523 166,874 172,063 Rheumatism New cases 1,468 1,375 1,224 1,100 Attendances 10,505 10,887 10,088 9,202 Enuresis New cases 86 830 911 1,267 Attendances 441 3,977 5,110 6,344 Nutrition New cases 1,178 1,222 1,350 1,380 Attendances 8,452 9,420 10,067 10,984 Scabies, impetigo and ringworm Children treated for scabies totalled 777, compared with 916 in 1950. The number of verminous children treated at bathing centres fell by 414 to 18,987, while treatments needed decreased by 5,281 to 28,829. Cases of impetigo treated at minor ailment and bathing centres numbered 2,224 compared with 2,607 in 1950. Scalp ringworm although having a greater incidence (40 cases) than in the previous year (27) was still comparatively rare. Enuresis The two sessions a week at Westminster Hospital (All Saints' Genito-Urinary Department) for pupils referred from Council schools suffering from enuresis were increased to three sessions a week in January. The year's figures were:— New cases seen 607 Attendance of old cases 2,421 Total attendances 3,028 Discharged dry 85 Lapsed, sufficiently improved to satisfy parents 127 Boys formed about 65 per cent. of the total. Similar arrangements also continued with the University College Hospital. At the six clinics established by the Council 516 pupils attended regularly during the year; of these 187 (36 per cent.) were cured, 203 (39 per cent.) improved and 126 (25 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. 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. The arrangements were continued under which the Royal National Orthopaedic Hospital repaired at short notice the surgical appliances (except artificial limbs) of children in London schools for the physically handicapped who had difficulty in getting repairs made. 96 Relatione with the National Health Service Transfer of specialist clinics Clinics situated in hospitals had been taken over by the hospitals themselves on 5th July, 1948. During 1951 negotiations were continued with each of the four metropolitan regional hospital boards for the take-over of rheumatism, ear, nose and throat, vision and orthoptic clinics not in hospitals. The boards took over responsibility for provision and payment of the specialists at these clinics, and for provision of spectacles. The clinics for which the Council remains completely responsible are the minor ailmeDts, audiology, consultative, nutrition and dental clinics, and the bathing centres. The Council and the appropriate board divide the responsibility for those child guidance units which are conducted in Council premises. While assumption of responsibilities by hospital authorities relieves the ratepayer of certain burdens and enables the school health service to concentrate on the preventive and positive health aspects of the work, it may not always be easy to ensure that the school children receive as effective care as before the change. The school health services were specially designed for the children (and their parents). Under the National Health Service, there will be competing claims from other sections of the community. To economise, hospital management committees may feel it necessary to move, integrate with adult clinics or even close certain clinics. The regional hospital boards, however, appreciate fully the needs of the children and such steps would be taken only after full consultation. To maintain effective liaison with the schools, medical social workers ("treatment organisers") from the school health service attend clinics, arrange appointments (see page 95), ensure that recommended treatment is carried out and generally develop social care work arising from the clinic visit. Minor ailment clinics During 1950 the attendances at these clinics rose slightly, but during 1951 there was a slight decrease. A further reduction in the hours of opening was made releasing nurses and doctors for other work. Consultative and reference clinics One of the difficulties always to be faced by the assistant medical officer is that in the school he so frequently has neither sufficient time nor suitable accommodation to examine some children as thoroughly as he would wish. The minor ailment clinic, serving as it does a group of schools, could, like the infant welfare clinic with which it should be associated in a health centre, become the centre of school health work in the area, but the historic development of the school health service in London has hitherto precluded this useful development. During the year several of the divisions have been able to move a step towards the grouping of these services by arranging for assistant medical officers to have a session in the minor ailment clinics where they can more thoroughly examine children previously seen in schools. Other divisions have special "consultative" clinics to which the medical officer may refer a child. By the end of 1951 there were eight such consultative clinics functioning. Too much attention should not be paid to the name of any clinic, for "enuresis" and "nutrition" clinics have also been used for this purpose. There is clearly a need for a service of this kind; in the new schools with their medical suites the work can be done, where it should be, in the school. In our older schools something else is required and experiment may give the most satisfactory answer. Audiology clinics During the year these clinics have been increased and there is now one clinic in each division. Older children are referred after failing two gramophone and one pure-tone audiometer tests carried out by a school nursing sister, for investigation of suspected deafness not obviously due to conditions requiring treatment, while younger children may be sent direct from any doctor. Advice is given on the need for special educational treatment and the provision of hearing aids. As the clinics are advisory in function, the specialists are employed by the Council. Special investigation, Vitamin B.12 After a pilot experiment in boarding open-air schools in 1950, a further investigation was carried out in the day open-air schools. The children were divided into two groups, one group receiving 10 mg. of vitamin B.12 daily and the other a similar tablet containing only sugar. It is sufficient to say that after eight weeks no difference of any kind could be observed by any method of analysis between the progress of 97 the two groups. A full report by B. Benjamin and G. D. Pirrie on this investigation was published in The Medical Officer, 87.137 (5 April, 1952). Children overseas Thirteen London children with asthma were sent to Manx in Switzerland in October, 1950, through the generosity of the Swiss Economic Council, who raised funds for this purpose in Switzerland. These children returned to their homes during the spring and summer. Generally they made good physical progress and were free from asthma while they were away. As they had been carefully selected, on the basis that they had relapsed badly after being at open-air schools, it is not surprising that home conditions did not always permit of the same good health on their return from Malix. Six months after their return the following results were noted:— Free from asthma (cured) 2 Substantially improved 5 Unchanged 6 It is noteworthy that the two girls who continued almost free from asthma both came from families rehoused outside London whilst the children were away. Many of the children lost weight as quickly as they had gained it and several are now again in day or boarding open-air schools. Seven London children recovering from pulmonary tuberculosis were part of a group of twelve sent in February, 1951, to Leysin by the Swiss Economic Council for six months. They did quite well during their stay but it is doubtful whether there was great advantage in such a step compared with stay in a boarding open-air school in this country. Two boys with asthma were, by the generosity of the Rt. Hon. Winston S. Churchill, included in a party of Birmingham children who went to the Christian-Kunzle Home at Davos for six months in July, 1951. Both have had asthma since their return in January, 1952, and have been re-admitted to open-air schools. It is quite clear that, while a stay in Switzerland offers a period of freedom from asthma and an opportunity for good physical development which will always be of advantage, the return to the old environment with its causes, physical or psychological that precipitated an attack in the past, will be likely to reproduce the same chain of events in the future; Switzerland can provide no certain cure for a child with asthma, but by careful selection of children who do not respond to treatment here, a great deal of lmnrovement can be sained. Follow-up by school health service of children discharged from hospital The arrangements for forwarding discharge reports in respect of child in-patients from the former L.C.C. hospitals by means of a special "follow-up" card were continued. In addition certain hospitals make use of a specially printed carbonbacked form by means of which a copy of the discharge summary is sent to the divisional medical officer and to the family doctor. Other hospitals send to the divisional medical officer a copy of the report sent by them to the family doctor. Co-operation with family doctor The school health service co-operates with the family doctor as well as with hospitals in the care of the school child. The practitioner is given the opportunity of himself making the arrangements, if he prefers to do so, for the investigation or treatment of any defects disclosed at school medical inspections. In the vast majority of cases the family doctor prefers to allow the school health service to make the arrangements. Speech therapy At the end of 1951 there were 23 speech therapy clinics for children attending ordinary schools. The staff, including 3 speech therapists recently added to the staff, consisted of 1 senior speech therapist, 4 whole-time speech therapists, and 4 part-time speech therapists, under the supervision of Dr. Copithorne, a senior assistant medical officer. The number of new cases attending clinics during the year was 206. 118 children were discharged cured, and 56, most of whom were improved, ceased to attend for various reasons. The number of children remaining under treatment at the end of December, 1951, was 536. The number on the waiting list was 296. 98 During the year 22 clinics have been opened in connection with the special E.S.N, schools. The number of children treated was 205, 20 children were discharged improved, and 7 ceased treatment for various reasons. The number remaining under treatment was 178. This has shown itself to be rewarding work. Results are obtained that are valuable though the rate of progress is slower in most cases than in those attending the clinics for normal school children. The clinics for E.S.N, schools have brought to particular notice some children whose main handicap appears to have been some degree of deafness, and some children have so improved in speech as to be able to give a more accurate account of themselves when their intelligence is being assessed. A new development has been the treatment of children too severely handicapped to attend school and who are receiving tuition at home. Four were visited by therapists and advice has been given to the parents and teachers. The children will continue to be visited at intervals. To further the very necessary co-operation betweeen the school and the speech therapist, a pamphlet has been produced for the guidance of the teacher and the care organiser. That this has proved to be valuable is evident from reports from the schools. Remedial exercise classes A course tor interested teachers and assistant medical officers was given at the L.C.C. College of Physical Education in the autumn by Dr. Doris Baker and the senior inspectors of physical education of the Education Officer's department. The arrangements are that one medical officer in each division is responsible for the selection of children for the class and their discharge on improvement and general supervision. Dr. Doris Baker visits each class at least once a year. The classes are held mainly in primary schools, mostly for children in their last year in the school, and are taken by a class teacher who has attended the course. While there is a general shortage of teachers in primary schools, this means considerable rearrangement of the work of the whole school while the daily class is being held. It says much for the interest of all concerned that there were 74 classes in operation at the end of 1951. It had been hoped to supplement the work of the teachers by the employment of some part-time remedial gymnasts, but the present economic conditions make this impossible. Handicapped children 6,660 examinations of children were made during the year with a view to ascertaining either the need for special educational treatment or for its continuance. The number of examinations in each category was as follows:— Vision 250 Hearing 251 Epilepsy 50 Educational subnormality 2,656 Delicate (i.e. suitable for open-air education) 1.994 Physically handicapped 549 Dual defects 41 Speech defects 869 In addition, 305 children were considered with regard to the need for special educational treatment as maladjusted pupils and 9 as diabetic pupils. Tables 16 to 24 in the atmendix show the results of the above examinations. Accommodation Day Special Schools Defect No. of schools Roll Partially sighted 6 414 Deaf 4 348 Partially deaf 4 87 Physically handicapped 19 1,497 Delicate 10 1,292 E.S.N. 24 2,911 67 6,549 99 Boarding Special Schools Defect No. of schools Accommodation Roll Boarding Day Blind 2 80 30 76 Deaf and partially deaf 3 152 62 152 Physically handicapped 2 119 — 110 Delicate 7 431 — 390 Educationally subnormal 6 548 — 482 Diabetic 1 40 — 41 Maladjusted 5 165 — 123 26 1.535 92 1.374 * Including Rayners for dual defects. In addition to the handicapped children in the Council's own boarding special schools there were at the end of the year 877 of the Council's children in non-Council boarding special schools catering for the following handicaps:— Blind 52 Partially sighted 4 Deaf and partially deaf 42 Physically handicapped 47 Delicate 214 Educationally subnormal 83 Epileptic 64 Maladjusted 366 Speech defect (Moor House) 5 877 Epileptic children At the beginning of the year arrangements were made for an assistant medical officer, Dr. Margaret Fynne, to see all epileptic children who were considered to be likely to need special education. This arrangement better enables a standard of the need for boarding school education to be maintained and allows of more thorough preliminary enquiries from general practitioners and hospitals. Above all the medical officer can devote part of her time to interviewing the staffs of ordinary schools that are to be asked to accept epileptic children. Centralisation of this nature is undesirable, but, while what is in effect a new approach to the problem is being worked out, it serves a useful pupose. The proper place for an epileptic child is in his home and in a day school, but, to secure this, effective treatment must be maintained and the co-operation of teaching staffs, other children in the school and their parents secured. Only uncontrollable epileptics and those in whom control is being established need to be in special boarding schools. The presence of a nurse, even for part of the day, in day schools for P.H. children is a great help and, could the nurse be there for the whole day, it would be possible for some more seriously affected epileptic children to attend these schools rather than go to boarding schools. During the year Dr. Fynne attended a course organised by the British Epilepsy Association and later addressed divisional representatives of the social-medical workers, and the divisional nursing officers. Partially sighted children The Council's day schools for the partially sighted were visited during the year by Dr. C. B. Huss of the Ministry of Education. Dr. Huss reported that he was impressed with the excellent manner in which ophthalmic records were kept. In the case of the myopes in particular, who formed by far the greatest number of children in the schools, full fundus changes had been recorded, increase in these changes noted, anxiety felt about any child expressed and results of consultations with teachers recorded. Thus it was possible to follow what was in the ophthalmic surgeon's mind at the time of the examination and so to understand the reason why any child 100 whom one might have thought of as borderline for admission to a blind school, or return to an ordinary school, was instead being retained in the special school. Dr. Huss observed that the heads of the schools appeared to have been consulted regularly about children, a practice which he considered an essential point in arriving at a decision in some cases when one was in doubt as to what was best for the child as regards the visual defect only. He felt that due weight should be given to the educational aspect. The policy in London to admit a young child to a partially-sighted school rather than to a school for the blind was, in Dr. Huss's opinion, the correct one. It was, he considered, often difficult or impossible for the ophthalmic surgeon to ascertain the magnitude of the visual defect from which a young child might be suffering. It was only as the child grew older, and as it learned by attendance at the special school for partially sighted, that an accurate assessment of the extent of the visual defect first became possible, and then it was so often found that placement in a partially sighted school had been the correct procedure. Dr. Huss added that H.M.I. Mr. Lumsden had examined many children newly admitted to the schools, and many who were near the blind borderline, and had found no reason to disagree with the classification as partially sighted from the educational aspect. It seemed to Dr. Huss that ascertainment of children with visual defects of such a degree that they required special educational treatment in partially sighted schools was accurate and probably complete in London, and that the children in these special schools were correctly placed. He also commented on the incidence of children who have been ascertained to be partially sighted, which for London is 0.83 per thousand children on the school register. Residential schools There were seven residential schools with accommodation for about 2,800 children committed to the care of the Council under the Children Acts. A visiting medical officer attended each school 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 437 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 two reception homes providing accommodation for 80 children, four 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. Infectious diseases in schools The number of infectious cases reported from the day schools during the year is shown in Table 14, page 149. 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 Measles Whooping Cough Chickenpox Mumps Poliomyelitis Other diseases Total 23 303 353 72 330 133 37 723 1,974 101 Mile Oak Approved School— scarlet fever outbreak When necessary, special visits were made by assistant school medical officers. An outbreak of scarlet fever took place in the latter half of November, 11 cases being notified. The medical officer of health of the area stated that the disease had been prevalent in the district before that time, and he had little doubt that the infection was introduced to the school from this source. After the main outbreak there was a pause of more than a week, but the occurrence of two more cases raised the possibility of a continuing source of infection, and it was decided to ask the public health laboratory at Brighton to investigate. Swabs were taken from the nose and throat of all children and staff. By this time the infecting strain of organism in the patients removed to hospital had been identified as hæmolytic streptococcus, Group "C," a comparatively uncommon variety. The result of the swabbing was that a fair number were found to be harbouring hæmolytic streptoccoci, but only 9 were carrying the Group "C" variety. Further reports from the laboratory indicated that only two of the Group "C" carriers were likely to be dangerous to others. Both were throat carriers, and they were isolated and treated with penicillin. The finding of only nine persons in the school with the epidemic strain seemed to justify the expectation that more general spread of the disease was unlikely, and this hope was fulfilled. Medical rooms Difficulties still continue in many schools in the facilities for medical inspections. Medical rooms are not available at all schools and consequently the inspections have to be held sometimes in halls, classrooms or other rooms. With the cooperation of the teaching staff, every endeavour has been made to overcome the difficulties. Steps have been taken to improve matters in the worst schools by structural alterations, improvements of washing facilities, better lighting and heating. Owing to financial considerations it has been possible, so far, to deal with only a limited number of schools, but the policy will be continued. Provision of meals The following information was supplied by the Chief Officer of the Restaurants and Catering Department:— Between October, 1950, and October, 1951, the number of centres at which school children dined rose from 854 to 878; the number of kitchens of all kinds in October, 1951, producing school meals being 577 (including 534 school and central kitchens). The school meals service aimed at concentrating the maximum food value into the quantity of food a child was willing to eat. It set itself the following standard:— Age group No. of calories (i) Under 7 years Minimum of 500 (ii) 7-11 years 650 (iii) Over 11 vears 800 Meals for children in Group (iii) were planned to contain a minimum of 20 grammes of first class protein; a minimum of 25 grammes of fat; and a minimum of 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 38). Audiometric testing During the year audiometric testing was extended to cover all the nine health divisions of the County. Eight sets of apparatus were available, Divisions 2 and 3 sharing. 102 The children were first tested on a group testing gramophone audiometer, by means of which up to 40 children can be tested at the same time. Those failing were again tested by the same method, to eliminate any who failed the first time through lack of attention and other causes. Children who failed the second gramophone test were then tested individually by a pure tone audiometer and those who failed were referred to see an otologist at the audiology centre (see page 00). During 1951 over 30,000 children were tested in this way, and the value of consecutive "screening" in reducing to a minimum the number of children that need be referred to an otologist is shown by the fact that although 25 per cent. failed the first gramophone test, only 6 per cent. (of the original number tested) failed the second gramophone test, and only two-thirds of these (i.e. 4 per cent. of the original number tested) failed the pure-tone test and were referred to an otologist. Rheumatism scheme The decrease in the number of children nominated for institutional treatment, noticed in the two previous years, continued in 1951, and tends to suggest that Dr. Glover's dictum of twenty years ago that "rheumatism is an obsolescent disease" might be true; nevertheless, in spite of the fact that the severity of the disease seems less than in the past, its crippling tendency and late manifestations play a prominent part in the total amount of illness and absenteeism from work in later life. For this reason alone we need to guard against being lulled into a false sense of security by failing to attempt to follow up and eradicate the causes of the condition. In fact, it is by attention to these causes, rather than to the treatment of the established condition, that we shall eventually hope to stamp out the disease. The preventive aspects of the work must always be kept in the forefront of our approach to the problem, and the success of the work will be measured by the number of persons prevented from developing carditis, rather than by the number of carditis cases treated. For this reason it is interesting to see that the percentage of cases in which there was no cardiac involvement remained reasonably and encouragingly high (see Table 28); and the numbers returned as fit for ordinary school or ordinary employment were well maintained (see Table 26). Of late years the number of children suffering from chorea of such severity as to need institutional treatment has fallen, and there seems some seasonal variation in the prevalence of their recurrence. Taken month by month, the numbers increase in the months of February and March, and again in October and, as usual, the condition is seen to occur more frequently in girls than in boys. It might be suggested that in the susceptible child the female sex is more sensitive to the trigger action of emotional shock or psychological stress, but the age group incidence does not suggest the possibility that the strain of scholarship examinations plays a very prominent part in deciding the time of onset. The hereditary factor still seems an important feature in deciding which members of the community are likely to develop the disease, and in assessing this, the work of the organisers and care committee workers, from whom reports are obtained of the family history and home conditions, is of much value and is greatly appreciated; while the active co-operation of the borough medical officers of health enables a good deal of headway to be made in correcting some of the deplorable housing conditions with which some of our children have to contend. Whenever possible an attempt is made to improve the local environment before a patient returns from institutional treatment, so that the liability of recurrence is lessened. Recent work on the surgery of the heart and great vessels has led us to review our cardiac cases more critically in the last few years, while the possibilities of mitral valvulotomy opens a fresh field of hope for some cases that have in the past seemed doomed to early and progressive congestive failure. Tables 25 to 28 (page 154) give details of this service. 103 Child Psychiatry By the end of 1951, the Council had three child guidance units, statistics for which are given below. The demand for the services of psychiatrists for children shows no sign of declining. In the autumn of 1950, the Battersea and Earl's Court Child Guidance Units moved to suitable premises, and on 1st October, 1951, a new child guidance unit was opened at Brixton in the rebuilt premises of the old Brixton Dispensary. Child guidance unit statistics Brixton (opened 1.10.51) Battersea Earl's Court Total Number of applications received 61 57 102 220 Number awaiting first interview at 31st December 6 10 31 47 Number interviewed and awaiting treatment — 14 2 16 Number of Patients In treatment at 1st January — 22 25 47 New 45 53 80 178 45 75 105 225 In treatment at 31st December 41 22 44 107 Discharged 4 53 61 118 Disposal of patients* Seen but not treated (diagnosis and advice only) 2 12 18 32 Placed or placement recommended — 11 6 17 Further attendance impossible — 4 3 7 Transferred to other treatment 2 1 2 5 Unco-operative — — 4 4 Treatment completed — 25 43 68 Total patients 4 53 61 118 Closing status of completed cases Recovered — 12 15 27 Improved — 9 19 28 No change — 4 9 13 Worse — — — — — 25 43 68 * In the case of Earl's Court the disposal classifications are not mutually exclusive and a patient may appear under more than one of these headings. Brixton' Child Guidance Unit The accommodation is most suitable for the purpose and the organisation is of interest. As in the other units, the premises are provided and maintained by the public health department, which also provides the secretarial staff (two) and the two whole-time psychiatric social workers, while the education department provides the two educational psychologists. In the other two units the psychiatrists are provided by the regional hospital boards, but at Brixton, the Institute of Psychiatry (Maudsley Hospital) has seconded Dr. W. Warren to be the medical director, with a whole-time senior registrar to assist him. In addition seven postgraduate students of child psychiatry work here for six months at a time, each spending four days in each week at the unit. It is considered that the stimulus of working with a postgraduate teaching hospital and the need to train more child psychiatrists outweigh any disadvantages arising from changes in the staff. The following is an extract of the medical director's report:— 104 "Patients can reach the unit fairly easily (important for mothers with young children); the Problem Case Conferences of Divisions 8 and 9 have been regularly attended by members of the unit staff; knowledge of the district is quickly growing; visits to homes and schools have been paid without undue loss of time. At a later date research by the unit on social matters may be facilitated." Referral of patients "There was at first an inevitable delay in the referral of patients, and the optimum case load cannot vet be assessed. The 44 patients taken on this year for treatment were referred by the following agents:— No. of Cases General practitioner 18 Problem Cases Conference 17 School (direct) 2 E.S.N, school (direct) 2 Maternity and child welfare centre 2 Central office 1 General hospital 1 Parent (direct) 1 44 The sources of referral are of interest for a number of reasons, and seem worth careful analysis in future years. A preliminary impression is gained that patients referred by the Problem Cases Conference are amongst the more serious and longstanding problems seen here, more so on the whole than patients referred from other sources. Further observation of this is necessary. Clinical routine and teaching "It has been arranged that this should follow closely the practice of the Children's Department of Maudsley Hospital. Experience there has proved its efficiency when doctors are under training in child psychiatry. It also allows a smooth exchange of senior medical staff during leave or sickness. Registrars and postgraduate students look after most of the patients with a close working liaison with the psychiatric social workers and educational psychologists, who may also be dealing with the parents or child. The doctors in training are supervised by the psychiatrist in charge and senior registrar, who have a controlling hand over all the cases, and who have taken on personally for treatment some patients because of peculiar difficulty or for other reasons. "Every patient is fully examined as a routine whatever the reason for referral, and a broad socio-psycho-biological approach is used for each clinical problem. Facilities have been made in the unit for the physical examination of every patient, and for urine examination when required. Dr. Kenneth Cameron and Dr. W. H. Gillespie visit the unit alternately each week to advise on specific patients and to teach. It will be possible to draw on the help of other consultants at the Maudsley Hospital, if required. Six electroencephalograms have been done at the Maudsley Hospital, and two patients have been referred to King's College Hospital for X-ray examination. The weekly routine includes a number of conferences and seminars, where ideas can be exchanged and the opinions of the various members of the staff are sought to further diagnosis and treatment of the patient under discussion. Doctors in training attend the Maudsley Hospital for certain lectures, and visits by the unit staff and doctors in training to other establishments dealing with children are planned. So far. a visit to Ashford Residential School was paid on 29th November. The staff have also exchanged visits with the Battersea Unit. "The unit staff wish to co-operate with others who work with children, especially in their catchment area. They are prepared to lecture to outside bodies, either in the unit or elsewhere ; to try to promote a realistic knowledge of psychiatric disturbance 105 in children and of the possibilities and limitations of child guidance. Educational work of this sort, and more so perhaps with parents, is experimental. Practical experience is necessary before assessing any influence it may have towards increasing the early referral of patients amenable to child guidance, and the possibility of helping to prevent psychiatric disturbance in children." The area from which the unit receives patients has been deliberately limited so that early treatment can be given, and so that time will be available to allow of other work than the treatment of children ; that is of preventive psychiatric work in the community and the conduct of medico-social work. It is almost axiomatic that it is impossible to provide all the facilities needed to treat established maladjustment, so that it becomes more important to develop methods of prevention which must mean the modification of attitudes in the community around the child, in the family as well as in the school. It is in this way that the philosophy and thought underlying the practice of child guidance will have its greatest effect. We are too inclined perhaps to think only of modern psychology in relation to the care of " difficult " children whereas already it has had immeasurable effects on educational thought and practice. Battersea Child Guidance Unit The redecoration of premises was completed in November, 1951. The number of sessions was doubled in October, 1951, the psychiatrist's being increased to four a week, the educational psychologist's to four a week, the psychiatric social worker's to eight a week and clerical to eight a week. The number of new cases seen increased slightly during the year compared with 1950. There was a considerable increase in treatment during the latter half of the year and there was a treatment waiting list at the end of the year. Useful contacts have been made during the year with probation officers, children's department welfare officers, health visitors and others. A series of informal meetings with voluntary care committee workers was held during the year. Direct contact with many head teachers is growing through the work and visits of the educational psychologist. Direct contact has also been established with a number of practitioners in the area. Earl's Court Child Guidance Unit Work in the past year has progressed well, and the new premises are very satisfactory. There are two psychiatrists (four sessions a week), two therapists (five sessions a week), two educational psychologists (three sessions a week), a full-time psychiatric social worker and secretary at the unit. The demand for treatment exceeds the supply (shown by the waiting list of thirty-one). A day special class for maladjusted children is taken on the ground floor of the building. Some of the unit patients attend the class. The general impression during the year is that broken homes and instability of care in the first five years of childhood produce most of the unit's problems, and the present overcrowding frequently accentuates them. Most of the child guidance care of London children falls on the units administered other units, by the teaching and other hospitals (approximately twenty). The problem case conference in each of the nine divisions cont inues to perform its important role of liaison between the school health service and the child guidance units. The two child guidance clinics for the pre-school child, to which reference was made in my Annual Report for 1950, have been continued. At these clinics psychiatrists, who are provided and paid by the regional hospital board, see children, and their parents, referred from local child welfare centres because of behaviour disorders. During the year, a course of lectures in mental health was arranged for health visitors as part of their training in the selection of children who would be likely to benefit by reference to a psychiatrist. 106 Boarding schools for maladjusted children. The education department opened two more boarding schools for maladjusted children during 1951, bringing the total number of children in these five schools to 124. This accounts for only a portion of the ascertained maladjusted children for by 31st December, 1951, there were in addition 366 children placed in non-Council boarding schools and another 152 on the waiting list. The care of the child in the boarding schools is only part of the problem of re-adjustment. If the child is to return to his home, the family from which he comes, and which was often responsible for his breakdown, must be ready to receive him and modify its attitude towards him. To this end the Council has appointed two psychiatric social workers to deal with the children in the Council's own boarding schools, as the social workers in the clinics are too heavily occupied to visit the homes of these maladjusted children. This should materially reduce the time these children have to spend in the boarding school. This intensive work with the parents cannot be provided for the other boarding special schools (more than 90) to which the Education Officer's department sends maladjusted children. Nevertheless every effort is made to keep in touch with the homes through the children's care organisation, and most of the children return to their Child Guidance Units during the holiday periods. Bredinghurst This is the only school for maladjusted children at which a psychotherapist is employed. He is Dr. R. W. Shields and the following is an extract from his report:— " In January of this year the new cottage was opened providing us with adequate room for psychotherapy for the first time. There is now a room for the psychiatric social worker, a room for group treatment and one for the therapist . "During the year 29 boys in all have been seen by the therapist for longer or shorter periods. In January there were 15 under treatment and in December there were 19. I have attended only five sessions a week and this limited amount of time has meant that in certain cases therapy has of necessity been inadequate. On a number of occasions I have come in on a Saturday afternoon to see parents. "In general we have had confirmation of our earlier opinion that the best results are obtained with children who are placed in psychotherapy as soon as they arrived at Bredinghurst. Also, of course, successful treatment is more likely with younger children and those with average or high I.Qs. "The group system continues to justify itself as a means of exposing a child's phantasies. It is of value with the introverted, nervous child and with many of those with lower I.Qs. "The close liaison between the cottage, teaching and psychiatric staff has been maintained and the regular conferences now held on Wednesday mornings enables each member of the staff to get a broader picture of the child and a deeper understanding of his particular problem. It has meant, too, that we are able to work together more adequately as a team, since the Wednesday morning meeting takes the form of a case conference." Dromenagh Arrangements were made temporarily with North West Metropolitan Regional Hospital Board to provide a psychiatrist, who visited Dromenagh school. Buckshaw House Arrangements were made for a psychiatrist to be provided by Dorset County Council to visit Buckshaw House. Problems of boarding school care The education officer arranged a most interesting meeting with representatives of nearly all the child guidance units in London to discuss the problems of boarding school care and it is now planned to hold a regular series of meetings to discuss solutions to the many difficulties. The Ministry of Education committee on the care of maladjusted children in boarding schools will have many difficult problems to discuss and during the year, evidence for presentation to this committee was prepared. 107 Special day classes for maladjusted children There are now 15 classes for maladjusted children. Hitherto children had only been admitted to these classes on the recommendation of a psychiatrist and after formal ascertainment. To avoid the delay caused by the long waiting period before children can be seen it has been agreed that admission need not be delayed so long as arrangements are made for the child to be seen by a psychiatrist as soon as possible after his admission to the class. Psychiatry at remand homes In addition to six sessions a week given by Dr. Peter Scott, authority was obtained for four sessions a week for psychiatrists to cover the work at Stamford House, Cumber low Lodge and Wood Yale (juvenile court cases). It proved impossible to obtain one psychiatrist who could undertake all four sessions, and three psychiatrists were engaged for this work. In September, 1951, the Ministry of Health ruled that psychiatric services in remand homes should be provided by hospital authorities. Negotiations were commenced with the Maudsley Hospital and Institute of Psychiatry to take over the services of the psychiatrists concerned. Psychiatry at other residential establishments Arrangements were made with North East Metropolitan Regional Hospital Board for a psychiatrist from a nearby hospital to visit Ardale, an approved school for senior boys. The Council's whole-time psychiatrist paid regular visits to Wood Yale, Langley House and Bredinghurst. He visited other residential establishments, at the request of the officer-in-charge. to give advice on individual children. Unfortunately the pressure of other work, particularly towards the end of the year when Dr. P. Scott was absent sick, made it impossible for him to pay regular visits to some of the other establishments where these would have been beneficial, or to deal with individual children as quickly as desirable. Diabetic unit At the end of 1951, there were 39 children in the Council's residential diabetic unit which 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 a technician under the supervision of the consultant. The pupils took part in all school activities, including a fortnight's visit to a holiday camp. Children under 5 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 5 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 1951 there were 145 nursery classes with accommodation for approximately 4,350 children over 3 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 108 containing iron were also prescribed. Nursery class children attend during the ordinary school hours of primary schools, hut nursery school children attend from 8.30 a.m. to 4.30 p.m. and have breakfast (when necessary), dinner and tea, and two-thirds of a pint of milk daily in addition to the other supplements supplied to the nursery class children. At the end of the year there were 20 maintained day nursery schools with accommodation for 1,220 children from 2 to 5 years and five aided day nursery schools with accommodation for 230 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 16,276 children under five years of age on the day school rolls, 14,126 being in the Council's schools and 2,150 in voluntary or aided schools. DENTAL SERVICES The Council's Chief Dental Officer, Mr. Wm. Ritchie Young, V.R.D., F.D.S., R.C.S.(Eng.), reports as follows:— In 1951 perhaps the most important development in the Council's dental services was the adoption of the agreed Whitley Council scales of remuneration for wholetime dental officers serving with Local Authorities, although it is still too early to assess the effect of these scales on recruitment to the service. During the year, efforts were continued to prevent still further loss of ground and the 1950 staff figures were almost exactly maintained. On 1st April, 1951, the London Executive Council took over the administration of their Part IV service in the three health centres at Shoreditch, Bermondsey and Finsbury. In the Council's Dental Services (Education Act, 1944 and Part III of the National Health Service Act, 1946) a staff of approximately fifty dental officers continued to deal with numbers which would have been completely overwhelming but for the system of control of patients appointments brought into force in 1950. Treatment was perforce in many cases ameliorative only, and in few of the cases of completed treatment was any revisional treatment possible. It is appreciated that without full and complete treatment followed by revisional treatment at least annually, full preventive dental care is not possible. The ameliorative and haphazard treatment given during 1951 cannot be regarded as satisfactory but was the best possible in the circumstances prevailing, and at least prevented a great deal of pain and oral sepsis. Dental inspections in schools—the basis of a proper dental care programmeunfortunately declined still further in number during the year. As in the three preceding years, tables of work carried out are shown under the headings of "School Dental Service" and "Maternity and Child Welfare Dental Service." 109 110 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 At end of 1951 28 22 12 40 66 Statistics 1948 1949 1950 1951 Number of inspection sessions held at schools 1,230 946 544 441 Number of children inspected at schools by Dentists 158,063 96,201 52,931 46.473 Number found to require treatment 102,344 61,445 32,733 29,397 Percentage requiring treatment 64.7% 63.9% 60.8% 63-2% Additional number inspected at centres 44,068 65,380 63,583 65,501 Total number found to require treatment 146,412 126,825 96,316 94,898 Total cases treated 118,439 102,495 82,650 82,564 Attendances 236,175 203,523 166,874 172,063 Ordinary treatment sessions 22,619 19,133 15,890 15,760 General anaesthetic sessions 1,774 1,685 1,559 1,516 Temporary teeth extracted 116,664 109,467 101,066 93,981 Permanent teeth extracted 20,641 18,103 16,247 15,850 Temporary teeth restored by fillings 43,033 34,506 23,960 21,684 Permanent teeth restored by fillings 94,561 67,395 53,388 54,356 Fillings in temporary teeth 45,617 36,341 25,191 24,206 Fillings in permanent teeth 104,913 73,740 58,000 60,568 Other operations—temporary teeth 28,406t 38,649 33,489 39,523 Other operations—permanent teeth 25,602t 32,888 25,485 28,199 Local anaesthetics for extraction 24,859 24,328 20,557 21,300 Local anaesthetics for conservative treatment 5,372 2,926 1,577 1,607 General anaesthetics 41,292 39,455 35,102 34,097 Cases completed 98,474 85,755 74,443 24,611§ Cases for whom immediate treatment was completed ‡ ‡ ‡ 8,481* Cases discharged as dentally fit ‡ ‡ ‡ 40,369* t Figures not available ; t Figures for April-December only ; * Figures for May-December only ; § Figures for January-April only. 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 1951 3-43 to 1 The slight improvement in the ratio of permanent teeth restored to permanent teeth extracted is encouraging and is illustrative of the value of the method of more exactly stabilising sessional attendances which was firmly continued throughout the year. 111 Residential Establishments The decline of the dental service in residential schools throughout 1951 gave even greater anxiety than did that in the ordinary schools. At many of the residential establishments a dental service by the officers of this and other Councils ceased entirely but temporary arrangements were made locally by which general dental service practitioners gave assistance. service practitioners gave assistance. These statistics are additional to those in the preceding table. 1948 1949 1950 1951 Ordinary treatment sessions 645 572 524 449 General anaesthetic sessions 11 12 10 7 Number of children inspected 6,781 5,648 5,783 4,635 Number found to require treatment 2,996 2,333 2,355 2,045 Percentage requiring treatment 44.2% 41.3% 40.7% 441% Attendances for treatment 4,688 4,179 3,791 3,427 Temporary teeth extracted 1,097 1,128 920 950 Permanent teeth extracted 390 271 172 173 Temporary teeth restored by fillings 1,202 1,058 854 699 Permanent teeth restored by fillings 1,916 1,555 1,547 1,365 Fillings in temporary teeth 1,354 1,116 976 746 Fillings in permanent teeth 2,128 1,715 1,708 1,515 Completed scalings 914 700 583 346 Temporary dressings, etc. 709 745 511 455 Local anaesthetics for extraction 830 832 666 580 Local anaesthetics for conservative treatment 133 71 53 113 General anaesthetics 183 163 272 332 Cases oompleted 2,524 2,357 2,363 1,911 Sodium Fluoride treatment and Dental Hygienists The three experimental dental hygienists engaged in 1949 on the request of the Ministry of Health continued throughout 1951 to work under the close supervision of dental surgeons in twin surgeries. Their main activity was, as in 1950, on work in connection with topical applications of sodium fluoride; and revisional examinations of children so treated in 1950 were extensively advanced. Until the re-examinations are completed in 1952-3 final figures will not be available, but a pilot survey towards the end of 1951 indicated substantiation for the claim that topical application of 2% sodium fluoride does materially retard the progress of dental caries. In the mouths of the children treated with sodium fluoride and re-examined, a formidable amount of caries requiring operative correction was found, however, and a warning note must be sounded that sodium fluoride is not a complete preventive of this condition. In addition to their work with fluoride, the hygienists assisted treatment by instruction on oral hygiene and by scalings and polishing of teeth. Dental Hygienists—Attendances and, Treatments 1950 1951 Sessions 1,370 1,499 Number invited to attend for first treatment 2,389 4,188 Number invited to attend for subsequent treatment 2,851 4,232 Attended—first treatment 2,109 3,365 Attended—subsequent treatment 2,662 3,936 Treated—first treatment 2,104 3,359 Treated—subsequent treatment 2,660 4,033 Discharged—treatment completed 1,834 3,121 Discharged—failed to complete treeatment * 104† Gum treatments 365 395 Scalings (cleanings) 3,122 3,986 Polishings (of artificial restorations) 1,823 2,553 Oral hygiene instruction 2,562 4,655 Sodium Fluoride: First application 658 1,220 Second „ 597 1,170 Third „ 559 1,102 Fourth „ 494 1,074 * Figures not available † Figures for June-December 112 Orthodontic treatment The need for special treatment to correct malocclusions or displaced teeth continued to present a major problem. With insufficient staff to carry out the more routine dental care it followed that treatment for many children requiring extensive attention had to go by default. The services of only two orthodontists continued on a part-time basis during 1951 and one of these resigned in November. At the close of the year only three sessions per week were expressly reserved for this urgently required service. Summary of Work Completed by Orthodontists 1950 1951 Sessions 425 245 New cases 266 117 Attendances 5,339 3.247 Unsuitable for treatment 84 51 Still under treatment (at 31st December) 491 187 Fixed appliances fitted 199 155 Removable appliances fitted 452 127 Discharged, treatment completed 424 222 In addition 210 new cases were treated in the course of the normal treatment sessions by clinicians (as compared with 247 in 1950) and a further 52 were accepted for treatment in hospitals (185 in 1950). In all a total of 379 new cases were treated, a reduction of 389 on the preceding year and of 825 on 1949. This serious decline in orthodontic service is a matter of grave concern, coupled with the knowledge that proper preventive care by the conservation of teeth is impossible with insufficient staff. Maternity and Child Welfare Dental Service 1948 1949 1950 1951 Number of ordinary sessions 4,982† 2,682 2,238 1,980 Number of general anaesthetic sessions 288† 364 368 333 Number of appointments offered * 31,338 26,308 23,342 Failed to attend * 6,477 5,876 5,060 Attendances—By appointment 36,710 24,861 20,432 18,282 Other 5,392 3,891 3,313 Examinations * 12,057 8,579 7,661 Treated—first treatment 10,959 7,032 5,116 4,753 others 4 13,447 11,851 10,216 Silver nitrate treatment 416 2,938 2,180 1,818 Scalings 1,324 1,364 859 669 Prolonged gum treatment 135 212 210 214 Fillings 8,549 8,564 8,255 7,929 Inlays * 23 22 27 Crowns 1 5 11 6 Number of teeth conserved * 7,988 7,841 7,507 Extractions 17,355 16,560 11,257 9,289 Dressings 598 2,236 2,077 1,687 Anaesthetics—local 349 1,784 1,457 992 general 3,645 4,563 3,372 3,318 Number of patients prepared for dentures * 3,359 2,518 1,822 Number of patients supplied with dentures * 960 918 590 Dentures supplied—new full 2,176 652 655 335 new partial 795 782 536 Remakes 8 7 19 10 Repairs 235 126 84 63 Number of patients X-rayed. * 56 23 65 Number made dentally fit * 5,283 5,057 4,654 † Includes sessions at which attendances were made by other than maternity and child welfare patients. * Figures not available; mainly because of variations in record keeping by the metropolitan borough council dental clinics prior to July, 1948. 113 A condition rather of stalemate continued in this service during 1951 but such movement as there was, was unfortunately in a downward direction. Hospitals (Part II, National Health Service Act), General Dental Service (Part IV, National Health Service Act) and Private Practice continued to deal with an unknown volume of treatment for the "priority" class but the Council was unable to meet its statutory obligation in full owing to lack of staff. In the Council's service during 1951, so far from it being possible to make any expansion, the number of weekly materrity and child welfare dental sessions dropped to 54 compared with 01 in the previous year Conclusion The year under review was one of intensive effort to prevent as far as possible further deterioration and I would place on record my appreciation of the clinic staff who have worked to capacity to make the effort fairly successful. The service suffered a severe blow owing to the death on 21st December, 1951. of the Assistant Chief Dental Officer Mr. F. D. Manners, L.D.S. Application of national salary scales STAFF During the year the Whitley Councils for the Health Services (Great Britain continued their work of formulating national scales of salary and conditions of service Recommendations from these bodies covering the following grades of staff in tin Public Health Department, were applied by the Council:— (1) Whole-time medical staff. (2) Whole-time dental staff. (3) Senior grades of nursing staff. (4) Residential school nurses and assistant nurses. (5) Medical auxiliaries (speech therapists, psychiatric social workers and physiotherapists.) In some of these recommendations, notably those covering the "field" grades of assistant medical officer and dental officer, the Whitley Council scales, although involving increases for the staff of most other local authorities, differed little from the Council's existing ones. The shortage of whole-time dental officers persisted during the year and efforts were continued to induce dental surgeons in private practice to give part-time service to the Council. Increases in pay In addition to the grades covered by the Whitley Councils the pay of other staff of the department was revised during the year, in most instances increases being granted in the light of the rise in the cost of living. An award of the Industrial Disputes Tribunal increased the pay of most manual workers in the department, including home helps. The Council itself revised the salaries of the supervisory staff of occupation centres for mentally deficient persons and of student health visitors. A number of grades benefited by the application of the 10 per cent. addition to remuneration granted by the Council at the beginning of the year to a large section of its staff. Home help organisers A comprehensive review was made of the organisation of the home help service leading to the fixing of an establishment of supervisory staff and the formulation of salary scales. Health visitors and clinic nurses A measure of success continued to reward efforts to increase the number of health visitors working in London. Specialised advertising met with an encouraging response and the Council's scheme for the training of health visitors continued to play a useful part, a good proportion of students remaining in the Council's service 114 after the fulfilment of their contractual obligations following qualification. The number of certificated health visitors increased during the year from 346 to 365. An attempt of a different kind to alleviate the shortage of certificated health visitors was introduced when the Council instituted a new grade of " clinic nurse." These officers who are qualified nurses, but not qualified health visitors, are employed on some of the clinic work in maternity and child welfare centres, thus enabling health visitors to devote more time to home visiting. They are also engaged on work in vaccination and immunisation clinics. Co-operation with borough councils Co-operation between the Council and the metropolitan borough councils in the administration of London's public health services continued during 1951. Almost all the borough medical officers of health take part in the administration of the Council's personal health services, and under an agreement reached during the year the Council pays 25 per cent. of their salaries in recognition of their work on its behalf. Complementary arrangements are not yet on such a large scale, but during the year two more assistant medical officers of the Council were seconded part-time for duty as deputy borough medical officers of health. By the end of the year such secondments were in force in three boroughs, viz., Finsbury, Fulham and Islington. Tripartite appointments Important though these developments were, they were overshadowed by the unique experiment designed for the Council's Health Division No. 9, comprising the metropolitan boroughs of Battersea and Wandsworth. The opportunity to attempt a really close integration of the health and environmental services in this area was afforded by the coincidence of the retirement of both borough medical officers of health. Consultation between the three authorities concerned, and with the Ministry of Health, culminated in the appointment of one officer to be the Council's divisional medical officer and medical officer of health for the two boroughs. Thus, for the first time in the history of London government, immediate control of all the public health services in a wide area (total population over 400,000) became the responsibility of one medical officer, himself responsible to three authorities. The officer appointed to this post was Mr. J. T. R. Lewis, M.D., D.P.H., formerly medical officer of health and school medical officer of West Bromwich. Two other medical officers were appointed to assist Dr. Lewis in his work for the Council and to deputise for him as medical officer of health in each borough. Although this scheme did not actually commence to operate before the end of the year and hence cannot be reviewed in this report, it is certain that it will be watched with critical interest, coupled with the hope that it may prove of great benefit to the efficiency of the public health services in the area. Staff medical examination* The number of references to the department for medical examination or advice concerning the health of staff or the fitness of candidates for appointment was 12,455, compared with 12,361 in 1950; 200 members of the staff were found to be permanently unfit for further duty with the Council and 191 candidates were found unfit for appointment. Reciprocal arrangements with provincial authorities for the examination locally of new entrants were continued. Provincial medical officers of health arranged for the examination of 15 entrants to the Council's service and the Council's medical officers examined 25 persons for provincial appointments. The Council's staff medical examiners made 95 home visits to examine members of the staff who were unable to travel, compared with 74 during 1950. Sewer workers Arrangements made for the ascertainment and the 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. 115 Staff of the department The following statement shows the number of staff employed in the Public Health Department in December, 1951 (part-time staff being expressed as wholetime equivalents). Type of staff Location Staff Employed at other establishments (a) Total 1951 Total 1950 Head office staff Divisional staff Administrative and clerical (including ambulance control clerks) 197 592 73 862 887 Medical staff 18 178 (b) 196 186 Dental staff 2 44 (c) 46 48 Chemists 16 — 7 23 23 Inspectors 15 — — 15 15 Nursing staff 9 2,306 339 2,654 2,773 Medical auxiliaries (d) — 121 19 140 132 Social worker grades (including mental health) 30 153 76 259 248 Supervisory staff (London Ambulance Service) 3 — 14 17 17 Manual workers, operative staff (L.A.S.), domestic grades, etc. 5 2,340 736 3,081 2,914 Totals 295 5,734 1,264 7,293 7,243 (a) Those establishments include residential schools and nurseries, welfare establishments, ambulance stations, occupation centres for mentally defective children, main drainage, outfall works, clinics and dispensaries, district offices (mental health), central dental laboratory, etc. (b) There are 66 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 6 visiting dental surgeons employed in a similar manner as the medical staff referred to in note (b) above who have been omitted from the statement. (d) Including physiotherapists, chiropodists, speech therapists, orthoptists, dental attendants and dental hygienists. FINANCE The total capital expenditure on the health services of the Council in the year ended Capitol 31st March, 1951 was £254,489 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. £47,065 was almost entirely in respect of 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 follows:— £ Ambulances 126,422 Children's Holiday Home, Littlehampton 1,392 Day nurseries—acquisition and adaptations 77,538 Health centre 47,065 Maternity and child welfare centres—acquisition and adaptations 2,050 Divisional health offices 22 254,489 116 Maintenance After allowing for Government grant the services administered by the Public Health department cost the London ratepayer a rate of 9id. in the £. This was divided as follows:— d. London ambulance service 1.07 Domiciliary midwifery service .39 Mental health .29 Maternity and child welfare 1.68 Day nurseries 1.78 School health 1.23 Clinics, centres and divisional offices .03 After-care and other preventive services (home nursing, domestic help, care of tuberculous, etc.) 2.28 General health services .83 9.58 The gross cost of the various services in 1950-51—including central administrative and loan charges and contributions to the Superannuation Fund—and the contributions recovered from recipients of the services were:— Service Cost Amount recovered in charges £ £ London ambulance service 536,988 — Domiciliary midwifery service 177,959 — Maternity and child welfare 829,570 40,959 Mental health 133,800 — Day nurseries 928,946 97,479 Medical inspection and treatment of school children 715,592 15,593 Clinics and divisional office maintenance 15,197 — Prevention of illness— Home nursing 230,226* — Domestic help 401,811 42,149 Other preventive services 440.943 19,914 General health service (including £143,985 contribution to metropolitan borough councils for salaries of sanitary officers) 226,935 — 4.637,967 216,094 * Excluding central administration. VISITORS TO THE DEPARTMENT During the year 202 individual visitors from 50 countries came over to study the Council's various health services compared with 195 from 46 countries in 1950 and 147 from 40 countries in 1949. The numbers of visitors from each country are set out below, the figures in brackets being those for 1950:— Afghanistan 2 (-); Australia 17 (19); Austria 2 (3); Brazil 1 (1); Burma 4 (2); Canada 2 (5); Ceylon 5 (5); Cyprus 1 (-); Denmark 3 (2); Egypt 3 (4); Finland 3 (2); Fiji 1 (1); France 7 (7); Germany 8 (7); Greece 3 (-); Hawaii 1 (-); Holland 4 (3); Hong Kong 2 (-); Hungary 3 (-); Iceland 1 (-); India 33 (22); Indonesia 4 (-); Italy 2 (5); Jamaica 1 (-); Japan 5 (1); Malaya 7 (-); Mauritius 3 (1); New Zealand 4 (7); Nigeria 1(1); Northern Rhodesia 1 (-); Norway 7 (4); Nyasaland Protectorate 1 (-); Pakistan 4 (4); Palestine (Israel) 3 (6); Persia 3 (1); Philippines 2 (1); Rumania 1 (-); Saudi Arabia 1 (-); South Africa 5 (-); Southern Rhodesia 1 (-); Sweden 6 (11); Switzerland 2 (4); Thailand 4 (4); Trinidad 1 (-); Turkey 1 (2); United States of America 18 (32); Uruguay 2 (5); U.S.S.R. 3 (-); Yugoslavia 3 (-). 117 Among these visitors there were one hundred and two doctors, sixteen nurses' fifteen administrative officers, six journalists, five social workers and twenty-six students. They spent periods varying from a day to eight weeks in visits to various types of health establishments and, where appropriate, were given talks by senior officers both in the divisions and at County Hall. Documents relating to the Council's health services were supplied to them and many visitors were advised with regard to their programmes for seeing the services of other authorities, metropolitan and provincial, which would be beneficial to them in their study of the health and allied services in Great Britain. Besides the individual visitors referred to above a number of delegations and parties of visitors, totalling over 400 persons, came as organised groups to study the Council's services. They included :- 12 members of a Yugoslavian parliamentary delegation who were given a talk on the Council's health services and also visited a day nursery. 25 American ministers of religion who had a talk from the Medical Officer of Health on the health services, followed by a visit to a welfare centre. 10 members of a Finnish parliamentary delegation who visited a welfare centre. 3 representatives of Yugoslavia (the Deputy Minister of Health, the Medical Officer in charge of the Tuberculosis Service and the Medical Officer in charge of statistics in the Yugoslavia Ministry of Health) who were given a series of talks by senior officers. 3 representatives from Belgrade (the President of Belgrade, the Vice-President of Belgrade and the Mayor of Zagreb) who witnessed a school medical inspection. 4 journalists (from Australia, Canada, New Zealand and South Africa), accompanied by officers of the Ministry of Health, who visited a day nursery and a welfare centre. 6 Indonesian Members of Parliament who were given a talk by the Medical ()fficer of Health on the health services. 17 Norwegian nurses on a study tour of Britain who were given a talk and also visited health service premises. 12 Soroptimists from Belgium, Denmark, France, Greece, Holland, Italy, and Norway, who were given a talk on child care services followed by a visit to a welfare centre and day nursery. 60 nurses belonging to an international group under the auspices of the National Council of Nurses visited welfare centres, day nurseries and school treatment centres. 6 wives of delegates to a Colonial Conference who visited a welfare centre and a day nursery. 3 Indonesian Army Officers who visited health service premises. 6 "Winant Volunteers" from the U.S.A. who visited divisional health services. 4 delegates of the International Women's Day who visited a day nursery. 20 health visitors and school nurses under the auspices of the Women Public Health Officers Association who visited maternity and child welfare centres. 82 medical officers under the auspices of the National Association for Mental Health who visited occupation centres for the mentally deficient. 5 members of the Northern Ireland Hospital Management Committee who visited an occupation centre. 30 nurses under the auspices of the National Council of Nurses, including some from abroad, who visited health service premises. 6 trade unionists from India who were given a talk on the public health services. 150 administrators, almoners, transport officers and foreign visitors visited the Headquarters of the London Ambulance Station. 118 REPORTS BY THE DIVISIONAL MEDICAL OFFICERS Division 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington. Dr. Violet Russell reports:— General There was no significant change in the volume of the divisional health services generally during the year, apart from a further expansion of the domestic help service. This expansion taken in conjunction with a decrease in the estimated population and a further steady decline in the birth rate has made it possible to meet more fully the demand for this facility. A particularly satisfactory tendency is the increasing co-ordination and cooperation between the services under different sections of the National Health Service Act, bringing the work nearer to the ideal of an integrated whole. Most noteworthy in this connection has been the successful linking-up between hospital almoners, health visitors and care committee workers in order to avoid overlapping and unnecessary visits in the home. This new scheme has worked smoothly and well. The liaison between doctors in the teaching hospitals and those in the Council's welfare centres is encouraged and medical students now attend at three welfare centres in the division. This should help to awaken the interest of young doctors in social medicine as well as assisting to produce an integrated service. Day nurseries The number of children on the priority waiting lists has greatly declined and there is now no appreciable delay when it is wished to admit a child to a nursery at short notice. This is partly due to a stricter definition of priority having been adopted but the position has also been helped by a reorganisation of the age-groups in the day nurseries and also by the reopening of Eridge House Nursery which had been closed for repairs. Divisional Home Nursing Committee This committee has met regularly and has discussed a large variety of subjects of interest to nursing. The value of these meetings between the representatives of the four district nursing associations and the voluntary organisations, doctors and almoners who come into contact and assist the nursing service has made itself manifest. The evolution of an active and co-ordinated committee from the various elements of which it was composed in 1948 has been most striking and is evidence of the value of the committee system under an efficient chairman in integrating the work of different authorities. Divisional Tuberculosis Care Committee School Health Service The second meeting of this committee was held in June when the annual reports of the four local care committees were received. There has been a notable increase in the number of sessions provided for visiontesting ; an expansion of the nutrition work was also necessary. Concentrated work on tonsillectomy cases in St. Charles' Hospital did much to relieve the waiting list. The audiometric testing of school children's hearing was inaugurated in the division and an audiology session once a month was started for the investigation of those whose hearing was found to be defective. The Council was asked to take over administrative control of this centre, formerly conducted by the Hammersmith District Nursing Association, and it now forms a normal unit in the divisional school health service. Care of the aged Home Help Service Co-operation is maintained with the Old People's Welfare Committees which exist in each borough of the division. The expansion of the home help service, which had made steady progress during 1950, continued during 1951. Service varying from a few hours a week to full-time was supplied to an average of over 1,500 households throughout the year. ChilitMinder Service In addition to the day nurseries, which provide for the daily care of 834 children, a well-developed service of child-minders, registered under the Council's scheme, has been maintained ; an average of over 200 children under 5, most of whom were ineligible for admission to a day nursery, have been provided for in this way. 119 Health education Great importance is attached to the spread of health education. It is satisfactory to report that the number of mothers attending educational sessions at the welfare centres was twice as large in 1951 as in the preceding year. Mothercraft clubs again are being established in the centres for teaching purposes. The divisional staff co-operated in the Health Week organised by the Fulham Borough Council in June and the exhibits and activities included material relating to the health services of the County Council. Intensive efforts were also expended to further the County Council's diphtheria immunisation campaign. In conclusion I must record my thanks to the Divisional Health Committee for their support and encouragement, to the Borough Medical officers of Health for their ready co-operation and to the divisional staff for their admirable work during the year. Division 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and Westminster. Staff Dr. H. L. Oldershaw reports:— (1) Medical Officers.—It has now been arranged for ten of the assistant medical officers in the division to have experience of both Maternity and Child Welfare and School Medical Services. In addition, three of the assistant medical officers attend the St. Mary's, Great Ormond Street and Westminster Hospitals, and four of them have the opportunity of the day to day medical administration of the personal health service of the Boroughs in which they work. (2) Health Visitors.—Gradually the Health Visitors are undertaking the home visiting of the family as a unit, including not only the pre-school child, expectant and nursing mothers, but also the home visiting of all age groups in respect of hospital after care. The number of nursing staff in the division showed a slight increase during the year, and although the number of home visits showed a slight decrease, the scope of these visits increased considerably. Nevertheless, herein may be in part the explanation of the decrease in attendances at the Welfare Centres. Premises During the year, the following additional accommodation was acquired by the Council:— (1) A prefabricated building in Peach Street, Paddington, was replaced by a new nursery on an adjoining site. This was opened in April, 1951, and named the Katharine Bruce Day Nursery after a local social worker who was also a member of the Paddington Council. The nursery provides for sixty-two places. (2) A house in Alderney Street, Westminster, was purchased to replace the Minor Ailment Centre in Greencoat Place and the School Treatment Centre at the Western Dispensary, Rochester Row. Certain adaptations, etc., are necessary before these premises can be brought into use. Day nurseries There has been a considerable reduction in the waiting list during the year, but there are still 231 priority cases awaiting admission. The Council's decisions in respect of staffing have been applied, and every effort is made to keep running costs of the nurseries to a reasonable minimum. Childminders The number of Child-Minders in the division continues to increase and it is estimated that over £2,000 will be spent in 1952/53. It should be noted that these children are not necessarily priority cases, and an amendment of the Nurseries and €hild Minders Regulation Act, 1948, to include all children minded would render the Council scheme unnecessary, with the consequential saving. 120 The following table shows the position in 1951 compared with 1948 : Hampstead Marylebone Westminster Paddington St. Patterns Total 1948 — — — 11 17 28 1951 19 6 — 34 84 143 Home Help Service The number of Home Helps (in terms of full-time units) has been increased from 160 in 1950, to 186 during 1951. It is only by the continued vigilance of the five Home Help Organisers operating in the division that one can be. assured that the Home Helps are being deployed to the best advantage. For the successful operation and economic use of this scheme each application must be carefully vetted before a Home Help is allocated, and frequent periodic home visits must be paid to ascertain any change in circumstances. Westminster quadruplets Considerable press publicity has been given to the quadruplets born in Westminster, and whose mother attended the Council Ante-Natal Clinic where the diagnosis was first made. Home nursing service as well as home help service has been provided for the Quads by the Council throughout the year. Specialist clinics As a result of negotiations between the Council and the Regional Hospital Board, responsibility for the provision of specialist services for certain clinics was transferred during the year to the Regional Hospital Board. The Board took over the financial responsibility for Vision, Orthoptic, E.N.T. and Rheumatism Clinics held on Council premises as from April, 1951, but close association with the Divisional Organisation was retained through the Treatment Organisers. Tuberculosis after care A Divisional Tuberculosis Care Committee has been formed, and they have reviewed the work of the Tuberculosis Care Committee already operating in the Division and reappointed the Care Committees in Hampstead and Marylebone which had lapsed. Opportunity has been taken to obtain voluntary funds from various sources for the use of certain of the local care committees. Vaccination and immunisation During the year, 12,876 cases were vaccinated as compared with 6,727 in 1950. The increase was due to the press publicity resulting from the occurrence of cases of Smallpox in a south coast resort at the beginning of the year. Unfortunately, there has been a decrease of about 12 per cent. in the number of diphtheria immunisations during the year, occasioned, no doubt, by the outbreak of Poliomyelitis and the possibility that diphtheria immunisation, at times of such prevalence, leads to a slightly increased risk of an attack. Health education Regular Mothercraft classes are being given in certain schools by the nursing staff. In the larger welfare centres, arrangements have been made for the groupteaching of Mothercraft, and also for short talks to be given on health subjects. In addition, ten cookery and needlework classes are given by the Council's teachers in our welfare centres. Parent clubs have been established in five of the welfare centres. Conclusion I express my sincere appreciation of the hard and conscientious work of all those operating the health services in the division. Division 3, comprising the boroughs of Finsbury, Holborn and Islington. Care of mother* and young children Dr. A. B. Stewart reports:— Places for 622 children existed in the eleven day nurseries in the division. In addition there were three private day nurseries (two associated with industrial premises) registered under the Nurseries and Child-Minders Regulation Act, providing up to a maximum of 175 places, and at the end of the year 136 children were being cared for during the day by 119 child-minders. The number of priority cases awaiting admission to the Council's day nurseries on the 31st. December, 1951, was 146 as compared with 302 at the beginning of the year. Fifteen maternity and child welfare centres (including branch clinics) were operating in the division throughout the year. The total number of live births in the division (4,745) showed an approximate decrease of 5 per cent. on the previous year's figure. The total attendances of children at the infant welfare clinics were. 121 maintained at the same level as the previous year, i.e. approximately 79,000, whereas there was a substantial increase of nearly 12 per cent. in the number of visits made by health visitors. Attendances by mothers at educational sessions were increased by over 100 per cent. as compared with 1950. Full use was made of the two family planning clinics to which 306 women were referred for advice. The home help service was utilised to assist in 185 home confinement cases. The help provided covers the confinement period and is of relatively short duration in contrast to the help provided to the aged and infirm (vide infra) where the help may be required indefinitely. Recuperative holidays Recuperative holidays were provided for 777 persons, 300 of whom were children. This service continued to expand and 2,065 households were attended by home helps during the year. The vast majority of cases assisted were aged and infirm persons who, under the Council's assessment scheme, were provided with a free service. Over the year the number of home helps employed increased from the equivalent of 119 whole time staff on 1st January to 138 on 31st December. Home Help Service Vaccination and immunisation 1,967 babies under twelve months of age were successfully vaccinated during the year, which represents a figure of 41 per cent. when compared with the total live births occurring in 1951. The comparative figure for last year was 28 per cent. There was also an increase of some 42 per cent. in the total number of vaccinations in all age groups as compared with the previous year. Based on the population figure as at 30/6/50 it is estimated that at the end of the year 54 per cent. of children 0-4 years and 92 per cent. 5-14 years had been immunised against diphtheria. 17 cases of diphtheria were confirmed during the year, and one death occurred in an unimmunised child. Foot clinic The foot clinic at the Finsbury Health Centre continued to provide a service much in demand and 19,235 attendances were recorded, representing a 12 per cent, increase over the previous year's figure. Five chiropodists were employed on a full time basis, in addition to part-time sessional staff. Housing The determination of priority to be given on medical grounds to applicants tor housing accommodation was decided in 3,863 cases. In addition, many requests from almoners for housing reports have been dealt with to assist hospital doctors in giving medical recommendations for rehousing. School health service The position with regard to the supply of spectacles has improved, and was considered satisfactory at the end of the year. The numbers referred for refraction tended to increase during the last few months of 1951. A consultative clinic was inaugurated in the autumn at the Pentonville Treatment Centre to which enuretic cases were referred. The results proved satisfactory and confirmed the need for the establishment of a clinic of this type. The attendances at the two nutrition centres showed an increase above the corresponding figures for last year, and the waiting list proved the need for extra sessions which are to be provided. There was a steady increase in cases (referred chiefly by school doctors for remedial exercises, sunlight treatment, etc.) at the physiotherapy clinics at the Finsbury Health Centre and the East Islington Welfare Centre. Personal hygiene has improved to such an extent that a curtailing of the sessions at the Islington Bathing Centre was found possible. Premises External and internal redecorations and various minor works at establishments carried out during the year in the division have improved the condition and appearances generally of public health premises. A number of infant welfare clinics continue to be held in premises which are unsuitable for the purpose, and efforts are continuing to provide better alternative accommodation. Health education A programme of health publicity was continued 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 122 being changed once a month. Talks by health visitors to groups of mothers at the welfare centres were intensified during the year and total attendance figures showed a big increase. Division 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports:— Maternity and child welfare Attendances at infant welfare sessions have remained at a satisfactory level and an additional weekly session was commenced at each of two centres at which attendances have increased. Despite a reduction in the number of ante.natal sessions held in the division, attendances at some ante.natal clinics fall somewhat short of a staisfactory level The division is very well supplied with maternity hospital accommodation and the mothers who book for hospital confinement almost invariably receive ante.natal supervision at the hospital of their choise. Midwives' ante.natal sessions are held concurrently with the clinic sessions. Despite the continuing shortage of health visitors the high level of visiting of premature infants (an average of 4.8 visits to each premature infant born) has been maintained. Attendances at the special toddlers sessions, 7 of which are now held each week have remained at a satisfactory level. The total attendances during the year numbered 3,966, approximately 25.5 per cent. of the children examined being found to require some form of treatment. The breast feeding clinic at the Kingsland Road welfare centre, at which mothers attend twice or thrice daily for test feeds and receive advice on feeding difficulties, continues to serve a very useful purpose. Attendances during the year totalled 490. A family planning clinic continues to be held in each of the three boroughs in the division, two being administered by the Family Planning Association and the third by the Council. Day nurseries and child. minders A marriage advisory clinic is also held weekly. In pursuance of the Health Committee's policy to make most effective use of the available day nursery accommodation and to secure economy in the maintenance costs, a review of the position was made early in the year and resulted in the closing of one nursery and a re.allocation of the age.groupings of children in other nurseries to meet the present changed needs. The effect was to reduce the total child.places from 709 to 668. Three day nurseries ceased to be used as training nurseries, the establishment of nursery students being reduced from 93 to 40. The priority waiting list for nursery admission contained the names of 163 children at the end of the year compared with 196 at the end of the previous year. Five private day nurseries, registered under the Nurseries and Child.Minders Regulation Act, 1948, provide accommodation for 177 children and there are 3 statutorily registered child.minders approved for the care of 12 children. In addition, there were at the end of the year 64 approved daily minders having in their care 66 children under school age. The supply of suitable women available to receive young children for daily minding continues to exceed the demand for this service. Vaccination and immunisation Joint vaccination and immunisation clinics have continued to be held in the larger maternity and child welfare centres in the division and the sustained efforts to secure the vaccination and immunisation of infants at the appropriate ages have continued to achieve a fairly successful result. The systematic "combing" of schools for children who have not been immunised against diphtheria or are in need of re.inforcing injections has continued throughout the year. It is pleasing to record that only one case of diphtheria (in an unimmunised child) occurred in the division during the year. 123 The demand for this service, particularly during the Summer months, was again heavy and 931 holidays were provided. The total included 376 holidays for schoolchildren and 140 for children under school age. Recuperative holidays The home help service has continued to deal with a large and unabating demand. Aged and infirm persons form the largest group of those needing help, though the needs of tuberculous persons and cases of acute illness also make heavy and urgent calls upon the service. Domestic help Help was given in 2,548 households during the year. This number included 1,353 new cases. The Northwold school treatment centre, established some years ago in two flats on the Council's Northwold estate, was closed at the end of the year, the minor ailment work being transferred to the nearby Upper Clapton welfare centre and the dental and vision clinics being removed to the Hackney school treatment centre. School health service A consultation clinic to which children suffering from enuresis can be referred was commenced at the Hoxton school treatment centre. The special arrangements made to deal with the long waiting list of children needing operative treatment of tonsils and adenoids, having achieved their purpose, were replaced by a scheme under which children are referred to and, if necessary, operated on at the Eastern Hospital. Consideration was given each week to an average of 130 to 140 applications for housing accommodation and appropriate recommendations as to priority on health grounds were made. Housing Two of the three tuberculosis care committees serving the division participated for the first time in the annual Christmas seals sale of the National Association for the Prevention of Tuberculosis. The third committee has taken part in this fund. raising effort for several years past. Thus all are now in receipt of an income from this source which greatly assists their work for tuberculous persons and their dependants. After.care of tuberculous persons The handicrafts class, run by the Hackney and Stoke Newington Tuberculosis Care Committee has continued and serves a useful purpose despite the usual difficulty of maintaining attendances at the desired level. Grants of extra nourishment to tuberculous persons increased greatly in number as a result of the relaxation of the Council's necessity scale and there has also been a considerable increase in the number of loans of beds and bedding made to facilitate home isolation. Premises Two welfare centres and a large day nursery were completely redecorated. With the completion of the 1952 redecoration programme all health premises in the division, for the maintenance of which the Council is responsible, will have been repaired and redecorated in the period since July, 1948. The house adjoining Barton House welfare centre has been acquired by the Council and adapted for use as an annexe to the welfare centre, providing accommodation for the foot clinic and for the Stoke Newington District Nursing Association who will, in future, use the centre as their headquarters. Conclusion Various minor improvements to premises, such as the provision of tarmac play space at two day nurseries, the provision or extension of perambulator shelters at welfare centres and the provision of additional water.closets and hand basins at a day nursery, have been made during the year. I have pleasure in recording my appreciation of the helpful co.operation of the Chairman and members of the Divisional Health Committee and of the Medical Officers of Health of the Boroughs in the division. I am also grateful for the high standard of work of the medical, nursing and administrative staff. 124 Division 5, comprising the boroughs of Bethnal Green. Poplar. Stepney and the City of London. Dr. G. 0. Mitchell reports: Resiting of Infant Welfare Clinic There were no spectacular developments in this division in 1951. The health services for which we are responsible ran smoothly from day to day, and we must remain content with the modest but solid achievement of a year which, for us, brought none of the headlines or floodlighting so appropriately associated with the Festival of Britain. It is true that the Live Architecture of Lansbury was an impressive exhibit in the division, but the health services have so far played little part in this project. We benefited indirectly from Lansbury, however, since its development necessitated the demolition of the old Guardians' Offices on the corner of Upper North Street and Gough Grove, on the first floor of which we had an Infant Welfare clinic. By suitably partitioning the rear portion of the School Treatment Centre at 69, East India Dock Road, we were able to accommodate there not only this Infant Welfare clinic but also the Home Helps Organiser for the Eastern Area who was hitherto based on Poplar Town Hall. We have now a compact unit at 69, East India Dock Road, which is not entirely put to shame by being in Lansbury but not of it. School Treatment Centre In January the Bethnal Green School Treatment Centre was transferred to newly adapted premises in the Mowlem Street Special School building. This treatment centre has had a chequered career. It began originally as a voluntary centre in St. James.the.Less hall, but moved temporarily to St. John's School when the church hall was completely destroyed by enemy action. In 1945 the centre was again moved to the main school in Mowlem Street. The derelict special school building has now been completely restored and adapted, and this treatment centre is now handsomely and, we trust, permanently, rehoused ; and with additional accommodation for dental treatment. But so far, unfortunately, no dentist has become available for this work, and we are still without a dentist at the Ida Samuel School Treatment Centre in Whitechapel. The decline in the school dental service has been a most disappointing result of the National Health Service Act. .School Dental Service Liaison with Almoners During the year the scheme agreed between the Council and the Regional Hospital Boards, whereby the majority of home visits required by hospital almoners are carried out by the Council's health visitors, came into force. This scheme is working admirably, and periodic meetings are held with all the almoners in the division for the discussion of mutual problems. This is a useful piece of liaison work. Home Helps and District Nurses The Home Help Service continued to meet a wide.spread need, particularly among the aged, although the number of home helps available was still a little below establishment. The various District Nursing Associations in the division gave their usual unstinted services in the home nursing of the sick. Their ministrations, together with the assistance of the home helps, succeeded in very many instances in keeping the elderly sick comfortable in their own homes, thereby reducing the call upon hospital beds. In some cases, however, where lone persons are concerned, even the combined services of the district nurse and home help are insufficient, and removal to hospital becomes inevitable. Physio. therapy Toddlers' Clinics During the latter part of the year when the services of a full.time Physiotherapist became available we were able to reintroduce some physiotherapy in the Poplar Infant Welfare Clinics. Also in three of the Poplar clinics special sessions for Toddlers were started. We have begun to implement the Council's policy of "Combined Work," which is an arrangement whereby certain health visitors and school nursing sisters become inter.changeable and each carries out the duties of both a health visitor and a school nursing sister. At the end of the year nine units of staff were engaged in this combined work. Combined work 125 Division 6, comprising the boroughs of Deptford, Greenwich and Woolwich. Dr. F. R. Waldron reports:— The year saw many advances, in the main within existing resources; none of exceptional note but none insignificant. Administration Administration was furthered by the establishment of a case index giving reference to social background information from many sources, e.g., child welfare, school health, preferential housing and the home help service. Preferential housing In September 1950 responsibility was delegated to the division for advising on applications received for preferential rehousing by the Council on health grounds. In handling nearly 3,000 applications during 1951 the division's intimate contacts with the health departments of the three Borough Councils have proved a great asset. Maternity and child welfare Ante.natal sessions taken by medical officers were in more instances made concurrent with booking sessions established for domiciliary midwives in the Council's centres, thereby promoting convenient reference of patients where necessary. Ante.natal exercise classes for selected expectant mothers were introduced at two additional centres. Four additional exercise classes for children were started. These developments were made possible, and existing services maintained, by utilising the time of physiotherapists hitherto engaged at the Health Centre, Market Street, Woolwich on the treatment of adults, which work the Council has no power to undertake and which has finally been absorbed by hospitals in the area. Seven staff are carrying out each in a given district the duties both of a health visitor and school nursing sister ; the advantages of this combined service are already apparent. Health risiting Coniey street Day Nursery was closed owing to insufficient demand from parents in priority categories. The number of children looked after by minders registered under the Nurseries and Child Minders Regulation Act and by minders voluntarily registered under the Council's own scheme increased during the year from 181 to 218. The figure at 31st December, 1948, was 25 only. Day nurseries and child. minders Children seen at school medical inspections and at child welfare centres some. times need more thorough examination than is possible in the time available and, where symptoms are sufficiently defined, the children can be referred to hospital or to specialist clinics, e.g., for rheumatic or ear nose and throat conditions. There are other children however, who are prone to bed wetting, minor behaviour problems, e.g., tantrums, or to difficulty in sleeping or eating. If passed over, the children may later present a stubborn problem for a hospital enuresis clinic or for a child guidance clinic. For these reasons a weekly consultative clinic to which children can be referred in the early stages of trouble was established at Chevening Road Centre, Greenwich. School health service In order to tree school accommodation tor educational purposes, a minor ailments treatment centre for school children was opened in an adapted medical relief station in Ormiston Road, Greenwich. The minor ailments clinic at Rusthall Lodge Centre, Eltham, situated in a developing area, was increased from half.time to whole.time. After.care Recuperative holidays,were provided for 364 children and 199 adults. A book.binding class was started at Deptford Chest Clinic, making six diversional therapy classes in the division for tuberculous patients. The number of persons provided with home help service again increased. On 31st December, 1950 they numbered 1,200 but a year later 1,450 were being aided. This figure represents nearly five times as many households as were being attended on 5th July, 1948. Home help service Another service which has continued to expand is chiropody. The facilities have been so re.grouped and re.organised that, by the provision of clerical assistance but without adding to the number of chiropodists, the treatments given have increased from 24,000 in the last six months of 1948 to 70,000 in 1951. The percentage Chiropody J 126 rate of increase is 46 per cent. Quantitative development has not de.personalised the service, for special arrangements have been made to treat some aged and housebound patients brought to the foot clinics by transport. Health education As an adjunct to the continuous preventive educational work carried on by medical officers, health visitors and other field staff throughout the year, film strips to illustrate group talks were increasingly used at maternity and child welfare centres. Division 7, comprising the boroughs of Camberwell and Lewisham. Dr. H. D. Chalke reports :— Premises During the year premises in Lordship Lane formerly used by the Restaurants and Catering Department, were made available. After adaptation they will be used as a maternity and child welfare, school treatment and dental centre. It was found necessary, unfortunately, to discontinue the infant welfare clinics held at St. John's Hospital; temporary accommodation for this session was found at a church hall, but it is hoped to replace this by a hutted centre in the vicinity of Blackheath Hill in the near future. Owing to the absence of alternative accommodation, infant welfare clinics continue to be held in 8 church halls. Many of these halls are ill. adapted for this purpose and high standards of cleanliness and adequate heating are particularly difficult to maintain. Health education is the prime function of infant welfare centres: it is not easy to disseminate it from centres such as these. The voluntary committees concerned are to be congratulated on their zeal and enthusiasm in an adverse environmental background. The Former Peckham Health Centre—renamed the Queen's Road Health Centre —was taken over by the Council during the year. This has entailed a great deal of extra work for the administrative staff of the division. Ante.natal and educational sessions were opened at the Centre for both Division 7 patients and those from Division 6. Clinics Additional diphtheria immunisation and vaccination clinics have been established. The practice of using only the subcutaneous method of inoculation at diphtheria immunisation clinics, has been maintained during the year. Dr. Bousfield continues his research work in the field of diphtheria immunisation and his advice and assistance are invaluable. Health education The chiropody clinic held at the Central Lewisham Weltare Centre was transferred to premises at Sangley Road. Accommodation was also found in this building for a sub.office of the school treatment service; this is advantageous since the building also houses the Youth Employment Officer and the District Care Organiser. Additions have been made to the film.strip library. The lending library scheme, which proved so successful, was extended to other centres. The practice of holding "open days " at selected centres continued, and the results were very encouraging. Mothercraft classes in schools, as well as at welfare centres, continued to be popular. A lecture demonstration course for fathers was commenced at one of the centres and though the numbers were small, the enthusiasm was large. This experiment is being repeated. Welfare of old people A further statistical survey has been made of the circumstances of aged persons in receipt of home help and district nursing. The information is now in process of being analysed. Every effort was made during the year to improve liaison with statutory and voluntary bodies—including hospital geriatric units—with considerable success. In a number of cases it has been found necessary to make available at week ends and public holidays the services of home helps for aged bedridden persons who are entirely alone. One of the outstanding requirements in this connection is the provision of a sitter.up service; it has been found impossible to set up such a service on a voluntary basis. A gap in the preventive services which would appear to require filling as quickly as possible is the lack of facilities for the routine examination and supervision of ageing people: gerontological "clinics," in association with chiropody and physiotherapy would meet this need. 127 More male home helps have been employed; the demand, unfortunately, exceeds the supply. Home help service Additional audiometer and enuresis clinics were opened and a speech therapy centre commenced. The taking over by the Regional Hospital Board of specialist clinics has proceeded smoothly. The attendances at cleansing centres have diminished, but the incidence of verminous conditions still remains high. Many return. cases occur, the result of infestation by older members of the family at home. By arrangement with the Medical Officer of Health, Camberwell, such families are provided with insecticidal preparations. It is too early as yet to assess the results of this scheme, but there are indications already that this may be a useful preventive measure. School health service A provisions costing experiment was carried out in the day nurseries; this continues. A number of daily minders visited the day nurseries for instruction before registration. Day nurseries Staff increases have been maintained—the case.load for whole.time health visitors averages 950. The policy of selective visiting has been adhered to, and considerable help has been given, in close co.operation with other social agencies, to families in special need. A family was sent to Brentwood Rehabilitation Centre: a marked improvement in the standard of care given by this mother on her return has so far been maintained. Health visiting and school nursing Many investigations and research projects have been undertaken, involving a good deal of additional work for the divisional staff. Despite difficulties in respect of transport, and staff changes in key positions, everyone has responded excellently to the additional effort required. My thanks are due to the Medical Officers of Health of Lewisham and Camberwell, hospital staffs, general practitioners and members of a host of voluntary and statutory bodies for their co.operation and assistance during the year, without which the work of the division could not have functioned satisfactorily. General Division 8, comprising the boroughs of Bermondsey, Lambeth and Southwark. Dr. W. H. S. Wallace reports:— The redecoration of premises in the division has been continued during the year. The divisional offices in Brook Drive, five day nurseries and two infant welfare centres were completely redecorated. Premises The Council s policy to effect economies in the running of the day nurseries has been put into effect. Fulford Street, St. John's, Marine Street and Knight's Hill Nurseries, ceased to be training schools. Part of Fulford Street Nursery had to be demolished as the space had to be made available for a new block of flats being erected by the Bermondsey Borough Council. The new priorities laid down by the Health Committee have been applied to all applications for admission to nurseries. They do not differ greatly from the priorities previously in force and there is still a considerable waiting list for admission, except in the Norwood area. Day nurseries The attendances at Infant Welfare Clinics have been well maintained, although there has been a further slight decline in the attendances at ante.natal clinics. Two further combined midwives and doctor clinics have been established and are working well. Clinics The policy of integrating the work of the health visitors and school nurses has been extended. Many school nurses assist at the clinics for weighing babies or at the immunisation clinics. Health visitors have assisted in the school health service. Health visiting Arrangements were made for closer co.operation between the almoners of hospitals and the staff of the department. Reports were made available to almoners on request to the divisional office. A complete street list giving the addresses and the welfare centres by which they were served was supplied to all almoners so that they Almoners 128 could get in touch by telephone with the health visitors concerned. Meetings were held with the almoners at which problems of mutual interest were discussed and the good relations that existed with the almoners were well maintained. Sohool health service It has, fortunately, been possible to improve the arrangements for the provision of physiotherapy at the schools for physically handicapped children. At The Venetian School, which is situated near to King's College Hospital, arrangements have been made for the physiotherapy to be carried out in a room in the school by a physiotherapist from the hospital. At the Caldwell School, which is situated near to the Belgrave Hospital, arrangements have been made for all the children requiring physiotherapy to be treated at the Belgrave Hospital. These arrangements have resulted in the children receiving more complete treatment and have saved considerably in travelling time and the expense of sending children to various hospitals in London. Unfortunately, the facilities for tonsils and adenoids operations at St. George's Dispensary have ceased, but there has been an increase in the facilities at the South Western Hospital to which many cases are referred. There has been some further decline in the number of children attending minor ailment clinics and the times of the sessions have been reduced accordingly. The Voluntary Committees of the Lambeth and Norwood School Treatment Centres intimated their desire to give up the administration of the centres and arrangements were accordingly made for the transfer of these centres to the Council. The routine audiometer testing of all school children has been continued. A new audiology session has been opened at St. George's Dispensary. This has improved the follow.up services for the children found to be deaf and facilitated the provision of hearing aids. The Brixton Child Guidance Unit was opened in the later part of the year. This should prove a most valuable asset in the division as there has in the past been a long waiting list at the Maudsley Hospital and children in urgent need of treatment have had to wait for several months. Welfare of old people The Divisional Health Committee has been much concerned over the problem of the aged and chronic sick. A conference was called by the Committee in March to which all organisations in the division connected with the problem were invited. The conference provided a valuable opportunity for all interested in the subject to get to know each other and to ensure full co.operation. The Old People's Welfare Association in each borough agreed to act as the co.ordinating body between the organisations concerned. The District Nursing Association, health visitors and home helps have continued to give assistance to the aged and chronic sick in their own homes. Unfortunately, the laundry provided by the Bermondsey Borough Council has had to be closed and thus additional work has been thrown on the home helps who have to do much laundry work in the homes. Recuperative holidays There has still been a steady demand for recuperative holidays. As a result of the necessity to ensure economy the period of holidays for school children has, whenever possible, been restricted to two weeks, and consequently expenditure was kept within the financial limits laid down, although more children were sent away. There has still been difficulty in obtaining suitable accommodation for mothers and babies. The increased demand for recuperative holidays for adults has, however, been adequately met. Division 9, comprising the boroughs of Battersea and Wandsworth. Dr. Bertha E. A. Sharpe reports:— Introduction Although the work of the division has made steady progress, there are no grounds for complacency and there are manifest opportunities for the development of and improvement in the local health services offered by the new organisation referred to later in this report. 129 The Earlsfield Welfare Centre was transferred from a church hall to specially adapted premises at 102, Earlsfield Road. This new centre was formally opened on 1st November, 1951, by the Right Hon. the Chairman of the Council—Mr. J. W. Bowen, C.B.E., J.P. As a result of this transfer it has been possible to hold an additional welfare clinic and a mothercraft class weekly at the centre. In the interests of economy and without inconvenience to the public, Queenstown School Treatment Centre was closed on 30th June, 1951. Premises The number of children immunised against diphtheria and whooping cough remained about the same as that for 1950, but the number of persons vaccinated was 60 per cent, higher. immunisation and vaccination Two day nurseries were closed during the year involving a loss of 101 places. In the fourteen day nurseries remaining there are 683 places. One of these nurseries is no longer recognised for training students. All the nurseries are closed on Saturdays. Day nurseries Additional clinics for consultation on bed.wetting were established at two centres. The total number of sessions held was 209 and the attendances 1,998; this shows an increase of 37½ per cent, and 22 per cent, respectively on the figures for 1950. There were 333 new patients. Consultative clinics The number of applications for recuperative holidays has remained steady but there has been a further increase in the percentage placed through the division. 62 per cent, of the total placings were made direct as compared with 51½ per cent, in 1950. Recuperative holidays Because of the condition of milk bottles returned from schools, which I noticed on a visit to a milk depot, I devised a scheme for the improvement in the standard of their cleanliness. The scheme needed the co.operation of a large milk supplier in the division and of the Borough Medical Officers of Health. Its main features were a series of lectures to children in their schools by the Food and Drugs Inspectors followed by visits of children selected from the classes with the best record for the condition of their milk bottles (i.e., the removal of caps and straws and the consumption of all the milk) to a milk bottling depot. The co.operation of this depot was whole.hearted as is evinced by the fact that they showed the visiting children films, supplied them with tea and provided transport where necessary. Between September, when the scheme started, and the end of November, ten lectures had been given in ten schools to 2,310 children and 150 children and a number of women who serve the milk in the schools had visited the depot. This educational experiment is expanding and a milk depot of another firm is participating. At the end of the year there was evidence that the scheme was achieving much success. In some schools the consumption of milk had more than doubled and the depot reported that there was a great improvement in the condition of the returned bottles. An increasing number of fleadteachers are asking for more talks. Health education The need for closer co.operation between the departments concerned with the moral health of the children has been appreciated. The Children's Department are charged with the duty of caring for children who become delinquents but both the Education Department and the Public Health Departments have responsibilities for the moral and physical welfare of school children. The Health Visitor who visits a family from the birth of the first child accumulates much knowledge of the family circumstances and characteristics and is therefore in a position to make an important contribution to the case work. With a view to assembling all possible information, conferences have been held comprising representatives of the three departments, the Moral Welfare Associations and the N.S.P.C.C. It is clear from the discussions that there was already some liaison between the departments and these bodies. Steps have been taken to intensify the means of co.operation. Juvenile delinquency There has been a small increase in the attendances of tuberculous patients at the handicraft classes held in the Chest Clinics. The diversional therapy scheme for Tuberculosis 130 home.bound patients which was started last year is continuing and is meeting a demand. The instruction is given by voluntary workers. 2,311 households were attended by home helps, a modest increase over the previous year's figures. Home help service Home nursing Home nursing equipment has been lent to twenty.nine patients as compared with two in 1949 and eight in 1950. At the end of the year fifteen patients were still using the equipment. 153,838 visits were paid by District Nurses, an increase of 8.7 per cent. Welfare of old people The problem of dealing with the aged sick has not abated. Co.operation has been maintained with the official and voluntary bodies concerned. Home helps have been provided where necessary and 396 visits to old people were made by health visitors. Organisation This report would not be complete without a reference to the new organisation planned during the year and designed to combine the personal health services of the Division and the environmental services of the Metropolitan Boroughs of Battersea and Wandsworth, by the appointment of a Divisional Medical Officer responsible for all this work assisted by two deputies who would give special attention to the medical duties of the two Borough Councils. I hope that this promising experiment will bear fruitful results. Conclusion On leaving the division 1 would like to place on record my gratitude to the divisional staff and also to voluntary associations and societies, the hospitals and the staff of the two Borough Councils whose help and co.operation were invaluable. Introduction DAY.TIME MIGRATION AND POPULATION OF LONDON The following statistics, which have been provided by and are produced here with the kind permission of the London Transport Executive, relate to the day.time migration of workers and students from their place of residence to that of work as disclosed by the London Travel Survey of 1949. The figures are based on movement of workers and scholars to destinations outside their borough of residence and in Boroughs where no interviews occurred in the course of the survey estimates of such regular journeys were made on the experience of neighbouring boroughs. The movements considered refer only to those workers and students living in Greater London and thus exclude journeys made from the residue of the London Transport Area and beyond. In short the estimates give a general idea of the number of Londoners regularly present during the day.time in the Central Commercial and other areas of industry in the County on an average day of the week (Monday to Friday). They include not only those travelling by public transport but also those using private means of conveyance and walkers. They exclude, however, both Londoners and visitors to London moving by public transport or otherwise regularly or less than once a week on business or pleasure, i.e., for purposes other than normal travel to and from work or school. For the purpose of this investigation the County of London has been divided into the following sectors, consisting of groups of local authority areas as below:— 1. Central Commercial Area Cities of London and Westminster, born and Finsbury. 2. West County St. Marylebone, Paddington, Kensington, Chelsea, Fulham and Hammersmith. 3. North County Hampstead, St. Pancras, Islington and Stoke Newington. 4. East County Shoreditch, Bethnal Green, Stepney, Poplar and Hackney. 5. S.E. County wich and Woolwich. 6. South County Battersea, Lambeth, Camberwell, sham and Wandsworth. 131 132 Day.time population The resident (night) population, daily inflow and outflow and estimated day population of each group as at the time of survey are given in the following table:— Net Movement of Workers and Scholars and Estimated Day Population Area Resident (night) Population (1,000s) Total Inflow Total Outflow Net Movement Estimated Day.time Population (1,000s) No. (1,000s) % Population No. (1,000s) % Population + In — Out (1,000s) Increase or decrease — % Population North of Thames Central Commercial 170 751 442 43 25 + 708 + 417 878 West County 676 240 36 216 32 + 24 4 700 North County 525 124 24 199 38 75 . 14 450 East County 451 132 29 139 31 . 7 .2 447 Total 1,825 1,247 68 597 33 + 650 + 36 2,475 South of Thames South East County 463 200 43 128 28 + 72 + 15 535 South County 1,086 161 15 352 32 . 191 .17 895 Total 1,549 361 23 480 31 119 . 8 1,430 County of London 3,374 1,608 48 1,077 32 + 531 + 16 3,905 Net Movement It will be seen that there is a regular daily inflow of 1,608,000 workers and students into the County and an outflow of 1,077,000 or a net daily inflow of 531,000 workers and students equivalent to an increase of 16 per cent, in the resident (night) population. The increase in the resident population of the Central Commercial area is estimated to be over 700,000, i.e., is fivefold on a typical weekday. About 1,600,000 workers and scholars enter metropolitan boroughs to go to work or school, i.e., about one half of the resident population. A total of over 1,000,000 workers and scholars travel to places outside their borough of residence to work or school, i.e., about a third of the resident population. Net increase and decrease in regular day.time population The net increase or decrease in regular day.time population in each borough is illustrated on the map attached. The cities and boroughs in the Central Commercial Area are shown to be net receiving areas. The group of boroughs in the Western Section of the County are mainly reception areas with the exception of St. Marylebone which contains in the south the highly commercialised fringe north of Oxford Street including Great Portland Street and attracts a large inflow of workers. The inflow and outflow of workers and scholars into and out of metropolitan boroughs, distinguishing between inter.metropolitan borough movements and those across the County boundary are showm in the following table. Daily Inflow Three quarter of a million persons enter the Central Commercial Area proceeding to work or school and another quarter of a million enter the West County group of boroughs. Half the people come into these two areas from other of the boroughs in the County (including those in the groups themselves) and about half enter from homes outside the County. Of those entering the two sectors south of the Thames about a third come from boroughs outside the County. Taking the County as a whole, of the 1,600,000 workers and scholars who enter Metropolitan boroughs to go to work or school nearly one half (730,000) come from outside the County. Daily Outflow A total of roughly 1,000,000 workers and scholars travel to places outside their borough of residence to work or school, or about one third of the resident population —a proportion which is fairly constant except in the Central Commercial Area where the proportion is about a quarter. About 80 per cent, proceed to destinations in other parts of the County. The rather lower proportions in groups north of the 133 Inflow and Outflow of Workers and Scholars between Metropolitan Boroughs and Out County Areas Area Resident Population (night) Inflow into Metropolitan boroughs Outflow from Metropolitan boroughs Total From other Metropolitan boroughs From outside the County Total To other Metropolitan boroughs To outside the County (1,000s) (1,000s) (1,000s) % total (1,000s) % total (1,000s) (1,000s) % total (1,000s) % total North of Thames Central Commercial 170 751 373 50 378 50 43 43 100 West County 676 240 121 50 119 50 216 166 77 50 23 North County 525 124 69 56 55 44 199 156 78 43 22 East County 454 132 76 58 56 42 139 107 77 32 23 Total 1,825 1,247 639 51 608 49 597 472 79 125 21 South of Thames S.E. County 463 200 138 69 62 31 128 110 86 18 14 South County 1,086 161 100 62 61 38 352 295 84 57 16 Total 1,549 361 238 66 123 34 480 405 84 75 16 County of London 3,374 1,608 877 55 731 47 1,077 877 81 200 19 river (except the Central Commercial Area) are probably due to the presence of industrial areas in Middlesex and Essex which have no counterparts in Surrey and Kent. For the purpose of estimating "day.time" populations the movements of workers and scholars have been considered together. In the following table these are shown separately. Separate movements of workers and scholars Movement of Workers and Scholars separately Workers Scholars Total (1,000s) % (1,000s) % (1,000s) % Leaving Metropolitan boroughs to destinations:. (i) In other Metropolitan boroughs 820 81 57 88 877 81 (ii) Outside the County 192 19 8 12 200 19 Total 1,012 100 65 100 1,077 100 Entering Metropolitan boroughs from residence:. (i) In other Metropolitan boroughs 820 54 57 63 877 55 (ii) Outside the County 697 46 34 37 731 45 Total 1,517 100 91 100 1,608 100 Net Movements + 505 + 26 + 531 — The proportion of scholars proceeding to school outside the County amount to 12 per cent, as compared with 19 per cent, of adults going outside to work. Similarly a smaller proportion of scholars than workers enter the County from outside areas. The net movement across the County boundary consists of an influx of 505,000 workers and 26,000 scholars. 134 The daytime increase and movement in the County population is very large, and its impact on the spread of such diseases as influenza or the common cold must be considerable. FAMILY ACCOMMODATION SURVEY Because of lack of time and staff and the enormous labour involved, the Council's Architect found it impossible to carry out a county survey of accommodation rates as suggested by the Ministry of Town and Country Planning as part of the Survey for the Development Plan for the County of London and to meet this difficulty in FAMILY ACCOMMODATION SURVEY 1950 VARIATION OF ACCOMMODATION RATES WITH SIZE OF DWELLING part it was agreed that the Health Visitors should assist by collecting information concerning the number of rooms and inhabitants for a sample covering the County. From records of approximately 400,000 families and personal records of each Health Visitor comprising 800 to 1,200 cases it was decided that the extraction of the information required from every twentieth case should provide an adequate sample. 135 Size and structure of the sample The actual number of cases investigated was 20,361, which involved 61,846 rooms and 88,956 persons. The types of property are shown in Table VIII. The scope of the sample was limited in that the Health Visitors call mainly upon families with:— 1. Expectant mothers. 4. Infants under five. 2. Premature babies. 5. Infectious diseases. 3. Still.births. Consequently, the results of the Survey may show the average Family Accommodation Rates to be somewhat higher than would be expected if the sample were drawn from the total population of the County, as for the most part it does not include childless couples, single occupants or old people nor does it cover families with children all over 5 years of age. These observations should be read in conjunction with the extracts on page 3 from the one per cent, sample tables of the 1951 Census. More than 90 per cent, of families with infants under one year are visited by the Health Visitors. Visits to these families are maintained until the infant attains age 5 and all the families included in the Survey would have been visited within the last 12 months and most of them more recently. The information was, therefore, representative and up.to.date. Table I compares the percentage distribution of family houses and purpose.built flats of different sizes as revealed by the sample with the actual distribution of dwellings belonging to the Council on 31st March, 1949. This comparison indicates how close were the sample results to the actual conditions, subject to limitations already stated. Table I Percentage distribution of dwellings of various size Rooms (excl. kitchens) 1 Per cent. 2 Per cent. 3 Per cent. 4 Per cent. 5 Per cent. Sample 2.50 15.70 34.70 24.90 22.20 L.C.C 0.78 10.24 39.83 38.55 20.60 The Survey revealed information concerning the distribution of various types of dwellings. Only 15 per cent, of the total are family houses and 24 per cent, purpose. built, flats Survey analysis— distribution of type of dwellings Table II Percentage distribution of different types of dwelling covered by the survey Health Divisioi No. Metropolitan Boroughs Family House Per cent. Converted Houses in Multiple Occ Per cent. Purpose. Built Flats Per cent. Other Per cent. 1 Chelsea, Fulham, Hammersmith, Kensington 8 71 19 2 2 Hampstead, Paddington, St. Marylebone, St. Pancras, Westminster 4 63 28 5 3 Finsbury, Islington, Holborn 5 68 22 5 4 Hackney, Shoreditch, Stoke Newington 11 56 28 5 5 Bethnal Green, City, Poplar, Stepney 20 43 34 3 6 Deptford, Greenwich, Woolwich 47 39 11 3 7 Camberwell, Lewisham 29 57 12 2 8 Bermondsey, Lambeth, Southwark 13 53 31 3 9 Battersea, Wandsworth 19 64 13 4 Table III Percentage distribution of different types of dwelling covered by the survey Family House Per cent. Converted House in Multiple Occ. Per cent. Purpose. Built Flats Per cent. Other Per cent. North of Thames 8 61 26 5 South of Thames 22 53 21 4 136 More than half (57 per cent, of the total) consist of converted houses, in multiple occupation (see Table VIII). The proportion of family houses is much higher south of the Thames (22 per cent.), while converted houses and purpose.built flats are predominant north of the river. The highest proportion of family houses covered by the survey is to be found in Greenwich, Woolwich and Deptford (47 per cent.), the lowest in Westminster, St. Pancras, St. Marylebone, Paddington and Hampstead (4 per cent.). Boroughs with the highest proportion of purpose.built flats are Poplar, Stepney, Bethnal Green and the City (33 per cent.) and Bermondsey, Lambeth and Southwark (31 per cent.) (see Tables II and III). Size of Dwelling The average size of a dwelling for the whole County (within the scope of the sample), is 3.0 living rooms. The most usual size of a family house is four rooms (34 per cent, of the total) and five rooms (29 per cent.). Flats, whether in converted houses or purpose.built blocks are, on the whole, smaller, the most usual size being 3.roomed. More detailed analysis is presented in Tables IV and V below. Family accommodation rates Only 7 per cent, of the total number of health visitors' districts showed accommodation rates below 1.1 persons per room. This represents only about 4 per cent, of the total number of dwellings in the sample. Table IV Percentage distribution of dwellings according to type and size Type Number of Rooms 1 2 3 4 5 6 + Family House — — 17 34 29 20 Converted House in multiple occupation 10 36 39 12 2 1 Purpose.built flats 4 26 46 19 4 1 Others 9 20 32 25 9 5 Table V Average size of dwellings covered by the survey (rooms per dwelling) Health Divisioi Nos. Metropolitan Boroughs Family House Converted, House in Multiple Occ. Purpose. Built Flats Others (1) (2) (3) (4) (5) 1 Chelsea, Fulham, Hammersmith, Kensington 4.7 2.6 3.1 3.0 2 Hampstead, Paddington, St. Marylebone, St. Pancras, Westminster 4.9 2.5 2.9 2.9 3 Finsbury, Islington, Holborn 4.3 2.5 3.0 3.2 4 Hackney. Shoreditch, Stoke Newington 4.8 2.8 3.0 3.8 5 Bethnal Green, City, Poplar, Stepney 4.3 2.5 2.9 3.5 6 Deptford, Greenwich, Woolwich 4.7 2.7 3.1 3.8 7 Camberwell, Lewisham 4.6 2.9 3.4 3.1 8 Bermondsey, Lambeth, Southwark 4.4 2.7 2.9 3.3 9 Battersea, Wandsworth 4.6 2.8 3.2 3.3 County 4.6 2.7 3.0 — The lowest family accommodation rates are to be found in South Woolwich, Greenwich, round Greenwich Park and Blackheath, South Lambeth, Streatham and Southfields. Small areas are also revealed in Fulham (in the vicinity of the Hammersmith Cemetery), Hammersmith (Stamford Bridge), Stoke Newington, and Hackney (Hackney Downs). The hard core of high family accommodation rates is associated chiefly with the areas built up in the second half of the 19th century. They are found in St. Pancras and Islington, North Kensington and North Paddington and in Southwark, northern portions of Battersea and Lambeth. Another concentration of high accommodation rates is found in highly industrialised areas (which comprise most of London's mixed development). These are Finsbury, Shoreditch, Bethnal 137 Green, Stepney, North Greenwich and North Woolwich. The third type of high accommodation rate is connected with Central London areas, particularly Notting Hill, Earls Court, Fulham and Belgravia, where people employed in the central business area live. The lowest accommodation rates in the sample were found in family houses, where the average is 1.18 persons per room. Islington, Holborn and Finsbury show accommodation rates ranging from 1.31 to 1.35 persons per room while most of the County is much below that figure, with Camberwell and Lewisham only up to 1.15 persons per room. Family accommodation rates according to type of dwelling The accommodation rates in the sample for converted houses were higher than in any other type of dwelling, averaging 1.54 persons per room for the whole County. Here again, Islington, Holborn and Finsbury have the highest rates (over 1.66 persons per room). On the whole, the highest rates are to be found north of the river. Purpose.built flats show average accommodation rates of 1.50 persons per room. The highest are in Islington, Finsbury, Holborn, Lambeth, Southwark and Bermondsey, while the lowest are in Hampstead, St. Pancras, St. Marylebone, Paddington, Westminster, Battersea and Wandsworth (where most of London's private blocks of flats are situated). Table VI Family accommodation rates according to type of dwelling covered by the survey (persons per room) Health Divisioi No. Metropolitan Boroughs Family Houses Converted Houses in Mutiple Occ. Purpose. built Flats (1) (2) (3) (4) 1 Chelsea, Fulham, Hammersmith, Kensington 11.6 1.65 1.46 2 Hampstead, Paddington, St. Marylebone, St. Pancras, Westminster 1.21 1.65 1.44 3 Finsbury, Islington, Holborn 1.31 1.67 1.51 4 Hackney, Shoreditch, Stoke Newington 1.18 1.42 1.49 5 Bethnal Green, City, Poplar, Stepney 1.26 1.56 1.47 6 I)eptford, Greenwich, Woolwich 1.18 1.53 1.50 7 Camberwell, Lewisham 1.14 1.37 1.42 8 Bermondsey, Lambeth, Southwark 1.17 1.48 1.55 9 Battersea, Wandsworth 1.16 1.42 1.30 County 1.18 1.54 1.50 Table VII Variations of accommodation rate according to size of dwelling covered by the survey Rooms Percentage of Total Number of dwellings in the Sample Persons Per Room (1) (2) (3) (4) Family houses 4.5 63 1.1.1.3 Converted houses in multiple occupation 2.3 75 1.4.1.9 Purpose.built flats 2.3 71 1.5.1.9 Variations of accommodation rates according to size of dwelling Average Accommodation Rates decrease as the size of dwelling increases. Rates for the most usual type of dwelling are given in the table above. Conclusions This sample survey revealed high occupancy rates for many parts of the County. The most congested areas coincide closely with those already earmarked by the Council as ready for redevelopment. The survey, when compared with the persons per acre survey, indicates that high density of persons per acre does not necessarily mean congestion and overcrowding. Many areas, where expensive purpose.built flats prevail (e.g., Battersea Park Mansions, Primrose Hill area, etc.) have high densities of persons an acre and 138 rather low occupancy rates. On the other hand, some areas with large houses now mostly converted into multiple occupation show comparatively low densities and high occupancy rates (e.g., the southern portion of Fulham, Campden Hill and Holland Park areas). Table VIII Distribution of dwellings and persons in the sample survey Type Number of Dwellings Per cent. Number of Rooms Per cent. Number of Persona Per cent. (1) (2) (3) (4) (5) (6) (6) Family houses, cottages or bungalows 3,086 15 14,114 23 16,709 19 Divided houses, cottage flats and maisonettes 11,705 57 30,989 50 47,811 53 Purpose.built flats and tenements 4,811 24 14,260 23 21,238 24 Accommodation over shops, public houses, etc 759 4 2,483 4 3,198 4 Total 20,361 100 61,846 100 88,956 100 STATISTICS Table 1—Population of the Administrative County of London, 1921.51 Year Mid.year estimate of population Average age Total 0.4 5.14 15.24 25.44 45.64 66+ 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 V 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 79,200 142,100 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 36.9 1951 3,358,000 274,000 381,000 419,000 1,101,000 812,000 371,000 139 Table 2—Vital statistics for the Metropolitan Boroughs and the Administrative County of London in the year 1951 (b) Metropolitan boroughs arranged in divisional order Estimated home population mid 1951 Lire births Death.Rates Notifications of infectious disease Deaths Infant mortality (per 1,000 Jive 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 Non. Pulmonary Division 1 . Chelsea 52,430 15.5 13.0 23 4.27 0.44 1.30 0.17 0.29 0.71 0.74 2.37 0.53 0.55 - - 0.02 0.04 0.40 12.76 3.32 1.13 0.08 Fulham 122,400 13.8 12.9 27 3.78 0.51 1.25 0.18 0.36 0.70 1.26 2.20 0.47 0.64 — 0.03 0.02 0.06 0.57 15.92 3.69 141 0.20 Hammersmith 118,300 15.9 12.7 22 3.58 0.36 1.33 0.22 0.35 0.74 1.60 2.21 0.46 0.99 0.02 0.04 0 02 0.01 0.95 13.48 4.13 1.63 0.13 Kensington 171,300 15.3 11.2 25 3.41 0.42 104 0.18 0.18 0.55 0.85 2.05 0.54 0.40 0.01 0.05 0.02 0.05 0.87 7.67 2.83 1.19 0.20 Division 2 Hampstead 97,750 14.5 11.5 27 3.27 0.49 1.38 0.16 0.26 0.52 0.82 2.26 0.56 0.72 0.01 0.02 - 0.01 0.76 12.14 2.96 0.99 0.12 Paddington 125,400 17.2 12.1 28 3.33 0.45 1.20 0.16 0.44 0.58 1.07 2.17 0.64 0.63 0.01 0.01 0.02 0.02 0.72 12.05 2.33 1.85 0.26 St. Marylebone 76,160 12.1 13.8 20 4.35 0.38 1.72 0.28 0.39 0.59 1.13 2.46 0.70 0.33 - 0.03 0.05 003 0.50 8.90 1.77 1.01 0.09 St. Pancras 139,100 15.1 13.0 27 3.83 0.44 111 0.24 0.48 0.85 1.26 2.47 0.58 0.74 0.01 0.02 0.01 0.05 0.86 14.31 2.81 1.78 0.26 Westminster, City of 100,000 12.5 11.9 34 3.45 0.36 1.03 0.21 0.35 0.66 0.84 2.42 0.56 0.60 - 0.01 - 0.01 0.82 10.18 3.72 1.78 0.12 Division 3 Finsbury 35,620 17.8 14 3 22 4.01 0.56 1.29 0.17 0.53 0.98 1.60 2.61 0.65 1.52 - - 0.03 0.93 25.18 5.36 1.97 0.45 Holborn 24,540 11.8 12.4 35 3.59 0.33 1.22 0.04 0.65 0.45 1.59 2.32 0.53 0.86 - - - 0.33 10.35 1.34 1.83 - Islington 235,800 16.4 13.3 28 4.18 0.47 1.30 0.19 0.29 0.65 1 .38 2.58 0.52 1.58 0.07 0.03 0.01 0.03 0.54 13.48 4.45 1.54 0.18 Division 4 Hackney 170,800 15.0 12.5 29 3.78 0.30 110 0.17 0.33 0.63 1.52 2.27 0.39 1.88 0.01 0.04 0.46 12.69 2.65 0.95 0.12 Shoreditch 45,010 18.4 13.4 16 3.75 0.56 1.33 0.29 0.36 0.64 1.76 2.42 0.29 1.69 0.02 0.04 0.02 0.98 21.37 2.22 1.49 0.16 Stoke Newington 49,440 17.4 12 4 30 3.94 0.38 0.99 0.24 0.30 0.89 1 .29 2.06 0.40 2.31 - - - 006 0.55 22.25 5.93 0.87 0.14 Division 5 Bethnal Green 58,000 17.1 13.5 22 3.74 0.52 1.05 0.24 0.14 0.72 1.98 2.52 0.45 1.76 0.02 - - 0.02 0.79 23.10 3 53 1.41 0.16 City of London (a) 5,200 7.5 13.1 77 3.27 0.19 1.35 0.19 0.58 0.96 0.77 2.88 0.96 0.38 — - - - 0.19 5.0 0.58 2.88 - Poplar 73,260 17.3 12.8 32 3.79 0.67 1.16 0.16 0.37 0.59 1.56 2.21 0.44 1.77 0.01 - - 0.01 1.53 24.04 4.78 1.13 0.12 Stepney 98,850 18.8 13.8 21 4.70 0.42 1.05 0.27 0.47 0.79 1.41 2.35 0.52 1.38 - 0.01 - 0.09 0.98 14.71 2.33 1.75 0.16 Division 6 Deptford 76,040 17.0 12.8 22 4.30 0.63 1.08 0.21 0.62 0.60 1.16 2.04 0.33 1.24 - 0.03 - 0.11 0.49 12.09 1.85 2.41 0.13 Greenwich 89,390 15.0 11.2 22 3.28 0.64 0.95 0.13 0.35 0.45 1.05 2.29 0.41 1.03 - - - - 0.32 16.58 4.30 1.35 0.25 Woolwich 149,800 15.1 12.3 28 3.95 0.41 1.25 0.23 0.34 0.67 0.97 2.17 0.40 1.39 - 0.02 0.01 0.05 0.87 19.63 3.50 1.59 0.10 Division 7 Camberwell 179,500 16.3 13.5 26 4.50 0.51 1.24 0.19 0.31 0.55 1.50 2.17 0.41 0.98 - 0.01 0.03 0.03 0.71 11.92 1.66 1.53 0.14 Lewisham 227,200 15.1 11.2 25 3.59 0.34 1.19 0.14 0.26 0.48 1.04 2.07 0.35 0.94 - 0.01 0.04 0.03 0.76 15.61 3.60 1.17 0.15 Division 8 Bermondsey 60,380 17.5 12.4 26 3.58 0.40 1.24 0.10 0.38 0.81 1.32 2.45 0.30 1.31 0.02 0.02 - 0.10 0.46 19.82 1.26 1.47 0.15 Lambeth 229,100 16.7 12.9 25 3.98 0.46 1.21 0.22 0.42 0.74 1.31 2.34 0.42 1.01 0.00 0.02 0.03 0.03 0.53 13.62 2.65 1.73 0.14 Southwark 97,930 18.0 13.5 19 3.97 0.47 1.25 0.17 0.33 0.91 1.67 2.42 0.40 1.46 0.01 0.03 0.01 0.05 0.41 18.28 2.95 1.42 0.14 Division 9 Battersea 117,000 15.9 12.4 28 3.74 0.49 1 .33 0.15 0.39 0.56 1.34 2.21 0.40 0.97 0.01 0.01 0.01 0.03 0.71 22.77 2.91 1.30 0.09 Wandsworth 332,300 13.7 12.9 23 4.09 0.62 1.40 0.16 0.29 0.48 1.24 2.21 0.39 1.21 — 0.01 0.02 0.01 0.93 12.94 2.96 1.43 0.10 London, 1951 3,358,000 15.6 12.6 25 3.87 0.46 1.22 0.19 0.34 0.64 1.26 2.27 0.46 1.10 0.01 0.02 0.02 0.03 0.72 14.64 3.11 1.46 0.15 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 (a) Including Inner and Middle Temple. (b) Rates are per 1,000 home population. 140 Period Annual rate per 1,000 living Annual mortality per 1,000 living (6) 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 Tuberculosis Pneumonia (all forms) Bronchitis Other resp. diseases Heart disease Cancer Diabetes Infants 0—1 Diarrhoea and enteritis 0—2 Puerperal fever Other child.birth Influenza Pulmonary Non.pulmonary 1891-95 30.8 17.3 19.8 (a) 0.53 0.13 0.24 0.02 0.52 0.59 0.41 1 .83 0.80 1.45 2.45 0.48 (a) 0.80 0.07 156 23.8 2.15 2.22 1896-1900 29.7 18.4 18.5 (a) 0.45 0.14 0.14 0.00 0.47 0.57 0.27 1.75 0.69 1.32 1.80 0.35 (a) 0.92 0.07 162 41.3 1.70 1.74 1901-05 28.6 17.7 16.4 (a) 0.20 0.08 0.11 0.07 0.36 0.45 0.17 1.58 0.57 1.46 1.41 0.26 1.31 1.01 0.08 139 30.4 1.64 1.52 1906-10 26.5 17.4 14.9 (a) 0.14 0.04 0.10 0.00 0.29 0.42 0.22 1.39 0.48 1.49 1.22 0.22 1.26 1.11 0.10 114 23.8 1.40 1.47 1911-15 24.0 20.0 14.8 0.02 0.13 0.03 0.05 0 00 0.22 0.43 0.16 1.39 0.39 1.33 1.29 0.21 1.54 1.16 0.11 108 28.0 1.40 1 .57 1916-20 20.0 20.1 15.1 0.04 0.17 0.02 0.03 0.00 0.20 0.28 1.01 1.43 0.34 1.38 1.30 0.19 1.71 1 .28 0.09 92 15.4 1.64 1.72 1921-25 19.9 17.9 12.3 0.01 0.17 0.01 0.04 0.00 0.15 0.17 0.32 1.01 0.19 1.14 0.97 0.16 1.66 1 .38 0.10 71 11.7 1.36 1.63 1926-30 16.2 18.6 12.3 0.02 0.10 0.01 0.02 0.00 0.11 0.16 0.30 0.90 0.14 1.00 0.72 0.16 2.29 1.52 0.12 64 10.2 1.60 1.63 1931-35 13.8 19.5 12.1 0.03 0.08 0.00 0.02 0.00 0.07 0.09 0.26 0.79 0.11 0.85 0.47 0.14 2.99 1.66 0.14 63 11.6 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 0.08 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 0.00 0.00 — 0.02 0.01 0.02 0.57 0.06 0.54 0.73 0.12 2.97 211 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 1951 15.6 20.6 12.6 0.01 0.00 0.00 0.00 — 0.01 0.01 0.24 0.34 0.04 0.64 1.14 0.12 3.87 2.27 0.09 25 0.8 0.06 0.39 (a) Comparable figures are not available for this period. (b) Death.rates from 1939 to 1949 relate to the civilian population only. Death.rates for tuberculosis are expressed per 1,000 total population in Table 10. (c) The rates are per 1,000 total births from 1928 when still births were first registered. Prior to this year the rates are per 1,000 live births, and are estimated to be approx. 0.05 in excess of the rate per 1,000 total births. (d) From 1931 death9 from abortion are exoluded. 141 Table 4—Administrative County of London—Civilian deaths in 1951 by cause Cause Sex 0— 1— 5— 15— 25— 45— 85— 75 + Total 1951 1950 1. Tuberculosis—respiratory M 2 1 - 19 177 395 177 55 826 829 F 1 2 3 34 137 99 33 19 328 396 2. Tuberculosis—other M 1 9 6 7 22 15 5 1 66 62 F . 9 9 7 8 13 4 9 59 60 3. Syphilitic disease M 1 . - — 5 65 55 26 152 143 F — . . - 5 27 25 16 73 67 4. Diphtheria M . . 1 . — . . . 1 4 F — _ _ — - 1 — _ 1 — 5. Whooping.cough M 6 6 . — — — . . 12 16 F 3 6 . — . — — . 9 14 6. Meningococcal infection M 8 3 . . 1 1 . . 13 13 F 3 6 1 . 1 1 . . 12 8 7. Acute poliomyelitis M . . . . 1 . . . 1 24 F . . . . 1 — — — 1 12 8. Measles M 4 9 - . . 1 - — 14 4 F 3 4 3 — . . 1 — 11 . 9. Other infective, &c. diseases M 2 3 3 3 13 22 7 7 60 44 F 1 3 — 2 7 22 4 7 46 51 10. Malignant neoplasm: stomach M . . . . 29 239 210 131 609 582 F . . . 1 17 128 175 171 492 458 11. „ „ Lung, bronchus M . . 2 63 696 401 122 1,284 1,238 F . . . 1 17 91 87 57 253 220 12. „ „ Breast M — . . — . 5 1 1 7 3 F . . . — 79 300 181 154 714 690 13. „ „ Uterus F . . — . 25 128 65 61 279 324 14. Other malignant and lymphatic neoplasms M 2 10 3 8 130 608 744 581 2,086 2,053 F 1 7 9 12 114 565 503 521 1,732 1,738 15. Leukemia, aleukemia and Hodgkins disease M 2 5 12 1 19 18 22 8 87 91 F 1 7 5 2 9 35 15 22 96 77 16. Diabetes M - - 1 2 7 23 36 28 97 86 F 1 1 1 — 7 47 92 64 213 170 17. Vascular lesions, nervous system M . . 2 1 25 331 588 671 1,618 1,525 F . . — 1 38 429 730 1,294 2,492 2.232 18. Coronary disease, angina ... M . . . . 101 1,025 1,026 705 2,857 2,621 F — . . . 13 299 639 806 1,757 1,623 19. Hypertension with heart disease M . . . . 12 191 285 287 775 715 F . . . 4 136 248 457 845 778 20. Other heart disease M . 1 . 9 85 364 747 1,512 2,718 2,448 F . . 1 7 107 381 796 2,747 4,039 3,818 21. Other circulatory disease M 1 . 1 1 18 136 185 380 722 702 F 1 . . 1 17 102 202 513 836 825 22. Influenza M 5 1 — 1 6 104 125 114 356 117 F 3 1 . 2 13 75 127 232 453 139 23. Pneumonia M 68 19 4 1 34 231 309 405 1,071 836 F 58 21 1 3 19 126 247 590 1.658 858 24. Bronchitis M 24 4 2 — 44 680 847 771 2.372 1,658 F 26 7 3 2 15 172 385 851 1.461 980 25. Other diseases of respiratory system M 2 3 5 1 15 107 71 42 246 240 F 1 1 2 1 7 22 48 68 150 114 26. Ulcer of stomach and duodenum M 1 — . 1 29 184 152 98 465 436 F 1 . _ . 4 34 61 66 166 131 27. Gastritis, enteritis and diarrhoea M 27 2 — 1 6 23 9 15 83 107 F 13 5 . 1 6 25 30 33 113 94 28. Nephritis and nephrosis M . . 4 4 32 73 45 39 197 206 F 1 1 5 7 24 62 49 61 210 179 29. Hyperplasia, prostate 30. Pregnancv, childb. : abortn. M . . . . . 23 116 201 340 340 F . . . 4 36 1 1 . 42 38 31. Congenital malformations M 111 17 9 6 15 29 8 3 198 200 F 89 10 4 6 12 33 23 9 186 205 k 142 Table 4—Administrative County of London—Civilian deaths in 1951 by cause Case Sex 0— 1— 1— 15 — 25— 45— 65— 75 + Total 1951 1950 32. Other defined and ill defined diseases M 466 29 25 16 104 333 257 305 1,535 1,585 F 341 17 18 26 138 332 345 585 1,802 1.627 33. Motor vehicle accidents M 1 12 19 29 48 38 22 29 198 151 F . 4 6 5 6 19' 19 25 84 94 34. All other accidents M 26 12 28 26 74 84 60 95 405 406 F 23 16 5 4 30 43 69 217 407 414 35. Suicide M . . 1 12 70 111 42 37 273 278 F . . . 5 36 74 21 13 149 135 36. Homicide, operations of war M . . . 1 5 2 2 — 10 10 F 2 1 — . 2 1 - 2 8 10 ALL CAUSES 760 146 126 152 1,190 6,157 6,554 6,669 21,754 19,773 573 129 76 134 954 3,823 5,225 9,670 20,584 18,579 Table 5—Administrative County of London, Live births and Still.births, 1931.51 Year Live-births Still-births No. Rate per 1,000 total population No. Rate per 1,000 live and still.births 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 45,030 161 1,137 24.6 1944 44,554 16.2 1,138 24.9 1945 45,532 15.7 1,095 23.5 1946 65,883 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 1951 52,387 15.6 1,073 20.1 143 Table 6—Administrative County of London—Infant mortality, 1951 Cause of death Age at death Total Rates per 1,000 live births Under 1 day 1 to 7 days 1 to 4 wks. 4 wks. to 1 yr. No. Male Female Total Male Female Measles ... Leg. — - - 7 7 4 3 0.13 0.15 0.12 Illeg. — — — Whooping-cough Leg. — — — 9 9 6 3 0.17 0.22 0.12 Illeg. — — —/ Influenza... Leg. — — 1 7 8 5 3 0.15 0.19 0.12 Illeg. — — - Tuberculosis Leg. — — - 4 4 3 1 0.08 0.11 0.04 Illeg. — — —/ Bronchitis Leg. — 1 1 48 50 24 26 0.95 0.90 1.02 Illeg. — — —/ Pneumonia Leg. 4 22 23 68 126 68 58 2.41 2.54 2.27 Illeg. — 5 4 Diarrhoea Leg. — — 5 34 40 27 13 0.76 1.01 0.51 Illeg. — — 1 Premature birth.. Leg. 115 84 14 5 247 136 111 4.71 5.08 4.34 Illeg. 17 10 2 Congenital malformation Leg. 30 39 38 88 200 111 89 3.82 4.14 3.48 Illeg. 1 2 2 Birth injury Leg. 69 60 9 2 156 96 60 2.98 3.58 2.34 Illeg. 8 6 2 Other diseases of early fancy Leg. 132 118 16 5 291 174 117 5.55 6.50 4.57 Illeg. 13 6 1 Other causes Leg. 4 9 101 149 195 106 89 3.72 3.96 3.48 Illeg. 22 1 - All causes Leg. M. 195 209 72 222 1,207 698 509 24.74 27.99 21.34 F. 161 124 45 179 Illeg. M. 23 16 10 13 126 62 64 35.03 33.48 36.68 F. 36 14 2 12 Total, 1951 415 363 129 426 1,333 760 573 25.45 28.37 22.38 Total 1950 371 392 139 470 1,372 824 548 25.75 30.03 21.20 1950 Leg. M. 193 228 70 255 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 Table 7—Administrative County of London—Infant mortality by cause, 1915.51 (Rates per 1,000 live births) Cause of death 1915 to 1918 1919 to 1922 1923 to 1926 1927 to 1930 1931 to 1934 1935 to 1938 1939 to 1942 1943 to 1948 1947 1948 1949 1950 1951 Measles 3.84 1.64 2.02 2.07 1.44 0.95 0.22 0.21 0.11 0.11 0.05 - 0.13 Whooping.cough 4.45 2.50 2.60 3.14 2.27 2.01 1.43 1.07 0.76 0.67 0.35 0.39 0.17 Influenza 1.10 0.81 0.38 0.48 0.40 0.24 0.39 0.29 0.17 0.07 0.27 0.17 0.15 Tuberculosis 3.20 1.52 1.26 0.89 0.77 0.56 0.63 0.36 0.35 0.28 0.09 017 0.08 Bronchitis 6.72 4.42 2.91 2.30 2.16 1.97 1.81 1.36 0.94 1.03 0.64 0.83 0.95 Pneumonia 14.96 12.60 11.51 12.10 11.45 10.39 7.64 6.74 5.61 4.37 3.31 2.36 2.41 Diarrhoea 16.10 12.16 9.36 8.87 10.86 12.10 6.96 6.93 4.30 2.54 1.54 1.16 0.76 Premature Birth 17.42 17.00 14.74 14.17 14.91 13.41 12.51 10.38 7.21 6.76 6.31 4.65 4.71 Congenital mal., etc. 14.66 11.26 8.39 7.38 7.22 6.35 10.08 11.96 10.75 11.27 11.30 12.33 12.35 Other causes 20.55 15.09 11.83 12.60 13.52 12.30 8.14 5.83 4.21 3.56 2.97 3.68 3.72 All causes 103 79 65 64 65 60 50 45 34 31 27 26 25 144 Table 8—Administrative County of London and England and Wales—Maternal mortality (excluding abortion)—1942.51 (Rates per 1,000 total births) 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 Puerperal sepsis:— London 0.29 0.24 0.17 0.26 0.12 0.12 0.13 0.02 — 0.06 England and Wales 0.42 0.39 0.28 0.24 0.18 0.16 0.13 0.11 0.12 0.10 Other causes:— London 1.27 1.06 0.85 1.09 0.80 0.55 0.37 0.38 0.53 0.39 England and Wales 1.60 1.44 1.24 1.23 1.06 0.86 0.73 0.71 0.60 0.56 Table 10—Administrative County of London—Primary notifications (a) of, and deaths from, tuberculosis 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 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 0.36 529 0.16 122 0.04 1951 4,897 1.46 1,154 0.34 507 0.15 125 0.04 (a) Excluding posthumous cases. Table 9—Administrative County of London—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—1931.1951 Year Anthrax Meningococcal infection Continued fever Diphtheria Dysentery Acute Encephalitis (g) Enteric fever Erysipelas Malaria Measles Ophthalmia neonatorum Pneumonia Poliomyelitis Puerperal pyrexia Scabies Scarlet fever Smallpox Typhus Whooping cough Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Oases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate 1931 2 0.0005 175 0.040 3 0.0007 8,384 1.90 58 0.013 40 0.009 186 0.042 2,294 0.521 32 0.007 (b) (b) 629 (f) 9.60 6,880 1.562 56 0.013 828 (a) 12.20 (b) (b) 12,025 2.73 1,452 0.330 — — (b) (b) 1932 3 0.0007 247 0.057 4 0.0009 8,087 1.87 79 0.018 47 0.011 195 0.045 2,230 0.515 41 0.009 (b) (b) 687 11.10 5,673 1.309 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 56 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 1.91 916 0.224 8 0.002 216 0.053 1,764 0.432 42 0.010 (b) (b) 453 8.26 4,798 1.175 108 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 (c) 10,537 1.87 1939 3 0.0008 169 0.045 3 0.0008 3,671 0.974 268 0.071 11 0.003 98 0.026 1,388 0.368 17 0.005 1,303 0.35 408 8.07 3,733 0.990 98 0.026 704 13.05 (b) (6) 5,677 1.51 — — — — 2.80 1940 3 0.001 839 0.274 6 0.002 1,844 0.601 161 0.052 8 0.003 158 0.052 1,076 0.351 16 0.005 5,447 1.78 303 7.10 2,688 0.876 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 (b) (b) 4,416 1.84 2 0.0008 — — 6,234 2.60 1943 4 0.002 231 0.093 1 0.0004 1,862 0.747 1,103 0.442 4 0.002 47 0.019 1,054 0.423 35 0.014 22,882 9.18 233 5.19 3,159 1.267 43 0.017 471 10.20 9,689 (d) 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 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 (e) — — 184 0.059 — — 747 0.240 845 0.272 6 0.002 44 0.014 844 0.271 168 0.054 22,846 7.35 268 4.08 2,125 0.683 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 3.13 1949 (e) 3 0.0009 76 0.023 — — 221 0.065 440 0.130 4 0.001 58 0.017 583 0.173 21 0.006 28,816 8.54 186 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. 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 Cases 267 Rate 0.079 Cases 163 Rate 0.048 371 6.83 823 0.24 4,157 1.23 — — — — 10,875 3.21 1951 (e) 1 0.0003 108 0.032 — — 30 0.009 4,069 1.212 19 0.006 66 0.020 496 0.148 23 0.007 49,148 14.64 93 1.78 2,409 0.717 61 0.018 51 0.015 911 17.04 572 0.17 3,705 1.10 — — 1 0.0003 10,448 3.11 (a) Rate per 1,000 total births. (6) Comparable figures not available for this period, (c) Cases relate to last quarter only — Rates are adjusted on an annual basis (d) Cases relate to last 22 weeks only—Rates are adjusted on an annual basis. (e) In order to preserve uniformity with published national figures the recently instituted practice of the Registrar.General has been followed in producing this table, namely in taking full account of any known changes in diagnosis after the receipt of the original notification. These corrections were not available prior to 1944, and for 1931.43 uncorrected figures are given, but on the basis of dual records kept from 1944.47, comparable figures can be obtained by multiplying the uncorrected notifications by the following factors:—Meningococcal infection 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. (f) Rate per 1,000 live births (g) Up to 1949 the figures relate to encephalitis lethargica. 145 Table 11(a)- Administrative County of London -Primary notifications of tuberculosis, 1951 Form of tuberculosis notified Sex Number of formal primary notifications of new cases of tuberculosis Total all ages 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Pulmonary tuberculosis M. 11 126 91 52 191 309 608 466 400 380 189 2,823 f. 14 109 76 51 281 435 595 271 122 71 49 2,074 Other forms of tuberculosis m. 4 25 35 22 19 22 44 18 11 6 10 216 F. 3 33 33 15 36 46 61 35 12 10 7 291 All forms of tuberculosis M. 15 151 126 74 210 331 652 484 411 386 199 3,039 F. 17 142 109 66 317 481 656 306 134 81 56 2,365 Table 11(6)—New cases of tuberculosis recorded by means other than notification, 1951 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 16 18 8 36 145 386 177 130 115 106 1,140 F. 1 17 21 11 46 239 353 107 51 21 25 892 Other forms of tuberculosis M. — 1 4 4 12 9 18 9 1 3 5 66 F. — 4 4 6 4 13 22 7 6 1 9 76 All forms of tuberculosis M. 3 17 22 12 48 154 404 186 131 118 111 1,206 F. 1 21 25 17 50 252 375 114 57 22 34 968 The sources of information as to the unnotified cases shown above were as follows:— Source of information Number of cases Pulmonary Non-pulmonary Death returns from local registrars 147 18 transferable deaths from Registrar-General 81 16 Posthumous notifications 40 4 " Transfers " from other areas 1,706 98 Other sources 58 6 Table 11(c)—Numbers on the registers, 1942-51 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 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 19,119 Females 9,441 10,232 10,990 11,496 12,262 12,862 13,.549 14,223 15,031 15,556 Other forms— Males 2,785 2,847 2,866 2,813 2,821 2,699 2,889 2,752 2,591 2,520 Females 2,963 3,074 3,185 3,123 3,099 3,142 3,147 3,015 3,068 2,954 Total 28,083 29,761 31,381 32.450 33,877 35,077 36,809 38,193 39,780 40,149 No per 1,000 of population 11.7 11.9 12.7 12.5 10.9 10.6 11.0 11.3 11.7 12.0 146 Table 12(a)—Administrative County of London—Primary notifications of tuberculosis, 1946.51, by age and sex Rates per 1,000 living (i) Pulmonary Sex Age 1946 1947 1948 1949 19 50 19 51 No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—4 105 0.90 108 0.81 149 1.08 153 1.08 162 1.15 137 0.98 5—14 175 0.98 187 1.01 158 0.87 153 0.82 141 0.75 143 0.74 15—44 1,787 2.61 1,809 2.56 1,873 2.66 1,886 2.70 1,711 2.46 1,574 2.18 45 + 849 1.45 973 1.61 957 1.60 1,093 1.84 945 1.59 969 1.91 All males 2,916 1.87 3,077 1.89 3,137 1.93 3,285 2.03 2,959 1.83 2,823 1.80 Females 0—4 81 0.73 96 0.76 124 0.94 126 0.94 116 0.86 123 0.92 5—14 177 101 174 0.96 171 0.96 188 1.04 140 0.77 127 0.68 15—44 1,682 2.32 1,811 2.41 1,797 2.40 1,821 2.45 1,740 2.34 1,582 1.98 45 + 281 0.40 263 0.36 244 0.34 279 0.39 234 0.33 242 0.36 All females 2,221 1.30 2,344 1.32 2,336 1.32 2,414 1.36 2,230 1.26 2,074 1.16 Total 5,137 1.57 5,421 1.59 5,473 1.61 5,699 1.68 5,189 1.53 4,897 1.46 (ii) Non.Pulmonary Males 0—4 43 0.369 69 0.520 55 0.398 39 0.275 34 0.241 29 0.207 5—14 89 0.499 87 0.472 87 0.479 75 0.40.1 50 0.265 57 0.294 15—44 143 0.209 118 0.167 116 0.165 109 0.156 114 0.164 103 0.143 45 + 24 0.041 36 0.060 29 0.048 32 0.054 29 0.049 27 0.053 All males 299 0191 310 0.190 287 0.177 255 0.157 227 0.140 216 0.138 0—4 44 0.397 56 0.444 38 0.289 42 0.312 40 0.296 36 5—14 96 0.550 71 0.391 69 0.388 68 0.375 49 0.271 48 0.257 15—44 144 0.198 190 0.253 171 0.229 159 0.214 183 0.247 178 0.223 45 + 28 0.040 35 0.048 35 0.049 29 0.041 30 0.042 29 0.043 All females 312 0.183 352 0.198 313 0.176 298 0.168 302 0.171 291 0.162 Total 611 0.187 662 0.194 600 0.177 553 0.163 529 0.156 507 0.150 Table 12(6)—Deaths from tuberculosis by age and sex (i) Pulmonary Males 0—4 16 0.14 12 0.09 8 0.06 3 0.02 7 0.05 3 0.02 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 0.34 196 0.27 45 + 731 1.25 748 1.24 762 1.27 719 1.21 585 0.99 627 1.23 All males 1,238 0.79 1,264 0.78 1,235 0.76 1,046 0.65 829 0.51 826 0.53 Females 0—4 9 0.08 13 0.10 7 0.05 4 0.03 __ 3 0.02 5—14 5 0.03 8 0.04 6 0.03 4 0.02 0 0.01 3 0.02 15—44 498 0.68 527 0.70 487 0.65 342 0 46 238 0.32 171 0.21 45 + 190 0.27 232 0.32 165 0.23 189 G.26 156 0.22 151 0.22 AH females 702 0.41 780 0.44 665 0*37 539 0.30 396 0.22 328 0.18 Total 1,940 0.59 2,044 0.60 1.900 0.56 1,585 0.47 1,225 0.36 1. 154 0.34 (ii) Non.Pulmonary Males 0—4 31 0.266 30 0.226 26 0.188 13 0.0S2 6 0.043 10 0.071 5—14 25 0.140 20 0.109 10 0.055 12 0.065 6 0.032 6 0.031 15—14 38 0.056 44 0.062 38 0.054 36 0.052 25 0.036 29 0.040 45 + 22 0.048 38 0.063 29 0.048 34 0.057 25 0.042 21 0.041 All males 116 0.074 132 0.081 103 0.063 95 0.059 62 0.038 66 0.042 Females 0—4 33 0.298 19 0.151 23 0.175 16 0.119 10 0.074 9 0.067 5—14 20 0.115 16 0.089 11 0.062 7 0.039 7 0.039 9 0.048 15—44 44 0.061 48 0.064 35 0.047 20 0.027 16 0.022 15 0.019 45 + 30 0.043 37 0.051 30 0.042 18 0.025 27 0.038 26 0.039 All females 127 0.074 120 0.067 99 0.056 61 0.034 60 0.034 59 0.033 Total 243 0.074 252 0.074 202 0.059 156 0.046 122 0.036 125 0 037 147 Table 13—Administrative County of London—Primary notifications of non.pulmonary tuberculosis 1946.51, distribution according to site Rates per 1,000 living are shown in parentheses against the number of cases Age group Year Site of tuberculosis lesion Bones and Joints Abdomen Peripheral glands Meninges Other sites («) 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) 1951 30 (0.046) 4 (0.006) 62 (0.095) 49 (0.075) 25 (0 038) 170 (0.260) 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) 1951 107 (0.040) 37 (0.014) 97 (0.036) 17 (0.006) 98 (0.036) 356 (0.132) (a) Includes miliary and genito.urinary. Table 14.—Administrative County of London—Cases of infectious illness reported from schools in 1951 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 1951 16,756 26 2,193 212 15,045 6,127 1,685 29 138 73 1,811 3,338 Conjunctivitis : The increase in 1951 was due to a local outbreak in schools in Stoke Newington. The epidemic was on the wane at the end of the term and did not recur after the holiday. 148 Table 15—School leavers contra-indications for employment (a) Contra-indications Boys Girls No. Per cent, of inspected pupils (11,702) No. Per cent, of inspected pupils (12,309) Heavy manual work 364 3.1 317 2.6 Sedentary work 25 0.2 22 0.2 Indoor work 12 0.1 11 (0.09) Exposure to bad weather 181 1.5 238 1.9 Wide changes of temperature 72 0.6 76 0.6 Work in damp atmosphere 125 1.1 153 1.2 Work in dusty atmosphere 122 1.0 112 0.9 Much stooping 25 0.2 38 0.3 Climbing 80 0.7 98 0.8 Work near moving machinery or moving vehicles 47 0.4 48 0.4 Prolonged standing, much walking or quick movement from place to place 151 1.3 256 2.1 Eye strain 890 7.6 1,060 8.6 Normally acute vision 789 6.7 778 6.3 Normal use of hands 3 (0.03) 4 (0.03) Work requiring freedom from damp hands or skin defects 12 0.1 19 0.2 Handling or preparation of food 74 0.6 73 0.6 Normal hearing 64 0.5 47 0.4 Any other work which would be unsuitable 13 0.1 5 (0.04) No. of pupils with contra.indications (6) 2,052 17.5 2,175 17.7 (а) Excluding special schools and certain grammar schools at which the leaver contraindications slip is not in use. (б) 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. Children recommended far ascertainment as handicapped pupils Table 16—Vision cases A. Children not in special schools :— Boys Girls Total Found to be blind 5 3 8 Found to be partially sighted 50 37 87 Found to be fit for ordinary school with " care " 37 47 84 Found to be fit for ordinary school 17 12 29 B. Children already in attendance at special schools Boys Oirls Total Found to be no longer blind 1 — 1 Found to be no longer partially sighted 3 6 9 Recommended to continue blind school 2 1 3 Recommended to continue partially sighted school 9 9 18 Recommended for transfer from blind school to partially sighted school 1 - 1 Recommended for transfer from partially sighted school to blind school 6 4 10 Recommended for treatment before decision — — — 131 119 250 149 Table 17—Hearing cases A. Children not in special schools :— Boys Qirls Total Found to be deaf 54 29 83 Found to be partially deaf 31 20 51 Found to be suitable for ordinary school with individual hearing aid and/or to sit in front row, etc. 27 13 40 Found to be suitable for ordinary school 8 12 20 Recommended for treatment before decision made 7 2 9 B. Children in special schools :— Found to be no longer deaf - 1 1 Found to be no longer partially deaf 10 8 18 Recommended to continue deaf school ... 8 4 12 Recommended to continue partially deaf school 5 5 10 Recommended for transfer from deaf school to partially deaf school 3 1 4 Recommended for transfer from partially deaf school to deaf school 1 2 3 154 97 251 Table 18—Epilepsy cases A. Children not in special schools. Boys Girls Total Found suitable for boarding special schools for epileptics 9 4 13 Found suitable for ordinary school 12 7 19 Found suitable for E.S.N, school 6 3 9 Found suitable for P.H. school 4 2 6 Found to be ineducable — — — Home tuition recommended — 1 1 Recommendation postponed 1 1 2 32 18 50 B. Two boys and one girl from boarding special schools for epileptics were examined and found to be fit to attend ordinary schools. Table 19— Educationally subnormal A. Children not in special schools :— Boys Girls Total Found suitable for day E.S.N, schools Over 11 84 80 164 Under 11 310 207 517 Found suitable for boarding E.S.N, schools Over 11 18 18 36 Under 11 46 24 70 Found suitable for special E.S.N, classes in O.S. Over 11 69 43 112 Under 11 256 148 404 Found to have no disability of mind Over 11 64 39 103 Under 11 307 99 406 Found to be unsuitable for school (e.g., ineducable) Over 11 4 2 6 Under 11 67 40 107 Decision postponed Over 11 — — — Under 11 15 10 25 1,240 710 1,950 150 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 29 11 40 Found to be suitable for transfer to special E.S.N, classes in ordinary schools 14 3 17 Found to be unsuitable for retention because ineducable, etc. 59 33 92 Found to be suitable to continue in special E.S.N, school 39 41 80 Recommended for transfer to boarding special E.S.N, school 29 13 42 Examined with a view to considering action under Section 57 (5) 190 133 323 360 234 594 B. (ii) Children in attendance at special E.S.N, classes in ordinary schools :— Boys Oirls Total Found to be no longer in need of special educational treatment 31 10 41 Found to be suitable for transfer to special E.S.N, schools 23 11 34 Found to be suitable to continue in E.S.N, class 22 15 37 76 36 112 In addition, 13 children were considered for action under Section 8 of the Education (Miscellaneous Provisions) Act, 1948. 6 children were found to be still ineducable and in the cases of 7 children it was recommended that the report should be withdrawn. Table 20—Delicate children 1,173 children (716 boys and 457 girls) were recommended for admission to boarding schools for delicate children. 451 children (245 boys and 206 girls) were recommended for admission to day schools for delicate children. 328 (182 boys and 146 girls) were found to be no longer in need of special educational treatment in day schools for delicate children while 42 (29 boys and 13 girls) were recommended for transfer from day to boarding schools. Table 21—Physically handicapped children A. Children not in special schools :— Boys Oirls Total Found to be suitable for day special schools for physically handicapped children (see (i) below) 141 121 262 Found to be suitable for boarding schools for physically handicapped children (see (i) below) 2 7 9 Found to be suitable for ordinary schools (see (ii) below) 16 10 26 Found to be unsuitable for education at school but suitable for home tuition or tuition in hospital 31 39 70 190 177 367 151 (i) Number of these children recommended for schools for physically handicapped children:— Morbid condition Day Boarding Grand Total Boys Girls Total Boys Girls Total Infantile paralysis 32 30 62 — — 62 Cerebral palsy 19 19 38 — 2 2 40 Various paralyses 2 — 2 — — — 2 T.B. bones and joints 7 5 12 1 — 1 13 Osteomyelitis 4 4 8 — — — 8 Perthes disease 11 3 14 — — — 14 Congenital deformities 17 7 24 — 2 2 26 Spinal deformities (including scoliosis) 3 2 5 — 2 2 7 Traumata and amputations 3 3 6 — — — 6 Non-T.B. arthritis and synovitis — 4 4 — — — 4 Rheumatism and chorea — 2 2 — — — 2 Heart disease, congenital 8 7 15 — — — 15 Heart disease, other 13 15 28 — — — 28 Other diseases 22 20 42 1 1 2 44 141 121 262 2 7 9 271 (ii) Number of these children recommended for ordinary school:— Morbid condition Boys Girls Total Infantile paralysis 2 4 6 Cerebral paralysis 1 — 1 Perthes disease 3 — 3 Spinal deformities (including scoliosis) — 2 2 Traumata and amputations 1 2 3 Rheumatism and chorea — 1 1 Heart disease, congenital 4 — 4 Heart disease, other 1 1 2 Other diseases 4 — 4 Total 16 10 26 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) 65 61 126 Found to be medically unfit to remain in special school... — 2 2 Other recommendations (see (ii) below) 26 28 54 91 91 182 152 (i) Number of these children found to be no longer in need of special educational treatment:— Morbid condition Day Boarding Grand Total Boys Girls Total Boys Girls Total Infantile paralysis 3 11 14 — — — 14 Cerebral paralysis 2 2 4 — 1 1 5 T.B. of bones and joints 4 11 15 1 — 1 16 Osteomyelitis 2 1 3 1 — 1 4 Perthes disease 9 1 10 — — — 10 Congenital deformities 5 8 13 — — — 13 Spinal deformities (including scoliosis) — 2 2 — — 2 Traumata and amputations 5 2 7 — 1 1 8 Non-T.B. arthritis and synovitis — — — 1 — 1 1 Rheumatism and chorea 1 3 4 — — — 4 Heart disease, congenital 10 5 15 1 — 1 16 Heart disease, other 10 10 20 — — — 20 Other diseases 9 3 12 1 — 1 13 60 59 119 5 2 7 126 (ii) Other recommendations :— Morbid oondition Day P.H. Schools Boarding 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 3 1 4 — 1 1 — 1 1 — — — 6 Cerebral paralysis 2 3 5 — 2 2 7 T.B. of bones and joints 3 1 4 — — — — — — — — — 4 Congenital deformities 2 3 5 1 — 1 — — — — — — 6 Spinal deformities (including scoliosis) — — 2 2 — — 2 Traumata and amputations 1 — 1 1 Rheumatism and chorea — — — 1 — 1 — — — — — — 1 Heart disease,congenital 2 — 2 1 1 2 4 Heart disease, other 3 2 5 1 — 1 — 1 1 — — — 7 Other diseases 6 7 13 — 3 3 — — — — — — 16 22 17 39 4 7 11 — 4 4 — — — 54 Table 22—Dual defects The following children were found on examination to suffer from more than one handicap :— Boys Qirls Total Recommended for Ravners Boarding Special School 6 5 11 „ „ other schools for dual defects 1 5 6 „ „ P.H. schools 7 6 13 „ „ partially sighted schools — 1 1 „ „ home tuition 3 5 8 Found to be blind, deaf and ineducable 1 — 1 „ „ „ P.H. and ineducable — 1 1 18 23 41 153 Table 23—Speech defects Children in attendance at ordinary schools:— Boys Oirls Total Recommended for speech therapy because of stammer 174 41 215 Recommended for speech therapy because of speech defect 273 113 3S6 Found to be unsuitable for speech therapy 46 17 63 493 171 664 Children in attendance at special E.S.N, schools:— Boys Girls Total Recommended for speech therapy because of stammer 27 9 36 Recommended for speech therapy because of speech defect 107 62 169 134 71 205 Table 24 Maladjusted children Boys Girls Total Found to be maladjusted and suitable for residential placement 138 44 182 Found to be maladjusted and suitable for special classes 68 21 89 Found to be no longer in need of special educational treatment ax maladjusted 26 5 31 232 70 302 In addition, one boy at a boarding special school was recommended to be allowed to return home and attend special classes, and two boys attending special classes were recommended for admission to a boarding special school. Table 25—Nominations for in-patient treatment under the Rheumatism Scheme, 1949-1951 1949 1950 1951 Received from hospitals 238 185 115 „ „ rheumatism supervisory centres 78 66 59 „ „ school doctors 17 8 2 „ „ other sources (private practitioners, welfare organisations, etc.) 11 11 9 344 270 185 Number outstanding from previous year 4 5 4 348 275 189 Number withdrawn before consideration — 1 — 348 274 189 Found unsuitable for admission to unit 6 7 4 Died before admission — — — Parents' consent to admission refused — 2 1 Accepted nominations subsequently withdrawn 5 8 3 Admitted to rheumatism unit 331 250 177 Removed from scheme (not rheumatic) 1 3 — Awaiting admission on 31st December 5 4 4 348 274 189 154 Supervision 1949 1950 1951 Number of children under supervision of school doctors on 31st December 375 306 186 Number of children under supervision at rheumatism supervisory centres on 31st December 3,021 2,790 2,696 Number of supervisory centres 24 24 24 Number of sessions at supervisory centres 988 930 905 Number of children attending for first time 1,375 1,224 1,100 Total number of attendances at centres 10,887 10,088 9,202 Table 26—Condition on discharge in 1951 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 72 82.7 12 13.8 2 2.3 1 1.2 87 Girls 64 76.2 12 14.3 8 9.5 — — 84 Total 136 79.5 24 14.0 10 5.0 1 0.6 171 Table 27—Percentage number of children with cardiac involvement admitted to the special rheumatism units, 1937.1951 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 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 49.1 Table 29—Treatment of venereal disease at London clinics New Cases Total venereal cases Total non.venereal cases Total attendances Year Syphilis S. Ch ancre 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 8,234 188,450 155,332 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 1951 1,077 549 105 6 5,060 1,028 6,242 1,573 16,443 5,648 200,778 101,787 155 Table 28—Admissions of London children to Queen Mary's Hospital, Carshalton, in 1951 Sex Articular rheumatism Chorea Articular rheumatism and chorea Percentage with Valvular damage Percentage with 1 Valvular damage Percentage with Valvular damage No. admitted Carditis Pericarditis only Mitral Mitral and aortic and pericarditis No cardiac involvement No. admitted Carditis Pericarditis only Mitral Mitral and aortic and pericarditis No cardiac involvement No. admitted Carditis Pericarditis only Mitral Mitral and aortic and pericarditis No cardiac involve. I ment Boys 82 20.7 1.2 23.2 13.4 - 41.5 11 9.09 - 9.09 - - 81.82 - - - - - Girls 65 20.0 — 24.6 — — 55.4 16 18 75 — 18.75 — — 62.50 3 66.7 — — — — 33.3 Total 147 20.4 0.7 23.8 7.5 — 47.6 27 14.8 — 14.8 — — 70.4 3 66.7 — — — — 33.3 156 Table 30 Statistics of the administrative work carried out by the Metropolitan Borough Councils in 1951 Borough No. of houses in borough Public Health Act Housing Acts, 1936 No. of houses inspected on account of complaints or illness No. of statutory notices served No. of prosecutions No. of houses repaired or nuisances remedied No. of houses inspected Section 25 Section 9 and 10 Number of houses demolished Closing Orders Overcrowding No. of dwellings for working oliisses erected during the year Underground rooms Houses let in lodgings No. of houses represented No. of houses demolished iNO. Ot houses repaired No. of families overcrowded No. of families alternative accom. obtained Xo. occupied but unlit No. closed or modified occupation approved No. of closing orders determined No. in borough No. of inspections No. of prosecutions No. of complaints ' remedied No. made No. determined i*y owners By L.A. Section 11 Voluntarily City of London 1,100 9 2 - 5 15 - - 7 - - - 3 1 - 5 - 19 9 — Battersca 27,480 4,132 1,816 202 8,756 — — — 4 1 1 — — 1 151 69 115 * 14 1 * * * * Bermondsey 15,735 4,470 4,510 48 4,210 560 — — — — 12 — 6 215 171 42 855 2 — 397 28 — 5 Bethnal Green 15,827 4,475 4,389 128 2,506 182 — 9 — — 23 — — — 672 330 83 * 5 — 180 405 — — Camberwell 40,852 7,621 2.098 147 3,823 — — 16 15 2 1 - 13 2 171 129 192 * 20 15 * ‡ ‡ — Chelsea 15,630 3,002 413 12 178 315 71 28 4 - — — 52 67 32 — - — 575 * — Deptford 16,155 3,539 972 14 2,495 — — — — — - 3 — 127 88 27 2 2 1 * — — — Finsbury 8,065 5,603 102 14 774 44 — — — — 60 - 4 4 1,200 55 200 1,200 17 16 456 — — 2 Fulham 32,048 4,981 2,120 461 3,811 — — — 1 2 2 — 3 — 103 51 190 255 — — — — — Greenwich 22,155 2.188 231 6 1,519 274 — 2 — — — - 2 — 286 110 369 67 13 1 12 27 — Hackney 39,776 8,638 MM 184 5,621 165 — 219 37 3 1 8 1.145 451 327 - 1 4 — — — Hammersmith 35,760 1.197 2,064 334 2,194 — 10 — 3 — — — — — 243 8H 73 * 15 12 9,600 ‡ — j Hampstead 20,665 3,071 119 11 1,960 33 — — 14 70 128 492 20 — 1,573 1,040 — 820 Holborn 5,725 713 44 4 595 — — — — — — 12 — - 180 47 490 14 — 299 270 — 41 Islington 44,076 10,070 6,850 260 7,191 724 38 — 1 1 17 47 1 - 602 369 198 * 27 2 * ‡ * — Kensington 37,006 4,812 1,125 70 2,397 955 48 20 55 7 7 8 7 — 254 128 124 3,872 38 45 4,000 3,110 ‡ ‡ Lambeth 51,410 12,890 2,074 335 5,921 — — — — — 15 4 3 1 100 84 192 * 2 1 * ‡ ‡ + + Lewisham 61,800 3,402 1,056 63 9,923 180 — — 38 7 16 — 5 1 158 102 163 — — — * 2 — — Faddington 23,319 5,370 1,093 35 1,965 — — — 15 2 1 1 4 3 554 269 18 * 236 10 5,879 1,342 3 201 Poplar 17,328 3,669 1,317 88 3,438 129 — — — — 4 — — — 144 101 48 1,840 7 — 144 13 - — St. Marylebone 22,772 2,567 298 8 802 28 28 — — 4 4 1 170 47 124 2,280 20 3 1,867 8 745 2 53 St. Pancras. 26,834 6,666 3,277 148 5,367 166 — — — — 6 — 10 — 484 689 233 1 000 170 16 5,000 ♦ ♦ 46 — Shoreditch 11,510 5,142 515 24 4,189 3,047 — — — — — — — — 482 92 169 258 9 — * * * • Southwark 24,571 4,383 1,077 13 2,305 283 26 — — — 4 136 2 — 216 112 102 106 18 — — — — — Stepney 31,561 8,181 1,327 34 4,976 39 13 — — — 2 — — — 217 158 115 3,760 77 39 1,770 938 8 Stoke Newington 8,500 1,826 272 9 1,162 33 10 60 3 1 — — 53 24 52 — 6 1 10 — — —— Wandsworth 95,890 11,013 5,620 87 4,930 — — — — 4 — — — — 151 60 252 12 28 — 3 11 1 Westminster, City of 22,914 2,332 34 1 1,306 642 1 1 106 45 219 2,506 60 28 3,350 3,351 1 3 Woolwich 39,105 7,093 1,142 41 16,986 382 — — — 1 6 — — — 91 47 227 * — 3 — — — — Total 805,658 145,455 4 8,948 2,781 111,605 8,196 145 75 503 98 185 218 76 20 8,859 4,054 4,024 18,745 1,076 198 35,134 19,291 52 1,134 167 Borough Table 30 (continued) Cowsheds Slaughterhouses Offensive trades Smoke nuisancer Common lodging houses Cleansing of persons and rooms Water supply Dairies and milk shops Ice.cream premises Restaurants ami eating houses No. licensed No. of inspections No. licensed No. of inspections No. authorised No. of inspections Observations Intimations Complaints Notices Houses licensed tfo. of inspections Persons Booms 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 — — — — 1 3 110 * 7 — — 4 426 2,436 18 2 - 35 52 81 145 631 1,391 Battersea 1 39 2 2 179 1 9 1 — — 200 1,858 673 236 14 141 287 176 490 195 953 Bermondsey — 9 62 412 2 — 2 94 155 1,432 14 608 — 109 287 140 63 59 367 Bethnal Green 1 1 — — 1 6 54 13 44 708 131 163 135 267 138 289 Camberwell 1 — 3 16 5 3 49 — 11 — 1 52 84 1,521 984 1,362 15 204 111 380 438 319 477 Chelsea 26 10 — 242 485 119 194 11 44 93 71 237 222 722 Deptford — — 2 — 2 12 — — — — 1 6 516 864 36 1,344 — 129 181 186 361 107 590 Finsbury 3 57 89 2 1 21 178 1,200 264 361 4 82 238 117 113 491 239 Fulham — — 844 — 24 — — 43 17 198 646 2 119 250 194 244 156 2,649 Greenwich — — — — — — 57 1 8 — — — 52 591 289 15 1 67 124 202 436 166 406 Hackney 1 6 5 10 1,310 13 12 2 1 10 141' 858 810 423 17 183 300 315 393 240 544 Hammersmith — — 2 — — — 94 3 3 — — — 399 1,281 254 613 6 81 301 232 259 242 570 Hampstead — — — — — — 25 1 17 — — — 14 18 491 174 86 74 158 142 200 181 785 Holborn — — 171 2 11 2 7 147 4 94 181 22 70 32 74 148 524 1,791 Islington — — 5 48 12 263 139 4 29 1 — — 234 1,031 544 833 83 396 1.003 484 443 627 2,326 Kensington — — — — — 18 — 11 — — — 239 1,585 466 677 11 162 424 272 231 215 224 Lambeth — — 1 2 2 13 58 6 26 — — — 183 66 993 1,964 5 204 235 600 123 230 554 Levvisham — — 2 6 — — 24 — 4 — — — 76 1,015 545 126 — 142 258 343 554 365 588 Paddington — — — — — — 35 — 5 — 1 4 458 83 305 1,212 57 115 318 170 278 142 808 Poplar — — 3 — 2 — 85 4 20 — 2 64 66 509 759 573 — 147 276 162 146 228 151 St. Marylebone 1 10 121 — 8 2 60 535 544 317 429 24 162 210 159 161 S34 1,124 St. Pancras — — 2 19 — — 96 10 25 — — — 906 2,040 731 500 182 335 712 352 767 850 1.244 Shoreditch — — — — 1 5 497 — 6 — — — — 1 225 636 13 88 345 154 432 286 871 Southwark — 1 4 7 8 96 — 16 — 6 40 1,561 2,073 232 2,599 160 383 197 193 380 1,379 Stepney — — — — 19 272 128 — 76 — 4 123 445 1 296 772 — 220 379 264 195 926 743 Stoke Newington — — — — — 17 1 — — — 00 517 232 211 8,500 40 160 70 127 46 61 Wandsworth — — 3 43 — — 73 9 11 1 — — 133 120 705 253 9 236 1,514 657 1,665 513 1,218 Westminster, C. of — — — — — — 1,371 15 130 1 3 64 503 436 459 1,185 6 119 169 188 123 2,524 4,432 Woolwich — — 2 † 2 21 694 7 57 4 2 16 150 1.403 351 712 — 117 283 316 388 595 631 Total 1 — 29 193 73 731 6,819 76 541 10 30 571 8,211 24.002 21.472 19,520 9,068 4,112 9,246 6.833 9,620 12,332 28,127 Note :—In the columns above a dash signifies a NIL return; * information not available; f daily supervision (one slaughterhouse not in use); and J included in inspections under Public Health Act. Seamen's Lodging Houses: Total 8—Poplar 3 (26 inspections), Stepney 5 (109 inspections). Prosecutions: Dairies—Hammersmith 5, Holborn 1, Islington 1, St. Pancras 1, Southwark 2; Restaurants—Hammersmifh 2, Hampstead 1, Islington 4, St. Marylebone 3, Stepney 5, (1 premises), City of Westminster 2. Water Supply—Hammersmith 3, St Pancras 12; Ice.cream Premises—Hackney 1, Islington 1, City of Westminster 3. 158 Table 31 Administrative County of London Occupations of males and females—Census 1931 ami 1951 Occupation Males Females Population (14 years and over 1931, 15 years and over 1951) 1931 1951 1931 1951 (14+) 1,598,954 (15. ) 1,217,300 (14+) 1,914,732 (15+) 1,467,700 Per cent. Per cent. Per cent. Per cent. Fishermen — — — — Agricultural 0-4 0.4 — — Mining and quarrying Non-metal mining products (excluding coal) 0.4 0.3 0.1 0.1 Coal, gas, coke, chemical and allied trades 0.3 0.5 Metal manufacture, engineering, etc. 8.6 10.8 0.8 1.0 Textile workers 0.1 0.1 0.2 0.1 Tanners, leather, fur dressing 0.7 0.5 0.5 0.3 Makers of textile goods and dresses 3.1 2.2 6.4 4.8 Food, drink, tobacco 1.3 0.9 0.6 0.6 Wood, cane, cork 3.9 3.0 0.2 0.1 Paper, board, printing 2.4 2.0 1.2 0.9 Other products 0.9 0.6 0.5 0.4 Building 4.0 5.5 — — Painters, decorators 2.8 2.9 0.2 0.1 Administrators, managers not included elsewhere (a) 0.4 2.6 - 0.5 Transport and communications 15.8 13.3 0.7 1.1 Commercial (retail trade), finance and insurance (excluding clerical) 12.3 8.8 3.8 4.1 Professional and technical (excluding clerical 2.9 5.0 2.7 3.7 Defence Services (including police) 2.2 3.3 — 0.1 Entertainment and sport 1.0 1.0 0.3 0.4 Personal service (domestic, waiters, etc.) 6.6 6.2 16.2 13.2 Clerks, typists, etc. 8.1 7.8 6.5 11.4 Warehousemen, storekeepers, packers, bottlers 3.1 3.4 1.7 1.5 Stationary engine drivers, tractor drivers, stokers, etc 0.7 0.9 - - Other unskilled occupations Other and undefined 9.4 7.2 1.7 2.3 Total occupied 91.4 89.2 44.3 46.7 Retired or not gainfully occupied (b) 8.6 10.8 55.7 53.3 Total 100.0 100.0 100.0 100.0 (а) 1931 and 1951 not comparable, 1951 includes Managers in industry and commerce who were shown piecemeal under their respective industries in 1931. (б) Includes housewives and students, but not persons out of work. 159 Table 32 Administrative County of London Household arrangements of private households—Census 1951 Households Proportion per 100 households without exclusive use of Persons per room (Nearest thousand) Water Closet Fixed bath Both stove and sink 1951 1931 Division 1. Chelsea 19 29 41 19 0.75 0.79 Fulham 43 29 71 10 0.86 0.97 Hammersmith 38 39 62 14 0.87 1.01 Kensington 61 43 53 28 0.83 0.80 Total 101 37 58 19 0.84 0.90 Division 2. Hampstead 36 39 54 19 0.78 0.70 Paddington 47 42 65 25 0.88 0.90 St. Marylebone 27 26 36 18 0.75 0.81 St. Pancras 48 53 76 26 0.93 1.13 Westminster, City of 32 41 58 27 0.78 0.76 Total 190 42 60 23 0.83 0.88 Division 3. Finsbury 12 46 76 29 0.95 1.42 Holborn 7 35 59 27 0.84 1.07 Islington 82 53 79 22 0.92 1.12 Total 101 51 77 23 0.91 1.16 Division 4. Hackney 58 39 70 10 0.83 1.00 Shoreditch 14 44 76 27 0.98 1.45 Stoke Newington 17 46 73 14 0.90 0.90 Total 89 41 72 14 0.87 1.07 Division 5. Bethnal Green 20 33 76 27 0.93 1.35 City of London 1* 36 50 14 0.70 0.91 Poplar 23 41 74 16 0.95 1.25 Stepney 31 34 75 20 0.93 1.32 Total 75 36 75 20 0.93 1.30 Division 6. Deptford 25 47 75 13 0.80 0.98 Greenwich 26 26 51 13 0.83 0.94 Woolwich 44 16 43 11 0.71 0.88 Total 95 27 54 12 0.76 0.93 Division 7. Camberwell 59 36 70 12 0.82 0.96 Lewisham 71 18 38 7 0.76 0.81 Total 130 26 53 9 0.79 0.88 160 Table 32—continued. Administrative County of London Household arrangements of private households—Census 1951 Households Proportion per 100 households without exclusive use of Persons per room (Nearest thousand) Water Closet Fixed bath Both stove and sink 1951 1931 Division 8. 19 41 72 18 0.90 1.25 Lambeth 76 32 61 13 0.83 0.97 Southwark 32 36 81 21 0.93 1.28 Total 127 34 68 16 0.86 109 Division 9. Battersea 38 31 73 13 0.81 0.98 Wandsworth 108 21 47 11 0.74 0.79 Total 146 24 54 11 0.76 0.84 London County 1,114 35 62 17 0.83 0.98 * Actual 1,400. 161 INDEX Adoption of children 59 Ambulance service 71 Analgesia 63 Anthrax 17 Audiometry 98, 101 Births 6 Blind persons 30, 99 Bronchitis 9 Cancer 9 Care of mothers and young children 50 Census, 1951 3 Chemical branch 33 Child guidance 103 Child.minders 58 Chronic sick 32 Civil Defence 74 Deaths 8 Dental services 93, 108 Diabetes 12, 107 Diarrhoea and enteritis 19 Diphtheria 17, 69 Domestic help service 67 Domiciliary midwifery service 60 Dysentery 17 Emergency obstetric service 61 Enteric fevers 19 Epileptic children 99 Erysipelas 19 Family accommodation survey 135 Fertility 6 Finance 115 Food poisoning 27 Foot defects 78 Handicapped children 100 Health centres 45 Health education 81 Health Service premises 39 Health visiting 65 Heart disease 9 Home nursing 66 Housing 28 Illegitimacy 7 Immunisation 68, 93 Infant mortality 13 Infectious diseases 17 Do. in schools 25, 100 Influenza 19 Introduction 1 Maladjusted children 106 Marriage guidance 55 Mass miniature radiography 79 Maternal mortality 15 Meals for children 103 Measles 21 Medical inspection of school children 89 Medical treatment of school children 93 Mental health services 81 Midwifery service 60 Milk sampling 29 Mortality 8 Nurseries, day 57 Do. residential 58 Nursing home registration 31 Occupation centres 87 Ophthalmia neonatorum 22 Peckham Pioneer Health Centre 46 Pneumonia 12, 22 Poliomyelitis 22 Population 6, 130 Premature babies 53 Prevention of illness 76 Problem children 108 Psychiatry 103,107 Puerperal fever and pyrexia 15 Queen's Road Centre 45 Recuperative holidays 80 Remand homes 109 Reports of Divisional Medical Officers 118 Rheumatic fever 23 Rheumatism scheme 102 Road accidents 13 Sanitary inspection 29 Scabies 23, 95 Scarlet fever 23 School health service 88 School children under 5 years 107 Smallpox 23 Specialist clinics 93, 96 Speech therapy 97 Staff 113 Statistical tables 139 Stillbirths 8 Sunday cinema grants 55 Tuberculosis 25. 76 Tuberculous milk 29 Typhus fever 24 Unmarried mothers 59 Vaccination 70, 93 Venereal diseases 79 Visitors 116 Vital statistics 6, 139 Voluntary organisations 52 Welfare Committee establishments 32 Whooping cough 24, 69 Woodberry Down Health Centre 45 6 Rey, (M'C. 64280) 8.12.52. G373.