LCC 58 LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and School Medical Officer for the Year 1952 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 1953 No. 3827 2s. 6d. Postage extra LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and School Medical Officer for the Year 1952 By J. A. SCOTT, O.B.E., M.D., M.R.C.P. COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER a* THE COUNTY HALL WESTMINSTER BRIDGE, S.E.I CONTENTS Page Introduction 3 Vital Statistics 4 Population 4 Fertility 5 Mortality 7 Infectious diseases 16 General Public Health 23 Housing 23 Tuberculous milk 24 Sanitary inspection 25 Blind persons 25 Registration of nursing homes 26 Welfare Committee establishments 27 Chronic sick 27 Chemical Branch 28 Special Survey of Health Services 35 Health Service Premises 42 Care of Mothers and Young Children 50 Expectant and nursing mothers 50 Child welfare 52 Premature infants 53 Marriage guidance 55 Day nurseries 55 Children neglected or ill-treated in their own homes 57 Unmarried mother and her child 58 Domiciliary Midwifery Service 60 Health Visiting and Nursing Services 68 Home Nursing 73 Domestic Help Service 78 Immunisation and Vaccination 80 London Ambulance Service 83 Prevention of Illness: Care and After Care 90 Tuberculosis 90 Foot clinics 97 Venereal disease 97 Recuperative holidays 98 Health education 99 Page Mental Health Service. 104 Staff 104 Co-ordination 105 Voluntary associations 106 Prevention of illness 106 Lunacy and Mental Treatment Acts 107 Mental Deficiency Acts 109 School Health Service 115 Organisation 115 Medical inspections 116 Medical treatment 120 Audiology centres 123 Bathing centres 124 Infectious diseases 124 Rheumatism scheme 125 Psychiatry 126 Speech therapy 128 Remedial exercise classes 129 Handicapped children 129 Epileptic children 129 Diabetic children 130 Children under five years 130 Dental services 131 Staff 135 Special investigations 136 Finance ,, 138 Visitors to the Department 139 Reports by the Divisional Medical Officers 140 Appendix 151 (a) Deaths and Sickness in London, December, 1952 151 (b) Poliomyelitis and inoculations 163 (c) Statistical tables 172 (d) Staff of the department 192 (W. & S. Ltd. 60324) 27.11.53 123997 INTRODUCTION this report, which records the activities of the Department for the year 1952, comes at the end of four and a-half years' experience of the working of the National Health Service. In accordance with the request of the Ministry of Health a special survey of this Service was carried out and the findings are included in the report. General comments on administration, co-ordination and co-operation with other services and the use of voluntary organisations are given on page 35 while comments on the individual services are included in the appropriate sections. The other outstanding event of the year was the enormous mortality associated with the fog period of December which in a space of a week contributed an extra 0.5 per thousand population to the year's total death-rate. A detailed statistical account of this catastrophe is given in Appendix A, page 151. But for this sudden increase in the number of deaths in December the total rate would have been back to approximately the 1950 level of 11.3 per thousand compared with 12.6 in 1951 and 12.0 in 1952 (page 8). The year 1952 was also the first year of the tripartite arrangement in Division 9 whereby the divisional medical officer is also medical officer of health for the two metropolitan boroughs constituting the Division. This interesting experiment in the co-ordination of the personal and environmental health services will be closely watched ; already after but one year's experience it appears very promising. The birth-rate (15.3 per thousand population) was slightly lower than in the previous year (15.6) (page 6). The death-rate from cancer, which is at 2.30 the second leading cause of death in London (diseases of the heart being the first), continues to show a slight increase (page 9). Infant mortality was again lower at 23.1 per thousand live births (25.4 in 1951). The neo-natal rate (deaths in the first four weeks of life) dropped to 15.8 per thousand live births, a new low record for London (page 12). The number of confirmed notifications of poliomyelitis, 309, which was higher than in 1951 (112) was considerably lower than for the epidemic years of 1947, 1949 and 1950 (page 20). An analysis of the 1949 epidemic in its relationship to previous inoculation is given in Appendix B, page 163. The Council's first comprehensive health centre, at Woodberry Down, was completed in September, and the ceremonial opening was performed on 14th October. A summary of the accommodation provided will be found on page 48. The centre has attracted many visitors ever since its opening, over 600 visiting before the end of 1952. The number of pregnant women making at least one attendance at a Council antenatal clinic continues to decline (page 50). It is believed that the other women receive advice either from their family doctor or from the hospital which they propose to enter for the confinement. The percentage of children attending a Council child welfare centre at least once in the first year of life remains fairly constant, more than eight out of every ten attended last year (page 52). The demand on the services of the District Nursing Associations, who carry out home nursing on behalf of the Council, continues to increase, over 1,600,000 visits being paid last year—an average of fourteen visits daily for each nurse (page 73). The demand on the Domestic Help Service continues to grow, nearly 28,000 cases being assisted last year. A regrettable feature in the Council's campaign for immunisation against diphtheria is the continued drop in the estimated percentage of children under five years of age who have been immunised. It is now only 50.2 per cent. Efforts are being made to increase this percentage (page 80). During the year the Department was co-operating in five research projects, and details of them are given on page 136. 4 VITAL STATISTICS Population the total home population of the County in the middle of 1952, according to the Registrar-General, was 3,363,000, compared with 3,358,000 in 1951. Corresponding estimates for metropolitan boroughs are shown in Table 2 on page 173 and the rates given in this annual report are calculated upon these figures. Table 1 shows the age distribution of the population, as estimated by the RegistrarGeneral, at the middle of each census year since 1921 and of each more recent year. The total numbers have now been fairly stable for several years at about 3⅓ million, a figure considerably lower than the 4 million odd which was the size of the County's population for the first twenty-five years of this century. It would be rash, however, to make any prediction as to how these numbers will vary in future. The population of the County of London, as is probably the case with the central area of any other great conurbation, differs from the population of the country as a whole, in that the effects of migration upon its constitution are constantly present and far from negligible; changes in the pattern of migration, which can easily occur on a large scale in such an area, may have very rapid effects. The large movements of population, to which London has been subject since 1939, have, however, left unaffected one of the more important contemporary aspects of population change—the constantly increasing proportion of elderly people. The figures below, based on the Census reports, show the proportion of the total population of London aged over 65 to have risen from just over 4 per cent. in 1901 to over 11 per cent. in 1951, and this rise follows, slightly more steeply, the corresponding rise in the country as a whole. Percentage of total population aged over 65 1901 1911 1921 1931 1951 London A.C. 4.09% 4.89% 5.80% 7.32% 11.06% England and Wales 4.67% 5.21% 6.05% 7.42% 10.90% Migration In the report for 1951 detailed estimates were given, by kind permission of the London Transport Executive, of the diurnal movement into and out of the central areas of the County; the publication of the London volume of the 1951 Census, which is expected soon, will, it is hoped, as in the 1921 Census, provide an even more detailed picture of that part of the daily movement contributed by travel to and from work. It does not need emphasising that a daily influx on the scale which is characteristic of London affects considerably the epidemiological characteristics of the area; nor should it be forgotten that many of the Health Authority's services are provided to the day time, no less than to the resident, population. The resident population itself is subject to a continuous process of change by families moving house into, out of and within the County. The total number of families who move in a year is unknown; but among children under five there are currently at least 30,000 movements a year, which is about 12 per cent. of the population under five, and represents change of residence by about 24,000 families ; these movements show a net balance of about 4,000 children a year outward from the County, or a net loss each year of 2 per cent. of the population under five. The net percentage rates of migration of children of school age can be deduced from the table below which shows for each year of age the difference between the number on school rolls in January, 1952, and in January, 1953, expressed as a percentage of the numbers in January, 1952. 5 London A.C. Net decrease (—) in numbers of children in school between January, 1952, and January, 1953, as percentage of numbers in January, 1952 Age last birthday January, 1952 Net decrease Age last birthday January, 1953 5 - 3.3% 6 6 - 1.4% 7 7 - 1.6% 8 8 - 1.o% 9 9 - 1.5% 10 10 - 0.5% 11 11 - 0.1% 12 12 - 0.4% 13 13 - 2.1% 14 Since the values of qx* at these ages are less than 0.002 the major part of this decrease represents the net migration among children of these ages. The same calculation for 1950/51 and 1951/52 show very similar results. In short, at all ages from birth to ten years old there is a constant net movement of children out of the County, such that at the age of ten only about 83 per cent. of the life table population of the County are in fact residing there; thereafter the net movement seems at present to be small until just before school leaving age. These movements of children presuppose corresponding movements of their parents and if, as is currently the case, the total population of the County remains fairly stable, these net outflows must be balanced by net inward movements, presumably among young adults. This hypothesis is lent support by the table below which shows the comparative age distribution of the population of England and Wales and London A.C. in 1951. Persons at various ages per 1,000 total population. 1 per cent. sample, 1951 Census Age Group England and Wales London A.C. Excess (+) or defect (—) London A.C. over England and Wales 0- 85 83 - 2 5- 72 64 - 8 10- 65 51 -14 15- 62 49 - 13 20- 66 75 + 9 25- 75 89 + 14 30- 70 81 + 11 35- 76 82 + 6 40- 77 77 - 0 45- 241 239 - 2 65- 111 110 - 1 All ages- 1,000 1,000 0 Since 1940 the crude live birth-rate in London has been substantially the same as in England and Wales; for a number of years before that date it was between 10 per cent. and 15 per cent. lower. The defects in the London population at the younger ages are, therefore, a true reflection of the effects of net outward migration at or below these ages and the excess at the young adult ages considerably understates the amount of net inward migration at these ages. Fertility The total births allocated to London for 1952 were : Live 51,558 Still 1,008 Total 52,566 * Probability of dying within one year. b The live birth-rate in 1952 was 15.3 per 1,000 total population, compared with 15.6 in 1951. 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 amounted to some 7,900 births in 1952. The corresponding figure in 1951 was 7,700 The number of marriages registered in London in 1952 was 33,482, or 19.9 persons married per 1,000 of the total population, compared with 20.6 in 1951. The birth-rate in London tends to follow the same trend as for the country as a whole. The diagram below shows the course of the two rates since 1932. The actual rates for London are given in Table 5 (page 176). LIVE BIRTH RATE IN ENGLAND AND WALES AND LONDON (A.C.) 1931-1952 PER 1,000 TOTAL POPULATION ENGLAND AND WALES LONDON (A.C.) Although the live birth-rate per 1,000 total population in 1952 was the same in London as in England and Wales, London's population has a greater proportion of women of child-bearing age. If the live births be expressed as a rate per 1,000 women aged between 15 and 45, the figure for London is 65 as compared with 71 for England and Wales, showing London women to be substantially less fertile than the female population as a whole. In view of the considerations brought forward in the next paragraph, the difference in fertility is probably even greater than the figures imply. 7 There were 3,577 illegitimate live births (6.9 per cent. of the total live births). Illegitimacy The percentages in recent years are : Year London A.C. 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 1952 6.9 4.8 The peak of the war-time rise occurred in 1945, with a rapid reduction after the end of hostilities. The Registrar-General has demonstrated in his Statistical Review of England and Wales (Text 1940-1948) that this rise was more than balanced by a fall in the numbers of pre-maritally conceived legitimate births and that, in fact, extramaritally conceived maternities were a lower proportion of all maternities during the war years than in 1938. The higher apparent rates of illegitimate births in London as compared with England and Wales (in 1952 in London 11.6 live births per 1,000 unmarried women aged 15-45, as compared with 9.7 in England and Wales) seem to reverse the position as found in the live births as a whole. In fact it is doubtful whether the true illegitimate fertility rate in London is now as high as in the country as a whole. Registrars must accept the residential addresses which they are given, and it is known that a very considerable number of pregnant unmarried women come to reside temporarily in London from the rest of the country, and also from Eire, for the sole purpose of bearing their children in the anonymity of a large city. Such births are allocated to London but the mothers are not, of course, part of the true residential population. This factor, which has always been present, and has been accentuated since the coming of the National Health Service, has the effect of considerably increasing the London illegitimate fertility rate above its true value and concomitantly increasing, but not so considerably, the total London fertility rate. Deaths under one year among illegitimate infants amounted to 33 per 1,000 illegitimate live births compared with a rate of 22 for legitimate births. The corresponding rates in 1951 were 35 and 25 respectively. A detailed comparison of deaths in the legitimate and illegitimate groups is given in Table 6 (page 177). Still-Births There were 1,008 still-births in 1952 or 19.2 per 1,000 of all births (legitimate 18.6, illegitimate 27.2). The number of still-births and the rate per 1,000 total births in each year since 1931 is shown in Table 5 (page 176), from which it will be seen that after remaining stable for many years the still-birth rate fell sharply in 1943 and continued to fall until 1948, since when it has remained fairly stable. Mortality The total deaths in 1952 amounted to 40,368, or 12.0 per 1,000 of the population. Detailed figures are given in Tables 2, 30 & 4 (pages 173-6). Mortality from infectious diseases is discussed below under that heading and tuberculosis is dealt with separately (see page 21). For the latter and other principal causes of death the trend is indicated by the diagram on pages 10-11.* *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 8 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 12.0 in 1952 is somewhat lower than that of the previous year; 1951 was a year in which there was a severe influenza outbreak, sufficient to raise the annual death-rate from 11.3 per thousand of 1950, to 12.6 per thousand. In 1952 the general rate would have been back to the 1950 level but for the enormous mortality associated with the fog period of December which, in a space of a week, contributed an extra .5 per thousand to the year's rate. A detailed statistical account of this catastrophe will be found on page 151, but it should be noted here that its effects on the year's specific death-rate were as profound as on the general rate, and more particularly in the bronchitic and heart disease group and, of course, the degenerative group. Bronchitis and heart disease The death-rate for the bronchitic and heart disease group which was 4.64 in 1952 compared with 5.01 in 1951 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 174). Cerebral hšmorrhage The death-rate from vascular lesions of the nervous systems in 1952 was 1.27 per 1,000, compared with 1.22 in 1951. The average for 1941-45 was 1.15, but a large proportion of the apparent reduction in the interval was due to the increase in the civil population upon demobilisation, a purely ' statistical' effect. Nephritis For nephritis the death-rate in 1952 amounted to 0.11 per 1,000, compared with 0.12 in 1951, 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 1952 6.64 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 caused Influenza — 11 per cent. Cancer — 3 „ „ Diabetes — 30 ,, ,, Heart diseases — 10 ,, ,, Other circulatory diseases — 6 „ „ Bronchitis + 100 „ „ Pneumonia + 5 ,, tt 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. 9 The true effects of the war cannot be separated from the statistical influences described in the footnote on page 7 (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. The cancer death-rate for all ages in 1952 was 2.30 per 1,000, slightly higher than in 1951. Cancer 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. Age group population estimates were not available for London 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 1952 Males : 0-14 0.02 0.03 0.06 0.11 0.10 0.11 15—44 0.35 0.30 0.29 0.38 0.35 0.37 45 + 5.34 5.61 5.81 618 7.45 7.35 All Males 2.13 2.21 2.27 2.45 2.60 2.61 Females : 0-14 0.04 0.03 0.05 0.07 0.09 0.08 15-44 0.34 0.36 0.33 0.37 0.35 0.35 45 + 4.27 4.44 4.42 4.51 4.83 4.87 AU Females 1.88 1.95 1.93 1.98 1.99 2.02 All Persons 2.00 2.08 2.09 2.20 2.27 2.30 Up to 1951, for England and Wales, the comparative mortality index for females had fallen to 0.92 (1938 = 1.000), while the male index had risen to 1.11. In London, for both sexes combined, the long-term trend of cancer mortality can be seen from Table 3 (page 174). 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 small drop in the death-rate for males over 45 in 1952, which is the first decrease for a considerable time, is entirely due to a decrease in the deaths registered as from cancer of the digestive organs (International Classification numbers 150-159) ; in 1951 the death-rates from cancer of these sites in this age sex group were 3.04 per 1,000, while in 1952 they were 2.81 per 1,000. Digestive Mortality from digestive diseases (other than cancer) in 1952 was 0.44 per 1,000. Within this group the death-rate from ulcer of the stomach or duodenum was 0.17 per 1,000 compared with 0.19 in 1951 and 0.17 in 1950. Diabetes Diabetes mortality fell steadily between 1939 and 1947, but in the last four years the death-rates have been 0.07, 0.08, 0.09, 008, 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 1952 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 1952 34 10 TREND OF MORTALITY LONDON 1936-52 DEATH RATE PER 1,000 11 TREND OF MORTALITY-LONDON 1936-52 DEATH RATE PER 1,000 12 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. The steady downward trend of these two rates, which is, no doubt, associated with the sulphonamide and antibiotic therapies, was broken in 1947, 1949 and 1951, when severe weather conditions in the first case and influenza epidemics in the two latter cases raised the rates above the prevailing level. In 1952 the pneumonia death-rate was 0.61 per 1,000, as compared with 0.64 in 1951 and 0.50 in 1950, and the rate for ' other respiratory diseases', excluding bronchitis, was 0.12, as against the same figure in 1951, and 0.10 in 1950. The rates in 1952 remained high in consequence of the lethal fog in December, already referred to, which caused the death-rates from all respiratory causes to leap to unprecedented heights in the subsequent week. Road accidents The number of London residents who died in motor vehicle accidents in 1952 was 221, as compared with 282 in 1951 and 245 in 1950. The number of persons who were registered in London in those years as dying in motor vehicle accidents, whether London residents or not, were—for 1952—205, for 1951—259, and for 1950—207. It is clear that many London residents come by their death in motor vehicle accidents outside the confines of the County. The current rate of slaughter on the roads within the County is substantially the same as it was between 1870 and 1890, that is, between 200 and 250 a year, having declined substantially from the peak of 822 deaths in the year which it reached in 1930. It is exceedingly doubtful, however, if this decline represents any increase in safety on the County's roads; almost certainly the major part of it must be attributed to the great improvements in the treatment of the injuries which continue to be inflicted. Other violence Other violent causes of death accounted for 1,142 deaths. The corresponding figure for 1951 was 1,252. The peaks in the diagram on page 11 are due to the heavy toll of air raids. Infant mortality The infant mortality rate in 1952 was 23.1 per 1,000 live births, which is an improvement on the rate of 25.4 for 1951. The movements of the death-rates from the principal diseases at ages below one year since 1911 are shown in Table 7 (page 177). The diagram 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 whooping-cough 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 salutarv effect on the mortality risk. Neo-natal mortality Deaths in various periods of the first year of life during 1952 are shown in detail in Table 6 (page 177). Deaths under four weeks numbered 817 or 15-8 per 1,000 live births, births. Comparative rates for London and England and Wales in recent years are : Year London England and Wales Year London England and Wales 1931-35 25.1 31.4 1948 17.5 19.8 1936-40 22.9 29.0 1949 17.5 19.3 1941-45 23.4 25.9 1950 16.9 18.5 1946 22.2 24.2 1951 17.3 18.9 1947 18.1 22.7 1952 15.8 18.3 13 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 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 INFANT MORTALITY MORTALITY PER 1,000 LIVE BIRTHS 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. 14 The distribution of causes of death in the first four weeks of life in 1952 was as follows : Cause No. of deaths Per cent, total Prematurity 209 25.5 Post-natal asphyxia and atelectasis 178 21.8 Birth injury 141 17.3 Congenital malformations 118 14.4 Other diseases of early infancy 74 9.1 Pneumonia of newborn 56 6.9 Diarrhoea and Enteritis 2 0.2 All other causes 39 4.8 Total 817 100.0 It is seen that deaths from prematurity, injury at birth and congenital malformations account for 57 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. 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 4.1 in 1952, and this comparatively large advance is doubtless associated with the contemporary emphasis on the care of premature infants. Birth injuries will, it is hoped, be reduced as specialised obstetrical assistance becomes more general. The average neo-natal rate from this cause over the period 1936-40 was 2.2 per 1,000 live births, but was 2.7 in 1952. 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 death-rate has thus increased, without any real increase in the risk necessarily being implied. The average neo-natal death-rate from congenital malformations was 2.8 per 1,000 live births over the period 1936-40, and in 1952 the rate was 2.3. 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 1952 the neo-natal mortality rate was about two-thirds of the average rate for 1931-35. 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 178). Year Live births and stillbirths Deaths in pregnancy or child-birth excluding abortion Post-abortion deaths Notification 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 1952 52,566 35 0.67 15 0.019 1,860 35.38 Rales 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 1952 was officially 0.67, as compared with 0.45 in the previous year. It is, however, necessary to point out that one case assigned by the Registrar-General (under the International Rules of Classification) to pregnancy or child-birth, experienced her last pregnancy 40 years ago, so that a truer maternal deathrate for 1952 is 0.65. The total number of maternal deaths in the County during a year has now fallen to such a low level that purely chance fluctuations will affect them considerably, and there is little value in giving the rates for component causes in 15 individual years. The following analysis has, therefore, been made on the basis of numbers and not rates. Cause of death Post-abortion Other pregnancy and child birth Total 1950 1951 1952 1950 1951 1952 1950 1951 1952 Sepsis 7 13 10 — 3 2 7 16 12 Other causes 2 5 5 29 21 33 31 26 38 Total maternal deaths 9 18 15 29 24 35 38 42 50 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 1952 was 35.38 per 1,000 total births, compared with 17.04 in 1951, and 6.83 in 1950. Puerperal Pyrexia This large increase in notifications since 1950 is misleading and is due to the Puerperal Pyrexia 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 accidcnts (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 B General 16 The leading causes of death in London in 1952 were as follows : Deaths Rate per 1,000 population Diseases of the heart 11,946 3.55 Cancer 7,726 2.30 *Pneumonia, bronchitis 5,699 1.69 Vascular lesions of the nervous system 4,528 1.35 Other circulatory 2,070 0.62 Digestive diseases 1,492 0.44 Violent causes 1,363 0.41 Diseases of early infancy (prematurity, birth injury, congenital malformation, etc.) 1,071 0.32 Tuberculosis 1,019 0.30 Hyperplasia of prostate 366 0.11 Nephritis 361 0.11 All other causes 2,727 0.81 Total 40,368 12.01 * Now includes pneumonia of the new born. 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 1952, are shown in Tables 2, 3 and 14. 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 14). Table 15 has not previously appeared in these reports ; it shows, in age groups, the distribution over the weeks of the year of the notifications of the following—dysentery, measles, meningococcal infection, pneumonia, poliomyelitis, scarlet fever and whooping cough. It should be noted that the totals in this Table, being for 53 weekly periods and not adjusted for final late corrections of diagnosis, will not correspond with the yearly corrected totals in Table 14. Anthrax There were no notifications of anthrax during 1952. Dysentery Although the number of notifications was considerably less than the record total of 4,069 in 1951, the level of 1,704 notifications recorded in 1952 has been exceeded in only two previous years, viz., 1945 and 1951. As in recent years the highest incidence was in the months of February, March and April, this being a characteristic which distinguishes this type of infection from the main group of intestinal infections which are commonest in the summer and autumn. Sonne dysentery, unlike the other intestinal infections, is spread only very rarely by infected food ; personal contact appears to be the most important factor in spread. In the report for 1951 mention was made of the fact that the proportion of notifications in the 5-14 years age group had increased. This year there has been very little change in the proportion of notifications falling in the different age groups. The disease continues to be most frequent in nursery groups, but outbreaks in schools and establishments for elderly persons have also been encountered. With the co-operation of the medical officers of health of the metropolitan boroughs an investigation was begun during the year into the social and environmental circumstances of all notified cases, and into the efficacy of different methods of control of institutional outbreaks. Diphtheria During the year there were only 18 confirmed notifications or diphtheria, compared with 30 in 1951. As in the previous year there were two deaths, the only one under 15 years of age being of an unimmunised child. The continuation in the decline in incidence of diphtheria can be attributed to the immunisation campaign, which has transformed the disease in little over ten years from 17 a scourge of mankind to a rarity. The improvement is well shown in the diagram, and once again it may be pointed out that the rate of improvement at ages under 15 years began to accelerate as soon as the immunisation campaign commenced in the early 1940's, but that the rate of improvement over the age of 15 years improved only in 1946, by which time a substantial number of those immunised in school had passed into this age group. In looking at this diagram it must be remembered that the logarithmic scale tends to obscure the full measure of achievement. The number of cases in 1941 was more than a hundred times that met with in 1952. DIPHTHERIA — AGE INCIDENCE NOTIFICATIONS PER 1,000 LIVING IN AGE GROUPS The number of deaths from diarrhoea and enteritis under two years of age (43) was one lower than in 1951. A notable feature was the fact that 10 of the 43 deaths from this cause occurred during the month of December, during the period that the general mortality rate was greatly increased as a result of the cold fog. A study of the death certificates of the enteritis deaths in December showed that nearly all the infants were b* Diarrhoea and enteritis 18 at the time of death suffering from a respiratory infection in addition to the enteritis. It is reasonable to suppose that the fog was responsible for the majority of the December deaths, and that if it had not been for the fog there would have been a continuation of the remarkable decline in the enteritis death-rate which has continued since the end of the war. Whereas before the war the enteritis death-rate in London was constantly" higher than the rate for England and Wales, since the war it has been well below the national level. Many possible causes can be put forward for this decline, and all may have played a part. The use of national dried milk in infants' feeds, health education, particularly on the preparation of feeds, better treatment of the disease, and improved social conditions, have all been important factors, but there are reasons for believing that the incidence of the disease is also lower now than formerly. DIARRHCEA AND ENTERITIS (UNDER TWO YEARS) MORTALITY PER 1,000 LIVE BIRTHS Enteric fevers Typhoid and paratyphoid fevers were at a low level, only 25 notifications being recorded. Outbreaks due to infected water or food were completely absent. Such cases as occurred were the result of contact with unrecognised carriers in the population. There is little doubt that this disease could be virtually eradicated if it were possible to detect and neutralise all carriers. Two methods of achieving this are the energetic search for the source of infection in all cases, and careful bacteriological examination of all those recovering from the disease to bring to light the convalescent carrier. Erysipelas There were 467 notifications of erysipelas in 1952, giving an attack rate of 0.139 per 1,000, compared with 0.148 in 1951. The incidence of this disease has been declining continuously since 1941. There was one death in 1952. 19 Since the beginning of 1949 food poisoning has been a notifiable disease in London. Food In 1952 612 cases were reported giving an attack rate of 0.18 per 1,000, compared with Polsoning 787 cases (0-23) in 1951. . The sex and age distribution was : Age Males Females 0-4 47 44 5-14 40 32 15-44 124 164 45-64 63 62 65 + 9 26 Age unknown 1 283 329 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. Influenza There were 162 deaths (0-05 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 1952 162 The last major outbreak was in the early months of 1951. By the end of December, 1952, there were signs that a considerable spread of influenza was beginning, but the weight of the epidemic fell after the year had ended. Leptospirosis Arrangements that have been in operation for many years for the ascertainment and treatment of leptospirosis among the Council's sewer workers have continued. Since the end of the war, with the resumption of building work in the sewers, there has been a slight increase in the frequency of these infections from the unusually low incidence during the war years. The figure of six confirmed infections during 1952 is comparable with the average figure during the years just before the war. Occasional sporadic cases in the general public associated with river bathing continue to occur. Measles The year saw the gradual rise in incidence of measles which culminated in the peak during the early months of 1953, interrupted by the customary fall in incidence during the autumn. The total number of notifications during the year, 31,055, was higher than in any year in the corresponding stage of the biennial cycle since the end of the war. Case fatality remains at a low level, due partly to the use of sulphonamides and antibiotics in the prevention and treatment of complications, and partly to the mildness of the prevalent disease. Meningococcal infections Incidence was at about the same level as in recent years. No part of the year was free from the disease, although incidence was as usual higher in the spring than at other times. Notifications were spread widely through the County without any localised concentration. 51 notifications (54.5 per cent.) were in children under the age of five years, the disease becoming steadily less frequent with increasing age. As in previous years, the highest case mortality rates were found at the extremes of age, this rate being particularly high in infants under the age of one year. Of 24 deaths in children under five years of age, 18 were less than a year old. The ratio of notifications to deaths at various ages was as follows : Age Deaths Notifications Deaths as percentage of notifications 0-4 years 24 51 52.8 5-14 years 2 17 11.8 Over 14 years , 3 14 21.4 Ophthalmia neonatorum 20 The incidence of ophthalmia neonatorum which, since 1921, has remained fairly constant between 8 and 10 new cases per 1,000 live births, commenced to fall slightly towards the end of the period 1931-40 and, in recent years, has fallen to below five per 1,000 live births. There were 202 cases in 1952 (3-9 per 1,000 live births), full details of which are shown below : Ophthalmia neonatorum Number of cases Domiciliary confinements Institutional confinements Total Notified during the year 47 138 185. Removed to hospital for special treatment 9 33 42 The condition at the end of the year of the 202 cases notified was : (a) Vision unimpaired 175 (b) Vision impaired — (c) Vision lost (id) Died 1 (e) Under treatment 3 (f) Removed from the County 6 Total 185 The difference between the 202 notified cases and the 185 cases included in the above analysis arises from the fact that the analysis includes only those cases of which the mother was a resident in the County. Pneumonia Notified cases of pneumonia in 1952 numbered 1,908 or 0.567 per 1,000, compared with 0.717 per 1,000 in 1951. This disease is considerably under-notified, particularly at ages over 65, and it is believed that over the whole age-range only about one-quarter to one-third of the total cases are notified. There is, however, no reason to 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 14 that the 1952 notification rate is lower than either war-time or pre-war rates. (See page 12 for comment on the death-rate.) Poliomyelitis The number of confirmed notifications of poliomyelitis (309) which was higher than that in 1951, was considerably lower than in the epidemic years 1947, 1949 and 1950. The weekly notifications rose sharply to 30 in the thirtieth week, and did not return to the inter-epidemic level until ten weeks later. Of the total notifications during the year, 204 were paralytic and 105 non-paralytic. At school ages the non-paralytic cases slightly exceeded the paralytic in number, but at all other ages the paralytic cases exceeded the non-paralytic. age incidence in 1952 was as follows: Age No. % 0-4 95 30.7 5-14 105 34.0 15 + 109 35.3 Total 309 100.0 There was a slight increase in the proportion of notifications falling in the 0-4 years age group, but this is seen in better perspective in the following figures:— [###\Year Percentage of notifications in the 0-5 age group 1947 27.9 1948 33.3 1949 53.3 1950 34.9 1951 24.1 1952 30.7 21 Deaths in London from rheumatic fever in 1952 were 25, of which 7, as in 1951, were children under 15. Rheumatic fever Account must also be taken of all deaths under 45 years assigned to heart disease, since, apart from deaths due to congenital heart disease, the vast majority of these deaths are rheumatic in origin. The following Table shows the distribution of heart disease deaths under 45 years, according to age, in recent years : Deaths from heart disease under 45 years Year 0-4 5-14 15-44 Total Rate per 1,000 living 0.44 1946 1 10 376 387 0.194 1947 1 11 398 410 0.197 1948 1 9 338 348 0.167 1949 5 3 350 358 0.172 1950 — 4 379 383 0.184 1951 1 1 338 340 0.156 1952 2 4 316 322 0.149 There would appear to be a fairly steady downward trend in the death-rate, interrupted in 1949 and 1950, but subsequently resumed. Under the age of 15 the number of deaths is so small that considerable fluctuation must be expected from random causes, and the six deaths in this age group in 1952 does not necessarily mean that any significant rise has taken place. Scabies Scabies became notifiable in London in August, 1943. Notifications in 1952 numbered 535, as compared with 572 in 1951, continuing the decline since the initiation of notification. The attack rate (0.159 per 1,000) in 1952 was less than l/40th of the rate experienced eight years earlier. Scarlet fever incidence was higher in 1952 than in 1951. There were 5,263 cases (1.56 per 1,000), compared with 1.10 per 1,000 in the previous year. Only three deaths from scarlet fever or streptococcal sore throat occurred in 1952. Fifty years ago the annual death roll in London was over 500. Scarlet fever There were no notifications of either smallpox or typhus in London during 1952. Smallpox and typhus Detailed figures of new cases of tuberculosis notified in 1952 are show in Tables 9 to 12 (pages 178 to 181). Non-civilians are included in the statistics and total (home) populations are used. fuberculosis The general trend of morbidity and mortality since 1921 is indicated in Table 9 (page 178) 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 population 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 tuberculosis was 0-64 per 1,000, i.e., about 40 per cent, lower than in 1920 ; a reduction of some 1,600 deaths annually at the 1938 population level. In the years of the war the general deterioration in living conditions, the strain placed upon the population by bombardment and the increased opportunities for the spread of infection, all combined to reverse the trend of both morbidity and mortality and by 1941 the ground gained in 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. 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 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 thev might have been expected to decline on the basis of the pre-war trends. The death-rates per 1,000 living in 1952 in London and for the whole country were: London Pulmonary 0-277 Non-pulmonary 0-026 England and Wales 0-212 0-028 22 With regard to morbidity the rate of diagnosis 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 services are now more used than ever before and also that new methods, such as mass miniature radiography, now discover early cases which normally might have recovered without notification or would not have been notified until the disease was more advanced. It is likely 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 1952, of 1..40 per 1,000, was less than the rate of 1.46 per 1,000 recorded in 1951. A war-time increase in non-pulmonary tuberculosis was less severe than for the pulmonary form and the rates have fallen below the pre-war level and have continued to decline to a very low level. The non-pulmonary notification rate in 1952 was 05. The age distribution of new notifications of tuberculosis is shown in Table 10, and specific notification and death-rates are show in Tables 11a and lib. TUBERCULOSIS MORTALITY & MORBIDITY 1923-1952 ANNUAL DEATHS PER 1,000 LIVING ANNUAL NOTIFICATIONS PER 1,000 LIVING 23 There were 5,587 notifications of whooping cough during the year compared with 10,488 in 195] and 10,875 in 1950. The two latter years were covered by one continuous epidemic with its peak at the turn of 1950-51. In contrast, 1952 was a year of light incidence. During the year there were nine deaths, giving a death-rate of 0.003 per 1,000, and a crude case mortality of 0.16 per cent. The corresponding rates for the previous two years were: Whooping cough 1950—Death-rate 0.009 per 1,000, case mortality 0.28 per cent. 1951—Death-rate 0.006 per 1,000, case mortality 0.20 per cent. Table 15 shows that during 1952 the notifications of whooping cough were fairly evenly spread over the year. 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 numbers of cases or various infectious diseases reported frorn schools in 1952 and previous years is shown in Table 13 (page 181). ! Infectious diseases in schools GENERAL PUBLIC HEALTH Housing during the year 13,162 houses and flats were erected by the Council and/or the metropolitan borough councils. Of these 7,318 were in London (2,922 by the Council and 4,396 by the borough councils) and the remainder (5,844) were erected by the Council outside the London area. The total number of houses or flats owned by the Council at 31st December, 1952 was 154,511 (an increase in the year of 8,710) of which 74,314 are situated in London and 80,197 outside the county. The number of applications registered on the Council's housing waiting list on 31st December, 1952, was 180,366 compared with 171,567 in 1951. Approximatel34,000 new applications were registered during the year. 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. Preferential rehousing During the year 37,748 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 3,000 less than in 1951. 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. (1,590) 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, 13 per cent. were classified as 'most urgen', and 34 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 49 per cent. 24 Slum clearance 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, four were represented to the Council during the period 1949-51, and the remaining two during the year under review. These six areas extended over approximately 31 acres and contained 1,291 houses. Reference was made in my report for 1951 to the submission to the Housing Committee of a detailed draft programme of slum clearance to be undertaken during the years 1951-55 by both the Council and the metropolitan borough councils. The task of implementing this programme, which provides for the demolition of 10,131 houses, was continued during the year, and 23 areas containing 1,187 houses were represented to the Housing Committee. In addition, preliminary surveys were completed in respect of a further 24 areas containing 793 houses and 11 blocks of dwellings. Five public local inquiries were held by the Minister of Health and confirmation of four of the Council's Orders was received. The result of the remaining inquiry was awaited at the end of the year. One additional Order was confirmed without the holding of a public inquiry. Notifications under section 33 of the Housing Act, 1936, of intention to deal with 542 unfit houses contained in 44 areas were received from 16 borough councils. Surveys were made of 95 houses contained in four areas, apart from those mentioned above, in connection with proposals for their acquisition by the Council. 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. Dangerous structures During the year 2,359 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: Source of sample Designation Samples Percentage positive of completed samples Total Positive Incomplete Negative 1952 1951 (a) Supplied to London by road and rail in churns Ordinary 336 8 9 319 2.4 1.8 Accredited 30 3 – 27 * * Tuberculin tested 117 – 3 114 – – (b) Plant at London depots Pasteurised 15 – 1 14 – – (c) Residential schools Tuberculin tested 2 – – 2 – – Total 500 11 13 476 2.4 1.8 * A percentage would be unreliable owing to the small number of samples taken. There has been a considerable increase in the amount of tuberculin-tested milk coming into London. As a result of investigations by the Ministry of Agriculture and Fisheries into the origin of positive samples in 11 herds, 5 tuberculous cows from five herds were removed and slaughtered under the provisions of the Tuberculosis Order, 1938. The source of infection in three other herds was presumed to be cows disposed of before investigations into the origin of positive samples were complete. No source of infection in one herd 25 could be traced, and investigation is still proceeding in the case of five herds, including three from which cows have already been slaughtered. All raw milk from which positive samples were obtained had been pasteurised before sale to the public. Sanitary inspection Disinflation Reports of 189 instances of infestation were received from 156 establishments controlled by the Council, e.g., school meals centres, schools, rest centres and parks. Infestation by rats, mice, cockroaches, bugs, ants, flies, fleas, mosquitoes and clothes moths were dealt with and 177 of the infestations satisfactorily remedied 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. Talks on the most effective measures for controlling and eliminating pests were given to staff employed in the restaurants and catering department, the London Fire Brigade, and at the Council's large welfare homes. Restaurants and catering Over 1,300 visits of inspection were made to school meals centres, dining centres and kitchens. Twenty-five reports of illness following consumption of school meals were investigated. In no case was contamination of food confirmed bacteriologically. Welfare establishments Regular inspections, at least once a quarter, were made of 72 homes, hostels, rest centres and other premises in connection with sanitary conditions. Complaints A large number of complaints of insanitary and overcrowded home conditions was received from the public. These were referred to the health departments of the appropriate boroughs. Food by-laws By-laws for the protection of food made by the Council under section 15 of the Food and Drugs Act, 1938, were confirmed by the Minister of Food and came into operation on 3rd November, 1952. Lectures on food hygiene were given to the staff of welfare establishments and to civil defence personnel. Advisory and research work Advice was given to staff of other departments within the Council's service on problems relating to sanitation, drainage, and other public health matters in connection with the preparation of plans for new buildings and for the adaptation of existing premises. Experiments were carried out during the year, in association with the architect's and the housing and valuation departments and the Plumbing Research Committee of the Department of Scientific and Industrial Research, to test the value of certain new plumbing theories. As a result of the exhaustive tests which have been applied to different plumbing systems specially installed in the Council's multi-storeyed dwellings in various parts of the county, it would appear that it may be practicable to instal a new and simple type of plumbing, known as the 'single pipe' system, which would prove less costly to Provide and more economical in the use of materials than the conventional svstems. Representation on committees of outside bodies The Chief Inspector continued to represent 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 185. 26 Examinations by the Council's ophthalmologists Classification Certified blind Not blind Grand Total Male Female Total Male Female Total New cases 271* 455* 726* 115 250 365 1,091* Previously blind, still blind 53 64 117 – – – 117 Previously not blind, now certified 32 53 85 – – – 85 Previously not blind, still not blind – – – 48 126 174 174 Previously blind, now not blind – – – 16 24 40 40 Total 356* 572* 928* 179 400 579 1,507* * These figures include 8 boys and 9 girls under 5 years of age. The standards used are those prescribed by the Ministry of Health (Circular 1353/ 5.10.33). The cases 'previously blind, now not blind' are mainly those in which cataracts have been removed surgically. Two hundred and forty-nine certificates were accepted from other authorities, hospitals and private ophthalmologists as follows : Blind persons 223 (104 male, including 5 children under 5 years ; 119 female, including 1 child under 5 years). Not blind persons 26 (15 male, 11 female). The causes of blindness in the 23 children under five years of age who were certified during the vear were as follow : Retrolental fibroplasia 7 Congenital, hereditary and development defects 6 Congenital optic atrophy 2 Cataract 2 Birth injury 2 Albinism 1 Encephalitis 1 Meningitis 1 Tubercular meningitis 1 The number of partially-sighted persons recommended for inclusion in the Observation Register was 343 (104 male, 239 female). Blind persons examined as to suitability for training and the results were : Male Female Total Suitable for training 19 4 23 Unsuitable for training – 1 1 Registration of nursing homes At the end of the year 48 nursing homes on the register were functioning compared with 53 at the end of 1951. In the 48 homes there were 864 beds distributed as follows: Number of beds in home Number of homes Patients accommodated Total All types† Medical and surgical only* 25 or over 5 227 87 314 20 to 24 11 78 160 238 15 to 19 4 8 59 67 10 to 14 13 57 92 149 5 to 9 11 36 48 84 Under 5 4 2 10 12 Total 48 408 456 864 * 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. 27 The number of maternity patients admitted to nursing homes during the year was 1,091 compared with 1,243 in 1951. Thirty-eight 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 (103 inspections) and public health inspectors (153 inspections). Close overall supervision of the homes and more frequent inspections of a number of them resulted in an improvement in the general standard. Welfare 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 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 1952. Homeless families units At the end of the year 300 mothers and 634 children (of whom approximately 58 per cent. were under 5 years of age and 22 per cent. under 1 year of age) were accommodated in the eight homeless families units attached to large homes. The occasional 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 were 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 at one of the large units a weekly session was held on the premises. Mother and baby units Nursery classes for children aged between 3 and 5 years were conducted under direction of the education officer at one of the large homes and at two of the rest centres. Close supervision of the health of infants accommodated in mother and baby units was continued during the year, and advice given on matters relating to diets and general hygiene. There were 9 cases of infective hepatitis during the year among families residing at one of the rest centres. All those affected over a period of eight months were children whose ages ranged between 2 and 11 years, and the many adults at risk escaped infection. In one family, three children were affected. The exact mode of spread was not determined, but syringe transmission was excluded. 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 acute shortage of suitable hospital beds. While 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, the number accommodated in the homes at the end of the year was 479 (144 men and 335 women). A large proportion of these residents were either permanently bedridden or in need of treatment in varying degrees and their continued care has given rise to many varied and complex 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 further conference of visiting medical officers was held at County Hall during the year to discuss problems associated with the care of the aged and chronic sick, and preliminarv arrangements were made for a similar meeting to be held early in 1953. 28 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 the Chemist-in-Chief has submitted the following report: One of the most important features of the National situation during the year 1952 was the financial stringency which developed, with the consequent need for exercising strict economy, having due regard, of course, to the preservation of efficiency. In this introduction it may therefore be appropriate to devote a short space to the consideration, from this aspect, of the use of the Chemical Branch to the service of the Council. A good example of the enormous scale on which this operates is in relation to paint; for 200,000 gallons of paint are used each year and, including the labour cost of the work, more than one million pounds is spent on this operation. The opportunity for effecting economy by ensuring that only paint of suitable quality is used and early failures thus prevented is readily apparent. Also many articles, including some foodstuffs, lubricating oils, polishes, etc., are purchased in large quantities. Tenders are invited for materials which must comply with quality specifications issued by the Council and samples submitted with the tenders are examined in the laboratory, the cheapest satisfactory material being recommended to the Chief Officer of Supplies for acceptance. The work of the Chemical Branch in the sewage treatment field is of direct economic value; for example, the development of a chemical method for cleaning air diffuser tiles in the activated sludge plant showed a large saving as compared with previous procedures. Other work done by the branch may be classified as 'insurance premiums'; for example, that on ensuring the satisfactory quality of water supplies (chlorinated) from private wells and the maintenance of efficient treatment of swimming bath waters. There must also be borne in mind the statutory work which has to be done in connection with various Acts administered by the Council; for example, the Fertilisers and Feeding Stuffs Act, 1926, the Petroleum Consolidation Act, 1928, London Building Act, 1930, Town and Country Planning Act, 1947, etc. The amount of advisory and consultative work devolving upon the senior officers of the branch from these and other activities increased considerably during the year and the very necessary and valuable time spent on Government committees dealing with matters of interest to the Council also increased; these committees related, for example, to the condition of the River Thames, Atmospheric Pollution, Flue Gas Washing at electricity generating stations, etc. The number of samples received for examination in 1952 showed a considerable increase and was the largest on record. It amounted to 26,642, as compared with 25,666 in 1951. The classification was: Air tunnels, etc. 267 Building materials 268 Chemicals, drugs and medical supplies 142 Clay, subsoils and borehole waters 1,265 Detergents and soaps 94 Disinfectants and insecticides 9 Fertilisers and feeding stuffs 106 Floor oils and polishes 53 Fuel (coal and coke) 16 Foods 715 Gases, sludge digestion plant, flue, de- greasing plants, etc. 412 Insulating materials for hot water systems 29 Lamps, gas detector 411 Laundry tests 92 Liquor, effluent from gasworks 406 Meals 93 Metals 34 Milk, liquid, condensed, dried 208 Miscellaneous 293 Oils, lubricating, fuel, etc. 60 Paints, varnishes and distempers 2,145 Petroleum and allied samples 98 Plastics 54 Rainwater (atmospheric pollution deposit gauges) 84 Rubber and rubber substitutes 10 Scouring powders and lavatory cleansers 12 Sewage and effluent 4,637 Sludge, primary, digested and activated 3,178 Sulphur gases and smoke in air 1,956 Water, steam-raising plants 1,794 Water, drinking 1,551 Water, swimming bath 1,231 Water, river 4,823 Water, miscellaneous 96 Total 26,642 29 The following paragraphs give a general indication of the source of origin of these samples and of the consultative and advisory duties carried out for the various services and departments of the Council. Rivers and drainage Throughout 1952 the whole of the sewage flow to the Northern Outfall Works was treated by sedimentation and approximately one-quarter 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 Northern Outfall Works was subject to analytical control, the rate of charge being decided accordingly, and it worked 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. 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 as was also that of the 'old reservoir' sludge digestion plant. Progress had been made there on the construction of the new sedimentation tanks. 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. Towards the end of the year the Minister received a joint deputation from the Council and the Port of London Authority which emphasised to him the necessity, in view of the condition of the water of the River Thames, for proceeding at the earliest possible date with the additional works for treating the sewage of London in order to lessen the pollution load on the river. In the report for 1951 it was mentioned that consideration had been given to any temporary palliative measures which could be adopted to improve the condition of the water of the river in the summer months and that chlorination of part of the effluent from the Northern Outfall Works had been tried as the only possible practicable policy. In 1952 chlorination of that part of the effluent from those works which was not subsequently subjected to secondary treatment was again started in May and continued until the end of August. The dosage adopted was one-third of the chlorine demand, which was about 40 parts per million; i.e., the addition of 13 parts per million of chlorine. This was achieved by dissolving it in final effluent from the activated sludge plant in absorption towers and adding the relatively strong solution to the primary effluent to be treated. In spite of this, as will be explained in more detail later, the condition of the water of the river at the end of August was bad over a long stretch of its course and it was decided to cease chlorination—which was a very expensive procedure requiring about 50 tons of chlorine per week—and use September as a 'control' period. Actually, the water of the river in that month did not become generally worse, although it still remained bad. It was concluded that chlorination on the scale which its great cost and quantity made feasible did not produce sufficiently beneficial results to justify its future use and the procedure was therefore abandoned; also that the only way of improving the condition of the water of the river was by lessening the pollution load added to it, which could best be accomplished by proceeding, as soon as possible, with the additional sewage treatment works. 30 The state of the water of the river is 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. By Statute, no abstraction is permitted which will have the effect of reducing the flow over the Weir to below 170 million gallons per day, although the appropriate Minister can, by Order, permit the reduction of the flow to as low as 50 million gallons per day. The rainfall in the summer of 1952 was rather below average and hence the average fresh water flow over Teddington Weir was also rather below average. It was, indeed, considerably less than that for 1951, though much greater than that in the dry year 1949. In the summer months of 1952 the condition of the water of the river became extremely poor and was bad over a considerable stretch of its course for several weeks, particularly between London Bridge and Gravesend, with a complete absence of dissolved oxygen and the development of sulphide (with its characteristic odour). 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 Chemistin-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 de watering of sludge by a new process involving freezing after the addition of chemicals; the pilot plant for dealing with one ton of sludge came into operation early in the year and research on the filtration of the material produced proceeded satisfactorily. The question of trade discharges into sewers was investigated in a number of cases as to compliance with the appropriate sections of the Public Health (London) Act, 1936. Attention was also directed to the ventilation of sewers and, in view of certain complaints of emanations, a joint working group of officers of the Council and of the Metropolitan Boroughs' Standing Joint Committee was set up to investigate the problem. It was decided that the increase in trade wastes was an important factor and that it was desirable to initiate legislation in order to obtain more effective control. The Chemist-in-Chief was a member of this Working Group. Safety lamps used in sewers were tested and adjusted periodically and an officer of the Chemical Branch gave advice and assistance in training men employed on sewerage work in the use of oxygen breathing apparatus under emergency conditions. The sewage treatment service is a joint function of the Chief Engineer's and Public Health Departments and special mention should be made of the cordial relations which have so greatly helped in maintaining the efficiency of the operations. Weekly conferences of the Divisional Engineer (Main Drainage) and the Chemist-in-Chief and their senior officers have been of the utmost value in this respect. Housing The work done by the Chemical Branch for this service covered a very wide field. The largest section was on paints and other decorative finishes, the economic aspect of which has already been mentioned. The Interdepartmental Paint Committee and SubCommittee held periodical meetings during the year and progress was made with the completion of 'approved lists' of brands of paint which must be used on work for the Council whether by direct labour or by contractors. Lists were compiled for hard-gloss paint (both interior and exterior), flat oil paint, semi-gloss paint, emulsion paint, 31 chlorinated rubber paint and bituminous paint, the classification depending primarily on the results of the analyses and tests made by the Chemical Branch. Samples of deliveries were also taken at the sites in order to ensure that the quality complied with the standard required. The technique of paint testing has advanced considerably in recent times and, in order to ensure the efficiency of the examination, the Council agreed during the year to expenditure necessary for equipping a new paint-testing laboratory at County Hall with the latest apparatus. In addition to facilities for determining the film hardness, flexibility, etc., provision is being made for an accelerated weathering test apparatus. A feature of the year's examination of products for approval was the large number of emulsion paints submitted. The majority of these were based on water emulsions of polyvinyl-acetate and it was necessary to study the properties of such materials and work out a suitable scheme of examination. Examples of a few defects were (a) the use of lithopone in a paint for exterior work; (b) offensive and toxic nature of the medium; (c) insufficient mixing before use. Special matters dealt with referred to: (a) colour permanence of applied paint (i.e., the fastness to light), (b) primers for hard-boards, (c) fire resistant paints, (d) paints for specially corrosive conditions, e.g. sewage. Much advice was sought regarding building materials and allied problems. A few examples were in relation to cements, asphalts, bitumen sheeting for roofing, etc., synthetic floorings, sand, plasters, mortars, etc. For example, many types of flooring materials were examined to ascertain their chemical composition, water absorption, shock and fire resistance, thermal conductivity, durability and liability to staining by certain materials. Their composition varied widely: coloured Portland cement, magnesium oxychloride, bitumen and sawdust, high alumina cement and rubber latex, powdered wood and resin were typical examples. Such a variety introduces not only problems in regard to construction but also as to cleaning and polishing. Plaster defects were investigated in some cases and the causes diagnosed. Asphalts were generally satisfactory as regards the bitumen content but in some cases adverse comment was made as to the grading of the aggregate. Materials for the eradication of wood-boring insects were examined and recommendations made. On the planning side the advice of the Chemical Branch was sought in many cases in regard to the Use Classes Order, 1950, relating to the Town and Country Planning Act, 1947; guidance was sought as to the exact classification of proposed industries with respect to the possible causation of nuisance or effect on the amenities of the areas in which their sites were located. Public health The examination of water supplies is an important part of the work of the branch from this aspect, for, although in the majority of cases the water is derived from the mains supply, there are a number of schools and other premises at which it is drawn from private wells. In these cases, before use, it is chlorinated by means of automatic dosing appliances. The Chemical Branch carries out regular monthly inspections (in addition to the daily free chlorine tests made by the resident engineer) and samples are taken for chemical analysis and bacteriological examination in the laboratory. Some hospitals formerly under the control of the London County Council which have private well supplies have, at the request of the hospital committees, continued to be included in the regular examination programme. The air in the Council's vehicular tunnels under the River Thames was regularly tested 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 periodically and found to be safe. Since nitrous fumes can be caused by diesel engines this constituent also received attention but it was well within safety limits. 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. 32 The results during the year again showed variations in different localities of the County due to factors such as local sources of pollution ; there was also a well marked contrast between urban and rural conditions. Seasonal fluctuations were clearly evident during the cycle of months. The generally higher level of pollution found in winter months is due to the combined effect of increased coal consumption and the occurrence of meteorological conditions unfavourable to dispersal of particles and gases emitted from chimneys. Apart from its long-term detrimental effects, atmospheric pollution is particularly objectionable in meteorological conditions where there is a lack of convective up-currents of air, since the contaminants may then accumulate to concentrations acutely dangerous to health. An extreme case of such conditions occurred during the period 5th to 8th December, 1952, when there were four consecutive days of frost and dense fog. During the period midday Saturday 6th, to the morning of Monday, 8th December, pollution rose to the highest yet recorded in the Chemical Branch records, namely, sulphur dioxide 1.34 parts per million, and smoke 4.46 milligrams per cubic metre at County Hall. Official notifications of deaths for the week ending 13th December showed that abnormally large numbers of persons had died from causes connected with difficulty of breathing, and this high general death rate was comparable with the peak mortality of such events as the cholera epidemic of 1866 and the influenza pandemic of 1918. By virtue of a standing agreement with the Ministries concerned, the Chemist-inChief accompanied the Chief Alkali Inspector of the Ministry of Housing and Local Government on his visits of inspection to test the efficiency of the flue gas washing plant at Battersea Power Station. Similar facilities for inspection were sought and obtained in regard to the newly constructed Bankside Power Station which is also to incorporate flue gas washing plant. 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 Chemist-in-Chief was a member of the Working Group set up by the Medical Officer to consider all aspects of disinfection in relation to all branches of the service and to make recommendations accordingly. Problems and work on industrial hygiene and safety ranged over a wide field; examples were: (a) safety precautions after the spillage or leakage of petroleum spirit; (b) some yellow coloured chalks for schools contained lead chromate and were rejected; (c)precautions were advised to prevent dermatitis when using water-insoluble synthetic resin glues. Public control Samples taken under the Fertilisers and Feeding Stuffs Act, 1926 (under which the Chemist-in-Chief is the Official Agricultural Analyst for the County), were examined as to whether they complied with the statutory statement of ingredients which is required to be given with every sale and also (in the case of feeding stuffs) as to their freedom from deleterious substances ; several were reported upon adversely. Many samples were also examined under the Petroleum (Consolidation) Act, 1928, the provisions of which govern licences for storage and safety precautions regarding petroleum spirit and petroleum mixtures. Cases were also considered and examined relating to certain sections of the London Building Acts, 1930-39, referring especially to dangerous businesses and to means of escape when inflammable materials are stored or used; alterations to plant were recommended in certain instances. Another Act with which the Chemical Branch was concerned was the L.C.C. (Celluloid, etc.) Act, 1915. 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. 33 Parks Although some work was also done for this department on fertilisers, soils and other matters the most important aspect of it related to the swimming baths and ponds provided for public use. The 13 open air baths have chlorination plants which provide continuous treatment of the water. The Parks Department, Chief Engineer's Department and the Chemical Branch are all concerned in these operations and close liaison was maintained which resulted in a high standard of purity of the water being maintained throughout the bathing season. Frequent tests for free chlorine were done by the staff at the baths and periodical visits were made by an officer of the Chemical Branch who took samples of water for chemical analysis and bacteriological examination in the laboratory. The investigations of a research team including officers of the Chemical Branch and the Chief Engineer's Department resulted in inexpensive changes being made to some of the plants which caused a considerable improvement in the efficiency of operation. The fundamental principles of the chlorination process were studied and it was proved, for example, that in an open-air bath the action of sunlight caused a greater loss of free chlorine residual than the impurities normally added by the bathers. 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. 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. The research team, already mentioned as working on swimming baths, devoted considerable attention to those of this type and devised improvements which, in the case of the particular bath where they were tried, rendered the operation partly automatic so that the length of period for which the water could be used without emptying and refilling was greatly increased. 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 then are dealt with in other paragraphs concerning the services which use them; for example paints and building materials for housing. Particularly close liaison was maintained with officers of all branches of the Supplies Department which facilitated discussions on matters on which a scientific aspect could be helpful. 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 preparation: could be of potential use in the service. Generally, a high standard of quality wa: 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 anc dried milks were examined as required. Other materials which might be mentionec included chemicals, drugs and medical supplies, lubricating and other oils, floor anc other polishes, soaps, solders and other metals, etc. Careful attention was given to the development of synthetic detergents and man) types were examined though the Council's own specification for a washing-up powder was still considered to be the most satisfactory. The use of plastics as substitutes for chins and earthenware in certain instances was investigated and many of the several different compositions now on the market were examined. For some, for example melamine, the curing in manufacture is particularly important and under-curing may result in an undue proportion of the incorporated zinc oxide being extractable by acid liquids 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. Other subjects c 34 dealt with were (a) the fire-resistant treatment of fabrics, (b) the efficiency of foaming compounds for fire extinguishers, (c) the relative efficiency of various fire retarding coatings for wood, (d) cause of fires, e.g. the careless use of a painter's blow-lamp. Steam raising, heating, etc., plants ; laundries 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. Samples from some of the larger installations were examined regularly. Phosphate conditioning of boiler water has now become standard practice though in some cases the use of soda ash and quebracho is being continued. An interesting investigation related to corrosion in a hot water circulating system; it was, most unusually, found to be due to the action of sulphate reducing bacteria which had gained access to the feed tank. Heat insulating materials of the magnesia plastic and hardsetting types were analysed as to their suitability for use. In co-operation with the Chief Engineer's Department investigations were made into the operation of the many laundries maintained by the Council. The problem was approached not only from the detergency angle but also from that of the effect on the clothes in the process. Both these aspects are now capable of being examined by scientific tests and, although the whole range had not been completed by the end of the year, it had already been possible to introduce certain improvements in operation. Miscellaneous Many other matters were dealt with of which a few examples are : (a) Estimating the thickness of chromium and other electroplating on manufactured goods. (b) Death of fish in a pond. (c) Assessing scientifically the approach to truth of the colour of colour photographs supplied by contract. (d) Civil Defence matters were considered. Attention was paid to the development of new analytical methods and close liaison was maintained with many Research Associations, Government Scientific Establishments, etc. During the year many visitors, both from home and abroad, were welcomed to inspect the work of the various laboratories. The Library of the Chemical Branch continued to develop and is an essential part of its equipment. The Chcmist-in-Chief served on four committees of the Ministry of Housing and Local Government, four of the Department of Scientific and Industrial Research and nine of the British Standards Institution. The Deputy Chemist (Dr. S. G. Burgess) served on a committee of the Ministry of Food and on five committees of the British Standards Institution. Publications and lectures during the year were : (a) 'The Condition of the Tidal Portion of the River Thames'—C. J. Regan. (b) 'Cleopatra's Needle'—S. G. Burgess in collaboration with R. J. Schaffer of the Building Research Station, D.S.I.R. (c) 'Investigations into Swimming Bath Water Treatment'—S. G. Burgess and D. Burns, in collaboration with C. W. Tidy of the Chief Engineer's Department. (d) 'Chemistry of Water Conditioning with respect to Economy'—S. G. Burgess. (e) 'Science and Painting Problems'—S. G. Burgess. (J) 'A Method of Estimating Sulphides in Waters '—J. E. Houlihan and P. E. L. Farina. (g) 'Total Hardness of Water by the Versenate Method: Direct titration with Ethylene diamine tetra-acetate (EDTA) '—J. E. Houlihan. 35 SPECIAL SURVEY OF LOCAL HEALTH SERVICES as required by the Minister of Health (Circular 29/52) a special survey was prepared of the services provided under the National Health Services Acts and forwarded to him early in March, 1953. The information given in the survey relating to individual services is included in the appropriate sections of this report. The following is the other information which was given : Administration For the purpose of administration the County is divided into nine divisions consisting of groups of from 2 to 5 of the Metropolitan Boroughs as follows: Metropolitan Boroughs arranged in divisional order Estimated home population mid 1951 Metropolitan Boroughs arranged in divisional order Estimated home population mid 1951 Division 1 Division 5 Chelsea 52,430 Bethnal Green 58,000 Fulham 122,400 City of London 5,200 Hammersmith 118,300 Poplar 73,260 Kensington 171,300 Stepney 98,850 Division 2 Division 6 Hampstead 97,750 Deptford 76,040 Paddington 125,400 Greenwich 89,390 St. Marylebone 76,160 Woolwich 149,800 St. Pancras 139,100 Westminster, City of 100,000 Division 7 Division 3 Camberwell 179,500 Lewisham 227,200 Finsbury 35,620 Division 8 Holborn 24,540 Islington 235,800 Bermondsey 60,380 Division 4 Lambeth 229,100 Southwark 97,930 Hackney 170,800 Division 9 Shoreditch 45,010 Stoke Newington 49,440 Battersea 117,000 Wandsworth 332,300 With the exception of the domiciliary midwifery, ambulance and mental health services the day-to-day administration of the personal health services is carried out on a divisional basis. The statutory Health Committee consists of the Chairman, Vice-Chairman and Deputy Chairman of the Council (ex-officio), 30 other members of the Council and 16 persons not being members of the Council of whom not fewer than 10 shall be appointed by the Council from members of the City Corporation or the Metropolitan Borough Councils after consultation with the City Corporation and the Metropolitan Boroughs' Standing Joint Committee. The Committee's constitution provide for representation of the Local Medical Committee for the County of London, the London Executive Council, the Metropolitan Regional Hospital Boards and the Teaching Hospitals Association. A Divisional Health Committee has been constituted for each of the nine divisions. These committees are sub-committees of the Health Committee and their constitution is as follows: Exclusive of ex-officio members, not more than eight or fewer than four members of the Council or the Health Committee; not more than 15 or fewer than eight members of the Metropolitan Borough Councils (or the City Corporation) appointed after consultation with the Metropolitan Boroughs' Standing Joint Committee (or the City Corporation); and not more than six other persons co-opted for special reasons. 36 Each divisional health committee includes representatives of the Local Medical Committee for the County of London, the London Local Dental Committee and the district nursing associations. Representatives of the Royal College of Nursing, Royal College of Midwives, Women Public Health Officers' Association, Local Pharmaceutical Committee, and of branches of the British Postgraduate Medical Federation (i.e., Institute of Obstetrics and Gynaecology, Institute of Child Health) are also included on individual committees. Arrangements have been made for the medical officers of health of the City of London and the City of Westminster and of all the metropolitan boroughs except St. Marylebone to participate in the day-to-day administration of the divisionalised personal health services. Particular mention may be made of the special tripartite organisation in one division, comprising the Boroughs of Battersea and Wandsworth, where an officer has been jointly appointed to act as divisional medical officer for the Council and as medical officer of health for the two boroughs. He has two assistants, each of whom acts as assistant divisional medical officer and as deputy medical officer of health for one borough. In addition to these special arrangements, two of the Council's divisional medical officers have been appointed by metropolitan boroughs (Paddington and Stoke Newington) as their medical officers of health, on a part-time basis. Other divisional medical officers have on occasion acted as borough medical officers of health, e.g. during sickness or holidays of the regular incumbent or hiatus between two regular appointments. Five of the Council's assistant medical officers are at present regularly employed for part of their time as deputy borough medical officers of health (in Finsbury, Fulham, Hampstead, Islington and Paddington). All the regular arrangements include appropriate financial adjustments between the Council and the metropolitan boroughs concerned and the officers carrying out the additional duties receive appropriate allowances in accordance with the relevant Industrial Court awards governing medical salaries generally. Conferences with appropriate officers from head office are held at regular intervals in order to ensure co-operation and co-ordination throughout the service, viz., with divisional medical officers ; divisional administrative officers; divisional nursing officers; chest physicians. In addition conferences are held at divisional level with the borough medical officers of health concerned with the day-to-day administration of the Council's health service. Arrangements are made for whole-time medical staff to attend short refresher courses from time to time. About 100 medical officers have so far attended, the majority of them at week-end courses arranged by the Society of Medical Officers of Health. Co-ordination and co-operation with other parts of the National Health Service Whilst an excellent spirit of co-operation exists throughout the various branches of the health service in London, co-ordination in the complex circumstances of the metropolis is not easy. Whilst there is one Local Health Authority and one Local Executive Council for the whole of the County area, there are parts of four Metropolitan Regional Hospital Boards whose boundaries cut across no less than five metropolitan boroughs. There are also, under the Boards, 25 hospital management committees, and in addition, 12 undergraduate and 14 postgraduate teaching hospitals each with independent boards of governors. The constitutions of the Health Committee and of the divisional health committees as set out in paragraphs 4 and 5 indicate the extent to which co-ordination has been achieved at member level with other bodies concerned with the health service. The report of the Central Health Services Council on co-operation between hospital, local authority and general practitioner services is receiving careful consideration and preliminary consultations are proceeding with the other bodies concerned to decide whether the Council could usefully convene a regional conference to devise further machinery for co-operation. 37 Conferences are held periodically at officer level to ensure co-ordination and cooperation in the administration of the services with the senior administrative medical officers of the four Metropolitan Regional Hospital Boards, the medical officers of health of the Home Counties, representative house governors of teaching hospitals, and representative metropolitan borough medical officers of health. Each of the nine divisional medical officers is a member of at least one hospital management committee in the area. Senior divisional staff also serve on many voluntary committees concerned with health (e.g. nursing associations, tuberculosis care, care of old people). From the inception of the National Health Service Act, 1946, the Council, through its divisional staff, fostered close co-operation between the almoners of hospitals and the divisional organisation in view of the fact that the two services are interdependent for a full knowledge of the patient, his background and his needs, and that the two services have a common concern in the well-being of the patient and the maintenance of his health. In view of Ministry of Health circular 160/48, negotiations took place with the hospital authorities and the Institute of Almoners on the after-care arrangements for persons discharged from hospitals. A scheme was introduced early in 1951 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 of almoners to the Council's fieldworkers for mutual discussion and exchange of information is encouraged, but all correspondence on arrangements for home visiting and after-care is conducted through the divisional medical officers. There was a good record of co-operation between hospital maternity and pediatric departments and the ante-natal and child welfare clinics at welfare centres before the National Health Service, and this has been maintained and developed since 1948. So far as the discharge of maternity patients from hospital is concerned, the Council introduced, with the co-operation of hospital authorities, a form which hospitals could use when notifying the Council's divisional medical officers of such discharges which has worked well. On the receipt of Ministry of Health circular LHAL 1/51 enclosing a copy of the memorandum RHB (51)74, divisional medical officers offered to co-operate with local hospitals by advising on admissions on social grounds. This is closely allied to the problem of the number of home confinements and the work of the domiliciary midwife. Detailed reference to the origin of the circular and its first results is made in the section on the domiciliary midwifery service. Reference may be made here to the approach which has been made to the secretaries of the Metropolitan Regional Hospital Boards and of hospital management committees and boards of governors of all hospitals with maternity beds, suggesting that the time has arrived for a review of the progress made in co-operation in this and allied matters, relating to the maternity services, under the following heads: (a) Selection of maternity patients for admission to hospital. (b) Co-operation between hospital maternity departments and the Council's antenatal clinics. (c) Notification to the Council of the discharge of maternity patients from hospital. (d) Provision of care and after-care for maternity patients as part of the scheme for provision of care and after-care at the request of hospital almoners. Reference is made in the section on the domiciliary midwifery service to the liaison between ante-natal clinics and the general practitioner. Arrangements have been in force for a long time for exchanging information between the Council's domiciliary midwife and the booked general practitioner obstetrician on the ante-natal examination of their patients. There is in existence also a form for notifying the general practitioner, subject to the patient's consent, that one of his patients is pregnant. General practitioners are notified when any of their patients (mothers or children) are referred from maternity and child welfare clinics to hospital out-patient departments for further advice and treatment. Co-operation is encouraged between general practitioners and the Council's health visitors and in some divisions arrangements have been 38 made for regular meetings between numbers of general practitioners and health visitors working in their areas. Health visitors discuss with the family doctor questions relating to a patient's treatment which may arise in the course of duties in the home or centre. There is no doubt that this co-operation is of benefit. Not only are the health visitors able to advise the general practitioners on the various local health authority and voluntary services available in particular cases, but they are able to supplement the treatment given by the doctors by visiting the patients in their homes. Further development of such co-operation between health visitors, hospital staff and doctors in general practice is restricted only by the general shortage of health visitors. Liaison is maintained with the mass miniature radiography services of the four Metropolitan Regional Hospital Boards who assist the Council to carry out its duties for the prevention of tuberculosis. The tripartite nature of the tuberculosis services in London creates continuous need for liaison which is not always easy, smooth or effective. Nor does it always ensure that the Council's viewpoint or wishes necessarily prevail. Publicity In 1949 a pamphlet was prepared for general distribution to the public. There were nine editions of the pamphlet, the appendix of clinic addresses and times differing in each. Similar information is supplied from time to time to local information centres, etc., as part of a loose-leaf publication on all services of the Council. Special information is supplied on request for directories, borough guides, etc. Information on the health services is often given in newspaper and magazine articles and through B.B.C. programmes. Every facility is offered to journalists for this purpose. On the introduction of the National Health Service, all general practitioners in the County were notified by letter of the services provided by the Council as local health authority. A further circular is in course of preparation reminding them of the services available and the method of obtaining them for their patients. Joint use of staff About 180 doctors in general practice are employed by the Council on a sessional basis, about 115 on work under the National Health Service Act, and the remainder in the school health service. The general practitioners work on an average two sessions a week each and are responsible for about one-third of all sessions taking place. General practitioners carry out all types of work for which non-specialist medical staff are employed, e.g. ante- and post-natal, child welfare, vaccination, immunisation and dental anaesthetics. The Council's proposals for carrying out duties under the National Health Service Act envisaged discussions with the four Metropolitan Regional Hospital Boards with a view to making joint appointments, on an agreed basis, of medical specialists to be employed in both the hospital and local health authority fields. Arrangements have now been made with all four regional boards and with a number of the teaching hospitals for the payment by the Council of three-elevenths of that part of the salary of chest physicians that is attributable to work in the chest clinics. In certain cases the Council also contributes towards the salaries of clerical and social workers employed by the hospitals in the chest clinics, as an alternative to the practice, in the majority of cases, of the Council itself providing staff in these grades for the care and after-care work of the chest clinics. By the end of 1952 arrangements for the exchange of medical officers, employed by the Council at maternity and child welfare centres and undertaking child welfare sessions, with pediatric registrars were operating at the following hospitals: St. George's Hospital (Tite Street Branch). The Hospital for Sick Children, Great Ormond Street. Westminster Children's Hospital. Paddington Green Children's Hospital. Queen Elizabeth Hospital for Children (Bethnal Green Road and Shadwell Branches). King's College Hospital. Guy's Hospital. 39 In addition there is an exchange system with St. James's Hospital, Balham, and a paediatrician from St. Thomas's Hospital goes to North Lambeth Babies' Care Welfare Centre to take weekly child welfare sessions and is paid the ordinary rate for a nonspecialist session. Among the services taken over from the metropolitan borough councils were a number of specialist clinics for expectant and nursing mothers and children (e.g. gynaecological, special women's, physiotherapy). Although these were provided under the maternity and child welfare powers of the borough councils, they were not services proper to the local health authority under the National Health Service. Negotiations have, therefore, been proceeding with the Metropolitan Regional Hospital Boards with a view to their assuming full responsibility for the administration of such clinics. In some cases, responsibility has been accepted for clinics held in Council premises; in others the work has been transferred to hospital premises or terminated. Negotiations are still proceeding in some instances. The Council has continued the employment, under arrangements made by the borough councils, of specialists provided by teaching hospitals for ante-natal advice (5 sessions a week) and child welfare (3 sessions a week). Generally speaking, however, specialist advice for maternity and child welfare patients is obtained by referring the patient to a hospital specialist clinic and there is adequate liaison between the clinics and the hospitals for this purpose. Voluntary organisations From the inception of the National Health Service the Council continued to utilise existing voluntary committees as in the case of the home nursing service which is carried out entirely by voluntary district nursing organisations on a grant-aided basis. Encouragement has also been given, in appropriate cases, to the formation of new committees such as those for tuberculosis care and the care of old people to which reference is made below. The use of voluntary associations in connection with mental health is dealt with on page 106. When the Council assumed responsibility for the maternity and child welfare services, an agreement to cover the period from 5-7-48 to 31-3-50 in the first instance was made with 24 voluntary organisations providing maternity and child welfare and/or day nursery services, arrangements being made for the Council to be represented on the managing committees of these bodies and to inspect the premises and services, and for a grant to be paid by the Council on a modified deficiency basis. The administration of two maternity and child welfare centres has since been assumed by the Council. New agreements in the light of the experience gained since July, 1948, are being negotiated with the remaining voluntary organisations, and in the meantime, by mutual consent, the original agreements have been extended. Arrangements were also made with the Mothercraft Training Society, Cromwell House, Highgate, for the Council to be financially responsible for the attendances of London residents at their two out-patient clinics for mothers and children (a) at 42 Penywern Road, Kensington, and (b) at Cromwell House, Highgate, and for financial responsibility to be accepted for the admission of London residents to the in-patient unit at Cromwell House for mothers and babies with breast-feeding difficulties and babies with dietetic upsets. These arrangements were terminated when the Society ceased its activities at the end of July, 1951. Records relating to London children who normally attended the out-patient clinics were passed to the appropriate divisional health office so that these mothers and children might be referred to convenient welfare centres. Patients who would have been referred by the Council for in-patient treatment at Cromwell House are now referred to the residential unit at the Violet Melchett Infant Welfare Centre (see page 51). Many of the former voluntary hospitals provided maternity and child welfare services, both ante- and post-natal clinics, child welfare clinics, and health visiting services, before the 'appointed day' often by arrangement with one or more of the metropolitan 40 borough councils, by whom they were assisted financially. Two of the Council's former hospitals provided ante- and post-natal facilities for metropolitan borough councils by agreement but without payment, and others provided dental services for expectant and nursing mothers and children under five years of age, payment being made on a case basis. Ante- and post-natal clinics may be provided under Part II of the Act of 1946 by hospitals for their own booked maternity patients, but in view of the ruling that a service for healthy babies and a health visiting service can be provided only by a local health authority either directly, or through a voluntary organisation on an agency basis, consultations took place with representatives of the teaching hospitals and of the Metropolitan Regional Hospital Boards about these services. It was pointed out during the course of these consultations that it would be possible for a medical school to be regarded as a voluntary body and to act as an agent of the Council in providing child welfare services. It was found that 10 hospitals were providing only consultative clinics or clinics for schoolchildren which were within their powers under Part II of the Act. Three child welfare clinics were being held at hospitals under the jurisdiction of the Metropolitan Regional Hospital Boards, but although the Council was willing to continue these, the hospital management committees concerned decided to discontinue them and arrangements were made for the children in attendance to be transferred to nearby Council welfare centres. Child welfare clinics were being provided at five teaching hospitals, one by agreement with the City of London on behalf of that authority. It was agreed that the Council should continue the same arrangements as the City Corporation. At one of the teaching hospitals it was agreed with the consent of all parties concerned that the Council should take over the services hitherto provided and run the clinic in the hospital premises as a municipal centre, paying rent to the hospital authorities. At the three remaining hospitals it was agreed that the medical schools would run the service as voluntary organisations grant-aided by the Council. A similar arrangement was subsequently made with the Institute of Obstetrics and Gynaecology for the provision of child welfare services at Queen Charlotte's Hospital. Broadly speaking the arrangements with these teaching hospitals is for the medical school to pay a rent agreed by the Council to the hospital authorities for the use of the clinic premises. The medical school also provide and pay for staff except health visitors. The Council reimburses the medical school at the rate of 90 per cent. of approved net expenditure subject to the payment by the Council of the full non-specialist rate for the services of the pædiatrician. The other ten per cent. of the expenditure with the balance of any specialist rate paid to medical staff is found by the medical school and is regarded as a fair return for the teaching facilities which are enjoyed at the clinic. By mutual agreement, at one hospital one health visitor is employed by the medical school and her salary is allowed to rank for the purposes of the Council's grant. These arrangements have been working very satisfactorily since their inception and are shortly to be confirmed by agreements between the Council and the medical school. The Council's health visitors attend the hospital child welfare clinics where they work to the paediatrician in charge, but they remain under the direction of the Council's divisional medical officer for their work outside the clinic. All the Council's duties under section 25 of the National Health Service Act, 1946, are carried out on its behalf by voluntary organisations. There are 24 district nursing associations, the Ranyard Nurses, the Nursing Sisters of St. John the Divine and the Catholic Nursing Institute, their work being co-ordinated by another voluntary body, the Central Council for District Nursing in London. All these organisations are grantaided by the Council (see page 73), but retain their independent and voluntary status. The loan of equipment to patients being nursed at home has been undertaken on behalf of the Council by the district nursing organisations and by the City of London and the County of London Branches of the British Red Cross Society, which are grant-aided by the Council (see page 73). 41 Since the appointed day the Council has continued and extended its use of voluntary organisations for the provision of services related to the prevention of tuberculosis and the care and after-care of tuberculous persons. The work of these organisations has enabled the Council conveniently to fulfil certain of its duties in this field and to meet needs which otherwise, at the present time, would be difficult to satisfy. Except in the case of the local tuberculosis care committees, the Council either makes grants-in-aid related to the expenditure incurred by the voluntary body on the service concerned (as in the case of the Invalid Children's Aid Association, British Council for Rehabilitation, district nursing associations and Invalid Kitchens of London) or meets the specific charges levied by the voluntary body (as in the case of the village settlements). Payments of grants from official funds are not made by the Council to the local tuberculosis care committees, but regular contributions are made to these committees from the Sunday Cinema Fund, which the Council administers through its Public Control Committee. Secretarial assistance and office facilities are provided by the Council without charge to the committees. There are 25 voluntary tuberculosis care committees in the administrative county serving 26 metropolitan boroughs; one of the committees was established after 5th July, 1948. These committees hold an important place in the Council's care and after-care arrangements. The scope of their activities is not fully demonstrated by statistical information, but the general outline contained in paragraphs 156-8 on extra nourishment, diversional therapy, articles on loan, etc., gives some measure of the services provided jointly by the Council and the care committees. The work of these committees and the Council's care organisers (who act as secretaries to the care committees) towards relieving, with advice and practical help, the personal, domestic and financial anxieties of tuberculous patients and their dependents, has not relaxed since the introduction of the National Health Service. This work necessarily involves close co-operation with statutory and voluntary bodies in order to bring to the patients' aid the help and benefits available from these sources. The funds of the care committees derive from voluntary contributions, grants from the Sunday Cinema Fund, sales of work and, in the case of affiliated committees, the sale of Christmas seals provided by the National Association for the Prevention of Tuberculosis. A divisional tuberculosis care committee has been set up in each of the nine health divisions to co-ordinate the activities of the local tuberculosis care committees in the division. Comments on the work of the other voluntary associations in connection with the tuberculosis service are given in the relative paragraphs. The Invalid Kitchens of London, a voluntary organisation established in 1905, provides meals for invalids and sick people in London from five centres, the meals being supplied at dining rooms attached to the centres or delivered by motor van to the homes of patients who are unable to attend. Meals are supplied only on the production of a medical certificate to the aged sick, persons discharged from or awaiting admission to hospital, cripples and invalids, e.g. diabetics in need of special diets. One meal is provided daily from Monday to Friday, additional meals for the week-end being supplied on Friday, if required. In London the service provided extends at present only to the whole or part of the following boroughs: Bethnal Green, Camberwell, Finsbury, Hackney, Hammersmith, Holborn, Islington, Kensington, Lambeth, St. Pancras, Shoreditch, Southwark and Stepney, but it is proposed to provide a new service in the borough of Fulham and to replace the existing kitchen in Bethnal Green by a larger and better one during 1953. The number of meals supplied during the year ended 30th September, 1952, was in the neighbourhood of 123,000. With the approval of the Minister of Health the Council has, since 1950, made an annual grant to this organisation in respect of the services it provides for sick people in London. 42 HEALTH SERVICE PREMISES the continued shortages of certain building materials, especially steel, and the national policy of restricting capital expenditure has not permitted the provision of specially designed clinic buildings and day nurseries at the rate necessary to overcome the difficulties inherent in maintaining some of the services in improvised accommodation in church halls, rented and requisitioned premises. Attention was drawn to this difficulty in the Annual Report of the medical officer of health for the year 1948, but since then steps have been taken in many instances, as opportunity has arisen, to secure a more permanent basis of tenure by acquiring leasehold or freehold interests or more satisfactory rental arrangements. Nevertheless, the continuance of the service still has to depend to a considerable extent on the continued availability of premises which provide only improvised accommodation, often held on insecure tenancies. The maintenance of the day nursery service presents the greatest difficulty in this respect, and the tendency has been that nursery premises have to be relinquished faster than replacements can be provided. The continuation of requisitioning powers to December, 1955, and the strict application of a priority system for admission to day nurseries has so far postponed a serious crisis in this service, but the occupation of day nursery premises under requisitioning powers remains a serious potential danger to the future of this service unless requisitioning powers are to be further extended in time, or considerable capital expenditure is to be incurred in the near future on the acquisition of premises or the building of replacement nurseries. It appears likely that the building of comprehensive health centres will not take place for many years in sufficient numbers to provide the much needed improvements to the standards of the maternity and child welfare clinic accommodation, especially by the replacement of church halls, or to provide new clinics on housing estates. Although these improvements should not be deferred until health centres can be built, it would be inappropriate to build maternity and child welfare clinics on the old pattern which could not be incorporated into health centres in due course. Accordingly, where there is an urgent need for a new clinic and a suitable site can be obtained for a health centre, plans will be prepared to erect a maternity and child welfare centre as a first instalment of a health centre. In suitable cases opportunity will be taken of incorporating some, or all, of the school health services required for the area in the new clinic, so that fuller integration of the two services can be achieved. The design of maternity and child welfare centres, and combined maternity and child welfare and school health centres, is now on the basis of multiple use of rooms for various purposes at various times. This effects substantial economies in the space required and consequently the land and capital expenditure needed. The areas served by the various centres are now more clearly defined and are adjusted if necessary when new centres are established to meet local demands due to increased population, erection of housing estates, etc. Every endeavour is made to ensure that no mother has to travel more than one mile to her nearest child welfare centre. It is to the advantage of mothers and children to attend the appropriate centre so that contact with the health visitor of the area can be maintained, but complete freedom of choice is given to mothers in this matter. Building programmes Further progress was made in the planning and building of new clinics and day nurseries and the adaptation and improvement of existing premises. Restrictions on expenditure and on the use of steel made it necessary, however, to modify some schemes and to postpone others. Early in the year advice was received from the Minister of Health that it was unlikely that it would be possible for steel authorisations to be given during the year for schemes which had not already received a starting date. He also requested that various schemes in hand should be revised with a view to avoiding the use of steel or reducing the amount and spreading requirements over more than one quarterly period. 43 Schemes in preparation In accordance with the procedure recommended by the Local Government Manpower Committee, an annual capital building programme comprising eighteen new schemes, costing more than 1,000 was submitted in November. In addition a number of schemes remained from previous programmes, and these were carried forward as part of the building programme for the next financial year. Unless, however, there is a marked relaxation in the restrictions on steel and expenditure it seems inevitable that many of these schemes will have to be held over until later and less stringent times. Details were included in the report for 1951 of 41 schemes submitted in that or previous years to the Minister. Of these, one had been cancelled by the Health Committee, two were withdrawn, because they were for adaptations of office accommodation which had become matters for reference to the Minister of Housing and Local Government, two had failed to receive the approval of the Minister of Health, five had been completed, eight were in progress and twenty-three were either under consideration by the Minister or full details had not been submitted to him. Five other schemes (Brook ambulance station, Eridge House day nursery, Moatside occupation centre, Pear Place temporary ambulance garage and Queen's Road centre Interim Stage II, adaptations), which were not included in any previous programme were approved for submission to the Minister of Health during the year. The capital building programme for 1953-54, comprising 18 schemes therefore brings the total number of schemes submitted to 61 excluding the three already cancelled or withdrawn. During the year one more scheme was cancelled by the Health Committee, while action on three others was postponed. Seven schemes were completed, and works on nine more were in hand at the end of the year. Particulars of the 33 schemes outstanding from earlier programmes, five extra schemes, and of the 18 schemes submitted in November, 1952, are as follows: Schemes for which approval was refused Division 2—Daleham Gardens, Hampstead.—Combined maternity and child welfare centre. Following a review of the clinic facilities in the metropolitan borough of Hampstead, a further proposal that the Minister should be asked to reconsider his decision not to approve this project or, if he could not do this, to agree in principle to the erection of part of the building which would be modified to form a maternity and child welfare and school treatment centre was under consideration by the Health Committee at the end of the year. Division 5—Brewhotise Lane, Stepney.—Permanent day nursery and child welfare centre. Following the Minister's refusal it was decided to investigate the possibility of retaining the Old Church Road day nursery or finding a site for its replacement. Scheme withdrawn Division 1—Gloucester Road and Clareville Grove, Kensington.—In view of the Minister's inability to sanction the provision of a day nursery and staff hostel on the site, and the fact that there was no immediate prospect of final approval being given to the provision of a maternity and child welfare centre, the Health Committee decided that no further action should be taken to develop this site for health service purposes and that the property should be relinquished by the Committee. Schemes postponed Division 1—Westway, Hammersmith.—The Minister of Health had asked for a revised plan for a smaller and cheaper day nursery. It was decided, however, to review the need for this nursery in twelve months' time, and in the meantime to retain the site, which is large enough for a day nursery and a health centre, and to seek the approval in principle of the Minister of Health to the erection on the site of a combined maternity and child welfare centre and school treatment centre to be designed as the first instalment of a comprehensive health centre. Division 7—Queen's Road Centre, Camberwell.—The scheme for the second stage of the adaptation of these premises provided for the installation of a supplementary heating and hot water supply system, installation of a passenger lift shaft, the conversion of a portion of the premises into classrooms, redecorating, electrical work and lay-out of grounds. The Minister of Health intimated that the steel required for these adaptations could not be authorised during 1952; nor could the allocation of building resources to 44 the work be justified as providing facilities for further education connected with the more essential industries. It was, therefore, not possible to carry out all the second stage adaptations as planned. An interim scheme was put in hand which included the partitioning of classrooms, electrical work and temporary supplementary heating by oil stoves during the winter months. Foxley Road, Kennington.—Conversion of a former fire station to an ambulance station. The Minister of Health suggested that the scheme should be reconsidered with a view to eliminating the use of steel entirely or reducing the amount to a very small quantity. The scheme was under review at the end of the year. Schemes approved but works not yet in hand Division 3—St. Alban's (C. of E.) School, Holborn.—A scheme of adaptation as a day nursery to replace the former day nursery in Clark's Buildings, which was demolished to make way for new buildings, was approved by the Minister of Health and a starting date awarded. Delays in securing completion of the lease of the part of the building to be adapted resulted in postponement of the work, which will be commenced as soon as the lease is completed. Division5—Peel Grove, Bethtial Green.—Maternity and child welfare centre. The Minister of Health approved the erection on this site of temporary buildings which it is intended to replace by a permanent comprehensive health centre in about 15 years' time. Commencement of work was deferred as the necessary steel could not be authorised until January, 1953. Division 9—Stormont Road, Battersea.—Maternity and child welfare centre. The Minister of Health approved, subject to agreement with the Borough Council on the use of the site, a scheme for the erection of a centre which would form the first instalment of a comprehensive health centre. A settlement as to the use of the site had not been reached at the close of the year. Works completed Starting dates awarded and works in hand at end of year Fleet Road, Hampstead.—Erection of accident ambulance station. Division Premises Servicc Work involved 3 4 7 7 8 2 5 5 6 7 Springdale Road, Stoke Newington St. John's Day Nursery, Hackney Churchyard, Mare Street, Hackney 60a Amott Road, Camberwell Queen's Road Centre, Camber- well (Stage I) West Norwood Welfare Centre, 12 Hannen Road, Lambeth Branstone Street, Kensington Roland House, Littlehampton (Stages I and 11) Westbourne Park Road, Paddington Christian Street, Stepney University House, Bethnal Green Merton Place, Greenwich Queen's Road Centre, Camberwell (Interim Stage II—Adaptations) Eastern Ambulance Station, Hackney Fulham Ambulance Station Day nursery Day nursery Maternity and child welfare centre Day nursery Child welfare centre Occupation centre Holiday home Day nursery Day nursery Day nursery Maternity and child welfare centre Maternity and child welfare centre and evening institute General ambulance station Accident ambulance station New building New building Extension Conversion of existing building War damage and maintenance repairs Building of additional classroom Conversion of existing building Completion of building Provision of play space Extension New building Conversion of existing building and temporary heating Adaptations — work on second block (B) will be subject to approval of revised scheme to reduce steel requirements Improvements 45 Starting dates not yet awarded Division Premises Service Work involved – – 1 1 3 5 5 Southwestern Ambulance Station, Lambeth West Smithfield Ambulance Station, City of London Eridge House, Fulham Highlever Road, Kensington Muriel Street, Islington Galbraith Street, Poplar Mary Hughes Centre, 22 Underwood Road, Stepney Brook Ambulance Station, Greenwich London Headquarters Ambulance Station, Waterloo Road, Lambeth Pear Place, Lambeth South Eastern Ambulance Station, Deptford Upper Richmond Road Ambulance station, Wandsworth 86 Fulham High Street, Fulham 9 Spencer Park, Wandsworth General ambulance station Accident ambulance station Day nursery Maternity and child welfare centre Day nursery Maternity and child welfare and school treatment centre Maternity and child welfare centre General ambulance station Headquarters of ambulance service Ambulance accommodation General ambulance station Accident ambulance station Occupation centre Occupation centre Extension New building Repairs on acquisition New building New building Conversion of first-aid post Extension to form a child welfare centre in association with London Hospital Re-instatement after war damage Conversion of fire station Provision of temporary garage accommodation Extension New building Adaptation of existing building (former Moatside Restaurant) Conversion of existing premises. Programme for 1953-54 The building programme for 1953-54 which was submitted for the Minister's consideration was as follows: Division Premises Work involved 1 Fulham Babies Hospital, Broomhouse Conversion of first floor for additional Road, Fulham residential accommodation 1 129 Fulham Palace Road, Fulham .. Adaptation for maternity and child welfare centre (a replacement of the Greyhound Road centre) and additional office accommodation 2 86 Carlton Hill, St. Marylebone .. Essential repairs on acquisition of requisitioned day nursery 2 Hampstead Health Institute, Dynham Adaptation as school treatment centre and Road, Hampstead maternity and child welfare centre in placement of the West End Lane welfare centre 3 Basire Street (Coleman Fields), Islington Erection of day nursery 3 Charles Lamb School, Popham Road, Adaptation as maternity and child welfare and Islington school treatment centre, in place of Tibber- ton Square maternity and child welfare centre 3 Drayton Hall, Islington Extension of maternity and child welfare facilities and addition of a school treatment centre 5 Rochelle Street School, Bethnal Green Adaptation as new maternity and child welfare centre for West Bethnal Green 5 1a Wellington Way, Stepney Re-instatement of war damaged front block of maternity and child welfare centre as residential accommodation for staff. 6 Amersham Road Health Centre, Dept- Adaptation of first floor as day nursery, and ford provision of offices and lavatories on ground floor 6 Burney Street, Greenwich Permanent maternity and child welfare centre to replace the centre in Bardsley Lane, Coroner's Court 46 Division Premises Work involved 8 Cynthia Moseley Day Nursery, Lambeth Extension of heating and consequential internal decorations 9 'Southlands Shuttleworth Road, Bat- Demolition of war damaged building, tersea tions to and severance of, maternity and child welfare centre and office accommodation, services, etc., from borough council premises Eastern General Ambulance Station, Demolition of buildings and tar paving in Hackney connection with major scheme of alterations - Shoreditch Accident Ambulance Station Improvements to entrance, widening way and rebuilding wall - Hostel for M.D. girls Adaptation of accommodation to be found Hostel for tuberculous men Adaptation of accommodation to replace Highbury Quadrant Hostel Hurlingham Lodge, Fulham Adaptation as an additional hostel for culous men Day nurseries The Health Committee, having decided in 1951 that the day nursery accommodation should remain substantially at its existing level, no additional nurseries were provided during the year. The completion of three building schemes enabled day nurseries to be transferred to accommodation designed for the purpose, and existing accommodation to be released; a fourth building was completed but transfer was not effected by the end of the year. Two other day nurseries where the premises were required for other purposes, were closed. Details of the changes are as follows: Replacement Division 3—Springdale Road, Stoke Newington.—Erection of a hutted day nursery, to be known as Springdale day nursery was completed for opening early in 1953 to replace a day nursery in requisitioned premises. Although situated in Division 4 it is near the boundary between Divisions 3 and 4, and will be administered by Division 3 whose area it will mainly serve. Division 4—Woodberry Down Day Nursery.—This nursery, adjacent to the Woodberry Down Health Centre, was opened on 15th October. The day nursery at Woodberry Hall, in requisitioned accommodation, was closed. Further details of the new nursery will be found in the description of the Woodberry Down Health Centre on page 48. Division 4—St. John's Day Nursery, Hackney.—This hutted day nursery was completed and opened on 20th September. The accommodation, formerly occupied in Ram's Episcopal school, Hackney, was released for educational purposes. Division 7—Queen's Road Centre, Camberwell.—Completion of the adaptation of part of the ground floor of this centre to form a day nursery and modification of the kitchen enabled the day nursery to be opened on 31st December. The nursery was formerly accommodated at 34 St. Mary's Road, which was derequisitioned. Closure of day nurseries Division 3—Pembroke Street Day Nursery, Islington.—This prefabricated day nursery stood on a bombed site required for part of a borough council housing estate. It was relinquished on 11th April. No replacement was available but it is hoped that this will be provided by a new day nursery, which it is proposed to erect on a health centre site in Muriel Street, Islington and by the day nursery in St. Alban's School, Holborn. Children displaced were accommodated, as far as possible, in neighbouring nurseries. Division 6—Avonley Road Day Nursery, Deptford.—This day nursery was in accommodation at the New Cross General Hospital. The Hospital Management Committee required this accommodation for use by resident nurses and the day nursery was closed on 28th March. Alternative accommodation for 30 children was made available by utilising part of the first floor of the Amersham Road health centre. This was originally designed and used for a time as a small day nursery, and by alterations in the use of rooms and the transfer of sunlight sessions elsewhere, part of the floor was readily adapted for a day nursery. It is proposed to consider taking over the whole of the first floor at this 47 centre for day nursery purposes at a later date when a more extensive scheme of adaptation can be undertaken. Building works in progress At the end of the year the following scheme, for which plans had been completed and Ministry sanctions obtained, was in hand : Division 2—Westbourne Park Road, Paddington.—Completion of prefabricated buildings which were partly erected during the war to form a new day nursery, to be known as St. Stephen's day nursery, was almost reached at the end of the year. When opened it will replace an existing nursery in a requisitioned dwelling-house. Closure of centrcs Maternity and child welfare centres Division 9—Blegborough welfare centre, Wandsworth.—This centre was held in a church hall, but the church authorities were no longer agreeable to the Council using the main hall. The centre was, therefore, closed on 28th April, and the clinic sessions were transferred to the Riegindale Centre. Replacement of centres Division 2—Dynham Road welfare centre, Hampstead.—This centre, which had been temporarily transferred from 60 West End Lane while the latter premises were reconditioned and repaired, was closed on 4th September when 60 West End Lane was re-opened. Division 2—Bickersteth Hall welfare centre, Hampstead.—This centre was in very unsatisfactory accommodation in a church hall. The Hampstead metropolitan borough council having agreed to the Council using a community centre in a block of flats on one of its housing estates, the welfare centre was transferred there on 27th October and called the Hampstead Wells welfare centre. Division 4— Woodberry Hall welfare centre.—This centre, in requisitioned accommodation, was transferred to the new Woodberry Down health centre (see page 48) on 15th October, when the former premises were de-requisitioned. Provision of additional centres Division 3—Bentham Court, Islington.—Midwife's clinic. Arrangements were made with the Islington metropolitan borough council for accommodation in a community centre in one of its blocks of flats to be made available for a midwife's session to be held weekly from 5th March. Division 9—Fairlight welfare centre, Wandsworth.—A centre was opened in Fairlight Hall on 5th December to supplement the clinics at Longley Road welfare centre, which was less accessible to mothers living in the area served by the new centre. Building work in progress Division 7—Merton Place, Greenwich. Maternity and child welfare centre.—The erection of a prefabricated hut, which had been sanctioned by the Minister of Health was well advanced by the end of the year. This centre will replace a centre in unsatisfactory premises in Division 7 which will be discontinued. It will also serve areas in Division 6, where there is an increasing demand due to the erection of flats and will be more convenient for mothers who live a considerable distance from existing centres in that division. Accommodation for tuberculous persons The Minister of Health agreed to consider a scheme for the adaptation of Hurlingham Lodge, Fulham, to be rented from the Parks Committee as a hostel for 25 tuberculous men. Recuperative holiday home The adaptation of Roland House Holiday Home, Littlehampton, was completed. The home which could not be used to capacity was closed for a short period during the summer holidays for installation of a new boiler, and was re-opened for full occupation on 14th September. Occupation centres for the mentally defective Details regarding premises used for occupation centres will be found on page 114. d 48 Centre closed School health service Division 8—St. John's Hall, Larcom Street, Southwark.—This minor ailment centre formed part of the St. George's Dispensary Trust. The accommodation was not satisfactory for the purpose, and with the consent of the Trustee the centre was closed and the service transferred to the Walworth Road health centre on 1st September. Works completed Division 1—Chelsea school treatment centre, Bramerton Street.—Works of adaptation and improvement on acquisition were completed. Schemes in progress Division 2—Westminster school treatment centre, Westminster.—The adaptation of 40 Alderney Street, Westminster was nearing completion at the end of the year. When completed these premises will replace accommodation rented at 38 Rochester Row and 41 Greencoat Place. Division 7—East Dulwich school treatment centre.—Adaptation of 475 Lordship Lane as a school treatment and maternity and child welfare centre was nearing completion at the end of the year. When this work is completed, the school treatment centre at 29 Amott Road, Camberwell, will be closed and the premises, which are unsatisfactory for health service purposes, disposed of. Division 8—St. George's Dispensary, 86 Blackfriars Road, Southwark.—As mentioned in the report for 1951, this property was vested in the St. George's Dispensary Trust which was offered to the Council. The scheme for transfer of the trust and premises to the Council was still in preparation at the end of the year. Division 9—Tooting school treatment centre, 1071 Garratt Lane, Wandsworth.—The freehold of this property was offered for sale, but the premises are unsuitable for acquisition by the Council owing to age and structural condition and the centre will have to be closed. The purchase of other premises at 193 Mitcham Road and preliminary expenditure on their adaptation was approved subject to agreement on covenants in the lease. This was still under negotiation at the end of the year. When terms are agreed a detailed scheme of adaptation will be prepared. Office accommodation The following changes in office accommodation were made during the year: Division 1—The home help organiser's office was transferred to 31/33 Bramerton Street from 21a King's Road, Chelsea. Division 5—The health visitors and clerical staff at 43 Whitehorse Road, rented from the Stepney metropolitan borough council, were transferred to the Mary Hughes welfare centre, Underwood Road. Division 9—By arrangement with the Battersea metropolitan borough council, additional rooms were made available at 'Southlands' Shuttleworth Road, to which the divisional treatment organiser's office was accordingly transferred from Stowey House School, Clapham. Woodberry Down health centre Health centres The Council's first comprehensive health centre at Woodberry Down, Stoke Newington, was completed in September, and the ceremonial opening was performed by Mr. Somerville Hastings, M.S., F.R.C.S., M.P. on 14th October. The centre will serve about 23,000 people. The site, about one and a half acres in extent, including one third of an acre for a day nursery, lies in the south-west corner of the Council's Woodberry Down Housing Estate, which is nearing completion. The planning, equipping and staffing of the building was carried out after discussion and consultation between the public health and the architectural departments of the Council, the London Executive Council, the London Local Medical Committee and the London Local Dental Committee. The Ministry of Health and the Ministry of Education were also consulted, and made additions and alterations to the plans before final approval was obtained. 49 A fuller description of the building and services is contained in the descriptive brochure* published by the Council. The following units are provided : General Medical and Dental Practitioners Unit.—This has six suites of rooms for medical practitioners. Each suite comprises a waiting room, consulting room, examination room and dressing cubicle. Night duty accommodation and an operating theatre, clinical side room, specialists' consulting suite, common rooms, etc. are provided on the first floor. Two dental suites and a dental workshop are provided for general dental services and X-ray facilities are available. School Health Unit.—This includes a minor ailment treatment room, doctor's consulting room, two dental surgeries (one used also for nursing and expectant mothers), an eye room and orthoptic room. Child Welfare Unit. Ante-natal Unit. Child Guidance Unit.—A playroom and rooms for a psychiatrist, psychiatric social worker and an educational psychologist are available. Foot Clinic.—This clinic was transferred to the centre from anotherpartof thedivision. Remedial Exercise and Light Clinic.—Remedial exercises will be provided for both school children and expectant mothers. Other Accommodation.—Staff rooms and refreshment rooms are available and sanitary accommodation for all units is provided. There is a caretaker's flat on the second floor and garage accommodation for general practitioners. Central heating is provided by a low pressure hot water system working at low temperature vario-statically controlled to maintain an equable temperature irrespective of outside temperature changes. Day Nursery.—A day nursery for 45 children is on the same site, and shares the engineering services. Staffing.—Specialist services are provided by the North-East Metropolitan Regional Hospital Board. The appointment of general practitioners and dental surgeons for the general dental services will be made by the London Executive Council. The general medical and dental services had not been started at the end of the year. Equipment.—Equipment and furniture of modern design was provided throughout the centre in keeping with the general design and decorative treatment. Future developments The Woodberry Down Health Centre was the first full scale comprehensive healtr centre to be authorised by the Minister of Health, and the experience gained from it: use will be valuable and have a considerable influence on future health centre developments. It appears likely, however, that in existing circumstances the building of comprehensive health centres will not take place for many years in sufficient numbers to provide the improvements to the standards of the maternity and child welfare clinic accommodation which are much needed in many areas in London, or to provide clinics on new housing estates. Although these improvements should not be deferred until health centres can be built, it would be inappropriate to build maternity and child welfare clinics on the old pattern which could not be incorporated into health centres in due course. Accordingly where there is an urgent need for a new clinic and a suitable site can be obtained for a health centre, plans will be prepared to erect a maternity and child welfare centre as a first instalment of a health centre. Reservation of sites During the year the London Executive Council agreed to the Council's proposals for the reservation of a further nine sites for health centres. * No. 3784, price 6d. 50 Acquisitions and leases All possible opportunities have 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 Eridge House, Fulham Freehold Day nursery 86 Fulham High Street, Fulham Freehold Occupation centre 9-11 Holland Street, Kensington Leasehold Maternity and child welfare centre 1b and lc Kenley Street, Kensington Leasehold School treatment centre Division 2 13 Woodchurch Road, Hampstead Freehold Day nursery Hampstead Health Institute, Freehold Maternity and child welfare and school stead treatment centre 40 and 44 Westbourne Park Road, Freehold Day nursery Paddington 1 Ebury Bridge Road, Westminster Leasehold Maternity and child welfare centre Division 3 Pine Street, Finsbury Freehold Maternity and child welfare centre 14-15 Lloyd Square and 9 Lloyd Leasehold Day nursery Street, Finsbury Division 4 135a Holmleigh Road, Hackney Freehold Day nursery Sun Babies, Upwey Street, Leasehold Day nursery ditch 13 Goulton Road, Hackney Leasehold School treatment centre 67 Stoke Newington Church Street Leasehold School treatment centre Division 5 Galbraith Street First Aid Post, Freehold Maternity and child welfare centre Poplar 2 Whitechurch Lane, Stepney Leasehold Mental health offices Division 8 Chestnut Day Nursery, Barston Freehold Day nursery Road, Lambeth 21-25 Pear Place, Lambeth Leasehold Ambulance station Bishop's House, Southwark Leasehold Day nursery Division 9 Cresset Street, Wandsworth Freehold Day nursery 37 Riggindale Road, Wandsworth. Leasehold Maternity and child welfare centre CARE OF MOTHERS AND YOUNG CHILDREN comments on the provision of clinic premises will be found on page 47. Expectant and nursing mothers First attendances at ante-natal clinics of all women needing ante-natal care have dropped from 52 per cent. in 1949 to 41 per cent. in 1952. Those who do not attend the Council's welfare centres may receive advice from the hospitals where they have booked for their confinement or from their doctors who have been booked for the delivery. There is perhaps a tendency for expectant mothers more and more to avail themselves of the general practitioner obstetrician service. There has been a corresponding decline in the attendances for post-natal examinations. Attendances at special breast feeding sessions tend to decline, mainly owing to the fact that breast feeding advice is given at the ante-natal and child welfare sessions, and at many of the latter test feeds are also carried out. It will be noted that there has been a satisfactory expansion in attendance at educational sessions, partly due to the increased efforts on the part of the health 51 visitors to expand these activities (see page 101). The following tabic gives comparative statistics: Ante-natal Post-natal Year Clinics at end of year (including combined ante-natal and post-natal) Sessions per Attendances Percentage of pregnant women making at least one attendance at ante-natal clinic Clinics at end of year Sessions per month month First Total 1949 117 957 29,917 184,018 52 31 263 1950 114 910 26,979 176,993 50 6 31 1951 112 905 24,819 162,667 45 6 17 1952 115 1,145 21,959 145,088 41 5 11 Year Post-natal—contd. Special breast feeding Educational Attendances First Total At post-natal clinics At combined ante- and post-natal clinics At post-natal clinics At combined ante- and post-natal clinics Sessions per month Total attendances Sessions per month Total attendances[/###$] 1949 2,614 3,225 3,396 4,090 44 1,554 133 21,779 1950 2,534 3,400 3,335 3,920 41 1,436 138 22,681 1951 1,669 3,993 2,218 4,642 33 1,303 196 30,414 1952 530 3,888 1,031 4,479 22 1,119 216 33,596 In some divisions relaxation exercise classes for expectant mothers have been started Physio-therapists and health visitors have co-operated in this aspect of the preparatior of the expectant mother for childbirth. Tests every expectant mother attending the Council s ante-natal clinics tor tne First time has a specimen of her blood taken in order that tests may be made for the Rhesus factor and for the Wassermann and Kahn reactions. In Rhesus negative cases further specimens are taken for antibody tests at the thirty-fourth week and the Council's midwives also take cord blood in those Rhesus negative cases which are fit for home confinement. Towards the end of the year, arrangements were made for routine haemoglobin tests to be carried out in eight divisions. The necessary laboratory services continued to be carried out at hospital laboratories free of charge. Pregnancy diagnosis tests are carried out for the Council at certain hospital laboratories or at the Ministry of Health's laboratory in Shrodell's Hospital, Watford. Mothercratt training The educational activities at the maternity and child welfare centres have been reviewed as the result of a report of a small working party of officers representing medical and nursing opinion and considerable expansion has already taken place. Details are given in the section on health education (page 101). The Violet Melchett Infant Welfare Centre, a voluntary organisation undertaking services on behalf of the Council under section 22 of the National Health Service Act, 1946, maintains a residential unit where treatment is provided for mothers and babies experiencing breast feeding difficulties and for babies with dietetic upsets. The North Islington Infant Welfare Centre, a voluntary organisation undertaking services on behalf of the Council under section 22, provides similar non-residential facilities. Rehabilitation )f mothers Approval was given by the Minister or Health to an addition to the Council s proposals, to provide, where necessary, for expectant and nursing mothers, and mothers 52 who have children under five, to be sent to a recuperative centre for several weeks for training in mothercraft, appropriate charges being made under the Council's assessment scales. Such mothers are generally below par physically and the health of the children may be affected as home circumstances may make them unable to benefit from the child welfare and school health services. This is an experiment the results of which will be carefully watched. Joint arrangement! with other local 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. Family planning In some health divisions the Council holds family planning sessions totalling six per week to which women for whom further pregnancy would be detrimental to health are referred. Where no such facilities exist, women are referred to the Family Planning Association, a per capita payment being made to the Association, and during 1952, 917 women were referred. Accommodation at certain of the Council's welfare centres is also let conditionally free of charge to the Family Planning Association for the purpose of holding family planning clinics. At the end of the year 32 weekly sessions were being held by the Association in Council or other premises. Child welfare It will be seen from the table below that attendances in the first year of life at child welfare centres amounted to 86 per cent. in 1949, 82 per cent. in 1950, 87 per cent. in 1951 and 84 per cent. in 1952. Those infants who attend in their first year do so about 12-15 times. It is general experience that during the first eight or nine months the mother is anxious about the progress of her baby and she brings him to the clinic regularly for weighing, medical advice, and for mothercraft guidance. With normal progress, attendances tend to fall off rapidly after this first year. All mothers are, however, encouraged to bring their children to the child welfare clinics or special toddlers' clinics, invitation cards to the latter being sent on birthday anniversaries of children in the 2-5 vear aee group the 2-5 year age group. It has been found that about one-fifth or the infants who attena in response to the invitations to the toddlers' clinics are referred to family doctors o hospitals for treatment for ailments which the parents might not otherwise hav recognised. Year Clinics at end of year (including toddlers) Sessions per month Attendances Percentage of infants attending a centre at least once in the first year of life Under i year Over i year Special toddlers First Total First Total 1949 165 1,784 48,489 683,089 6,641 282,202 35,500 84 1950 169 1,815 43,916 649,983 5,496 245,484 41,817 79 1951 169 1,893 45,534 626,164 4,540 235,942 43,145 82 1952 169 2,029 44,452 653,759 4,147 229,134 43,976 84 Child guidance Two child guidance clinics for the pre-school child, taken over from the metropolitan borough councils, have been continued because of the value of the work done and as an experiment in this particular field. The psychiatrists see children, and their parents, referred from local child welfare centres because of various behaviour disorders. Expansion is not taking place, however, until experience has shown the most appropriate methods of meeting the needs of the pre-school child. To this end, arrangements 53 have been made to train centre doctors and health visitors to select children for reference to the school child guidance units, and lectures in mental health have been provided. A survey was instituted in one of the health divisions in 1952, to gauge the extent to which a psychiatric service for young children is necessary. Reference is made in the section on mental health (page 112) to the provision of special child welfare services for backward children. Care of premature infants When premature infants are nursed at home, with a midwife in attendance, steps are taken to ensure that the midwife, in addition to her normal care of mother and baby, has adequate time to devote to the infant by relieving her of other work. The supervisors of midwives visit all premature infants to give advice, including recommendations for supply of any special equipment needed. Twenty-seven sets of special equipment (divided into five packs, i.e., cot pack, scales, clothing pack, nursing pack, feeding pack) are provided (three for each of the nine health divisions). Small deposits are made for the loan of the packs and these are refunded in full when the equipment is returned in good order, subject to fair wear and tear. Nine of the sets are placed at strategic points throughout the County, mainly at district nursing association premises or at welfare centres with a resident caretaker. These particular sets are available at week-ends and public holidays for collection and delivery by the ambulance service to any home requiring equipment immediately. There is not a great demand for the special equipment, except in health division 4. The number of times sets, or part sets, were supplied to homes was as follows : (Part year) 1948 1949 1950 1951 1952 Nil 23 92 74 52 Special transport facilities for premature infants who have to be removed to hospital are operated. Specially heated cots and supplies of oxygen are carried in the ambulances and were used on 43 occasions in 1952. Before the Council assumed responsibility for the welfare services, the Shoreditch Borough Council had organised a special service for premature infants, including the appointment of a trained health visitor as a premature baby visitor, who devoted the whole of her time to the care of premature infants in that borough and to a breast feeding clinic. The Council felt that continuity of home visiting was essential if the health visitor was to be accepted as the friend and counsellor of the family. It is undesirable that when a premature infant is born, the health visitor who normally visits the home should be replaced by another officer who is unknown to the mother. Moreover, as the present syllabus of training of health visitors includes advice on the care of premature infants, it is considered that no additional training, except for a refresher course from time to time, is necessary. The aim has been to ensure that all health visitors have the necessary knowledge to advise on the care of premature infants and that these children are given priority in visiting. The special visiting arrangements in health division 4 were therefore gradually discontinued. There is, however, a special premature baby clinic held at one of the welfare centres in Shoreditch, at which each infant is able to receive a thorough medical examination at the age of 4, 8 and 12 months. As far as is known, the following hospitals have special units or cots for the reception of premature infants—Hammersmith, King's College, University College and British Hospital for Mothers and Babies, Woolwich. Other hospitals are able to take them into cots attached to the maternity units. There is a close Liaison between hospital almoners and the Council's health visitors to ensure immediate follow-up on discharge from hospital. Premature babies born at home During 1952, 449 infants weighing 5½ lbs. or less were born on the district to 404 mothers; 276 of these infants were between 5 lbs. and 5½ lbs. in weight and by the dates were of at least 38 weeks gestation and showed no clinical signs of prematurity. There were 46 twin pregnancies. In 50 instances the mothers were small in stature themselves or had had small babies previously. 54 No cause to which abnormality could be attributed was found in 342 cases and in the remaining 62 cases abnormalities of pregnancy were as follows : Toxaemia 25 Trauma 5 Ante-partum haemorrhage 10 Anaemia and malnutrition 22 The degree of prematurity by dates was : Under 32 weeks 11 32-36 weeks 70 Over 36 weeks 321 Unknown (unbooked) 2 and the weights of the infants : Under 3 1 bs. 15 3½bs.—44½ lbs. 48 4£ lbs.—5 lbs. 74 5 lbs.- 5½ lbs. .. 312 67 infants were transferred to hospital within a few hours of birth, 11 were transferred later owing to an unsatisfactory condition developing, and the remaining 371 were nursed at home. Of the 449 infants 416 made good progress and were alive and well when discharged by the midwife or from hospital and 329 (79 per cent.) of these were completely breastfed. 18 infants showed some congenital abnormality, for example, talipes, hypospadias, spina bifida, congenital heart. There were 33 deaths, i.e., 8 per cent. of the total. Four of these occurred at home very shortly after birth : two were non-viable infants of less than 2 lbs. and less than 30 weeks gestation; one was a 4½ lb. baby with multiple deformities, and one (2f lbs.) an unbooked emergency. The remaining 29 deaths were in hospital : six were feeble infants under 3 lbs.; 11 were feeble infants between 3 and 5½ lbs., either very premature by date or showing marked clinical signs of prematurity ; six had congenital abnormalities ; one died from cerebral haemorrhage, and five died from pneumonia having been transferred to hospital later in the neo-natal period. Maternity and child welfare services provided by hospitals Details of the arrangements whereby the medical schools of four teaching hospitals, acting as voluntary organisations grant-aided by the Council, provided child welfare centres on its behalf are given on page 39. Drugs, medicaments, welfare foods, etc. Cod liver oil compound, tablets of vitamins A and D, national dried milk and concentrated orange juice are distributed under the Government's welfare foods scheme. In addition a number of proprietary brands of dried milk and of nutrients, including cod liver oil and malt, cereals, glucose D and vegetable and iron products, are made available when approved by the clinic medical officer, at fixed charges, subject to abatement where necessary. Simple drugs according to an approved list are provided free of charge when recommended by the clinic medical officer. The list of items is reviewed by a departmental committee from time to time to keep abreast of modern medical development. Non-proprietary items are supplied wherever possible. Sunday cinema grants The Council continued to receive contributions from the Sunday cinema entertainments, out of which an allocation was made to each of the nine health divisions for the purpose of providing amenities for mothers and children attending the welfare centres and day nurseries. The amenity funds are administered by small voluntary committees. 55 Marriage guidance In accordance with its decision to give financial aid over a period of five years (commencing in April, 1951), the Council agreed to make a grant to each of the three marriage guidance organisations operating in London—the London Marriage Guidance Council, the Catholic Marriage Advisory Council and the Family Discussion Bureaux of the Family Welfare Association—for the year ending March, 1953. The Council also agreed to an expansion of the arrangements whereby the London Marriage Guidance Council holds sessions in available accommodation at a number of welfare centres. A similar facility was also granted to the Catholic Marriage Advisory Council, who are commencing to establish divisional centres. Day nurseries Day nurseries and occasional creches On 5th july, 1948, there were 114 municipal day nurseries and six voluntary day nurseries. This number dropped to 111 municipal and six voluntary by June, 1951, when the first annual review of day nursery accommodation was carried out. The guiding factor of this review, and the subsequent annual reviews, was that the total day nursery provision should remain substantially at the level then obtaining, with every effort being made to secure full occupation within the limits imposed by the scheme of priorities for admission. Any indication of redundancy has been kept constantly under review, and where necessary day nurseries have been closed. The position following each annual review was : Number of day nurseries Voluntary Date L.C.C. (Grant aided) Total At 30- 6-51 Ill 6 117 At 30- 6-52 106 6 112 At 31-12-52 105 6 111 The accommodation provided at the above day nurseries at 31st December, 1952, was : Age group L.C.C. Voluntary Total 0-2 years 2,017 50 2,067 2-5 years 3,879 189 4,068 Totals 5,896 239 6,135 The priorities and rules for admission to the day nurseries are as follows : (1) (a) The first priority as regards admission to be given equally, subject to the other rules, to the children (including adopted children) of: (i) mothers who are widows, separated or divorced wives, or wives whose husbands are totally disabled or in prison, or unmarried mothers, provided they are maintaining an independent home and are employed at least 35 hours a week, including meal times ; (ii) parents where the mother is in ill-health and cannot care adequately for the child, or during the mother's confinement; (iii) parents who are living in housing conditions detrimental to health, or where other environmental factors are such that it is desirable for the health of the child that it should be admitted to a day nursery ; and (iv) widowers, or where the mother has left the home. (b) The second priority as regards admission to be given, subject to the other rules, to the children of parents where, because the father is unemployed or his earnings are so low, the mother is compelled to go to work as an economic necessity, providing that in all cases the mother is employed at least 35 hours a week, including meal times. (2) The divisional medical officer to have over-riding discretion to admit any other cases presenting special features—any appeal from his decision to be considered by the Chairman of the Divisional Health Committee. 56 (3) In assessing applications for admission, an over-riding consideration to be that the parent(s) is/are unable to make other satisfactory arrangements for caring forthe child. (4) A review of the circumstances of the parents of all children admitted to day nurseries, including, where appropriate, verification of parents' incomes, to be made at six-monthly intervals from the date of admission and parents to be required to withdraw their children from nurseries after reasonable notice as and when the cases no longer fall within the approved priority classes. (5) Arrangements for all admissions to be made by the divisional medical officer and not by individual nurseries. The number of children on the priority waiting lists was 4,797, 1,932, 977 and 1,130 at the end of 1949, 1950, 1951 and 1952 respectively. The Council's standard charge for a child in a day nursery was 1s. a day in 1948. This was subsequently raised to 2s. a day, assessable according to means, and as from 1st January, 1953, was increased to 4s. a day (the charge for the second and subsequent children of the same parents or parent is 2s. a day). As a result of the comprehensive enquiry into the day nursery service undertaken in the latter part of 1950 the following action was taken : (i) 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) 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 over-riding 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. (iii) The former ratio of three nursery students to one staff place was replaced by a ratio of 2:1. (iv) The number of training nurseries has been gradually reduced by approximately one-third. (v) 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) 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 on Saturdays, and only two are now open on Saturday mornings. (vii) Experiments were instituted 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 nurserv articles. Occasional creches The limited number of sessions in occasional creches (nursery play centres) which the Council took over on 5th July, 1948, has remained substantially unchanged. Consideration was given to the possibility of extending the facilities, but no further action was taken in view of the opinion of the Minister of Health that the time was inappropriate for such expansion, having regard to the national financial position. Private day nurseries Nurseries and Child-Minders Regulation Act, 1948 The number of private day nurseries statutorily registered under the Nurseries and ChildMinders Regulation Act, 1948, and the number of places provided were : At 31st December 1948 1949 1950 1951 1952 Number of private day nurseries statutorily registered 8 28 41 49 63 Number of places provided 367 972 1,294 1,583 1,841 57 During the year one of the two private day nurseries provided by industrial undertakings closed. Childminders The child-minders 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. Voluntary 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. 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 if December 1948 1949 1950 1951 1952 Number of child-minders statutorily registered .. 35 73 96 93 96 Number of children minded 243 501 570 604 504 Number of child-minders voluntarily registered .. 284 584 766 749 794 Number of children minded 323 579 834 840 856 The small variation in the numbers of registered child-minders since 1950 suggests that the service has found its own level. Children neglected or ill-treated in their own homes After considering the joint circular from the Home Office, Ministry of Health and Ministry of Education (78/50), the Council decided that the main objects of the circular were being achieved under the Council's existing organisation. Measures were taken in each of the health divisions 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 sc 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 one great problem. An attempt to face the problem as a whole was planned ir two health divisions by holding experimental conferences attended by all organisations (voluntary or statutory) who are interested in or can help the children who live under these conditions. These conferences were held early in 1952. Their main object was tc examine the co-ordination which already existed between local organisations with regard to (a) the welfare of parents and children (including the problem of the neglected or ill-treated child) and (b) the prevention of juvenile delinquency. In particular, the) were asked (i) to exchange information about the action taken by various agencies (ii) to consider ways in which such action might be more closely co-ordinated, (iii) tc consider whether, under the existing system, any particular aspect of a problem might fail to be dealt with by local workers concerned, (iv) to consider whether it might be desirable in some cases for one agency to help with the problem of a family when it appeared that one visitor would make more progress than several. The conclusion: reached at these conferences were considered by the appropriate committees of the Council. In view of the real value of these conferences in bringing together all the organisations and persons concerned, in reminding the voluntary organisations of what each does and of the extent of the work done in the field by the Council's own services and in making a broad survey of the problems of the locality, similar conferences an being held in all health divisions. It had been found in some health divisions that the maintenance of a central register of problem families at the divisional health office was of real value. The Council': officers and voluntary and other bodies had been asked to notify to the divisiona health office cases with which they were dealing and which presented special problem: for inclusion in a register for the information of other interested departments anc organisations. Each voluntary organisation retained full discretion whether informatior at their disposal should be passed on and the register does not involve building up; dossier of confidential matters relating to the family. After due consideration it was 58 felt that such an index, with the co-operation of all the statutory and voluntary bodies concerned, would become a record of action taken on behalf of problem families and would tend to encourage voluntary workers and others to consult the Council on any new problem. Further, when action is required in any particular case, all those interested could be consulted and, if necessary, brought together. Their knowledge could be pooled, the next step planned, under the aegis of Council officers, and carried out effectively by the most appropriate organisation. The general aim would be to reduce the number of workers visiting the family to one, if possible, but in more complex problems where more than one worker's help was needed the aim would be to keep the number to the minimum; the family, therefore, would be saved the embarrassment and confusion resulting from overlapping visits and enquiries. The appropriate committees of the Council have therefore agreed to the development of divisional indexes of families where there appears to be a need for help in bringing up the children, the index to be adapted to suit local needs. Where considered desirable, the establishment in each of the health divisions of a small standing committee of the Council's officers, with representatives of other bodies, as desired, to co-ordinate the case work has been recommended, no obstacle being placed in the way of a merger with other case conferences held in the divisions, e.g., for maladjusted children or those referred to the N.S.P.C.C. It was also decided that health divisions should prepare and publish a directory of organisations undertaking social case work for circulation to all interested parties. Medical supervision of residential establishments for children The public health department has continued during the year to supervise the health of the children in the Council's residential establishments. Apart from unusually heavy outbreaks of measles at one residential nursery, chicken-pox at another and infective hepatitis and Flexner dysentery at a third, the pattern of sickness was much as usual. There was an outbreak of influenza in one residential nursery school in January. The children in the residential nurseries and nursery schools 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 establishments are visited at frequent intervals by senior members of the Council's central medical and nursing staff. The high incidence of infection in the Council's three large residential nurseries (The Downs, Ladywell and St. Margaret's) was the subject of a conference between representatives of the Home Office and the Council. A large nursery with a large turnover of admissions inevitably produces a large crop of infections and many of the hospital admissions to which the Home Office drew attention were mild infections. Other children were admitted to hospital for diagnosis. The children nursed in the nurseries represented either the ' secondary crop ' or those for whom no hospital bed could be found. The Cliffs Residential Nursery school, Dawlish, was closed on 30th June, and the children transferred elsewhere. Adoption and boarding-out During the year 743 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 122 were passed as fit for adoption and 621 fit for boarding-out. Care of the unmarried mother and her child The Council's duties for the care of expectant and nursing mothers and young children include the care of the unmarried mothers and their babies. This duty is performed 59 mainly through the agency of voluntary organisations in accordance with the policy recommended by the Ministry of Health in circular 2866/43 and endorsed by the Council in its proposals under the Act. As stated in the Council's proposals, some women not admitted to voluntary mother and baby homes, chiefly because of their unsuitability, are accommodated in two mother and baby homes and two special units under the management of the Welfare Committee. This arrangement has continued since the ' appointed day ', although provision was made in the National Health Service (Amendment) Act, 1949, to make charges for residential accommodation and this enactment would thus have enabled the Council to provide such accommodation under its National Health Service Act powers and to charge therefor in the same way as the voluntary homes have always done. The Council's Welfare Committee also accepts financial responsibility for the maintenance on a ' per capita ' basis for unmarried expectant mothers in voluntary mother and baby homes in circumstances where the unmarried mother is unable to pay for her own maintenance. Grants in aid for maintenance and upkeep of voluntary mother and baby homes are paid annually by the Council. Before the inception of the National Health Service Act, 1946, the Council paid grants to 21 mother and baby homes and five baby homes under section 101 (6) of the Local Government Act, 1929. Since 5th July, 1948, the Council has paid similar grants under section 22 of the National Health Service Act, 1946. In 1948, 23 homes were concerned, the total payments amounting to ,£19,286, and in 1952 there were 20 homes, the total payments amounting to .£13,114. Following the inception of the Children Act, 1948, the responsibility for ' deprived ' children was taken over by the Council's Children's Committee and the grants to the five baby homes were dealt with by that committee. Before 5th July, 1948, the Metropolitan Boroughs Standing Joint Committee made payments on behalf of the boroughs to moral welfare associations in London who employed moral welfare workers. Under section 22 of the Act, the Council took over responsibility for the payment of grants to five moral welfare associations (two C. of E., two R.C. and one Jewish), and in 1952 the grants amounted to .£9,260. The headquarters of the five large associations are visited periodically to review the service provided and to discuss matters of mutual interest. An annual Moral Welfare Conference is held at which the past year's work is reviewed and current problems brought forward. The voluntary homes take expectant unmarried mothers during the later stages of pregnancy and for several weeks after confinement which, except at two homes, takes place in hospital. The homes are visited by medical officers of the public health department at least twice a year. Standards of staffing, space and management which have been approved by the Ministry of Health are carefully applied to the running of the homes. Grants towards the expenses of the homes are made subject to the carrying out by the voluntary bodies of any improvements suggested by the Council. The Council is represented on the home committees. The moral welfare associations undertake the case work for unmarried mothers during the ante-natal and the immediate post-natal period. The voluntary committees and matrons of the mother and baby homes also assist in this snhere. Ante-natal care Particular attention has been given to the ante-natal care of the unmarried expectant mother. Moral welfare workers and health visitors work closely together with the aim of giving the mothers the full benefits of the ante-natal clinics. Experimental evening clinics have been held. To obtain definite information of the extent to which the unmarried expectant mother avails herself of the services provided, a survey of the ante-natal care received by each new admission to the mother and baby homes under the control of voluntary organisations and of the welfare department of the Council was planned for the first six months of 1953. Welfare of illegitimate children The welfare of the children of unmarried mothers has also been given attention and in order to find out what changes take place in the child's environment, the effects of these changes in the child's mental and physical development and the proportion of unmarried mothers who achieve a continued association with their children it is 60 proposed to undertake a survey to try to follow up all illegitimate children born in London during a specified period in 1953. The co-operation of voluntary associations dealing with the unmarried mothers and their children has been promised and it is proposed that the survey shall be carried out within the scope of the normal work of the health visitors who will make visits at specified intervals until the children reach school age. Changes in the child's environment will be noted and the effect observed of such changes on physical and mental development, behaviour and habits. Incidence of illness and accidents will be included. The survey will extend to boarded-out children and to those placed in residential, voluntary and private nurseries. The fact of adoption will be noted when it occurs. From the survey there should emerge a picture of the number of mothers who do manage to maintain a stable relationship with the child. DOMICILIARY MIDWIFERY SERVICE the council's domiciliary midwifery service had its origin in the Mid wives Act of 1936, which laid on the Council the duty of providing an adequate service of midwives for attendance on women in their own homes in London. To provide this service the Council employed salaried midwives and entered into agreements with voluntary hospitals and district nursing associations already employing midwives, and the service commenced in 1938. Midwives attended patients either as midwives on their own responsibility or as maternity nurses under the direction of a doctor and were encouraged to make the fullest use of the maternity and child welfare services then provided by the Metropolitan Borough Councils. The hospitals and voluntary associations received payment from the Council for each confinement undertaken. Every woman attended by a midwife in her own home was charged a fee which was reduced if necessary, but medical aid, if summoned by the midwife, was provided free to the patient. The service underwent no fundamental change as a result of the coming into force of the National Health Service Act, 1946, except that it became a free service. The main result of the Act was to effect closer integration of the domiciliary midwifery service with the maternity and child welfare services and the other health services for which the Council became responsible under the Act, and also with the maternity medical services provided under Part IV of the Act. The service is still administered centrally and the whole county is kept under close and constant supervision, the service being adapted to the changing character and requirements of the area. Every effort has been made to integrate the domiciliary midwifery service with the maternity medical services provided by general practitioner obstetricians and general practitioners under Part IV of the National Health Service Act, and with the maternity services already provided by the local authorities and by hospital authorities. Early consultation was established with the London Local Medical Committee to ensure co-operation between doctors providing maternity medical services and the midwives engaged in domiciliary practice. This co-operation and understanding has been gradually increased by continued emphasis to the midwives of the need for good liaison with the family doctor and the introduction of forms for exchange of information between doctor and midwife. Doctors who agree to give maternity medical services to a patient send this information to the midwife and let her know the services they propose to undertake so that the midwife may know whether she is to act as a midwife or a maternity nurse. The midwife reports her findings to the booked doctor on the 1st and 36th week ante-natal examinations. The doctor returns her report form after each examination with his findings, if different from her own, and adds any instructions he may wish to make on the care of the patient. Midwives are encouraged to try to conduct these examinations with the general practitioner but in practice this is very difficult to arrange. Attached to the form is the analgesia certificate which the booked doctor fills in and sends to the midwife. The midwife sends the doctor a notice of the delivery of a booked patient 61 within 36 hours of the baby's birth. After discussions with the London Medical Committee, the midwife is now asked to notify, with the patient's consent, the list doctor when she has been booked for a home confinement. The introduction of these forms for the exchange of information has greatly facilitated co-operation between midwives and doctors providing maternity medical services. The number of domiciliary confinements since the end of the 1939-45 war shows a steep increase in 1946 and 1947, the immediate post-war period, and a gradual decline since 1948. The following table and diagram show the number of home confinements attended during the years 1945-52 by the Council's midwives, hospital district midwives and association midwives. The chief factors affecting the decline in the number of home confinements have been : (a) the fall in the birth-rate ; (b) shortage or unsuitability of housing accommodation ; and (c) the attraction of hospital confinement and the increase in the number of maternity beds provided. Owing to the reduction in the number of home confinements any developments in the domiciliary midwifery service must be looked for not in any expansion but in the quality of the service provided by the midwives and the measure of co-operation and integration with other health services and with the maternity medical services provided under the National Health Service Act. L.C.C. midwives Five hundred and seventy-three of the confinements attended by Council midwives during 1952 were primigravidae and 5,474 multi-gravidae. 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 98 compared with 111 at the end of 1951 and 121 at the end of 1950. The average number of confinements attended by each midwife was approximately 61 compared with 62 in 1951 and 57 in 1950. Agency organisation: At the end of the year, 71 (including supervisory staff) midwives for domiciliary confinements were employed by hospitals and 42 (including supervisory and part-time staff) by district nursing associations. Ante-natal sessions The Council s poliery is that midwives shall use ante-natal clinics for the booking and examination of their patients. A doctor, who is either a full-time assistant medical officer or a general practitioner with special experience, attends all or alternate sessions depending on the numbers in attendance at the clinic. Emphasis is placed on the importance of ante-natal care and the midwife is expected to hand over a delivery to her relief midwife in order to attend her ante-natal session. Each midwife does one clinic session weekly. A health visitor is also present at most midwives' clinics in order to give talks to mothers on mothercraft and health education generally. In some divisions, these talks are given as a series of demonstration talks arranged by the health visitor on separate afternoons. In other divisions, talks are given during the sessions to small groups of mothers or to individuals. Many of the newer centres are equipped with demonstration kitchens and cases for exhibits of layettes, etc. Most of them have libraries of books and journals which can be lent to expectant mothers. Classes are held for relaxation exercises by physiotherapists in some divisions but midwives take such sessions at a few clinics. Specimen blood is taken from all mothers attending ante-natally and tested for Wassermann and Kahn reaction and for Rhesus factor. In eight of the nine divisions, routine haemoglobin tests are made. Further specimens are taken for antibody tests in Rhesus negative cases at the 34th week and midwives also take cord blood in those Rhesus negative cases which are fit for home confinement. General practitioners who have arranged to give maternity medical service to their patients are encouraged to send them to the centres for intermediate ante-natal examination by a booked midwife. Reports are exchanged between the midwife and the doctor on the 1st and 36th week examinations (see above). If, as occasionally happens, the general practitioner wishes to take full responsibility for the whole ante-natal care of a patient, he may send her to the centre for a blood specimen to be taken. It is known that general 62 Domiciliary confinements attended by L.C.C., hospital and nursing association midwives, 1945-1952 Year Maternity nursing cases Midwifery cases Grand total L.C.C. Hospital Association Total L.C.C. Hospital Association Total 1945 440 53 327 820 6,427 3,502 1,584 11,513 12,333 1946 805 129 501 1,435 10,834 6,120 3,225 20,179 21,614 1947 899 169 390 1,458 12,025 6,525 3,716 22,266 23,724 1948 630 116 290 1,036 9,533 5,095 2,940 17,568 18,604 1949 749 112 285 1,146 7,831 4,532 2,581 14,944 16,090 1950 649 131 219 999 6,659 3,881 2,213 12,753 13,752 1951 679 102 161 942 6,361 3,144 1,912 11,417 12,359 1952 708 145 146 999 5,339 2,897 1,791 10,027 11,026 63 practitioners are, in the main, willing to allow their patients to attend centres for intermediate ante-natal examination by a midwife, especially if they have stated that they do not wish to be called in to the confinement unless needed. Mortality Patients attended by Maternal deaths Still-births Neo-natal deaths London County Council midwives 2 53 14 Hospital district midwives 2 26 7 Association midwives 2 23 6 6 102 27 Transport Transport by ambulance cars continued to be available for the use of midwives in emergencies, particularly at night-time and when undertaking additional relief duties. Housing of midwives accommodation for domiciliary midwives continued to be provided by tne council. On 31st December, 1952, 53 midwives were housed in 51 houses and flats, of which 31 were owned by the Council and 20 taken on leave or licence. Payments to district nursing associations and hospitals Payments to district nursing associations under section 23 or the National Health Service Act, 1946, continued to be merged in the grants made to them for home nursing services orovided under section 25 of the Act. The rate of payment to hospitals providing midwifery services on behalf of the Council continued at the rate of 10 guineas a patient, except in the case of the Mothers Hospital (Salvation Army) where the rate was £9 15s. 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 salary. Maternity outfits Every woman delivered at home under the National Health Service is eligible tor a free maternity outfit, containing accouchement sheet and dressings required for the confinement. The Council supplies these outfits to its own midwives and to district nursing associations and hospitals providing a domiciliary midwifery service. Emergency obstetric service During the year 66 calls were made to hospitals for the emergency obstetric service ; 36 of these calls were made by doctors and 30 by midwives. The time interval between the calling and arrival of the service was : 10 minutes 4 cases. 15 to 30 minutes 45 cases. 30 to 45 minutes 12 cases. 50 to 60 minutes 3 cases (cause of delay not stated). Time interval not recorded 2 cases. The conditions necessitating the use of the service were : Primi- Multi- Parity Total para parae unknown Obstetric shock 1 — — 1 Post-partum haemorrhage with shock 1 3 1 5 Post-partum haemorrhage (following delivery of placenta) 4 22 2 28 Retained placenta with post-partum haemorrhage 11 11 2 24 Retained placenta .. — 1 — 1 Retained membranes — 2 — 2 Acute inversion of uterus with adherent placenta — 1 — 1 Secondary post-partum haemorrhage .. — 1 — 1 Ante-partum haemorrhage .. — 1 — 1 Malpresentations .. — 1 — 1 Abortions — 1 — 1 17 44 5 66 64 The action taken by the emergency obstetric service was : Removed Remained Treatment given to at Total hospital home Obstetric shock Blood transfusion 1 — 1 post-partum haemorrhage with shock Blood transfusion 4 4 Administration of drugs — 1 1 post-partum haemorrhage (following delivery of placenta) Blood transfusion 8 14 22 Plasma transfusion — 1 1 Dextrose transfusion — 1 1 Administration of drugs 2 — 2 No treatment 2 — 2 retained placenta with post-partum haemorrhage Blood transfusion 9 2 11 Dextrose transfusion 2 2 Administration of drugs 1 — 1 Manual removal with blood transfusion . 1 5 6 No treatment 4 — 4 retained placenta Administration of drugs only — 1 1 retained membranes 1 1 Administration of drugs 1 — 1 Manual removal of membranes — 1 1 acute inversion of uterus with adherent placenta Blood transfusion. Manual removal of placenta and replacement of uterus 1 — 1 secondary post-partum haemorrhage Blood transfusion 1 — 1 ante-partum haemorrhage Blood transfusion 1 1 No treatment required — 1 1 abortions No treatment 1 — 1 35 31 66 All 66 cases to which the service was called were true obstetric emergencies. There was only one maternal death and this occurred 11 hours after an acute inversion of the uterus. In all other cases the mother made a good recovery. Gas and ail Analgesia The use of gas and air analgesia by the Council began in 1946. The apparatus is held at selected ambulance stations throughout the county and delivered by ambulance to the patient's home on the request of a midwife. The number of midwives qualified to administer analgesia has steadily increased and, since 1950, all midwives employed by the Council have been so qualified. Progress in its use has been rapid and its administration, shown as a percentage of all domiciliary confinements, has risen from 3 per cent. in 1946 to over 75 per cent. in 1952. A similar increase in the use of gas and air analgesia has also been effected in confinements attended by hospital district midwives and association midwives. Analgesia is always offered by the Council's midwives. The cases in which it is not used are those in which the mother refuses or sends too late in labour, is considered medically unfit to receive it, or the doctor giving maternity medical services himself provides the analgesic or anaesthetic. The following table shows the progress made: 65 Administration of gas and air analgesia, including percentage of confinements attended Confinements attended by 1948 1949 1950 1951 1952 London County Council midwives Number 3,447 5,479 5,027 5,338 4,588 Percentage (34) (64) (68) (75.8) (75.8) Hospital district midwives Number 1,838 1,571 2,783 2,323 2,310 Percentage (35) (55) (69) (72.5) (75.9) Association midwives Number 903 3,033 1,400 1,443 1,401 Percentage (28) (65) (57) (68) (72.3) Pethidine Statutory Instrument No. 380, issued under the dangerous drugs regulations, came into operation on 1st April, 1950, and authorised certified midwives who had notified intention to practise to the local supervising authority to be in possession of and to administer medicinal opium, tincture of opium and pethidine so far as is necessary for the practise of their profession of employment as midwives. Conditions were laid down which provided that midwives could only obtain supplies of these dangerous drugs by production of a drug book and their personal registers of cases. Records of supplies and administration of the drugs have to be kept in the drug books. To ensure that all practising domiciliary midwives in London were qualified to administer pethidine, lectures on the subject were arranged. The number of administrations of pethidine by midwives was : The number of women given pethidine by midwives Administered by As midwives As maternity nurses 1951 1952 1951 1952 London County Council midwives 1,442 1,287 175 194 Hospital district midwives 158 638 43 53 Association midwives 205 316 52 26 Trilene For many years the use of trilene by midwives in domiciliary practice has been under discussion. At the request of the Ministry of Health, the Council's domiciliary midwifery service is participating in a trial of trilene inhalers organised by the Joint SubCommittee of the Medical Research Council and the Royal College of Obstetricians and Gynaecologists. To enable the domiciliary midwives to participate in this trial, lectures and demonstrations on the types of inhalers to be used were attended by all the Council's midwives and by midwives employed by the district nursing associations. The trial is in progress at present and special reports on the cases selected for inclusion are being sent to the Medical Research Council who will assess the result. Maternity beds in hospitals On 1st November, 1950, the Minister of Health received a deputation from the Council with regard to the domiciliary midwifery service and was asked to make a policy decision regarding the provision by hospitals of maternity beds. At the Minister's suggestion, a conference was held in January, 1951, between officers of the Council, the four Metropolitan Regional Hospital Boards and Boards of Governors of the 14 teaching hospitals in London to discuss policy regarding the provision of maternity beds in relation to the domiciliary midwifery service. The Minister of Health was informed of the results of the conference and asked to indicate his policy with regard to what the ratio should be of maternity beds to the estimated number of births. As a result of these representations, the Minister of Health addressed a circular (LHAL. 1 /51) and memorandum to all local health and hospital authorities on the subject of the selection of maternity patients for admission to hospital. On the issue of this circular, divisional medical officers arranged to co-operate with the hospitals on the lines suggested. 66 The response from the hospitals to the offer of co-operation was varied. In one or two instances the Council was approached by the regional hospital boards when proposals to close or open maternity beds were under discussion, but on the whole it was felt that there was room for co-operation to be further developed. The varied practice of different hospitals within the same regional board area, in asking for the co-operation of the local health authority in applying social standards for the admission of women to maternity beds reacts unfavourably on neighbouring hospitals who loyally co-operate. A further approach has been made to the hospital authorities to review the progress made since the issue of the Ministry's circular and to obtain agreement on the best means for establishing and improving mutual co-operation in the fields in which the interest of the hospitals and the local health authority converge. The main problems on which cooperation is desired are : (a) Selection of maternity cases for admission to hospital, (b) co-operation between hospital maternity departments and the Council's ante-natal clinics, (c) notification of the discharge of maternity patients, and (d) provision of care and after-care for maternity patients at the request of hospital almoners. Midwives Act, 1951 The Council, as local supervising authority, has the duty to inspect midwives and maternity nurses practising in its area in accordance with the rules of the Central Midwives Board. Originally, these inspections were carried out by medical supervisors but in 1939 two positions of non-medical supervisor were substituted for two of medical supervisor. The number of non-medical supervisors employed by the Council subsequently rose to six in 1948 but as the number of domiciliary confinements declined, the number of non-medical supervisors employed has been reduced to four. These supervisors maintain a 24-hour supervision of the domiciliary midwifery service. They supervise the work of the L.C.C. midwives and supervise and inspect the district midwives employed by hospitals and district nursing associations. They carry out the routine inspections required by the rules of the Central Midwives Board of all independent midwives and maternity nurses, investigate all cases of puerperal pyrexia, skin and eye infections, neo-natal deaths and still-births occurring on district and arrange, if necessary, for the suspension of midwives coming into contact with infection and inspect all medical aid notices issued by midwives. Notifications of intention to practise Notifications of intention to practise were received as follows : 1948 1949 1950 1951 1952 As midwives 1,213 1,252 1,275 1,337 1,331 As maternity nurses 289 242 241 205 232 An analysis of the notifications for 1952 shows : Midwifes Maternity nurses Practising in hospitals 1,023 — Practising in nursing homes 13 54 London County Council domiciliary 118 — District nursing associations 79 — Hospital districts 87 — Nursing co-operations — 162 Independent 11 16 1,331 232 67 The number of medical aid notices issued by midwives during 1952 was ; By domiciliary midwives 6,110 By midwives in institutions with less than 15 beds and/or no R.M.O. 89 6,199 Summoning of medical aid The following statement shows the number of claims received from doctors in respect of medical aid provided by them under the Midwives Act and the total amount of fees paid each year by the Council. The introduction in 1948 of the maternity medical services has had a bearing on the number of claims received which have shown an expected decline. A few cases have occurred where, as a result of checks made of claims submitted to the Council against payments made by the London Executive Council, duplicate payments have been disclosed, and action has been taken to recover any fees wrongfully claimed. The effect of the introduction under the National Health Service Act, 1946, of the general medical services and the maternity medical services has been to restrict the period under which attention is given to the period of 14 days after the confinement, as medical attention after this period is now provided by the family doctor as part of the general medical services. The only exception to this is when a doctor—not being the family doctor or the booked doctor—is called in by the midwife for an emergency between the 15th and 28th day after confinement. Number of claims received from medical practitioners and amount offees paid under the Medical Practitioners (Fees Regulations) since 1948 1948 1949 1950 1951 1952 Number of claims received 6,354 5,368 4,216 3,932 3,135 Total payments £15,594 £15,829 £12,682 £12,042 £9,491 Pupil midwives Training of midwives The Council provides facilities for the district training of Part II midwifery pupils through its domiciliary midwifery service. Midwives employed by the Council are approved by the Central Midwives Board as district teachers for pupil midwives. In spite of the progressive decline since 1947 in the number of domiciliary confinements attended by the Council's midwives, there has been a great expansion of the arrangements for providing pupil midwives with their district training. At the end of 1948, 45 out of 155 midwives were approved as district teachers whereas, at the end of 1952, 71 out of 98 midwives were approved. The number of pupils for which the Council undertakes to provide district training has also risen from approximately 20 each quarter to 65 and during 1952, a total of 191 was received. The majority of these pupils reside with the midwife during their district training, but a few remain resident at their Part II training school, and come out to cases on notification by the teacher. Allowances for board and lodging and tuition fees while the pupils are on district are paid direct by the hospitals employing the pupil midwives to the L.C.C. teachers or the associations concerned. In addition to the training arranged by the Council through its midwives there are eight hospitals and two district nursing associations in London approved as complete Part II training schools. At the two associations pupils spend the whole of the six months Part II training on district. A few pupils take their district training outside the London area but, on the other hand, some 14 pupils from Part II training schools outside London are accepted for district training by associations in London. 68 Refresher courses The Council, in conjunction with the County Councils of Middlesex and Surrey, arranges for the provision annually of two courses, each of six lectures, for all midwives in these areas who have notified their intention to practise. The lectures are held at the County Hall, S.E.1, in the early months of the year and distinguished lecturers are engaged. In all, about 350 midwives attend these lectures each year. For the L.C.C. midwives attendance is compulsory. In addition, three whole-day intensive courses, comprising demonstrations at hospitals and other centres are held in the autumn of each year for domiciliary midwives (including independents) working in London, Middlesex and Surrey. About 45 midwives and supervisors attend these demonstrations in groups of about 15. The lectures and demonstrations arranged by the Council under section 17(g) of the Midwives Act do not, however, constitute a complete refresher course as envisaged by section G of the rules of the Central Midwives Board, which is at present in abeyance. Domiciliary midwives attend refresher courses every five years in accordance with the recommendations of the former Midwives Salaries (Rushcliffe) Committee. The courses are arranged by the Royal College of Midwives and last a week, the Council meeting all expenses (except, in the case of courses held out of London, for a contribution of 15s. by the midwife towards the cost of board residence). Non-medical supervisors attend in rota a special refresher course for teachers, also arranged by the Royal College of Midwives and the courses organised by the Association of Supervisors of Midwives. By these means, midwives are kept abreast of developments in obstetric teaching. HEALTH VISITING AND NURSING SERVICES the transfer of the Council's hospitals to the regional hospital boards in July, 1948, greatly reduced the number of nursing and ancillary staff employed in the public health department. This was to some extent compensated by the taking over of the maternity and child welfare and tuberculosis functions and staff of the metropolitan boroughs. The central and divisional administrative nursing staff of the department, under the direction of the chief nursing officer, advises on the recruitment, selection and appointment of nursing and allied staff not only to day and residential establishments administered by the Health Committee, but to a number of welfare homes and mother-and-baby homes administered by the Welfare Committee, boarding and special schools by the Education Committee, and certain children's nurseries and homes administered by the Children's Committee. The total nursing and allied staff employed in the public health department at the end of 1952, was 2,347. Health visitors, tuberculosis visitors and school nursing sisters The following table shows the number of such staff in the service of the Council as on 5th July, 1948, and on 31st December, 1952. 1948 1952 Health visitors 319 413 School nursing sisters 367 331 Tuberculosis visitors 67 70 Clinic nurses 11 33 764 847 The Council has been handicapped in fulfilling its policy of expanding the functions of health visitors to cover the whole range of duties envisaged in section 24 of the Act and in the Ministry's circular 118/47 because of the fact that the health visiting and school nursing services in London were statutorily separated until 5th July, 1948. A result of this separation is that the Council has in its employ nearly 300 school nursing 69 sisters who cannot play a part in the health visiting service because they lack the qualification specified in the National Health Service (Qualifications of Health Visitors and Tuberculosis Visitors) Regulations, 1948. Since the coming into force of the Handicapped Pupils and School Health Service Regulations of 1945, under which school nursing sisters are required to possess the health visitor's certificate, efforts have beer made to encourage the school nursing sisters to secure this qualification. A special intensive course was instituted in 1947 to this end, and with the approval in principle of the Ministry arrangements are now in hand for the establishment of a similar course oi training for the certificate. It is hoped that this course will lead to an additional 30 school nursing sisters obtaining the health visitor's certificate. Selected school nurses may be granted up to one year's leave without pay to enable them to take other courses of training to qualify as health visitors and 25 school nurses have taken advantage of this concession since 5th July, 1948. The fact remains, however, that the majority of the school nursing sisters are unable to secure the health visitor's qualification as they are not accepted, because of age, for the normal training courses. Of the 847 public health nursing staff employed on the maternity and child welfare, tuberculosis and school health services of the Council at the end of 1952, 463 were qualified as health visitors. Some progress has thus been possible in extending the function of the health visitor to cover the care and welfare of the family as a whole. As a step towards this there is increasing co-operation and consultation between health visitors, general medical practitioners and the voluntary and statutory organisations which serve the family. Arrangements have been made for health visitors to extend their sphere beyond the visiting of expectant and nursing mothers and young children but, because the possibihties are governed by the general shortage of health visitors, and by local needs the degree to which it has been possible to bring the whole family within their sphere has varied between divisions and indeed within divisions. Although the importance of regular visiting of young children is fully appreciated it has been found possible, on the principle of putting first things first, to enable health visitors to meet the needs of others such as old people, homeless families units and after-care of patients discharged from hospital, by exercising discretion in the frequency of visits paid to those children whc appear to be well cared for. To make the best use of the health visitors available the practice has been followed of allocating the greater proportion of the health visitors tc those parts of the county where their services are most likely to be needed. Thus the areas allocated to health visitors in districts where conditions are generally poor are smaller than elsewhere. The opinion has been formed that if health visitors were available in sufficient numbers to meet the needs throughout the whole county, their working time could most suitably be allocated on a basis of one-half to maternity and child welfare and one-half to school health and other duties. Health education Health visitors are trained to undertake individual and group health teaching in the normal course of their duties. Some, however, have obtained special qualifications after attending advanced courses in educational psychology and methods of teaching. Altogether 48 health visitors (including 18 specially selected and granted financial assistance under a scheme approved by the Health Committee) have obtained such a qualification. During the year an outline syllabus on the teaching of parentcraft was prepared as a guide for health visitors responsible for health education work in maternity and child welfare centres and for school nursing staff taking classes in citizenship courses in - secondary modern and grammar schools. Requests continue to be received for health visitors to assist in polytechnics and institutes in training courses and refresher courses for nursery matrons, nursery nurses, wardens and house-mothers. Some also undertake special classes in certain Teachers' Training Colleges. During the year the syllabus of general nurse-training was revised by the General Nursing Council and a number of hospitals, including Teaching 70 Hospitals, have sought the help of the department in providing student nurses with theoretical and practical instruction in personal and communal health and the social aspects of disease. This forms part of their training for admission to the Final Examination for State Registration and is intended to provide every nurse with an insight into the public health services. Tuberculosis visitors The tuberculosis visitor is an important link between the diagnostic and curative work of the chest clinics and the preventive and care measures in the patient's home. Approximately 70 tuberculosis visitors are employed in 31 chest clinics. Each visitor paid an average of 1,400 home visits during the year. Training scheme The main source of recruitment to the health visiting service is the training schemes operated by the Council in conjunction with Queen Elizabeth College (University of London) and with the Royal College of Nursing.*Approximately 40 students are appointed each year for a one year course leading to the examination of the Royal Sanitary Institute. Liaison with the University and the organisation of practical field instruction is carried out by the Council's health visitor tutor. During training students receive three-quarters of the minimum commencing salary of a health visitor and are required to continue in the service for six months after qualification. More than twothirds of the students remain on the permanent staff after this six-months service is completed. Home visits An average of 367 health visitors were employed by the Council during the year in connection with the various health services, excluding the tuberculosis service. During 1952, these health visitors made 864,107 visits, equivalent to about eight home visits per working day, apart from clinic and other duties. The following table analyses the visits paid since 1949 : Health visiting—Visits paid 1949 1950 1951 1952 Expectant mothers— First 29,011 25,166 25,439 25,226 Revisit 20,649 20,212 19,311 18,708 Per cent, of notified live and still-births 50 45 46 47 Premature babies— First 1,979 1,698 1,601 1,834 Revisit 3,818 4,406 4,552 5,509 Still-births— First 1,092 949 918 930 Revisit 494 490 390 349 Per cent, of still-births 99 88 86 90 Children under 1— First 54,562 50,436 49,605 48,755 Revisit 171,288 174,935 180,901 183,816 Per cent, of live births 97 93 92 91 Children 1 to 5— First 361,313 5,796 5,188 4,572 Revisit 391,589 387,383 377,986 Infectious diseases 26,287 17,429 26,518 13,396 Miscellaneous 158,181 42,971 48,334 51,278 Unsuccessful 141,626 137,108 131,748 Total 829,674 886,751 887,247 864,107 Health visitors (whole-time, plus whole-time equivalent) at end of year 354 376 373 382 Departmental enquiries into social and public health problems Increasing use is being made by the department and by various organisations of the knowledge of social conditions obtained by health visitors in the course of their work. During 1952 they co-operated in a number of enquiries and researches aimed at measuring social and public health problems. (See page 136.) * From October, 1953, the courses will be at University of London Institute of Education, the Royal College of Nursing and the Battersea Polytechnic. 71 Day nurseries The number of nursing and ancillary child care staff employed in day nurseries numbered (at the end of the year) 1,273, and included matrons, deputy matrons, nursery nurses, wardens, nursery assistants and students. At any time during the year there were 290 nursery students undergoing a two years' training in preparation for admission to the examination of the National Nursery Examination Board. This included those who received special instruction in the care of the child under six months in order to apply for an endorsement of their N.N.E.B. certificate in infant care. The supply of nursery students varies from one division to another. Since the number of approved training nurseries has been reduced it is possible to make a more suitable selection from available candidates. A number of experienced nursery nurses and nursery assistants have been referred for further training in Supplementary and Senior Child Care Reserve courses arranged by the Education Department prior to appointment as nursery wardens. The ratio of non-domestic staff to children is 1 : 3 and 1 : 8 for children aged 0-2 and 2-5 years, respectively, based on the number of approved places in each of these age groups, with a relaxation of this standard in day nurseries catering for children aged 2-5 years only, subject to the over-riding consideration that in no day nursery shall there be fewer than five places for children of all ages to one unit of non-domestic staff. The ratio of nursery students to staff places in the Council's maintained and grantaided training day nurseries is 2 : 1. Residential nurseries The medical officer of health remains responsible for the staffing of five of the larger residential nurseries under the Children's Committee accommodating a preponderance of children under two years of age. This includes the recruitment, selection and training of nursery students. During 1952, the recruitment of junior grades of staff has considerably eased because qualified nursery nurses are available in increasing numbers, but senior grades capable of undertaking responsibility for the 24-hour care of young children are in short supply. It has been necessary to engage State Registered Nurses without previous nursery experience from nursing agencies to fill senior vacancies and this is not regarded as satisfactory. Nursery students undergoing training in day and residential nurseries for admission to examination Training of the National Nursery Examination Board during 1952 Day nurseries Health division Total Res. nurseries Grand total 1 2 3 4 5 6 7 8 9 Number of students undergoing training in day and residential nurseries on 1st January, 1952 33 51 10 44 20 7 27 44 59 295 97 392 Number of students who resigned from the training scheme before completing training in 1952 — 11 3 9 11 — 3 11 24 72 10 82 Number of students who entered for N.N.E.B. examination during 1952 17 32 3 19 2 7 11 12 11 114 56 170 Number of students who passed the examination 16 25 2 15 1 2 9 10 10 90 45 135 Number of students who fully passed the N.N.E.B. ination and who have remained or intend to remain for 6 months as staff nursery nurses in the service 6 13 2 4 1 1 1 7 6 41 12 53 Number of nursery students maining in training on 31st December, 1952 33 60 14 43 22 3 23 43 57 298 93 391 72 Residential boarding and special schools and children's homes Thirty-seven state registered nurses and nine state enrolled assistant nurses are employed whole-time in residential establishments administered by the Education and Children's Committees. Their duties are to recognise early symptoms and prevent the spread of infection, apply first-aid measures in the event of accident, undertake the bedside nursing of children for whom admission to hospital is unobtainable and generally to be responsible for the health educational aspects of the care of children. Owing to the shortage of trained staff for appointment the most effective use has to be made of those available. In certain special schools in out-County areas it has been possible to obtain non-resident nursing staff willing to give part-time services. This scheme is working well, particularly where residential accommodation for whole-time staff is limited. Every effort is made to ensure that nursing staff in out-County schools and homes who work rather in isolation are visited regularly by a senior member of the central administrative nursing staff and lectures and demonstrations are arranged to keep them familiar with modern techniques in child care. One nursing sister is in charge of the unit for diabetic children attached to Hutton Children's Home. School camps Three National Holiday Camps are open each year from March to November. Six school nursing sisters are seconded for duty with the parties of London school children sent everv fortnight durine this period. Roland House It was found possible during the year to maintain a stable nursing staff at this Holiday Home which is now open to the fullest extent for the reception of 36 children between four and eight years. (See page 98.) Large welfare homes Forty-three state registered nurses are employed as ward sisters in the large welfare homes for duties concerned with the care of old and infirm residents and those confined to bed who need nursing attention. Considerable difficulty is experienced in securing the admission to hospital of acutely ill as well as chronic sick patients and the nursing establishment of these homes had to be increased during 1952 to meet the demand. A high standard of nursing care is maintained by welfare assistants working under the direction and supervision of trained nursing staff. Medical examination section at County Hall The volume of work in the medical examination section required the services of four school nursing sisters throughout the year with additional relief and help for special sessions. Duties undertaken include the medical examination of new entrants to the service, sick staff, and large numbers of children attending for special examination. The nursing staff is also available for the treatment of casualties or sudden illness amongst staff and visitors to County Hall and they undertake first-aid duty at all receptions held in County Hall. Inspection of nursing agencies A senior member of the central administrative nursing staff is available to the public control department for advice and consultation in the inspection, under the Nurses Act, 1943, of agencies supplying trained nurses. Refresher courses and post-entry training All nursing staff engaged on health education duties are given facilities to attend approved refresher courses periodically. In addition to these refresher courses lectures, discussions and staff conferences at County Hall are arranged at intervals to ensure that staff are kept 73 fully informed of developments in all aspects of public health work. Examples during 1952, were ' The Family in a Changing Society' and ' Tuberculosis and the Public Health ' at which lecturers included Professor A. Moncrieff, m.d., f.r.c.p., m.r.c.s., Institute of Child Health, A. T. M. Wilson, Esq., m.d., b.sc., Tavistock Institute of Human Relations, Professor Richard Titmuss, London School of Economics and Political Science, Professor F. R. G. Heaf, m.d., f.r.c.p., Welsh National School of Medicine, Cardiff. HOME NURSING home nursing in London is carried out on behalf of the Council by the undermentioned voluntary organisations: 24 district nursing associations, employing at 31st December, 1952, the equivalent of282½ whole-time nurses 2 religious organisations (the Nursing Sisters of St. John the Divine and the Catholic Nursing Institute), employing between them at 31st December, 1952, the equivalent of 7 whole-time nurses The Ranyard Nurses, employing at 31st December, 1952, the equivalent of 115½ whole-time nurses. Male and female, full-time and part-time, resident and non-resident nurses and assistant nurses are employed. Eleven of the organisations participate in the Council's domiciliary midwifery service (see page 60). The activities of the voluntary bodies are co-ordinated by another voluntary body, the Central Council for District Nursing in London, which in addition to transmitting decisions of the Council to the home nursing organisations and, in reverse, collating information for presentation to the Council, is responsible for such matters as adjustment of boundaries between nursing areas and arranging for the continuation of the home nursing service if a voluntary organisation should cease to function in any area. All these organisations which act as the Council's agents receive grants, the Central Council for District Nursing in London—£450 a year; the Catholic Nursing Institute— £900 a year (subject to review should their work expand or contract appreciably); and the others, 90 per cent. of approved net expenditure on the service. Apart from the financial control implicit in the expression ' approved expenditure ' the voluntary organisations have almost complete freedom of action and retain their individual and independent status. Premises The Council is prepared to consider applications from district nursing organisations for loans to enable them to undertake capital works (e.g., extension of premises), the loan charges being approved for grant purposes. The successful employment of non-resident nurses, both male and female, may, however, indicate that extensions to residential accommodation will be less necessary than has been thought in the past. During 1952 the Council agreed the preliminary plans and costs of a new building which the Duchy of Cornwall Estate proposes to erect for an association in South London. The Council will lease the premises from the Duchy Estate and will sub-let to the nursing association. Several associations effected considerable repairs and decorations to their nurses' homes in order to bring them up to a reasonable standard. Much detailed checking of plans by the Council's technical staff is obviated by the associations employing approved firms of surveyors for this work. The director of housing and valuer does all in his power to find accommodation for the Ranyard Nurses, who do not work from district homes, but several requests were still outstanding at the end of 1952. Liaison Liaison with the other local health authority services is maintained at member and officer level, (a) by a member of the divisional health committee and the divisional medical officer or his representative representing the Council on the voluntary committee 74 of each home nursing organisation; (b) by direct personal contact (particularly divisional nursing officer to superintendent); and (c) by joint membership of the divisional home nursing voluntary committee. One of these committees has been set up in each of the nine health divisions. They include representatives of all organisations administering the home nursing service in the division; the principal divisional officers of the Council; and representatives of all allied services with which co-operation should be maintained, e.g., general medical practitioners, nurses, midwives, hospital almoners and the British Red Cross Society. There is still evidence that home nursing superintendents make insufficient use of the divisional health office facilities and that some visits of a purely social nature are paid by home nurses, and particular attention is to be given to these matters. Consideration is being given to the possibility of extending liaison arrangements to include field workers, i.e., by direct contact between district nurse and health visitor, home help organiser, and care committee workers, etc. There is a long-established tradition of co-operation with general medical practitioners and hospitals. The Central Council for District Nursing supplies printed forms for use by general medical practitioners and hospital almoners by which application may be made for the services of a district nurse for any patient needing nursing care at home, but the telephone is used at least as frequently as the forms. The majority of the cases attended by district nursing organisations are referred by general medical practitioners, somewhat under one-fifth being referred direct by hospitals. Maternity patients who either develop some infection or are discharged from hospital before the last day of the puerperium are referred to the general district nurses for home care unless they are booked patients of one of the Council's midwives. Where a district nurse calls in response to an application from other than medical services (e.g., from relatives of the patient) she will not normally make more than two visits unless a doctor has been called in, and she will work under the doctor's instruction. Staff The number of nurses employed at the end of 1952 was 455 whole-time and part-time (whole-time equivalent 405 nurses). This compares with 341 whole-time and 114 parttime nurses (397 whole-time equivalent) employed at the end of 1951. The employment of state enrolled assistant nurses on a limited scale has been of assistance in easing the work of the district nurses, but some organisations are reluctant to use them and the Council has not so far seen fit to bring any pressure to bear. Where these nurses are employed the view has been expressed that one S.E.A.N. working to five trained district nurses is appropriate. Now that S.E.A.N.s are required to have experience in the care of sick children it is likely that their services will be utilised to a greater extent than hitherto. The use of nursing auxiliaries to supplement the work of the trained staff has also been found to vary in extent, and here again the desirability of enrolhng such workers where they were available has been left entirely to the discretion of the individual organisations. Transport The bicycle remains the form of transport most widely used by district nurses, although autocycles are increasingly in evidence, particularly among male nurses. Some organisations possess cars, and the Council has embarked on a programme of supplying cars on loan to those whose work justifies the provision of additional means of transport, but who are unable for various reasons to acquire a car. The basis of the scheme is that the Council licenses, insures and periodically overhauls the vehicles, running costs being borne by the organisation and ranking for grant from the Council. At the end of the year eight associations were operating Council cars under this arrangement. One car was lent to an association until the delivery of a new car which the association had ordered. Consideration is being given, in association with the Central Council for District Nursing, to the provision of a lighter nursing bag to ease the district nurses' work, but the replacement of all bags by new types will necessarily be a long process. Night service Owing to the pressure on the staff, consideration of a night service has had to be postponed until such time as more staff, and more accommodation for them, may be available. Several of the district nursing organisations, however, are able to arrange 75 (from sources outside their own staff) for the services of persons who are prepared, for a small fee, to ' sit in ' with chronic sick and other patients for whom night attendance is required but is not otherwise available. Notes on the Council's new service of night home helps are given on page 78. Statistics Statistical returns rendered to the Council by nursing organisations have been standardised since 1948 and have been designed to meet the requirements of the Ministry of Health. Some organisations have from time to time experienced difficulty in adapting their clerical methods to the standard returns, and where waste of time and effort has been apparent advice has been offered by the statistical section of the public health department. The whole question of records and returns is now under review with the object of devising less laborious methods and persuading the home nursing organisations to use them. The total number of visits paid during the year was 1,610,428 compared with 1,452,410 in 1951, giving an average of 14 visits daily for each nurse (13 for 1951). The average case load of a nurse at any one time was 22 patients (21 in 1951). Treatments completed totalled 58,213 and there were 9,680 patients still in nursing care at the end of the year. The completed treatments were diagnosed as : Number Percentage of total Infectious and parasitic diseases 1,639 2.8 Tuberculosis 2,070 3.6 Cancer and other neoplasms 2,378 4.1 Diabetes 1,454 2.5 Mental and other nervous diseases 669 1.1 Ear, eye and other sense organs 4,426 7.5 Cerebral lesions of vascular origin 1,840 3.2 Heart and arteries 5,593 9.6 Veins and other circulatory diseases 729 1.3 Respiratory diseases 13,402 23.1 Digestive diseases 5,074 8.7 Genito-urinary 3,713 6.4 Pregnancy 611 1.0 Skin 5,938 10.2 Bones and organs of movement 1,368 2.3 Injuries 1,411 2.4 Other diseases or ill-defined 5,878 10.1 These patients were referred to the nursing organisations as follows: Number Percentage of total By General practitioners 46,060 79.1 Hospitals 9,191 15.8 Public health authorities 635 1.1 Direct application 1,199 2.1 Chest clinics 1,128 1.9 The bad atmospheric conditions in December caused extra pressure on the service owing to the increase in respiratory complaints. The expanding tendency of the home nursing service is shown in the graphs on page 76. Increasing demand in the four-year period 1949-52 led to the employment of more nurses. The numbers of visits paid and of treatments commenced and completed rose fairly steadily with consistent well-marked peaks in the March quarter of each year. Peak periods apart, the average number of completed treatments per nurse employed remained fairly constant. Equipment on loan The supply of equipment on loan to patients being nursed at home is undertaken on the Council's behalf by the medical loan depots maintained by the British Red Cross Society and (for their own patients) by the district nursing organisations. Financial assistance is given to these organisations to enable them to deal with the increasing number of applications received for a wide range of nursing equipment. Since difficulty has been experienced by the voluntary committees in purchasing and storing large and expensive items of equipment and in replenishing stocks when articles are on loan for 76 77 long periods, the Council will in future itself supply all equipment to patients suffering from tuberculosis, and large articles to all patients. The type of equipment supplied ranges from special bedsteads and Dunlopillo mattresses to hot water bottles, and a deposit and a small charge varying from 3d. to 1s. a week are required from those who can afford to pay. Training Training of district nurses in London is undertaken by the Ranyard Nurses and by certain district nursing associations approved for this purpose by the Queen's Institute of District Nursing. Not all the students trained subsequently work in London, but the Council nevertheless recognises for grant purposes all expenditure incurred by the home nursing organisations in connection with the training schemes, including the payment of a fee of £6 to the Queen's Institute of District Nursing in respect of each student district nurse trained under their auspices, this fee representing an agreed contribution toward the overhead costs of the Queen's Institute scheme. The Council also pays for the hire of a hall used by the Queen's Institute for lectures to student district nurses. The training offered by the Ranyard Nurses covers much the same ground as that of the Queen's Institute, but the approach is necessarily different, since the Queen's Institute system of district nursing is based on a number of group nurses' homes each in charge of a superintendent, whereas the Ranyard system is based on individual nurses each living in her own home and subject to supervision by peripatetic district superintendents. Both types of training overlap to some extent the syllabus of instruction for the health visitor certificate in their approach to the social side of nursing and both will undoubtedly be affected, both in length and content, by the experiments now being planned by area nurse training committees following the publication by the General Nursing Council of the revised syllabus of general nursing training which will be compulsory from 1st January, 1954. In this connection, it is of interest that state enrolled assistant nurses employed in the home nursing service are generally given one month's introduction to home nursing and then succeed very well under supervision. The Queen's Institute of District Nursing have been pressing for some time for the statutory recognition of district nursing training, and their initial approach to the problem seemed to indicate a desire that their own particular method of training, backed as it was by many years of experience, should be recognised for the award of a national certificate. Local health authorities generally, however, have felt that in view of the great changes impending in nurse training schemes it would not be advisable at this stage to interfere with existing arrangements. It is clear that whilst the Council is using as its agents differing types of voluntary bodies employing nurses trained by different methods, it cannot well support the claims of any of them against the others. Post-certificate training for district nurses is also organised by the Queen's Institute of District Nursing on a national basis, and London associations send members of their staff on some courses. Where a course is regarded as necessary for the improvement of the service to the people of London, the Council approves, for grant purposes, the expenditure incurred in sending the nurse to it. Instances have occurred, however, of nursing staff being sent to courses designed to enable them to acquire certificates which are neither required nor recognised for district nurses by the Whitley Council, and in these cases the organisation has itself paid the cost out of its own resources. It is rare for post-certificate courses to be held in London, but it is hoped that London nurses may eventually be able to get refresher courses nearer home. Inspection Inspection of most district nurses and district nursing homes in London is undertaken by the Queen's Institute of District Nursing and by the district superintendents of the Ranyard Nurses. The cost to the Queen's Institute is covered by the payment by the district nursing associations inspected of an 'affiliation fee' of £315s. 15s. annually in respect of each Queen's Nurse employed on duties under section 25 of the National Health Service Act, 1946. These payments are approved by the Council for grant purposes. Three of the district nursing associations and the two religious organisations, however, are not affiliated to the Queen's Institute and their work is not inspected professionally although their voluntary committees keep in close touch with the daily work of the 78 nurses. The Council's staff have not so far carried out professional inspections, but there is no doubt that in future this work will be increasingly undertaken in the proper fulfilment of the Council's duties. Such a development would enable the Queen's Institute to shed their administrative functions, which are strictly within the province of the local health authorities. DOMESTIC HELP SERVICE the domestic help service in London has been until 31st December, 1952, essentially a day-time service, normally available on five and a half days a week, although a small number of households (particularly old people living alone) receive some assistance at week-ends and on bank holidays, when no other help is available. Approval has been given to the inauguration from 1st January, 1953, of a limited service of night home helps to attend certain categories of chronic sick persons in their own homes and afford some measure of relief for one or two nights each week to the relatives of the patient, who would otherwise be 'on call' every night. This service will operate between 11 p.m. and 7 a.m. and will be staffed initially by members of the existing day-time service. They will be paid at slightly higher rates than for day-time work, will work from 11 p.m. to 7 a.m. and perform those duties for the patient, other than nursing, which a relative would normally do. Although no separate statistics have been kept, it is known that a large proportion of the householders receiving service are aged or chronic sick persons who require semi-permanent help; this is reflected by an increase in the number of cases on the books (other than maternity and tuberculous) from 9,634 at 31st December, 1950, to 14,208 at 31st December, 1952. First priority is given to maternity cases and the occasions when the needs of these people cannot be met are rare: in fact, no maternity case has had to be refused help in the past two years. The home helps who attend tuberculous households volunteer to do so and no pressure is put upon them to undertake this work; special instructions are issued as to the precautions to be taken. The Council provides overalls for the use of its whole-time home helps and of parttime workers employed for more than 20 hours a week, the overalls remaining the property of the Council and being returnable on cessation of employment. A small quantity of household equipment is held in each of the nine health divisions for use by home helps attending households where brushes, brooms, etc. are not available, but ordinarily the provision of this equipment is regarded as the responsibility of the householder. The service is organised on a divisional basis, a total of 30 organisers and 32 assistant organisers, with appropriate clerical assistance, being employed. The organisers' areas were originally coterminous with metropolitan boroughs, but in the interests of efficiency and of convenience to the public, adjustments have been made so that each organiser now has approximately the same responsibilities. The organisers' offices are in the main situated apart from the divisional health offices and so placed as to be of easy access to residents in the area served. At 31st December, 1952,196 whole-time and 2,725 part-time helps were employed, being the equivalent of 1,692 whole-time workers. Applications for the services of a home help may be made to the organiser's office or to the divisional health office. The organiser or her assistant will visit the household and assess the amount of help required, but in cases where this cannot be done at once the health visitor will often make a preliminary assessment to enable the service to start without delay, the allocation of help being revised when the organiser has investigated all the circumstances. The employment of a relative of the householder as a home help may be authorised in special circumstances provided that the relative has given up paid employment in order to care for the householder; each case is subject to the approval of the divisional health committee and is kept under constant review. 79 The income from the service is about 7 per cent. of the cost and many households enjoy a free service. The needs of each household are reviewed periodically and such modifications as may be necessary are made in the number of hours' service provided and the charge made. The normal service for maternity cases is 44 hours a week for two weeks. Under arrangements made with the National Institute of Houseworkers, Ltd., a total of 191 of the Council's home helps were tested in 1949. 166 were successful and were awarded the diploma of the Institute, in virtue of which their rate of pay was enhanced by 1d. an hour. A short refresher course was organised in association with the Institute in November, 1951, and was attended by 14 of: the Council's home helps, but it was not an unqualified success. No further arrangements for courses or tests have been made, and it may well be that future plans in London, as in other parts of the country, may be made in association with the education service rather than with an outside body. In some areas specially selected home helps have been allocated to households which presented certain social problems—e.g. neglectful mothers; parent discharged from mental hospital, etc. It has been found that a contribution can be made by the home help, by example and advice, towards the rehabilitation of the family. In one health division a home help has been allowed to work with a Family Service Unit to help problem families who come within the categories set out in section 29 of the National Health Service Act, 1946. One way in which the domestic help service could be of further use to the community is, to look after children in their own homes when they are temporarily deprived of the care of both parents. It is thought that a scheme which would overcome the need for such children to be taken into residential care under the Children Act, 1948, with consequent emotional disturbance, could not but be of benefit. A certain amount of help is already given in some of these cases, but it is a matter of great difficulty to arrange for morning and evening care (when most of the home helps have their own domestic commitments to consider) and it is not easy to see at present how help of this kind can be extended. The suggestion is being explored that a home help might sleep in the home, her duties starting with the preparation of the children's tea and ending with the children's departure for school or a day nursery on the following morning. Negotiations as to an appropriate rate of pay are in progress; it is not yet apparent whether the cost of such a service would be prohibitive. The growth of the service is shown by the following table : 1949 1950 1951 1952 Cases assisted 25,933 25,805 26,542 27,896 Hours worked 2,783,000 3,159,728 3,441,152 3,834,688 Home helps employed at end of year 2,310 2,525 2,663 2,921 Equivalent of whole-time staff 1,265 1,381 1,562 1,692 The demand on the service and the extent to which it was met in 1952 is shown by the following figures: Maternity Tuberculosis Other Total Applications received 2,673 804 15,063 18,540 Households attended: (a) Completed periods of help 1,989 602 10,290 12,881 (b) Service incomplete at end of year 134 673 14,208 15,015 No. of applications refused or deferred: (a) Owing to inability to supply — 23 192 215 (b) For other reasons 1,275 96 1,361 2,732 Although every effort is made to supply at least a little service to all who need it, some households have had to be refused or service deferred because of inability to supply, but this number was smaller in 1952 (192) than in 1951 (385). Help is never refused to a F 80 maternity case, the disparity between the number of applications and the number of cases helped being usually caused by the mother's being admitted to hospital for her confinement or making other arrangements for help. Normally the services of a home help are given to maternity cases for two weeks of 44 hours each. The average number of hours service given to non-maternity cases in 1952 was five, which continued over an average period of 45½ weeks. IMMUNISATION AND VACCINATION the council's arrangements for securing infant vaccination against smallpox and primary immunisation against diphtheria fall into two main parts: (a) work performed by full-time or part-time medical staff employed by the Council in child welfare centres, etc., and (b) work performed independently by general medical practitioners, who are paid a fee of 5s. on receipt of each record of a completed course of immunisation or of a successful vaccination or two unsuccessful attempts. Prophylactic material approved for national free issue is provided by the Council to general medical practitioners on request. The following table indicates the amount of work done in the last four years: Prophylaxis 1949 1950 1951 1952 Smallpox vaccinations— Cases completed by L.C.C. 18,585 22,349 28,297 22,866 Cases completed by general practitioners 5,942 9,707 19,597 14,542 Diphtheria immunisation— Cases completed by L.C.C. 36,033 34,345 33,270 33,954 Cases completed by general practitioners 4,767 3,600 5,020 5,532 Whooping cough inoculation— Cases completed by L.C.C. 7,987 7,354 8,874 17,632 Cases completed by general practitioners 823 324 432 1,129 Whooping cough and diphtheria combined— Cases completed by L.C.C. 15,797 7,101 559 1,815 Cases completed by general practitioners 1,332 2,559 1,490 1,657 Grand total of diphtheria immunisations 57,929 47,605 40,339 42,958 Estimated percentage at end of year of population 0—4 who had at any time been immunised against diphtheria 54.7 55.4 53.0 50.2 The health visitor, midwife and clinic doctor constitute the joint spearhead of the attack on smallpox and diphtheria. Health visitors are advised of the birth of every child in their area, so that they may visit the homes. They are able to do much to encourage the parents of newly-born infants to have their children vaccinated and immunised when the time is ripe and, in respect of children born at home, the ground will already have been prepared by the midwife. This continuous propaganda campaign is supplemented in varying ways in each health division. Ministry of Health and Central Council for Health Education publications are used in all divisions, and in some special administrative action is taken to follow up or introduce the health visitor's approach to parents. One division has a highly developed administrative system of records based on birth notifications and all parents are circularised when the children reach the ages of four months, eight months and 12 months, with a personal follow-up by the health visitor after this age where parents have resisted all previous efforts. These records provide a complete picture of the immunisation and vaccination state of all children born in or entering the area since the commencement of the scheme. Another division has recently arranged for immunisation against diphtheria to be available at all child welfare sessions instead of only at special sessions, and the results of this experiment will be watched 81 with interest. Close contact is maintained with general medical practitioners undertaking vaccination and immunisation and circular letters are sent to them from time to time, with the approval of the local medical committee, encouraging them to intensify their efforts and offering them further supplies of propaganda material. Intensified efforts are made in all divisions during national campaigns, local 'health weeks' or following an outbreak of infection. A mobile clinic and loudspeaker van are used with success on these occasions. A keen interest in the work is taken by members of the divisional and central health committees, who receive regular progress reports. Parents who are being asked to consent to the vaccination, primary immunisation or further protection of their children are advised of the alternative means available. Prominent notices are displayed at appropriate centres announcing the days and times of special sessions, and pamphlets are also issued in which are listed all the local health authority services available in each health division, with sessional details. Particular attention is paid to the vaccination and immunisation of children in the Council's residential establishments inside and outside the county, and all visiting medical officers appointed to such establishments are required to give the necessary injections, subject to parental consent, as one of the routine duties of medical care. Immunisation against whooping cough is undertaken in all residential nurseries and residential nursery schools. Diphtheria immunisation The steady decline since 1949 in the number of children receiving primary immunisation, referred to in my last report, has now been checked. General apathy because of the low incidence of diphtheria, and concern over the possible association of paralysis in poliomyelitis with the site of recent injections (see below), are still present, but the determined efforts made to combat these by increased publicity and personal approach have resulted in 42,232 children receiving primary immunisation in 1952 compared with 40,656 in 1951, and 27,820 children receiving reinforcing doses in 1952 compared with 22,908 in 1951. This increase must be accelerated if an increase in diphtheria incidence is to be prevented. Public alarm about the danger of paralysis following inoculations causes great difficulty both in the maintenance of a continuous propaganda campaign and in explaining to parents the necessity for postponing immunisation during the season when poliomyelitis is most likely to occur. From this point of view it is perhaps unfortunate that national immunisation campaigns tend to be launched just before the poliomyelitis season and it seems that much might be gained by intensifying propaganda as soon as possible after poliomyelitis has ceased to be widely prevalent. Difficulty has been experienced in devising an adequate scheme of dealing with 'booster' doses owing to the incomplete records available of work done before the operation of the National Health Service Act, 1946. Since 1942, a note has been made against each name in the school registers indicating whether the child has been immunised, but this information has frequently been obtainable only from the parents without any supporting evidence. Generally the head teachers send out letters to parents of children requiring primary or boosting doses and special sessions are arranged in schools or welfare centres. The opportunity is to be taken of reviewing this scheme with the entry into school of the first generation to be fully documented under the National Health Service Act, 1946, and it is hoped to link the ' booster ' dose more closely with the statutory routine medical inspections of children under the Education Act, 1944. In one division duplicates of the school registers are kept in the divisional office, and after the information therein has been checked with all other available records the following-up for primaries and 'boosters' at appropriate ages is done by means of letters, followed by a personal approach by the school nurse where necessary. In many cases health visitors arrange for children to have ' booster ' doses before starting school. In the Council's residential establishments for children inside London, 52.8 per cent. of the children were fully immunised at 31st December, 1952; parental consent had been F* 82 refused for 3.4 per cent. of the children and the remainder were either awaiting immunisation, awaiting parental consent or were not suitable for immunisation. The corresponding figures for out-county establishments were 82.6 per cent. immunised, 1.9 per cent. parental consents refused, 15.5 per cent. awaiting immunisation or parental consent or unsuitable for immunisation. Whooping cough immunisation There is no organised scheme in London for promoting immunisation against whooping cough, although the matter is kept under close watch with a view to the establishment of arrangements as and when medical developments justify. Parents who ask to have their children immunised against whooping cough can have the work done at a session in one of the Council's centres by arrangement, and the Council pays the standard fee for records of such immunisation received from general practitioners. It is generally found that parents enquire about immunisation against diphtheria and whooping cough at the same time and it frequently happens that the two protections are given at about the same age, either by the use of a combined prophylactic or by concurrent courses of immunisation; but efforts are being made to secure the immunisation of infants against whooping cough at an age considerably younger than that officially recommended for diphtheria, in order that protection against whooping cough can be given at an age when it can save lives. The amount of whooping cough immunisation performed increased greatly in 1952. 17,632 children were immunised in the Council's centres and day nurseries compared with 8,874 in 1951, and 1,129 children were immunised by general practitioners compared with 432 in 1951. In residential nurseries and nursery schools 49 per cent. of the children had been immunised at 31st December, 1952; parental consent had been refused for less than one per cent. of the children, and the remainder were either awaiting immunisation, awaiting parental consent or were not suitable for immunisation. The use of combined diphtheria and whooping cough antigen has been recommenced since the latest types available have proved to be satisfactory; 3,472 children were immunised with the combined antigen during the year. Vaccination There has been a fall in the number of persons vaccinated this year. This was anticipated after the exceptionally high figures for 1951 resulting from the outbreak of smallpox in Brighton. The number of vaccinations of children under five (26,406) is, however, higher than in 1950 (24,796) or 1949 (20,093) and apart from the abnormal conditions of 1951 the figures appear to be following a welcome upward trend. Full details of the amount of work done follow. amount of work done follow. Figures for 1951 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 23,106 3,300 1,025 2,002 29,433 (19,700) (8,614) (2,712) (4,444) (35,470) Re-vaccinations 61 252 804 7,230 8,347 (35) (254) (1,330) (15,641) (17,260) One child vaccinated in London in 1952 was removed to the area of another authority and there developed generalised vaccinia. There was also one case of post-vaccinal encephalitis. Primary vaccination of older children is not recommended in the absence of smallpox, but re-vaccination of school children is undertaken as part of the Council's scheme. Parental consents had been refused, at 31st December, 1952, for 6.2 per cent. of the children in the Council's residential establishments inside London, and 3.6 per cent. in out-county establishments. 49.5 per cent. children in in-county, and 54.3 per cent. 83 in out-county establishments had been vaccinated. Parental consents were being obtained for the remainder. Discussions have been held with the Ministry of Health, the County Councils Association and the Association of Municipal Corporations on, among other matters, the necessity for maintaining records of vaccination of adults, particularly those who are vaccinated before leaving the country. Although the Ministry did not consider it essential to maintain records of the latter category, they wished to have full statistical information of all other vaccination and it was decided to continue to keep records in London of both infant and adult vaccinations, including those performed on persons going overseas. Vaccination of staff and patients in hospital was considered to be a hospital responsibility and the Ministry have arranged for local health authorities to obtain, without charge, information of the extent of such vaccination. LONDON AMBULANCE SERVICE as in every previous year since the inception of the National Health Service there was during 1952 a substantial increase in the demand for ambulance transport, the number of patients conveyed by the General section of the service being 660,206 compared with 550,621 in 1951, an increase of 20 per cent. The increases in the number ofjourneys made and in the mileage run in dealing with this increased demand, 13 and 12 per cent. respectively, are appreciably lower than the increase in the number of patients carried and this is due to the additions made during the year to the list of hospitals to which some degree of decentralisation is applied and, so far as the road mileage is concerned, to the still increasing number of 'ambulance-train-ambulance' removals which, though adding considerably to the administrative work of the headquarters staff, result in very appreciable reductions in road mileage run and in vehicle and man hours occupied and hence in an increased availability of ambulance vehicles within the area of the county, besides effecting a considerable financial saving. In 1952, a total of 4,759 patients, travelling a total of 377,501 miles by rail, were conveyed by this means compared with 3,998 patients, travelling approximately 302,000 miles by rail, in 1951. Railway stretchers In collaboration with the chief officer of supplies and with a firm of manufacturers, modifications were made in the design of the special stretcher used in the Service for the conveyance of immovable recumbent patients by rail and 51 stretchers of this latest design were added to the existing stock. Decentralisation—ambulance vehicles stationed at hospitals, etc. As mentioned above, the arrangements under which ambulance vehicles are stationed at hospitals, etc., for varying periods on weekdays to convey patients to and from these hospitals on the instructions of the hospital Transport Officers were extended during 1952 and more hospitals, etc., were brought into the scheme, bringing the total to 43. Review of administrative organisation and of methods of operational control The ever growing demands upon the service have led to very severe pressure upon the central control room and upon the administrative and control staff both at headquarters and at the general ambulance stations as well as upon the operative staff and vehicles. A comprehensive review of the various clerical and operational procedures employed in the service was accordingly undertaken with a view to the elimination of outmoded practices and the promotion of greater service efficiency. This review was conducted in close collaboration with officers of the organisation and methods section of the department of the clerk of the Council, to whom I am greatly indebted for much expert advice and practical assistance. As a result a number of changes in procedure have already been adopted and others are in contemplation, designed to reduce the pressure upon the central control room, to simplify the control work at the general ambulance stations and at the same time to promote still closer association between the hospitals and their local ambulance stations. 84 Concurrently with these changes, arrangements were made to discontinue the maintenance of separate stores at each of the six general ambulance stations and to centralise these in the existing headquarters stores. The preparation of local wages sheets at the general stations, also, was discontinued and this work was absorbed by the department's central finance section. The lying-in-slate and funeral procession of His late Majesty, King George VI Among the special tasks falling to the service during the year was the removal of casualties from among the very large number of people witnessing the lying-in-state and funeral procession of His late Majesty, King George VI. At the request of the Lord Great Chamberlain an accident ambulance was stationed in the courtyard adjacent to Westminster Hall from 3 p.m. on Monday, 11th February, and a stretcher party of two drivers stood by at the Hall from 8 a.m. on Tuesday, 12th February. On the day of the funeral, Friday, 15th February, following consultation with the metropolitan police, a number of ambulances stationed near the route of the procession were specially reserved for emergency purposes and, at the request of the Railway Executive, an accident ambulance stood by at Paddington Station from 7.30 a.m. until the funeral train had departed. Letters of thanks for the arrangements made were received from the Lord Great Chamberlain and from the Railway Executive. Festival of Britain—South Bank site demolition Direct telephone communication between the South Bank Exhibition site and the central control room was maintained during the demolition of the exhibition buildings and a total of nine emergency calls, involving ten patients, were received during the year. Major accidents The emergency call involving the removal of the greatest number of casualties during the year was to the London Pavilion on 10th April, where a plaster cast light fitting had fallen from the dress circle into the stalls. Twenty-three casualties were conveyed to various hospitals. Among other major accidents were: 21st April 11 persons overcome by gas fumes in a deep tunnel in Holborn and taken to hospital. 21st April Collision between two buses in Rye Lane, Camberwell; 21 casualties taken to hospital. 16th June Collision between a bus and a coach at Hyde Park Corner; 22 casualties taken to hospital. 16th August Collision between a bus, a coach and a taxi in Brixton Road, Lambeth; 11 casualties taken to hospital. 17th August Collision between two buses in King's Road, Chelsea; 14 casualties taken to hospital. 30th December Bus caught on Tower Bridge as one half of the bridge began to rise; 13 casualties taken to hospital. In addition to these accidents, with which the service was directly concerned, assistance was rendered to the Middlesex Fire and Ambulance Service in the task of dealing with the very large number of casualties resulting from the railway accident at Harrow and Wealdstone Station on 8th October. Six ambulance vehicles in all were made available to that service for varying periods on the day of the disaster. Following this tragic incident, advantage was taken of the experience of the Middlesex service to review and improve the already existing procedure for dealing with major accidents and to augment the reserve stock of equipment held against the possibility of an accident of similar magnitude occurring within the County of London. 85 Abnormal weather conditions The dense fog which persisted in the London area from 5th to 8th December imposed a very severe strain upon the service. During this period every essential call was answered, although all other forms of road transport were virtually at a standstill and the movement of ambulances was possible in many cases only with one member of the crew walking ahead carrying a flare. Some members of the operative staff" of the service walked many miles in this way and a total of 5,036 removals, consisting of 3,824 general cases and 1,212 emergency calls, were dealt with. In the days following the fog the number of requests for ambulance transport for the admission to hospital of patients suffering from respiratory conditions rose to a very high level and in order to deal with this situation it was necessary at times to restrict the service provided for non-urgent cases—mainly the conveyance of out-patients to and from hospital. A number of letters were received from the Emergency Bed Service, hospital management committees, etc., expressing appreciation of the work of the service during and on the days immediately following the fog. Calls for medical assistance Calls are frequently received in the Control Room in circumstances indicating that the summoning of medical assistance, rather than the despatch of an ambulance, is required. In such a case the caller is either recommended to call the patient's own doctor or is given the names, addresses and telephone numbers of local medical practitioners who may be summoned in emergency. During the year 780 such calls were dealt with. Inter-authority financial adjustments Following the refusal, in 1951, of some local health authorities to accept recommended increases, from 2s. to 2s. 9d. a mile for ambulances and from 6d. to 1s. 3d. a mile for sitting-case vehicles, in the rates of charge previously agreed on a national basis for application to ambulance work performed by local health authorities on behalf of other such authorities, the Council decided to adopt the recommended rates as its standard rates for inter-authority charges with effect from 1st October, 1952, or, in certain special cases, 1st April, 1952, with the proviso that any authority charging the Council at higher rates should be charged the full cost of any ambulance services provided by the Council. To obtain as wide an area of uniformity as was practicable with the discontinuation of the nationally agreed rates, it was decided further that adjustments between the Council and local health authorities in the home counties should, on a reciprocal basis, be at the rates of 2s. 6d. a mile for ambulances and 1s. a mile for sitting-case vehicles. Home service ambulance department Agency arrangements With the continued operation of the arrangements referred to in my report for 1951, whereby the home service ambulance department of the Joint Committee of the Order of St. John of Jerusalem and the British Red Cross Society took over a large proportion of the work involved in conveying patients to and from the limb-fitting centre of the Ministry of Pensions at Roehampton, the number of patients conveyed by vehicles of the home service ambulance department and the mileage run each shows an increase over the figure for 1951 from 10,111 to 13,682 patients and from 263,087 to 285,075 miles. It will be observed that the increase in mileage is small compared with the increase in the number of patients. This improvement in the ratio of patients to mileage is due in part to the continuing substitution of 'ambulance-train-ambulance' journeys for long road journeys of the type with which the home service ambulance department dealt almost entirely prior to 1951 and, for the rest, to the greater economy of the ' decentralised ' arrangements in operation at the limb-fitting centre. 86 Hospital car service Both the number of patients conveyed and the mileage run by the County of London hospital car service decreased during the year as compared with 1951 but the decline in mileage from 1,740,930 miles to 1,504,138 miles is greater, proportionately, than that in the number of patients—from 149,046 to 135,523. This again, reflects the greater proportion of ' ambulance-train-ambulance ' journeys. During the year the last of the four area offices of the hospital car service occupying rented premises was transferred to accommodation provided at one of the Council's general ambulance stations. Arrangements in North Woolwich The arrangement whereby the West Ham county borough council provides, on behalf of the Council, ambulance services in the two parts of the metropolitan borough of Woolwich which lie north of the River Thames, continued during the year. Premises During the year, following long delays due to the restrictions upon capital investment and, more recently, to the shortage of steel, work proceeded on three of the proposals contained in the Council's scheme, approved by the Minister of Health in 1948, for the development of the ambulance service, as follows: Eastern ambulance station—Adaptations to provide increased vehicle accommodation. Block A, commenced in November, 1951, was completed in June, 1952. Work on Block B, which was delayed owing to the necessity of revising the scheme to reduce the quantity of steel required, commenced in December, 1952, and was still in progress at the end of the year. South-Western ambulance station—Adaptations to increase the vehicle accommodation, to provide a new administrative block and to improve the entrance to the station. Work commenced in September, 1952, with the demolition of the former office block. This stage was completed and the extension of the garage was commenced. 'V' (City of London) accident ambulance station—Replacement of former temporary structure by a permanent building. Work commenced in December, 1952, and, by courtesy of the Board of Governors of the nearby Royal Hospital of St. Bartholomew, arrangements were made for the ambulance and crew to be temporarily accommodated within the precincts of the hospital during the rebuilding period. In addition to the above-mentioned items, major works were carried out during the year at 'A' (Fulham) accident ambulance station to provide a new petroleum store, additional lavatory accommodation and improved facilities for civil defence training. Other development proposals have been further delayed owing to the need to revise building plans to reduce the use of steel. Vehicles During the year, two large ambulances and five single-stretcher ambulances were added to the fleet and four large ambulances were modified to take either recumbent or sitting patients. To complete the revised 1952-53 vehicle replacement programme approved by the Council, ten single-stretcher ambulances remain to be delivered and 21 large ambulances to be similarly modified. In December, 1952, the Council authorised the purchase in 1953-4 of 15 taxi-cab type vehicles to assist in dealing with the mounting volume of sitting-case work. Road safety During the year, facilities were made available to a number of newspapers and periodicals in connection with articles on road safety, etc., and vehicles, equipment and off-duty staff were made available to the British Broadcasting Corporation in connection with three documentary programmes on this and other related subjects. 87 Staff Award of British Empire Medal Her Majesty the Queen was graciously pleased in Her 1952 Birthday Honours to award the British Empire Medal to Driver F. W. Summerfield for his outstanding devotion to duty during his 32 years' service in the accident and general sections of the London Ambulance Service. The citation stated that his duties had always been carried out in such a manner as to leave no doubt of his concern for the sick and injured. The Medal was presented to him by the Lord Lieutenant of the County of London at an investiture at the Countv Hall on 22nd October. Award of Meritorious Conduct Medal The Council, in 1938, resolved that a silver medal should be awarded to any officer or employee in the London Ambulance Service whose conduct in the execution of his duty should be considered to be sufficiently meritorious. In July, 1952, Driver H. C. Legon, headquarters station, supervised the removal of a workman who, whilst engaged on the demolition of the Dome of Discovery on the Festival of Britain site, had been trapped by a fallen wall 50 feet above ground where he could be reached only by way of a broken staircase and a steel girder. The action taken by Driver Legon was considered by the Council to merit the award of the medal, which was presented to him on 28th October by the Chairman of the Health Committee. Recruitment I stated in my Annual Report for the year 1951 that owing to the continued difficulty in obtaining suitable male ambulance drivers to fill vacancies, the Health Committee had authorised the recruitment, in a temporary capacity, of women ambulance drivers and by the end of that year 30 women had been so engaged, resulting in a total increase in the numbers of operative staff from 628 to 699. During 1952 the standard of candidates seeking employment showed a considerable improvement, with the result that wastage due to retirements and resignations was more than made good and the total number of operative staff employed rose by the end of the year to 692, including 45 women; 54 of those employed were temporary reliefs engaged to take the place of those absent owing to sickness or on annual leave. All new entrants to the operative staff are required to obtain a recognised qualification in first-aid to the injured, normally within six months of engagement, and receive an additional 6s. a week for holding the qualification. They are then examined orally and practically by a medical officer on the staff of the department to ensure their competence. Wage increases Members of the operative staff received increases of 1½d. an hour with effect from 28th February, 1952, and Id. an hour with effect from 27th November, 1952, which were authorised by the Council in accordance with a recommendation of the National Joint Council for Local Authorities' Services (Manual Workers) and an award of the Industrial Disputes Tribunal, respectively, thus resulting in a basic wage of a driver qualified in first-aid of 147s. a week. This wage could be enhanced by payments for shift, Sunday and stand-by duties. The Council also adopted further recommendations of the National Joint Council regarding the payment of subsistence allowances, the effects being (a) an increase from 17s. 6d. to 20s. for absence on duty necessitating absence from home for a period of 24 hours and (b) an increase from 2s. to 2s. 6d. and from 5s. to 6s. for absence from the usual place of employment of five and under nine hours, and of nine hours and over, respectively. Running repairs allowance The revised occupation groupings for motor drivers approved by the National Joint Council with effect from March, 1949, and adopted by the Council, made no provision for the extra payment for drivers qualified in running repairs, which had been payable under the former grading of motor drivers. The running repairs test was, therefore, suspended but after negotiation the allowance of 3s. a week was restored to those drivers who had passed the test prior to its suspension. In October, 1951, the test was re-instituted and the Council approved, with certain provisos, the payment of the allowance to drivers who passed the test. Uniform In September, 1952, a new scale of issue of uniform to members of the operative staff was approved whereby the period of replacement of some items of uniform was extended and a cheaper overcoat provided. It had been the practice for some years to 88 allow staff to discard their jackets in summer months provided white shirts were worn and an issue of these shirts, which were not previously provided, will be made in future for use in hot weather. At the end of the year, the staff comprised, in addition to the headquarters administrative and clerical staff: 1 Chief Superintendent 8 Superintendents 7 Assistant Superintendents 21 Station officers 692 Operative staff (drivers and attendants). Included in the above the following were engaged on civil defence training : 1 Superintendent 2 Station Officers 15 Operative staff. Civil defence During the year the first stage in the training of the operative staff of the service in their wartime duties in an expanded civil defence ambulance service was almost completed. The arrangement continued whereby the basic general training of all volunteers in the ambulance section of the Council's Division of the Civil Defence Corps was given by the metropolitan borough councils. On completion of this preliminary training further instruction is given by the Council and considerable progress was made during 1952. The main emphasis has continued to be placed on first aid, in which a very satisfactory proportion of volunteers attained pass standard in the theoretical and practical examinations at the conclusion of their courses. A comprehensive course of training for instructors in the duties of the ambulance section, which was also attended by senior members of the Council's administrative staff who would have operational responsibilities in war, was held in the early part of the year and the instructors who qualified then undertook the further training of those volunteers who were qualified in first aid. Ambulance section and first-aid training is undertaken at 7 ambulance stations throughout London and, where there is considerable demand for facilities in any particular area which is not immediately adjacent to a training station, additional premises are utilised. The number of volunteers remained inadequate, having regard to the heavy responsibilities which would face the ambulance service in London in war. A house to house canvass designed to arouse interest in, and obtain recruits for, civil defence was successful in securing some increase in numbers but it is essential to bring about a considerable expansion of trained volunteers if the service in London is to be adequate in any national emergency. I am pleased to report that in this, as in other matters relating to civil defence training, there is the closest co-operation between the officers of the Council and those of the metropolitan borough councils. Statistics The statistics for the directly provided service are divided into two sections—Accident and General. The Accident section statistics include not only street accidents and other emergencies but also the bulk of maternity removals and the conveyance of analgesia apparatus to women being confined at home. The following tables show : (i) comparative statistics for 1938 (the last full year before the war); 1947 (the last full year before the inception of the National Health Service) and subsequent years for both sections of the directly provided service and for 1948 and subsequent years for the agency and supplementary services. (ii) an analysis of the Accident section work for 1952 and a comparative analysis for 1951; 89 Work performed by the directly provided service Tear Accident Section General Section Total Patients Non-patient carrying journeys Total journeys (calls) Mileage Patients Journeys Mileage Patients Journeys Mileage 1938 54,070 4,126 56,318 293,166 217,908 171,000 (est.) 1,930,172 271,978 227,000 (est.) 2,223,338 1947 61,136 5,007 64,560 362,880 182,206 155,122 1,768,550 243,342 219,682 2,131,430 1948 59,912 7,764 66,373 367,627 239,157 192,881 2,072,545 299,069 259,254 2,440,172 1949 65,989 11,391 75,901 410,917 362,963 279,600 2,808,550 428,952 355,501 3,219,467 1950 73,853 11,523 83,791 437,416 480,048 340,876 3,041,569 553,901 424,667 3,478,985 1951 77,661 11,488 87,012 443,683 550,621 361,664 3,092,902 628,282 448,676 3,536,585 1952 78,692 10,851 87,691 442,268 660,206 410,469 3,470,442 738,898 498,160 3,912,710 Work performed by the agency and supplementary services Tear City of London Police Home Service Ambulance Hospital Car Service West Ham C.B.C. Total Patients Mileage Patients Mileage Patients Mileage Patients Mileage Patients Mileage 1948 907 2,546 5,454 204,048 30,052 430,121 37 469 36,450 637,184 1949 835 2,619 9,557 376,564 107,667 1,496,090 113 1,468 118,172 1,876,741 1950 7,966 281,223 144,669 1,787,434 246 4,373 152,881 2,073,030 1951 10,111 263,087 149,046 1,740,930 208 3,338 159,365 2,007,355 1952 — — 13,682 285,075 135,523 1,504,138 591 7,806 149,796 1,797,019 Work performed by both sections of the directly provided service and by the agency and supplementary services Tear Total Emergency Work Total General Section Work Grand Total Patients Mileage Patients Mileage Patients Mileage 1938 54,070 293,166 217,908 1,930,172 271,978 2,223,338 1947 61,136 362,880 182,206 1,768,550 243,342 2,131,430 1948 60,819 370,173 274,669 2,706,755 335,488 3,076,928 1949 66,824 413,536 480,300 4,682,672 547,124 5,096,208 1950 73,853 437,416 632,929 5,114,599 706,782 5,552,015 1951 77,661 443,683 709,986 5,100,257 787,647 5,543,940 1952 78,692 442,268 810,002 5,267,461 888,694 5,709,729 NOTES :—1. The figures are based on the Council's definition of a 'patient' which differs from that adopted by the Ministry of Health. 2. The agreements with the agency and supplementary services have been in operation only since 5th July, 1948, the * appointed day 'under the National Health Service Act, 1946, and that with the City of London Police terminated on 4th July, 1949. 3. The work carried out by the City of London Police consisted of the removal of accident cases and has been included in the table for ' Total Emergency Work '; that performed by the other agency and supplementary services is almost entirely analogous to the ' General Section ' work of the directly provided service and has been included in the table for * Total General Section Work. 90 Analysis of Accident section work (a) Number of patients of various types: 1951 1952 Street accidents 13,631 13,655 Other accidents 17,858 18,080 Assault cases 1,559 1,612 Attempted suicide 381 591 Mental 602 611 Epilepsy 1,379 1,226 Other sudden illness 17,873 17,625 Maternity 24,249 25,169 Special journeys with patients 129 123 77,661 78,692 (b) Non-patient carrying journeys: Delivery of analgesia apparatus 5,848 5,069 Special journeys without patients 234 276 Ambulance not required 5,406 5,506 11,488 10,851 The average time taken to reach street accidents in 1952 was 7.2 minutes. PREVENTION OF ILLNESS: CARE AND AFTER-CARE Tuberculosis the council's services for the purpose of preventing tuberculosis and of the care and after-care of persons suffering from tuberculosis are provided or continued to the extent directed by the Minister of Health in Circular 118/47. A subsequent development has been the scheme for the B.C.G. vaccination of susceptible contacts of known cases of tuberculosis which, with the Minister's approval, was started in September, 1950. Before the National Health Service came into operation, most of these services formed part of the Council's comprehensive scheme for the treatment of tuberculosis although some were performed by the metropolitan borough councils with grant-aid from the Council and the Ministry. The difficulties inherent in a service for the care and treatment of the tuberculous divided between local health authorities and regional hospital boards have called for close integration and liaison on matters where responsibilities meet and overlap. The progress made in London owes much to the regular meetings between the medical officer of health and the senior administrative medical officers of the Metropolitan Regional Hospital Boards. The medical officer of health also holds regular meetings with the London chest physicians. Many of the services mentioned below involve cooperation with general practitioners. Contact is also maintained with local and central representatives of the Ministry of Labour and National Service and of the National Assistance Board. Chest clinics There are 31 separate clinics in London and six of these are in 'teaching' hospitals. They vary in size from a register of 67 tuberculous at St. Bartholomew's Hospital to one of 2,745 at Lewisham Clinic. There were 35,388 patients on the registers at the end of 1952, of whom 32,008 were suffering from pulmonary tuberculosis. The medical staff, the radiographer and the physician's clerks at chest clinics are provided by the Metropolitan Regional Hospital Boards or Boards of Governors of teaching hospitals, which also maintain the premises and equipment. The Council reimburses the Metropolitan Regional Hospital Boards three-elevenths of the salaries of the chest physicians for the local health authority aspects of their work. It rents from the hospital management committees the clinic accommodation used by its own staff, which include tuberculosis 91 visitors, tuberculosis care organisers and their clerks, and handicraft instructors. Most 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 to provide a basis for measures to improve them. The care organisers are concerned with the patient's social needs other than medical and nursing. They also act as the secretaries to the local tuberculosis care committees, whose activities are co-ordinated by divisional tuberculosis care committees. T.B. visitors The tuberculosis visitor remains an important link between the diagnostic and curative work at the chest clinic and the preventive and care measures in the patient's home. She works in association with the chest physician while remaining under the local direction of the Council's divisional medical officer. She is in touch with the hospital services and voluntary home nursing organisations and, as regards after-care measures in the home, with the tuberculosis care organiser. Tuberculosis health visitors are provided by the Council to work in chest clinics at an average spread of one visitor to 400 registered tuberculous patients. The introduction of a scheme for B.C.G. vaccination has added to her clinical duties. The increasing number of epidemiological investigations carried out as a result of cases of tuberculosis at schools, nurseries and welfare homes has also to be taken into account. In order to relieve generally the pressure of nursing work at the clinic it has been necessary at certain chest clinics to employ state registered nurses. The importance of relieving tuberculous patients of domestic, social, industrial and financial anxieties cannot be over-emphasised. Most necessitous tuberculous persons receive a higher rate of financial grant from the National Assistance Board than do other necessitous persons. In 1952, clinic care organisers made first investigations in respect of 5,951 patients; 2,559 newly assisted patients received extra nourishment; 541 were provided with beds and bedding; 496 were provided with nursing requisites; 961 were provided with clothing and 606 with other commodities. At the end of the year 2,234 tuberculous patients were receiving extra nourishment from the Council or care committee resources and 673 were receiving the services of home helps. In addition to arranging for the provision of food, clothing, etc., as outlined above, the Council's 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 family concern. Home care and treatment At the end of 1952, there were 738 tuberculous persons in London awaiting admission to hospital, compared with 773 at the end of the previous year; 808 patients (compared with 658 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 treatment 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 ensure their safety and care while mothers were undergoing treatment at home or in hospital. At the end of the year 367 patients were receiving attention by the Council's home nursing service. The Council's ambulance service 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. Domestic help The Council has recruited a body of home helps willing to work in tuberculous households and they are advised by printed notice to take certain precautions whilst employed on this work. There has been a steady increase in the number of tuberculous persons receiving domestic help (536 at the end of 1951, rising to 673 at the 31st December, 1952). The use of home helps when mothers are in hospital or in bed at home enables the family to keep together and reduces work and anxiety for the patient. 92 Hostels for homeless infective ambulant tuberculous men One effect of the fragmentation of the Council's pre-1948 tuberculosis service was to leave uncertain the position as to responsibility for the care of ambulant chronic infective tuberculous persons not requiring further treatment but having no homes. When the Council was a hospital authority it made arrangements for care of these persons in suitable residential establishments in various parts of the country. The Minister of Health having ruled that responsibility for the care of these persons rested with the local health authority, the Council established in October, 1951, a hostel at 20/22 Highbury Quadrant, Islington, N.5, providing 35 beds, for tuberculous men, the criteria for admission to the hostel being homelessness, infectivity, and ability to keep up and about. The men are under the close supervision of the local chest physician and continuous medical care is provided by local general practitioners. Premises in Fulham, South-West London are being adapted to provide a second residential hostel. The need for hostel accommodation in London is estimated to be approximately 80 beds per 30,000 tuberculous adults (male and female), mostly for unemployed elderly men with advanced disease and therefore in practice only intermittently ambulant. Experience will in due course show whether this kind of provision for men in this category is an adequate substitute for special wards in a chronic hospital. There does not appear to be any demand for hostel accommodation for tuberculous women. No special nursing facilities are provided, but use is made, when needed, of the local home nursing service. These hostels are a good social service for indigent disabled tuberculous men who are thereby provided with good meals and good lodgings at a charge each is able to bear. At the beginning of 1952, 17 men were in residence at the Islington hostel, and 37 more severely disabled men were accommodated by arrangement in a private establishment, St. Catherine's Hostel, Sopwell House, St. Albans. The arrangement for the use of the accommodation at St. Catherine's Hostel was terminated on 6th September, 1952, some of the residents being transferred to the hostel at Islington and the remainder to accommodation made available temporarily at the British Legion Village, Preston Hall, near Maidstone, Kent, pending the establishment of the second hostel. During the year 61 recommendations for admission to a hostel for homeless infective tuberculous men were approved and at the end of the year 32 men were in residence at the Council's hostel and 12 at the British Legion Village. Rehabilitation Selected patients recommended by chest physicians are sent by the Council to village settlements where they undergo courses of instruction in work suitable to their capacity and temperament. The Council has in the main met little difficulty in agreeing financial terms with the settlement managements and, with the regional hospital boards, the stage at which a patient is deemed to come within the Council's after-care. Maintenance charges are the Council's responsibility when the patient is judged fit for work at the settlement for five hours a day. The Council was financially responsible for 31 patients at the end of 1948. At the end of 1952 the Council was responsible for 23 exservice men and two women at the British Legion Village, Preston Hall, near Maidstone; 16 men and one woman at Papworth Village Settlement, nr. Cambridge; 18 men at the Enham Alamein Village Centre, Andover, Hants; and two men at East Lanes. Tuberculosis Colony, Barrowmore Hall, nr. Chester, a total of 62 patients. The Council arranges for the facilities for correspondence courses provided by the British Council for Rehabilitation to be available for tuberculous patients undergoing prolonged medical treatment at home who wish to train for their future occupation but are not fit to attend technical colleges; 25 patients were accepted for training in this way in the six months ended 30th September, 1952. The problem of the disabled patient's resettlement in industry, primarily the concern of the Ministry of Labour and National Service, is marked by the difficulty of finding suitable employment and may, particularly in the case of the infectious patient, call for delicate negotiations with prospective employers. Chest physicians give valuable assistance in this connection, with the Council's care organisers and the voluntary care committees. In pursuance of the Ministry of Health Circular 7/52 (8-4-52), dealing with 93 the occupational resettlement of tuberculous persons, London chest physicians are undertaking on behalf of the medical officer of health the necessary approval and surveillance of places of employment of persons with open tuberculosis, having regard to the patient's physical capacity and the risk to the health of others. In view of limited housing facilities the managements of the village settlements now prefer to admit, for training, tuberculous persons who have prospects of returning to normal civilian life. The one London Remploy factory affords only limited facilities for the employment of 83 tuberculous workers. Considerable difficulty is, therefore, experienced in providing suitable training and employment, especially part-time, for substantially handicapped and potentially infective tuberculous persons and for this group there is a need for more sheltered workshops. The Council has for some time considered the establishment of a sheltered workshop for disabled tuberculous workers, but lack of suitable premises and the general need for economy have restricted progress. B.C.G. vaccination The Council s scheme tor the B.C.G. vaccination or tuberculin negative contacts of known cases of tuberculosis was started in September, 1950. The number of contacts vaccinated by chest physicians under the Council's approved scheme, and, by cooperation of other local health authorities concerned, by chest physicians of areas in which children are boarded-out under the Council's tuberculosis contact scheme, is as follows : 1950 1951 1952 (since Total September) Vaccinated by London chest physicians 271 2,287 3,034 5,592 Vaccinated by out-County chest physicians (as notified by them) 42 220 139 401 In addition, 73 children, the majority of whom were newly-born babies, were vaccinated in hospital during 1952, prior to boarding out. During the year, 67 children were boarded-out solely for segregation during vaccination, but it has been found that many of these could not return home after converting to Mantoux positive owing to adverse home conditions or to the mother becoming unfit to undertake the care of the child. Boarding out of child contacts Under a scheme which has been in operation for over 25 years the Council arranges for the boarding-out of children exposed to infection by tuberculosis in their own homes or whose parent or parents are receiving residential treatment for tuberculosis. The Invalid Children's Aid Association, as the Council's agents, arrange for the placing of the children with suitable foster parents, or in private nurseries or voluntary homes. All remain under surveillance by the chest physicians of the clinics covering the areas of the foster homes and regular reports are received on their progress. Since the war, overcrowding and the housing shortage, the long hospital waiting lists and the steady increase of domiciliary treatment of tuberculosis have led to heavier demands on this service. Concurrently with the greater competition for foster homes following the passing of the Children Act, it has become increasingly difficult to find and retain sufficient suitable foster homes. The need for segregation of children during B.C.G. vaccination has also led to a widening of the boarding-out arrangements. The average number of children boarded-out at any one time in 1952, under these arrangements, was 460 (including 18 children boarded-out solely for segregation during B.C.G. vaccination) compared with between 130 and 140 before 1939, 180 in 1946, 230 in 1947, 257 in 1948, 326 in 1949, 405 in 1950, and 448 in 1951. The total number of children boarded-out during the year was 991 (949 in 1951), of whom 434 were children whose stay extended from 1951. The number of children, included in these figures, who were segregated for the purpose of B.C.G. vaccination was 82 of whom 15 remained boardedout from 1951. Arrangements are made to ensure that B.C.G. is given to negative reactors. At the end of the year 464 children remained boarded out. The co-operation of medical officers of health and chest physicians outside London has been excellent in the boarding-out scheme. 94 Boarding open-air schools Residential convalescent care is provided for children with a history of incipient or recent tuberculosis, at boarding open-air schools maintained by the Council under the Education Acts and, by arrangement, in voluntary open-air schools. The co-operation of the local health authorities of the areas in which the schools are situated permits regular surveillance of these children by the local chest physician during their stay at the school. No child with known ' open ' or infectious tuberculosis is, however, admitted. The schools maintained by the Council's Education Committee in 1952 were : Burrow Hill Colony School, Frimley. George Rainey School, St. Leonards-on-Sea. Warnham Court, Horsham, Sussex (moved fromWhite Oak Hospital, Swanley, in March, 1952). Kathleen Schlesinger School, nr. Henley. Wanstead House, Cliftonville, Margate. Bowden House School, Seaford. Wainwright Residential School, Broadstairs. These schools provide 425 places for delicate children. In addition some children were accommodated in private open-air boarding schools. The total number of children with a history of primary tuberculosis accommodated in open-air boarding schools during 1952 was 80 (44 boys and 36 girls), 33 of whom (17 boys and 16 girls) were children whose stay extended from 1951. At the end of the year 29 such children (20 boys and 9 girls) were still in these schools, while 11 children (4 boys and 7 girls) were awaiting admission in January, 1953. 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. Mass miniature radiography Protection of children against tuberculosis Measures suggested in recent Ministry of Health and Home Office circulars for the protection of organised groups of children against the risk of infection by adults suffering from tuberculosis were introduced in 1952. They provide for chest X-ray examinations, on appointment and annually, of certain staff whose employment brings them into close contact with children, and for epidemiological investigations among contact staff and children at establishments where cases of tuberculosis have occurred. The following summary gives the results of investigations made during 1952 at Council schools, nurseries, etc., where a case of tuberculosis in a member of the staff or a group of cases in children had been reported. Health education in tuberculosis During 1952, a sample survey of adult public opinion on tuberculosis was undertaken throughout the administrative county. The questions asked were designed to explore and measure public knowledge of facts on the origin, symptoms, treatment and prevention of tuberculosis. 1,063 persons whose opinions represented a fair sample of the main social adult groups were successfully interviewed. The findings revealed marked ignorance on causation, prevention and infectivity of tuberculosis, valuable indications being gained of what is lacking in public knowledge of tuberculosis, so that a basis on which to plan educative measures is now available. Co-operation with the mass miniature radiography service of the metropolitan regional hospital boards allows the Council to carry out certain of its preventive measures. In conjunction with the service epidemiological investigations are made on tuberculosis contacts at schools, nurseries, welfare homes and other establishments (see page 95). The mass X-ray examination of school-leavers is now a feature of the programmes of the London units. The units also provide facilities for the periodic examination of the Council's staff working in close contact with children. Details of the movements of the mobile units are regularly circulated throughout the Council's service and this information is also given to the public on enquiry. Facilities for propaganda by poster and leaflet are also provided at the Council's establishments. The existence of three static units in London has been of special help in this regard. One of these units established in Islington attempted during 1952 a borough-wide X-ray survey of the resident and local working population. 95 Summary of investigations made into tuberculosis 'incidents' at Council establishments in 1952 Establishment Notified case Children Adults Tuberculin tested Positive result Xrayed Abnormal cases Xrayed Abnormal cases Home for aged and infirm (1) Resident — — — — 16 1 Homeless Families Units (4) Adult resident 101 40 30 4 — — Adult resident 3 2 — — — — Adult resident and 2 children 13 9 13 2 13 5 3 Adult residents 85 41 75 7 55 1 Schools (16) Teacher 314 61 140 — 23 — Teacher — — — — 24 — Teacher — — 674 2 23 — Teacher — — 559 3 19 — Teacher 369 12 369 2 12 — Teacher — — 00 00 * 1 6 — Student — — — — 45 — Teacher — — 160 — 19 — Student — 309 1 48 — Pupil — — 78 1 — — Pupil 6 1 12 1 — — Pupil — — 738 3 17 — Pupil — — 226 1 — — Gatekeeper .. — — — — 90 — Cook 460 12 67 — 27 — Kitchen helper — — 457 — 24 — Nurseries (2) Nurse 74 4 74 2 27 — Nursery asst. 23 — — — 24 — Occupation Centres (2) Attendant — — 40 2 3 — Pupil — — 40 — 4 — Totals — 1,448 182 4,149 32 519 7 g 96 Pulmonary tuberculosis mass X-ray units, 1952 Regional Hospital Board unit Metropolitan boroughs visited during 1952 Total number X-rayed during year (a) Diagnostic classification Active Inactive Males Females Total Males Females Total Rate per 1,000 Males Females Total N.W. 5A Hammersmith, Kensington 35,065 31,268 66,333 79 69 148 2.23 * * * 5B Paddington, St. Pancras, Holborn, St. Marylebone 34,619 30,002 64,621 49 59 108 1.67 168 94 262 5D Static—Islington 14,233 18,811 33,044 111 117 228 6.90 231 190 421 N.E. 6B Stoke Newington, Poplar, Hackney, Bethnal Green 4,598 6,140 10,738 6 5 11 1.02 90 97 187 6D City, Finsbury 29,794 21,114 50,908 55 53 108 2.12 1,639 563 2,202 S.E. 7A Woolwich, Camberwell, Bermondsey, Southwark 21,198 17,623 38,821 98 79 177 4.56 * * * 7D Camberwell, Lewisham, Woolwich, Deptford, Southwark 10,224 8,534 18,758 64 17 81 4.32 * * * S. W. 8C Westminster, Battersea, Wandsworth, Fulham, Chelsea 25,260 20,785 46,045 73 61 134 2.91 971 662 1,633 8D Fulham Westminster Static May-Dec., serving all S.W. London. 14,882 15,510 30,392 136 95 231 7.60 734 672 1,406 Total London Administrative County 189,873 169,787 359,660 671 555 1,226 3.41 * * * Tavistock Square Civil Service * * 32,366 * * 132 4.08 * * 427 (a) These are not all Londoners but persons attending units while operating in County area. * Figures not available. 97 I am indebted to the four metropolitan regional hospital boards and to the Ministry of Health for the figures (page 96) showing the number of persons (mostly working adults) examined during the year by their mass X-ray units operating in London and the number of cases of tuberculosis whose diagnosis was established during 1952. It will be seen that a number of the diagnoses completed during 1952 related to persons X-rayed in 1951. Likewise a number of persons X-rayed during 1952 will remain under surveillance until a firm diagnosis becomes established in 1953. Foot clinics The Council has continued to operate the 26 foot clinics established by the metropolitan borough councils before 5th July, 1948, but the demand for foot treatment continues to be unsatisfied. There is need not only for a further expansion of the service at existing foot clinics but for the establishment of new foot clinics in areas which at present are very poorly served. Liaison between clinics, general practitioners and hospital orthopaedic departments is good, although the need remains for the laying down of standards for the types of foot conditions which are suitable for treatment by a chiropodist and those which should be referred to a general practitioner or hospital. In some divisions it has been possible by grouping chiropodists into larger units so that three, four or even five work simultaneously at one session, to make it economical to provide a clerk to relieve the chiropodists of clerical work. Arrangements have been extended for dealing with special categories of patients, viz., children and the infirm aged. School children found to be suffering from verrucae pedis and other foot conditions can be referred for treatment. For infirm aged and housebound patients unable to reach a clinic in any other way, transport has been provided. In one division, diabetic patients have been treated in association with a local hospital which has a special unit for such persons. The following are particulars of sessions, attendances, etc.: Year *Clinic sessions New cases Attendances Staff (in terms of whole-time units) 1949 7,673 9,446 129,682 35 1950 9,811 10,165 153,687 44 1951 9,759 10,348 162,163 43.5 1952 10,971 10,828 169,598 43.2 * 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 1952 at the London V.D. clinics will be found in Table 20, page 189. Approximately 75 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. There was, however, a slight increase in the number suffering from 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. 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 1952. G* 98 Syphilis Gonorrhoea Male Female Male Female Number of patients discharged after completion of treatment and final test of cure 743 774 2,302 605 Number of patients who ceased to attend after completion of treatment but before final tests of cure 690 267 2,257 481 Number of patients who ceased to attend before completion of treatment 161 111 233 56 Number of patients who died from the disease while still undergoing treatment 11 3 — — Under section 28 of the National Health Service Act, 1946, the Council's male and female welfare officers have continued to undertake the tracing of contacts of patients, details of whom have been provided by hospitals, by medical services of the British, Dominion and United States Armed Forces, and by local health authorities. The welfare officers have also been available to assist clinics in case of difficulty in following up patients who have defaulted. At the request of the Prison Commissioners the part-time services of a welfare officer were made available during 1950 for attendance at clinics at Holloway Prison and for following up contacts and prisoners on discharge, and arrangements were made in 1952 for the appointment of a whole-time welfare officer to undertake this work. Despite the many difficulties encountered, good results continued to be achieved in overcoming the reluctance of prisoners to attend out-patient clinics on discharge or, where necessary, to complete treatment in hospital. The task of following-up patients and their families for the purpose of securing tests involves much visiting and enquiry and is carried out in close co-operation with Probation Officers and other social workers engaged in this field. Thirty-three 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. Recuperative holidays In 1948 demands for recuperative holidays outstripped the available accommodation. Recuperative holiday home accommodation has increased during the intervening years, and now there is sufficient accommodation for all categories of persons medically recommended for a recuperative holiday. Accommodation for mothers and babies has been particularly difficult to obtain, and in addition to using the larger type of recuperative holiday home a policy has recently been followed of using small private residences accommodating one or two mothers with their babies, where the mothers live in with the family. The Council uses accommodation (36 places) in its own recuperative holiday home for children at Roland House, Littlehampton and makes a 90 per cent. grant towards the approved maintenance expenditure of the Women's Voluntary Services' recuperative holiday home for children at Aldeburgh, in return for which it has the first claim on the beds at the home. Selected children in parties of 30 are sent to a private hotel on the Kent coast and their supervision is undertaken by a holiday organiser and two assistants. Persons are also sent to homes belonging to voluntary organisations, and to those under private ownership. Recuperative holidays are provided for expectant and nursing mothers and children under five years of age under section 22 of the National Health Service Act, 1946, and under section 28 for other adults. No charge is made to school children for recuperative holidays provided under the Education Act, 1944, but a standard charge, subject to abatement, is made to other categories of persons sent for recuperative holidays under 99 the provisions of the National Health Service Act, 1946. School children are medically examined on return from the holiday. Unaccompanied children 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, are used in providing recuperative holidays for unaccompanied children. Special arrangements were made during 1952 to send a limited number of educationally sub-normal children for recuperative holidays and additional facilities were obtained for recuperative holidays for physically handicapped children. Expectant and nursing mothers, accompanied young children and other adults The majority of adults, expectant and nursing mothers and accompanied young children are placed in recuperative holiday homes direct by the Council but the Family Welfare Association is used as a placing agent in a few especially difficult cases. The services of the St. Henry Convalescent Fund were also used in 1952 for the provision of recuperative holidays for a small number of adults and accompanied children living in the City of Westminster. The Spero Fund for the Welfare of Tuberculous Workers co-operates with the Council in the placing of tuberculous persons in recuperative holiday homes. Statistics The number of recuperative holidays since 1948 is shown in the following table, from which the marked drop in the number of holidays provided for children under five years of age in 1952 emerges significantly as a hopeful pointer to the improvement in the health of the children in this age group, and to the general reluctance of medical practitioners to send young children, especially those under two years of age, on recuperative holidays apart from their mothers. Year Unaccompanied children Expectant and nursing mothers and accompanied young children Other adults Total Under 5 years School children Mothers Children 1948 (6 months) 637 1,098 128 148 754 2,765 1949 1,517 3,121 379 671 2,779 8,467 1950 1,548 4,255 340 566 3,439 10,148 1951 1,309 3,501 219 386 3,154 8,569 1952 686 3,507 190 352 3,308 8,043 Health education As part of its proposals under section 28 of the National Health Service Act, 1946, for the prevention of illness, the Council decided to develop, as opportunity should permit, a comprehensive educational programme in physical and mental health, and for this purpose to seek the co-operation of the metropolitan borough councils and to utilise the services and material available from the Central Council tor Health Education and other appropriate bodies. During 1952 a senior medical officer of the Council reviewed the existing arrangements for health education in the county. Concurrently, two public health departmental working parties studied (i) educational activities in maternity and child welfare centres, and (ii) the prevention of accidents in the home. Comments on the three subjects follow. Health education review The review confirmed the general impression that since July, 1948, the metropolitan borough councils have tended to concentrate on propaganda for those services remaining under their control, while the County Council has concentrated on 'personal' health services. The subjects covered by the boroughs include clean food and food handling, infectious diseases, pests and flies. The devices adopted to encourage health education are: Lectures, exhibitions, public meetings, films, campaigns, posters, pamphlets and show-cases. There is a general concensus of opinion that while lectures to large audiences 100 are ineffective, talks to small groups in a more intimate manner give good results. The use of films and other visual aids is considered to be important. The subjects covered by the Council's headquarters and health divisions naturally differ from those of the boroughs. Apart from the teaching of mothercraft the main aim of divisional propaganda is protection against smallpox, diphtheria and whooping cough. Great reliance is placed on the personal services and influence of the medical officers and of the health visitors both in the homes and in the centres. As in the boroughs, experience shows that talks to small groups have greater value than talks to larger audiences. Increasing use is being made of films, film-strips and other demonstration material. The departmental collection of films and film-strips on health education is augmented as necessary by hiring from outside. Show-cases at centres serve a useful purpose and lead to questions by the mothers, but exhibits need to be changed sufficiently often to stimulate interest. Apart from material provided centrally, health visitors are encouraged to make their own demonstration material, the Council providing the necessary paints, brushes, wax, etc. Posters and pamphlets are used in all divisions and are purchased, mainly from the Central Council for Health Education. Some district nursing associations are supplied with leaflets on diphtheria and smallpox. Open days are held in some divisions, as a means of improving contacts with voluntary agencies, general practitioners and teachers. Similarly, divisional lending libraries have been started at maternity and child welfare centres and liaison established with borough libraries. The Central Council for Health Education to which this Council contributes an annual sum of £1,700, provides an advisory service on the content and methods of health education, courses on health education technique for staff, exhibition topics, and, at cost price, leaflets and posters. The National Baby Welfare Council, to which this Council contributes an annual sum of £5 5s., has a permanent exhibition on maternity and child welfare at its headquarters and also publishes leaflets and a monthly book 'Mother and Child'. The latter is purchased for circulation amongst divisional staff, and some of the leaflets are purchased for distribution at welfare centres. Leaflets are also purchased from the National Association for Maternity and Child Welfare to which the Council contributes £10 10s. a year. In the Council's schools health education takes the following forms : Primary (including nursery schools and classes) and special schools—The inculcation of cleanliness and hygiene. Secondary schools—The curriculum of all schools includes physical education. At some biology is included either as a special subject or as part of a general science course. Housecraft and mothercraft teaching is given in girls' schools. Opportunities for health teaching occur in all schools and, in addition, much incidental teaching is given. Polytechnics and technical institutes—Certain of the polytechnics arrange courses in subjects connected with health—hygiene and public health, sister tutors, health visitors, sanitary inspectors, nutrition, dietetics, first-aid, home nursing, etc. The technical institutes maintained by the Council have similar lectures in health subjects. The evening institutes provide instruction in first-aid, home nursing, infant care, hygiene, parentcraft, physical exercises, keep fit and various forms of dances. Health education in schools is properly a matter for teachers though there are times when doctors and, more especially, health visitors can help. Health education of children, not only for their own personal benefit but also because of their influence as future parents of the next generation, is so important that no effort should be spared to improve the standard in this country. The present crisis in juvenile delinquency and maladjustment is sufficient evidence of the gaps in this form of education. For many years school nursing sisters and health visitors have given courses of instruction in mothercraft to girls in secondary schools and during 1952 a small committee drew up some notes for a course of 12 lessons with a list of appropriate demonstration 101 material and visual aids. A school health council, composed of the school children assisted by the staff, was inaugurated in a South London comprehensive secondary school in the autumn. The object of the council is to enquire into the needs of the school and the community for health, physical and mental, and into how these needs are being met. There are great possibilities in this experiment and the outcome will be watched with interest. The review showed that health education in London is being developed satisfactorily along the broad lines of the proposal approved by the Minister. The possibility of improving existing methods and stimulating new ideas will be kept under constant review. The only new recommendation arising out of the review related to lectures. As already stated, talks to small groups are a valuable means of health education, but no special effort has so far been made to stimulate a demand that undoubtedly exists, because of the difficulty of providing speakers, although any requests have been met wherever possible and in particular sex education talks to youth organisations have been arranged by the employment of approved lecturers. Lectures are best given by staff engaged in the work rather than by lecturers from outside the service, but if lecturers are to be selected from the Council's staff the question of recompense for attendance at evening meetings must be considered. Normally it is not possible to give equivalent time off duty unless sessional staff are employed to take their place. The alternative is to pay fees for talks given outside official hours and the Council has agreed to do this. It is proposed to prepare syllabuses of health talks (with visual aids) suitable for various audiences and to select lecturers. Educational activities at maternity and child welfare centres Since 1948 the Council has continued to emphasise the part played by the maternity and child welfare centre in attracting mothers for advice on their own health and that of their children and for lessons on mothercraft. Centre staffs appreciate the need for planned group instruction, and excellent efforts have been made and are being made in spite of the limitations sometimes imposed by unsuitable premises and inadequate equipment. The working party (i) considered the opportunities for health education in centres and suggested methods by which such teaching could be carried out, (ii) prepared an outline syllabus of talks as a guide to health visitors, and (iii) recommended suitable demonstration material and other visual aids. The outline syllabus has since been printed, copies being distributed to divisions as a guide to health visitors and others preparing courses of lectures. The working party's general proposals were that: (a) Wherever possible each maternity and child welfare centre should have a room, apart from the general waiting-room, capable of seating 10 to 20 mothers and another room equipped with play equipment where children could be minded apart from their mothers. (b) Where possible centre premises might be made available in the evenings for use as parents' clubs, the social activities being organised by the parents themselves, with centre staff assisting on a voluntary basis, as these clubs afford an excellent opportunity for health education. (c) The main responsibility for health education should remain with the health visitors, although it is useful for specialists in particular fields (e.g., midwife, domestic science teacher, sanitary inspector) to speak or demonstrate, from time to time. Courses in instruction and in teaching methods, including the use of the epidiascope and film-strip projector, should be provided for health visitors, and appropriate journals should be circulated regularly in each division. (d) All suitable centres should prepare a scheme of health education to meet the needs of the mothers concerned. Divisional review of existing educational activities showed that many of the suggestions covered by the working party's proposals had become standard practice, although the extent varies between centres and between divisions. These include : 102 (a) Short informal talks by health visitors to mothers and at the larger and better equipped centres, weekly mothercraft classes; (b) cookery and needlework classes, conducted by an evening institute instructor; (c) divisional files of posters and pamphlets, kept up to date by central office; (d) at larger centres, displays of (e.g.,) infant layette and model garments, bathing and needlework equipment, play equipment, etc.; (e) a lending library at the centre or by arrangement with the municipal libraries; (f) parents' clubs at a few centres in some divisions; (g) voluntary workers who, among other duties, look after children while their mothers are at classes, etc. Film shows are arranged on request. Film-strip projectors have been provided for general use on the basis of one for each division, with a small reserve for issue to divisions requiring a second apparatus on certain occasions, and a small pool of epidiascopes. Information on suitable films and film-strips is already provided. Unfortunately there are few film-strips suitable and available for health education at welfare centres and divisions are being encouraged therefore to co-operate in the making of film-strips by inviting divisional staff who show special interest to attend one of the courses on this subject arranged for teachers by the education officer. Health visitors qualifying from 1950 onwards receive instruction in teaching methods, including the use of film-strip projectors and epidiascopes, as part of their basic training and arrangements are being made for selected health visitors from among those trained before 1950 to attend special courses in these subjects. Most divisions have designated an officer (usually an assistant divisional nursing officer) to deal with health education as part of her normal duties. The present staffing position does not make it possible to adopt a suggestion that a health visitor should be detailed to deal solely with educational activities. There remained a number of proposals for development or expansion which divisional medical officers wished to carry out. Some of these could be put into effect by administrative action, e.g., : (i) improvement of standard of decoration, lighting and hygiene at welfare centres, as these are considered to be important factors in health education ; (ii) extension of mothercraft classes at the larger and better equipped centres to which mothers normally attending smaller centres or at church halls can be invited ; (iii) mothers themselves to be invited to participate in health education sessions or discussion groups and to be encouraged to set up 'good neighbour' movements whereby efficient mothers can help others in practising the technique taught at the centres. Approval has been given generally to the lines of development of educational activities at maternity and child welfare centres set out above and the question of their detailed application referred to the Divisional Health Committees. Prevention of accidents in the home Much attention has been paid in recent years to the prevention of accidents in the home and a public health departmental working party which had assistance from members of other departments of the Council, from a medical officer of the Ministry of Health and from the Royal Society for the Prevention of Accidents has studied the problem. At the instance of the Ministry of Health, Dr. Leslie Banks, Professor of Human Ecology at the University of Cambridge, is initiating an inquiry into the causes of sudden death in infants which are usually classed under the heading of suffocation, and the Council has agreed that the health visitors shall supply details of home circumstances where these accidents occur. Accidents in the home are not notifiable and there is no exact information available of non-fatal accidents, but the cost of hospital treatment of accidents in the home in 1949 was estimated at between £4,000,000 and £5,000,000, of which £1,000,000 was due to in-patient treatment of burns and scalds. These figures take no account of the indirect cost to the community through absence from work, provision of sickness benefit and financial relief, or through the allocation by local health authorities of health visitors, home nurses and home helps to such cases. 103 Since 1947 a Government Interdepartmental Committee, including representatives of the Home Office and the Ministries of Health, Education and Works, has been studying the problem. The experience of the Interdepartmental Committee has confirmed that education of the individual in the home is the best way of preventing accidents. Posters, pamphlets and films play a part, but are not thought to be very effective on their own. The Home Safety Department of the Royal Society for the Prevention of Accidents have produced some very useful posters and pamphlets which are in use in the Council's maternity and child welfare centres. The housing and valuation department of the Council is very conscious of the importance of trying to eliminate accidents by means of good design. Balustrades on staircases are of various designs and are constructed in several types of materials, but very particular attention is paid in the design to eliminate footholds which might encourage children to climb on them ; attention is paid to safety as well as to appearance in the design of sun balconies, and protective rails are usually provided ; steps within flats have been totally eliminated ; much attention has been given to the construction of safe windows, which are designed so that they can be cleaned from the inside and with the bottom pane of glass fixed so that it cannot be opened ; side-hung opening windows have safety catches fitted to the casement stays to limit initial opening. Other measures which have been taken include the siting of meters and fuses, so that they can be reached without standing on chairs and yet be out of reach of small children. The working party came to the conclusion that accidents in the home are caused mainly through (a) the personal carelessness or negligence, physical frailty or infirmity of some individual, not necessarily the victim; (b) the bad design or misuse of appliances and equipment; (c) defects in the structure or maintenance of buildings, and (d) overcrowding, particularly where children and old people are concerned. Having regard to the unnecessary loss of life, the deformity and disablement not infrequently left in survivors, the distress caused to the victims and their relatives, and the heavy cost, particularly in personnel, of the ensuing medical and nursing treatment, accidents in the home should be considered a major public health problem. It may be considered that it is the responsibility of local authorities to try to make people more aware of the dangers of accidents in their home and that the best way to do this is through the education, by its own staff, of the individual in the home. As the health visitor already visits the home and is accepted as a trusted friend and adviser, it is considered that she is the most suitable person on whom to base the work, more particularly since over 75 per cent. of all deaths caused through accidents in the home are among children under five years of age and the elderly—those with whom her work is normally associated. Midwives, district nurses, home helps and sanitary inspectors could also help in educating people as they are in close contact with the homes. Other ways in which the local authority can help are in the relief of overcrowding and the provision for the elderly, the blind, etc., of homes in which the risks of fire and falls on stairs are minimised. The working party took the view that it is desirable to establish practical means of measuring the incidence of and morbidity from accidents in the home and the collection of information additional to that already available (mainly from the Registrar-General) is, therefore, necessary. They regarded the need to secure information about non-fatal accidents as particularly vital and suggested means of collecting such information. The first suggestion of the working party was that the Council could most fruitfully and quickly approach the subject of home accidents through its existing organisation covering health education. It proposed that information of fatal and non-fatal accidents in the home should be collected and analysed so as to provide indices of trends and information of those accidents against which propaganda is especially needed. This information could be obtained by analysis of accident reports in the health visitors' records, by seeking the co-operation of the district nursing associations in the reporting of home accidents, by extraction of detail of home accidents from the ambulance service reports, by the inclusion by teachers of notes of accidents on their daily return of 104 infectious diseases and by asking certain hospitals to extract information about outpatients attending for treatment as a result of accidents in the home. The inauguration of an analysis on the lines suggested would be a task of some magnitude but as a first step it is proposed to investigate the possibility of obtaining some samples so as to judge the need to consider the extension of all or any of the recommended methods. Another recommendation, for the holding of a series of one-day training courses on home accident prevention as part of the normal post-entry training carried out for the Council's nursing staff will be implemented and it is intended to offer places to the borough medical officers of health for their staff. One person in each division will be responsible to the divisional medical officer for continuous effort in the prevention of home accidents. Consideration is being given to the inclusion of talks on the prevention of home accidents in the syllabuses of classes in mothercraft, domestic science and education in citizenship. The working party felt that additional exhibition and demonstration material, including working models showing the causes of home accidents, should be provided. In point of fact three working models showing three common causes of accidents in the home (falling down stairs, non-provision of a fireguard and pulling cloth off table) have been acquired from the Royal Society for the Prevention of Accidents. These have been shown in some of the welfare centres and also at the recent mothercraft exhibition in the Central Hall, Westminster. The working party felt that an annual intensive campaign should be held to supplement the everyday effort and consideration is being given to this. The need to continue to bear in mind the importance of home safety in the designing, erection and management of houses and flats was emphasised by the working party and the subject is being discussed with the chief officers concerned, bearing in mind the Heating Appliances (Fireguards) Act, 1952. The co-operation of voluntary associations should be sought in publicising these problems and this will be done at divisional level. MENTAL HEALTH SERVICES the council's Health Committee, which is charged by the Council with the control of the mental health services, has a Mental Health Sub-Committee which deals with all matters relating to mental health, except those concerned with policy and staff. Staff The equivalent of approximately three full-time medical officers are employed on mental deficiency work. All the medical officers engaged on this work, who include a principal medical officer and a senior assistant medical officer, are specially experienced in mental deficiency and all also carry out other medical duties in the Council's general and school health services. Five women inspectors (including one senior inspector) are employed on the work of ascertainment and guardianship of mentally deficient persons. The inspectors either possess a social science certificate or have had considerable experience in dealing with mentally deficient persons over a period of many years. Twenty-eight women social workers (including the psychiatric social worker already mentioned), almost all of whom possess a social science certificate or diploma, are employed on the 105 work of supervising mental defectives living in the community and are allocated between four district offices as follows: District Address Area covered. The metropolitan boroughs of *Total number of staff authorised A 37-38 Strand, W.C.2 Finsbury, Hampstead, Holborn, Islington, Paddington, St. Marylebone, St. Pancras, Westminster 6 B 2 Whitechurch Lane, E.l Bethnal Green, City, Hackney, Poplar, Shoreditch, Stepney, Stoke Newington 7 C 250 King's Road, S.W.3 Battersea, Chelsea, Fulham, Hammersmith, Kensington, Wandsworth 7 D 12 Baldwin Crescent, S.E.5 Bermondsey, Camberwell, Deptford, Greenwich, Lambeth, Lewisham, Southwark, Woolwich 8 * Each office is under the direction of a local organiser included in the total staff mentioned. Consideration is being given to the need for the employment of an additional unit of staff to cope with increased numbers of cases. The basis of staffing the Council's occupation centres for mentally deficient children and adults is one supervisor for each centre plus one assistant supervisor for each 15, or substantial part of 15, pupils on roll, except the first 15. At present, 17 supervisors and 30 assistant supervisors are employed, of whom six possess the qualification of the National Association for Mental Health for staffs of occupation centres. Women attendants are employed as required, provided that at no centre is the ratio of the total number of staff (i.e., supervisors and attendants) to pupils of 1 to 10 exceeded. Two boot-repairing and two woodwork instructors are employed at the four elder boys' centres. Each instructor undertakes duty at two centres. An organiser of occupation centres is employed to exercise general supervisory control over all the centres. This position is at present held in an acting capacity by one of the supervisors. A consultant psychiatrist is employed for two sessions a week as medical adviser in mental health on matters other than those relating to mental deficiency and child guidance. One psychiatric social worker, who is also employed on the work of supervising mental defectives living in the community, undertakes part-time the visitation of patients boarded out in Mental After Care Association homes and other miscellaneous duties in connection with the psychiatric care and after care service. A senior mental welfare officer, 17 mental welfare officers and five assistants are authorised to take initial proceedings in providing care and treatment for persons suffering from mental illness. All the officers are men. Training of staff Almost all staff employed by the Council in connection with its mental health services possess appropriate qualifications. All new staff are carefully instructed and initiated into their duties by experienced officers. Refresher courses have been arranged periodically for occupation centre staff Visits to mental deficiency institutions and other establishments are also arranged for staff Co-ordination Close co-operation is maintained by means of correspondence, telephone and meetings, where necessary, with the staff of the four metropolitan regional hospital boards, hospital management committees and boards of governors of teaching hospitals. It has not been found necessary or practicable to consider the joint use of officers. Patients on trial from mental hospitals are not supervised by officers of the Council. It is understood that this work is undertaken by psychiatric social workers employed by the hospitals. Patients on licence in London from mental deficiency institutions (throughout England 106 and Wales) are supervised by the Council's social workers from the four district offices on request from the physician superintendents concerned. Medical reports are also provided when necessary to avoid the return of defectives to institutions at the time of statutory consideration and reconsideration of orders and when discharge is under consideration. Of the six mental deficiency institutions which have catchment areas wholly or partly in London, two (St. Lawrence's and the Fountain Hospitals) now undertake the supervision of their own patients on licence by their own social workers who, in the case of the Fountain Hospital, also report on home conditions as required in connection with the statutory consideration and reconsideration of orders and the consideration of the grant of leave of absence or discharge. This latter duty is undertaken by the Council's social workers in respect of relatives of defectives living in London for all institutions other than the Fountain Hospital. Voluntary associations The Guardianship Society, Brighton, assists the Council to find suitable guardians for patients under the Mental Deficiency Acts and carries out supervisory duties in respect of those patients so placed on payment of agreed charges. In addition, the Council makes use of voluntary associations in carrying out services provided under section 28 of the National Health Service Act, 1946 (see page 39). Domiciliary After Care Service Prevention of mental illness and care and after-care Following the receipt of circular 146/48 from the Ministry of Health, arrangements were made for the National Association for Mental Health and the Mental After Care Association to provide between them, on behalf of the Council, on payment of 90 per cent. of the cost of the service to each Association, care and after care for persons suffering from psychiatric illness. The service, which was a continuation and extension of the after care scheme for ex-service personnel which had been operated by the National Association since 1943 at the request of the Board of Control and the Ministry of Health, is largely carried out by means of domiciliary visits. The service provides help and guidance in problems of adjustment to social and home life and in finding employment, etc., for those persons suffering from psychiatric illness who do not need, or no longer need, in-patient or out-patient treatment. It was made clear to the two Associations that the arrangements for them to carry out the work on the Council's behalf were of an interim nature only. A recent review of the cases dealt with by the associations revealed that about one-third of the cases referred, or seeking help themselves, are dealt with comparatively quickly and with little difficulty by being referred to psychiatric out-patient clinics or to their own doctors or by other similar means. Onethird require help of a varied nature which usually involves co-operation with Government departments, such as the Ministry of Labour, Ministry of Pensions, etc. The remaining one-third are long-term cases requiring supervision and domiciliary visits over a prolonged period. Since the inception of the scheme up to 31st December, 1952, 1,129 cases have been dealt with, 705 by the National Association for Mental Health and 424 by the Mental After Care Association. At 31st December, 1952, there were 231 active cases on the registers. Careful consideration has recently been given to this service and it has been decided that to enable the work to be carried out under the immediate supervision and direction of the Council's medical adviser in mental health, the work shall be done by the Council's staff and the arrangements with the two associations terminated on 31st March, 1953. The thanks of the Council have been conveyed to both associations for the satisfactory manner in which they have carried out this important and useful service. It is proposed to employ two psychiatric social workers and additional clerical help as necessarv on this work. Social clubs and rehabilitation centre A grant is made to the Institute of Social Psychiatry of 90 per cent. of the cost incurred for London patients attending the rehabilitation centre and five psychotherapeutic social clubs run by the Institute. The centre is open each morning and afternoon on five days 107 a week and provides training and occupation under the direction of an occupational therapist for mentally sick patients with a view to their rehabilitation to normal life. The clubs meet on one evening a week and are attended by persons living in the community who need a measure of mental support and assistance to enable them to carry on their normal lives. The Council is represented on the board of governors of the Institute. Long term care The Council has undertaken responsibility for the cost of maintenance of a number of mentally sick persons in homes owned or sponsored by the Mental After Care Association and in one home managed by the National Association for Mental Health. There are at present 71 patients boarded-out under this scheme and they are nearly all chronic or senile patients who have neither homes nor relatives able to care for them and do not require hospital or nursing care. It is considered that the maintenance of this type of patient in these special homes provides a very valuable service as the patients need a greater degree of supervision than can be given in ordinary welfare homes or hostels. The patients are visited regularly by the social workers of the Mental After Care Association and also by one of the Council's psychiatric social workers. The weekly charge made by the Mental After Care Association was increased from 54s. 10d. to ₤33s. a head for those patients maintained in homes sponsored, but not owned, by the Association and to ₤313s. 6d. a head for those maintained in homes owned and managed directly by the Association. Patients are assessed according to their means and some contribute towards the cost of maintenance. Those who have no means receive 6s. 6d. a week pocket money from the National Assistance Board. In suitable cases, voluntary patients on their departure from hospital and certified patients on discharge are maintained for periods up to a maximum of three months in Mental After Care Association homes to enable them to adjust themselves to community life and to find employment. Recuperative holidays Recuperative holidays are provided in Mental After Care Association and other selected holiday homes on medical recommendation for persons suffering from mild psychiatric disability, including those attending psychiatric out-patient clinics, who primarily need rest, fresh air and good food and who present no special behaviour difficulties. A contribution towards the cost of each holiday is recovered according to the means of the person for whom the service is provided ; 158 recuperative holidays were provided in 1952. This figure, which includes cases of certified and voluntary patients discharged from mental hospitals maintained temporarily in Mental After Care Association homes, shows a considerable increase compared with 1951, when 93 holidays were provided. There is no doubt that holidays arranged in the early stages of mental illness, in conjunction with suitable out-patient treatment, if necessary, often avoid the necessity for admission to hospital. The cost of maintenance rose considerably during the year and the average weekly cost per head was approximately £3 18s. compared with just over £3 in 1951. The average length of each holiday was three weeks. Removal of persons of unsound mind Work under the Lunacy and Mental Treatment Acts The Council's proposals under section 51 of the National Health Service Act, 1946, provided that the work performed by duly authorised officers of securing that persons of unsound mind are placed under care and control and subsequently of obtaining reception orders for their detention if necessary, should be carried out from the four district offices from which mentally defective persons are supervised. Owing to problems caused by the shortage of beds in observation wards and office accommodation difficulties, however, it was not possible to arrange this and, with the approval of the Minister, the work was centralised at the County Hall as a temporary measure. The question of decentralisation has been reconsidered from time to time but the shortage of observation ward accommodation has persisted and this and the further factor that decentralisation would involve considerable additional expenditure and manpower have resulted in a continuation of the centralised arrangements. The question has been reviewed annually. It was the intention that the duly authorised officers (mental welfare officers) should 108 follow the practice previously taken by relieving officers in London of taking action under section 20 of the Lunacy Act, 1890, in all cases of persons alleged to be of unsound mind needing to be placed under control by removing them to an observation ward in the first instance before taking steps to secure certification. Owing to the shortage of beds in observation wards this has not been possible in a considerable number of instances since July, 1948, and, as will be seen from the statistics submitted with this report, during the year 1952, it was necessary for 1,130 patients to be brought directly before a Justice of the Peace for examination with a view to certification without being admitted to an observation ward and for 39 patients to be admitted directly to mental hospitals under urgency orders made under section 11 of the Lunacy Act, 1890. As the following table shows, the number of persons in respect of whom the duly authorised officers have been required to take action has increased steadily since the appointed day : Year Number of cases dealt with Male Female Total 1947 2,049 2,603 4,652 1948* 1,047 1,485 2,532 1949 2,333 3,017 5,350 1950 2,399 3,163 5,562 1951 2,488 3,303 5,791 1952 2,570 3,533 6,103 * 5th July to 31st December only. These figures are now considerably higher than pre-war. Notwithstanding this increase the number of beds available in observation wards in London is now 217 compared with 353 in 1938, making it necessary, as shown in the following table, to deal with an increasing number of patients otherwise than by admission to an observation ward. Observation ward accommodation Because of its concern at this situation and at the shortage of institutional accommodation for mental defectives, referred to later (page 110), the Council, in December, 1951, sent a deputation to the Minister of Health to urge the pressing need for more accommodation to be provided for London cases in observation wards and in mental deficiency institutions, particularly in the latter case for infants and young children. The accommodation position in observation wards remains unaltered but some minor reliefs have been afforded as regards mental defectives (see page 110). The shortage of accommodation in observation wards is aggravated by the inadequacy of the accommodation in Tooting Bec and Abbots Langley Hospitals for senile patients and there is little doubt that if additional methods of dealing with this type of patient were available, the problem of accommodation in observation wards would be very much reduced. The Council's medical adviser in mental health has recently reviewed the records of a large number of patients over 65 years of age dealt with by the mental welfare officers and he is of the opinion that the provision of an adequate number of psychiatric geriatric units with in-patient and out-patient facilities would avoid the certification and admission to mental hospitals of all old people, except those who are grossly disturbed and obviously require immediate psychiatric care. Conveyance Patients are conveyed to observation wards and, in cases of direct admission, to mental hospitals whenever possible by private car but ambulances are used when necessary. Patients transferred from observation wards to mental hospitals are conveyed by ambulance and are escorted by nurses from the observation wards as was the practice prior to the ' appointed day'. 109 The following table shows the number of persons dealt with by the Council's mental Statistics welfare officers during 1952 and the action taken : 1952 1951 Male Female Total Admitted for observation to hospitals designated under section 20 of the Lunacy Act, 1890 2,142 2,792 4,934 4,880 Dealt with in their own homes, etc., under sections 14 and 16 of the Lunacy Act, 1890 407 723 l,130† 890* Admitted direct to mental hospitals under section 11 of the Lunacy Act, 1890 21 18 39 21 No action under the Lunacy Acts found necessary 702 1,058 1,760 1,602 Total 3,272 4,591 7,863 7,393 *Of these 144 male and 323 female patients were certified and removed to mental hospitals. † Of these 263 male and 410 female patients were certified and removed to mental hospitals. The following table shows the ultimate disposal of the patients admitted to observation wards (including 167 patients in wards on 1st January, 1952): 1952 1951 Male Female Total Certified and sent to mental hospitals 761 1,045 1,806 1,762 Admitted as voluntary patients to mental hospitals 482 699 1,181 1,009 Admitted as temporary patients to mental hospitals 11 32 43 28 Discharged to care of relatives (Section 22) 7 31 38 43 No order made by Justice and patient discharged 29 18 47 118 Transferred to general wards 65 61 126 148 Transferred to Tooting Bec Hospital without certification.. 114 160 274 277 Transferred to Abbots Langley Hospital without certification 4 8 12 27 Transferred to Mental After Care Association homes 1 1 2 3 Died 77 72 149 208 Discharged by Medical Officer 572 661 1,233 1,238 Dealt with privately 5 7 12 13 Dealt with under Mental Deficiency Acts 3 8 11 10 In ward on 31.12.52 75 92 167 167 Total 2,206 2,895 5,101 5,051 Ascertainment and supervision Work under the Mental Deficiency Acts All the arrangements for the ascertainment and supervision of defectives and the presentation of petitions continue to be carried out as envisaged in the Council's scheme under section 51 of the National Health Service Act. These arrangements are working satisfactorily. The medical work involved in ascertainment is carried out by medical officers on the Council's central staff and the necessary social enquiries are made by women inspectors also on the central staff. The medical examination of defectives or alleged defectives is normally carried out at the County Hall but where necessary, e.g. the defective is severely physically handicapped, a visit is paid to the home. The Council has continued to carry out the supervision of defectives in their own homes by social workers employed in the four district offices. During 1952 a total of 17,498 visits were paid to persons under statutory supervision or on licence from hospitals. In addition, 802 visits were paid to persons under voluntary supervision. It has not yet been possible on economic grounds to institute an arrangement for the systematic medical re-examination of defectives under supervision at regular intervals. 1,867 visits were paid on behalf of hospital management committees and local health authorities to ascertain the home circumstances of patients in connection with the statutory reconsideration of orders and the consideration of applications for leave of absence or discharge. 110 Petitions Petitions for orders for institutional care or guardianship under section 6 of the Mental Deficiency Act, 1913, are normally presented once a week by an authorised office ron the central administrative staff to a Judicial Authority who attends at the County Hall by special arrangement. As a matter of convenience, children and other persons placed by their parents under section 3 of the Act are also dealt with at these sessions. The necessary medical certificates are provided by the Council's approved medical officers following examinations immediately prior to the proceedings. The senior inspector or one of the local organisers from the district offices joins the petitioning officer in making the statutory declaration. Attendance at Magistrates' Courts The arrangement has been continued whereby one of the Council's medical officers attends at Courts, on request, after examination of alleged defectives in prison or on bail, to give evidence on the mental condition of defectives charged with criminal offences to enable the Courts to consider dealing with them under section 8 of the Mental Deficiency Act, 1913. Institutional accommodation The reduction in the amount of institutional accommodation for mental defectives available for London by about 25 per cent. as a result of the re-allocation of accommodation by the four Metropolitan Regional Hospital Boards in 1948 has given rise to serious concern and difficulty, although within the limits of the resources available the utmost co-operation has been received from all four Boards and the Hospital Management Committees in attempting to solve a problem which is nation-wide but which prior to 1948 caused little anxiety in London. This co-operation enabled the Council, during the year, to secure the admission to hospital of no fewer than 369 mentally deficient persons. This figure is not only higher than in 1951 when 303 were admitted but exceeds the number of London patients admitted to institutional care during any year since 5th July, 1948, and is somewhat greater than the annual number admitted for some years prior to that date. Nevertheless, more patients were awaiting institutional care at the end of the year than at 31st December, 1951. There were then 154 patients awaiting institutional care, while there were 169 on the waiting list at 31st December, 1952. There were thus 81 more cases requiring institutional care during the year than in 1951. Of the 154 persons for whom beds were needed at the end of 1951, no fewer than 117 were infants and young children awaiting admission to the Fountain Hospital. At the end of 1952, however, only 89 were awaiting admission to that hospital. The reduction in the waiting list for this hospital is all the more satisfactory because during the year the Hospital Management Committee provided greatly increased facilities for the admission of patients for short term care. Temporary care Although not specifically authorised to do so, the Fountain Hospital had, during 1951, admitted children for short periods to provide a measure of relief to hard pressed parents. The position with regard to this short term care was regularised by the issue of Ministry of Health Circular 5/52 on 21st January, 1952, which authorised local health authorities to find temporary accommodation and pay for the maintenance therein of mentally defective persons to enable emergencies, such as the illness of a parent, to be overcome and permitted Hospital Management Committees to admit such persons temporarily without legal formality when their condition made them unsuitable for accommodation in homes found by local authorities or they needed hospital treatment which could not be given in a general hospital. The circular limits the provision of such care generally to periods not exceeding two months. The Council decided to exercise the authority given by the circular and during the year has provided temporary care for 12 persons for an average period of 4 weeks 2 days each. Accommodation was found for adolescent and adult patients with nominees of the Guardianship Society, Brighton, and for infants and young children at Lynsted, the 1ll home run by the National Association for Mental Health at Walmer, and Orchard Dene, Rainhill, Liverpool, a home managed by the same association on behalf of the National Association of Parents of Backward Children. The Council recovers a contribution towards the cost of maintenance in such cases according to the means of the patient's family. In view of the power conferred on local health authorities by the circular the arrangement for the admission of children to Lynsted at the expense of the South East Metropolitan Regional Hospital Board was discontinued by the Board. 38 London patients were admitted to hospitals under the provisions of the circular for a variety of reasons during the year for an average period of approximately one month each. The demand which has developed since the issue of the circular has indicated that the provision of these facilities fills a real want and reports show that the families of patients have benefited considerably as a result of the temporary relief afforded to them. Farm training Although no boys leaving special schools for the educationally sub-normal had been placed under the Y.M.C.A.'s British Boys for British Farms scheme, which enables suitable boys to be given farm training and placed in employment, since July, 1951, when it was agreed with the Association that such boys would be accepted, it was decided, when the matter was reviewed after twelve months, that the arrangement should be continued. Subsequently one boy was provided with training under the scheme and was found employment on a farm. Guardianship Guardianship is not now provided for defectives solely to enable financial assistance to be given and a number who were placed under guardianship for this reason now receive National Assistance grants and have been discharged. Generally speaking, patients are placed under guardianship when they have no homes or their homes are unsuitable and institutional care is unnecessary. A number of patients are placed in foster homes, small homes, hostels and convents in and around London under the guardianship of the matron or superintendent. The Guardianship Society, Brighton, also finds suitable foster homes for defectives, some of whom are self-supporting. During 1952, 24 patients were placed under guardianship. Of these 17 were school leavers who, it was felt, would justify a trial in the community as they were likely with careful supervision and guidance, to be able to support themselves. They were placed under the guardianship of the Council's inspectors who became responsible for placing them in foster homes of approved standard and finding suitable employment or, alternatively, finding resident employment within the scope of their abilities. For guardianship of this type of patient to be successful, it is essential that the patients themselves should be mentally capable of work, that they should be relatively stable and of normal social behaviour. It has been decided to provide a hostel in or near London for girls leaving special educationally sub-normal schools at the age of 16 years who have no homes (or unsuitable homes) and do not need care and training in an institution. An endeavour is being made to acquire suitable premises for a hostel to accommodate not more than 12 girls who will be placed under the guardianship under the Mental Deficiency Acts of officers of the Council. The hostel will be in the nature of an experiment and the possibility of setting up a similar hostel for boys will be considered in the light of the experience gained. At 31st December, 1952,222 patients remained under guardianship. Of these 45 were under the personal guardianship of the Council's inspectors, 68 under the guardianship of nominees of The Guardianship Society, Brighton, 91 under the guardianship of relatives and friends, and 18 under the guardianship of superintendents of voluntary homes. H 112 Maintenance costs which have continued to increase during the year are paid in accordance with the rates shown in the following table: To The Guardianship Society, Brighton Foster parents of patients placed under the guardianship of inspectors of the public health department Relatives or friends and superintendents of small homes, hostels, etc. Maximum allowances 53s. 1d. a head a week made up as follows: maintenance 40s., clothing 6s., pocket money 6s. 6d., medical fee 7d. In addition, a fee of £8 3s. a year is paid for supervision. 56s. a head a week made up as follows: maintenance 42s., clothing 6s. 6d., pocket money 7s. 6d. An initial outfit of clothing is provided in accordance with needs. 35s. a head a week. In addition clothing may be supplied in appropriate cases. In special cases the Council authorises allowances in excess of these maxima. An allowance of 10s. a head, for Christmas extras, was made, in certain cases, to patients under the guardianship of the Council's inspectors. As in previous years, holidays have been provided for patients under guardianship for whom it has been considered necessary on medical grounds. Patients under guardianship in London (including 14 for whom other local health authorities were responsible) continued to be visited 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, Brighton, each London patient in the care of a nominee of the Society 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. Welfare centre Some parents are reluctant to take their mentally deficient children to ordinary maternity and child welfare clinics, especially when, as is frequently the case, the children are not of normal appearance. Moreover, at these clinics, the doctor is not always able to discuss fully the needs of mentally deficient children and the mothers feel that their special requirements are not being met. Arrangements were, therefore, made for a special clinic for backward children to be set up at the Mary Hughes welfare centre, Underwood Street, E.l, in January, 1953, as an experiment. Sessions will be held once a month to begin with and will be conducted by a medical officer experienced in mental deficiency and in child welfare. If the centre proves successful, the possibility of setting up similar centres in other parts of London will be considered in due course. Students During the year facilities were given for 14 students taking university courses of training in social science to spend periods up to eight weeks in the district offices of the supervision section to enable them to gain practical experience in social work. Nine students (6 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. Statistics The following table shows the sources from which cases have been brought to notice under the Mental Deficiency Acts and the action taken thereon : Totals from Sources of information 1949 1950 1951 1952 1.4.14 to 31.12.52 Supervision section 8 12 8 14 1,575 Local education authority 357 439 453 570 15,553 Police authority (section 8) 28 39 31 32 1,973 Transfers from prison (section 9) 1 1 — — 229 Transfers from approved school (section 9) 5 2 2 — 565 From hospitals and institutions 111 89 103 124 514 Miscellaneous 168 157 187 222 10,522 Total 678 739 784 962 30,931 113 The position at 31st December, 1952, with regard to the cases referred to in the last column of the preceding table is shown in the following table, together with the position on the same date in the three preceding years: 1949 1950 1951 1952 Detained in institutions 7,720* 7,767* 7,809* 7,862* Discharged from institutional care 2,584 2,738 2,902 3,075 Removed to mental hospitals 509 522 543 555 Not subject for action 9,098 9,403 9,668 9,922 Died 4,251 4,380 4,523 4,678 Total removed from active list 24,162 24,810 25,445 26,092 Under guardianship 246 229 221 222 In places of safety awaiting the presentation of a petition 11 5 8 11 Under supervision 3,964† 4,092† 4,222† 4,556† In hospitals, residential nurseries, etc. awaiting the presentation of a petition 54 45 52 41 Still under consideration 9 4 21 9 Total remaining on active list 4,284‡ 4,375‡ 4,524‡ 4,839‡ Grand Total 28,446 29,185 29,969 30,931 *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: 1949 1950 1951 1952 338 366 352 259 † In addition to the cases under supervision, persons known to the local authority to be mentally defective but not subject to be dealt with, are visited on a voluntary basis, as follows: 1949 1950 1951 1952 970 968 1,020 1,040 ‡ Of these the following were awaiting institutional care. 1949 1950 1951 1952 135 139 154 169 The following is a summary of the cases dealt with during 1952, with the comparable figures for the three preceding years: 1949 1950 1951 1952 Placed in institutions 293 330 303 369 Placed under guardianship 12 9 10 24 Placed in places of safety pending the presentation of a petition 23 37 56 70 Placed under supervision 453 591 618 787 Discharged from institutional care or guardianship 212 192 182 203 Removed to mental hospital under the Lunacy Acts 22 19 27 21 Ascertained not subject for action 51 58 68 69 Withdrawn from supervision 238 258 217 201 Removed to other areas 40 44 49 65 Died 111 128 140 165 Total 1,455 1,666 1,670 1,974 H* 114 Occupation centres There are now 17 occupation centres provided for mentally deficient persons in London as follows: Centre Accommodation Centre Accommodation Centres for children Centres for elder girls Branstone Street School, N. Kensington, W.10 (also takes elder girls) 75 Fellowship Hall, 182, Hammersmith Road, W.6 30 Cecil Rooms, Woolwich Road, S.E.10 45 Christ Church Hall, Mowll Street, S.W.9 40 Old Gravel Pit Hall, Vallette Street, E.9 40 Claremont Central Mission, White Lion Street, N.l 60 St. Chrysostom's Hall, Goldsmith Road, S.E.15 45 Earlsfield Congregational Hall, Earlsfield Road, S.W.18 60 Centres for elder boys Lewisham Methodist Church Hall, Albion Way, S.E.13 30 All Saints' Hall, Blenheim Grove, S.E.15 55 London Mission Methodist Hall, Shepherd's Bush Road, W.6 40 Dalston Congregational Hall, Bay Street, E.8 45 Orchard Mission, Mission Place, Peckham High Street, S.E.15 40 19, Compton Terrace, Islington, N.l 30 Oxford House, Mape Street, E.2 30 St. Michael's Hall, Darley Road, S.W.ll 30 St. Michael and All Angels' Hall, Northwold Road, E.5 60 With one exception the centres have been established in hired premises (mainly church halls) which are the best obtainable but in many cases are not entirely suitable. At Branstone Street the premises, originally provided and used as a school, serve the needs of a centre very satisfactorily. The Minister of Health has approved proposals to adapt a large house, No. 9 Spencer Park, Wandsworth Common, and a prefabricated former restaurant building in Fulham High Street for use as permanent occupation centres and arrangements are proceeding for the adaptation of the premises as soon as the necessary starting dates are given. Plans are also being made for the opening of new centres and the transfer of existing centres to more suitable premises. The centres are open from 10 a.m. to 4 p.m. daily from Monday to Friday during primary school terms. Accommodation is now provided for a total of 755 children and adults. Fares of pupils attending the centres are paid by the Council under the same conditions as apply to children attending special schools for the educationally sub-normal, viz., if they are over 12 years of age and have to travel two miles, or 1½ miles if under that age, or for shorter journeys if one of the Council's medical officers certifies that conveyance is necessary on medical grounds. It has been possible to arrange for the conveyance of children attending the Branstone Street centre by two vehicles released from the ambulance service and operated by the education transport service. Three private hire coaches are used to convey children attending the Oxford House Centre and the St. Michael and All Angels' Hall Centre. Children and older persons attending the other centres are, if necessary, escorted by guides employed by the Council. Mid-day meals are provided at all centres at a small charge, which is waived in cases of hardship. Cod liver oil and malt (or halibut liver oil) is provided for children under the age of 16 years at a small charge or free where recommended by one of the Council's medical officers. Regular medical inspection is arranged. The provision of home teachers has been considered from time to time but in view of the number of occupation centres available, the fact that transport is now provided at three centres and that it is hoped to extend these facilities to other centres, no arrangements have been made to provide home teaching which would be an expensive service. The matter is, however, kept under constant review and when conditions permit, it is hoped that it will be possible to provide home teaching for those who are unable to attend at an occupation centre. Inspections Visits by Inspectors of the Board of Control were paid to all centres during the year and their reports were generally satisfactory. Members of the Health (Mental Health Sub-) Committee also visited centres in their areas. 115 Open days and sales of work Parents and friends were invited to displays of work and sales of articles made at the centres. Sales realised £3917s. 5d. at junior centres, £453 8s. 4d. (including £144 l1s. 6d. for shoe repairs) at elder boys' centres and £119 15s. 6d. 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 coach to nearby parks or open spaces during the summer months, approximately once a fortnight, when the weather was suitable. During May a party of 178 children and adults attending the centres, accompanied by staff, again spent two weeks at a holiday camp at Dymchurch, Kent. The Council bore the expenses of the staff and wholly or partly those of 47 necessitous children and adults. Apart from three cases of infectious disease which developed during the period, the holiday proved to be as successful as last year's and again drew the praise of the Director of the camp for the organisation and conduct of the party. Gifts Some centres were provided with outings to a circus or a pantomime by parents' associations and these associations presented a cinematograph projector to one centre and a folding wooden slide to another. Christmas parties Christmas parties and entertainments were arranged for all centres and parents and friends were generous with gifts of extra food, sweets, etc., and some donations towards the cost of entertain merit were rereiverl SCHOOL HEALTH SERVICE Organisation During 1952 the school health service continued to carry out its prescribed role in the examination and inspection of school children, the detection and arrangements for the treatment of defects, the control of communicable disease in schools, and the examination and recommendation for ascertainment of handicapped pupils. The 'following-up' of children found at medical inspections to be in need of treatment is the responsibility of the voluntary care committees. This work is regarded by care committees as one of their most interesting responsibilities, and often results in constructive family case work, including preventive measures. The care committees' main channel of information is through the children's care organisers who work in the public health department. There are now 2,330 voluntary workers, and the number is steadily rising. This arrangement, unique to London, is a good example of service given to the community by means of a partnership between official and voluntary workers. Pupils on school rolls At the end of 1952 there was a total of 425,362 pupils on the day school roll—302,998 children of primary and secondary school age were in attendance at County schools and 101,303 at voluntary or assisted schools; 14,436 children under five years of age in nursery schools and classes or in primary schools and 6,625 children in day special schools. 116 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 1949 1950 1951 1952 No. % No. % No. % No. % Nursery 10,021 6.2 11,294 6.5 12,320 7.1 9,063 4.9 Entrants 40,287 24.8 41,598 24.1 45,324 26.1 58,039 31.1 7 year old 29,541 18.2 32,607 18.9 34,597 19.9 32,902 17.6 11 year old 31,725 19.6 33,037 19.2 31,415 18.1 28,558 15.3 Leavers 26,382 16.3 27,464 15.9 27,272 15.7 26,908 14.4 Other ages 22,115 13.6 23,742 13.8 19,952 11.5 28,300 15.2 Special schools 1,633 1.0 2,143 1.3 2,215 1.3 2,319 1.2 Training colleges 465 0.3 543 0.3 533 0.3 482 0.3 Total 162,169 100.0 172,428 100.0 173,628 100.0 186,571 100.0 Other inspections Special inspections* 110,026 — 119,901 — 122,302 — 139,908 — Re-inspections 87,915 — 106,350 — 112,667 — 121,751 — Residential schools 9,845 — 10,441 — 9,961 — 8,077 — Total 207,786 — 236,692 — 244,930 — 269,736 — Grand Total 369,955 — 409,120 — 418,558 — 456,307 — *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, 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 1952 reached the highest total since the war. Children seen at routine inspections formed 43.9 per cent. of the total of 425,362 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 1949 1950 1951 1952 Nursery Boys 16.5 15.1 16.4 13.0 Girls 14.5 13.0 14.4 11.3 Entrants Boys 18.7 17.8 17.4 15.6 Girls 17.2 16.5 15.3 14.1 7 years old Boys 21.6 20.4 19.8 18.9 Girls 20.6 19.7 18.6 18.4 11 years old Boys 18.8 17.5 16.5 16.1 Girls 20.4 18.8 18.2 18.0 Leavers Boys 14.4 13.6 12.2 12.2 Girls 18.9 16.0 16.6 16.9 Other ages Boys 18.0 17.1 16.1 16.2 Girls 23.6 21.5 21.7 20.6 Total Boys and Girls* 18.9 17.6 17.0 16.2 *Exclusive of special schools and training colleges. 117 Referral rates in 1952 were generally lower in all age groups except leavers and markedly so among nursery children and entrants. 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 previous years: 1949 1950 1951 1952 *Numbers examined 160,071 169,742 170,880 183,770 Percentages Skin diseases 1.22 0.97 1.13 1.14 External eye diseases 0.58 0.57 0.71 0.72 Defective hearing 0.41 0.44 0.51 0.58 Otitis media 0.75 0.69 0.87 0.94 Enlarged tonsils and adenoids 8.91 8.98 8.44 8.26 Defective speech 0.62 0.60 0.63 0.72 Enlarged cervical glands 1.33 1.38 1.67 1.71 Heart and circulation 0.68 0.69 0.80 0.78 Lung disease (not T.B.) 1.44 1.62 1.95 1.83 Orthopædic defects 4.66 4.84 4.52 4.83 Defects of nervous system 0.34 0.33 0.31 0.41 Psychological defects 0.75 0.70 0.72 0.81 Anæmia 0.31 0.36 0.33 0.34 *Excluding special schools and training colleges. Increased incidence in nursery, entrant and seven year old girls was mainly responsible for higher rates for otitis media. Higher rates for defective hearing were found in entrants and 11 year olds. For speech defects, rates were higher in nursery and eleven year old groups of both sexes, and in girl entrants. An increase in orthopaedic defects was noted in all age groups except nursery children and entrant girls. Eleven year old boys and entrants account for the rise in nervous defects, and for psychological defects higher rates were found in nursery and 11 year old groups, and in entrant and seven year old boys. Cleanliness Improvement in personal hygiene is shown by the percentage of verminous children found at nurses' rota visits: Total No. of inspections Rota visits No. found to be verminous Percentage found to be verminous 1949 1950 1951 1952 Boys 442,336 4,919 1.9 1.7 1.4 1.1 Girls 466,431 17,424 61 5.0 4.1 3.7 Infants 530,617 9,562 3.4 2.7 2.2 1.8 Total 1,439,384 31,905 3.8 3.2 2.6 2.2 During the year the number of individual 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 17,051 (18,503 in 1951, 22,159 in 1950, and 22,063 in 1949). The total of advice cards issued during the year was 20,259 compared with 25,177 in 1951. Children who attended the cleansing centre after the issue of advice cards numbered 14,531 (16,938 in 1951); the number of statutory notices served was 2,788 (3,848); 1,007 (1,084) of the children concerned attended voluntarily, and 1.667 (2.089) were cleansed compulsorily. Vaccination The upward trend in the proportion of pupils vaccinated against smallpox noted in the post-war years although interrupted in 1951 was resumed in 1952. Vaccinated pupils formed 57.6 per cent. of those inspected in 1952, 55.8 per cent. in 1951, 56.5 per cent. in 1950, and 54.9 per cent. in 1949. The percentages of children inspected found to have a visual acuity standard of Vision 6/6 (Snellen) are contained in the following table: 118 Visual acuity 6/6 (with glasses, if worn) 1949 % 1950 % 1951 % 1952 % 7 year old Boys 78.2 78.3 77.8 75.7 Girls 76.5 76.3 76.7 73.4 11 year old Boys 80.1 80.9 80.3 80.3 Girls 76.9 77.9 77.0 77.3 Leavers Boys 79.7 80.1 80.7 80.5 Girls 76.0 76.5 76.1 76.6 Other ages Boys 77.4 78.8 79.8 80.4 Girls 73.4 75.2 75.0 76.8 A further table shows the percentage of children referred for treatment of defective vision: Total 1949 % 1950 % 1951 % already wearing spectacles 1952 Percentage not wearing spectacles total 7 year old Boys 6.8 7.2 7.0 0.7 6.4 7.1 Girls 7.5 7.5 7.5 0.7 6.8 7.5 11 year old Boys 9.3 8.4 8.6 2.0 6.2 8.2 Girls 10.4 10.0 10.0 2.5 7.0 9.5 Leavers Boys 9.3 9.2 8.6 2.7 5.5 8.2 Girls 12.4 10.8 11.3 4.0 7.2 11.2 Other ages Boys 9.3 8.5 7.3 2.1 6.3 8.4 Girls 12.0 10.8 11.2 3.0 7.7 10.7 As can be seen a proportion of those referred for treatment of defective vision were already wearing spectacles. This proportion rose from one-tenth at age seven 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 1952, 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 1.1 per cent. compared with 1.0 per cent. in 1951,0.9 per cent. in 1950 and 1.1 per cent. in 1949. Co-operation of parents and care committee The attendance of over 90 per cent. 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 which include the grammar and technical schools where the committees do not function. Choice of employment Children advised against particular forms of employment formed 15.0 per cent. of both sexes examined. Forms of employment involving eye strain, those requiring normal vision and 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. Details are given in Table 16 (page 182). Re-inspections Each child referred for treatment is re-inspected by the school doctor a few months after medical inspection and further re-inspections are made, if necessary, to ensure that, as far as possible, every child gets adequate treatment. During the year, 121,751 such re-inspections were carried out. 119 General condition Since 1947, in accordance with Ministry of Education requirements, medical officers conducting routine medical inspections classify the 'general condition' of the pupils on a 3-point scale, 'Good', 'Fair' or 'Poor'. This classification replaced a 4-point scale for recording the doctor's assessment of 'nutrition' as 'excellent', 'normal', 'subnormal' or 'bad' All these terms are subjective, and it is to be expected that it will be a matter of years before the statistics of assessments on the new scale settle down sufficiently to enable significant conclusions to be drawn from year to year comparisons: Excellent Normal Sub-normal and bad 1946 18.0 76.4 5.6 Good Fair Poor 1947 42.0 54.3 3.7 1948 40.8 56.0 3.2 1949 41.8 55.1 3.1 1950 46.3 50.9 2.8 1951 47.6 49.8 2.6 1952 50.5 47.1 2.4 However, within any one year, comparisons between groups of pupils may be accepted as valid, and the following figures for the different age groups in 1952 are of interest: Good Fair Poor Nursery 54.2 43.8 2.0 Entrants 47.6 49.4 3.0 7 year old 46.3 50.7 3.0 11 year old 49.4 48.2 2.4 Leavers 59.0 39.9 1.1 The percentages of children referred for treatment or observation on account of nutrition were: Referred for 1949 1950 1951 1952 Treatment 1.0 1.0 0.9 0.9 Observation 0.7 0.7 0.8 0.8 1.7 1.7 1.7 1.7 Although the proportion of 'poor' children appears to have diminished gradually, no corresponding reduction is found in the percentage of children noted for nutritional defects. Pupils receiving school meals, milk, halibut liver oil or cod liver oil and malt on the recommendation of the doctor, head teacher or care committee are re-inspected by the doctor each term. During 1952 the total number of 'nutrition re-inspections' carried out was 57,851. The classification of general condition at these inspections was: Good Fair Poor 1951 10.5 65.5 24.0 1952 10.7 68.0 21.3 School meals and milk A return to the Ministry of Education for a typical day in October, 1952, showed that 212,743 children, 55.3 per cent. of the number in attendance, were provided with school dinners. Of these 18,837 received free dinners. On the same day 340,578 day school pupils, 88.5 per cent. of the number in attendance, were provided with milk. Between October, 1951, and October, 1952, the number of centres at which school children dined rose from 878 to 911; the number of kitchens of all kinds in October, 1952, producing school meals being 596 (including 563 school and central kitchens). The 120 school meals service aims at concentrating the maximum food value into the quantity of food a child is willing to eat. It has set the following standard: Age group No. of calories (i) Under 7 years Minimum of 500 (ii) 7-11 years „ „ 650 (iii) Over 11 years „ „ 800 Meals for children in Groups (ii) and (iii) are 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 33). Weighing and measuring of school children At the beginning of the year the Council decided that in future school pupils should be weighed and measured at the time of the four routine medical inspections held during their school life. This terminated the practice of six monthly weighing and measuring which was introduced in 1935, primarily as part of the measures then taken by the Council for the supervision of the nutritional condition of school children, and the selection of those in need of special investigation at nutrition centres, or of milk, cod liver oil or meals in school. With the many published articles on the subject now available, a brief retrospect of the Council's experience in this field may be of interest. The original concept was that Livi's index (100 ∛W ̅̅/H) was to provide the 'yardstick' by means of which an individual pupil could be 'screened' for special investigation. Later on the results of the 1938 biometric survey (L.C.C. publication No. 3464) were used as the standard. By this time the classic paper of Huws Jones (Jour. R. Stat. Soc. 101.1-34) had clearly demonstrated the defects inherent in attempting to use physical indices as clinical screens. Whatever the limitations of using biometric standards for assessing individuals, the potential value of such standards for comparing groups was evident, and the Council accordingly carried out surveys, and comparative standards were computed in 1942, 1943, 1946, 1947, 1949 and 1950. (See Medical Officer 27.5.44; 5.6.48; and L.C.C. publication No. 3692. The 1950 results have not been published.) The problem now was one of the interpretation of the real physiological meaning behind such results as 'over some 30 years there has been an average increase of 5.6 cm. in the height and 3.4 kg. in the weight of boys' (1938 report) and 'between 1938 and 1949 the average height of London school children increased by about 2 cm. and the average weight increased by 0.8 kg.' (1949 report). Authorities differ radically in their interpretations of results such as these. For example, Morant (Proc. Roy. Soc. B. 137.443) thinks that the final adult stature is unchanged, while on the other hand, Weir (B.M.J. 10.5.52, p. 1006) thinks that there has been a real secular increase in height. Since growth is a complex involving many factors—general health, nutrition, race, environment, social status, climate, season, etc.—it would appear that caution is needed in the interpretation of the results of large scale surveys of heterogeneous groups. It is interesting to recall that this is virtually what the late Dr. F. C. Shrubsall—one of the pioneers of the London school health service—told the Board of Education Consultative Committee in his ' Notes on the Growth of School Children' as long ago as 1922. Medical treatment Although the duty of the Council as local education authority, under the Education Act, 1944, to secure the provision of free medical treatment of school pupils was not statutorily modified by the National Health Service Act, 1946, administrative decisions by the Ministries of Health and Education indicate the principles upon which the responsibilities for the treatment of school pupils should be shared between the Council and the various elements of the national health service. 121 The freedom of choice of the individual parent necessarily remains. For example, a school pupil's spectacles may be provided through a school treatment centre, through a teaching hospital or by an optician; the cost falling, respectively, upon a hospital management committee, a board of governors, or an executive council. Similarly, if the parent wishes, a school pupil may obtain dental treatment at a school health service dental surgery, a teaching or other hospital or from a general dental service or a private practitioner. Certain anomalies in the charges which the parent may in certain circumstances be called upon to pay, arise from the regulations in the various statutory instruments which govern the parallel, but differing, health services. In certain cases, e.g. repair of spectacles in lack of care cases, the Council can and does make a payment to other health services to prevent a charge falling on the parents; while in others, e.g. provision of orthodontic appliances, prescriptions for medicines, etc. the Council cannot take this action. The co-ordination of these services, to provide a scheme for the treatment of school pupils which is both comprehensive and efficient, and at the same time economical of both exchequer and local rate expenditure, is a matter for continuous liaison and co-operation between the Council and the various bodies administering the national health service. By no means has finality yet been reached in this matter. Specialist clinics The responsibility for the provision of specialists at rheumatism, ear, nose and throat, vision and orthoptic clinics held in school treatment centres has been accepted by three of the metropolitan regional hospital boards; negotiations are continuing with the fourth. In addition, facilities for such specialist treatment are available at many hospital clinics. The Council remains wholly responsible for the minor ailment, audiology, special investigation, nutrition and dental clinics. School treatment centres At the end of the year there were 103 school treatment centres, 76 run directly by the Council and 27 by voluntary committees. Negotiations continued with the voluntary committees for formalising their arrangements with the Council in new agreements, the old ones having lapsed. The following table shows the number of clinics available in school treatment centres for the treatment of each defect: Type of clinic L.C.C. Voluntary Committee Total Minor Ailments 60 24 84 †Dental 42 17 59 *Vision 28 14 42 *Orthoptic 6 2 8 *Ear, Nose and Throat 9 3 12 Audiology 6 3 9 Speech Therapy 20 6 26 *Enuresis — 1 1 Special Investigation 11 3 14 Nutrition 23 7 30 *Rheumatism (Supervisory) 12 2 14 *Specialists provided in most cases by regional hospital boards. † Several of these are 'twin' surgeries. Treatment of school pupils at hospitals Before July, 1948, the Council had made special arrangements with a number of hospitals for the treatment of school children, and it is gratifying to be able to report that the hospitals have been willing to allow them not only to continue, but also to develop. The co-operation between the school health service and the hospitals takes several forms, most of which depend upon the important part played by the medicosocial workers of the childrens' care organisation in the school health service. At 23 hospitals, special sessions are provided for the treatment of school pupils, and organisers make the appointments and attend the sessions. At ten other hospitals the organiser undertakes the making of appointments, although she is not present at the sessions. In addition, at 16 hospitals one or more of the Council's organisers attends to act as the link between the children's out-patient department, the specialist clinics, the school health 122 service and the children's care organisation. The wide scope of this type of work is well exemplified by the report of the work of the organisers attached to Guy's Hospital, of which the following is a summary: Department New cases Attendances Children's 344 1,249 Ear, Nose and Throat 454 750 Vision 224 1,610 Orthoptic 98 810 Orthopædic 134 294 Skin 204 474 The total attendances of school pupils in departments of this hospital covered by the organisers was 6,645. The following table summarises the numbers of clinics for school pupils held in hospitals in association with the Council's treatment scheme: Children's Medical 9 Enuresis 6 Minor Ailments 1 Rheumatism 10 Dental 1 Nutrition 1 Eyes 13 Skin 1 Ear, Nose and Throat 19 Orthopaedic 1 Children were also referred to 23 child guidance units at hospitals and clinics within the national health service, but organisers do not attend these clinics. Treatment statistics The Ministry of Education annual returns call for information on all treatment known to have been provided, whether by the Council or otherwise. From what has been said above it will be clear that all treatment statistics are essentially incomplete. No figures are available from general medical or dental practitioners or from opticians. No figures are available from the many hospitals that have no direct link with the Council's organisers. Even at some of the co-operating hospitals, the medical records and documentation adopted by the hospital, for the purposes of their own returns to the Ministry of Health, do not enable separate figures for the L.C.C. school pupils to be extracted. Great caution should therefore be exercised before attempting to draw any conclusions about the incidence of defects or the extent to which treatment has been obtained, from the figures that follow. An additional point in this connection is that the function of certain clinics has developed and changed, and the compilation of statistics lags behind these changes. For example, 'special investigations' were not separable from 'enuresis' until halfway through the year. Type of clinic 1949 1950 1951 1952 *Vision New Cases 32,292 32,462 34,231 35,649 Attendances 79,777 85,364 86,758 91,693 *Orthoptic New Cases — 942 1,435 1,401 Attendances — 12,745 15,385 15,784 *Ear, Nose and Throat New Cases 5,749 6,974 7,289 7,769 Attendances 14,815 15,138 16,565 17,408 Audiology New Cases — — — 1,206 Attendances — — — 2,407 Minor Ailments New Cases 171,731 163,658 155,080 151,903 Attendances 1,002,051 1,014,155 1,005,549 954,532 Dental New Cases 102,495 82,650 82,564 93,823 Attendances 203,523 166,874 172,063 202,571 *Rheumatism New Cases 1,375 1,224 1,100 971 Attendances 10,887 10,088 9,202 7,988 Nutrition New Cases 1,222 1,350 1,380 1,151 Attendances 9,420 10,067 10,984 11,162 Special Investigation New Cases — — — 590 Attendances — — — 3,027 *Enuresis New Cases 830 911 1,267 952 Attendances 3,977 5,110 6,344 5,449 *Hospital and specialist services provided by boards of governors or regional hospital boards. 123 Vision During 1952 the hospital eye service assumed complete responsibility for the testing of sight and provision of spectacles for school pupils attending school treatment centres, and the interim and agency arrangements with the supplementary ophthalmic services terminated. The attendance at each session of an optician for the convenience of parents was continued, but it was made quite clear, both on the prescription form and by notice, that the parents could take the form to any optician of their choice. The Council continues to be responsible for the cost of replacement or repair to school pupils' spectacles which are deemed to be due to lack of care. Special investigation clinics Reference was made in last year s report to the development of consultative and 'reference' clinics, and it was pointed out that too much attention should not be paid to the name of the clinic, since both 'nutrition' and 'enuresis' clinics have been used in this connection. The name of 'special investigation' has now been adopted for these clinics, and at the end of the year 14 were functioning. Enuresis Special enuresis clinics were held at six hospitals, although some children were seen at the special investigation clinics. The following summary of the report from the Westminster Hospital (All Saints Urological Centre) exemplifies the work being done at these clinics: Three sessions a week are available for school pupils. The number of new cases seen was 445—a reduction on the previous year. This was because it was felt that the number of new cases accepted in 1951 made the sessions too heavy for real personal work to be done, thus defeating the object of these clinics. Boys formed 62 per cent. of the current cases. An analysis of the cases over a period of two years gave the following results: Percentage improved Males Females Attended twice only 21% 33% Still attending 34% 37% Attended a course of treatment 49% 54% Minor ailments During the year further reductions in the hours of opening were made, thus releasing nurses for other work. This is a matter which is under continuous review by the divisional medical officers, and the part-time opening of these centres at certain 'peak' hours effects a useful economy without lessening the value of the service. About a million attendances are made at these centres each year, and the value of this service in relieving hospital out-patient departments and general practitioners from treating such a large number of miscellaneous minor defects, while reducing the loss of schooling to a minimum, is obvious. Audiology centres By the end of 1952 plans for the future development of these nine centres were formulated. At present they are used for the investigation of suspected deafness not obviously due to conditions requiring treatment, and advice is given on the need for special educational treatment and hearing aids. It is proposed that a certificated teacher of the deaf should join the existing team of otologist, medico-social worker and nurse, and that the centres should be used for the pre-school training in speech and understanding of very young deaf children from the age of nine months or so, and for advice and help for the parents. The centres would also be used for teaching hp-reading to children becoming deaf after recovery from meningitis, and for supervising those children who have been transferred to ordinary schools from partially-deaf schools. Audiometer testing During the year routine group gramophone testing continued throughout the nine health divisions of the county. Children failing two consecutive group gramophone tests are tested individually with a pure tone audiometer and referred, if necessary, to the otologist at the audiology centre. Ideally the deaf child should have been detected before the age of five years, but some are not. The next best thing would be to carry out group tests on all school entrants, at about five years of age. At this age, however, the child is still too young to achieve the degree of co-operation required by the gramophone test. The 124 Council's endeavour therefore, is to test each year all junior school children at about eight years of age. During 1952 52,865 school pupils were tested, 1,252 of whom failed their pure tone test, and were referred to audiology centres. It is likely that the gramophone test will be succeeded in a few years' time by some other form of testing that can be effectively used at a younger age. Bathing centres The cleansing of verminous school pupils (see page 117) is carried out at eight bathing centres run directly by the Council and, by arrangement with the metropolitan borough councils concerned, at 21 borough cleansing stations. Scabies, impetigo and ringworm Children treated for scabies totalled 657, compared with 777 in 1951. The number of verminous children treated at bathing centres fell by 3,137 to 15,850, while treatments needed decreased by 1,812 to 27,017. Cases of impetigo treated at minor ailment and bathing centres numbered 2,063, compared with 2,224 in 1951. The incidence of scalp ringworm (29 cases) was lower than in the previous year (40). Sanitary accommodation in day schools The Standards for School Premises Regulations, 1951, lay down scales of provisions for cloakrooms, wash basins, changing rooms, showers, water closets and urinal stalls. Of the 1,358 schools for which the Council is responsible, many were built over 60 years ago, and at many old schools these modern sanitary standards are not attained. For example a number of schools are still equipped with trough closets. Although these are outmoded they are not inherently insanitary given regular flushing and during the year steps were taken to ensure that the necessary rates of automatic flushing continued to be available and used. Medical officers when visiting schools do not confine themselves to seeing the children but interest themselves in general hygiene arrangements and the condition of the sanitary accommodation in so far as these may affect the health of the pupils and staff. Residential schools In accordance with the Memorandum by the Home Office on the Conduct of Children's Homes the public health department takes responsibility for the health of the children in residential schools and other establishments under the direction of the Children's Committee (see also page 72). There were seven residential schools with accommodation for 2,800 children, four approved schools with a total accommodation of 482, two remand homes with accommodation for 142 children, and a number of other smaller establishments—reception centres, small homes, family homes and aftercare hostels. At the larger establishments a visiting medical officer, appointed by the Council, attended for routine medical examinations, and also took the children on to his national health service ' list.' Periodic visits were made by senior medical and nursing officers from County Hall. Arrangements were made for the dental treatment of the children, and visits were made by the Council's psychiatrists (see also page 126). The problem of enuresis in residential establishments had been the subject of a survey by Dr. H. G. Williams, one of the Council's psychiatrists in the previous year, and in 1952, a pamphlet was issued containing his notes on the problem of enuresis for the guidance of housemothers, and other staff concerned with the residential care of children. Infectious diseases in schools When a pupil is absent from school, and the cause is either known or suspected to be due to infectious disease, the headteacher immediately notifies the divisional medical officer, as well as the borough medical officer of health. Table 13, page 181, gives the number of such cases reported during 1952. As these figures are uncorrected for diagnosis they differ from the notifications shown in Tables 14 and 15, pages 183-4, which are discussed on pages 16 to 23. 125 Nevertheless the figures reported from schools do indicate the trend of infectious disease in the child community, and are the only available figures for diseases which are not notifiable to the borough medical officer of health. For example, during 1952, an epidemic of german measles was starting when the schools reopened after the Christmas holidays. The peak was reached towards the end of March, when over 2,000 cases a week were reported. The outbreak tailed off very gradually and over 100 cases a week were still being reported during July. Diphtheria outbreak at St. Michael's School, N.W.i At the end of October and during the first half of November four cases of diphtheria were notified as having occurred among the pupils attending this school. Swabs had been taken and these showed the presence of C. diphtheriae though apparently only one case showed actual clinical signs of the disease—slight membrane formation. One of the cases was rediagnosed as tonsillitis and discharged home from hospital. On 18th November a medical officer visited the school and took swabs from the nose and throat of 26 selected pupils and four staff. As a result one carrier was discovered; he had recently been absent with a ' cold ' and showed ' unhealthy mucous membrane of the nose.' It was decided that all other pupils attending the school and also the staff should be swabbed. This work occupied seven sessions and in all 185 swabs were taken from the children and 17 from the staff. It was found that seven pupils were carriers of C. diphtheriae (intermedins type) six of them being virulent. These carriers were at once excluded from school and sent to their own doctors for treatment, and some of them were sent to hospital by their doctors. While it was not possible to say exactly how this rather indefinite epidemic began, it is possible that it may have had some connection with the fact that one of the school carriers lived in the same house as a young woman who had come from Cyprus about two months previously, and who was removed to hospital at the beginning of December, suffering from diphtheria. As a result of all these activities there was an increase in the number of children immunised against diphtheria at this school, and the percentage of these rose from about 74 to 84. There were no further cases reported after the beginning of January, 1953, and all the carriers were permitted to return to school. Rheumatism scheme The number of admissions to the acute unit at Queen Mary's Hospital for Children, Carshalton, seem to have become more stabilised during the past few years, and the drop that has been noticeable since 1948 is now less marked; in fact in comparison with 1951 there was a slight rise in 1952: 1949 1950 1951 1952 Nominations received 344 270 185 219 Outstanding from previous year 4 5 4 4 348 275 189 223 Admitted to rheumatism unit 331 250 177 216 Nominations withdrawn 5 11 4 2 Not suitable for unit 7 10 4 1 Awaiting on 31st December 5 4 4 4 348 275 189 223 As would be expected with a smaller number of cases, the percentage of severe cases remains high since the less severe cases can be dealt with elsewhere : Percentage of children with cardiac involvement admitted to the special rheumatism unit 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 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 43.7 126 The number of children suffering from chorea of such severity as to need institutional treatment still seems to fall, but it is noted that the percentage of those with cardiac and valvular damage has risen somewhat, and that this is more noticeable amongst the girls than amongst the boys (see Table 18, page 188). The schools for physically handicapped children still prove a valuable haven of refuge for cardiac cripples and enable them to return to a more satisfactory attitude of mind with regard to their disability. The modified activities and rest periods which are available for them, help to tide over that period between invalidism and competitive life which would otherwise engender strain to their cardiovascular system and cause possible relapse. Table 19, page 188, gives details of the condition on discharge from hospital. The role of the streptococcus as a factor in causing cases to relapse has always to be kept in the forefront of the picture, and physicians in charge of rheumatism supervisory centres are careful in checking upper respiratory infection and sore throats at the earliest possible stage; while it has now become routine to deal with dental extractions in cardiac cases under a penicillin umbrella. The following table gives details of the rheumatism supervisory scheme: 1950 1951 1952 Number of children under supervision of school doctors on 31st December 306 186 177 Number of children under supervision at rheumatism supervisory centres on 31st December 2,790 2,696 2,218 Number of supervisory centres 24 24 23 Number of sessions at supervisory centres 930 905 877 Number of children attending for first time 1,224 1,100 971 Total number of attendances at centres 10,088 9,202 7,988 Child guidance units Child psychiatry In London most child guidance clinics have always been provided by or in association with the teaching hospitals and by voluntary associations taken over by the metropolitan regional hospital boards. There are now 23 such clinics which, however, draw their patients from a wide area in the south of England and which tend to be concentrated in central London, so that there are parts of the County which are not so well served. The Council opened its fourth child guidance unit in October in a well designed suite in the new comprehensive health centre at Woodberry Down. The consultant psychiatrist and medical director is employed by the regional hospital board and the rest of the staff, educational psychologist, psychiatric social worker and clerk, by the Council. All the units have more cases than they can treat and a child has to wait for between two weeks (Earls Court) and three months (Woodberry Down) before being seen, but more serious is the much longer period of up to six months before therapy can be commenced for those children found to require it. The Earls Court unit continued throughout the year without any staff changes. At Battersea the psychiatrist resigned in June and a new appointment was made; the educational psychologist's sessions were increased from four to six weekly and the psychiatric social worker gave all her time (instead of only eight sessions a week) to the work of the unit. At Brixton one of the psychiatrists and one of the psychiatric social workers resigned during the year and the other psychiatric social worker transferred to other work in the school health service; two new social workers and one educational psychologist were appointed. The medical director continued to be responsible for the training of a number of child psychiatrists from the Institute of Psychiatry and, in addition to the therapeutic work in the clinic, was able to develop educative work among teachers, health visitors, and other adult groups in the area. The senior Registrar at the unit attends two of the local infant welfare centres each week and it is noteworthy that more than 10 per cent. of the new cases referred were under the age of five. 127 Though only opened in October it was apparent by the end of the year that the demand in the area of the Woodberry Down unit was going to be larger than had been expected and that more sessions from the psychiatrist and from a psycho-therapist will be required if the needs of the local community are to be met. The two clinics at Harrow Road and at John Street which are run in association with the local infant welfare centres continued (see page 52). Maladjusted children There are 15 day classes for maladjusted children in addition to any remedial teaching in child guidance clinics. As an experiment some maladjusted educationally sub-normal children attend these classes. There are five boarding schools for 147 maladjusted children. In addition, 362 children were at the end of the year in 93 schools and homes run by other local authorities or by voluntary bodies. The experiment of attaching a psychiatric social worker to Bredinghurst School was so successful that it was agreed to attach part-time workers to each of the other four schools to enable skilled case work to be continued with the families against the time of the child's return. Though the families present even greater problems than most of those coming to child guidance units (otherwise the child would not have been recommended for admission to a boarding school), yet these social workers do enable many of the children to return home more quickly than would otherwise have been possible. Psychiatrists visit each of these schools frequently, with the exception of Buckshaw House, where the Dorset County Council has arranged for their consultant psychiatrist to visit regularly. The valuable work of a lay psychotherapist at Bredinghurst School has continued and has been increased to eight sessions per week. Other types of residential establishments Two additional part-time psychiatrists were appointed in September to visit regularly the residential establishments where such visits were thought desirable. The object of this is not to undertake the treatment of individual children presenting emotional or behaviour problems, which is properly the duty of the hospital authority, but to advise the members of the staff on psychological aspects of the problems of child care and to see individual children to decide whether psychological treatment is needed and to arrange for it to be obtained. It is perhaps by this kind of training that preventive psychiatry will exert its greatest effect. At Ardale Approved School a psychiatrist from a local hospital visits each week. Reception home A whole-time psychiatric social worker is employed at the Council's reception home and a psychiatrist visits weekly to help in deciding on the most suitable placing for each child. Remand homes The Maudsley Hospital has assumed responsibility for the psychiatric examinations in the two remand homes of children appearing before juvenile courts. Some difficulty has been experienced in obtaining reports on children who have for one reason or another been placed in remand homes outside London. A part-time psychiatric social worker has been appointed to Cumberlow Lodge, the home for girls, in addition to the wholetime psychiatric social worker at the home for boys. She also visits Wood Vale where are placed a number of children who have not committed offences, but who are to be brought before the court as being in need of care or protection. The part-time psychiatrist here is employed bv the South-East Metropolitan Regional Hospital Board. Summary The plan of child psychiatry and its development for London schools is now becoming clearer. The local authority and the hospital authority can work together in providing treatment facilities, for early treatment and prevention are inseparable. The training of ' lay ' staff in the care of children, particularly in residential ' homes ' is properly preventive medicine and true health education and the continual demand for therapy must not be allowed to obscure the need for prevention. The need for cooperation in the detection and prevention of psychological problems between the health and educational services is axiomatic and it is interesting to see how each year greater interest is taken in the problems of the younger child. In the spring a series of lectures and discussions, with psychiatrists, psychologists and psychiatric social workers were J 128 held for medical officers; they dealt with the detection of psychological problems in children at as early a stage as possible. In this sphere, as in others, it is not possible to draw any distinction between work for the pre-school child and that for schoolchildren. Child guidance unit statistics Brixton Battersea Earls Court Woodberry Down (opened Oct., 1952) Total No. of applications received 239 89 95 25 448 No. awaiting first interview at 31st December 9 29 19 11 68 No. interviewed and awaiting treatment Nil 13 10 5 28 Number of patients In treatment at 1st January 41 26 57 — 124 New cases treated 199 68 97 9 373 240 94 154 9 497 In treatment at 31st December 144 26 63 9 242 Discharged 96 68 91 — 255 No. of follow-ups – 5 25 – 30 No. of home visits by psychiatric social worker 61 32 19 12 124 No. of school visits by staff 52 49 102 1 204 Disposal of patients* Treatment completed 32 35 42 — 109 Transferred to other treatment 17 10 3 — 30 Further attendance impossible 12 6 10 — 28 Unco-operative 37 17 23 — 77 Placed or placement recommended — — 3 — 3 Not stated — 2 10 — 12 Total 98 70 91 — 259 Closing status of completed treatments Recovered 11 12 14 — 37 Improved 19 17 20 — 56 No change 2 6 8 — 16 Worse — — — — — Total 32 35 42 — 109 * The disposal classifications are not mutually exclusive and a patient may appear under more than one of these headings. Speech therapy During the latter part of 1952, speech therapy clinics were opened in 16 day schools and two boarding schools for the physically handicapped and at one boarding school for the educationally sub-normal. The opening of the clinics in the schools for the physically handicapped was a new venture which revealed a considerable demand for speech therapy at these schools. The number of clinics for children attending ordinary schools rose to 28 and it was found possible to make increases in the number of sessions provided at some of the 22 clinics for children at day schools for the educationally sub-normal. At the end of the year 1,059 children were still under treatment at the Council's clinics. New admissions during the year totalled 778 and 250 children were discharged cured or improved ; 101, most of whom were improved, ceased to attend for various reasons. Further visits were paid to the homes of children who required speech therapy but who were too severely handicapped to attend school. 129 The staff employed on this work was increased in 1952 and at the end of the year comprised, under the supervision of a senior assistant medical officer, one senior speech therapist, eight whole-time and four part-time speech therapists and two employed on a sessional basis. Remedial exercise classes Special classes to correct foot defects, before they develop into permanent disabilities, were introduced in 1948. They 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 a course given by the Council's consultant on postural defects Dr. Doris Baker, and the senior inspectors of physical education of the Education Officer's department. A refresher course was held in December, 1952. The general medical supervision of the classes is undertaken by one assistant medical officer in each division who is also responsible for selecting the children and for their discharge on improvement. Dr. Baker visits each class at least once during each year. Difficulties are experienced in holding the classes owing to shortages of staff and accommodation. Because of these difficulties the number of classes dropped from 74 to 65 during the year. Handicapped children 7,238 examinations were made during the year to determine whether special educational treatment should be provided or whether it should be discontinued. The number of examinations in each category was as follows: Vision 263 Delicate 2,274 Hearing 255 Physically handicapped 627 Epilepsy 67 Dual defects 56 Educational subnormality 2,758 Speech defects 938 In addition to these examinations, 414 children were considered with regard to the need for special educational treatment as maladjusted pupils and four as diabetic pupils. Table 17 in the appendix gives details of the results. Furthermore, pupils in special schools or units were examined to ensure that the special educational treatment they were receiving was still suitable to their disability. Epileptic children To obtain some idea of the number of epileptic school children in the County, a central register has been kept since January, 1951, and school physicians have been asked to notify all cases of epilepsy that they come across in the course of their work, stating the type of fit and the education provided. Where special educational treatment is considered necessary the children are seen at the County Hall by a medical officer. The consultants at hospitals, particularly at the Maudsley and National Hospitals, have been most co-operative in carrying out special investigations and reporting on them. At the end of the year there were 350 names on the register. Of these 214 were in ordinary schools, 30 in day schools for educationally sub-normal children, 27 in day schools for physically handicapped children and 58 in boarding schools for epileptics. This does not represent all the epileptic children in London schools as there are still some in ordinary schools who have yet to be notified. Considerable work has been necessary to gain for these children the sympathy and help which they need if they are to establish themselves in the community. The Council's medico-social workers have been particularly helpful in the many social problems presented by these children and the British Epilepsy Association has helped many parents, while the Council's youth employment officer has been most cooperative in the difficult task of fitting children leaving school into suitable employment. These children present one of the most difficult problems of social medicine where all agencies, medical, educational and social have to work closely together to achieve success. 130 Diabetic children The Council's diabetic unit is housed in the residential school at Hutton, Essex, and at the end of 1952, contained 38 pupils. Children suffering from diabetes mellitus, which cannot be adequately controlled at home, and who are of such intelligence as to profit by their stay are admitted. The principles of the control of the disease and the importance of dietary are taught at the unit, and the children are trained to render their own insulin injections and to guard against the accidents of a diabetic life. They take part in all school activities, including a fortnight's visit to a holiday camp. A visiting medical officer and nursing staff with special experience provide the day to day care and a consultant visits fortnightly and at such other times as are necessary. The laboratory work to ensure control is undertaken by a technician under the direction of the consultant. During the year the Diabetic Association organised a scheme whereby diabetic children from various parts of the country attended holiday camps at Walton-on-Naze, Essex, Pateley Bridge, Yorkshire, and Deal, Kent. A small number of diabetic children attending ordinary schools in London were sent to these camps and benefited not only from the holiday itself but also from instruction in the diabetic way of life. The accommodation at Martello Camp, Walton-on-Naze, was provided by this Council and the camp was held in conjunction with the Council's diabetic unit. Children under five years of age An inspector of the Education Officer's Department continued to visit primary schools with accommodation available for nursery classes after the needs of the children over five had been met, and in those cases where she was prepared to approve a nursery class, the divisional medical officer was consulted, and arrangements were made to introduce some approximation to nursery school conditions. At the end of 1952 there were 157 nursery classes with accommodation for approximately 4,710 children aged 3 to 5 years. In addition to a midday meal, these children had one-third of a pint of milk daily and cod liver oil and other vitamin preparations; for those who required them medicaments containing iron were also prescribed. Nursery class children attend during the ordinary school hours of primary schools, but nursery school children attend from 8.30 a.m. to 4.30 p.m. and have breakfast (when necessary), dinner and tea, and two-thirds of a pint of milk daily in addition to the other supplements supplied to the nursery class children. 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 14,436 children under five years of age on the day school rolls, 12,532 being in the Council's schools and 1,904 in voluntary or aided schools. Research and investigation A joint committee of the Institute of Child Health (University of London), Society of Medical Officers of Health and the Population Investigation Committee has been following the health, growth and development of 6,000 children born in one week in March, 1946, who are drawn from all social classes and from all parts of Great Britain. The chief aims are to collect information on accidents, illnesses, growth and development, to show the effect of environment on the health and growth of young children, to compare the history of prematurely-born children with those born at term, and to observe the achievement of children against the background of their ability, health and opportunities. The Council, in common with other local authorities, has assisted in 131 the inquiry since its inception. During 1952, the children came under the supervision of the school health service and detailed forms of inquiry were completed by school doctors and school nursing sisters. In the latter part of the year facilities were granted to Professor F. S. Cotton, Professor of Physiology at the University of Sydney, Australia, to carry out research into the physiology of exercise and sport by testing children in primary schools. DENTAL SERVICES the council's Chief Dental Officer reports as follows: In 1952, for the first time in several years, the graphs (page 132) of the school dental service showing the numbers of dental inspections and of treatment sessions ceased to drop and showed an upward trend. Attention for the pre-school child and for expectant and nursing mothers also showed some improvement. A main difficulty, as formerly, was insufficiency of staff and for a further year it was impossible to attempt an educational drive and a systematic inspection programme, without which full dental care is unlikely to be possible. Systematic follow-up of absentees and revisional treatment of patients rendered dentally fit were operated only to a slight extent where a better staff-patient ratio permitted or by special selectivity on the part of a dental officer. The 1952 staff figures show a considerable improvement compared to those of 1951 and fewer officers with lengthy experience of the Council's dental service resigned. The signs throughout the year were, generally of a return to the possibility of building a sufficient dental care service to improve the ameliorative treatment service still operating. Reference has been made in reports on preceding years to efforts to clarify the responsibility for the provision of dental service by the authorities responsible for Part II (hospital), Part III (local health authority) and Part IV (general dental) services. During 1952 continued effort was almost entirely successful. The principal problem remaining was in relation to dental treatment of expectant and nursing mothers at hospitals where, under Part II service, charges to patients in respect of dentures supplied were introduced by the Act of 1951. In the Council's (Part III) service such appliances are provided free of cost to the patient. Consultations on the possibility of reference of patients to the Council's service, or of payment by the Council of the patient's share of cost were inconclusive. Every effort was made to increase and strengthen the maternity and child welfare section of the dental services having due regard meantime to the dental needs of the school children. Throughout 1952 much of the dental treatment of expectant and nursing mothers continued to be done under hospital auspices or by general dental service and private practitioners. 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 At end of 1952 35 32 16 51 66 132 133 Attendances and treatments 1949 1950 1951 1952 Number of inspection sessions held at schools 946 544 441 584 Number of children inspected at schools by Dentists 96,201 52,931 46,473 59,677 Number found to require treatment 61,445 32,733 29,397 38,069 Percentage requiring treatment 63.9% 60.8% 63.2% 63.8% Additional number inspected at centres 65,380 63,583 65,501 71,452 Total number found to require treatment 126,825 96,316 94,898 109,521 Total cases treated 102,495 82,650 82,564 93,823 Attendances 203,523 166,874 172,063 202,571 Ordinary treatment sessions 19,133 15,890 15,760 19,563 General anaesthetic sessions 1,685 1,559 1,516 1,494 Temporary teeth extracted 109,467 101,066 93,981 96,561 Permanent teeth extracted 18,103 16,247 15,850 17,283 Temporary teeth restored by fillings 34,506 23,960 21,684 26,353 Permanent teeth restored by fillings 67,395 53,388 54,356 66,680 Fillings in temporary teeth 36,341 25,191 24,206 27,556 Fillings in permanent teeth 73,740 58,000 60,568 72,369 Other operations—temporary teeth 38,649 33,489 39,523 45,985 Other operations—permanent teeth 32,888 25,485 28,199 30,291 Local anaesthetics for extraction 24,328 20,557 21,300 24,667 Local anaesthetics for conservative treatment 2,926 1,577 1,607 3,753 General anaesthetics 39,455 35,102 34,097 33,448 Cases for whom immediate treatment was completed ‡ ‡ 8,481* 13,135 Cases discharged as dentally fit ‡ ‡ 40,369* 63,638 ‡ Figures not available; * Figures for May-December 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 1952 3.86 to 1 Residential establishments The decline in the dental service in residential establishments appeared to be arrested in 1952 but the problems in this particular field remain pressing. Every effort was made to obtain dental aid for the children but the rise in the percentage found to require treatment is ominous. The following table indicates the sessional attendance and treatments given, but an unknown volume of treatment was given in addition by local dental practitioners: 1949 1950 1951 1952 Ordinary treatment sessions 572 524 449 488 General anaesthetic sessions 12 10 7 2 Number of children inspected 5,648 5,783 4,635 3,912 Number found to require treatment 2,333 2,355 2,045 1,836 Percentage requiring treatment 41.3% 40.7% 44.1% 46.9% Attendances for treatment 4,179 3,791 3,427 3,622 Temporary teeth extracted 1,128 920 950 690 Permanent teeth extracted 271 172 173 179 Temporary teeth restored by fillings 1,058 854 699 703 Permanent teeth restored by fillings 1,555 1,547 1,365 1,936 Fillings in temporary teeth 1,116 976 746 721 Fillings in permanent teeth 1,715 1,708 1,515 2,037 Completed scalings 700 583 346 246 Temporary dressings, etc. 745 511 455 432 Local anaesthetics for extraction 832 666 580 546 Local anaesthetics for conservative treatment 71 53 113 103 General anaesthetics 163 272 332 145 Cases completed 2,357 2,363 1,911 1,909 Sodium fluoride treatment and dental hygienists 134 During the year the investigation on the efficacy of applying a 2 per cent. solution of sodium fluoride to teeth was continued, but the resignations of two of the three dental hygienists employed on the work caused difficulties in the planned investigation. The remaining hygienist drew first part of the investigation to a close towards the end of the year but an account of it was not available for inclusion in this report. Dental hygienists—Attendances and treatments 1950 1951 1952 Sessions 1,370 1,499 1,592 Number invited to attend for first treatment 2,389 4,188 4,348 Number invited to attend tor subsequent treatment 2,851 4,232 1,284 Attended—first treatment 2,109 3,365 3,653 Attended—subsequent treatment 2,662 3,936 1,237 Treated—first treatment 2,104 3,359 3,652 Treated—subsequent treatment 2,660 4,033 1,235 Discharged—treatment completed 1,834 3,121 3,618 Discharged—failed to complete treatment * 104† 72 Gum treatments 365 395 495 Scalings (cleanings) 3,122 3,986 3,989 Polishings (of artificial restorations) 1,823 2,553 1,695 Oral hygiene instruction 2,562 4,655 4,137 Sodium Fluoride: First application 658 1,220 260 Second application 597 1,170 270 Third application 559 1,102 262 Fourth application 494 1,074 215 * Figures not available. †Figures for June-December. Orthodontics At the close of 1951, owing to the resignation of orthodontists, only three sessions per week were expressly reserved for the urgently required service for the correction of malocclusions. It was not possible throughout i952 to augment this service and only 50 patients could be completed by the part-time orthodontist, a reduction of 172 compared with the preceding year. Clinicians, however, in addition to their routine treatments treated a further 209 malocclusions and 47 additional patients were referred to dental teaching hospitals. The following table summarises the work done by the part-time orthodontist 1950 1951 1952 Sessions 425 245 134 New cases 266 117 85 Attendances 5,339 3,247 1,816 Unsuitable for treatment 84 51 17 Still under treatment (at 31st December) 491 187 205 Fixed appliances fitted 199 155 122 Removable appliances fitted 452 127 159 Discharged, treatment completed 424 222 50 Such meagre figures, compared to the widespread clinical evidence of need for this type of treatment, are disturbing and very many children who might have benefited had perforce to be turned away untreated. 135 Maternity and child welfare dental service The slight increase in maternity and child welfare treatment during 1952 is shown by the following table : 1949 1950 1951 1952 Number of ordinary sessions 2,682 2,238 1,980 2,031 Number of general anaesthetic sessions 364 368 333 306 Number of appointments offered 31,338 26,308 23,342 24,609 Failed to attend 6,477 5,876 5,060 5,614 Attendances—By appointment 24,861 20,432 18,282 18,995 Other 5,392 3,891 3,313 2,162 Examinations 12,057 8,579 7,661 7,362 Treated—first treatment 7,032 5,116 4,753 5,444 others 13,447 11,851 10,216 10,339 Silver nitrate treatment 2,938 2,180 1,818 2,907 Scalings 1,364 859 669 739 Prolonged gum treatment 212 210 214 228 Fillings 8,564 8,255 7,929 8,852 Inlays 23 22 27 18 Crowns 5 11 6 12 Number of teeth conserved 7,988 7,841 7,507 8,388 Extractions 16,560 11,257 9,289 8,463 Dressings 2,236 2,077 1,687 2,090 Anaesthetics—local 1,784 1,457 992 844 general 4,563 3,372 3,318 2,837 Number of patients prepared for dentures 3,359 2,518 1,822 1,471 Number of patients supplied with dentures 960 918 590 476 Dentures supplied—new full 652 655 335 310 new partial 795 782 536 400 Remakes 7 19 10 10 Repairs 126 84 63 47 Number of patients X-rayed 56 23 65 105 Number made dentally fit 5,283 5,057 4,654 5,479 Conclusion Towards the close of the year an important decision was taken by the Council which, if recruits are forthcoming, will do much to assist the development of the school dental service. For the first time in the history of the service an ultimate dental staff—schoolchild ratio of 1 : 3,000—was officially approved and an immediate establishment of the equivalent of 93 whole-time dentists authorised. Every effort is being made to secure the additional staff which will enable this goal to be reached and to provide the additional accommodation necessary. The period under review was one of improvement compared with the preceding year but much remains to be done before the ground lost in the past few years is regained and satisfactory progress made to implement the Council's statutory obligations under the 1944 Education Act and the National Health Service Acts. STAFF in staff matters there were no developments of any magnitude during the year. As in most fields of employment there was an upward trend in salaries and wages. Many groups of staff received increases, some as a result of agreements reached by national negotiating bodies and others, not covered by such agreements, by reason of action taken by the Council itself. Visiting medical officers An agreement on the remuneration of visiting medical officers to residential establishments was implemented by the Council during the year. This agreement was negotiated in 1949 with the primary object of dealing with the new situation arising from 5th July, 1948, under the National Health Service Act, 1946, whereby residents in local authority establishments, in common with the populace at large, became entitled to ' family doctor ' medical treatment under arrangements made, and paid for, 136 by the State, whereas previously this responsibility had rested on the authorities providing the establishments. The new agreement fixed the remuneration to be paid by local authorities for services rendered by visiting medical officers outside the ' family doctor ' services paid for by the State. Because of the national economic situation the date of operation of the agreement was deferred for nearly two years. The Council took the opportunity presented by the need for reviewing the terms of remuneration of its visiting medical officers to bring up to date the duties of these officers and to standardise their conditions of service. Dental officers A number of dental surgeons offered their services to the Council as whole-time dental officers and for the first time for some years the Council was in a position to appoint whole-time dental officers to the staff. The number of dental surgeons prepared to give part-time service to the Council also increased, following appeals made to the London Local Dental Committee and a more intensive advertising campaign, coupled, perhaps, with an improvement which the Council made in the sessional fees for this work. Health visitors The Council's scheme for the training of health visitors continued to play an important part in providing qualified staff for this work and once again the number of health visitors showed an increase during the year. Since the commencement of the scheme 155 student health visitors have been appointed including 40 at present under training. Of the 114 students who had qualified as health visitors, by the end of 1952, 86 were still in the service at that date. The work of health visitors is dealt with on page 68. Co-operation with the borough councils Co-operation between the Council and the metropolitan boroughs in public health matters was further extended during the year. Details of joint appointments of medical staff are given on page 36. Staff medical examinations The number of references made to the department for medical examination or advice concerning the health of staff, or the fitness of candidates for appointment, totalled 13,436, compared with 12,455 in 1951; 189 members of the staff were found to be permanently unfit for further duty with the Council and 252 candidates unfit for appointment. The Council's staff medical examiners made 70 home visits to examine members of the staff who were unable to travel, compared with 95 during 1951. Reciprocal arrangements with provincial authorities for the examination locally of new entrants were continued. Provincial medical officers of health arranged for the examination of 21 entrants to the Council's service and the Council's medical officers examined 38 candidates for provincial appointments. Staff of the department A statement showing the staff employed in the department is given on pages 192-3. SPECIAL INVESTIGATIONS the following research projects were undertaken in 1952 : Inquiry into virus infections during pregnancy In the Report for 1950 (page 55) details were given of an investigation sponsored by the Ministry of Health to estimate the frequency with which certain virus diseases (rubella, measles, chicken-pox, mumps, poliomyelitis) during pregnancy are followed by congenital abnormalities in the children. The Ministry of Health were able to obtain a sufficient number of mothers for the purposes of the main inquiry and up to the end of the year 951 women (290 virus infection, 661 control) had been registered in London. Some of these were lost to the survey by removals out of London, refusal to co-operate and other reasons. London, in common with a few of the larger authorities, was asked to continue to register and follow up any rubella cases occurring in their areas as it was hoped to obtain additional information on the effects of this infection. 137 Nutritional investigation in day nurseries Facilities were granted in 1951 to Professor John Yudkin, Department of Physiology, King's College of Household Science (University of London), to carry out a nutritional investigation at four day nurseries. 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 children and was designed to ascertain the effect on the height and weight of young children by the daily administration of a vitamin B preparation. Of the original 75 children, 15 left during the experiment, so records of growth were available for 60 children (31 boys and 29 girls) and as no differences in growth between the boys and the girls were evident, the results for both sexes were combined. Of the 60 children, 32 (17 boys and 15 girls) were in the experimental group and 28 (14 boys and 14 girls) in the control group. Average absences from the nurseries were almost the same for the two groups. It was calculated that the average consumption of liver powder by the children in the experimental group amounted to 1.2 g. daily for the 91 days (13 weeks) of the test. The 32 children taking the supplement gained on average about ¼ inch (0.6 c.m.) more in height and 10 oz. (285 g.) more in weight than the 28 control children (i.e., roughly 20 per cent. and 40 per cent. more than the control group). For various reasons, Professor Yudkin is of the opinion that the dietary factor responsible for the effect on growth is not vitamin B12. He is continuing his work to determine the distribution and nature of the growth factor. Inquiry into prematurity At the request of the National Birthday Trust Fund the Council agreed to co-operate in an inquiry, the object of which was to investigate the causes of prematurity with special reference to the effect of the mother's employment during pregnancy. Briefly, the inquiry required health visitors to complete questionnaires in respect of (i) all live-born premature first births in each of the months of December, 1952, and February, April, June and August, 1953, and (ii) all live-born non-premature first births on the 7th, 14th, 21st and 28th of each of the months mentioned (the control group). The health visitors were supplied by the Trust Fund with notes for guidance in completing the questionnaires. Inquiry on retrolental fibroplasia In October the Ministry of Health expressed concern at the increasing number of cases of retrolental fibroplasia in premature infants, resulting in blindness or seriously impaired vision. The Ministry stated that the Medical Research Council was conducting an inquiry, but that there might be epidemiological factors which might not be revealed by this investigation, which was mainly clinical and pathological. The Ministry therefore requested the co-operation of local health authorities in a wide survey to throw light on the incidence and distribution of the disease and the Council agreed to participate in the survey. The survey concerned all premature babies born in 1951, weighing up to 4 lb. 6 oz. at birth, surviving two months or more and still resident in the County (or who had died in the County at more than two months old). Schedules were supplied by the Ministry to provide for information (in addition to birth weight, etc.) under the following heads: (i) place of birth (if born at home, whether admitted to hospital or nursing home within first two months); (ii) date of death (if child died after two months old); (iii) condition of eyes (present condition of eyes, or at time of death, if known). Schedules were completed in respect of 480 babies. 138 Investigation into the early detection of infantile cerebral palsy Dr. W. F. Dunham of the Department of Physical Medicine at Charing Cross Hospital, asked for facilities in connection with a scheme of research on the early detection of infantile cerebral palsy. During the past six years, by arrangement with the Medical Research Council, he has been conducting an investigation into disorders resulting from central nervous disease in the adult. He has also studied special problems of infantile cerebral palsy at the Unit at Queen Mary's Hospital for Children, Carshalton, and has come to the conclusion that, in general, the earlier treatment is begun the better are the results attained. Early diagnosis is, therefore, of prime importance. Diagnosis of cerebral palsy at birth, however, is possible for only a relatively few babies who show gross central nervous abnormalities. The majority of those children who are subsequently found to have cerebral palsy show no abnormal signs for some months after birth on the application of the usual methods of examination. Dr. Dunham is of the opinion, therefore, that new methods of examination are required and his object was to develop these from a study of infantile reflexes. He has already carried out some work along these lines but he wished to have facilities for further investigation in order to corroborate what had been done by applying it over a period to a series of apparently normal babies. At the same time, steps would be taken to prevent abnormal function. The Council agreed that facilities for a pilot investigation should be granted in health division No. 9 (covering the boroughs of Battersea and Wandsworth) and that if successful, similar facilities in other divisions might be made available. The pilot investigation commenced towards the end of the year. Capital FINANCE the total capital expenditure on the health services of the Council in the year ended 31st March, 1952, was £287,098, details of which are as follows: £ Ambulance service 112,692 Central Dental Laboratory 72 Children's Holiday Home, Littlehampton 2,118 Day nurseries—acquisition and adaptations 24,656 District nursing—purchase of cars 4,411 Maternity and child welfare centres—acquisition and adaptations 13,821 Occupation Centre—appropriation and adaptation 2,297 Queen's Road Centre 67,472 Woodberry Down Health Centre 59,559 £287,098 Maintenance After allowing for Government grant the services administered by the public health department cost the London ratepayer a rate of 91/2in the £, divided as follows: d. Ambulance service 1.18 Day nurseries 1.5 Domiciliary midwifery service 0.4 General health services 0.76 Maternity and child welfare 1.57 Mental health 0.33 Prevention of illness (home nursing, domestic help, care of tuberculous, etc.) 2.45 School health 1.14 9.33 139 The gross cost of the various services in 1951-52—including central administrative charges and contributions to the Superannuation Fund but excluding debt charges—and the contributions recovered from recipients of the services were : Service Cost Amount recovered in charges £ £ Ambulance service 645,344 — Day nurseries 872,874 119,226 Domiciliary midwifery service 184,423 — General health services (including £135,504 contribution to metropolitan borough councils for salaries of sanitary officers) 223,386 — Maternity and child welfare 821,504 50,343 Mental health 156,342 3,288 Prevention of illness— Home nursing 275,940* — Domestic help 489,692* 38,777 Other preventive services 435,140 19,713 School health 699,576 16,841 £4,804,221 £248,188 * Excluding central administration. VISITORS TO THE DEPARTMENT individual visitors to the department during 1952 totalled 259 from 53 countries, including 71 visitors from Great Britain. The foreign countries from which visitors were received, with the number from each were Aden 2, Argentina 1, Austria 1, Australia 18, Belgian Congo 2, Bombay 2, Brazil 4, British Honduras 1, Burma 1, Chile 1, Cyprus 1, Ceylon 2, Denmark 2, Egypt 1, Ethiopia 1, Finland 3, Formosa 1, France 3, Germany 2, Gold Coast 5, Greece 3, Holland 1, India 23, Indonesia 1, Israel 2, Italy 1, Japan 2, Korea 1, Malta 1, Malaya 2, Mexico 1, Nigeria 2, New Zealand 3, Norway 9, Pakistan 8, Palestine 1, Persia 2, Portugal 1, Salvador 1, Sierra Leone 1, South Africa 6, Sweden 9, Southern Rhodesia 2, Syria 4, Sudan 2, Switzerland 2, Thailand 4, Trinidad 2, Uruguay 1, U.S.A. 31, U.S.S.R. 2, Viet Nam 1, West Africa 1, Yugoslavia 1. These visitors were given, according to their individual needs, programmes covering visits to maternity and child welfare centres, school treatment centres, day nurseries, occupation centres, etc., and in practically every case talks by senior medical, nursing or administrative staff. In addition to these individual visitors, 549 visitors, including 226 from Great Britain, came in organised parties, sometimes for talks and sometimes for visits as set out above. These visitors were :— 146 American university students in six parties. 60 postgraduate students from Society of Medical Officers of Health. 27 German social science students. 70 delegates to the National Council of Nurses. 17 Surrey County Council health visitor students. 5 from the International Labour Office of the United Nations. 4 Indian public health doctors. 18 German local government officials. 15 students from various countries. 4 medical officers from the Middlesex County Council. 25 Norwegian Government employees. 9 Soroptimists. 140 4 Dutch journalists. 11 nurses from Staff College for Ward Sisters. 6 employees of the Emergency Bed Service. 5 The Minister of Health and party. 11 students of Institute of Hospital Administrators. 112 medical officers attending the National Association for Mental Health Conference. An indication of the volume of visitors to the department is given in the following table : 1949 1950 1951 1952ø Individual visitors 147 195 202 259 Parties 203 200 400 549 ø Excluding visitors to Woodberry Down Health Centre Endeavours are made to meet all reasonable requests for visits as the exchange of views and information is of mutual benefit. Woodberry Down Health Centre From its opening in October, to the end of the year, there were 641 visitors to thi health centre, very few of whom are included above. REPORTS BY THE DIVISIONAL MEDICAL OFFICERS Division 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington. Dr. Violet Russell reports: Expansion of services There has been a considerable expansion of the work during the year, most notably in the home nursing and home help services. The smaller waiting lists at day nurseries were offset by a large increase in the number of child-minders registered under the Council's scheme. The popular chiropody sessions have been increased, the new sessions being devoted to the treatment of old people and expectant and nursing mothers. To meet an increased demand, more audiology sessions have been instituted for school children. A speech-therapy class has been moved to improved accommodation in Fulham, and further sessions began in Kensington and Hammersmith. An additional session for orthoptic treatment is being held at Fulham school treatment centre. In the tuberculosis service the number of patients receiving extra nourishment free or at reduced cost increased substantially and now amounts to about 10 per cent. of those on the register. Ante-natal sessions The maternity and child welfare service has carried on its excellent educational work but there has been a decline in the number of women attending ante-natal sessions. As a result two weekly ante-natal sessions in Fulham and one in Hammersmith have been discontinued. This decline is associated with the increasing proportion of mothers who have their confinements and ante-natal care at hospitals; the percentage of home confinements in the division is the lowest in London. Marriage guidance I am glad to report the institution or a weekly advisory clinic conducted by the London Marriage Guidance Council in the division. Homeless families Early in 1952 a weekly infant welfare session was started at the Homeless Families Unit in Fulham Road, Chelsea, as there had been difficulty in persuading the mothers resident there to attend the local welfare centres. The new session is appreciated by the mothers and is doing good educational work. A mothercraft session has been organised bv the health visitors, who give lectures on mothercraft and hygiene. Ill-treatment and neglect of children and juvenile delinquency Two conferences were held in the division with a view to co-ordinating measures for the prevention of ill-treatment and neglect of children and juvenile delinquency: the conferences were attended by representatives of the public health, education, and housing departments, a borough council housing department, the police, the 141 probation service, the local hospitals, and about 25 voluntary organisations. A standing committee of the divisional medical officer, the divisional education officer, the area children's officer, and the district care organiser was formed for the purpose of keeping the problems under constant review. Problem families Official interest was first drawn to problem families in West London before July, 1948, when a pilot enquiry in Kensington was organised by the Eugenics Society. The results of this investigation are now published and the Eugenics Society have elected one of the health visitors in the division an honorary Life Fellow in recognition of her work on the enquiry. In October, 1948, a branch of the Family Service Units started work among the problem families in Kensington and Paddington. The divisional staff have kept in close touch with the unit, whose workers co-operate with health visitors and children's care workers. A home help is provided to serve problem families in the division, working in collaboration with the staff of the unit. Home nursing A great expansion in the work of the district nurses has helped to solve difficulties which might otherwise have been caused by the demand for hospital beds. Improved recruiting of staff has been reflected by visits showing an increase of 500 a week compared with 1951 and 1,000 a week compared with 1950. The popularity of the service is well deserved bv the efficiency and devotion of the nursing staff. Home help service The steady increase in the volume of home help work continued throughout the year. The Kensington home help office has been transferred to North Kensington, where it is more conveniently situated for the majority of the clients. At the same time the boundary between the Kensington and Chelsea home help areas was adjusted so that most of South Kensington is now served by the Chelsea office, which has been transferred to a more central point off King's Road, Chelsea. Co-operation with local hospitals For some time there has been useful co-operation in the Division between the childwelfare clinics and children's hospitals. A paediatrician from the Victoria Hospital for Children conducts a weekly infant-welfare session at South Kensington welfare centre, and in exchange one of the Council's assistant medical officers acts as clinical assistant at a weekly hospital session. There is also an interchange of medical officers between Westway welfare centre and the Institute of Child Health at Hammersmith Hospital; one of the hospital registrars takes a weekly welfare session, and one of the Council's medical officers attends a weekly follow-up clinic for infants at the hospital. Conclusion 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. Dr. H. L. Oldershaw reports : Staff The arrangement by which most of the medical officers have experience of both maternity and child welfare and school health services was continued, and most of them will also have the opportunity of clinical experience in one of the children's departments of certain of the hospitals in the division. One of the medical officers was appointed deputy medical officer of health by the Paddington borough council which is in accordance with the policy approved by the County Council. It is pleasing to report that no less than 26 of the health visitors in the division now undertake combined work. Day nurseries and child-minders There was another reduction in the waiting list for day nursery accommodation, and at the end of the year only 195 priority cases were awaiting admission. On the other hand accommodation provided by private day nurseries increased from 541 places in 1951 to 621 places in 1952. The occupation in the Council's day nurseries increased from 81.2 per cent. in 1951 to 88.2 per cent. in 1952. The number of child-minders showed a further increase, but the children concerned are not necessarily priority cases. 142 Home help service The gradual expansion of this service has continued. The number of home help units was increased by 29, but what is of greater significance is that there was an increase of over 20 per cent. in the number of cases assisted as compared with the previous year. Ante-natal clinics It was decided to commence an evening ante-natal clinic in Paddington to meet the convenience of working mothers who find it difficult to attend in the day time. This experiment at once proved successful, and arrangements are already in hand for similar clinics to be opened in Hampstead and St. Marvlebone. Old people (foot clinics) The divisional committee gave approval to accommodation being made available in premises in both Hampstead and Paddington for foot clinics organised by the local old peoples welfare committees. Facilities had already been granted for a similar clinic to be opened in St. Marvlebone. Research All grades of the divisional staff have contributed their share to the many investigations and research projects which have been initiated both from County Hall and elsewhere. Diversional therapy A divisional therapy service for people suffering from tuberculosis and confined to their homes is to be started as an experiment in Paddington. The handicrafts to be taught will include weaving, tapestry making, leather work, basket work, jewellery and lampshade making. A part-time occupational therapist has been engaged and if the project is successful, consideration will be given to its extension to other parts of the division. Premises During the year the following additional accommodation was acquired by the Council: Hampstead Health Institute.—The Council completed the purchase of these premises which will be adapted for maternity and child welfare and school health purposes. A scheme has been prepared and is awaiting necessary approvals. Hampstead Wells House centre.—Through the co-operation of the Hampstead borough council a suite of rooms for use as a maternity and child welfare centre is now rented in their Wells House estate. Westminster treatment centre.—These premises are now adapted and their use as a school treatment centre will commence early in 1953. St. Stephen s day nursery (Paddington).—This purpose-built nursery will accommodate 51 children, and replaces requisitioned premises. Conclusion I express my sincere appreciation of the loyal co-operation and successful work of all my colleagues in the divisional health service. Division 3, comprising the boroughs of Finsbury, Holborn and Islington. Dr. Bertha E. A. Sharpe reports : Medical officers The Division lost the services of Dr. A. B. Stewart as divisional medical officer during the year by reason of his promotion to the position of deputy medical officer of health for the County. Co-operation with the hospital and specialist services and the environmental health services in the Division was encouraged. Regular meetings with the medical officers of health of the three boroughs were continued when problems were discussed and concerted action agreed. The scheme for interchange between hospital registrars at the Hospital for Sick Children, Great Ormond Street and the Council's assistant medical officers continued satisfactorily throughout the year. The exchange of experience has become mutually appreciated. The number of full-time assistant medical officers employed in the Division has been increased by one, viz. from 5 to 6. Co-operation with hospitals and general practitioners Special arrangements continued with the Hospital for Sick Children whereby medical reports were received following the discharge of patients. All cases were followed up by the health visitors and school nursing sisters and the reports were made available without delay to the doctors responsible for the children. Requests were received from hospitals in the area for reports on home conditions before patients were 143 discharged, and reports on patients after their discharge were given to the hospitals when they were asked for. Close co-operation was maintained with the family doctor and regular meetings with hospital almoners were held to improve co-ordination. General The following services show expansion : Recuperative holidays by 23 per cent., viz. from 777 in 1951 to 951. Home help service—the total number of households attended increased by 17 per cent. compared with the corresponding figure for 1951. Vaccinations of under one's—Compared with the total live births occurring during 1951 and 1952 the percentage of vaccinations of children under one year increased from 41 per cent. to 43 per cent. Foot clinic—9 per cent. increase in attendances. Housing—Reports on applicants for priority on medical grounds increased from 3,863 to 3,954. Other services which need special mention are : Care of mothers and young children—15 maternity and child welfare centres (including branch clinics) were in full operation in the Division during the year. There were 79,000 attendances and first attendances of infants under one year was 86 per cent. of the total of live births. 263 women were referred for advice to the two family planning clinics in the Division. Day nurseries have been reduced by one because the site was required for housing purposes. The number of priority cases awaiting admission on 31st December, 1952 was 328 compared with 146 twelve months ago. One of the three private day nurseries registered under the Nurseries and Child-Minders Regulation Act closed during November, 1952. Vaccination and immunisation A mobile clinic for diphtheria immunisation equipped with a loud speaker was again in use during the summer months. In September an intensive effort was started to strengthen the state of immunity amongst school children by increasing the numbers of school sessions for administering reinforcing injections to children immunised in infancy, and for immunising those who had not been protected in infancy. Based on the population figures as at 30th June, 1951 it is estimated that at 31st December, 1952, 51 per cent. of children 0–4 years had been immunised against diphtheria. Only two cases of diphtheria were confirmed during the year. During the year, two vaccination sessions were combined with two immunisation sessions with a consequential saving in man-power and sessional fees to medical officers. Sessions for the re-vaccination of school children were started during the Christmas holidays to save the children's school time. It is proposed to extend this service at all holiday periods and on Saturday mornings. School health service The special investigation clinic at Pentonville school treatment centre continued to achieve encouraging results. Of 117 first attendances during the year, only two cases (where parents were of low type and unco-operative) failed to respond to treatment. The ear, nose and throat Clinic, although now operated by the Regional Hospital Board, was still, for convenience, held at the Islington school treatment centre and the majority of children was referred by school doctors. Discharging ears were quickly cured, a large proportion resulting from nasal catarrh. The audiology clinic worked very smoothly, partly due to the fact that the same specialist attended both this and the ear, nose and throat Clinic at the same centre. Twelve vision sessions a week were devoted to schoolchildren only at the Royal London Ophthalmic Hospital (Moorfields) and two at the Westminster Hospital. Tuberculosis Early in 1952 accommodation at the East Islington welfare centre was made available to the North West metropolitan regional hospital board for the establishment of a static mass radiography unit. The advertising of the scheme, which aimed at securing the X-ray of all the adult population in Islington, was assisted by the Council's divisional organisation. The unit was used for the routine examination of the Council's divisional staff. K 144 About 3,764 children from 14 schools in Islington had tuberculin skin tests and 974 of these had X-ray examinations at the mass radiography unit: 412 were positive reactors to the skin test and 3,352 were negative. Seven children were subsequently referred to the local chest clinic for further examination and observation. The hostel for tuberculous men at Highbury Quadrant was opened on 29th October, 1951. There is accommodation for 37 residents which includes two chalets installed in the gardens towards the end of the year. The hostel has been fully utilised and is visited on a rota basis by members of the Divisional Health Committee. Health education Lectures and demonstrations, supplemented by films were given at welfare centres. A programme of health publicity was followed by which the same topics were concentrated upon at each centre. The various establishments exhibited posters and distributed leaflets according to this programme, the topic being changed once a month. Short articles on health matters were published from time to time in the Islington public library bulletin. General practitioners and hospitals in the area assisted the Council's campaign for immunisation against diphtheria by displaying posters on their premises. Conclusion As a newcomer to the division I should like to say how much I have appreciated the interest shown and the encouragement given by the Chairman and Members of the Divisional Health Committee. I have also much valued the help and co-operation of the three borough medical officers of health; and I owe gratitude to many general practitioners, voluntary societies, hospital staffs and last, but not least, to my own divisional staff, medical, nursing and administrative. Division 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports : Woodberry Down health centre This comprehensive health centre was opened on 14th October, 1952, and by the end of the year 41 sessions of local health authority services were being held each week. The general practitioner and dental services, which are the responsibility of the London Executive Council and which are to be open to the public generally had not been commenced by the end of the year. A mothers' club and sewing class have been inaugurated successfully and the hall at the centre has been used for a number of lectures. The centre has attracted considerable publicity and by the end of the year well over 600 visitors had been conducted over the premises. Maternity and child welfare Attendances at infant welfare and ante-natal sessions and home visits by health visitors all showed improvement compared with the previous year, despite the continuing shortage of health visitors. Under an arrangement made with Hackney Hospital some mothers have, since 17th November, 1952, been referred from the hospital to the Council's clinics for interim ante-natal care. It is hoped that this co-operation may be extended to other maternity hospitals in the division. Day nurseries and child-minders Two day nurseries were transferred to newly erected premises (Woodberry Down and St. John's, Hackney Churchyard) during the year. The move to the new nurseries reduced the total available accommodation in the division from 668 to 666 child places. The priority waiting list for nursery admission contained the names of 110 children at the end of the year compared with 163 a year earlier. Five private day nurseries registered under the Nurseries and Child-Minders Regulation Act, 1948, provide accommodation for 177 children and there are three statutorily registered child-minders approved for the care of 13 children. There were at the end of the year 71 approved daily minders having in their care 57 children under school age. Vaccination and immunisation Considerable work has been done in the division in carrying out schick-tests on schoolchildren over ten years of age. It is of interest to note that approximately onethird of those children tested gave a positive reaction and were immunised against diphtheria. Only two cases of diphtheria (one adult, and a child for whom no record of immunisation is held) occurred in the division during the year. 145 Recuperative holidays A total of 899 holidays were provided, including 453 for schoolchildren and 60 for children under school age. Home help service Help was given to 2,928 cases during the year, of which 1,255 were new cases. premises ana minor improvements Various minor improvements to premises have been made or commenced during the year, such as the acquisition and laying-out of additional play space to provide grass and hard areas for the children, the provision of improved heating in a staff dormitory and the installation of additional pedestal closets at day nurseries. Redecoration in the modern colour schemes provided by the Council's architect has been completed at several establishments with pleasing effect. Division 5, comprising the boroughs of Bethnal Green, Poplar, Stepney and the City of London. Dr. G. O. Mitchell reports : Special investigation clinics In January two special investigation clinics were established, one at the Ida Samuel school treatment centre, Underwood Road, Whitechapel, and the other at the Bromley school treatment centre, Coventry Cross, Bromley-by-Bow, being held on Thursdays alternately at each centre. These clinics provide an opportunity for a full-time assistant medical officer to examine and investigate more thoroughly those children who present certain abnormalities at routine school medical examinations, e.g. enuresis, minor behaviour problems, doubtful cardiac conditions, etc. These clinics are a successful experiment. The great majority of children referred to them suffer from enuresis. Health visitors During the year the final step in decentralising the health visitors was taken when those health visitors based on the Stepney public health department in White Horse Lane were transferred to the Mary Hughes centre in Whitechapel, and the Council's policy of locating health visitors in or near their districts is now fully implemented in the division. We were, and we remain, rather short of health visitors; the East End does not seem to have any special attractions for new entrants in the Council's service. Day nursery playground Towards the end of the year a piece of vacant land opposite the Christian Street day nursery was developed as a playground for the nursery children. This was a welcome addition to the day nursery amenities since the limited site of the nursery affords practically no external playspace at all. School dental service Last year 1 lamented the decline in the school dental service. During 1952, however, things began to brighten up a bit with the appointment of a full-time dental surgeon at the Ida Samuel centre and the re-introduction of school dental inspections. There are encouraging signs of further development in this direction and we hope for an expansion of the dental services for children under school age and for expectant and nursing mothers, as well as for school children. Liaison with almoners The periodic meetings with almoners in the division continued during the year, and the scheme whereby the health visitors supply special reports to almoners continued to work well. In addition to these reports, the almoners frequently made contact with the health visitors by telephone in urgent cases. District nursing An indication of the work of the district nursing associations may be obtained from the fact that for the September quarter the visits paid per 1,000 of the population were the highest of any division, while the average visits per nurse were also the highest, as indeed they were for the quarter preceding. Immunisation and vaccination Immunisation against diphtheria continued at a fairly satisfactory level, and many re-inforcing doses were given in the schools, but in spite of continual propaganda by health visitors and doctors, vaccination for protection against smallpox is still relatively unpopular, and our vaccination figures continued to disappoint us. The only sure stimulus to increased vaccination in these parts seems to be the immediate threat of an outbreak of smallpox. Home helps There was a small but steady expansion of the home help service during the year, and a pleasing feature was the entertainment of some of the house-bound old people at Christmas parties organised by the home helps. K* 146 Childminders The registration of approved daily minders has been actively pursued and at the end of the year 77 such women were caring for 62 children. This scheme is a useful Day nurseries addition to the day nursery service which, of course, continued to admit only those children coming within the Council's priority groups. There were 111 children on the priority waiting list at the end of the year. Problem families Some concern has been felt about the best way of tackling the problem of the family where difficulties in bringing up the children exist, or where questions of moral and physical danger to the children may arise. As a result several conferences were held with the area children's officer, the divisional education officer, the district organiser of children's care work and the N.S.P.C.C. inspector, and plans have now been formulated for a continuation and extension of this liaison, with special emphasis on the prevention, wherever possible, of the development of a ' problem family '. Division 6, comprising the boroughs of Deptford, Greenwich and Woolwich. Dr. F. R. Waldron reports : Administration Upon the appointment of a joint medical officer of health for Deptford and Greenwich, the sub-offices in those two boroughs were combined, with consequential saving of clerical staff. Liaison Among the methods used, the following deserve special mention: (i) The monthly meetings with the borough medical officers of health have continued to facilitate the day-to-day running of the personal health services; (ii) At both the British Hospital for Mothers and Babies, Woolwich, and St. Alfege's Hospital, Greenwich, monthly meetings have again been held between the Council's medical, nursing and midwifery staff and the consultant and nursing staffs of the hospital maternity and paediatric departments. These gatherings have proved very helpful in solving many common problems. Prophylaxis Diphtheria immunisation and vaccination have both been carried out at six sessions held weekly for this combined purpose. The work is also undertaken (a) at some outlying centres in conjunction with ordinary infant welfare sessions and (b) at day nurseries. Inoculation against whooping cough is available on request. Diphtheria immunisation ' booster ' sessions have been arranged at schools; 1,987 cases were completed. Subcutaneous inoculation and separate antigens are used except at one centre where a trial commenced in September of a combined diphtheria and whooping cough subcutaneous antigen. Only four confirmed cases of diphtheria occurred during the year, three in children at a rest centre who had not been immunised and the other in a soldier 27 years of age whose immunisation state is unknown. There were no fatalities. Day nurseries The day nursery (60 places) which occupied a ward in New Cross General Hospital was closed. Accommodation in lieu for a 30-place nursery, which has proved adequate to the need, was made available at the Health Centre, Amersham Road, Deptford. Special investigation clinics To the special investigation clinic in Greenwich, two others have been added, viz., in the Health Centres at Amersham Road, Deptford and Market Street, Woolwich. Children are referred from welfare centres or school medical inspections for investigation of minor behaviour problems, and improvement has occurred in many instances. Old people Exchange of information has extended between the Council's officers and staffs of the Greenwich-Deptford and Woolwich hospital management committees who have shown special interest in geriatric problems. The old people's welfare committee in Deptford is now amongst the voluntary bodies on which the division is represented. Home help service This service has further expanded. On 31st December, 1951, the households attended numbered 1,450. At the end of 1952, they were 1,665. Chiropody Attendances totalled 73,000 or a rate of increase of 50 per cent. over those of five years ago. Other services Other maternity and child welfare, school health and care services have continued to do a great volume of varied work. Behind the organisation and the figures he much 147 endeavour to help in the very human task of improving personal health, as the following eloquent plea received from a clinic for a piece of equipment brings out : ' We know that auriscopes are dear But when a child's in pain To know what's wrong inside its ear Is worth financial strain. Shall we send them to " Special Ears " » Appointments must be made And minor turn to major fears And still the drum not saved ! ' The auriscope was provided. Division 7, comprising the boroughs of Camberwell and Lewisham. Dr. H. D. Chalke reports : Accommodation The need for a number of more suitable premises still remains. No new centres were opened during the year but adaptations to a house in Lordship Lane were completed and a small hutted unit is in process of erection on a site near Blackheath Hill. The Amott Road Centre has been enlarged and the St. Mary's Road Day Nursery transferred to new premises in the nearby Queen's Road Centre. Clinics The main feature has been a slight reduction in the number of ante-natal clinics and some increase in those for older children, and for diphtheria immunisation. A mobile immunisation unit toured the division in July. The use of combined diphtheria and whooping cough immunisation is being extended. An ' all purpose' clinic in the early evening for the benefit of those unable to attend at normal opening times was started at a Lewisham centre : this is largely experimental. Health education Open days at the centres were held as before. Health educational evening film shows were arranged throughout the division at which the attendances were very encouraging. Talks to Parent Associations and schoolchildren were extended. A health exhibition held at the Central Lewisham Welfare Centre was very well attended; the response of the public is an incentive to further effort in this direction. A special exhibition of pictures on the prevention of tuberculosis was held, for one week, at a centre in each of the two boroughs. Care of the aged The welfare of older members of the community has received considerable attention. The results of a divisional survey have been published*; they may prove of some assistance to those who are concerned with the welfare of older people in their own homes. There are many reasons why the majority of old folk are much better off in their own homes than in institutions, provided they can be given adequate attention and assistance. It was found that home care was far less costly than treatment in hospital. Home helps This service has now established itself as an essential part of the personal health services. Problems of administration have multiplied with its expansion; nevertheless, in no case in which the need existed was help not provided. Where considered essential, weekend service was given in a number of cases. There is still a tendency on the part of the public to forget that the duties of the home help must be confined to cleaning, cooking, light washing, shopping and so on. School health service There has been a welcome increase in the number of dental clinics. Some reduction has been made in the minor ailment sessions. In a number of schools chest X-rays of the pupils have been taken by arrangement with the mass miniature radiography unit. Day nurseries Attendances and new applications suggest that the need for this service has not diminished. Some children have been admitted for reasons connected with their physical or mental health or that of their parents, and on account of adverse environmental circumstances : this has proved well worth while. Health visiting and school nursing Health visitors have been called upon to an increasing extent in connection with family problems and difficulties; this work shows great enterprise and enthusiasm. Arrangements have been made which should increase the co-operation between general practitioners and health visitors. ♦Lancet I, 588. 1953 148 General The number of research projects undertaken has added greatly to the work of the divisional staff. A survey of the housing conditions of the infectious tuberculous on a chest clinic register yielded interesting results, which have been published. †The setting up of a regular problem family conference at the divisional office in connection with the difficult problem of child neglect and delinquency and the problem family—from its preventive aspect—has already given good results. This work is closely related to the keeping of 'family folders,' one of the advantages of which is to prevent unnecessary visiting to the homes. I am greatly indebted to the staff of the division and to my medical and lay colleagues in the area for their great help and co-operation during the year. Division 8, comprising the boroughs of Bermondsey, Lambeth and Southwark. Dr. W. H. S. Wallace reports : Premises The redecoration of premises in the division has been continued during the year. Three day nurseries, two infant welfare clinics and the foot clinic in Bermondsey, were completely redecorated. Day nurseries Efforts have been made to ensure the fullest economy in the running of the day nurseries. The scheme to allow matrons to do their own housekeeping, within set financial limits, was put into operation and has worked successfully. The nurseries have been working to capacity, the daily average attendance reaching 99 per cent. of the approved places. This has been due, in part, to the fact that temporary vacancies have, wherever possible, been given to children whose mothers have been ill or have had to go to hospital. Home help service The home help service was re-organised in June and the division divided into three areas for the purposes of administration of the service. Permanent appointment of three home help organisers was made, one in charge of each area. The new scheme has worked satisfactorily and the demand for the service is increasing steadily. The number of home helps on a full-time basis has increased from 223 in 1951 to 290 in 1952. Foot clinic: By re-arrangement of the sessions at the foot clinics in Bermondsey it has been possible to open the clinic in the evenings. This has improved the service considerably and reduced the waiting list so that applicants can now obtain appointments soon after booking. Diphtheria immunisation There has been a considerable increase in the number of children receiving diphtheria immunisation. Two additional immunisation sessions have been opened, one at Stockwell and one at the Rose McAndrew centre. Special sessions have also been arranged in schools to ensure that children receive the ' booster ' dose. The number of children under five who were immunised during the year was 5,320 compared with 4,535 during 1951. School health service The work of the school health service has continued during the year and arrangements were made to keep the family doctors informed of all defects found at school medical inspections. The scheme has worked smoothly and the vast majority of private practitioners welcome the arrangements made for treatment through the Council's services. The work of ensuring that all school children found to be mentally retarded are fully investigated and properly treated has always been a difficult task. Fortunately, it has been possible to place one medical officer with special experience in the examination of these children in charge of the work and thus to ensure that the children are properly placed without delay. There is still a considerable waiting list for refraction examination of school children. The South-East Metropolitan Regional Hospital Board have been unable to provide additional refraction sessions but an orthoptic session has been opened. The situation regarding dental treatment has improved slightly and the Cutten Memorial dental clinic was re-opened for the first time since the war. † Medical Officer 89-183 149 Child guidance The work of the Brixton child guidance unit has increased steadily during the year. It has been found to be particularly important to treat children with behaviour difficulties at an early age. Many children under five have been referred to the unit and doctors from the unit have attended the maternity and child welfare clinics to advise mothers on problems of child management. Recuperative holidays The demand for recuperative holidays has remained about the same as last year. It is of interest to note that a large proportion (25 per cent.) of applications are cancelled before placing is arranged. This is usually due to the fact that mothers are unable to leave their families or to make other arrangements for the care of their children. Unfortunately, Fairby Grange, a home for mothers and young children, was closed and there has been some difficulty in finding alternative accommodation. Health education The work of health education has been carried on throughout the year. The window of the sub-office in Brixton Road, Lambeth, has been used for the display of health education material. Division 9, comprising the boroughs of Battersea and Wandsworth. Dr. J. T. R. Lewis reports: I had the honour to commence my duties as divisional medical officer, division 9, on 7th January, 1952, and so this is the first report which I am privileged to make on the health services in this division, which were formerly in the capable charge of Dr. Bertha Sharpe. My two senior medical colleagues were also newly appointed to the division as assistant divisional medical officers, and the divisional administrative officer, after extensive experience of the public health service in another division had been in this division only since the previous November. The divisional nursing officer took over her duties at the inception of the divisional organisation and her experience of the work in the area proved of the greatest value. Much time, therefore, has been spent in 'feeling our way,' but some measure of positive work has also been achieved, to which brief reference is made in the following report. Premises The Gideon child welfare centre in Battersea was closed for some months while the adjoining school was demolished, but was later re-opened and returned to normal working. A new child welfare centre was opened at Fairlight Hall, Tooting. Steps have been taken to obtain additional school treatment accommodation to replace premises which will shortly be vacated in Tooting. Immunisation and vaccination The number of children immunised against diphtheria and whooping cough remained about the same as that for 1951, but the number of persons vaccinated was 20.7 per cent, fewer. Day nurseries In the fourteen day nurseries there are 683 places. Eleven of these nurseries are recognised for the training of students. A review of places and attendances was carried out during the year. Special investigation clinics The total number of sessions held at these clinics, which are concerned with the problem of bed-wetting, was 220 and the attendance was 1,957. This shows an increase of 5.2 per cent, and a decrease of 2 per cent, respectively on the figures for 1951. There were 256 new patients. Recuperative holidays The number of applications for recuperative holidays has remained fairly steady but there has been a slight decrease in the percentage placed through the division 55 per cent, of the total placing were made direct compared with 62 per cent, in 1951. Home help service Home helps attended 2,580 households, an increase of 10 per cent, over the previous year's figures. Home nursing Home nursing equipment has been lent to 24 patients compared with eight in 1950 and 29 in 1951. At the end of the year 19 patients were still using the equipment. District nurses paid 183,814 visits, an increase of 19.5 per cent. Health education As mentioned in last year s report, arrangements were made tor officers or the borough councils to give talks to school children on milk and its processing and bottling, designed to improve the condition of milk bottles returned from schools. These talks 150 have continued and have been much appreciated. By the end of the year, and since the inception of the scheme, 65 talks had been given to 14,390 children. During the year further talks to school children were introduced on food hygiene, with special reference to cleanliness in the kitchen, totalling 13 talks to 1,040 children. Careful consideration has been given to the whole subject of health education and my senior colleagues and I have taken every opportunity of speaking to parent-teacher associations and similar organizations. The department took part in an Old People's Exhibition which brought to the notice of the public the work done in the division for this section of the community. Business premises in prominent positions were loaned for a public exhibition illustrating various branches of the personal health services, and this aspect of health education is being actively pursued. Child neglect Particular attention has been paid to this problem during the year and meetings and discussions have been held with colleagues of other Council departments in the division. Arrangements were made for the maintenance of a register of neglected children and for the exchange of information between departments. It is essential that this very important work should be on a firm basis. Welfare of old people A close liaison has been maintained between the divisional staff and the other statutory and voluntary bodies concerned with this important work, and members of the divisional staff sit on various Committees dealing with this question. Particular attention has been paid to the arrangements made for the removal of old people to hospitals or homes and considerable success has been achieved in this direction without resort to statutory powers. Home helps have been provided where necessary and the health visitors made a large number of visits to old people. Review of sessions A comprehensive review of maternity and child welfare sessions and sessions held at school treatment centres was undertaken. Within the division the work has been re-organized on an area basis with, so far as practicable, one assistant medical officer undertaking all the clinical duties in that area. Child welfare sessions have been made ' combined sessions ' where immunisation and vaccination are carried out in addition to child welfare work. Co-operation with general practitioners and teachers The closest co-operation has been maintained with teachers organizations and meetings have been held with representatives of both the Battersea and the Wandsworth head teachers' associations. There has also been close contact with general practitioners, both through the local division of the British Medical Association, on which senior medical officers are represented, and with individual doctors. Cerebral palsy investigation An investigation is proceeding into the problem of cerebral palsy, in association with workers appointed by the Medical Research Council. Organization A brief reference might be permitted to the tri-partite arrangement in this division whereby the divisional medical officer is also medical officer of health for the two metropolitan boroughs constituting the division. There is, of course, everything to be said for the personal and the environmental health services being as closely co-ordinated as possible, and one way of achieving this end should be by means of the arrangement which operates in this area. No effort has been spared, therefore, to weld closely together the environmental health services, for which the borough councils are responsible, and the personal health services, which are the concern of the county Council. The new arrangement is of particular benefit and value in connection with those services which may be partly the responsibility of the borough councils and partly the responsibility of the county Council. For example, it is now possible to employ both borough and county Council staff, as may be desired, in the investigation and control of infectious disease, and the same principle applies in such matters as housing and the care of old people and their removal to hospitals or institutions. After only a year's experience of the new procedure it would be unwise to arrive at any final conclusion as to the practicability of the new scheme, but while maintaining 151 every caution in this respect a modest claim to some degree of success might, I think, be justifiable. In an effort of this kind the most important single factor making for success is the team-work and co-operation of all persons at all levels who are concerned with the services. I should, therefore, like to say a word of appreciation and thanks to everybody engaged in this important work at both member and officer level. I am very happy to record that I have received the greatest possible encouragement and help from the members of the two borough councils and the divisional health committee, and particularly from the chairmen of the two metropolitan borough public health committees and of the divisional health committee. My colleagues in both the borough councils and also the division have added to their extensive knowledge and efficiency (which were never, of course, in doubt) a readiness to co-operate and work together and to give of their best which has been most gratifying. We look forward to consolidating such success as has so far been attained and a further more detailed report will be made in due course. APPENDIX A—DEATHS AND SICKNESS IN LONDON IN DECEMBER, 1952. the most outstanding incident concerning the public health of London in 1952, was the sudden great increase in deaths and sickness which occurred simultaneously with the dense four-day fog at the beginning of December. Some idea of the relative size of this phenomenon is given by considering that in a comparatively short time this increase contributed directly between 0.5 and 1.0 per thousand to the year's general death-rate of 12.0 per thousand; had no such increase occurred the death-rate would in all probability have been between 11.0 and 11.5 per thousand. During December the weather had been on the whole slightly worse than might be expected for the time of year, with periods of cold and fog somewhat above the average. The general state of health in the County, as measured by such indices of morbidity as are available, was also a little worse than normal for the season with signs, towards the latter part of the month, of the growth of a moderate ' respiratory ' epidemic, which in itself is by no means unusual at this time. Of a true influenza epidemic there were no signs and it was not until the very last week in December that one of the influenza viruses was isolated in South-East England, heralding the spread of ingluenza in London in January and February, 1953. The table below shows the weekly values of the main morbidity indices from the beginning of November until the end of the first week in December, together with the weekly averages for these weeks in the preceding three years. In addition to the figures there shown the district nursing associations completed 5,026 cases of all types of home nursing in November as against an average figure of 4,040 for the same month in 1950 and 1951. Weekended 8 No. 15 Nov. 22 Nov. 29 Nov. 6 Dec. Av. of wks. 45-49, in 1949, 1950, 1951, Week number 45 46 47 48 49 Deaths registered in London A.C. 693 747 753 853 945 827 National insurance first certificates of sickness benefit issued in London A.C.* 9,281 9,182 9,099 10,606 11,678 10,623 Removals of in-patients to hospital by ambulance (excluding maternity and accident cases) in London A.C. 2,049 2,071 2,183 2,421 2,493 l,836† Emergency Bed Service applications (Greater London) 930 1,030 1,070 1,280 1,610 950§ *The week for sickness benefit certificates ends on Tuesday, i.e., Nov. 4,11, 18, 25 and Dec. 2. †1951 only. § 1950 and 1951 only. 152 In comparison with previous years both the numbers of persons removed by ambulance to hospital as in-patients in the County, and the number of applications to the Emergency Bed Service in the whole of Greater London were running at an appreciably higher rate throughout November. But it is necessary to use these figures with considerable caution in making comparisons over a period of years. Admissions to hospital depend as much on the availability of beds as on the need for them and the figures from year to year may reflect the former as much as the latter. (Judging by the yardstick of the E.B.S. warning system there was no undue pressure on hospital beds during this month, the first white warning being issued on 8th December). Again, the numbers of applications to the Emergency Bed Service may reflect the amount of use general practitioners choose to make of the service as much as the amount of acute sickness. District nursing cases completed were appreciably higher than in the previous two years and this was even more marked for those of their cases classified as respiratory, 1,126 in November, 1952, as against a November average of 750 for 1950 and 1951. These respiratory cases form the major part of the acute sickness dealt with by the district nursing associations during the winter. Some part of this increase can be accounted for by the fact that the district nursing service in London has been expanding steadily since 1948 but there remains a definite indication of a higher incidence of acute sickness so far as it affected district nursing. Of the two measures, the deaths registered and the First Certificates for Sickness Benefit, neither would appear, a priori, to be by itself a particularly accurate index of morbidity, the deaths relating only to those whose illnesses have terminated in one particular way and the sickness benefit claims being restricted to the employed (and presumably healthier) section of the community. Both measures, however, are free from the distortion introduced by variations in the availability of services and for comparative purposes depend only on the numbers exposed to risk—in the case of deaths the total population, in the case of sickness benefit claims the employed population. Over the years concerned the total population has remained substantially constant and the employed population in November, 1952, was less than 1 per cent, different from the average in November, 1950 and 1951. Both measures have shown themselves in the last few years particularly sensitive to widespread winter changes in morbidity and during the growth of a considerable epidemic, as for instance an influenza epidemic, they move very closely together. The correlation between the numbers of sickness benefit claims in the week ending on a Tuesday and the number of deaths, registered in the week ending the following Saturday is strikingly high especially during an epidemic period. For this November both measures were running at much the same rate as in the immediately preceding years, but showing a steady increase. Altogether it is reasonable to say that in November, 1952, there was a slightly higher incidence of sickness generally in London than might have been expected at this time of year from experience of the immediate past, while at the same time the weather was also somewhat worse than normal. There was nothing, however, in any of the morbidity indices on the scale of what is experienced during the growth of an influenza epidemic when the sickness benefit claims rise above 20,000 a week for several weeks in succession. As December began, this slow steady increase in new sickness continued. The sickness benefit claims were 11,678 in the week up to and including 2nd December, and 12,553 in the week up to and including 9th December. The deaths registered were 945, in the week up to and including 6th December. On the basis of the relationship between the sickness benefit claims to a Tuesday and the deaths to the following Saturday, as experienced in the period 14th October-6th December, 1952, and during the first 8 weeks of the influenza epidemic of early 1951, the 12,553 sickness benefit claims in the week ending 9th December, would be accompanied by an expected number of about 1,100 registered deaths in the week ending 13th December; or to allow for 153 some variation in any normal circumstances not less than 890 or more than 1,270.* In fact such expectation was quite confounded ; there were 2,484 deaths registered in the week ending 13th December. the week ending 13th December. The morbidity indices already given for the period up to 6th December, are continued in the table below for the remainder of December : Week ended 6 Dec. 13 Dec. 20 Dec. 27 Dec. Deaths registered in London A.C. 945 2,484 1,523 1,029 National insurance first certificates of sickness benefit issued in London A.C. §.. 11,678 12,553 17,977 9,624 Removals of in-patients to hospital by ambulance (excluding maternity and accident cases) in London A.C. 2,493 3,287 2,594 2,286 Emergency Bed Service applications (Greater London) 1,610 2,510 1,680 1,400 § The week for sickness benefit certificate ends on Tuesday, i.e., Dec. 2, Dec. 9, Dec. 16, Dec. 23. It is clear that at some time in the latter part of the week ended 6th December, or the early part of the following week, there was a sudden and radical change in the incidence of sickness and deaths, quite unlike anything experienced in a normal winter epidemic however severe. A day-by-day account of certain aspects of the weather and of sickness and deaths in the County of London from 1st December, to 10th December, is as follows : Monday, lsf December—Weather at Kew—Fine most of the day except for periods in morning and afternoon when fair. Mist in afternoon and evening. Fresh wind 06.40h., 09.30h.-14.40h. (ENE). Frost in morning ; mean air temperature 36-9°F. Atmospheric deposits at County Hall (reading taken at 09.30h. relating to the previous 46 hours)— 0-30 mg. of black matter per cubic metre, and 0-090 parts per million of sulphur dioxide. District nurses in London County began treatment of 81 new respiratory cases ; 112 deaths occurred f in the County ; 261 calls were met by the accident ambulance service and the average time the ambulances were out for a call was 44 minutes. Tuesday, 2nd December—Weather at Kew—Fine until mid-evening, then fair to cloudy. Mist in morning, haze in afternoon, then fog for a time in evening, thick 17.30h.-18.30h.; mist until mid-evening. Frost morning and evening ; mean air temperature 34-2°F. Atmospheric deposits at County Hall (reading taken at 16.30h. relating to the previous 31 hours)—0-49 mg./cubic metre smoke, 0-155 p.p.m. sulphur dioxide. District nurses began treatment of 69 new respiratory cases ; 140 deaths occurred in the County ; and 215 calls were met by the accident ambulance service (average time per call 35 minutes). Wednesday, 3rd December—Weather at Kew—Cloudy at first then fair till mid-morning, afterwards cloudless. Haze in evening. Fresh wind 02.50h.-15h. (N). Frost morning and evening ; mean air temperature 39-0°F. Atmospheric deposits at County Hall (reading taken at 16.30h. relating to the previous 24 hours)—0-61 mg./cubic metre smoke, 0-220 p.p.m. sulphur dioxide. District nurses began treatment of 71 new respiratory cases ; 143 deaths occurred in the County ; and 248 calls were met by the accident ambulance service (average time per call 43 minutes). Thursday, 4th December—Weather at Kew—Fine to fair early ; then generally cloudy until mid-evening, afterwards fair to fine. Haze in afternoon and early evening, then fog, thick 19.45h.-20.15h. Frost morning and evening ; mean air temperature 36.5°F. *For weeks No. 43-49, 1952 and No. 50, 1950-No. 5, 1951 inclusive, the correlation between the weekly number of sickness benefit claims expressed as a percentage of the mean of the three preceding years and the weekly number of registered deaths similarly expressed is 0 94. The regression of the deaths so expressed on the sickness benefit claims is y=48.6+0.54x. The 95 per cent, confidence limits for this regression coefficient are 0.44<b<0.64. The standard error of estimate is 11 as a percentage of the average for previous three years or 96 deaths in the week ended 13th December. †The number of daily deaths occurring are taken from a paper by the Chief Medical Statistician at the General Register Office. Logan, W. P., 'Lancet,' 1953, 1. 336. 154 Atmospheric deposits at County Hall (reading taken at 16.30h. relating to the previous 24 hours)—0.49 mg./cubic metre smoke, 0.144 p.p.m. sulphur dioxide. District nurses began treatment of 48 new respiratory cases ; 120 deaths occurred in the County ; and 244 calls were met by the accident ambulance service (average time per call 34 minutes). These first four days of December were normal winter days with nothing unusual in their load of morbidity and mortality. On the Thursday evening the thick fog came down. Friday, 5th December—Weather at Kew—Fine until mid-morning, then fair, sky becoming obscured by fog afterwards. Fog all day, thick 05h.-08.15h., 11.10h.-24h. Frost all day, rime in morning, mean air temperature 29.5°F. Atmospheric deposits at County Hall (reading taken at 16.30h. relating to the previous 24 hours)—2.64 mg./ cubic metre smoke, 0.751 p.p.m. sulphur dioxide. District nurses began treatment of 98 new respiratory cases; 196 deaths occurred in the County; and 311 calls were met by the accident ambulance service (average time per call 39 minutes). Saturday, 6th December—Weather at Kew—Sky obscured by thick fog all day. Frost and rime all day; mean air temperature 28.9°F. Atmospheric deposits at County Hall (reading taken at 11.30h. relating to the previous 19 hours)—3.45 mg./cubic metre smoke, 0.855 p.p.m. sulphur dioxide. District nurses began treatment of 78 new respiratory cases; 294 deaths occurred in the County; and 337 calls were met by the accident ambulance service (average time per call 96 minutes). Sunday, 1th December—Weather at Kew—Sky obscured by thick fog all day. Frost all day; mean air temperature 28.9°F. Atmospheric deposits at County Hall*. District nurses began treatment of 42 new respiratory cases; 513 deaths occured in the County; and 247 calls were met by the accident ambulance service (average time per call 118 minutes). Monday, 8th December—Weather at Kew—Sky obscured by fog until morning, then cloudy to fair until late afternoon, afterwards fine. Fog most of day, thick until mid-day, and from 16.45h. Frost morning and evening; mean air temperature 31.5°F. Atmospheric deposits at County Hall (reading taken at 09.30h. relating to the previous 46 hours)*—4.46 mg./cubic metre smoke; 1.339 p.p.m. sulphur dioxide. District nurses began treatment of 175 new respiratory cases; 518 deaths occurred in the County; and 316 calls were met by the accident ambulance service (average time per call 76 minutes). Tuesday, 9th December—Weather at Kew—Fine at first becoming fair, then cloudy most of day. Fog in morning, thick until 04.30 h.; mist in afternoon. Frost in morning; mean air temperature 36.0°F. Atmospheric deposit at County Hall†. District nurses began treatment of 227 new respiratory cases1; 430 deaths occurred in the County; and 277 calls were met by the accident ambulance service (average time per call 48 minutes). Wednesday, 10th December—Weather at Kew—Cloudy until early evening, then fair. Intermittent light drizzle and rain morning and afternoon ; light to moderate rain late. Fresh wind 11.05-25h., 12h-14h. (S), 16.15h.-17h. (SSW). Mean air temperature 43.3°F. Atmospheric deposit at County Hall (reading taken at 16.30h. relating to the previous 55 hours)—1.22 mg./cubic metre smoke, 0.472 p.p.m. sulphur dioxide. District nurses began treatment of 184 new respiratory cases; 274 deaths occurred in the County; and 273 calls were met by the accident ambulance service (average time per call 41 minutes). It is apparent from this brief diary of the ten days covering the fog period that the pattern of sickness, accident and death changed abruptly shortly after the fog and cold *No readings are taken at County Hall on a Sunday, and the figures here given for Sunday and Monday are the averages for the 46 hours since 11,30h. on Saturday. †On this particular Tuesday no readings were taken at County Hall; the figures here given for the Wednesday are the averages for the 55 hours ending at 16.30h. on Wednesday. 155 began. What is perhaps not immediately obvious is the magnitude of this change ; by the time the fog had lain over London for two days and three nights with the temperature below freezing for almost the whole of that time, the death rate had risen to a height last experienced in this city in the influenza epidemic of 1918 and the deaths continued at this rate for two whole days and fell only slightly on the third. During these three days, December 7th, 8th and 9th, in London Administrative County approximately 440 persons out of every million living died; in 1918 during the worst three days of the week ending 9th November, approximately 470 persons out of every million living in London died; and during Monday, Tuesday and Wednesday, September 3rd, 4th and 5th, 1849, approximately 570 persons out of every million living in London died—these were the worst three days in London of the worst cholera epidemic on record. With regard to the extent of sickness, it is not possible to make such clear and chilling comparisons for want of information. But the rise in incidence was as sudden from the level of the previous weeks as was the rise in the deaths; district nurses took on an average of 67 new respiratory cases a day in the first four days of December; on December 8th, 9th and 10th they took on 173, 227 and 181 such cases. Dr. Abercrombie in a detailed analysis* of the work of the Emergency Bed Service covering Greater London during this period says: 'In 1952, owing to the prevalence of cold weather since early November, the work of the service rose steadily throughout that month with the result that on 1st December, 243 general acute applications were received instead of the normal 130 or so. This rise continued until 6th December, when the fog settled on London, and the number of applications rose very rapidly, reaching an unprecedented peak on 9th December, when 492 were received. Applications continued in abnormally high but diminishing numbers until the 13th, after which a fairly stable state was reached.' It has already been noted that the Emergency Bed Service applications tend to over-emphasise a rise in acute sickness since general practitioners will make more use of the service under such conditions; but a rise such as that described by Dr. Abercrombie must very largely represent a real and sudden increase. In the Administrative County the total number of patients removed to hospital by the ambulance service (excluding maternity and accident patients) was 2,493 in the week, Sunday, 30th November-Saturday, 6th December ; in the following week it was 3,287. The proportion of these removals, for whom arrangements were made through the Emergency Bed Service, had been rising steadily over the preceding weeks; it was 17 per cent, in the week ending 8th November, 18 per cent, in the two following weeks, 19 per cent, in the next week, 22 per cent, in the week ending 6th December and 24 per cent, in the week ending 13th December. The variation in this proportion can be taken as an indication of the extent to which general practitioners shifted their demands for hospital accommodation from the more usual channels to the E.B.S. Dr. Abercrombie describes also how the demands on the hospitals through the E.B.S. were met and the workings of the E.B.S. warning system : 'When the percentage of admissions to applications, calculated on the moving weekly totals, falls below 85 per cent., a "white" warning is sent to the appropriate hospital authorities' 'If the percentage falls below 80 per cent, a "yellow" warning is issued, and if below 75 per cent, a "red" warning' 'On 1st December the admission-rate was 88.5 per cent., and in spite of increasing pressure it was kept above 85 per cent, until Sunday, the 7th, when it fell to 84.9 per cent.; a "white" warning was issued at 11 a.m. next day. On Tuesday, the 9th, the rate was 79.9 per cent., and the "yellow" warning was issued. The response was such that, despite the high total of applications, the admission-rate fell only a further 1.5 per cent. The "yellow" warning was cancelled on 15th and the "white" on the 17th. *Abercrombie, G. F. * Lancet,'1953, 1.234. 156 A moving weekly total, however, is not a very sensitive measure when the incidence of acute sickness is changing with the rapidity which characterised the period 6th—10th December ; and Dr. Abercrombie shows that on the day when applications for admission were at their maximum, Tuesday, the 9th, the daily admission-rate fell steeply to only just over 71 per cent. On this particular day some 30 new respiratory cases were taken on in the Administrative County by the district nursing associations, either on direct application from hospitals for attention pending admission or where the cases were admitted to hospital within a day or two; few other cases of this type occurred during November or December. It seems therefore that by this Tuesday, the incidence of new acute sickness had been rising and was still rising so rapidly that for a very short period there was a substantial gap between the demands on the hospitals and the ability to meet these demands immediately. In view of the present efficiency of the system for emergency admission, this gives an indication of how sudden and how great was the rise in acute sickness. The diagram opposite shows graphically the variation day-by-day from 27th November to 18th December of the atmospheric conditions and of mortality in the County of London ; also the number of new respiratory cases undertaken by District Nurses and the average time per call taken by the accident service ambulances, the former as an index of the variation in morbidity and the latter as an index of the difficulty of traffic movement. All these measures show a close correspondence in their movements over this period. Dr. Logan, Chief Medical Statistician at the General Register Office, *says of the mortality 'One of the most striking features was the rapidity at which deaths started to increase Even on 5th December, the first day of the fog, there was an obvious increase in the number of deaths, and the daily totals mounted rapidly to their highest levels on 7th and 8th December There was some decline on 9th December, and a still greater decline on 10th December; but even on 15th December, the daily total was almost twice as high as before the fog began.' The increase on 5th December in new respiratory cases begun by district nurses was almost exactly the same as the increase in the deaths—the deaths increased 52 per cent, over the average of the preceding four days, the new nursing cases 45 per cent. On Saturday, 6th and Sunday, 7th, however, the new respiratory nursing cases declined again before rising sharply on Monday, 8th, and again on Tuesday, 9th, to a peak 240 per cent, above the average of the first four days of December. Normally the number of new nursing treatments falls off on a Saturday and Sunday, due in part no doubt to patients' unwillingness to bother their doctor at the week-end; a similar drop every Sunday is noticeable in the applications to the Emergency Bed Service and this drop duly took place in the applications on 7th December as compared with 6th December. The true pattern of daily incidence of sickness is thus obscured in the only figures available by the fact that the critical days fell at a week-end; but it is clear enough that the daily number both of persons needing admission to hospital and of those needing home nursing began to increase with startling fapidity on the first day of the fog simultaneously with the rise in the number of deaths; and it is a reasonable assumption that the number of persons falling sick, as distinct from the numbers contacting the medical services, continued to increase over the week-end so that their accumulated numbers gave rise in part to the great increase of apparent new sickness on Monday and Tuesday. It is also reasonable to assume that this does not wholly account for the peaks of sickness falling later than the peak of deaths. The maximum deaths were on Sunday and the maxima of applications to E.B.S. and of new respiratory cases begun by district nursing associations were both on Tuesday. If the two latter maxima represented merely the back-log from the weekend they should have fallen on the Monday rather than Tuesday. The figures strongly suggest that there was some difference between the time incidence of deaths and that of acute sickness in relation to the fog ; that whereas the daily number of deaths started *Logan, W. P. D. 'Lancet,' 1953, 1. 336. 157 LONDON ADMINISTRATIVE COUNTY CERTAIN DAILY MEASURES FROM 27.11.1952 TO 18.12.1952 158 Table A Deaths in the six weeks ended 27th December, 1952 Classified by age groups Week 0-4 weeks 4 weeks to to 1 year 1-4 years 5-14 years 15-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75 and over (years) All ages No. Ending 47 22nd Nov. .. 13 5 11 4 4 14 28 85 118 229 242 753 48 29th „ 22 9 5 3 3 7 22 61 152 226 343 853 49 6th Dec. 16 12 6 4 9 16 36 80 157 254 355 945 50 13th „ 28 26 7 6 7 28 64 204 448 717 949 2,484 51 20th „ 19 15 13 6 14 17 29 96 251 444 619 1,523 52 27th „ 12 11 7 2 7 11 34 83 167 258 437 1,029 Average—47,48,49 17.0 8.7 7.3 3.7 5.3 12.3 28.7 75.3 142.3 236.3 313.3 850.3 Weeks 50, 51, 52 as a percentage of the average for weeks 47, 48 and 49. Average—47,48, 49 100 100 100 100 100 100 100 100 100 100 100 100 50 .. .. .. 165 300 96 164 131 227 224 271 315 303 303 292 51 .. .. .. 112 173 177 164 263 138 102 127 176 188 198 179 52 .. .. .. 71 127 96 55 131 89 119 110 117 109 139 121 Classified by certain causes Week Pul. T.B. Cancer of lung Heart disease High blood pressure Other diseases of circulatory system Influenza Pneumonia Bronchitis Other resp. Illdefined causes All other causes All causes No. Ending 47 22nd Nov 18 38 225 12 27 1 31 46 10 19 326 753 48 29th „ 19 27 272 17 23 7 28 73 8 26 353 853 49 6th Dec. 14 45 273 19 26 2 45 76 9 25 411 945 50 13th „ 77 69 707 47 46 24 168 704 52 79 511 2,484 51 20th „ 37 32 389 36 31 9 125 396 21 35 412 1,523 52 27th „ 21 36 272 21 32 6 91 184 13 37 316 1,029 Average—47,48,49 17.0 36.7 256.7 16.0 25.3 3.3 34.7 65.0 9.0 23.3 363.3 850.3 Weeks 50, 51, 52 as a percentage of the average for weeks 47, 48 and 49. Average—47, 48, 49 100 100 100 100 100 100 100 100 100 100 100 100 50 .. .. .. 453 188 275 294 182 720 486 1,083 578 339 140 292 51 .. .. .. 218 87 152 225 123 270 362 609 233 150 113 179 52 .. .. .. 124 98 106 131 127 180 264 283 144 159 87 121 159 to increase rapidly as soon as the fog and cold began, and started to decrease as soon as the fog lifted and the temperature rose, the number of people falling seriously ill each day, while starting to increase as rapidly and as soon as the deaths, continued to increase throughout the period of fog and cold, was at its highest on the first day of return to normal weather, and thereafter decreased more slowly than the deaths. This means that during the week after the fog there were very considerably more persons lying seriously ill, especially with respiratory complaints, than on any of the four days of the fog itself; but the numbers of deaths were greatest on the four days of the fog and the day following. Table A, page 158, shows an analysis of the deaths registered in the County of London each week from 15th November to 27th December, by age groups and by certain causes. There is in general a certain delay between the occurrence and the registration of a death and a large part of the deaths occurring on Friday, 5th and Saturday, 6th, will have been registered in the week ending Saturday, 13th December. The sudden great increase in mortality reflected in the registration during this week although most pronounced among babies and the elderly, was not confined to persons of any particular ages. Among children aged 4 weeks to 1 year and among persons aged over 55, three times as many deaths were registered in the week ending 13th December as could be expected from the figures for the three previous weeks, and among persons of all other ages rather over twice as many. The causes associated with the excess deaths were confined almost entirely to disorders of the circulatory or respiratory systems. Compared with the average per week in the previous three weeks, deaths from bronchitis in the week ending 13th December were ten times as many, from influenza seven times as many, from pneumonia nearly five times as many, from pulmonary tuberculosis four-and-a-half times as many, and from other respiratory diseases nearly six times as many; from cancer of the lung they rose rather less, to nearly twice as many; from disorders of the heart and circulatory system they were nearly three times as many. Deaths from any other defined cause show no significant increase with the exception of gastro-enteritis, deaths from which increased considerably among children under one year old; reference to the certified causes of death in these cases reveals that for half of them there was a parenteral infection shown as an associated cause. At no age were any excess deaths registered from causes which are not normally characteristic of that age during winter. Deaths from influenza, although they rose markedly in the week after the fog, rapidly fell back to a normal winter level and at their highest were well below the numbers to be expected in a developing epidemic. Table B, page 162, shows day-by-day from 16th December to 31st December, the numbers of nursing treatments begun by the district nursing associations for respiratory causes according to the age of the patient. The age distribution here, as might be expected, is very similar to the age distribution of deaths. Striking increases in mortality have previously occurred in London in conjunction with periods of intense fog and cold. The last two occasions on which mortality changes thus observed were on a scale as great as in 1952, were in December, 1873, and February, 1880. Extracts from the Registrar-General's returns giving details of the weather at the times of the fogs and the numbers of registered deaths each week by age and certain causes for the seven weeks covering the fog periods for each of these years are given below. These figures refer to an area which is substantially the area now included in the Administrative County. At both times almost exactly the same pattern of changes made itself apparent in the week following the fog and cold as was observed in 1952 ; namely, rises in mortality at all ages but more especially among the very young and the old, these rises being almost entirely confined to deaths from respiratory and heart diseases. (No very direct comparison is possible between the numbers dying of various causes in 1873 or 1880 and 1952, owing to the very considerable changes in the methods of classification of causes of death which have taken place over the intervening period.) l 160 London deaths in period covering fog in 1873 London population 3,356,073 Mean dai\y temperature Tuesday, 9th December, 29.7° Wednesday, 10th December, 24.6° Thursday, 11th December, 28.3° Friday, 12th December, 34.6° Saturday, 13th December, 35.3° Hoar frost, overcast during middle of day. Fog varying in density, generally very thick. Overcast with exception of a period during afternoon. Very dense fog throughout. Visibility 10 yards. Cloudy in morning and at night. Cloudless during mid-day. Dense fog. Clouds broken, sunshine at times. Fog prevalent but not so dense. Overcast and dull. Foggy at times. Registered deaths by age Week ended All ages Under 1 1-4 5-19 20-39 40-59 60 and over 22nd Nov. 1,674 (1,546) 422 318 118 207 264 345 29th Nov. 1,585 (1,537) 352 319 85 226 244 359 6th Dec. 1,484 (1,558) 370 304 101 173 236 300 13th Dec. 1,759 (1,544) 329 333 90 261 331 415 20th Dec. 2,415 (1,487) 409 427 126 304 452 697 27th Dec. 1,540 (1,542) 281 292 84 221 290 372 3rd Jan. 1,842 (1,542) 401 341 96 226 325 453 Registered deaths by certain causes Week ended All causes Phthisis Bronchitis Pneumonia Heart disease Whoopingcough 22nd Nov. 1,674 152 (172) 262 (226) 128 (117) 85 (75) 46 (39) 29th Nov. 1,585 136 (163) 285 (235) 127 (107) 72 (72) 34 (40) 6th Dec. 1,484 148 (166) 248 (235) 80 (109) 77 (71) 41 (48) 13th Dec. 1,759 201 (159) 364 (231) 102 (113) 94 (68) 42 (52) 20th Dec. 2,415 205 (157) 632 (208) 163 ( 94) 145 (70) 70 (54) 27th Dec. 1,540 138 (165) 352 (224) 87 ( 96) 72 (74) 53 (52) 3rd Jan. 1,842 175 (165) 351 (224) 132 ( 96) 94 (74) 69 (52) Figures in brackets are the averages in the corresponding week over the previous ten years. In early 1880 there appears to have been a whooping-cough epidemic in progress and the deaths from this cause showed a marked increase. In 1880 again the rise in deaths from all causes was greater in the week following the fog than in 1873, although the deaths in the preceding weeks had been running at about the same level in both years. In 1880, however, the fog wais associated with slightly colder weather than in 1873 or 1952. Below are shown the rates per million inhabitants of the deaths registered in the weeks following the fogs in these three years. 161 London deaths in period covering fog in 1880 London population 3,769,390 Mean daily temperature Monday, 20th January, 26.1° Tuesday, 27th January, 25.9° Wednesday, 28th January, 23.4° Thursday, 29th January, 24.0° Friday, 30th January, 39.6° Saturday, 31st January, 36.7° Fog and hoar frost in morning; fine throughout day. Fog and hoar frost in morning; fine in afternoon ; foggy at night. Fog prevailed all day; much hoar frost. Dense fog prevailed generally. Much hoar frost. A very fine day; cloudless throughout. A rapid thaw. Fine; hoar frost in morning; fog prevalent, very dense in low grounds. Registered deaths by age Week ended All ages Under 1 1-4 5-19 20-39 40-59 60 and over 10th Jan 1,754 (1,830) 389 385 128 188 291 373 17th Jan. 1,730 (1,760) 396 359 117 180 251 427 24th Jan. 1,900 (1,761) 466 366 109 214 292 453 30th Jan. 2,200 (1,705) 473 434 112 266 382 533 7th Feb. 3,376 (1,718) 546 593 152 404 664 1,017 14th Feb. 2,495 (1,764) 476 493 140 264 451 671 21st Feb. 2,016 (1,791) 502 402 115 208 310 479 Registered deaths by certain causes Week ended All causes Phthisis Bronchitis Pneumonia Heart disease Whoopingcough 10th Jan. 1,754 148 (175) 301 (322) 108 (110) 79 (101) 120 (63) 17th Jan. 1,730 149 (176) 347 (306) 113 (102) 74 ( 94) 114 (64) 24th Jan. 1,900 160 (171) 372 (303) 120 ( 96) 95 ( 90) 140 (68) 31st Jan. 2,200 207 (178) 531 (273) 149 ( 91) 111 ( 96) 193 (72) 7th Feb. 3,376 313 (186) 1,223 (284) 212 ( 98) 187 ( 94) 248 (75) 14th Feb. 2,495 212 (190) 760 (308) 171 (101) 105 ( 94) 197 (74) 21st Feb. 2,016 159 (191) 479 (312) 148 (102) 84 ( 95) 171 (80) Figures in brackets are the averages in the corresponding week over the previous 10 years. Deaths per million inhabitants in London Week ended 20th December, 1873 7th February, 1880 13th December, 1952 Number of deaths registered during week per million inhabitants 719 896 739 162 Table B District nursing associations Respiratory cases begun day by day 16.11.52—31.12.52 Date Age All* ages Under 1 1-14 15-44 45-64 65+ 1952 Nov. 16 — 4 5 4 3 16 „ 17 1 6 10 10 9 36 „ 18 2 14 14 13 9 52 „ 19 1 13 13 8 12 47 „ 20 — 16 12 13 12 53 „ 21 3 16 10 13 13 55 „ 22 3 14 11 5 14 47 „ 23 — 6 2 6 3 17 „ 24 — 8 8 17 18 51 „ 25 1 11 14 12 19 57 „ 26 — 13 10 12 21 56 „ 27 1 12 16 9 15 54 „ 28 1 9 13 19 21 63 „ 29 3 15 14 11 13 56 „ 30 1 6 8 2 7 24 Dec. 1 1 16 14 21 29 81 „2 3 12 11 22 21 69 „ 3 2 11 12 21 25 71 „ 4 3 10 10 11 14 48 „ 5 2 18 23 28 27 98 2 6 1 4 19 15 38 78 „7 1 7 7 10 17 42 „ 8 2 11 18 51 91 175 „ 9 3 23 23 54 124 227 „ 10 3 16 26 48 90 184 „ 11 6 16 21 51 86 180 „ 12 4 23 18 30 65 141 „ 13 2 15 12 33 55 117 „ 14 1 6 1 18 15 41 „ 15 1 19 11 32 47 110 „ 16 2 19 21 30 53 125 „ 17 2 14 28 25 39 108 „ 18 4 12 17 26 25 84 „ 19 3 23 13 26 33 98 „ 20 1 17 21 27 31 98 „ 21 — 10 13 12 12 48 „ 22 2 9 16 24 37 88 „ 23 3 12 22 14 26 77 „ 24 2 16 13 14 24 69 „ 25 — 4 5 3 7 19 „ 26 1 5 5 8 6 25 „ 27 5 9 15 15 21 66 „ 28 2 5 9 9 6 31 „ 29 2 14 23 19 39 97 „ 30 2 18 21 30 38. 109 „ 31 5 5 13 15 22 60 *The 'all ages' figures exceed the totals of the individual age groups in certain cases where the patient's age was not given. 163 It should be borne in mind that in 1873 and 1880 the general level of winter mortality was higher than it is now ; it was about 450 per million inhabitants per week then compared with about 300 per million inhabitants per week now. On the other hand in both 1873 and 1880 the fogs and cold prevailed during the middle of a week and the deaths which occurred simultaneously would have been registered partly in the week of the fog and only partly in the subsequent week, whereas in December 1952 when the fog prevailed at the week-end the concurrent deaths would almost all have been registered in the subsequent week. In conclusion it is perhaps worthwhile to reproduce from the Registrar-General's weekly returns the numbers of deaths from all causes registered weekly from 15th November to 27th December, 1952, in the eight towns in the South-Eastern Region outside the London conurbation. These eight towns are Brighton, Canterbury, Eastbourne, Gillingham, Hastings, Hove, Maidstone and Worthing. The weather conditions experienced during this period by these towns were not greatly dissimilar from those experienced by London. But these towns do not disgorge into the air so vast a volume of smoke and noxious fumes as does the conurbation of London. The figures are as follows : Deaths in the eight towns in South-Eastern Region outside Greater London, 1952 Week ended 22nd Nov. 29th Nov. 6th Dec. 13th Dec. 20th Dec. 27th Dec. Registered Deaths 200 215 194 230 220 191 APPENDIX B POLIOMYELITIS AND INOCULATIONS A survey relating to the epidemic in 1949 (By B. Benjamin and A. T. Gore, of the statistical section) during an epidemic of poliomyelitis in Melbourne, Australia, which began in January, 1949, McCloskey (1) reported an apparent association between the site of paralysis involved in poliomyelitis and the limb in which injections had been given in the course of immunisation against diphtheria and whooping-cough. Consequently, attention was directed to a number of cases in which paralysis followed closely upon inoculation and in which the limb paralysed was that inoculated during the course of the epidemic in this country in the summer of 1949. The coincidence was not in itself proof of cause and effect since association in time could and should occur in accordance with the same laws of chance which also determine that a certain number of people are likely to pass over a railway bridge at the same instant as a train passes under it without being suspected of designing the time-table. In addition to taking certain control action, e.g., stopping the use of the antigen most often involved, the London County Council made an immediate local investigation (as did also the Ministry of Health on a national scale) of these cases of paralysis after inoculation. The immediate object was to ascertain whether the frequency of occurrence of such double events (i.e., inoculation and paralysis) was greater than could be accounted for by chance coincidence. The results of this inquiry, which were made public (2), indicated that there was a prima facie case for causal association in a proportion of the cases leaving a proportion to be accounted for by chance. 164 Table 1A—A.P.T. antigen Poliomyelitis in the month of: Immunised in the month of No. at risk 1949 1950 Total Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Observed Expected 000 001 0-01 0-01 January 863 — — — — — 0.03 O.OO 0.02 0.01 0.02 February 1,658 — — — — — 0.05 0.01 0.02 0.02 0.02 March 1,711 — — — — — 0.07 0.00 0.01 0.01 0.03 April 1,315 — — — — — 0.05 0.01 0.01 0.03 0.63 May 1,545 — 1 — — 1 0.68 0.01 0.03 0.56 0.43 June 1,385 1 1 — — 2 1.03 0.01 0.52 0.40 0.62 July 1,280 1 2 — — 3 1.55 0.27 0.41 0.65 0.39 August 1,336 1 2 — — 3 1.72 0.21 0.67 0.40 0.13 September 1,381 2 2 — — 4 1.41 0.72 0.85 0.28 0.09 October 2,947 1 — — — 1 1.94 0.36 0.24 0.08 0.08 November 2,517 1 — — — 1 0.76 0.07 0.05 0.05 0.05 December 1,598 — — — — — 0.22 Total diagonals observed 1.67 2.84 2.50 2.50 15 9.51 7 8 — — Figures in italics are the expected cases calculated from the not inoculated group, see text. 165 Table IB—Combined diphtheria and whooping-cough antigen Poliomyelitis in the month of: Immunised in the month of No. at risk 1949 1950 Total Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Observed Expected 0.00 0.00 0.01 0.00 January 711 — — — — — 0.01 0.00 0.01 0.00 0.01 February 718 — — — — — 0.02 0.01 0.02 0.02 0.02 March 1,790 — — 1 — 1 0.07 0.01 0.02 0.02 0.03 April 1,708 — — — — — 0.08 0.01 0.02 0.04 0.82 May 2,030 — — — — — 0.89 0.01 0.03 0.70 0.53 June 1,714 — 2 1 — 3 1.27 0.02 0.83 0.63 1.00 July .. .. 2,044 2 2 2 1 7 2.48 0.41 0.63 0.98 0.58 August 2,017 3 8 1 — 12 2.60 0.34 1.10 0.64 0.21 September 2,224 8 3 — — 11 2.29 0.17 0.21 0.07 0.02 October 707 3 — — — 3 0.47 0.07 0.05 0.02 0.02 November 517 — — — — — 0.16 0.01 0.01 0.01 0.01 December 290 — — — — — 0.04 Total diagonals observed 1.06 2.93 3.14 3.25 37 10.38 16 15 5 1 Figures in italics are the expected cases calculated from the not inoculated group, see text. 166 Table 1C.—All other antigens Poliomyelitis in the month of: Immunised in the month of No. at risk 1949 1950 Total Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Observed Expected 0.00 0.00 0.01 0.01 January 531 — — — — — 0.02 0.00 0.00 0.00 0.01 February 446 — — — — — 0.01 0.00 0.01 0.01 0.01 March 647 — — — — — 0.03 0.00 0.00 0.01 0.01 April 536 — — — — — 0.02 0.00 0.01 0.01 0.27 May 653 — — — — — 0.29 0.01 0.01 0.28 0.21 June 681 — — — — — 0.51 0.01 0.25 0.19 0.31 July 620 — — — — — 0.76 0.11 0.17 0.27 0.16 August 559 — — — — — 0.71 0.10 0.32 0.19 0.06 September 665 — — 1 — 1 0.67 0.12 0.14 0.05 0.02 October 485 — — — — — 0.33 0.08 0.05 0.02 0.02 November 522 — — — — — 0.17 0.02 0.01 0.01 0.01 December 361 1 — — — 1 0.05 Total diagonals observed 0.45 0.97 1.05 1.10 2 3.57 1 1 — Figures in italics are the expected cases calculated from the not inoculated group, see text. 167 Later Bradford Hill and Knowelden (3) made a thorough analysis of national data the results of which may be summarised as follows : (a) In cases of poliomyelitis the distribution of paralysis by site was abnormal in children who had had an injection of antigen in the month preceding onset of illness. In children not so inoculated or without any recent injection paralysis occurred equally in the right and left arms and paralysis in the legs was between two or three times as frequent as paralysis in the arms. In those inoculated within the preceding twenty-eight days paralysis was more frequently observed in the left arm than in the right, arm and paralysis in the arms was more frequent than paralysis in the legs. (b) Comparison of poliomyelitis cases with 'controls showed that more of the former had been inoculated at some time. Division by time revealed that this excess lay wholly in inoculations given within the month preceding the onset of the attack of poliomyelitis, suggesting that inoculation had brought some children into the paralysed group who would not otherwise have been there. In reporting the London County Council data (2) which were similar in sort to those referred to in (b) above it was stated that' these figures suggest that in a few cases poliomyelitis has been associated with inoculation with the combined (diphtheria and whooping-cough) antigen, but they do not measure the risk of an inoculated child being attacked by poliomyelitis. To measure this risk would mean comparing the incidence of poliomyelitis in inoculated and uninoculated infants and would not be easy to do because of difficulty in assessing the proportions of these two groups in the population.' Nevertheless it was considered essential that the difficulties should be faced and that the risks should be assessed as accurately as possible. It was therefore decided to survey inoculations carried out during 1949 in London. A total survey was considered impractical and indeed unnecessary since the numbers involved were so large that a random sample was likely to be statistically adequate. In fact, a one in five sample was made of children who had been inoculated. In Tables 1A, 1B and 1C are shown cases of poliomyelitis aged nine months to two years in the month in which they occurred related to the month of inoculation and up to the third month following inoculation. This has been tabulated for A.P.T. and the combined antigen separately and for all other antigens together (these are a mixture of P.T.A.P., F.T., T.A.F. and the three proprietary brands of pertussis vaccine). The month of inoculation is the month in which the last injection was given ; earlier injections arc ignored. This assumes that if the last injection was given, say seventeen days before onset and the earlier injection, say, forty days before onset, the earlier injection did not influence the incidence of poliomyelitis. Thus the cases of poliomyelitis in these Tables are shown once only in relation to the most recent inoculation ; there is no question of duplicate entries. The last injection may have been a first, second or third primary, i.e., they are entered irrespective of order. In Table 2 is a group labelled 'not inoculated group' being the residue of poliomyelitis cases not inoculated within three months of contraction of poliomyelitis. It is assumed that an injection more than three months before onset of the disease could not have exerted any influence thereon. These then form the numerators in the subsequent calculations. The reason for confining this study to the narrow age limits of 9 months to 1 year 11 months is that the sample survey demonstrated that it is within these ages that immunisation very largely took place in 1949. The age of the children throughout this study is reckoned as the age at the date of inoculation. The ' exposed to risk ' in these tables are the number of children receiving in any given month the final inoculation of a series with stated antigen. This number has been estimated by taking those who completed a course in the stated month together with an allowance for those who had an inoculation (not the last of a complete course) and who did not return for further inoculations. There remains the calculation of the denominators for the ' not inoculated ' group Table 2. In the inoculated groups, cases of 168 Table 2 Not inoculated, or inoculated three or more months before onset of poliomyelitis [###Month No. at risk No. of cases of poliomyelitis Rate per 1,000 inoculated January 58,487 1 mean rate 0.0090 February 59,269 March 57,203 1 April 54,966 — May 52,843 1 June 52,085 — July 52,089 1 0.0192 August 51,736 21 0.4059 September 51,694 16 0.3095 October 51,335 25 0.4870 November 51,723 15 0.2900 December 53,386 5 0.0937 January 53,954 — mean rate 0.0313 February 53,741 4 March 52,295 1 poliomyelitis have been shown as they occurred in the same month and in the first, second and third months following inoculation, i.e., a total period of four months. Therefore, in construction of the ' exposed to risk ' for the ' not inoculated ' group, children given a final inoculation in the same month and in the preceding three months should be excluded and this has been done in the Table. The number of children inoculated was derived from the one in five sample census of the entire inoculated ' population' in 1949. The numbers inoculated in the last three months of 1948 and the first three months of1950 have been estimated on the basis of the 1949 figures. The former are required in the calculation of the exposed to risk in January, February and March, 1949, and the latter for the calculation of the exposed to risk in January, February and March, 1950. From these figures attack rates have been calculated month by month. These attack rates have been applied to the numbers at risk in the inoculated groups to calculate the expected number of cases, shown in italics against the relative observed number (Tables 1A, IB and 1C). We have, therefore, month by month, the number of cases observed with the expected number on the basis of the experiences of the ' not inoculated' children at the particular seasonal level of prevalence of poliomyelitis. Correction for seasonal fluctuation of risk has thus been fully carried out. The reason for carrying the calculation of the expected rates into January, February and March, 1950, is to apply these rates to those inoculated in the months of October, November and December, 1949, for the first, second and third months of exposure following inoculation. A comparison of the observed number of cases of poliomyelitis with the expected number (based on the experience of the children not inoculated) for the different antigens used month by month is given in Table 3. This is for all intervals following inoculation aggregated together. 169 Table 3 Poliomyelitis cases by different types of antigens by months of the year with the expected number of cases calculated from the not inoculated group. Month A.P.T. Combined All other antigens Observed Expected Observed Expected Observed Expected January — 0.03 — 0.01 — 0.02 February — 0.05 — 0.02 — 0.01 March — 0.07 1 0.07 — 0.03 April — 0.05 — 0.08 - 0.02 May 1 0.68 — 0.89 — 0.29 June 2 1.03 3 1.27 — 0.51 July 3 1.55 7 2.48 - 0.76 August 3 1.72 12 2.60 — 0.71 September 4 1.41 11 2.29 1 0.67 October 1 1.94 3 0.47 - 0.33 November 1 0.76 — 0.16 - 0.17 December — 0.22 — 0.04 1 0.05 In the early months of the year the number of cases of poliomyelitis was sporadic and the use of any kind of rates at all based on such small data may be held to be not justifiable. However, as poliomyelitis became epidemic in the summer months the comparison becomes more realistic. In the months of June and July the observed number of cases is nearly twice the expected number for A.P.T. and more than twice as great for the combined antigen; in August the observed number exceeds the expected by 70 per cent, for A.P.T., while, for the combined vaccine, the observed cases are more than four times those expected ; in September the observed cases rise to more than double the expected number for A.P.T. and nearly five times the expected number for the combined antigen ; thereafter both the expected number and the number of inoculated poliomyelitis cases fall rapidly. By adding up the diagonals of Tables 1A, 1B and 1C it is possible to show the observed and expected number in the same month as inoculation and in the three months following inoculation separately and this is done in Table 4. The average period of exposure to risk will be, for the same month—2 weeks ; for the first, second and third month following inoculation—4 weeks each. Allowance has been made for the average period of exposure of two weeks only in the calculation of the expected rates for the cases of poliomyelitis occurring in the same month as inoculation. It is apparent, that either for the whole year or the three summer months of high epidemic proportions, the excess of observed cases is concentrated in the same month or 170 Table 4 Poliomyelitis cases by different types of antigen with expected number calculated from the not inoculated group according to the month of inoculation. Same month In the following month In the second month following inoculation In the third month following inoculation Total of the four preceding columns * Obs. Exptd. Obs. Exptd. Obs. Exptd. Obs. Exptd. Obs. Exptd. For the year 1949 A.P.T. 7 1.67 8 2.84 — 2.50 — 2.50 15 9.51 Combined 16 1.06 15 2.93 5 3.14 1 3.25 37 10.38 All other antigens 1 0.45 — 0.97 1 1.05 — 1.10 2 3.57 For the three months July, August and September only A.P.T. 4 0.49 5 0.96 — 0.99 — 1.09 9 3.53 Combined 13 0.77 12 1.49 3 1.37 — 1.38 28 5.01 All other antigens — 0.22 — 0.43 0.48 — 0.49 — 1.62 *This column shows the total experience of observed and expected cases over the same month and three months following inoculation. month following injection, i.e., within six weeks of injection. The proportion of observed to expected cases is summarised below : Period In the same month In the following month In the same month and the month following together In the same month and all the three months following inoculation A.P.T. Year 1949 Four times Nearly three times Three times Slightly less than twice. July—September only Eight times Five times Six times Three times. Combined antigen Year 1949 Fifteen times Five times Eight times Nearly four times. July—September Seventeen times Eight times Eleven times Five times. Only with the combined antigen does the excess of expected cases in the same month, the month following inoculation and these two together attain statistical significance both for the year and for the three months of July, August and September; the differences in the A.P.T. figures only attain statistical significance in the case of the same month and the month following inoculation taken together though they should not be ignored merely on that account. The excess of actual over observed cases declines month by month from the time of 171 Table 5 Site of paralysis related to period since last inoculation by antigens. Period Same Site Included site* Different site No record of paralysis Total No. % No. % No. % No. % No. % A.P.T. Same month — — 2 28.6 3 42.8 2 28.6 7 100.0 Following month 3 37.5 — — — — 5 62.5 8 100.0 Second month following inoculation — — — — — — — — — — Third month following inoculation — — — — — — — — — — Total 3 20.0 2 13.3 3 20.0 7 46.7 15 100.0 Combined Same month 10 62.5 3 18.7 1 6.3 2 12.5 16 100.0 Following month 8 53.3 6 40.0 1 6.7 — — 15 100.0 Second month following inoculation — — — — — — 5 100.0 5 100.0 Third month following inoculation — — — — — — 1 100.0 1 100.0 Total 18 48.7 9 24.3 2 5.4 8 21.6 37 100.0 *Included site means that the site of injection was included in the sites of paralysis. Inoculation. Thus the excess in the same month is followed by a very much smaller excess in the second month until in the third month following inoculation the relationship between observed and expected is reversed. It seems natural to expect that there would be this kind of inverse correlation since an excessive incidence in the first month would remove some of the more susceptible children from those at risk in subsequent months. Lastly in Table 5 is shown for A.P.T. and the combined antigen separately the association of paralysis with poliomyelitis of the inoculated cases according to whether it was in the inoculated limb alone, or included that limb or excluded it. The proportions shown under the same or included site for the combined antigen are outstanding, 81 per cent, in the same month and 93 per cent, in the month following inoculation had paralysis involving the limb in which the injection was given. The evidence is not nearly so convincing with the A.P.T. prophylactic. Earlier in this note it was stated that the object was to measure the risk of an inoculated child being attacked by poliomyelitis. The risk of poliomyelitis without the complication of inoculation is, at the outset, small, 91 cases in a population of 50,000, or 1 in 550 children aged 9 months to 2 years in the course of a year in which the disease reached epidemic proportions. The conclusions to be drawn from this investigation are that in the conditions pertaining in 1949 and over the whole year there was an increased risk— nearly four times the normal risk in the three months or so following inoculation—of poliomyelitis following inoculation with the combined diphtheria and pertussis vaccine 172 but that injections with A.P.T. involved a smaller increase in risk, and one to which less statistical confidence could be attached. In July to September the increase of risk for the combined vaccine was five times and even for A.P.T. the risk may have been multiplied three times. The action taken in discontinuing the use of the combined vaccine during September, 1949, was, therefore, fully justified. It does not follow that these considerations would apply in the face of any future epidemic as the newer combined prophylactics may not be subject to the same risks and it is now the practice in many areas to suspend inoculation during epidemic prevalence of poliomyelitis. We are indebted to Dr. J. Knowelden, of the London School of Hygiene and Tropical Medicine, for much helpful advice during the protracted course of the calculations involved in this investigation. References: 1.McCloskey, B.P. (1950), * Lancet', 1, 659. 2. Proc. of Royal Soc. Med. (1950) Vol. XLIII, No. 4. 3. Bradford Hill, A. and Knowelden, J., B.M.J. (1950) vol. ii, p. 1. APPENDIX C STATISTICS Table 1—Population of the Administrative County of London, 1921-52 Year Mid-year estimate of population Average age Total 0-4 5-14 15-24 25-44 45-64 65+ 1921 4,484,523 376,055 809,212 796,590 1,365,546 877,145 259,975 31.2 1926 4,605,400 404,800 746,900 826,300 1,380,400 961,300 285,700 31.9 1931 4,374,300 297,700 646,700 827,940 1,330,200 951,000 320,760 33.4 1936 4,141,100 254,400 576,600 729,500 1,306,100 935,700 338,800 34.5 1937 4,094,500 249,300 555,000 721,800 1,296,800 930,000 341,600 34.7 1938 4,062,800 249,300 538,600 709,700 1,291,200 927,300 346,700 34.8 1939 3,800,300 211,900 457,500 3,130,900 1940 3,236,600 141,300 232,500 2,862,800 1941 2,507,800 79,200 142,100 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 1951 3,358,000 274,000 381,000 419,000 1,101,000 812,000 371,000 36.9 1952 3,363,000 256,000 400,000 416,000 1,091,000 822,000 378,000 37.1 173 Table 2—Vital statistics folr the Metropolitan Boroughs and the Administrative County of London in the year 1952 (b) Metropolitan boroughs arranged in divisional order Estimated home population mid 1952 Live births Death.rate* Notifications of infectious disease Deaths Infant mortality (per r,ooo live births) Heart disease Other circulatory Cerebral vascular lesions Peptic ulcer Pulmonary tuberculosis monia Other respiratory diseases Cancer Violence Scarlet fever Diphtheria Poliomyelitis Meningococcal infection Acute pneumonia Measles Whooping cough Tuberculosis Paralytic Non Paralytic Pulmonary pul- monary Division 1 Chelsea 52,140 15.1 12.8 20 3.53 0.90 1.76 0.12 0.23 0.92 0.71 2.55 0.56 1.17 — 0.23 0.02 0.02 0.31 6.81 1.96 1.59 0.15 Fulham 122,800 14.0 11.9 26 3.26 0.55 1.29 0.20 0.27 0.74 1.31 2.28 0.46 1.11 — 0.10 0.02 0.02 0.21 5.86 0.41 1.56 0.24 Hammersmith 118,800 15.0 11.4 21 3.38 0.47 1.35 0.13 0.33 0.56 1.09 2.52 0.26 1.75 — 0.06 0.03 0.05 0.72 12.63 1.99 1.51 0.12 Kensington 172,800 16.3 11.2 27 3.27 0.50 1.33 0.14 0.17 0.57 0.75 2.20 0.50 0.63 — 0.10 0.02 0.02 0.41 4.86 1.32 1.31 0.14 Division 2 Hampstead 97,700 14.9 11.2 24 3.46 0.49 1.47 0.14 0.15 0.34 0.75 2.21 0.53 MS — 0.07 0.04 0.01 0.38 5.74 1.98 1.06 0.10 Paddington 124,800 16.7 11.6 27 3.42 0.68 1.07 0.21 0.26 0.50 1.03 2.16 0.60 0.84 006 0.02 0.06 0.62 8.75 0.91 1.93 0.21 St. Marylebone 74,290 12.5 15.3 25 4.72 1.10 2.13 0.16 0.19 0.63 1.08 2.79 0.61 0.86 — 0.05 0.04 0.01 0.24 6.00 1.51 1.05 0.11 St. Pancras 139,600 15.7 11.9 26 3.14 0.55 1.33 0.11 0.31 0.56 1.20 2.53 0.52 1.01 0.02 0.06 0.11 0.03 0.74 8.45 1.80 1.63 0.20 Westminster, City of 100,800 12.3 10.9 25 2.99 0.56 1.06 0.17 0.46 0.53 0.73 2.43 0.51 0.45 — 0.07 0.03 0.31 7.75 2.31 1.37 0.12 Division 3 Finsbury 35,740 191 13.4 16 3.53 0.64 0.81 0.20 0.53 0.67 1.76 2.74 0.56 2.27 0.03 0.03 1.23 13.54 2.24 1.90 0.14 Holborn 23,950 12.2 11.5 34 4.01 0.33 0.75 0.25 0.25 0.50 0.67 2.51 0.58 0.75 — 0.25 — — 0.17 5.55 1.34 1.92 0.08 Islington 235,300 16.6 12.2 23 3.57 0.59 1.29 0.20 0.30 0.68 1.38 2.39 0.37 1.91 — 0.03 0.03 0.03 1.01 11.75 2.07 1.74 0.23 Division 4 Hackney 171,000 14.8 11.5 20 3.47 0.45 1.01 0.25 0.25 0.74 1.22 2.37 0.24 2.29 — 0.05 0.04 0.02 0.40 10.22 1.35 0.98 0.09 Shoreditch 45,800 181 12.2 28 2.97 0.74 0.96 0.24 0.28 0.74 1.79 2.31 0.37 1.86 0.02 0.04 0.04 0.02 0.72 15.55 2.21 1.22 0.13 Stoke Newington 50,610 16.2 11.0 13 2.92 0.45 0.87 0.30 0.24 0.63 1.17 2.41 0.34 2.21 0.02 0.04 0.02 0.04 0.18 11.05 2.17 0.91 0.08 Division 5 Bethnal Green 57,040 17.4 12.0 29 2.81 0.72 0.88 0.23 0.33 0.68 1.58 2.52 0.37 3.24 0.04 0.04 0.02 0.56 9.66 1.67 1.24 0.14 City of London (a) 5,220 7.1 11.9 54 3.07 1.15 1.34 — 0.96 0.96 0.38 2.11 0.57 0.38 — — — — — 6.13 — 1.72 — Poplar 72,670 16.8 11.9 24 3.11 0.66 1.10 0.21 0.23 0.65 1.61 2.26 0.43 2.86 — 0.01 0.01 0.03 1.17 11.12 2.49 1.25 0.10 Stepney 99,000 19.1 13.8 18 4.10 0.72 1.15 0.19 0.49 1.01 1.61 2.43 0.54 2.09 — 0.06 0.03 0.03 0.65 12.98 1.57 1.38 0.12 Division 6 Deptford 75,910 17.4 12.0 32 3.66 0.70 1.13 0.14 0.36 0.62 1.42 2.13 0.28 1.84 — 0.01 0.03 0.18 11.18 1.84 1.77 0.17 Greenwich 90,880 14.3 10.5 15 3.16 0.84 1.11 0.14 0.32 0.53 0.94 1.85 0.39 2.33 0.04 0.07 0.01 0.03 0.20 10.10 2.09 1.07 0.18 Woolwich 151,800 14.5 11.0 21 3.41 0.44 1.33 0.14 0.24 0.56 1.00 2.13 0.37 1.71 — 0.16 0.03 0.01 0.81 9.33 2.14 1.14 0.14 Division 7 Camberwell 181,200 16.1 12.2 24 3.68 0.57 1.31 0.20 0.26 0.40 1.54 2.16 0.37 1.46 — 0.03 0.01 0.44 9.74 2.03 2.08 0.13 Lewisham 227,100 13.9 11.4 23 3.80 0.38 1.32 0.13 0.15 0.45 1.08 2.13 0.35 1.67 — 0.04 0.03 0.02 0.39 9.61 2.25 1.17 0.18 Division 8 Bermondsey 59,780 16.7 12.2 19 3.56 1.02 0.99 0.20 0.37 0.74 1.44 2.02 0.45 1.37 0.02 0.02 0.03 0.42 11.98 0.67 0.99 0.13 Lambeth 230,200 15.8 12.3 25 3.81 0.64 1.31 0.14 0.26 0.65 1.24 2.16 0.31 1.12 — 0.06 0.02 0.03 0.54 10.28 1.32 1.40 0.15 Southwark 97,970 17.7 14.1 28 3.89 1.04 1.48 0.17 0.46 0.91 1.86 2.16 0.41 2.98 0.04 0.04 0.04 0.06 0.59 10.15 1.81 1.68 0.20 Division 9 Battersea 116,400 15.2 11.9 18 3.76 0.57 1.32 0.21 0.29 0.55 1.33 2.09 0.43 1.05 0.01 0.07 0.05 0.02 0.97 8.65 1.21 1.47 0.15 Wandsworth 331,700 13.2 12.6 20 3.83 0.71 1.34 0.16 0.24 0.54 1.20 2.49 0.34 1.61 — 0.06 0.04 0.01 0.67 6.90 1.21 1.15 0.15 London, 1952 3,363,000 15.3 12.0 23 3.55 0.62 1.27 0.17 0.28 0.61 1.21 2.30 0.41 1.56 0.01 0.06 0.03 0.02 0.57 9.23 1.66 1.40 0.15 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 (a) Including Inner and Middle Temple. (b) Rates are per 1,000 home population. 174 Table 3—Administrative County of London—Principal vital statistics, 1891-1952 Period Annual rate per 1,000 living Annual mortality per 1,000 living (b) Annual mortality per 1,000 Live births Total births (c) Live births Marriages Deaths (all causes) Meningococcal infection Diphtheria Enteric fever Scarlet fever Smallpox Whoopingcough Measles Influenza Tuberculosis Pneumonia (all forms) Bronchitis Other resp. diseases Heart disease Cancer Diabetes Infants 0—1 Diarrhoea amd enteritis 0—2 Puerperal fever Other child-birth Pulmonary Non-pul- monary 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) 0.80 007 156 23.8 215 2.22 1896-1900 29.7 18.4 18.5 (a) 0.45 0.14 0.14 0.00 0.47 0.57 0.27 1.75 0.69 1.32 1.80 0.35 (a) 0.92 0.07 162 41.3 1.70 1.74 1901-05 28.6 17.7 16.4 (a) 0.20 0.08 Oil 0.07 0.36 0.45 0.17 1.58 0.57 1.46 1.41 0.26 1.31 1.01 0.08 139 30.4 1.64 1.52 1906-10 26.5 17.4 14.9 (a) 0.14 0.04 0.10 0.00 0.29 0.42 0.22 1.39 0.48 1.49 1.22 0.22 1.26 1.11 0.10 114 23.8 1.46 1.47 1911-15 24.0 20.0 14.8 0.02 0.13 0.03 0.05 0.00 0.22 0.43 0.16 1.39 0.39 1.33 1.29 0.21 1.54 1.16 0.11 108 28.0 1.40 1.57 1916-20 20.0 20.1 15.1 0.04 0.17 0.02 0.03 0.00 0.20 0.28 1.01 1.43 0.34 1.38 1.30 0.19 1.71 1.28 0.09 92 15.4 1.64 1.72 1921-25 19.9 17.9 12.3 0.01 0.17 0.01 0.04 0.00 0.15 0.17 0.32 1.01 0.19 1.14 0.97 0.16 1.66 1.38 0.10 71 11.7 1.36 1.63 1926-30 16.2 18.6 12.3 0.02 0.10 0.01 0.02 000 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 i.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 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 to 0.97 1941-45 15.4 23.3 16.0 0.02 0.02 0.00 0.00 - 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 1946-50 18.6 22.4 11.8 0.01 0.00 0.00 0.00 0.00 0.02 0.01 0.08 0.53 0.06 0.62 0.87 0.13 3.31 2.10 0.07 32 3.0 0.08 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 1952 15.3 19.9 12.0 0-01 0-00 - 0.00 - 0.00 0.00 0.05 0.28 0.03 0.61 1.09 0.12 3.55 2.30 0.08 23 0.8 0.04 0.63 (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 deaths from abortion are excluded. 175 Table 4—Administrative County of London—Civilian deaths in 1952 by cause Cause Sex 0- 1- 5- 15- 25- 45- 65- 75+ Total 1952 1951 1. Tuberculosis—respiratory M - - - 10 117 347 161 49 684 826 F - - - 23 102 72 21 31 249 328 2. Tuberculosis—other M 1 6 2 7 12 9 7 1 45 66 F 1 4 2 3 11 9 3 8 41 59 3. Syphilitic disease M - - - - 4 47 64 29 144 152 F - - - 1 4 27 20 17 69 73 4. Diphtheria M - - 1 - - - - - 1 1 F - - - - - 1 - - 1 1 5. Whooping-cough M 3 2 1 - - - - - 6 12 F 1 1 1 - - - - - 3 9 6. Meningococcal infection M 5 4 2 - - 1 - - 12 13 F 13 2 - - - 1 - 1 17 12 7. Acute poliomyelitis M 1 - 5 3 7 2 - - 18 1 F 1 - 1 2 1 - - - 5 1 8. Measles M - 3 1 - - - - - 4 14 F - 1 3 - - - - - 4 11 9. Other infective, &c., diseases M 2 1 2 1 10 13 8 6 43 60 F 4 1 4 1 7 17 10 9 53 46 10. Malignant neoplasm: Stomach M - - - 3 30 223 207 130 993 609 F - - - 1 22 135 159 189 506 492 11. Malignant neoplasm: Lung, bronchus M - - - 3 73 673 439 141 1,329 1,284 F - - - - 19 127 72 65 283 253 12. Malignant neoplasm: Breast M - - - - - 5 2 2 9 7 F - - - - 69 320 178 169 736 714 13. Malignant neoplasm: Uterus F - - - 1 28 137 67 63 296 279 14. Other malignant and lymphatic neoplasms M 2 11 11 15 129 628 696 575 2,067 2,086 F 3 7 8 9 111 532 506 552 1,728 1,732 15. Leukemia, aleukemia and Hodgkins disease M - 6 6 3 8 31 25 15 94 87 F - 2 6 2 14 30 10 21 85 96 16. Diabetes M - - 1 1 4 19 34 25 84 97 F - - 1 2 6 37 73 76 195 213 17. Vascular lesions, nervous system M - 1 3 4 40 365 546 710 1,669 1,618 F - - 1 7 36 451 762 1,332 2,589 2,492 18. Coronary disease, angina .. M - - - 1 97 1,085 1,111 801 3,095 2,857 F - - 1 1 5 292 702 879 1,880 1,757 19. Hypertension with heart disease M - - - 1 82 164 167 414 775 F - - - - 3 70 194 288 555 845 20. Other heart disease M 2 - 3 8 84 360 581 1,350 2,388 2,718 F — — - 10 106 350 694 2,454 3,614 4,039 21. Other circulatory disease .. M - - - 3 18 192 300 425 938 722 F - - 1 4 20 151 290 666 1,132 836 22. Influenza M 1 1 1 1 5 25 23 29 86 356 F - 1 - 2 8 13 15 37 76 453 23. Pneumonia M 82 18 7 4 31 204 294 399 1,039 1,071 F 75 23 2 4 19 122 210 543 998 1,065 24. Bronchitis M 28 6 1 1 20 737 819 729 2,341 2,372 F 15 3 3 — 20 162 378 740 1,321 1,461 25. Other diseases of respiratory system M 1 4 4 1 21 101 70 65 267 246 F - 2 4 2 9 31 40 56 144 150 26. Ulcer of stomach and duodenum M 1 - - 3 32 166 141 84 427 465 F — — — 1 2 32 51 68 154 166 27. Gastritis, enteritis and diarrhoea M 22 2 - 2 7 10 10 15 68 83 F 19 - 1 2 10 17 28 36 113 113 28. Nephritis and nephrosis M - 4 3 4 41 54 39 31 176 197 F - _ 3 5 21 64 39 53 185 210 29. Hyperplasia, prostate M - - - - - 35 113 218 366 340 m 176 Table 4 (contd.)—Administrative County of London—Civilian deaths in 1952 by cause Case Sex 0— 1 — 5— 15— 25— 45— 65— 75+ Total 1952 1951 30. Pregnancy, childb.: abortn. F - - - 9 39 1 1 - 50 42 31. Congenital malformations M 96 6 8 5 17 11 7 4 154 198 F 106 9 4 6 20 16 9 10 180 186 32. Other defined and ill defined diseases M 425 19 25 27 104 328 275 314 1,517 1,535 F 245 18 13 24 118 343 309 595 1,665 1,802 33. Motor vehicle accidents M 1 4 9 25 55 16 15 14 139 198 F - 4 8 4 14 18 12 22 82 84 34. All other accidents M 16 17 19 18 91 103 60 98 422 405 F 15 6 6 7 21 41 55 157 308 407 35. Suicide M - - - 11 60 116 36 25 248 273 F - - - 2 34 62 34 4 136 149 36. Homicide, operations of war M 1 - 2 3 6 4 2 1 19 10 F 1 - 3 1 1 1 2 - 9 8 ALL CAUSES M 690 115 117 167 1,124 5,992 6,249 6,452 20,906 21,754 F 499 84 76 136 900 3,682 4,944 9,141 19,462 20,584 Table 5—Administrative County of London, Live births and Still-births, 1931-52 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 56,853 134 1,844 314 1935 55,780 13.3 1,854 32.2 1936 56,273 13.6 1,857 31.9 1937 55,011 134 1,864 32.8 1938 54,495 134 1,711 304 1939 52,366 134 1,579 29.3 1940 46,213 14.3 1,405 29.5 1941 33,944 13.5 1,046 29.9 1942 40,654 154 1,225 29.3 1943 45,030 16.1 1,137 24.6 1944 44,554 16.2 1,138 24.9 1945 45,532 15.7 1,095 23.5 1946 65,883 20.0 1,598 23.7 1947 71,323 20.9 1,554 21.3 1948 60,934 17.9 1,191 19.2 1949 56,545 16.7 1,134 19.7 1950 53,281 15.7 1,054 194 1951 52,387 15.6 1,073 20.1 1952 51,558 15.3 1,008 19.2 177 Table 6—Administrative County of London—Infant mortality, 1952 Cause of death Age at death Total Rates per 1,000 live births Under 1 day 1 to 7 days 7 to 4 wks. 4 wks. to 1 yr. No. Male Female Total Male Female Measles Leg. . . . . . . . . . . Illeg. . . . Whooping.cough Leg. . . . 4 4 3 1 0.08 0.11 0.04 Illeg. . . . Influenza Leg. . . . 1 1 1 . 0.02 0.04 . Illeg. . . . Tuberculosis Leg. . . . 2 2 1 1 0.04 0.04 0.04 Illeg. . . . Bronchitis Leg. . 2 l 40 43 28 15 0.83 1.06 0.60 Illeg. . . . Pneumonia Leg. 3 26 23 101 157 82 75 3.05 3.10 2.99 Illeg. . 2 2 Diarrhoea Leg. . . 2 39 41 22 19 0.80 0.83 0.76 Illeg. . . . Premature birth Leg. 109 65 11 7 216 142 74 41.9 5.37 2.95 Illeg. 13 11 . Congenital malformation 32 42 35 84 202 96 106 3.92 3.63 4.22 Leg. Illeg. 4 4 1 Birth injury Leg. 68 53 5 4 145 93 52 2.81 3.52 2.07 Illeg. 8 4 3 Other diseases of early infancy Leg. 131 84 12 8 260 155 105 5.04 5.86 4.18 Illeg. 17 8 . Other causes Leg. 6 6 11 82 118 67 51 2.29 2.53 2.03 Illeg. 12 1 . All causes Leg. M. 211 172 54 177 1,070 614 456 22.30 24.98 19.48 F. 138 106 46 166 Illeg. M. 34 19 3 20 119 76 43 33.27 40.55 25.25 F. 20 11 3 9 Total, 1952 403 308 106 372 1,189 690 499 23.06 26.08 19.87 Total 1951 415 363 129 426 1,333 760 573 25.45 28.37 22.38 1951 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 36.66 F. 36 14 2 12 Table 7—Administrative County of London—Infant mortality by cause, 1915.1952 (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 1946 1947 1948 1949 1950 1951 1952 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 0.08 Influenza 1.10 0.81 0.38 0.48 0.40 0.24 0.39 0.29 0.17 0.07 0.27 0.17 015 0.02 Tuberculosis 3.20 1.52 1.26 0.89 0.77 0.56 0.63 0.36 0.35 0.28 0.09 0.17 0.08 0.04 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 0.83 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 3.05 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 0.80 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 4.19 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 11.77 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 2.29 au causes 103 79 65 64 65 60 50 45 34 31 27 26 25 23 178 Table 8—Administrative County of London and England and Wales—Maternal mortality (excluding abortion)—1943.52 (Rates per 1,000 total births) 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 Puerperal sepsis: London 0.24 0.17 0.26 0.12 0.12 0.13 0.02 - 0.06 0.13 England and Wales .. 0.39 0.28 0.24 0.18 0.16 0.13 0.11 0.12 0.10 0.09 Other causes: London 1.06 0.85 1.09 0.80 0.55 0.37 0.38 0.53 0.39 0.53 England and Wales 1.44 1.24 1.23 1.06 0.86 0.73 0.71 0.60 0.56 0.50 Table 9—Administrative County of London—Primary notifications of, and deaths from, tuberculosis—1921-52 (a) 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 1952 4,713 1.40 933 0.28 518 0.15 86 0.03 (a) Excluding posthumous cases, 179 Table 10(a)—Administrative County of London—Primary notification of tuberculosis, 1952 Form of tuberculosis notified Sex Number of formal primary notifications of new cases of tuberculosis Total all ages 0- 7- 5- 70- 75- 20- 25- 35- 45- 55- 65+ Pulmonary tuberculosis M. 6 79 72 37 221 276 586 466 427 332 211 2,713 F. 9 79 70 49 239 377 610 275 155 81 56 2,000 Other forms of tuberculosis. M. 2 24 34 22 16 23 46 18 14 12 10 221 F. 1 20 21 13 20 46 81 37 28 15 15 297 All forms of tuberculosis M. 8 103 106 59 237 299 632 484 441 344 221 2,934 F. 10 99 91 62 259 423 691 312 183 96 71 2,297 Table 10(b)—Numbers on the registers, 1942.52 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 * 1952 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 17,336 Females 9,441 10,232 10,990 11,496 12,262 12,862 13,549 14,223 15,031 15,556 14,672 Other forms : Males 2,785 2,847 2,866 2,813 2,821 2,699 2,889 2,752 2,591 2,520 1,530 Females 2,963 3,074 3,185 3,123 3,099 3,142 3,147 3,015 3,068 2,954 1,850 Total 28,083 29,761 31,381 32,450 33,877 35,077 36,809 38,193 39,780 40,149 35,388 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 10.5 * On the chest clinic registers. Prior to 1952 numbers supplied by the metropolitan borough councils under the Tuberculosis Regulations, 1930, now rescinded. 180 Table 11(a)—Administrative County of London—Primary notification of tuberculosis, 1946.52, by age and sex Rates per 1,000 living (i) Pulmonary Sex Age 1946 1947 1948 1949 1950 1951 1952 No. Rate 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 1.08 162 115 137 0.98 85 0.65 5—14 175 0.98 187 1.01 158 0.87 153 0.82 141 0.75 143 0.74 109 0.53 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 1,549 216 45 + 849 1.45 973 1.61 957 1.60 1,093 1.84 945 1.59 969 1.91 970 1.88 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 2,713 1.73 Females . . 0—4 81 0.73 96 0.76 124 0.94 126 0.94 116 0.86 123 0.92 88 0.70 5—14 177 1.01 174 0.96 171 0.96 188 104 140 0.77 127 0 08 119 0.61 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 1,501 1.90 45 + 281 0.40 263 0.36 244 0.34 279 0.39 234 0.33 242 0.36 292 0.43 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 2,000 1.11 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 4,713 1.40 (ii) Non-Pulmonary Males 0—4 43 0.369 69 0.520 55 0.398 39 0.275 34 0.241 29 0.207 26 0.198 5—14 89 0.499 87 0.472 87 0.479 75 0.404 50 0.265 57 0.294 56 0.275 15—44 143 0.209 118 0.167 116 0.165 109 0.156 114 0.164 103 0143 103 0.144 45 + 24 0.041 36 0.060 29 0.048 32 0.054 29 0.049 27 0.053 36 0.070 All males. . 299 0.191 310 0.190 287 0.177 255 0.157 227 0.140 216 0.138 221 0.141 Females . . 0—4 44 0.397 56 0.444 38 0.289 42 0.312 40 0.296 36 0.269 21 0.168 5—14 96 0.550 71 0.394 69 0.388 68 0.375 49 0.271 48 0.257 34 0.173 15—44 144 0.198 190 0.253 171 0.229 159 0.214 183 0.247 178 0.223 184 0.233 45 + 28 0.040 35 0.048 35 0.049 29 0.041 30 0.042 29 0.043 58 0.085 All females 312 0.183 352 0.198 313 0.176 298 0.168 302 0.171 291 0.162 297 0165 Total 611 0.187 662 0.194 600 0.177 553 0.163 529 0.156 507 0.150 518 0.154 Table 11(b)—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 0.27 127 0.18 45 + 731 1.25 748 1.24 762 1.27 719 1.21 585 0.99 627 1.23 557 1.08 All males. . 1,238 0.79 1,264 0.78 1,235 0.76 1,046 0.65 829 0.51 826 0.53 684 0.44 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 2 0.01 3 0.02 - - 15—44 498 0.68 527 0.70 487 0.65 342 0.46 238 0.32 171 0.21 125 0.16 45 + 190 0.27 232 0.32 165 0.23 189 0.26 156 0.22 151 0.22 124 0.18 All females 702 0.41 780 0.44 665 0.37 539 0.30 396 0.22 328 0.18 249 0.14 Total 1,940 0.59 2,044 0.60 1,900 0.56 1,585 0.47 1,225 0.36 1,154 0.34 933 0.28 (ii) Non-Pulmonary Males 0—4 31 0.266 30 0.226 26 0.188 13 0.092 6 0.043 10 0.071 7 0.053 5—14 25 0.140 20 0.109 10 0.055 12 0 065 6 0.032 6 0.031 2 0.010 15—44 38 0.056 44 0.062 38 0.054 36 0.052 25 0.036 29 0.040 19 0.027 45 + 22 0.048 38 0.063 29 0.048 34 0.057 25 0.042 21 0.041 17 0.033 All males. . 116 0.074 132 0.081 103 0.063 95 0.059 62 0.038 66 0.042 45 0.029 Females . . 0—4 33 0.298 19 0.151 23 0.175 16 0.119 10 0.074 9 0.067 5 0.040 5—14 20 0.115 16 0.089 11 0.062 7 0.039 7 0.039 9 0.048 2 0010 15—44 44 0.061 48 0.064 35 0.047 20 0.027 16 0.022 15 0.019 14 0.018 45 + 30 0.043 37 0.051 30 0.042 18 0.025 27 0.038 26 0.039 20 0.029 All females 127 0.074 120 0.067 99 0.056 61 0.034 60 0.034 59 0.033 41 0.023 Total 243 0.074 252 0.074 202 0.059 156 0.046 122 0.036 125 0.037 86 0.026 181 Table 12—Administrative County of London—Primary notification 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 o f tuberculosis lesion Bones and Joints Abdomen Peripheral glands Meninges Other sites (a) 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. Information not available for 1952 owing to change in the regulations governing the notification of tuberculosis. Table 13—Administrative County of London—Cases of infectious illness reported from schools in 1952 and preceding years Year Chicken-pox Diphtheria German measles Impetigo Measles Mumps Ophthalmia and conjunctivitis Poliomyelitis Ringworm Scabies Scarlet fever Whoopingcough 1938 11,018 3,576 2,383 1,018 31,852 4,805 342 - 278 2,718 3,988 4,067 1946 5,602 290 349 381 8,291 5,296 251 5 245 1,488 1,654 2,421 1947 7,423 263 1,571 264 6,684 2,845 233 153 180 650 1,974 3,660 1948 7,745 187 491 243 11,545 9,162 297 34 119 323 2,078 3,691 1949 5,528 135 313 178 7,651 2,113 361 132 71 120 2,359 1,814 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 1952 14,281 31 16,115 266 13,127 8,391 1,245 70 138 93 3,042 2,028 182 Table 16—School leavers contra-indications for employment (a) Contra.indications Boys Girls No. Perccnt. of inspected pupils (11,779) No. Percent. of inspected pupils (11,480) Heavy manual work 280 2.4 267 2.3 Sedentary work 24 0.2 22 0.2 Indoor work 8 0.1 16 0.1 Exposure to bad weather 170 1.4 234 2.0 Wide changes of temperature 69 0.6 74 0.6 Work in damp atmosphere 108 0.9 136 1.2 Work in dusty atmosphere 125 1.1 109 0.9 Much stooping 27 0.2 29 0.3 Climbing 84 0.7 87 0.8 Work near moving machinery or moving vehicles. . 73 0.6 50 0.4 Prolonged standing, much walking or quick movement from place to place 155 1.3 187 1.6 Eye strain 800 6.8 1,192 10.4 Normally acute vision 774 6.6 731 6.4 Normal use of hands 4 (0.03) 10 0.1 Work requiring freedom from damp hands or skin defects 16 0.1 30 0.3 Handling or preparation of food 61 0.5 78 0.7 Normal hearing 53 0.4 45 0.4 Any other work which would be unsuitable 20 0.2 16 0.1 No. of pupils with contra-indications (b) 1,716 14.6 1,784 15.5 (a) Excluding special schools and certain grammar schools at which the leaver contra-indications slip is not in use. (b) The total number of contra-indications is greater than the number of pupils since an individual may be noted for two or more contra-indications. 183 Table 14—Administrative County of London—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—1933.1952 Year Anthrax Meningococcal infection Continued fever Diphtheria Dysentery Acute Encephalitis Enteric fever Erysipelas Malaria Measles Ophthalmia neonatorum Pneumonia Poliomyelitis Puerperal pyrexia Scabies Scarlet fever Smallpox Typhus Whooping. cough Food poisoning Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate 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 to - 527 (f) 9.31 6,299 1.469 66 0.015 838 (a) 14.28 (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) - 467 8.24 5,569 1.320 74 0.018 758 12.91 (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) - 382 6.87 3,707 0.888 85 0.020 652 11.31 (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 to — 462 8.10 4,141 0.986 38 0.009 635 10.92 (.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) — 453 8.26 4,798 1.175 108 0.026 793 13.94 to — 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) — 8,093 2.00 - - - - 1,891 (c) 10,537 1.87 (b) - 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) — 5,677 1.51 - - - - 2.80 (b) - 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) — 2,498 0.81 - - - - 669 0.218 (b) - 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) — 2,372 1.00 - - - - 7,944 3.36 (b) - 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) — 4,416 1.84 2 0.0008 - - 6,234 2.60 (b) - 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)16,450 9.18 9,477 3.80 - - - - 6,661 2.67 (b) - 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 6.70 3,862 1.57 2 0.0008 - - 7,136 2.90 (b) - 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 (b) - 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 (b) - 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 (b) - 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 (b) - 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 1.70 630 0.19 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 (g) 823 0.24 4,157 1.23 - - - - 10,875 3.21 863 0.25 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 3.11 787 0.23 1952 (e) . - - 82 0.024 1 0.0003 18 0.005 1,704 0.507 21 0.006 25 0.007 467 0.139 22 0.007 31,055 9.23 202 3.92 1,908 0.567 204 0.061 105 0.031 1,860 35.38 535 0.16 5,263 1.56 - - - - 5,587 1.66 612 0.18 (a) Rate per 1,000 total births, (b) Comparable figures not available for this period, (c) Cases relate to last quarter only—Rates are adjusted on an annual basis, (d) Cases relate to last 22 weeks only—Rates are adjusted on an annual basis, (f) 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. Comparable figures can be obtained by the method given in the footnote to this table in previous annual reports. ( f)rate per 1,000 live births. (a) For cause of increase since 1950 see page 15. 184 Table 15—Administrative County of London—Notification of certain Infectious Diseases Distribution by age and date of notification—53 weeks commencing week ended 5th January, 1952 Four weekly periods 1952 Meningococcal infection Dysentery Measles Pneumonia Poliomyelitis Scarlet fever Whooping-cough Paralytic Non-paralytic or not stated Ages Ages Ages Ages Ages Ages Ages Ages 0—4 5—14 15+ Total 0—4 5—14 15+ Total 0—4 5—14 15+ Total 0—4 5—14 15+ Total 0—4 5—14 15+ Total 0—4 5—14 15+ Total 0—4 5—14 15+ Total 0—4 5—14 15+ Total 1—4 2 4 1 7 60 20 66 150 76 71 14 161 52 20 163 237 3 1 4 8 1 1 - 2 99 202 10 311 220 101 5 327 5—8 6 2 2 10 128 55 63 249 115 185 34 334 31 21 134 188 1 — 2 3 2 - 1 3 128 339 21 488 271 122 8 402 9—12 6 4 4 14 97 62 66 228 213 537 63 813 23 21 131 176 - - - - - 1 1 2 116 343 29 492 306 203 6 515 13—16 7 5 2 14 128 40 56 226 347 560 89 998 17 28 129 176 - - 1 1 1 1 - 2 94 240 16 351 317 180 6 504 17—20 7 2 1 10 54 43 66 163 504 475 63 1,045 16 19 123 159 3 1 - 4 1 - - 1 75 133 19 229 403 236 10 652 21—24 2 3 - 5 49 27 33 109 967 1,131 29 2,134 8 13 50 71 2 3 - 5 2 3 3 8 76 184 6 266 327 165 10 503 25—28 1 1 1 3 74 27 20 123 1,559 1,172 31 2,765 7 12 47 67 7 2 3 12 6 4 2 12 102 253 10 365 250 171 9 433 29—32 3 - 2 5 25 8 17 50 1,796 1,606 26 3,438 13 8 31 52 14 21 14 49 10 17 6 33 102 229 12 343 251 130 2 391 33—36 2 - - 2 39 13 26 80 1,447 545 19 2,017 5 8 30 43 9 10 16 35 7 11 16 34 78 92 10 180 260 118 6 385 37—40 5 1 - 6 40 20 26 87 795 616 9 1,422 14 10 46 70 7 8 9 24 4 8 5 17 99 252 9 363 225 95 3 324 41—44 1 2 - 3 28 12 17 57 1,902 2,061 23 3,999 18 18 104 140 5 3 5 13 1 8 2 11 185 428 7 621 163 86 5 254 45—48 4 1 1 6 47 18 28 99 2,469 2,361 38 4,880 34 35 90 161 4 6 9 19 1 4 5 10 212 466 13 692 278 165 4 447 49—52 3 3 - 6 35 16 23 76 2,856 2,768 45 5,683 50 49 234 336 - 2 3 5 1 2 4 7 143 309 15 468 186 146 3 335 53rd week 4 2 - 6 16 3 8 27 1,382 1,279 22 2,693 37 20 80 138 1 - - 1 - - - - 33 64 5 102 70 38 1 109 Total (53 weeks) 53 30 14 97 820 364 515 1,724 16,428 15,367 505 32,382 325 282 1,392 2,014 56 57 66 179 37 60 45 142 1,542 3,534 182 5,271 3,527 1,956 78 5,581 Note: 1. Where the total figures are in excess of the sum of the age groups, the difference is due to cases 'age not known 2. The totals of these figures will not necessarily agree with the total notifications given in Table 14 which relates to the calendar year 1952. Table 17.—Recommendations made in respect of children referred to determine the need for special educational treatment (see page 129) (a) Children not attending special schools Type of case Blind Partiallysighted Deaf Partially-deaf Special School for the Delicate, boarding Maladjusted, boarding Physically handicapped, day Physically handicapped, boarding Ordinary school Ordinary school with special treatment Decision postponed (pending treatment, etc.) Unsuitable for school (e.g. ineducable) Individual tuition at home or in hospital Educationally subnormal, day Educationally subnormal, boarding Epileptic, boarding Delicate, day B G B G B G B G B G B G B G B G B G B G B G B G B G B G B G B G B G Vision 14 3 61 51 - - - - - - - - - - - - - - - - - - - 10 5 32 40 1 0 ¬— - - - Hearing - - - - 31 23 23 19 - - - - - - - -- - - - - - - - - 8 9 26 32 8 4 - - - - Educationally subnormal - - - - - - - 379 265 70 43 - - - - - - - - - - - - 202 100 475‡ 224‡ 25 15 82 47 - - Maladjusted - - - - - - - - - - - - - - - - - - 131 54 - - - - - - 130* 30 - - - - - - Epilepsy - - - - - - - - 3† 3† - - 7 3 - - - - - - 7 7 - - 14 14† - - - 1 2 1 - - Physically handicapped - - - - - - - - - - - - - - - - - - - - 171* 106* 7* 7* 21* 20* - - - - - - 35 37 Delicate - - - - -- - - - - - - - - - 413 286 739 448 - - - - - - - - - - - - - - - - * Attendance at special classes part-time. * See (b) below. † Includes children for whom restrictions on certain physical activities have been prescribed (e.g. gymnastics). ‡Represents those children who were recommended to attend ordinary school with special coaching following statutory examination. It does not include children for whom special coaching has been provided by the head teacher on the advice of the Council's educational psychologists, etc. 186 Table 17—(b) Physically handicapped children Morbid condition Day P.H. school Boarding P.H. school Total P.H. school Ordinary school Boys Girls Total Boys Girls Total Boys Girls Total Infantile paralysis 43 16 59 2 - 2 61 5 3 8 Cerebral palsy 20 13 33 1 - 1 34 - 1 1 Various paralyses 5 1 6 - - - 6 1 - 1 T.B. bones and joints 12 11 23 2 1 3 26 - 2 2 Osteomyelitis - 1 1 - - - 1 - 2 2 Perthes disease 13 - 13 - - - 13 2 - 2 Congenital deformities 13 9 22 1 1 2 24 2 4 6 Spinal deformities (including scoliosis) - 1 1 - - - 1 1 - 1 Traumata and amputations 9 2 11 - - - 11 4 1 5 Non-T.B. arthritis and synovitis 1 - 1 - 1 1 2 - - - Rheumatism and chorea - 1 1 - - - 1 - - - Heart disease, congenital 14 10 24 - 2 2 26 - 5 5 Heart disease, other 13 18 31 - 2 2 33 - - - Other diseases 28 23 51 1 - 1 52 6 2 8 171 106 277* 7 7 14 291 21 20 41 Table 17—(c) Children in special schools Recommendation Blind Partiallysighted Deaf Children attending special schools for the Delicate, day Physically handicapped Maladjusted, boarding Partiallydeaf Educationally subnormal Epileptic, boarding B G B G B G B G B G B G B G B G B G No longer in need of education in a special school - - 3 6 2 - 18 9 109 33 2 2 184 117 82 53 57 12 Unsuitable for retention because ineducable, etc. - - - - - - - - 49 44 1 - - - - - - - Transfer from day school to boarding school - - - 4 - - - - 24 7 - - 25 22 11 5 - - In addition 5 pupils at boarding P.H. school were recommended for transfer to day schools for the physically handicapped. 187 Table 17—(d) Other handicapped pupils Change of category—vision and hearing cases Six pupils of schools for the blind were recommended for transfer to schools for the partially-sighted and 6 attending partially-sighted schools for transfer to schools for the blind. Children recommended for transfer from schools for the deaf to schools for the partially-deaf numbered 10 and from partially-deaf schools to deaf schools 4. Section 57(5), Education Act, 1944 During the year 424 children were recommended for reporting under this section of the Act as requiring supervision after leaving school. Section 8, Education (Miscellaneous Provisions) Act, 1948 Five children examined under this section of the 1948 Act were found to be suitable to attend schools for the educationally subnormal. Diabetic children Four children (two boys and two girls) were found to be diabetic and suitable for residential treatment. Speech defects Recommended for speech therapy because of Children in attendance at Stammer Speech defect Ordinary school Boys 164 308 Girls 47 130 Schools for the educationally subnormal Boys 15 64 Girls 2 41 Schools for the physically handicapped Boys 11 69 Girls - 48 239 660 Dual Defects Boys Girls Total Recommended for Rayners School (deaf and some other defect) 15 6 21 Recommended for other schools for dual defects 3 3 6 Recommended for home tuition 1 1 2 Found to be blind and ineducable - 3 3 Recommended for partially-sighted schools 1 2 3 Recommended for E.S.N, schools 7 11 18 Invalid from school 1 - 1 28 26 54 188 Table 18—Admissions of London children to Queen Mary's Hospital, Carshalton, in 1952. Sex Articular rheumatism Chorea Articular rheumatism and chorea No. admitted Percentage with No. admitted Percentage with No. admitted Percentage with Carditis Pericarditis only Valvular damage No cardiac involvement Carditis Pericarditis only Valvular damage No cardiac involvement Carditis Pericarditis only Valvular damage No cardiac involvement Mitral Mitral and aortic and pericarditis Mitral Mitral and aortic and pericarditis Mitral Mitral and aortic and pericarditis Boys 91 18.7 2.2 25.3 5.5 1.1 47.2 17 23.6 - 11.7 - - 64.7 1 - - - - - 100.0 Girls 77 15.6 - 17.0 1.2 1.2 65.0 26 11.5 - 27.0 - - 61.5 3 33.3 - 66.7 - - - Total 168 17.3 1.2 21.4 3.6 1.2 55.3 43 16.3 - 20.9 - - 62.8 4 25.0 - 50.0 - - 25.0 Table 19—Condition on discharge in 1952 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 Total No. Percentage No. Percentage No. Percentage Boys 56 76.7 15 20.6 2 2.7 73 Girls 75 81.5 14 15.2 3 3.3 92 Total 131 79.4 29 17.6 5 3.0 165 189 Table 20—Treatment of venereal disease at London clinics Year New cases Total venereal cases Total non-venereal cases Total attendances Syphilis S. Chancre Gonorrhoea M. F. M. F. M. F. M. F. M. F. M. F. 1918 3,764 3,002 116 13 4,844 1,940 8,724 4,955 1,345 1,348 169,485 1928 3,433 1,837 229 6 8,249 2,647 11,911 4,490 6,369 3,226 544,969 218,566 1938 1,799 1,065 235 9 7,120 2,151 9,154 3,225 8,249 5,269 588,815 263,908 1939 1,573 904 164 5 5,982 1,652 7,719 2,561 7,468 5,008 412,067 189,355 1940 1,493 709 146 9 4,591 1,319 6,230 2,037 5,383 3,515 305,693 131,375 1941 1,381 773 205 12 3,862 1,425 5,448 2,210 4,675 3,709 224,954 122,492 1942 1,369 917 148 9 3,082 1,444 4,599 2,370 4,960 5,177 222,864 155,559 1943 1,362 1,107 104 15 2,839 1,442 4,305 2,564 7,627 8,867 219,014 177,859 1944 1,176 967 89 13 2,929 1,363 4,194 2,343 6,568 8,234 188.450 155,332 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 1952 811 490 91 3 5,625 1,176 6,527 1,669 16,920 5,632 220,871 100,420 190 Table 21-Statistics of the administrative work carried out by the Metropolitan Borough Councils in 1952 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 No. of houses inspected Section 25 Section 9 and 10 Number of houses demolished Closing Orders Overcrowding No. of dwellings erected for working classes during the year Underground rooms Houses let in lodgings No. of houses represented No. of houses demolished No. of houses repaired No. of families overcrowded No. of families alternative accommodation obtained No. occupied but unfit 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 By owner By L.A. Section It Voluntarily City of London 1,100 8 4 - 8 13 - - - - - - - - * * - 5 - - 19 21 - - Battersea 27,391 4,103 1,466 139 6,800 - - - 2 - - - - - 43 25 - * 4 - * * * * Bermondsey 17,018 3,590 1,060 58 3,446 181 45 - - - 6 - 5 - 207 47 217 853 - 2 396 15 - 4 Bethnal Green 15,939 3,860 1,134 106 2,848 76 140 - - - 5 - 3 - 668 72 90 * 4 2 180 314 - - Camberwell 41,391 6,676 1,616 83 3,442 - 26 - 20 3 3 1 13 2 117 99 191 * 22 16 * ‡ * - Chelsea 15,800 1,627 365 15 411 138 - - 31 - 20 10 1 - 56 9 105 - - - 575 ‡ - 30 Deptford 16,313 2,859 662 17 1,709 - - - 2 - 1 - 4 - 141 47 20 1 1 1 * - - - Finsbury 9,334 1,694 89 14 877 15 25 - - - - 4 76 42 24 1,200 9 4 456 Fulham 32,336 4,430 1,973 214 2,851 - - - 1 2 - - 5 - 13 60 216 255 Greenwich 22,255 2,378 210 13 1,479 312 26 - 1 - 20 - - - 337 65 304 65 3 6 8 24 - - Hackney .. .. 39,728 6,695 2,332 227 5,429 22 16 77 34 5 2 1,156 136 287 • 9 3 • • 3 * Hammersmith 25,830 4,623 1,079 125 1,467 - - - - - 2 - 2 2 187 79 88 • 29 24 9,600 ♦ ♦ Hampstead 20,890 2,836 322 10 1,260 236 3 - 14 3 1 - 2 - 588 66 125 489 3 2 1,573 910 452 Holborn 6,197 654 34 7 585 2 - - - - - 1 10 - 158 33 488 2 1 300 478 20 Islington 44,277 9,401 5,400 316 5,559 1,404 38 - - - 1 17 - - 699 553 272 • 56 - • * 7 Kensington 37,600 7,346 1,061 122 2,249 347 - - 32 2 1 - - - 208 131 228 3,812 50 60 4,000 ‡ - ‡ Lambeth 51,451 12,137 1,888 252 4,778 - 19 - - - 8 5 4 * 82 78 • 1 3 • + + + Lewisham 60,420 2,580 700 31 6,576 - 125 - 42 3 5 18 1 38 57 262 • • • Paddington 23,366 4,376 890 55 1,692 - - - 37 2 10 - 2 9 411 216 114 • 216 216 5,879 1,095 4 116 Poplar 17,463 3,076 1,046 69 2,732 183 29 - - - 6 - 1 - 88 50 90 3,654 13 144 12 St. Marylebone 22,904 2,400 233 7 655 11 - - - - - 21 3 1 175 8 42 2,214 33 8 1,851 4,954 3 55 St. Pancras 27,525 5,597 2,437 181 4,286 102 - - - - - - - - 389 621 289 • 73 13 5,000 ‡ 49 - Shoreditch 11,200 4,070 397 29 3,378 2,675 48 26 1 1 3 - 6 - 260 258 264 408 24 - * * * * Southwark 24,571 4,322 1,509 16 2,303 194 55 - 15 - 2 108 6 - 732 125 84 204 142 - * * * * Stepney 29,003 5,765 1,236 57 4,173 155 45 7 - - 2 1 - - 1,184 104 118 3,640 59 16 1,471 222 - - Stoke Newington. 8,500 5,138 234 21 1,006 54 - - 39 - 1 - - - 40 20 44 - 5 - 10 - - - Wandsworth 96,729 9,834 1,041 57 3,875 - - - - - - - - - 146 100 343 29 15 2 * 2 - - Westminster, City of 23,086 2,437 28 9 1,491 555 - - - - - - - - 63 76 172 2,477 60 19 3,350 4,299 - 7 Woolwich 39,697 2,643 827 21 1,534 384 27 - - - - - - 1 99 42 286 * 26 15 * - - - Total 809,314 127,355 31,273 2,171 78,899 7,059 667 33 314 50 112 164 87 20 8,279 3,223 4,353 19,539 1,114 413 34,812 12,346 66 684 191 Table 21 (continued) Borough Cowsheds Slaughterhouses Offensive trades Smoke nuisances Common lodging houses Cleansing of persons and rooms Water supply Dairies and milk shops Ice-cream premises Restaurants and eating houses No. licensed No. of inspections No. licensed No. of inspections No. authorised No. of inspections Observations Intimations Complaints Notices Houses licensed No. of inspections Persons Rooms or premises Tenement houses extra supply No. on register No. of inspections No. on register No. of inspections No. of places No. of inspections Adults Children After infectious disease For vermin City of London - - - - 3 15 153 7 7 - 1 - 471 3,003 71 133 - 41 30 79 104 671 1,937 Battersea - - 1 - 2 2 205 2 7 - - - 176 1,994 910 257 12 140 297 233 376 200 1,076 Bermondsey - - - 9 60 442 1 5 1 2 40 189 1,280 12 371 - 110 250 159 160 61 477 Bethnal Green - - - - 5 88 2 - - - 1 5 30 8 29 713 - 129 465 151 369 146 359 Camberwell 1 - 3 18 5 2 44 - 41 - 1 45 110 1,160 799 1,711 1 206 81 414 346 354 353 Chelsea - - - - - - 14 - 8 - - - 457 704 318 249 14 44 73 88 301 225 721 Deptford - - - - 2 6 - - - - 1 7 526 1,165 252 479 - 138 63 212 114 102 98 Finsbury - - - - 3 65 108 - 5 - 1 15 45 1,273 405 454 22 84 321 124 120 496 252 Fulham - - - - - - 1,665 - 31 - - - 41 7 206 691 - 121 441 209 169 159 1,056 Greenwich - - - - - - 110 2 6 - - - 239 582 374 30 - 85 221 216 441 139 567 Hackney - - - - 5 8 1,453 28 14 8 1 6 140 786 1,062 394 3 206 214 328 350 241 447 Hammersmith - - 2 - - - 58 3 3 - - - 502 1,197 104 713 2 81 597 236 649 248 817 Hampstead - - - - - - 116 8 41 - - - 24 13 264 148 12 42 197 184 274 204 782 Holborn - - - - - - 202 1 9 - 2 6 95 - 144 156 12 41 19 83 164 530 1967 Islington - - 5 73 13 45 150 3 36 1 - - 196 610 649 749 47 302 861 506 259 657 2,361 Kensington - - - - - - 16 1 6 - - - 259 1,444 609 1,640 14 162 39 290 26 217 199 Lambeth - - 1 2 2 9 51 3 15 1 - - 258 85 1,008 2,350 4 264 280 626 173 236 815 Lewisham - - 2 8 - - 22 - 5 - - - 85 900 1,365 390 - 37 253 350 564 260 656 Paddington - - - - - - 85 - 6 1 1 3 335 71 226 1,538 62 117 468 193 225 143 605 Poplar - - 3 - 1 4 8 - 1 - 2 41 112 8 577 738 - 137 245 173 156 258 207 St.Marylebone - - 1 8 - - 181 4 24 - 2 45 609 507 385 459 18 106 203 169 180 838 1,096 St.Pancras - - 2 13 - - 67 - 18 - - - 1,062 1,598 750 688 154 286 723 414 639 850 1,708 Shoreditch - - - - 1 4 341 1 3 - - - 35 4 200 625 13 85 245 150 328 287 740 Southwark - - 1 4 2 16 122 - 7 - 6 45 1,585 1,686 462 2,501 - 164 343 209 223 445 1,575 Stepney - - - - 19 136 100 - 52 - 4 45 469 18 448 872 - 235 264 273 238 916 1,141 Stoke Newington - - - - - - 13 - 1 - - - 39 437 194 159 - 43 195 86 167 43 145 Wandsworth - - 3 47 - - 51 1 14 - - - 129 47 1,011 322 - 240 1,544 718 1,611 492 1,352 Westminster,C. of - - - - - - 1,565 11 101 1 3 71 551 256 393 3,405 4 121 198 206 113 3,001 3,714 Woolwich - - 2 † 2 4 53 - 11 - 2 26 145 1,049 517 603 - 117 267 257 855 282 1,015 Total 1 - 26 173 74 464 7,397 77 477 13 30 400 8,964 21,892 13,744 23,538 394 3,884 9,397 7,354 9,694 12,701 28,268 Note :—In the columns above a dash signifies a NIL return ; * information not available ; † daily supervision (one slaughterhouse not in use) ; and ‡ included in inspections under Public Health Act. Seamen's Lodging Houses : Total 9—Poplar 3 (31 inspections), Stepney 6 (75 inspections). Prosecutions : Dairies—Bethnal Green 1, Hammersmith 1, Hampstead 1, Holborn 1, Islington 1, St. Pancras 2; Restaurants : City of London 1, Hackney 2, Hampstead 1, Islington 1, Kensington 1, St. Marylebone 2 ; Water Supply : Battersea 1, Islington 7, Paddington 1, St.Pancras 9; Ice-cream premises—Westminster 1. 192 APPENDIX D STAFF OF THE PUBLIC HEALTH DEPARTMENT (AS AT 31st DECEMBER, 1 952 ) Medical Officer of Health and School Medical Officer J.A. Scott Deputy Medical Officer of Health and Deputy School Medical Officer A.B.Stewart Senior Principal Medical Officer M.MacGregor Principal Medical Officers Maternity and child welfare Dorothy F.Egan School health G.D.Pirrie Epidemiology I.Taylor Tuberculosis W.Hartston Staff examinations and mental health C.W.J. Ingham Chief Dental Officer W.Ritchie Young Chief Nursing Officer Jean M.Calder* Chemist-in-Chief C.J.Regan Chief Inspector J.Croft Administrative Administrative Officer C.R.Geere Establishment Officer R.H.J.Stronge Principal Clerks G.Berridge D.J.B.Cooper W.H.Joyce Officer-in-Charge, London Ambulance Service A.G.Hellman Senior Officers of the Divisions Divisional Medical Divisional Administrative Divisional Nursing Division Officer Officer Officer 1. Violet I.Russell L.Welsh Mary Sidebotham 2. H.L.Oldershaw H.J.Norton Evelina Beattie 3. Bertha E.A.Sharpe L.Wilkes Catherine Walsh 4. S.King J.C.Minter Eileen M.Hazel 5. G.O.Mitchell A.J.Cridland Kathleen M.Roe 6. F.R. Waldron L.R.T.Coward Lilian Berry 7. H.D.Chalke G.J.Newton Flora E.Frederick 8. W.H.S.Wallace W.H.C.Bishop Bessie Thom 9. J.T.R.Lewis F.E.Willson Ethel E.K.Woods * Resigned 8th August, 1953. 193 The following statement shows the number of staff employed in the Public Health Department in December, 1952 (part-time staff being expressed as whole-time equivalents). Type of staff Location Staff employed at other establishments (a) Total Head office staff Divisional staff Administrative and clerical (including ambulance control clerks) 206 592 75 873 Medical staff 23 154 (b) 177 Dental staff 1 63 (b) 64 Chemists 19 - 7 26 Inspectors 15 - - 15 Nursing staff 9 2,235 103 2,347 Medical auxiliaries (c) 25 136 15 176 Social worker grades (including mental health) 33 168 83 284 Supervisory staff (ambulance service) 3 - 15 18 Manual workers, operative staff (ambulance service), domestic grades, etc. 36 2,422 777 3,235 Totals 370 5,770 1,075 7,215 (a) These establishments include residential schools and nurseries, welfare establishments, ambulance stations, occupation centres for mentally defective children, main drainage outfall works, clinics and dispensaries, district offices (mental health), central dental laboratory, etc. (b) There are 80 visiting medical officers and 9 visiting dental 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) Including physiotherapists, chiropodists, speech therapists, play therapists, psycho-therapists, dental attendants, dental hygienists, dental technicians and apprentices. 195 INDEX Page Page Accidents in the home 102 Maternal mortality 14 Adoption of children 58 Meals for children . • 119 Ambulance service 83 Measles 19 Analgesia 64 Medical inspection of school children 116 Appendix 151 Medical treatment of school children 120 Audiometry 123 Mental health services 104 Midwifery service 60 Births 5 Milk sampling 24 Blind persons 25 Mortality 7 Bronchitis 8 Nurseries, day 55 Cancer 9 Nurseries, residential 58 Care of mothers and young children 50 Nursing home registration 26 Chemical branch 28 Child guidance 126 Occupation centres 114 Child-minders 56 Ophthalmia neonatorum 20 Child welfare 52 Pneumonia 12, 20 Chronic sick 27 Civil defence 88 Poliomyelitis 20,163 Population 4 Premature babies 53 Day nurseries 55 nn Prevention of illness yu Deaths 7 Dental services 131 Psychiatry 123 Diabetes 9,130 Puerperal pyrexia 15 Diarrhoea and enteritis 17 Recuperative holidays 98 Diphtheria 16,80 Remedial exercises 129 Domestic help service 78 Reports of Divisional Medical Officers 140 Domiciliary midwifery service 60 Rheumatism scheme 125 Dysentery 16 Road accidents 12 Emergency obstetric service 63 Sanitary inspection 25 Enteric fevers 18 Scabies 21 Epileptic children 129 Scarlet fever 21 Expectant mothers 50 School health service 115 School children under 5 years 130 Fertility 5 School meals 119 Finance Smallpox 21 Fog 151 Special investigations 130,136 Food poisoning 19 Speech therapy 128 Foot defects 97 Staff 135,192 Statistical tables 172 Handicapped children 129 Stillbirths 7 Health centres 48 Sunday cinema grants 54 Health education 99 Survey of Health Services 35 Health service premises 42 Health visiting 68 Tuberculosis 21,90 Heart disease 8 Tuberculous milk 24 Home nursing 73 Housing 23 Unmarried mothers 58 Illegitimacy 7 Vaccination 80,82,117 Immunisation 80 Venereal diseases 97 Infant mortality 12 Visitors 139 Infectious diseases 16 Vital statistics 4 Infectious diseases in schools 124 Voluntary organisations 39 Introduction 3 Welfare Committee establishments 27 Marriage guidance 55 Whooping cough 23,82 Mass miniature radiography 94 Woodberry Down Health Centre 48