Lcc59 LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1953 Published by the London County Council Sold at the County Hall, Westminster Bridge, S.E.I and, directly or through any bookseller, from Staples Press Limited, Mandeville Place, W.l 1954 No. 3854 2s. 6d. Postage extra LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1953 By J. A. SCOTT, O.B.E., M.D., M.R.C.P. county medical officer of health and principal school medical officer THE COUNTY HALL WESTMINSTER BRIDGE, S. E. i CONTENTS Page Page Introduction 3 Mental Health Service 93 Vital Statistics 5 Lunacy and Mental Treatment Population 5 Acts 93 Fertility 6 Mental Deficiency Acts 95 Mortality 8 Occupation Centres 98 Intectious diseases 16 General Public Health 23 School Health Service 99 Housing 23 Organisation 100 Public Health laboratory 24 Medical inspection 100 Tuberculous milk 24 Cleansing scheme 103 Sanitary inspection 24 Blind persons 25 Hygiene inspections 105 Registration of nursing homes 26 Children under five years 107 Welfare Committee establishments 27 infectious diseases 108 Chronic sick 27 Medical treatment 109 Chemical Branch 28 Health Service Premises 49 Handicapped pupils 111 Care of Mothers and Young Children 54 Speech therapy 115 Expectant and nursing mothers 54 Audiometry and Audiology 116 Child welfare 57 Marriage guidance 58 Epileptic children 117 Special investigations 58 Enuresis 117 Day nurseries 60 Rheumatism scheme 118 Children neglected or ill-treated in their own homes 61 Remedial Exercise Classes 120 Residential Establishments 61 Diabetic children 120 Unmarried mother and her child 62 Psychiatry 120 Domiciliary Midwifery Service 63 Residential Schools 122 Health Visiting and Nursing Services 72 Home Nursing 74 Dental services 123 Domestic Help Service 76 Staff 128 Immunisation and Vaccination 77 Finance 129 London Ambulance Service 79 Visitors to the Department 130 Prevention of Illness : Care and After Care 85 Reports by the Divisional Medical Tuberculosis 85 Officers 132 Foot clinics 89 Appendix 144 Venereal disease 91 Recuperative holidays 91 (a) Statistical tables 144 Health education 92 (b) Staff of the department 159 (W. & S. Ltd. 60785) 10.54 323366 3 INTRODUCTION TO THE ANNUAL REPORT, 1953 The population of the County at mid-year 1953 was estimated by the Registrar General to be 3,343,000, a decrease of 20,000 as compared with the previous year. The constantly increasing proportion of elderly people is referred to on page 5. The live birth rate (15.2 per thousand population) was slightly lower than in the previous year (15.3) and the decline in the birth rate since 1948, though continuing, is tending to slow down. 7.1 per cent. of the total live births were illegitimate and is the highest figure recorded since 1946 although reasons for doubting this figure as indicating the true illegitimate fertility rate in London are referred to on page 7. The death rate was somewhat lower this year as compared with last year (11.6 per thousand as against 12.0) and it is pleasing to record that for the first time on record there were no deaths from diphtheria. The death rate from cancer (2.34 per 1,000) continues to increase and to constitute the second leading cause of death in London and the effect on this rate by variations in the age constitution of the population is referred to on page 9. Deaths due to violent causes, which during 1953 totalled 1,437 as compared with 1,363 in 1952, continue to give rise to much anxiety. Amongst those deaths many preventable fatal accidents are still occurring in the home apart from the much larger number of non-fatal accidents and the activities of the department are being directed towards the prevention of home accidents as constituting a major public health problem. The infant mortality rate in 1953 was 23.9 per 1,000 live births compared with 26.8 for England and Wales and the corresponding neo-natal rates (deaths in the first four weeks of life) were 16.1 and 17.7 respectively. Prematurity was again the major single cause of death in the first four weeks of life. The number of confirmed cases of poliomyelitis (332) was slightly higher than in 1952 (309) but was considerably lower than for the epidemic years of 1947, 1949 and 1950. The fall during recent years in the death rate from tuberculosis was maintained during 1953 and this, paralleled by the decrease in the notifications of new cases, gives grounds for encouragement. The incidence of dysentery, influenza and whooping cough (pages 17, 18 and 22, respectively) was relatively high during the year. Many of the services at the Woodberry Down Health Centre were extended and new services commenced, including the inauguration of a general medical practitioner service. Details about these services will be found on page 135. The expansion of the London Ambulance Service which has continued year by year since the inauguration of the National Health Service and the training of the operative staff in Civil Defence duties are referred to on pages 79 and 83. The attendances at child welfare centres continue to give grounds for satisfaction and it is pleasing to note that the percentage of infants attending a centre at least once in the first year of life rose to the highest recorded figure of 85, and that first home visits of health visitors to children under one year was equivalent to 90 per cent, of the total live births. The success of the experiment in establishing a special welfare clinic for backward children under five led to a decision to inaugurate more clinics (page 98). Further evidence of the growing co-operation with other parts of the National Health Service which was dealt with more fully in the 1952 Report, will be found on page 59. Further progress was made during the year in co-ordinating the efforts of statutory and voluntary bodies interested in the prevention of child neglect and ill-treatment and reference is made to this matter on page 61. Increased charges for attendance at day nurseries were introduced from 1st January, 1953, and their effect on the occupation of the nurseries and the decision to extend the priority groups to enable vacancies not required for children in the first and second 4 priorities to be offered to a new third priority group (on payment of supplementary charges), are discussed on page 60. A special feature of this Report is the section relating to the work of the Chemical Branch which was prepared by the Chemist-in-Chief, Mr. C. J. Regan. This section, which gives a full account of the historical and other major developments in the use of chemistry and allied sciences in the service of the population of London from 1869 to the present day, will be found on pages 28 to 48. The number of domiciliary confinements, which has been declining since 1948, again fell from 11,026 in 1952 to 10,472. The large increase in the use of analgesia by midwives is referred to on page 65. The demand on the services of the District Nursing Associations, which carry out home nursing on behalf of the Council, continues to increase. Over 1,700,000 visits were paid during 1953. 44 per cent. of all those whose treatments were completed during the year were over 60 years of age and the average case load of a nurse at any one time was over 22. The domestic help service was expanded still further ; over 30,000 persons were assisted (75 per cent. of whom were aged and chronic sick) and nearly 3,000 full-time and part-time home helps were employed at the end of the year. Two new extensions to the scheme relating to the provision of night helps and child helps were introduced, details of which will be found on page 77. Although the number of confirmed cases of diphtheria (11) reached the lowest on record in 1953, the number of primary immunisations again fell and the annual total was less than two-thirds of what it was in 1949 (page 78). This situation, regrettable though it is, must be regarded as a challenge for redoubling the efforts to bring about a higher state of immunity amongst the child population. The vaccination of children under one year of age showed further improvement and over 24,000 such children were vaccinated in 1953, which represents 48 per cent. of the total live births. The considerable decline in the number of verminous pupils in recent years made it possible in 1953 to introduce a revised approach to this problem with a view to securing an even more rapid decline in the incidence of uncleanliness. The scheme, which involves a more intensive investigation by the health visitor at the level of the family, is referred to in more detail on page 105. The large increase in the number of dental inspections in schools is referred to on page 123. The percentage of school-children who were found to require treatment was 63.8. There was an appreciable increase in dental treatment given to the priority groups. (Tables II, V and VI, pages 125-127.) The application of sodium fluoride and the use of dental hygienists are referred to on page 127. The provision of new premises at the rate considered necessary to overcome the difficulties inherent in maintaining some of the health services in improvised accommodation in church halls and rented and requisitioned premises continues to give rise to concern by the Council. These difficulties and the possibility of an increase in the annual sum allowed for capital expenditure have been discussed on more than one occasion with the Ministry of Health. The work of providing domiciliary care and after-care for persons suffering from psychiatric disabilities carried out on behalf of the Council by the National Association for Mental Health and the Mental After-Care Association, and the placing of unaccompanied children in recuperative holiday homes by the Invalid Children's Aid Association was taken over by the Department during the year and I place on record my appreciation of the valuable service rendered by these Associations. In view of the need to reduce administrative work and to economise in staff, and bearing in mind the satisfactory arrangements for tuberculosis care work at each chest clinic, it was decided that Divisional Tuberculosis Care Committees, which were set up in 1949 for the co-ordination of tuberculosis care work, should be discontinued. 5 The Department lost, by resignation on the 8th August, 1953, the services of Miss J. M. Calder, Chief Nursing Officer. Miss Calder has had a distinguished nursing career in Northumberland, Manchester and London. Her knowledge, energy and enthusiasm were invaluable in developing the personal health services of the department since 1948, when the National Health Service came into being, and she takes with her to her married life in Australia the warm good wishes of every member of the department. She was succeeded by Miss E. Robinson on the 14th September, 1953, who vacated the post of Superintendent School Nurse/Health visitor for Lancashire for this purpose. VITAL STATISTICS Population the total home population of the County in the middle of 1953, according to the Registrar-General was 3,343,000, compared with 3,363,000 in mid 1952. Corresponding estimates for metropolitan boroughs are shown in Table 2 on page 145 and the rates given in this annual report are calculated on these figures. Table 1 (page 144) shows the age distribution of the population, as estimated by the Registrar-General, at the middle of each year since 1936 and at the middle of the census years 1921 and 1931 and the mid-census year 1926. Total numbers have been falling slowly since 1947, except for 1952, which would appear to indicate that the Council's policy of decentralisation has begun to take effect but the gradual diminution in the out-county building programme and the increasing reliance on new and expanded towns to cater for the planned overspill of population make future numbers hard to predict. In any case the net yearly losses are insignificant in relation to the volume of migration which occurs in London and other great conurbations. It will be noted that the average age of the population has risen slightly during the year mainly as a result of a lessening in the numbers and proportions of persons under 5 and between 15 and 44 years of age which implies in turn that the net emigration is of young families and the younger adults. Population aged 60 years and over The proportion of the population aged 60 years and over in the administrative County of London in 1951 according to the Census was 16.07 per cent. of which 11.06 per cent. were aged 65 years and over. The proportion of the aged is gradually increasing (see page 4, of the 1952 Annual Report) and reflects the general decline in the birth rate and the greater expectation of longevity since the beginning of the present century. The Census report provides some interesting facts about old people residing within the County, which are shown in the following table : Persons aged 60 years and over in London A.C. Census 1951 Status Number 0/ /o Heads of: All private households % 1 person households % 2 person households % Married : M 151,200 28.1 146,900 27.3 9,000 1.7 73,200 13.6 F 117,400 21.8 *Unmarried : M 60,900 11.3 37,700 7.0 20,300 3.8 9,200 1.7 F 208,600 38.8 142,100 26.4 78,500 14.6 36,700 6.8 Total 538,100 100.0 326,800 60.7 107,800 20.1 119,100 22.1 * Single, widowed or divorced. 6 It will be seen that out of some 538,100 persons aged 60 years and over, 60.7 per cent. comprised heads of private households ; of these 20.1 per cent. were living alone while 22.1 per cent. were couples living alone of which at least one was an aged person. 49.9 per cent. of the old people were married, while 11.3 per cent. were unmarried males and 38.8 per cent. unmarried females. As would be expected as the result of two World Wars and higher female survival rate, the number of aged unmarried females is nearly four times that of unmarried males. Among the 20.1 per cent. of aged persons living alone, 14.6 per cent. were unmarried females and 3.8 per cent. unmarried males ; here again a proportion of nearly four females to one male. The number of aged persons in the community, of which at present 42.2 per cent. are either living alone or comprise married couples living alone, will increase yearly and is likely to intensify the problem of care of the aged in the future. Fertility The total births allocated to London for 1953 were : Live 50,880 Still 1,091 Total 51,971 The live birth-rate in 1953 was 15.2 per 1,000 total population, compared with 15.3 in 1952. 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. This excess of registered over allocated births amounted to some 7,500 births in 1953. The corresponding figure in 1952 was 7,900. The number of marriages registered in London in 1953 was 32,925 or 19.7 persons married per 1,000 of the total population, compared with 19.9 in 1952. The birth-rate in London tends to follow the same trend as for the country as a whole. The diagram (page 7) shows the course of the two rates since 1933. The actual rates for London are given in Table 5 (page 148). The live birth-rate for London has continued to fall since the decline started in 1948 but the rate of decline seems to be slowing down. The live birth-rate for the country as a whole on the other hand has risen slightly, also for the first time since 1948. As has been stated in earlier reports, the proportion of women of child-bearing age (15-45) in the population is greater in London than in England and Wales as a whole (23.8 per cent. as compared with 21.7 per cent. according to the 1951 Census) and hence the true disparity in the fertility of the two populations is greater than would appear from the crude figures of 15.2 and 15.8 live births per 1,000 total population, respectively. The fall in the London population in recent years has been in part among the younger adults and in fact the proportion of women of child-bearing age has fallen from 23.8 per cent. in 1951 to 23.5 per cent. in 1952 and 23.2 per cent. in 1953 which goes some way towards explaining the divergence in the course of the live birth rates in London and England and Wales. 7 LIVE BIRTH RATE IN ENGLAND AND WALES AND LONDON (A.C.) 1933-1953 PER 1,000 TOTAL POPULATION ENGLAND AND WALES LONDON (A.C.) There were 3,614 illegitimate live births (7.1 per cent. of the total live births). The Illegitimacy percentages in recent years were : 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 1953 7.1 4.7 As was stated in the Annual Report for 1952 it is doubtful if the true illegitimate fertility rate in London is as high as would appear from the crude figures because of the natural desire of the unmarried mother to bear her child in the anonymity of a large city and to take advantage of the facilities available therein. Such births are allocated to London and consequently increase both its illegitimate and total fertility rates. Deaths under one year among illegitimate infants amounted to 36 per 1,000 illegitimate live births compared with a rate of 23 for legitimate births. The corresponding rates for 1952 were 33 and 22, respectively. A detailed comparison of deaths in both groups is given in Table 6 (page 149). 8 Still Births There were 1,091 still births in 1953 or 21.0 per 1,000 total births—the legitimate and illegitimate rates being 20.3 and 30.1 respectively. The number of still births and rate per 1,000 total births in each year since 1931 is shown in Table 5 (page 148). It will be seen that after remaining stable for several years the still birth rate fell sharply in 1943 and continued to fall until 1948. There has been a rise in 1953, as there has been in neo-natal deaths (see page 12) but the rate still remains below that of England and Wales. Mortality The total deaths in 1953 amounted to 38,636 or 11.6 per 1,000 of the population. Detailed figures are given in Tables 2, 3 and 4 (pages 145.8). Mortality from infectious diseases is discussed below under that heading and tuberculosis is dealt with separately (see page 86). For the latter and other principal causes of death the trend is indicated by the diagrams on pages 10.11.* 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 in the footnote below but the heavy toll of air raids was an important contributory factor. Between 1944 and 1950 there was, however, a decline. The rate of 11.6 in 1953 is somewhat lower than that of the previous year, and might but for the influenza epidemic in the first quarter of the year have fallen to the 11.3 per thousand of 1950. It will be noted that for the first time on record there were no deaths from diphtheria. Bronchitis and heart disease The death-rate for the bronchitic and heart disease group which was 4.32 in 1953 compared with 4.64 in 1952 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 146). Cerebral haemorrhage, etc. The death-rate from vascular lesions of the central nervous system in 1953 was 1.20 per 1,000, compared with 1.27 in 1952. The average for 1940-44 which covered the complete war years was 1.14 as compared with 1.06 for the period 1946-1950. In fact, except in 1948, the number of cases increased and much of the reduction in the deathrate was due to the increase in the civil population in the younger age groups following demobilisation. The rates over the five years ending in 1952 had shown a steady increase from 1.01 in 1948, 1.07 in 1949, 1.11 in 1950, 1.22 in 1951, 1.27 in 1952—thus the lower rate of 1.20 of 1953 has arrested the hitherto existing trend. * The sharp changes that occurred between 1939 and 1940 are attributable to two causes. In the first place, the Registrar-General abandoned the rates of selection which had hitherto operated in multiple causes of death, and, as from 1940, accepted the principal cause of death as shown on the medical certificate. In addition, the International List of Causes of Death, which was revised in 1938, was applied in 1940, in accordance with international agreement. The general movements resulting from these alterations are estimated to be : Cause Approximate change as a percentage of those formerly assigned to this cause † Influenza — 11 per cent. Cancer — 3 „ „ Diabetes — 30 ,, ,, Heart diseases — 10 ,, „ Other circulatory diseases — 6 ,, ,, Bronchitis + 100 ,, ,, Pneumonia + 5 ,, ,, Other respiratory diseases + 50 ,, ,, Nephritis + 12 ,, ,, Diseases of pregnancy, etc. + 10 ,, ,, †Based on the dual classification of deaths for England and Wales, 1939. The second cause affecting the statistics was the outbreak of war. The young and healthy section of the population was, from September, 1939, excluded from the mortality statistics, which henceforth related only to civilians. This selective factor was found 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 For nephritis the death-rate in 1953 amounted to 0.10 per 1,000, compared with 0.11 Nephritis in 1952, and an average of 0.36 over the years 1931-40. If, as an indication of mortality from degenerative diseases, heart disease, other Degenerative circulatory diseases, cerebral vascular lesions, nephritis and bronchitis are combined, the diseases following trend becomes apparent : Mortality (per 1,000) from cardiovascular—renal disease and bronchitis 1931-40 (average) 5.33 1947 6.27 1941 7.93 1948 5.47 1942 6.93 1949 6.11 1943 7.23 1950 5.99 1944 7.12 1951 6.82 1945 6.67 1952 6.64 1946 6.11 1953 6.21 The true effects of the war cannot be separated from the statistical influences described in the footnote on page 8. The rates in post-war years appear to be running higher than pre-war. Degenerative diseases thus continue to be of greater relative importance, and while over recent years the rates have fallen, so have the total death rates—thus the degenerative diseases continue to be responsible for over half the death rate. The cancer death-rate for all ages in 1953 was 2.34 per 1,000, slightly higher than in Cancer 1952. 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 specific rates since 1948 are shown below : London A.C. : Cancer Mortality Rates per 1,000 living (total population) Age and Sex 1948 1949 1950 1951 1952 1953 Males : 0-14 0.03 0.06 0.11 0.10 0.11 0.12 15- 44 0.30 0.29 0.38 0.35 0.37 0.39 45+ 5.61 5.81 6.18 7.45 7.35 7.45 All Males 2.21 2.27 2.45 2.60 2.61 2.68 Females : 0-14 0.03 0.05 0.07 0.09 0.08 0.07 15-44 0.36 0.33 0.37 0.35 0.35 0.38 45+ 4.44 4.42 4.51 4.83 4.87 4.86 All Females 1.95 1.93 1.98 1.99 2.02 2.04 All Persons 2.08 2.09 2.20 2.27 2.30 2.34 Up to 1952, for England and Wales, the comparative mortality index for females had fallen to 0.94 (1938 = 1.00), while the male index had risen to 1.13. In London, for both sexes combined, the long-term trend of cancer mortality can be seen from Table 3 (page 146). 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, was accounted for by 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 but the increase in 1953 to 2.83 only partly accounts for the total increase of 0.07 to 2.68. 10 Digestive Mortality from digestive diseases (other than cancer) in 1953 was 0.42 per 1,000. Within this group the death-rate from ulcer of the stomach or duodenum was 0.16 per 1,000 compared with 0.17 in 1952 and 0.19 in 1951. Diabetes Diabetes mortality fell steadily between 1930 and 1947, but in the last five years the death-rates have been 0.07, 0.08, 0.09, 0.08, 0.07 which supports the impression that the previous decline had been connected with the dietary stringency of the war and post-war years. As will be seen from Table 3 (page 146) the current figure of 0.07 is the same as that for the period 1946.50 and lower than that for any other quinquennium in the TREND OF MORTALITY - LONDON 1933-53 DEATH RATE PER 1,000 11 present century : the continuous fall during the last three years is, however, over too limited a period to make any safe prediction as to future trends. At ages under 55, where treatment is more effective, the number of deaths in 1953 was 20 which compares with recent figures of: 1935-38 (mean annual deaths) 86 1939-41 „ „ „ 71 1942-44 „ „ „ 42 1945-47 „ „ „ 31 1948 27 „ „ „ 1949 26 1950 39 1951 34 1952 34 TREND OF MORTALITY-LONDON 1933-53 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 causes of death, but thereafter declined fairly steadily until 1951 since when it has remained stable at 0.12 per 1,000. What had seemed to be a steady decline in the mortality rate from pneumonia, doubtless associated with antibiotic therapy, has, since 1946, turned into a biennial rise and fall with peaks in 1947, 1949, 1951 and 1953 associated with influenza epidemics. Road accidents The number or London residents who died in motor vehicle accidents in 1953 was 247, as compared with 221 in 1952 and 282 in 1951. 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 1953—233, for 1952—205 and for 1951—259. 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 remains about the same as it was between 1870 and 1890, having declined substantially from the peak of 822 deaths which it reached in 1930. While the toll is still a matter for grave concern, it is nevertheless some small satisfaction that the rate has remained of the same order in the face of a continuous increase in the number of road vehicles currently licensed : it is impossible to assess whether the fall in the fatal accident rate per vehicle is due to road safety campaigns, better highway maintenance or improvements in treatment, but the first and last of these factors are probably the more important. Other violence Other violent causes of death accounted for 1,190 deaths. The corresponding figure for 1952 was 1,142. The peaks in the diagram on page 11 are due to the heavy toll of air raids. Infant mortality The infant mortality in 1953 was 23.9 per 1,000 live births which compares with rates of 23.1 in 1952 and 25.4 in 1951. The movements of the death rates from the principal diseases at ages below one year since the years 1931-35 are shown in Table 7 (page 150). The diagram on page 13 illustrates these movements. The increase in deaths assigned to congenital malformations and injury at birth between 1936-40 and 1941-45 is partly attributable to changes in classification following the adoption of the fifth revision of the International Causes of Death in 1938, and partly, perhaps, to increased numbers of post-mortem examinations with resultant precision of certification. Under all the other headings given in the table there has been a pronounced improvement in mortality rates although in 1953 there was an increase over 1952 due in part to an influenza epidemic in the first quarter of the year and a carry over into the early part of the year of the effect of the smog of 1952 on the death rates from diarrhoea and enteritis. Neo-natal mortality Deaths in various periods of the first year of life during 1953 are shown in detail in Table 6 (page 149). Deaths under four weeks numbered 821 or 16.1 per 1,000 live births, and like still births, have increased slightly over those for 1952 but remain below those for England and Wales. Comparative rates for London and England and Wales in recent years are : Year(s) London England and Wales 1931-35 25.1 31.4 1936-40 22.9 29.0 1941-45 23.4 25.9 1946-50 18.4 20.9 1951 17.3 18.9 1952 15.8 18.3 1953 16.1 17.7 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 but this setback was soon recovered. The reduction in infant mortality is a result of many factors and they have mainly been effective against the causes of death (principally infectious, diarrhoeal or respiratory), which do not operate until after the first few weeks of life. Deaths within 13 the first four weeks of life, which result largely from prematurity, congenital malformations and injury at birth, have been more resistant to reduction. INFANT MORTALITY MORTALITY PER 1.000 LIVE BIRTHS The distribution of causes of death in the first four weeks of life in descending order of magnitude in 1952 and 1953 was as follows : Cause No. of deaths Per cent. of total 1952 1953 1952 1953[/### ] Prematurity 209 202 25.5 24.5 Post-natal asphyxia and atelectasis 178 196 21.8 23.9 Birth injury 141 136 17.3 16.6 Congenital malformations 118 114 14.4 13.9 Other diseases of early infancy 74 66 9.1 8.0 Pneumonia of newborn 56 59 6.9 7.2 Diarrhoea and Enteritis 2 4 0.2 0.5 All other causes 39 44 4.8 5.4 Total 817 821 100.0 100.0 14 It will be seen that deaths from prematurity, injury at birth and congenital malformations account for some 55 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, 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, which had fallen comparatively slowly to 11.6 in 1938, rose temporarily during the war and, after regaining the pre-war level of 11.6 in 1944, fell to 4.0 in 1953. This comparatively large reduction in the rate is doubtless associated with the contemporary emphasis on the care of premature infants. Birth injuries offer less ground for satisfaction—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 and remained at this figure in 1953. The birth injury deathrate has been understated in the past but now more post-mortem examinations are performed and more injuries 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 and had fallen to 2.2 in 1953. 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 150). 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 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 1953 51,971 21 0.40 16 0.021 1,712 32.94 Rates per 1,000 total births, except for deaths following abortion where the rates are expressed per 1,000females (15-44). The maternal mortality rate in 1953 was 0.40, as compared with 0.67 in the previous year. It is, however, necessary to point out that in 1952 one case assigned by the Registrar-General (under the International Rules of Classification) to pregnancy or childbirth, 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 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 1953 1950 1951 1952 1953 1950 1951 1952 1953 Sepsis 7 13 10 8 — 3 2 — 7 16 12 8 Other causes 2 5 5 8 29 21 33 21 31 26 38 29 Total maternal deaths 9 18 15 16 29 24 35 21 38 42 50 37 Puerperal Pyrexia 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 1953 was 32.94 per 1,000 total births, compared with 35.38 in 1952, 17.04 in 1951, and 6.83 in 1950. 15 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 1896 is shown in Table 3 (page 146). It will be observed from this Table that maternal mortality fell very slowly until the introduction of the sulphonamides in the middle '30's, resulting in a substantial decline in the mortality from puerperal infection. In recent years puerperal sepsis has lost its position as the most serious mortality risk in pregnancy and has been displaced by toxaemia, haemorrhage and other accidents (trauma of the pelvic organs, etc.), which now contribute the greater part of the total mortality, though the risk of death from this cause has also been falling rapidly. It will be noted that if abortion is excluded there were, as in 1950, no cases of maternal mortality from this cause in 1953. 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 The leading causes of death in London in 1953 were as follows : Deaths Rate per 1,000 population General Diseases of the heart 10,852 3.25 Cancer 7,823 2.34 *Pneumonia, bronchitis 5,647 1.69 Vascular lesions of the nervous system 4,018 1.20 Other circulatory 1,967 0.59 Violent causes 1,437 0.43 Digestive diseases 1,420 0.42 Diseases of early infancy (prematurity, birth injury, congenital malformation, etc.) 907 0.27 Tuberculosis 763 0.23 Nephritis 333 0.10 Hyperplasia of prostate 274 0.08 All other causes 3,195 0.96 Total 38,636 11.56 * Excluding pneumonia of the new born (under 4 weeks) which is included in Diseases of early infancy B 16 There have been no material changes in death rates or in the order of causes of death from that of 1952 except that violence has displaced digestive diseases in sixth place and nephritis, hyperplasia of the prostate in tenth place. Infectious diseases The attack rates and death rates of the principal infectious diseases in London are shown in Tables 2, 3 and 14 (pp. 145, 146 and 155) : Table 2 shows both types of rates for the constituent Metropolitan Borough Councils in 1953 ; Table 3, death rates since 1896 for the County as a whole ; and Table 14, attack rates for the County since 1933. 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 (page 156) 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 52 weekly periods and not adjusted for final late corrections of diagnosis, will not correspond with the yearly corrected totals in Table 14. DIPHTHERIA — AGE INCIDENCE NOTIFICATIONS PER 1,000 LIVING IN AGE GROUPS 17 Anthrax There were no notifications of anthrax during 1953, as was also the case in 1952. Diphtheria The outstanding feature of the diphtheria figures was that for the first time on record there were no deaths in the County of London from this disease. There were only 11 confirmed notifications of the disease during the year compared with 18 in 1952 and 30 in 1951. The progress of diphtheria prevention during the last 20 years is shown graphically in the diagram (page 16) from which it is seen that the present low figures are the result of a trend which began in children under the age of 15 years in 1941. No unprejudiced observer would dispute that this trend resulted directly from the immunisation campaign. Nothing could be more dangerous, however, than to feel that the present low figures are any excuse for complacency with regard to immunisation. Even if the number of cases could be further reduced the risk of importation of infection is always present and the only safeguard against the spread of this disease is a high level of immunity in the child population. Diarrhoc; and Enteritis The number of deaths from diarrhoea and enteritis under 2 years of age rose from 43 in 1952 to 72 in 1953, and the death rate from this cause in London was slightly above that for England and Wales for the first time since the end of the war. The heaviest mortality from this cause occurred during the early months of the year in continuation of the increased mortality beginning in the week of the severe fog of December, 1952. In spite of the rise in mortality the 1953 figure of 1.4 per 1,000 live births was still below that of any year before 1950. DIARRHOEA AND ENTERITIS (UNDER TWO YEARS) MORTALITY PER 1,000 LIVE BIRTHS Dysentery Dysentery, with 2,639 notifications, showed a high incidence, although not so high as in 1951, when 4,069 notifications were registered. After a rise in incidence during May and June there was a lull until the early winter when the figures began to rise again towards very high epidemic figures in the early months of 1954. This pattern of incidence was very similar to the various stages in the biennial cycle of measles, and in recent years Sonne dysentery has increasingly shown the epidemiological features of other contact diseases rather than those of the food-borne infections. As in 1952, slighdy less than half B* 18 the notifications were aged 0-4 years, and the disease continues to be prevalent in day nurseries and residential nurseries for young children. In a number of outbreaks in day nurseries an attempt was made to limit spread by sulphonamide prophylaxis using succinyl-sulphathiazole or phthalyl-sulphathiazole ; while considerable success appeared to follow the use of the drug in some cases, in others no demonstrable benefit could be seen. The investigation into the circumstances of notified cases mentioned in the report for 1952 continued until November, 1953 and the findings are now being examined. Enteric fevers The incidence or typhoid and paratyphoid fevers continued to be low, only 45 notifications being recorded, with an absence of sizeable local epidemics. In some cases the infection had been acquired abroad, but the majority appeared to be indigenous infections. Erysipelas There were 408 notifications of erysipelas in 1953 giving an attack rate of 0.122 per 1,000 compared with 0.139 in 1952. There were 3 deaths in 1953. If the notifications of this condition can be regarded as reliable, incidence of erysipelas would appear to have been declining since 1941. Food poisoning Food poisoning has been a notifiable disease in London since the beginning of 1949. In 1953 1,269 cases were reported giving an attack rate of 0.38 per 1,000, compared with 612 cases (0.18) in 1952. The sex and age distribution was : Age Males Females 0-4 79 61 5-14 148 113 15-44 172 234 45-64 63 97 65 + 100 188 Age unknown 2 12 564 705 As in the previous year there was a slight male excess in childhood and a female excess in adults. During July three outbreaks of food poisoning following school meals in Paddington, Battersea and Camberwell were traced to the consumption of spray dried milk infected with staphylococcus aureus in the factory. The infected milk was withdrawn from supply, and from that time spray dried milk has not been used in school meals unless the prepared dish was a cooked one. Influenza There were 514 deaths (0.15 per 1,000) from influenza during the year. During recent years the deaths have been : Year Influenza deaths Year Influenza deaths 1942 198 1948 78 1943 726 1949 372 1944 206 1950 256 1945 171 1951 809 1946 371 1952 162 1947 284 1953 514 Following the ' smog ' at the end of 1952 there was an outbreak of influenza during the first quarter of 1953. The last major outbreak was during the early months of 1951. Leptospirosis Arrangements which 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 1953 is the same as in 1952 and both are 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. 19 Measles The epidemic peak occurred at the beginning of January, and this year saw the gradually declining incidence characteristic of the second year of the biennial cycle of measles. The number of notifications during the 1952-53 epidemic was considerably smaller than the two previous epidemics. Mortality from this disease continues to be very low indeed. Meningococcal infections The incidence of this infection (98 notifications) during the year was at about the same level as during the last six years. The last epidemic years were 1940 and 1941 when 839 and 706 cases respectively were notified. During 1953 the cases occurred sporadically throughout the year without any distinct local concentrations. 65 notifications were in children under the age of five years. Of the 21 deaths in children under five years of age, 9 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 0-14 years 21 65 32.2 5-14 years — 19 — Over 14 years 3 14 21.4 Chemotherapy produces good results in the meningeal form of this disease, but most of the deaths in infants resulted from the fulminating septicaemic forms of the disease for which therapy is more difficult. Ophthalmia neonatorum 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 2-4 per 1,000 live births. There were 161 cases in 1953 (3.2 per 1,000 live births) of which 146 were those in which the mother was a resident of the County of London; full details of the latter are shown below : Ophthalmia neonatorum Number of cases Domiciliary confinements Institutional confinements Total Notified during the year . . 40 106 146 Removed to hospital for special treatment 10 11 21 The condition at the end of the year of the 146 cases was : (a) Vision unimpaired 141 (b) Vision impaired (c) Vision lost .. — (d) Died — (e) Under treatment .. — (f) Removed from the County 5 146 Pneumonia Notified cases of pneumonia in 1953 numbered 2,434 or 0.728 per 1,000 compared with 0.567 in 1952 and 0.717 per 1,000 in 1951. This disease is considerably undernotified, particularly at ages over 65, and it is believed that over the whole age-range only about one-quarter to one-third of the total cases are notified. There is, however, no reason to believe that this fraction varies from year to year so that the notifications may still be used as a relative index of incidence. It will be seen from Table 14 (page 155) that the 1953 notification rate was a little lower than war-time. (See page 12 for comment on the death-rate.) Poliomyelitis The number of confirmed notifications of poliomyelitis (332) was about the same as in 1952, and considerably lower than in the epidemic years 1947, 1949 and 1950. 20 The weekly notifications rose gradually to 28 in the 29th week, and did not return to the inter-epidemic level until about ten weeks later. Of the total notifications during the year, 235 were paralytic and 97 non-paralytic. At all ages (except the 10-14 range) the paralytic exceeded the non-paralytic in number. The age incidence in 1953 was as follows : Age No. % 0-4 116 35.0 5-14 104 31.3 15+ 112 33.7 Total 332 100.0 There was again an 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 from 1947 onwards : Year Percentage of notifications in the 0-4 age group 1947 27.9 1948 33.3 1949 53.3 1950 34.9 1951 24.1 1952 30.7 1953 35.0 Rheumatic fever Deaths in London from rheumatic fever in 1953 were 24, of which 8 were children under 15. 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) 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 1953 2 4 273 279 0.130 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 and 1953 compared with the lower figures of 1950 and 1951 does not necessarily mean that any significant rise has taken place. Scabies Scabies became notifiable in London in August, 1943. Notifications in 1953 numbered 527, as compared with 535 in 1952, continuing the decline since the initiation of notification. The attack rate (0.158 per 1,000) in 1953 was less than one-fortieth of the rate (6.70) experienced in 1944, the first complete year for which notifications were received after the disease became notifiable. Scarlet fever Scarlet fever incidence in 1953 was 3,425 cases (1.02 per 1,000) compared with 5,263 cases (1.56 per 1,000) in 1952. The incidence was predominantly among children of school age. The notification rate of 1.02 per 1,000 in 1953 was one of the lowest on record, and mortality (two deaths—both female, one under 5 and the other over 65) 21 remains very low when it is remembered that fifty years ago before modern methods of treatment were available and when the disease was more severe than now, the annual death roll in London from scarlet fever or streptococcal sore throats was over 500. Smallpox and typhus Tuberculosis There were no notifications of either smallpox or typhus during 1953. Detailed figures of new cases of tuberculosis notified in 1953 are shown in Tables 9 to 12 (pages 150 to 154). Non-civilians are included in the statistics and total (home) populations are used. The general trend of morbidity and mortality since 1921 is indicated in Table 9 (page 150) and is also illustrated by the diagram (page 22). 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 deathrate 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 well below the level to which they might have been expected to decline on the basis of pre-war trends. The death-rates per 1,000 living in 1953 in London and for the whole country were : Pulmonary Non-pulmonary London 0.206 0.022 England and Wales 0.184 0.023 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. The notification rate of pulmonary disease in 1953, of 1.40 per 1,000, was the same as the rate recorded in 1952. 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 1953 was 0.12 as compared with 0.15 for 1952. The age distribution of new notifications of tuberculosis is shown in Table 10(a) ; the numbers on the registers at 31st December for 1943 to 1953 in Table 10(6) ; the numbers of new cases diagnosed as tuberculosis at chest clinics during 1953, the percentage found to be positive and the number of contacts examined, in Table 10(c) and the occupations of adult cases notified in 1951 and 1953 in Table 10(d). Specific notification and death-rates are shown in Tables 11(d) and 11(6), and the distribution of notified cases of non-pulmonary tuberculosis by site in Table 12. Tables 10(c) and (d) are new. No particular significance should be attached to the fact that the rates in Table 10 (d) differ unduly in some instances—the numbers involved are in many cases so small that random fluctuations are to be expected and in any case 22 the rates are based on the assumption that the occupational distribution of the population is relatively constant. It is intended to repeat the table in future years, for certain classes of employment at least, to see if any trend becomes perceptible. TUBERCULOSIS MORTALITY AND MORBIDITY 1923-1953 ANNUAL DEATHS PER 1,000 LIVING ANNUAL NOTIFICATIONS PER 1,000 LIVING Whooping cough An epidemic of whooping cough took place during the year, culminating during the summer months. It was considerably smaller than that of the winter of 1951-52. The number of notifications in the year, 11,027 was higher than in 1952 (5,587). The 20 deaths during the year, all under 4 years of age, gave a death-rate of 0.006 and a crude case fatality rate of 0.18 per cent. The corresponding rates for the three previous years were : 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. 1952—Death-rate 0.003 per 1,000, case mortality 0.18 per cent. Infectious diseases in schools The number of cases of various infectious diseases reported from schools in 1953 and previous years is shown in Table 13 (p. 154). 23 GENERAL PUBLIC HEALTH Housing dtiring the year 15,591 houses and flats were erected by the Council and the Metropolitan Borough Councils. Of these 11,093 were in London (5,868 by the Council and 5,225 by the Borough Councils) and the remainder (4,498) were erected by the Council outside the London area. The total number of houses and flats erected or acquired by the Council for housing purposes at 31st December, 1953, was 156,924 (an increase in the year of 10,277) of which 74,910 were situated in London and 82,014 outside the county. In addition 7,863 temporary prefabricated bungalows erected by the Ministry of Works are managed by the Council. The number of applications registered on the Council's housing waiting list on 31st December, 1953, was 170,225 compared with 180,366 in 1952. Approximately 29,000 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 33,312 requests for preference in re-housing on health grounds were considered, and suitable recommendations made to the Director of Housing and Valuer. This figure included a number of applications which had been considered in previous years but were reviewed in the light of changed medical or domestic conditions. The number of new applications considered was some 4,000 less than in 1952. 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 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. (1,259) 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 urgent,' and 39 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 44 per cent. Slum clearancc Reference was made in the annual 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 provided for the demolition of 10,131 houses, was continued during the year, and 44 areas containing 1,641 houses were represented to the Housing Committee. In addition, preliminary surveys were completed in respect of a further nine areas containing 572 houses. Five public local inquiries were held by the Minister of Health and confirmation of one of the Council's Orders was received. The result of the remaining four inquiries was awaited at the end of the year. Notifications under section 33 of the Housing Act, 1936, of intention to deal with 364 unfit houses contained in 14 areas were received from nine Metropolitan Borough Councils. 24 Improvement grants Surveys were made in respect of three 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 1,985 searches were made in connection with enquiries concerning properties scheduled as dangerous structures. Public Health Laboratory The Medical Research Council Public Health Laboratory at the County Hall was opened on 1st January, 1953, and during the year increasing use was made of the facilities available. The close liaison with the Director of the Laboratory which has grown up has proved of great value. In addition to the bacteriological work carried out for the central department (e.g. testing of milk samples) the majority of the health divisions and several establishments in other departments have made use of the services provided. In addition, considerable use has been made of the laboratory by general practitioners and by the medical officers of health of the Metropolitan Boroughs and of neighbouring County Boroughs. Tuberculous milk The following are details of the sampling for biological examination of milk coming into London and the results of the examinations : Source o f sample Designation Samples Percentage positive of completed samples Total Positive Incomplete Negative 1953 1952 (a) Supplied to London by road and rail in churns and bottles Ordinary 364 15 11 338 4.1 24 Accredited 64 4 7 53 * * Tuberculin tested 53 — — 53 — — Tuberculin tested (farm bottled).. 7 — — 7 — — (b) Plant at London depots Pasteurised 8 — — 8 — — (c) Residential schools Tuberculin tested 4 — — 4 — — Total 500 19 18 463 3.8 2.2 * A percentage would be unreliable owing to the small number of samples taken. As a result of investigations by the Ministry of Agriculture and Fisheries into the origin of positive samples in 12 herds, one of which had been the source of positive samples on two occasions, five 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. Investigation was still proceeding at the end of the year in the case of six herds, including one from which a cow had already been slaughtered. All the raw milk from which positive samples were obtained had been pasteurised before sale to the public. Sanitary inspection Disinflation Reports of 200 instances of infestation were received from 173 establishments controlled by the Council, e.g., school meals centres, schools, welfare establishments and parks. Infestation by rats, mice, cockroaches, bugs, ants, flies, fleas, mosquitoes and clothes moths were dealt with and 165 of the infestations were satisfactorily remedied by the end of the year. 25 The disinfestation of dwelling-houses owned by the Council was undertaken by the staff of the housing and valuation department. Advice on the latest method of control was given as the occasion arose. Talks on the most effective measures for controlling and eliminating pests were given to staff employed in the restaurants and catering department and at the Council's large welfare homes. Restaurants and catering Over 1,200 visits of inspection were made to school meals centres, dining centres and kitchens. Nineteen reports of illness following consumption of school meals were investigated compared with 25 during 1952. In three instances it was confirmed that illness was due to staphylococcal food poisoning caused by infected dried milk. Welfare establishments Regular inspections, at least once a quarter, were made of 70 homes, hostels and other premises relating to sanitary conditions. Complaints A large number or complaints ot insanitary and overcrowded home conditions were received from the public. These were referred to the health departments in the appropriate Metropolitan Boroughs. Advisory and research work Advice was given to stall or 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. The plumbing experiments referred to in the Report for 1952 were continued in association with the architect's department and the Plumbing Research Committee of the Department of Scientific and Industrial Research. A number of ' single pipe ' systems of plumbing were installed in some of the Council's multi-storey dwellings and compared with orthodox methods of plumbing, the installations effected a saving of £11-£12 per flat. Representation on committees of outside bodies The Chief Inspector continued to represent the Council on a number or committees of the British Standards Institution and is chairman of the three committees and three sub-committees appointed to consider standards in relation to sanitary appliances, chemical closets, water closet seats, 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 103. Examinations by the Council's ophthalmologists. Classification Certified blind Not blind Grand Total Male Female Total Male Female Total New cases 252* 459* 711* 128 242 370 1,081* Previously blind, still blind .. 44 51 95 — — 95 Previously not blind, now certified 18 37 55 — — — 55 Previously not blind, still not blind — — — 63 204 267 267 Previously blind, now not blind — — — 13 16 29 29 Total 314* 547* 861* 204 462 666 1,527* * These figures include 7 boys and 6 girls under 5 years of age. 26 The standards used are those prescribed by the Ministry of Health (Circular 1353/33). The cases 'previously blind, now not blind' are mainly those in which cataracts have been removed surgically. 280 certificates were accepted from other authorities, hospitals and private ophthalmologists as follows : Blind persons 241 (109 male including one child under five years, 132 female including three children under five years). Not blind persons 39 (16 male, 23 female). The causes of blindness in the 17 children under five years of age who were certified during the year were as follows : Retrolental fibroplasia . 3 Congenital, hereditary and development defects . 9 Congenital optic atrophy 1 Cataract 1 Intra ocular tumour 1 Buphthalmos 1 Opaque corneae 1 The number of partially-sighted persons recommended for inclusion in the Observation Register was 348 (117 male, 231 female). Blind persons examined as to suitability for training and the results were : Male Female Total Suitable for training 4 1 5 Unsuitable for training - - - Registration of nursing homes At the end of the year there were 48 nursing homes on the register, the same number as in 1952. In the 48 homes there were 858 beds distributed as follows : Number of beds in home Number of homes Patients accommodated All types\ Medical and surgical only* Total 25 or over 6 234 102 336 20 to 24 10 66 148 214 15 to 19 5 83 83 10 to 14 10 50 65 115 5 to 9 12 43 51 94 Under 5 5 2 14 16 Total 48 395 463 858 † Each bed is registered for a medical, surgical or maternity case. * Numbers include beds for medical and surgical patients which cannot be used if a maternity patient is accommodated in the same room. Visits of inspection to the homes were made at regular intervals by medical officers (92 inspections) and public health inspectors (130 inspections). Close overall supervision of the homes was maintained. The lifting of certain restrictions on the use of building materials, etc., resulted in some improvement in the structural and decorative condition of some homes. The shortage of properly-qualified nursing staff continued to present a variety of problems and underlined the need for maintaining a close scrutiny of the staff provided at all homes. 36 exemptions from the operation of Part XI of the Public Health (London) Act, 1936, were granted. 27 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, hostels for mothers at work, 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 the Report for 1950, were continued during 1953. Homeless families units At the end of the year 239 mothers and 459 children (of whom approximately 51 per cent. were under five years of age and 16 per cent, under one year of age) were accommodated in the six homeless families units attached to large homes. The occasional overcrowding of these units, due to pressure on available accommodation, continued to give rise to many difficulties, while the concentration of a larger number of families in one establishment, following the provision of additional accommodation, presented fresh problems. 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 five 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. Nursery classes for children aged between three and five years were conducted under the direction of the Education Officer at two of the large homes and at two half-way houses. Mother and baby units and hostels for mothers at work Close supervision of the health of infants accommodated in one mother and baby unit and in two hostels for mothers at work was maintained during the year, and advice given on matters relating to diets and general hygiene. Children from one of the hostels attended a neighbouring day nursery. Care of the chronic sick Continued attention was given to the needs of the considerable number of chronic sick persons who remained 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 506 (106 men and 400 women). A large proportion of these residents were either permanently bedridden or in need of treatment in varying degrees and their continued care gave rise to many varied and complex problems. Sick bays were 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 vear to discuss problems associated with the care of the aged and chronic sick. Invalid Kitchens of London The provision by the Invalid Kitchens of London of meals for invalids and sick people continued throughout the year as outlined in the Report for 1952 (page 41) and the number of meals provided (year ended 30th September, 1953) was 128,211. During the year the Council decided to make an increased grant of £8,000 per annum for the three years ending 31st March, 1956. 28 CHEMICAL BRANCH Introduction the following report on the Chemical Branch, prepared by Mr. C.J. Regan, who retired from the position of Chemist-in-Chief in March, 1954, includes a history of the branch since its formation : In view of my forthcoming retirement this is the last annual report for which I shall be responsible and I much appreciate the compliment that this has been chosen to be the occasion on which an account shall be given of the history of the use of chemistry and the allied sciences in the service of the population of London, and also a more extensive description of the investigations which have been made by the Chemical Branch in 1953. The first known instance of the appointment of a chemist to a predecessor of the London County Council was that of a consulting chemist (T. W. Keates) to the Metropolitan Board of Works in 1869. A few years later, in 1878, this was made a whole-time position and there was formed a Chemical and Gas Department. W. J. Dibdin was appointed to succeed Keates in 1887 and when the London County Council was formed in 1889 to take over the functions of the Board of Works this was one of the few departments into which it was organised. In those early days its duties were largely concerned with the questions of sewage disposal and gas supplies. At that time the sewage disposal works at Beckton and Crossness were under construction, it having been decided, following the findings of the Royal Commission on Metropolitan Sewage Discharge, 1882-4 (Bramwell Commission), to treat the sewage by the addition of chemicals. This service hence became a joint one between the Chief Engineer and the Chemist. In the nineteenth century gas was used principally as an illuminant and Acts of Parliament governed its testing for illuminating power and also the maximum amount of sulphur which it should contain. Another subject which, in the 1890's, was of first importance from the chemical aspect was that of water supply and the London County Council gave much attention to it. The need of co-ordination in the London area had been realised and consideration was given to the possible sources which might be utilised for what it was realised would be the greatly increasing future demand. The Council appointed a special Water Committee and a large scale survey was carried out and many samples were analysed from rivers and streams in Wales with a view to possible reservoir and pipeline construction to convey the water to London ; but the final decision was against this project and the Metropolitan Water Board was later formed to take over the responsibility for the water supply of London. In addition to that concerned with these special services, other chemical work carried out at the formation of the London County Council dealt with the examination of general stores such as soaps, oils, etc., and foodstuffs for residential institutions and statutory work on the testing of petroleum in relation to the issue of storage licences. In 1897 W. J. Dibdin resigned and Dr. F. Clowes was appointed to be Chemist. On his retirement in 1912 the Chemical and Gas Department was abolished and the bulk of its work was merged in the then rapidly developing Public Health Department of which it became the Chemical Branch ; so it has remained ever since, the Chemist-in-Chief working under the general direction of the Medical Officer of Health. Succeeding Chemists-in-Chief have been J. H. Coste 1912-1936, E. T. Shelbourn 1936-1938, E. R. Andrews 1938-1941, and the present author 1941-1954. The known use of chemistry started in 1869 and has thus existed for 85 years. Since my own service has covered exactly half this time (1911-1954) it may be of some interest to comment on the changes which have occurred in that period. The field of work in 1911 was much smaller than that at the present day and the simplicity of the chemical analyses then required as contrasted with the complexity of those of the present time illustrates the vast strides which have been made in the 29 vening period in the increase of scientific knowledge. This, of course, has had its repercussions in the development of new manufacturing processes involving chemical synthesis. Examples which may be quoted are in regard to modern and more effective insecticides (e.g. D.D.T. and Gammexane) and synthetic resins and dyestuffs for use in paints, etc. Thus, at the beginning of the period, paints generally consisted of a simple inorganic or natural pigment compounded with linseed oil and turpentine: the pigment could, for instance, be manufactured white lead or natural ochrc; the chemical preparation and subsequent analysis of such a material was a comparatively simple process. Nowadays the pigment may contain a fast artificial dyestuff (such as monastral blue) mixed with other substances, and the medium, instead of being just linseed oil, may contain synthetic resins or chlorinated rubber. Such a complex mixture is extremely difficult to separate chemically and hence other methods of assessing the suitability of the paint had to be developed. These have been mainly on the lines of physical testing : for example, the film produced by the paint on painting out is examined for such properties as elasticity, flexibility, gloss and gloss retention as well as being exposed to a process of accelerated weathering. The requirements of modern architects for a much extended series of colour ranges and the need for a scientific assessment of these in the case of samples examined has also complicated the position. Incidentally, these considerations illustrate the fact that the Chemical Branch deals not only with the chemical aspects of the requirements of the service, but also with those of the Wlated sciences, particularly physics. Another field of activity of the Chemical Branch in which the scientific aspects and analytical control have become of much greater importance than in the old days is that of sewage treatment. Formerly the system of operation was to add a small dose of chemicals, settle in sedimentation channels, decant the liquid direct to the river, and pump the settled sludge to a sludge vessel for dumping in the North Sea. But in 1913 the 'Activated Sludge' process was invented by two chemists at Manchester, and, later, the 'Sludge Digestion' process was devised by a chemist at Birmingham. These two procedures revolutionised the science of sewage treatment ; they arc both biological in character and need careful analytical control to ensure that the conditions are suitable for optimum operation. Whilst both were great developments the latter is possibly of more obvious value since it yields sufficient sludge gas (containing 70 per cent. methane) which, on combustion, will produce enough power to render the sewage works selfsupporting from the power point of view. Both these processes have operated at the Northern Outfall Works for some years and will do so on a much larger scale at both works when the additional plants, now under construction or authorised, have been completed. One aspect of the work of the Chemical Branch which should be emphasised at the present time is its economic value. In many instances savings of expenditure have been achieved by means of its activites. For example, by the scheme of approved lists for paints which may be used, and by checking the qualities of deliveries, paint failures have been reduced to an exceedingly low level. In one or two cases which have occurred and the trouble has been identified as being due to the use of a paint of unauthorised composition, the contractor has replaced the work. When it is pointed out that the annual cost of painting, using nearly a quarter of a million gallons a year, is more than one million pounds per year the scale of the saving is apparent. Many other instances could be quoted such as the buying, from tendered goods, of the lowest priced articles found to be satisfactory on analysis. The very wide field covered by the work of this branch will be realised from the succeeding sections and the appreciation of its value by the executive services of the Council is evidenced by the ever-increasing demand which is being made for its advice on a vast variety of problems. 30 Synoposis of work done and samples examined Much of the work of the branch comprises consultative and advisory duties and these have continued to increase though the actual number of samples examined in 1953 showed a slight decrease compared with 1952 the respective figures being 25,268 against 26,642. The following table indicates the types of sample received for analysis and the wide range covered by the work of the branch. Air—tunnels 265 Air—miscellaneous 191 Bacteriological, miscellaneous 57 Building materials 422 Chemicals, drugs and medical supplies 80 Clay, sub-soils and borehole waters 1,221 Detergents and soaps 146 Disinfectants 6 Fertilisers and Feeding Stuffs 114 Fire Extinguishers 9 Floor oils and polishes 56 Foods : Baking Powder 10 Bread 82 Butter, margarine, cheese, fats, etc. 41 Cocoa, coffee, tea 12 Condiments 17 Dried fruits and herbs 33 Fish 18 Flavouring essences 69 Flour, semolina, oatmeal, custard powder, etc. 98 Gelatine 40 Gravy and soup powders, gravy browning 29 Milk foods 31 Miscellaneous 63 Pickles 22 Sugar and syrup 20 Vegetable and meat extracts. 17 Tinned foods 84 686 Fuel (coal and coke) 32 Gases : Degreasing and rubber spreading works 41 Flue 180 Sludge digestion plant 475 Grit (from Power Stations) 32 Inks (marking, drawing and writing) 6 Insecticides 5 Instrument Sets (ambulance) for sterilisation 9 Insulating materials for hot water systems 21 Lamps, gas detector 424 Laundry tests 33 Liquor (effluent from Beckton Gas Works) 358 Meals 83 Metals (various) 51 Milk, condensed and powdered 16 Milk, liquid 140 Miscellaneous 115 Oils, lubricating and fuel, etc 79 Paints, varnishes and distempers 1,556 Petroleum and allied samples 116 Plastics 13 Rain water (atmospheric pollution deposit gauges) 84 Rubber and rubber substitutes 19 Scale from boilers, etc. 6 Scouring powders and lavatory cleaners 25 Sewage and effluent 3,476 Sludge, activated 735 Sludge, primary and digested 2,701 Smoke in air, determinations 952 Soils 150 Sulphur gases in air, determinations : Lead peroxide, cylinder method 130 Volumetric method 952 Water, etc., from steam raising plants 1,425 Water, drinking, bacteriological 670 Water, drinking, chemical 64 Water, drinking free chlorine tests 537 Water, river, chemical 4,564 Water, river bacteriological 305 Water, miscellaneous 85 Water, swimming bath, chemical 437 Water, swimming bath, free chlorine tests 390 Water, swimming bath, bacteriological 523 Total 25,268 The following sections of this report deal in greater detail with many aspects of the work done. In previous annual summaries it has been customary to classify the samples, so far as this is possible, according to the particular service of the Council for which they were examined; but this is somewhat difficult owing to overlapping. In this report the classification is arranged according to the type of sample or investigation concerned, and the main services and the purposes for which they utilise the facilities provided by the Chemical Branch are as follows: Rivers and Drainage—Sewage treatment, condition of River Thames, trade effluent discharges, safety and ventilation of sewers, some corrosion and painting problems, etc. GENERAL LABORATORY, THE COUNTY HALL BACTERIOLOGICAL LABORATORY, THE COUNTY HALL PAINT LABORATORY, THE COUNTY HALL PHYSICS LABORATORY, THE COUNTY HALL 31 Housing—Building materials, paints and surface coatings, Town and Country Planning Act enquiries, certain metal problems, soils and subsoil waters (in relation to the effect on concrete), etc. Public Health—Water supplies, ventilation of tunnels, air pollution, insecticides, disinfectants, industrial hygiene and safety, etc. Public Control—Samples under the Fertilisers and Feeding Stuffs Act, the Petroleum Act, London Building Act, L.C.C. (Celluloid) Act, the Bread Order, etc. Parks—Water of swimming baths and ponds, soils (horticultural), fertilisers, etc. Education and children—School meals, swimming bath waters and drinking waters, instructional visits of school parties to laboratories, etc. Restaurants and Catering—Foodstuffs enquiries, and meals, utensils, etc. Supplies—A wide range of all kinds of supplies such as foodstuffs, milk, paints, chemicals, drugs, oils of all classes, floor and other polishes, soaps, solders and other metals, synthetic detergents, plastics, etc. Fire Brigade—Foaming compounds for fire extinguishers, rubber hose, fire proofing materials, causes of fires and preventive measures, etc. Miscellaneous—Efficiency of operation of steam raising and heating plants, corrosion problems, laundry operation, civil defence, etc. Sewage treatment Throughout 1953 the whole of the sewage flow to the Northern Outfall Works was treated by sedimentation and about 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 oxgygen demand) load on the water of the river as could be expected. The pilot sludge digestion plant at the Northern Outfall Works was subject to analytical control, the rate of chargc being decided accordingly, and it functioned satisfactorily, the gas produced (containing about 70 per cent. methane) being used for power production at the Works. As was mentioned in the report for last year, in an endeavour to improve the condition of the water of the River Thames, a large programme of additions to the sewage treatment works in order to producc better quality effluents was approved by the Council, an expenditure of about 12 million pounds being involved. During 1953 the whole of this project was approved by the Ministry of Housing and Local Government though the actual construction will, of course, take several years to complete. At the Northern Outfall Works the new detritus pits were nearly finished at the end of 1953 and a considerable proportion of this installation was in operation. Good progress had also been made with the new sedimentation channels which should be completed by the end of 1954. The greater efficiency of these as compared with that of the very old ones at present in operation should have a beneficial effect on the effluent, particularly when the new activated sludge plant comes into operation to give secondary treatment to a further portion of the primary sedimentation effluent. This latter additional plant will be of the diffused air activated sludge type and will treat 60 million gallons per day in addition to the 50 million gallons per day already dealt with by the present bioaeration plant. The total flow to the works is about 200 million gallons per day. In addition to the pilot sludge digestion plant mentioned above there was put into operation towards the end of 1953 the ' old reservoir ' sludge digestion plant to deal with about 1,200 tons of sludge per day. This was constructed by utilising redundant large reservoirs from the original works of eighty years ago and it proved most successful, C 32 producing well over half a million cubic feet of sludge gas per day. This effected a considerable economy of other fuel when used for power production on the works. In the programme of extensions is also included a major sludge digestion plant to deal with the whole of the primary sedimentation sludge produced, and when this is complete some years hence the works should be practically self-supporting from the power production aspect. At the Southern Outfall Works the programme of new works includes a diffused air activated sludge plant to treat 60 million gallons per day of primary sedimentation effluent—from the total flow of about 100 million gallons per day—and a sludge digestion plant to deal with all the primary sedimentation sludge, which in this case also should make the works practically self-supporting from the power production aspect. Research continued on the new process discovered by officers of the Chemical Branch for dewatering sludge by slow freezing with the addition of chemicals. The pilot plant to deal with 1 ton per day was utilised and the filtration problem was studied. In co-operation with a firm of refrigerating engineers and officers of the Chief Engineer's Department a design study was made to assess the economic aspects of the process. In view of its high value as a fertiliser, special attention was given to the question of the recovery of activated sludge by this process. Sludges from other sources outside the Council's service were examined and, in this respect, one from an Atomic Energy Research Establishment should be specially mentioned since this technique was adjudged to have solved a very difficult problem. Research work was also done on many other matters during the year, for instance on the operation of a new proprietary type of heater which was tried out in the pilot sludge digestion plant with promising results. The inauguration of the 'old reservoir' sludge digestion plant entailed much work, for it was essential, from the safety aspect, to ensure that the air purging had been satisfactorily accomplished. The contents of synthetic detergents in sewage and at various stages of the treatment process were determined in connection with the proceedings of a Government Committee dealing with this matter. Work was also done on the relative efficiencies of the standard type of plate air diffuser in an activated sludge plant and the new type of dome diffuser. Certain potential disadvantages of the latter became apparent though it has advantages from the aspect of simplicity of maintenance. In view of the high nitrogen content of activated sludge (6 to 7 per cent. on a dry matter basis) research was initiated during the year—and was still continuing at the end of it—on the availability of this nitrogen. It appeared that it was relatively very high, being of the same order as that of dried blood, which is generally regarded as the greatest of the ordinary fertilisers in general use. It must be remembered that it is mostly of protein origin being derived from protozoa, etc. Throughout the year weekly conferences continued to be held at County Hall between the Divisional Engineer (Main Drainage) and the Chemist-in-Chief, and their respective senior officers to consider the current analytical results and all aspects of the sewage treatment problem, and to decide on any variation of the operational practice which seemed desirable. These meetings were of the utmost value and helped greatly to maintain the cordial spirit of co-operation which exists in this joint service. At both Outfall Works, too, the collaboration continued on a most friendly basis between the officers of the two departments concerned. Some 14 premises outside the County which are maintained by the Council have individual small sewage treatment plants. The effluents from these were examined periodically in order to ensure that efficient purification had been achieved. 33 River Thames The pollution load with which any river will deal without becoming itself in an offensive condition is limited ; it is, therefore, the condition of the water of the river which is the governing criterion as to the degree to which it is necessary to treat sewage before the final effluent is discharged to the river. Natural oxidation by the dissolved oxygen in the river water is the final process of purification. In this operation the dissolved oxygen is used up and, if the river is not to become putrescent, the rate of reabsorption of oxygen from the air by the water at the surface must be greater than the rate at which it is used up by the organic matter in the bulk of the water ; so that there is at all times some dissolved oxygen present. The condition of the water of the River Thames is a matter of great importance 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, a total distance of 86 miles. 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 summer of 1953 was not abnormal in regard to rainfall and the freshwater flow was above the statutory minimum, the average daily figure for July to September (inclusive) being 225 million gallons per day. Nevertheless, the condition of the water of the river became extremely poor and was bad over a considerable stretch of its course for many weeks, particularly between London Bridge and Gravesend. The additional treatment of the sewage, which will be available on the completion of the Council's new works, will reduce the pollution load on the river and should counteract the progressive deterioration which has occurred in recent years. The Chemist-in-Chief continued to be a member of the Thames Survey Committee of the Department of Scientific and Industrial Research and also of the Heated and Other Effluents Committee of the Ministry of Housing and Local Government. Both Committees deal with aspects of the condition of the water of the river and are to report in due course their recommendations for its improvement. It should be emphasised in this connection that there are many other sources of pollution gaining access to the river as well as the effluents from the Council's works ; for example, other sewage effluents, trade waste discharges, water from impure tributaries and contamination from the large shipping traffic. Mention should be made of research work done at the Southern Outfall Works laboratory on the determination of iron in the ferrous and ferric states. This balance is of importance in relation to the conditions which govern the presence of sulphide. Sewers Trade waste discharges Samples of trade discharges and of deposits in sewers were examined from the aspect of the control powers included in the Public Health (London) Act, 1936, and on this basis many were found to be objectionable. For example, discharges from a chemical works to a local sewer were found to contain carbon tetrachloride and monochlorbenzene, both of which give rise to toxic vapours. Entry to the sewer was thereby rendered hazardous. In the course of the sampling an officer of the Chemical branch and a sewer inspector were partially overcome by the fumes. The firm was prosecuted and a conviction registered. Another case in which four sewermen were affected by hydrogen sulphide was found to be due to the discharge of iron sulphide to the sewer from a c* 34 photographic processing works. The iron sulphide was formed by the interaction of photographic chemical solutions with an iron drain-pipe. Advice was given in some cases as to whether proposed new discharges were acceptable, or whether some form of pre-treatment would be necessary. Safety The Spiralarm lamps used in the main drainage service to give warning of potentially dangerous atmospheres were periodically overhauled and adjusted in the laboratory and finally tested by exposing them to the atmosphere of a test chamber containing measured concentrations of inflammable gas. Another type of lamp, the Ringrose, was also used to some extent and similarly maintained. Sets of self-contained oxygen breathing apparatus adopted as standard for an emergency were available, and advice was given as required on their use. Ventilation The question of ventilation received much attention particularly in view of complaints from certain places of emanations. A working group on ventilation was consequently set up by the Council in conjunction with the Metropolitan Boroughs Standing Joint Committee and the Chemist-in-Chief was a member. As a result of its recommendations the Council decided to seek additional powers of control of trade discharges by means of clauses in a forthcoming General Powers Bill, and also to initiate experiments to secure increased ventilation by removing interceptors. Paints and surface coalings During the year under review the new paint laboratories (rooms 623 and 624) were equipped and put into service. Some difficulties were encountered, not the least of which was to maintain the work output whilst testing the new equipment and adopting new quantitative standards without vitiating comparison with results previously obtained. Troubles experienced with the plant and its installation in a small compass were overcome by the maintenance architects and engineers and to both of these branches of the service grateful thanks are due. When the laboratories were officially opened some two dozen press representatives attended and articles appeared subsequently in many technical and general journals. Considerable interest has been shown by paint manufacturers and complete agreement with the Ministry of Supply methods of examination has been maintained. In addition to accelerated weathering tests which form a valuable ' sorting ' basis, panels are exposed on the roof so that the shorter term tests can be correlated with long period exposure to London's atmosphere. The interdepartmental paint committee (chairman the Chemist-in-Chief) has held four meetings during the year and the sub-committee (chairman the deputy chemist) met eleven times. The former was concerned with matters of policy whilst the latter dealt, in detail, with the many problems encountered. A large proportion of the new brands of paint submitted during the year by manufacturers for examination was rejected as being of unsatisfactory quality ; details are : Approved Rejected Hard gloss paint 26 26 Semi-gloss paint 8 3 Flat oil paint 2 1 Emulsion paint 23 11 Chlorinated rubber paint 5 7 Black protective bitumen 7 4 When unsatisfactory paint is found on the site as the result either of complaint or of the normal examination of site samples an unopened makers' can is requested and tested. If the complaint is confirmed the manufacturer is asked as a warning measure to attend a discussion on the matter and if complaint is again made and justified the brand is struck off the approved list. Ten manufacturers have been cautioned and one brand deleted during the year. Many painting troubles occurred for which the paint manufacturer should not be blamed and the following causes have been found—failure to 35 remove an alkaline paint stripper, failure to remove grease, inadequate stirring, efflorescence due to water inleakage, excessive moisture content of plaster, poor drying due to wax derived from a paint stripper, blackening due to a lithopone paint applied over old lead paint. Many investigations of various aspects of paint and painting were made and a few examples are : Paint removers—Recommendations were made to avoid using the alkaline types owing to the difficulties encountered and, in addition, care was advised that the methylene chloride types were only used where adequate ventilation could be provided. Epoxy resins—Paints which incorporated these newly developed resins were examined and experiments were made on a large scale. It was considered that the difficulties of application of the brands tested were such that further commercial development was required before the products were suitable for normal Council work. Silicone paints—Many experiments were made to utilise these high temperature paints (up to 900°F.) but, in general, unless the painted surface could be uniformly heated to the correct ' setting ' temperature they were not successful. This precluded their use on some exhaust pipes and steel chimneys. Emulsion paints—A report on these products was issued to user departments through the paint sub-committee pointing out that basically there were three types, polyvinyl acetate, polystyrene and alkyds, which had different properties, and details were given of these, e.g., resistance to alkali, resistance to the bleeding through of creosote or bitumen, resistance to washing, porosity to water vapour, behaviour under condensation conditions, outdoor durability. On approval these products were classified under their respective types so that easy reference could be made to their properties. Aqua paint—It was claimed by the manufacturer that, by adding a quantity of a proprietary liquid (found to be a substituted tertiary amine of the quaternary type) to a paint, wet materials could be painted successfully. This claim was not found to be substantiated. Amongst other matters investigated were anti-condensation paints, stoving enamels, rust removers, the painting of Bellrock plaster (which owing to its nature presents many difficulties), coating of balsa wood, zinc sprayed ironwork, etc. During the year advice was given to four other local authorities and to the British Standards Institution on painting questions and the Ministry of Defence granted permission to the Council to use and quote their recent D.E.F. specifications. The revision of Painter Specification Clauses for the Architect's Department was undertaken and a committee was appointed consisting of officers of that department and of the chemical branch. After 18 meetings new specifications were put forward especially for primers for iron, steel, zinc and aluminium, etc. Thus considerable improvement was accomplished particularly in the requirement for the priming work, on which the rest of the paint system so vitally depends. Building materials and allied problems This section of the work again expanded considerably and its complexity increases yearly with the introduction of new materials and new methods of building construction. Of the materials regularly examined in order to determine whether or not they complied with British Standards or other specifications, mention can be made of asphalt (for roofing, flooring, paving, etc.), bitumen felts (for dampcourses, roofing, flashing or tanking), cements, mortars, plasters, jointless flooring, etc. Many other products which might be of use to the Council were examined and tested critically to assess their quality and behaviour: items in this category included coated hardboards, resin-bonded chipboards and laminated boards, fire-resistant and insulating constructional materials, 36 adhesives, building papers, concrete and stone water-proofers, timber-preservatives, etc. In addition, regular examination was made on a large scale of samples of sub-soil and soil-water to ascertain the amounts of sulphate present (high concentrations being injurious to ordinary Portland cement) and hence to decide which type of cement should be used. Four basically different types are available. Many samples were examined to elucidate the causes of site trouble experienced with various building materials. These included plasters, concretes, mortars, floorings, asphalts, etc., and in a large number of cases investigation necessitated visiting the site. The material itself was not always found to be responsible for the defects observed. Remedial treatments were recommended. The following examples of work are perhaps of special importance or interest: A sudden increase was observed in the number of domestic baths which developed cracks in the vitreous enamel shortly after installation at new housing sites. Despite the strenuous denial of liability by suppliers this defect was eventually traced to the lack of control at the manufacturers' works over the thickness of enamel build-up and hence to strains set up in this fired glaze on cooling. Assistance was given in efforts made to trace and account for the inleakage of water through new foundations which were tanked in bitumen felt. The cause was found to be damage sustained by the felt sheeting owing to insecure positioning. British Standards Specification 476 having to be revised and re-issued, a new apparatus was included (largely as the result of the efforts of the Deputy Chemist on the B.S. Committee) for determining ' The preliminary surface spread of flame.' This apparatus has now been installed in the laboratory and many materials have already been tested on it. Assistance was given in identification of certain stones and other materials of historic interest. Problems of maintenance, e.g., special cleaning difficulties, arose in various buildings, and, after making the necessary test, it was usually possible to recommend a suitable procedure. In many cases of disintegration or weakness of mortars, renderings or floor screeds, analysis showed that the mix used was not in accordance with that specified. Many varieties of jointless flooring and of flooring tiles continue to appear on the market. These were examined by a standardised procedure designed to give as much useful data as possible. In order to answer the problem of floor maintenance many products now exist which are intended either to seal, or to yield a semi-permanent glaze coat upon, the floor surface. Several such compounds were examined during the year. Foodstuffs A wide variety of food samples were examined on behalf of the Supplies Department, of user departments, and of hospital boards. Some in the first category were examined to ensure the acceptance of the most economical and suitable tenders, but the majority were for the purpose of checking the quality of deliveries against that of the tender samples. Others involved complaints from users where some deterioration had occurred or suspicions had been aroused. In other cases an opinion was required by the Public Control Department as to whether certain fancy preparations would come under given definitions such as 'sugar confectionery 'or' biscuits.' Numerous loaves of short-weight bread were examined to show that they were not 'protein-enriched' as this would be a defence under the Bread Order. In some cases the analyst was required to attend court to give evidence as to his findings. A number of estimations of the fat content of tinned soups were made by different methods, at the request of a technical sub-committee of the canned soup section of the 37 Food Manufacturers' Federation. These results together with those from several other laboratories were considered by the sub-committee, on which the deputy chemist represented the Society of Public Analysts, and the method giving the best agreement by all users was recommended for general adoption. A few samples of findings in certain instances of the many investigated were : Some deliveries of dried herbs contained up to 2 per cent. of coarse sand. This was considered a possible danger to consumers' teeth. Later deliveries were found to be free from sand. There have been many instances of difficulties in the use of dried milk. Some samples showed defects in manufacture resulting in the presence of brown specks or crusts of partly caramelised milk solids which were evident on reconstitution. Others tended to high acidity which can cause curdling in some circumstances. Other apparently satisfactory samples were blamed for custards reliquefying when kept hot for any length of time. It is clear that many factors are involved in this phenomenon, and it is best not to hold custards at a high temperature for longer than is necessary. Sometimes a moderate increase in the amount of custard powder will reduce the tendency to instability. A sample of shredded suet was found to be below the official minimum of 83 per cent. of fat. A sample of anchovies was found to be contaminated with lead, but as further samples were lead-free this may have been an isolated mischance. Old stocks of certain commodities, from institutions that had been closed, were examined to assess their usefulness, and some batches of mould-tainted farinaceous goods and some inactive rennets were condemned. School meals The analysis of school meals was carried out as usual in co-operation with the Restaurants and Catering Department. 82 samples were examined, which were divided as far as possible into three age groups, although there is some overlapping owing to variation in the age groups to which the meals are served. In all three groups there was an increase in the average weight of the portions which represents an all round improvement in nutritive value. The amounts of fat and protein found were also higher in each case than in previous years. Average calorific values came very near the generous target figures. A satisfactory feature was a marked increase in the minimum figures over those found for 1952, showing that an evening-up of nutritional values was being achieved. The general standard of the meals provided over the year can thus be regarded as satisfactory. There were again a number of enquiries as to the suitability of various ingredients which presented abnormalities or were suspected by the various staffs ; most of these were approved or, in a very few cases, condemned as a result of laboratory examination. Milk The Council purchases large quantities of milk for consumption in its establishments (schools, nurseries, restaurants, etc.) and supplies are examined regularly to ensure that the quality is in accordance with the standards prescribed by the Regulations under the Food and Drugs Acts, 1938-1950, etc. These Regulations specify minimum values for the butter-fat and solids-not-fat contents of genuine milk and also require conformity with the methylene blue and phosphotase tests, which indicate bacterial content, assess keeping quality and check pasteurisation efficiency. Enforcement is the responsibility of the local food and drugs authorities and reports are received from the Metropolitan Borough Councils (for establishments in London) and from a number of out-county authorities: where Council supplies are not otherwise reported upon, samples are obtained regularly and examined chemically in the County Hall Laboratory. 38 During 1953, reports were received on 2,274 samples taken by local foods and drugs authorities and of these only 7 were regarded as unsatisfactory. 140 samples were examined chemically in the County Hall laboratory and five were unsatisfactory. Whenever a sample was found to be unsatisfactory, ' follow-up ' samples were taken. 16 samples of powdered and condensed milk were examined and 4 were unsatisfactory. In some cases deterioration in condition was regarded as due to prolonged storage and a complaint of discoloration was considered to be caused by faulty processing in manufacture. Drinking water Much care and attention is given to ensuring that the water supplies to Council establishments are of satisfactory quality. Although in the majority of cases the water is taken from a Company supply, there are a number of residential schools and other premises at which it is drawn from private wells. In these cases continuous treatment and supervision is given, the well supply being chlorinated before use by means of automatic dosing apparatus. The Chemical Branch undertakes regular monthly inspections and samples are taken of both untreated and treated water for chemical and bacteriological examination in the laboratory ; chlorine tests are made to confirm the adequacy of the dosage, which is also determined daily by the resident engineer at each establishment. The well supplies of some hospitals formerly under the control of the London County Council have, at the request of the hospital committees, continued to be included in the regular programme of water examination. During 1953, the water supplies to 18 establishments were regularly examined, and visits were made to other premises to investigate particular complaints, check the suitability of water from various sources and give advice. In all, 1,271 samples were taken during the year ; of these, 537 were tested for free chlorine, 64 were examined chemically, and 670 bacteriologically. The following are some examples of matters arising from water examination during the year. A case of pollution was found to be due to birds gaining access to a tower tank ; the trouble was eliminated by the use of wire netting. At two hospitals in the same locality sudden deterioration in the quality of the well water occurred after a period of heavy rainfall. Contact was made with the local water authority and it was found that the trouble was fairly widespread in this particular area. The chlorine dosage was raised as a precautionary measure and a sterile supply was maintained at service taps. The private well supply of a large house in Suffolk was found to have an unusually high content of nitrate (20 parts per million of nitrate nitrogen). There have been a few recorded cases of cyanosis in very young infants due to methaemoglobinaemia caused by ingestion of nitrates in water and it happens that the first two cases reported in the United Kingdom were from the same part of the county. Advice was, therefore, given that babies should not be exposed to any risk from this water. Air pollution The Council maintains instruments for the measurement of air pollution at County Hall, the two Outfall Works at Beckton and Crossness, seven parks and other sites within the County, Kew Observatory and King George V Hospital at Godalming. The work is done in conjunction with the Department of Scientific and Industrial Research and it forms part of a long-term investigation covering the whole of the country. At the first three sites mentioned, daily measurements are made of sulphur dioxide and smoke concentrations and at the other sites a monthly assessment of conditions is obtained using the deposit gauge and lead peroxide methods. In addition to these regular observations, other individual problems were dealt with from time to time relating to emission of black smoke and the deposition of grit and ash. 39 The measurements made during 1953 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 being 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. The rainfall in 1953 was appreciably below the annual average and this tended to render the air pollution deposit, as measured by the deposit gauge, rather less than in recent years. A slight increase in the average amount of sulphur gases present in the air was attributable to the same cause. By a standing agreement with the Ministries concerned, the Chemist-in-Chief accompanied the Chief Alkali Inspector of the Ministry of Housing and Local Government on visits of inspection to test the efficiency of the flue gas washing plants at Battersea and Bankside Power Stations. In October, 1953, the Chemist-in-Chief gave a Chadwick Lecture on ' Air Pollution ' at the Royal Society of Arts. He was also appointed to be a member of the Government Committee set up, under the Chairmanship of Sir Hugh Beaver, to report on the problem of Air Pollution. Swimming baths and ponds The Council maintains 15 open-air swimming baths for public use and 20 others, mostly indoor baths, at schools and institutions. Recommendations on treatment are given by the Chemical Branch and close collaboration is maintained with the other departments concerned on all aspects of maintenance, alterations and improvements. Reports are received of the daily tests made by bath attendants and, in addition, all the baths are visited at regular intervals for inspection and sampling. In 1953, 437 samples of water were examined chemically and 523 bacteriologically. During the bathing season all water used in the public swimming baths is chemically treated, filtered and chlorinated, the breakpoint system of chlorination being used. This system ensures that a satisfactory residual of free chlorine is present without causing inconvenience to bathers, and a sufficiently large dosage can be applied to deal with the heavy pollution load when the baths receive intensive use. Care is taken to maintain good clarity in the water and instruments for making clarity measurements have been provided at the baths. It is of interest to record that full-length visibility under the surface was sometimes achieved, the maximum length being 300 feet, and the water then had the deep blue colour which bathers find attractive. Some of the results established by special investigations made during the year were : Equalisation of chlorine residual over the bath was obtained by use of the suction sweeper line at the deep end ; this led to improved bacteriological results. It was shown that the time necessary to obtain deep-end chlorine residuals, using only shallow-end inlets, was about one-quarter of the turnover time. An improvised filtration plant, for small indoor baths, functioned successfully throughout the year and gave a satisfactory bacteriological condition. During the winter season, with bathing limited to a few hardy early morning bathers, turbidity in an untreated open-air bath was reduced by the use of hypochlorite extracted from bleaching powder. In September, 1953, a paper by officers of the Chemical Branch and Chief Engineer's Department was read to the Annual Conference of the National Association of Bath Superintendents. 40 Tunnels Ventilation of tunnels, buildings, etc. To provide a check on the functioning of the ventilation plants at Blackwall and Rotherhithe Tunnels, systematic weekly examination of the air is undertaken by the Chemical Branch. The times chosen for the tests are those when the tunnels are normally carrying their heaviest traffic. Measurements are made of the carbon monoxide content, the amount of black suspended matter and the temperature and humidity of the air. The volume of motor vehicle traffic in both tunnels has increased every year since the war and in 1953 it equalled the pre-war level in Rotherhithe Tunnel and considerably exceeded the pre-war figures in Blackwall Tunnel. The tests indicated that the amount of forced ventilation had been efficiently adjusted to meet the variations in traffic and, of 202 air samples only 4 at Blackwall and none at Rotherhithe contained carbon monoxide in excess of the specified limit of 250 parts per million. The use of tetra-ethyl lead in petrol produces traces of lead compounds in the air of the tunnels and nitrous fumes from diesel engine exhausts can also be detected. Special tests made during the year showed that the amounts of these contaminants were well below the accepted toxic concentrations. Underground workings When exploration was made of a large system of underground chalk workings which had caused subsidences, analysis of the air showed some deficiency of oxygen and also the presence of carbon dioxide in excess of the normal concentration. Advice was given on the appropriate safety measures to be taken. Petrol leakage Several cases or accidental leakage of petrol from storage tanks were investigated and ventilation tests were made of neighbouring premises to ensure that suitable precautions were taken against the presence of petrol vapour in the atmosphere. Factory In co-operation with H.M. Inspector of Factories, tests were made of the atmosphere of a factory licensed to use petroleum spirit. It was found that conditions in a machine room called for an improved system of ventilation and a suitable ventilating plant was subsequently agreed upon. Royal Festival Hall Advice was given on matters relating to the ventilation of the Roval Festival Hall. Gas heaters Consideration was given to the use of flueless gas heaters and the degree of ventilation needed to avoid perceptible vitiation of the air of rooms. Fire : precautions and investigations A number of types of material were examined for their quality and suitability for use in the fire service; these included rubber hose, foam producing compounds and chemical extinguishers. Fire retardant compositions for application to building materials were examined for efficacy in preventing flame spread and a practical test was formulated to serve as the criterion of fire-resistance where safety regulations called for fireproof curtain material. Advice was given on miscellaneous problems, of which the following are examples : In co-operation with Fire Brigade officers, detailed consideration was given to the special measures needed in combating fires involving dangerous chemicals. The routine procedure for maintenance of foam extinguishers was reviewed at the request of the Chief Officer of the Fire Brigade and it was found that a saving in cost could be effected by a modification which was subsequently approved by H.M. Inspector of Fire Services. Recommendations were made on the degree of flame-proofing necessary for a diesel-engined crane to be operated at a petroleum wharf. After examination of conditions at a pumping station, advice was given that it was unnecessary to incur the expense of a flame-proof electric motor in the particular circumstances of this case. 41 Steam raising plants and hot water installations, etc. Steam raising The regular examination of samples from the steam raising plants and ancillary equipment has continued at the Northern Outfall Works and at County Hall. Considerable extension of boiler water conditioning and the regular examination of samples for control purposes has taken place at institutions under the control of the Chief Engineer's Department. Phosphate conditioning of boiler water has been adopted as standard practice and is showing satisfactory results in the prevention of scale formation and the removal of old scale. Hot water plant Regular examination of samples from the softening and hot water plants at the Royal Festival Hall has been continued to check the performance of the plants. Regular tests on other hot water installations have also been continued. In addition, problems arising from scale formation and corrosion have been investigated and advice given as to the appropriate steps to be taken. Interesting examples of such work are : Severe corrosion was found in the heating system of a new infants' school. The heater batteries were choked with the product of corrosion—black magnetic iron oxide. A peculiar feature, namely, loss of chloride from the water, suggested electrical leaks and electrolysis as one of the factors. The investigation was still proceeding at the end of the year. A black sludge from a boiler house sump and associated water ; the water was found to be a hard ground water high in sulphate. The black sludge was a mixture of coke ash, organic and vegetable debris, the black colour being due to iron sulphide formed from iron oxide in the coke ash and hydrogen sulphide produced by bacterial action on the sulphate in the water. Statutory duties Petroleum (Consolidation) Act, 1928 Ninety-three samples were examined to decide whether their use could be controlled under the Petroleum Act or to estimate fire or explosion risks. Statutory certificates were issued where appropriate. Two of the samples were petroleum spirit within the meaning of the Act and 53 were petroleum mixtures such as rubber solutions or cellulose paints. Thirty-eight were found not to come within the provisions of the Act, five because they did not contain petroleum spirit although flashing below 73 degrees Fahrenheit, and 33 because their flashpoints were not below this temperature. Some of these samples were taken after accidental spillages or escapes of spirit and were examined to ascertain whether spirit was still present in sumps or manholes. In one case, a fire hose used to pump out a tank believed to contain water was found to be full of motor spirit. In another case, spirit and paraffin had been inadvertently mixed, and it was desired to ascertain what was the least proportion of paraffin necessary to bring the flash point up to 73 degrees Fahrenheit. London Building Acts (Amendment) Act, 1939 Advice was given on the properties of materials in use in certain premises to which various sections of the London Building Act apply. L.C.C. (Celluloid, etc.) Act, 1915 A sample of special film examined under this Act was found not to be celluloid and not to be highly inflammable. Town and Country Planning Act, 1947 During the year an officer of the Branch was required to attend the hearing of an appeal under this Act in order to advise the officers presenting the Council's case. It was also necessary to visit a number of premises in order to assign various processes to their most suitable classification under the Use Classes Order, having regard to the chemical nature of the operations and their potential nuisance value in the neighbourhood. 42 Fertilisers and Feeding Stuffs Act, 1926 The Chemist-in-Chief is the official agricultural analyst under the Fertilisers and Feeding Stuffs Act, 1926, for the County of London, excepting those parts within the purview of the City Corporation and Port Sanitary Authority. 110 samples were examined under the Act and, of these, 52 were found to vary in some particular from the statutory statements or voluntary warranties given or to have deficient or incomplete statements. In only one fertiliser and two feeding stuffs were the differences clearly to the disadvantage of the purchaser. Three unscheduled feeding stuffs contained so much fibre as to be of very little nutritional value and one contained, in addition, a very high proportion of chalk or ground limestone. Oils and polishes Lubricating and other oils Samples of many different lubricating oils were examined for use in steam engines, diesel and gas engines, thrust bearings, and motor vehicles generally, in order to ascertain that they were suitable for the purpose required or that they complied with the requirements of the specification. Attention is constantly drawn to the fact that a clear oil from a streamline filter is not necessarily fit for use because it may contain a large quantity (10 per cent.) of' heavy ends' of the fuel which reduces its load carrying capacity and, furthermore, the acidity may be unduly great. One instance was reported where the grade of oil supplied was unsuitable for the machinery for which it was intended and this was discovered before use, otherwise bearing trouble would most probably have occurred. Bearing trouble was reported from a pump which was thought to be due to the oil in use ; examination showed this not to be so but that it had occurred because of the pressure of water in the crankcase. Polishes This category includes many types of polishes for various purposes ; for example, wax polishes in white spirit, water emulsion polishes, metal polishes for silver and brass and also oils tor floor treatment. The wax polishes generally complied with the specifications, although occasionally comment was necessary on a deficiency of wax. Attention is frequently drawn to the fact that these polishes are not allowed to dry sufficiently after application and before polishing, which leads to unjustifiable complaints in respect of quality. Many water emulsion polishes were examined and a general failing was poor water resistance. Complaint of the odour of metal polish was proved to be due to the quality of the ammonium soap used to assist emulsification and cleansing ; this was remedied by the manufacturer. A sample of floor sweeping compound was found to have an excess of sand (the cheapest constituent). Disinfectants and air deodorisation During the year under review, not only were periodical tests made of the standard specification items but a variety of proprietary products were examined as to their potential usefulness. In the former group, criticism was made of emulsion instability and the staining of linen, both points being regarded as of considerable importance. The proprietary products included the chlorxylenol and quaternary types and, at the present time, it is not considered that the latter should be regarded as satisfactory general disinfectants although, for particular purposes, their activity is very high. A sterilising gel containing synthetic detergent and a quaternary germicide was claimed to be effective for the cleaning of kitchen equipment, etc., but it also included sodium sulphate and was not recommended because of corrosion possibilities. The problem of air deodorants again arose and proprietary compounds for this purpose and appliances for producing fine sprays were examined. Most of the materials could only be considered to have an aesthetic value and, in most instances, cleanliness and proper ventilation were recommended. In a special case of a home for the aged various cheap, pleasant smelling compounds were tried experimentally. However, the lasting power of the essential oils increases with their cost and, unless considerable 43 expenditure is incurred, no long term effect can be obtained. At the end of the year an experiment was in progress, using ultra-violet radiation. Chlorophyll products which also contained some formaldehyde and pine oil were examined but these are of limited efficacy. Chemicals, drugs and medical supplies This group comprises a wide range of materials. Various proprietary vitamin preparations were examined and in one case the accessory food factors were negligible in concentration and in another very expensive when compared with the British Pharmacopaeia preparations. Some complaints (e.g., oculent albucin and halibut liver oil) were investigated and found either to be groundless or due to personal idiosyncrasy. Complaint of the cloudiness of mist, ferri: sulph. pro infantibus was due to the orange flavouring added and in no way deleterious. Warning was given on some proprietary silver cleaning compounds which contained thiourea and could, by regular ingestion cause depression of the thyroid gland. A powder supposed to give a chromium finish was found to be potassium sulphostannate, magnesium powder and an organic acid. The metal deposited was tin and not chromium and had a soft and not very durable finish. Various zinc oxide plasters were evaluated, especially as regards their action on the skin, and a compound found in a building was shown to be calcium hydride, a dangerous chemical if wetted with water, for inflammable and explosive gas (hydrogen) would be evolved. Insecticides and fungicides The Council's specifications for insecticides which include both D.D.T. and Gammexanc formulations continue to give satisfaction and economical treatment. Many proprietary products marketed at a greater price based on these chemicals were examined and, as a result, no modification in the present specified products was advised. Attention was called to the spraying of absorbent surfaces with insecticides with a kerosene base for, although the base may have satisfactory evaporation characteristics, an odour may linger for a considerable time and, furthermore, the efficacy of the spraying treatment is adversely affected if the absorption is high. A proprietary product, claimed to produce a film permanently lethal to insects, was examined but the film was found to be highly inflammable and so would increase the fire risk of the premises. It was, of course, rejected because the risk of fire must be carefully considered and it is futile to reduce one nuisance and cause danger in another important direction. The so-called seaweed flies reported on the South Coast were found at the Southern Outfall Works in November. They were attracted to the laboratory when chloroform was used. They did not bite, but their presence was, to some degree, a nuisance. Gammexane proved most effective for their destruction and 110 difficulty was experienced in dealing with the trouble. Detergents Kitchen and general cleansing Under this heading are included the examination of many soaps of all types supplied under contract to L.C.C. specification and also the special powder incorporating synthetic detergents for washing up in the Council's establishments. These specifications are constantly under review with the object of obtaining maximum efficiency at the minimum cost. New tests were introduced for the assessment of efficiency of washing up and work was initiated to determine the general bacteriological condition of crockery when a variety of different detergents, with and without germicides, were employed. Detergent tablets have been introduced in eight kitchens and, after an extended trial, the policy of using the material in this form will be decided. 44 Two washing-up machines were examined and, in one case, the design, with modifications, would be of interest but, in the other case, the efficiency was poor. Several quaternary ammonium compounds were examined but generally, where practicable, heat sterilisation was advised as being more positive. Laundry work Considerable work was done in this field to improve the efficiency of washing in hard water. By employing a synthetic detergent and carboxy-methyl cellulose an appreciable improvement was attained as compared with the use of soap. Further substantial improvement was made by introducing sodium meta-silicate instead of soda ash as usually employed. The details of the process were worked out and a reduction of the damage done to the fabric has been accomplished. On the results of the work so far carried out it is considered that, in most cases, it would not be justifiable to recommend installing water softening plant having regard to the problem of the maintenance and also to its appreciable capital cost. Work was also undertaken on the assessment of various laundry starches and 011 the removal of stains from linen. The question of washing clothes by hand was investigated and a specification was evolved for a suitable efficient powder for this purpose. There was, in some quarters, a demand for greater foaming power and, whilst it is appreciated that this property does not indicate detergent efficiency, some attempt to increase the foaming power will, for psychological reasons, be made to prevent complaint. A comprehensive report on the activities of the branch in the field of detergency was presented to the Royal Sanitary Institute in December, the authors being Dr. S. G. Burgess, Mr. D. Burns and Mr. C. W. Tidy. Plastics This type of product, which is also mentioned under surface coatings, paints, etc., is coming increasingly into our daily life. Feeding bottles, plates and sputum jars made of polythene, bath mats of plasticised and pigmented polyvinyl chloride and spoons of melamine have been examined. In general, they serve their purpose and, in some cases, possess a great advantage as regards utility. However, in other cases, special considerations must be borne in mind ; for example, coal tar disinfectants should not be applied to the bath mat mentioned above and scratched polythene retains fat rather tenaciously. The spontaneous disintegration of some of the harder plastics was investigated. This is due to injury by unsuitable treatment allowing water absorption and the eventual expansion very occasionlly causes violent disintegration. Hypochlorites should be avoided when urea-formaldehyde and melamine resins (or mixtures of these) are present and, in consequence, it is necessary to establish the particular type of every product before employing it in the Council's service. Standard tests were established to ascertain the efficiency of curing of melamine resins. The application of dye under specified circumstances gives an indication of the correct curing and, if treatment for 24 hours with a one per cent. solution of citric acid extracts not more than 20 parts per million of zinc, cups, beakers and drinking utensils can be employed without the risk of contamination of the normal liquids ingested therefrom. Rubber-spreading and skin degreasing works There are four works in the County using inflammable solvents for processes which are operated in accordance with the terms of licences issued by the Council under the Petroleum (Regulation) Acts, 1928 and 1936. Periodical visits of inspection were made to see that the stipulated conditions were complied with and to examine air samples to ensure that the content of petroleum vapour did not exceed the safety limits. During the year, 10 visits of inspection were made and 37 samples were examined. In most cases it was found that the plant was being operated in a satisfactory manner, but there were single occasions at two different premises where the tests disclosed defects in the systems and advice was given to rectify the position. 45 Industrial hygiene, safety, etc. Mention has been made in preceding sections of some of the matters in which advice was given or action taken to avoid hazards of various kinds. Other cases which can be instanced under this general heading were : Mercury discharge lamps designed to sterilise and deodorise air were given a practical trial in occupied rooms, measurements being made to ensure that the production of ozone and ultra-violet light was kept within appropriate limits. A report was made on the properties of trichlorethylene with reference to its use as a domestic dry cleaning agent. Precautionary recommendations were made for the siting of a building in which methyl bromide and hydrogen cyanide were used as fumigants. Analysis of special tools, to be used in excavating ground contaminated with petrol, confirmed that they were of a suitable non-sparking alloy of beryllium-copper. In another similar case, where a steel auger had to be used, a non-inflammable atmosphere was maintained in the bore hole by repeated addition of small pieces of solid carbon dioxide. The use of electrically conductive rubber for petrol pump hose was considered, it being a matter of importance for static electric charges to be discharged without a spark passing which could ignite petrol vapour. Practical trials were made to investigate the durability of the material. Metals As in previous years, regular analyses were made of the various grades of solder purchased by the Supplies Department. Compliance with the appropriate requirements of British Standard 219 was, on the whole, better than in previous years. Other fairly regular examinations made were those to determine the quality of chromium and other electro-plating on various fittings. Advice was given on many particular problems of combating corrosion, especially of iron and steel. Interesting examples of work in this section were : The cause of corrosion of an aluminium flush pipe was found to be the ability of the water to take up traces of copper from other parts of the system and hence to form minute centres of galvanic attack where this copper was desposited. (It cannot be over-emphasised that mixed-metal' water systems—e.g., zinc tanks with copper piping—should be avoided.) For reasons similar to the above, consideration had to be given to avoiding the possible corrosive attack on the aluminium Eros statue in Piccadilly Circus from the recirculating water which falls from the fountain into bronze basins. Grades of hot applied bitumen were tested after application as ¼ inch thick layers inside sections of iron piping to see if satisfactory protection of the pipe would be afforded against the action of sewage liquors. It was found that both grades submitted gradually flowed at the temperatures likely to be met. Further consideration was given to particular cases of metal corrosion-protection, e.g., by zinc-rich paints, metallic lead paints, flame-sprayed metal, sacrificial cathodic protection, etc. Lengths of electrical conduit were examined to determine whether it was the quality of it which was responsible for difficulties encountered in bending. Poor technique and not quality was found to be the cause. Miscellaneous Advice was given on a variety of other matters not included in the previous sections of this report. The following may be mentioned as examples : Samples of hair lotions from hairdressers' establishments were examined and found to consist of (i) sulphur, methylated spirit and green dye; and (ii) methylated spirit containing about 10 per cent. of castor oil. As these preparations were sold at 46 an exorbitant price, the licences of the establishments were revoked, after a public enquiry. Evidence as to the samples was given by the deputy chemist, Dr. S. C. Burgess. Experiments were made on the staining of wood and subsequent varnishing. The wood could not be stained uniformly because absorption depended on grain pattern ; the penetration was of the order of 1/100th inch and also the colours faded to some extent. The most satisfactory dyes were established and also the most suitable type of varnish for protection. The failure of an L.C.C. coat badge was investigated and it was established that, after two washes, the laundry in question had caused the severe chemical damage. Special tests were devised for evaluating polychromatic and pigmented finishes for tubular steel school furniture as regards probable durability in use. Earthenware and vitrified crockery were compared for strength and other aspects for general use in the service. In some samples of vitrified ware examined it was found possible to dissolve 1.5 milligrams of lead from a cup. The staining of cutlery was investigated and it was found that all detergents, soda and bicarbonate, and even mains water could, under some circumstances, stain the nickel-silver ware generally used in the service. It was established that rapid drying was essential and the introduction of metallic aluminium (clean milk bottle tops) in the alkaline wash water and even in the rinsing water materially assisted in obviating the trouble. The cleaning of the glass of greenhouses having presented some difficulty, an investigation was made of the nature of the deposit and a rapid and simple method of operation was devised. Samples of soil were examined for acidity and plant nutrient status for horticultural purposes. Amongst many other problems investigated may be mentioned such articles as tree wound-dressings; combs, plastic and horn; potting sand; oil damage to trees; pig food; metro-grate; pipettes, burettes and chemical equipment for schools; staining of fabric by the sand in a recreation ground, and the chemical purity and safety of powder paints used by young children in schools. Visits to the laboratories As usual, during the year many visitors were welcomed to inspect and discuss the work of the Chemical Branch in its laboratories at county hall and the two outfall works. The largest organised visit to the Headquarters laboratory was made by a party of 70 members of the Science Masters Association. The visitors were shown a coloured film with sound commentary dealing with some aspects of the work of the Northern Outfall Works and the laboratory there, after which they were conducted around the county hall laboratories where they were given talks and demonstrations on various aspects of the work by specialist members of the staff. Instructional visits were made by parties of post-entry trainees, and senior boys from St. Marylebone School and St. Paul's School. Other visitors to the laboratories included a party from the London branch of the Institute of Housing, professional officers from Government departments and research establishments and from other local authorities, and meals supervisors from the Restaurants and Catering Department. Overseas visitors from Australia, Austria, Eire, Israel and Portugal were also welcomed. Committees During 1953 the Chemist-in-Chief, in addition to attending committees of the Council as required, was a member, either as a Council representative or with official sanction, of the following committees convened under the auspices of other bodies : SPECTROMETER ROOM DISTILLED WATER PLANT for accelerated weathering of paint films PLANT CONTROL LABORATORY, NORTHERN OUTFALL WORKS PILOT PLANT FOR SLUDGE Dewaterinq by freezing with added chemicals 47 Government Inter-Departmental. Air Pollution Committee. Air Pollution Sub-Committee—Domestic Appliances (Chairman). Ministry of Housing and Local Government. Committee on the Revision of the Methods of Chemical Analysis as applied to Sewage and Sewage Effluents. Committee to enquire into the effect of Heated and other Effluents on the Tidal Reaches of the River Thames. Ministry of Fuel and Power. Battersea Flue Gas Washing Committee. Department of Scientific and Industrial Research. Water Pollution Research Board. Thames Survey Committee. Working Group on the Removal of Sulphur Compounds from Industrial Gases. Atmospheric Pollution Research Committee. Standing conference of co-operating bodies : atmospheric pollution. Honorary Observers Scheme—Building Research Station. British Standards Institution. Chemical Divisional Council. Technical Committee on Methods for Testing Atmospheric Pollution. Technical Committee on Carbide of Calcium. Technical Committee on Glass Containers for Heavy Acids, etc. Technical Committee on Fire Resistance and Incombustibility. Technical Committee on Soaps for Domestic Use. Technical Committee on the Testing of Water. Technical Committee on Black and White Disinfectant Fluids. Disinfectant Industry Standards Committee. The Chemist-in-Chief was also Chairman of the Interdepartmental Paint Committee, a member of the Chemical Society's Committee on Analytical Definitions and of the Public Analysts and Official Agricultural Analysts Committee of the Society of Public Analysts and other Analytical Chemists. The Deputy Chemist (Dr. S. G. Burgess) was a member of the following committees: Ministry of Food. Working Party on Nutrition in Relation to Catering Problems. Food Manufacturers' Federation. Technical Sub-Committee—Canned Soup Section. British Standards Institution. Technical Committee on Boiler Water Tests. Technical Sub-Committee on Analysis of Boiler Scale. Technical Committee on the Inflammability of Films (Chairman). Technical Committee on Paints. Pigments, Paints and Varnishes Industry Standards Committee. Dr. Burgess was also a member of the Interdepartmental Paint Committee and Chairman of the Paint Sub-Committee. Liaison The work of the Chemical Branch extends to practically every aspect of the Council's activities, necessitating frequent consultation with officers of other departments. Once again it is most gratifying to record the full and friendly co-operation which obtained at all times during the year and which proved so helpful in the discharge of joint responsibilities. d 48 Cordial relations were maintained with Government departments, research organisations and scientific societies. These contacts were most valuable in enabling the Chemical Branch to have access to the most up-to-date and authoritative information on many specialised subjects. Officers of the Branch are members of a number of scientific societies and during the year these included the Royal Institute of Chemistry, the Chemical Society, the Society of Chemical Industry, Society of Public Analysts and other Analytical Chemists, Institute of Petroleum, Institute of Sewage Purification, Oil and Colour Chemists Association, Royal Sanitary Institute and Royal Society of Arts. Publications and lectures Publications and lectures by members of the staff during the year were : 'Air Pollution '—C.J. Regan (Chadwick Lecture). 'The Chemist in Local Government Service'—C. J. Regan. 'Investigation into Detergency in Kitchens and Laundries'—S. G. Burgess and D. Burns, in collaboration with C. W. Tidy of the Chief Engineer's Department. 'Paint in the Public Service '—S. G. Burgess and C. A. Chaplin. 'Swimming Bath Water Treatment'—S. G. Burgess and D. Burns, in collaboration with C. W. Tidy of the Chief Engineer's Department. 'Recent Research Work at the Northern Outfall Works of the London County Council'—G. S. Clements and R. J. Stephenson, in collaboration with A. Bruce of the Chief Engineer's Department. 'The Thiocyanate Determination of Iron with Hydrogen Peroxide'—J. E. Houlihan and P. E. L. Farina. Library With the rapid development of scientific knowledge and the wide range of problems referred to the branch for investigation, it is essential to have up-to-date information on a variety of subjects. Hence the Reference Library, which continued to grow during the year and now comprises over 2,000 books, reports, pamphlets and specifications, as well as sets of over 300 technical journals and periodicals, has become an essential feature of the equipment of the branch. During the year help on specialised subjects was received from other libraries and acknowledgments of this are due to the libraries of the Public Health and Education Officer's Departments, H.M. Patent Office, the Science Museum, the Chemical Society, and other scientific societies. Staff The staff of the branch numbered 54, which included 27 professionally qualified chemists, 23 ancillary staff and 4 in the clerical section attached to it. In concluding this report on the year's work I should like to express my appreciation of the loyal and whole-hearted efforts of the whole staff, without which it would have been impossible to carry out the great amount of work which was dealt with during the year. 49 HEALTH SERVICE PREMISES the difficulties in providing new buildings to replace improvised accommodation in church halls and other rented or requisitioned premises were referred to in the Report for 1952. One difficulty was removed with the lifting in June of the restrictions on the use of steel, but the need for economy continued to limit expenditure on new buildings required to provide for additional services or the replacement of unsatisfactory centres and those which had to be relinquished. Building programme Some progress was however made in the planning of new centres, the erection of new buildings and the adaptation or improvement of existing premises. The capital building programme for the financial year 1954/55 was submitted as usual to the Minister of Health in December. This included only five new schemes in view of the need to restrict proposals to those which were most urgent and because a considerable number of projects were brought forward from earlier programmes. The total number of projects still to be commenced is substantial, but in existing economic circumstances it seems likely that some of these will have to be deferred. Particulars of outstanding schemes which had previously been submitted to the Minister for approval and of the additional five schemes are given below. Scheme for which approval was refused Division 5—Brewhouse Lane, Stepney.—Day nursery and child welfare centre. Following the Minister's refusal in the previous year to sanction this scheme it was finally abandoned by the Health Committee. Schemes abandoned or withdrawn from programme Division 1—Fulham Babies Hospital, Broomhouse Road, Fulham.—Conversion of first floor for additional residential accommodation. Owing to a falling demand for day nursery places the Health Committee decided to close this nursery and the scheme was, therefore, abandoned. Division 3—St. Alban's School, Holbortt.—The scheme of adaptation of part of the building as a day nursery was held up by delay in securing completion of the lease. Meanwhile, the need for the nursery diminished and the Health Committee decided to abandon the scheme. Division 8—CynthiaMoseley Day Nursery, Lambeth.—The scheme for extension of the heating system was withdrawn from the capital programme as the cost was found to be less than 1,000. It was expected that the work would be carried out during the financial year 1953-54. Schemes postponed Division 1—Westway, Hammersmith.—Day Nursery.—This scheme was deferred owing to a diminishing need for day nursery places. The Minister was asked to approve in principle the erection of a maternity and child welfare and school treatment centre on the adjacent health centre site. Division 2—Daleham Gardens, Hampstead.—The Minister agreed to consider a modified scheme for a combined maternity and child welfare and school treatment centre to meet existing needs. Division 3—Charles Lamb (Popham Road) School, Islington.—Adaptation as a maternity and child welfare and school treatment centre. The adapted premises were intended to replace a centre in a decontamination shelter in Tibberton Square, but in the meantime other premises in Clephane Road (formerly used as a day nursery) became available, and while negotiations for a lease of these premises were proceeding, the Popham Road Scheme was in abeyance. D* 50 Division 3—Drayton Hall, Islington.—Extension of maternity and child welfare facilities and addition of school treatment centre. As part of these premises was still in use by the North West Metropolitan Regional Hospital Board for mass radiography, the Health Committee decided to withdraw the scheme from the 1953-54 programme. Division 7—Queen's Road Centre, Camberwell.—The scheme for the second stage works for adaptation of these premises was postponed because of the shortage of steel and the cost involved. Foxley Road, Kennington.—Conversion of a former fire station to an ambulance station. At the request of the Minister of Health a revised scheme and estimates were in preparation. Schemcs approved but works not yet in hand Division 2—86 Carlton Hill, Marylebone.—Essential repairs on acquisition of a requisitioned day nursery. These works awaited confirmation of a Compulsory Purchase Order. Division 9—Stormont Road, Battersea.—Maternity and child welfare centre. Agreement had not been reached with the Battersea Metropolitan Borough Council on the use of this site. Division Premises Service Work involved 2 St. Stephen's Westbourne Park Road, Paddington Day nursery Completion of building 5 Christian Street, Stepney Day nursery Provision of play space 5 University House, Bethnal Green Day nursery Extension 6-7 Blackheath Hill Welfare Centre, Mcrton Place, Greenwich Maternity and child welfare centre New building 7 Queen's Road Centre, Camberwell (Interim Stage II adaptation) Maternity and child welfare centre and evening institute Conversion of existing building and temporary heating - Eastern Ambulance Station, Hackney General ambulance station Adaptation - Eastern Ambulance Station, Hackney General ambulance station Demolition of buildings and tar paving - Fulham Ambulance station Accident ambulance station Improvements - South Western Ambulance Station, Lambeth General ambulance station Extension - West Smithfield Ambulance Station, City of London Accident ambulance station New building 1 Highlever Road (St. Quintin), Kensington Maternity and child welfare centre New building 6 Amersham Road Health Centre, Deptford Day nursery and office accommodation Adaptation - London Ambulance Service Headquarters, Waterloo Road, Lambeth Ambulance service Conversion of fire station - 86 Fulham High Street, Fulham Occupation centre. . Major works of adaptation to provide full tion - 9 Spencer Park, Wandsworth Occupation centre. . Conversion of existing mises 5 Mary Hughes Centre, 22 Underwood Road, Stepney Maternity and child welfare centre Extension to form a child welfare centre in association with the London Hospital 5 Peel Grove, Bethnal Green Maternity and child welfare centre New building - Brook Ambulance Station, Greenwich General ambulance station Reinstatement after war damage - Pear Place, Lambeth Headquarters ambulance station Additional accommodation Works completed Starting dates awarded and works in hand at end of year Starting dates awarded but work not commenced by end of year 51 Starting dates not yet awarded 1 Eridge House Day Nursery, Fulham Day nursery Repairs on acquisition 1 129 Fulham Palace Road, Fulham Maternity and child welfare centre and office accommodation Adaptation 2 Hampstead Health Institute, Dynham Road, Hampstead Maternity and child welfare centre Adaptation 3 Basire Street (Coleman Fields), Islington Day nursery New building 3 Muriel Street, Islington Day nursery New building 5 Galbraith Street, Poplar Maternity and child welfare and school treatment centre Conversion of first-aid post 5 Rochelle Street School, Bethnal Green Maternity and child welfare centre Adaptation 5 1a Wellington Way, Stepney Maternity and child welfare centre Reinstatement of war damaged block as accommodation for staff 6 Burney Street, Greenwich Maternity and child welfare centre New building 9 ' Southlands', Shuttleworth Road, Battersea Maternity and child welfare centre and office accommodation Demolition of war damaged building and severance of services from Borough Council's premises - Shoreditch Ambulance Station .. Accident ambulance station Improvements - South Eastern Ambulance Station General ambulance station Extension - Upper Richmond Road Ambulance Station, Wandsworth Accident ambulance station New building - 'Dover Lodge', Wood Vale, Camberwell Hostel for M.D. girls Adaptation on acquisition - Hurlingham Lodge, Fulham Hostel for T.B. men Adaptation for full occupation - To be found Hostel for T.B. men To replace Highbury Quadrant hostel Programme for 1954-55 In addition to the schemes not commenced during the year 1953-54 the programme for 1954-55 includes the following new projects : Division Premises Work involved 1 Walmer Road, Threshers Place, Kensington Erection of day nursery to form ultimately a maternity and child welfare centre as first instalment of a comprehensive health centre 2 283a Harrow Road, Paddington Extension of premises to provide additional accommodation for maternity and child welfare, school treatment and office purposes. 3 Drayton Hall, Islington Extension of maternity and child welfare facilities and addition of a school treatment centre 9 67 Victoria Drive, Wandsworth (or alternative premises) Completion and adaptation of premises as maternity and child welfare and school treatment centre - Mottingham Ambulance Station, Woolwich Erection of new accident ambulance station Day nurseries The opening of two new day nurseries in purpose-built premises, one of which was completed at the end of 1952 and the other early in 1953, enabled the existing accommodation to be released. Two nurseries were closed, one because of diminishing demand and the other because the premises were required for other purposes. 52 Replacements Division 2—Westbourne Park Road (St. Stephen's), Paddington.—Prefabricated buildings, partly erected during the war, were completed. The nursery replaced the Maida Vale day nursery, 14 Blomfield Road, Paddington, which was derequisitioned. Division 3—Springdale Day Nursery, Springdale Road, Stoke Newington.—The opening of this nursery which was completed at the end of 1952, enabled the nursery at 6 Clephane Road, Islington, to be closed. These premises were held on requisition but negotiations were opened with a view to securing a lease for maternity and child welfare purposes. Extension to existing nursery Closures Division 5—University House Day Nursery, Betlmal Green.—Work was completed on an additional wing to accommodate ten babies. Division 1—Fulham Babies Hospital Day Nursery, Broomhouse Road, Fulham.—On the closure of the nursery these premises which were held on lease were declared surplus to Health Committee requirements. Division 9—Southfields Day Nursery, 72 West Hill Road, Wandsworth.—This nursery was closed to enable the premises to be demolished to make way for the completion of a block of flats. No suitable alternative accommodation being obtainable the children were admitted to neighbouring nurseries. Works in progress Division 6—Amersham Road Day Nursery, Deptford.—Work was commenced on adaptations to provide additional accommodation on the first floor. When ready this will permit the closure of Evelyn Street day nursery which is to be demolished. Maternity and child welfare centres Replacements Division 3—South Islington Welfare Centre, 6 Clephane Road, Islington.—These premises became vacant on removal of the former day nursery and were then brought into use as a welfare centre to replace very inadequate accommodation at Tibbcrton Square Welfare Centre which was derequisitioned. A midwife's clinic held at Bentham Court, Islington, was also transferred to 6 Clephane Road. Division 5—St. George's Welfare Centre, Library Place, Stepney.—New purpose-built accommodation was provided as part of a scheme for a new temporary library built by the Stepney Borough Council. The St. George's Town Hall Welfare Centre was closed and the accommodation released. Division 7—Blackheath Hill Welfare Centre, Merton Place, Greenwich.—The erection of a prefabricated hut was completed and the centre was transferred from unsatisfactory accommodation at the Salvation Army Hall, Romer Avenue. The new centre is administered by Division 7 but also serves areas in Division 6. Provision of additional centres Division 3—Archway Welfare Centre, Congregational Church Hall, Junction Road, Islington.—A new centre was opened in accommodation provided in a newly erected church hall. Division 6—St. Alban's Church Hall, William Barefoot Drive, Woolwich.—A new centre was opened to serve the recently developed housing estates pending the erection of a permanent centre. Division 7—Langbourne Primary School, Kingswood Drive, Camberwell.—A temporary centre was opened at this school to serve the newly developed Kingswood estate pending the provision of an ad hoc centre. Division 7—Lordship Lane Centre, Lewisham.—A new centre was opened in premises acquired and adapted for maternity and child welfare and school treatment purposes. Accommodation for tuberculous men Preliminary works necessary to allow partial occupation were carried out at Hurlingham Lodge, Fulham, which was rented from the Parks Committee and the premises brought 53 into use as a hostel for 12 tuberculous men. Tenders were obtained for major works to bring the hostel into full occupation by 26 men and the award of a starting date was awaited at the end of the year. Efforts to secure suitable premises for adaptation as a hostel to replace the one at Highbury Quadrant, Islington, were unsuccessful but were being continued. Occupation centres for the mentally defective Details regarding premises used as occupation centres will be found on page 98. Works in progress 86 Fulham High Street, Fulhatn.—Adaptation of an existing building as an occupation centre. Preliminary works were completed and the premises brought into partial use to accommodate the elder girls transferred from unsatisfactory premises at Fellowship Hall, Hammersmith, the use of which were discontinued. Replacements Congregational Church Hall, Junction Road, Islington.—A centre for elder boys was opened in this newly erected church hall. 19 Compton Terrace, Islington, formerly used for the elder boys, was brought into use temporarily for elder girls. St. James's Church Hall, Islington.—This centre was opened for elder girls who were transferred from 19 Compton Terrace. Use of the latter premises as an occupation centre was then discontinued. School health service Replacements Division 2—Westminster Treatment Centre, 40 Alderney Street, Westminster.—Adaptation of these premises was completed and the centre opened to replace accommodation rented at 38 Rochester Row and 41 Greencoat Place, which were closed. Division 7—East Dulwich Treatment Centre.—Adaptation of 475 Lordship Lane was completed and a school treatment centre was opened to replace 29 Amott Road, Camberwell. The latter premises were unsuitable for health service purposes and were declared surplus to requirements. Centre closed Division 6—Ormiston Road Centre, Greenwich.—The work of this centre was transferred to other centres, and the accommodation, which was rented from the Welfare Committee, was vacated. Schemes in progress Division 8—St. Georges Dispensary, 86 Blackfriars Road, Southwark.—The transfer of the trust and premises to the Council from the St. George's Dispensary Trust had not been completed at the end of the year. Division 9—Tooting Treatment Centre.—The purchase of 195 Mitcham Road, Wandsworth, was completed and a scheme prepared for adaptation of these premises to replace the centre formerly at 1071 Garratt Lane. This centre was closed on termination of the tenancy as the premises, which were to be sold, were unsuitable for acquisition for health service purposes. Office accommodation Division 9—89 Trinity Road, Wandsworth.—A new home help office was opened to replace an inconvenient and overcrowded office at 91 Bedford Hill, Wandsworth. Health centres The progress made in the planning of health centres in accordance with the pohcy approved by the Council in 1951, especially with regard to the utilisation of vacant sites acquired or reserved for health centres, was reviewed. Steps had been taken to reserve twenty-nine sites, all of which had been approved by the Executive Council. Of these, four are in the possession of the Health Committee, twelve were included in the Development Plan 1951 and five were reserved on housing estate sites. The total area of these sites is 34.34 acres, 14.53 acres being vacant land. It is intended to utihze 54 most of this vacant land for the erection of maternity and child welfare and school treatment centres which can be extended later to form comprehensive health centres. It was decided to continue the existing policy of providing such facilities as first instalments of health centres and reserving sites on housing estates, etc., where ultimate provision might be difficult if such action were not taken. Finsbury Health Centre At the end of July, the gynaecological clinic administered by the Central Group Hospital Management Committee at the Finsbury Health Centre was closed. Patients resident in the area and requiring advice and treatment for gynaecological conditions were thereafter referred to the out-patient department of appropriate nearby hospitals. Acquisitions and leases Opportunities were taken wherever possible to acquire suitable properties and sites for health service purposes or to secure long-term leasehold tenancies. The following acquisitions and leasehold tenancies were completed during the year. Division Property Interest obtained Service 1 Site of 188 Walnicr Road, Kensington Freehold Comprehensive health centre site 2 37, 38, 39 Bloomfield Terrace Westminster Leasehold Day nursery 2 Sites of 9, 11, 15 and 17 Solent Road, Hampstead Freehold Comprehensive health centre site 2 Sites of 1-4 Heath House, New End Square, Hampstead Freehold Maternity and child welfare centre site 9 315 Garratt Lane, Wandsworth.. Leasehold School treatment centre - Mottingham Ambulance Station, Woolwich Freehold Ambulance station 1 New Cross Road, Deptord Freehold Ambulance station (extension) CARE OF MOTHERS AND YOUNG CHILDREN Administration day to day administration of the services was continued by the nine divisional health committees. In each division, the Divisional Medical Officer is responsible, through his administrative staff, for the co-ordination of the personal health services in his area. During the year, members of the committees regularly visited health establishments in their divisions. Maternity and Child Welfare Centres Details of changes in centres during the year will be found in the section on Health Service Premises, page 52. Expectant and nursing mothers First attendances at ante-natal clinics of all women needing ante-natal care were 43 per cent. compared with 41 per cent. in 1952. Attendances at post-natal clinics continued to decline. Attendances at educational sessions continued to increase mainly 55 clue to the expansion of educational activities at welfare centres (see page 92). The following table gives comparative statistics: Year Ante-natal Clinics at end of year (including combined ante-natal and post-natal) Sessions per month Attendances Percentage of pregnant women making at least one attendance at ante-natal clinic First Total 1949 117 957 29,917 184,018 52 1950 114 910 26,979 176,993 50 1951 112 905 24,819 162,667 45 1952.. 115 1,145 21,959 145,088 41 1953.. 114 976 22,713 129,451 43 Post-natal Year Clinics at end of year Sessions per month 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 1949 31 263 2,614 3,225 3,396 4,090 1950 6 31 2,534 3,400 3,335 3,920 1951 6 17 1,669 3,993 2,218 4,642 1952 5 11 530 3,888 1,031 4,479 1953 5 10 486 3,228 910 4,311 Year Special breast feeding Educational Sessions per month Total attendances Sessions per month Total attendances 1949 44 1,554 133 21,779 1950 41 1,436 138 22,681 1951 33 1,303 196 30,414 1952 22 1,119 216 33,596 1953 24 1,388 243 34,977 56 Relaxation exercise classes for expectant mothers conducted either by health visitors or physiotherapists were held at some of the welfare centres. Tests Every expectant mother attending the Council s ante-natal clinics had a specimen of her blood taken for the Wassermann and Kahn reactions and for the Rhesus factor. Laboratory services continued free of charge to the Council at hospital laboratories or at the Medical Research Council's laboratory at County Hall. Pregnancy diagnosis tests, when required, were carried out for the Council at certain hospital laboratories or at the Ministry of Health laboratory at Shrodell's Hospital, Watford. Chest X-rays Arrangements were gradually being extended for the routine chest X-ray either by mass X-ray units or at chest clinics of all women who were to be confined at home. The Violet Melchett Infant Welfare Centre, a voluntary organisation providing services on behalf of the Council under section 22 of the National Health Service Act, 1946, continued to maintain a residential unit where treatment was provided for mothers and babies experiencing breast feeding difficulties and for babies with dietetic upsets. The North Islington Infant Welfare Centre, a voluntary organisation, also providing services on behalf of the Council under section 22, continued to provide similar nonresidential facilities. Rehabilitation of mothers Ten mothers (with young children) were sent to recuperative centres (usually for a period of eight weeks) for training in mothercraft and housecraft. There was follow-up by the health visitor and in some cases by the family service unit in addition. Reports on discharge and six months after discharge were being studied to assess the value of these residential courses and to ascertain whether the benefits derived during the stay at the recuperative centres were of lasting value. Joint arrangements 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 attend either the Kent or London maternity and child welfare centres, whichever may be nearer to their homes. The arrangements whereby mothers and young children living in that part of the County Borough ofWest Ham adjacent to North Woolwich may, if they so wish, attend the Council's North Woolwich Centre, Fernhill Street, E.16, were also continued. Clinics Attendances at sessions of different types held in maternity and child welfare centres are shown in the tables on pages 55 and 57. The areas served by the various centres are defined, and this is to the advantage of the mothers and children who attend, as continuity of care by the health visitor of the area can be maintained. Complete freedom of choice is, however, given to the mother. Areas are adjusted as necessary, when new centres are established, to meet local demands. Some of the sessions are conducted by doctors engaged in private practice who are employed by the Council as part-time medical officers. Maternity and child welfare services provided by hospitals The medical schools of four teaching hospitals, acting as voluntary organisations grant-aided by the Council, provided child welfare centres on its behalf. With the exception of one health visitor, who continued to be employed by the medical school, the health visiting staff was provided by the Council. For duties at the clinic, the health visitors were under the direction of the Paediatrician in charge, but were responsible to the Divisional Medical Officer for work outside the clinic. Exchange of medical officers Reciprocal arrangements were continued with certain teaching and other hospitals under which assistant medical officers employed by the Council obtained further experience in the paediatric departments of the hospitals and hospital registrars worked at the Council's welfare centres. Voluntary organisations 18 voluntary organisations provided maternity and child welfare centres under agreement with the Council, in accordance with Section 22 of the National Health Service Act. The centres were administered by voluntary committees, on which the Council was represented either by members of divisional health committees or the appropriate divisional medical officer, or both. The premises and services provided by the voluntary organisations were inspected from time to time. 57 One voluntary organisation, the Downham Infant Welfare Centre, which held child welfare sessions at the Downham Health Centre (Council premises), decided to cease administering the sessions, and the Council assumed responsibility for them at the beginning of October. Arrangements with six voluntary associations providing day nurseries continued satisfactorily during the year. Financial assistance was also granted towards the maintenance costs of one part-time day nursery. Family planning Family planning sessions totalling six a week were provided by the Council for advising women for whom further pregnancy would be detrimental to health. Where no such facilities were provided by the Council, the services of the Family Planning Association were used, a per capita payment being made to the Association. 978 women were referred to the Association during 1953. At the end of the year 32 weekly sessions were being held by the Association, some in the Council's centres, where accommodation was made available free of charge to the Association. Child welfare It will be seen from the table below that attendances at child welfare centres in the first year of life amounted to 84 per cent. in 1949, 79 per cent. in 1950, 82 per cent. in 1951, 84 per cent. in 1952 and 85 per cent. in 1953. Those infants who attend in their first year, do so about 12-15 times. Attendances tend to fall off rapidly after the first year. All mothers are, however, encouraged to bring their children to the child welfare clinics, or toddlers' clinics, special invitation cards to the latter being sent on birthday anniversaries. It has been found that rather less than one in five children who attend in response to these invitations are referred to family doctors or hospital to be treated for ailments which the parents might not otherwise have recognised. Year Clinics at end of year (including toddlers) Sessions per month Attendances Under 1 year Over 1 year First Total First Total Special toddlers Percentage of infants attending a centre at least once in the first year of life 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 1953 174 1,901 43,969 615,530 4,671 213,976 42,576 85 Child guidance Toddlers' clinics offer special opportunities for the study of emotional disturbances and maladjustments in the pre-schoolchild. In division 9 some of the child welfare clinics are working closely with the psychiatrist at Brixton Child Guidance Unit. Visits are paid by psychiatrists to the child welfare sessions at frequent intervals, and centre medical officers refer cases requiring skilled treatment to the psychiatrist at the child guidance unit. A different approach to the same problem is provided by two child guidance clinics for pre-school children which are held in centres in divisions 2 and 3. A study group of medical officers of all grades and health visitors, under the chairmanship of Dr. John Bowlby of the Tavistock Clinic, is meeting to consider the question of the introduction of preventive psychiatry into the child welfare services. Reference is made in the section on mental health (page 98) to the provision of special child welfare services for backward children. 58 Drugs, medicaments, welfare foods, etc. Cod liver oil compound, tablets of Vitamins A and D, national dried milk and concentrated orange juice were distributed at welfare centres on behalf of the Ministry of Food. In addition a number of welfare foods and nutrients were available, when approved by the clinic medical officer, at fixed charges, subject to abatement where necessary. Simple drugs and medicaments according to an approved list were 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. Sunday cinema grants The Council continued to receive contributions from the Sunday cinematograph 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. These amenity funds are administered by small voluntary committees. Marriage guidance The Council makes 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. All these organisations devote part of their effort to pre-marriage work. The London Marriage Guidance Council and the Catholic Marriage Advisory Council, in particular, extended their activities during the year in connection with preparation for marriage and family life. The London Marriage Guidance Council arranged discussion groups and individual consultations to meet the need of the increasing numbers of young people seeking advice and help. The Catholic Marriage Advisory Council ran pre-marriage training courses in various parts of London and also youth club courses. During the year the Family Discussion Bureaux undertook research work into the value of the methods applied by their organisation. Ministry of Health inquiry into virus infections during pregnancy Investigation into the early detection of cerebral palsy Special investigations The registration of new cases and controls for the Ministry of Health inquiry into virus infections during pregnancy ceased at the end of 1952, but the Council in common with a few of the larger authorities, was asked to continue to register, and follow up, rubella cases. At the end of the year 14 cases had been registered. The 1952 Annual Report referred to facilities which had been granted to Dr. W. F. Dunham, of the Department of Physical Medicine at Charing Cross Hospital for carrying out a pilot scheme of research into the early detection of infantile cerebral palsy amongst selected babies at special sessions at maternity and child welfare centres in Health Division 9. The pilot scheme was successfully completed and the Council agreed that it could be extended to the other health divisions in turn. At the end of the year the survey in health division 8 had been completed. Investigation into the health history of female children who have never received human milk. Survey of illegitimate children The Council is co-operating in an investigation, being conducted by Mr. H. J. B. Atkins, Director of the Department of Surgery, Guy's Hospital, under which a follow-up is carried out of female children who have never received any human milk. It is hoped to build up a panel of 5,000 cases. The collection of the panel throughout the country may take up to ten years. A survey is being undertaken of illegitimate children born in London in November, 1953, and May, 1954, to establish what changes occur in the environment of children of unmarried mothers in the first five years of life and to try to assess the effects of these changes on their mental and physical development, as well as their experience of 59 accidents and illnesses. The selection of children, who are matched with legitimate children born in the same month, of the same birth weight and sex, whose mothers are the same age and same school leaving age, is being carried out entirely by health visitors, and a follow-up visit is being made at four-monthly intervals. Co-operation has been promised by medical officers of health of the home counties and county boroughs in the follow-up of children who move to other counties. Children's officers all over the country, whose assistance is so essential to the success of the survey, are helping to keep contact with the children, and valuable assistance is being received from voluntary organisations concerned in the care of children. The fact that a child has been placed for adoption is recorded and if adoption is successfully completed, the child's name will be removed from the survey. The first sample of children has already been taken and the second sample will be taken in May, 1954. The children thus selected will be followed-up at least until they reach school age. It is hoped that in this way valuable evidence may be obtained which may be helpful in the formulation of future policies for the welfare of the illegitimate child. Co-operation with other parts of the National Health Service Efforts to foster and improve co-operation with other branches of the National Health Service were continued. The scheme introduced 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 continued satisfactorily. The direct approach of almoners to the Council's field workers for mutual discussion and exchange of information is encouraged. There is close and effective co-operation between hospital maternity and paediatric departments and the Council's ante-natal and child welfare clinics. Hospitals also notify the divisional medical officers of the discharge of maternity patients from hospital, and this procedure continued to function satisfactorily. Consultation has taken place with representatives of the hospital authorities on the co-operation existing between their maternity services and the Council's domiciliary midwifery, health visiting and maternity and child welfare services. The discussions centred on the Ministry of Health circular L.H.A.L. 1/51, on the selection of maternity patients for admission to hospital, and circular 5/53 on the need for continuity in the care of mothers and babies as between the general practitioner, the hospital and the local health services. The procedure for continuity of care is generally effective. The selection of patients for hospital confinement and the closely allied question of the extent of hospital provision for confinements present a more complex problem which is still under consideration. General practitioners Reference is made in the section on the domiciliary midwifery service (page 64) to the liaison between ante-natal clinics and the general practitioner. Endeavours were made during the year to effect even closer co-operation between general practitioners and the Council's centre medical officers and health visitors. In some divisions regular meetings were held and, in all divisions, general practitioners were notified when it was proposed to refer any of their patients (mothers or children) to hospital out-patient departments for further advice and treatment. A new trend was shown in the direct association of a health visitor with a large group practice and similarly of two domiciliary midwives with the ante-natal sessions held at a group surgery. These were experimental and present some administrative problems, but they may show the way to further co-operation. 60 Day nurseries Day nurseries and occasional creches During 1953, four day nurseries were closed and two replacement nurseries were opened. A former play centre was brought into use as a part-time day nursery. The accommodation provided in the Council s 104 maintained and 6 grant-aided day nurseries at 31st December, 1953, as compared with the previous year when the numbers were 105 and 6, respectively, was: Age Group Maintained Grant-aided Total 31.12.52 31.12.53 31.12.52 31.12.53 31.12.52 31.12.53 0-2 years 2,017 2,006 50 50 2,067 2,056 2-5 years 3,879 3,813 189 189 4,068 4,002 Total 5,896 5,819 239 239 6,135 6,058 The priority waiting list for admission to day nurseries was 621 at the end of the year, as compared with 1,130 at the end of 1952. The increased charges introduced on 1st January, 1953, for attendance at the day nurseries, had an immediate effect on occupation, but the position had substantially improved by the middle of the year. There was, however, still considerable underoccupation, and the Council decided to amend its scheme of priorities for admission to day nurseries by the introduction of a third priority. This decision enabled vacancies not required for children in the first and second priorities to be offered (subject to the rules governing admission to the nurseries) to parents who were both working and were unable to make other satisfactory arrangements for the care of their children but whose income precluded their children qualifying for admission on economic grounds under the second priority. The standard charge, which is reducible according to the parents' means, of 4s. Od. a day (2s. Od. a day for the second and subsequent children of the same parent or parents), was retained but the Council introduced a supplementary charge to parents whose net income (calculated in accordance with a scale which takes into account certain outgoings) exceeded a fixed sum. The amount of this supplementary charge varies according to the parents' income. These decisions came into force on 2nd November, 1953, in respect of children admitted to day nurseries on and after that date, but were deferred until 4th january, 1954, for children admitted before 2nd November, 1953, to enable the parents' circumstances to be reviewed. No further general reduction was made in the number of training day nurseries, and only two day nurseries opened on Saturday mornings. Facilities were made available for the attendance of speech therapy and educational psychology students at selected day nurseries. Occasional creches There was a small increase in occasional creche facilities during the year, but no general expansion took place having regard to the view of the Minister of Health that the expenditure would be undesirable. Nurseries and Child-Minders (Regulation) Act, 1948 Private day nurseries The number of private day nurseries registered under the Nurseries and Child-Minders (Regulation) Act, 1948, and the number of places provided, as compared with 1952, were : At 31st December 1952 1953 Private day nurseries statutorily registered 63 60 Places provided 1,841 1,795 Child-minders The number of child-minders, both statutorily and voluntarily registered, as compared with 1952, were as follows: At 31st December 1952 1953 Number of child-minders statutorily registered 96 112 Number of children minded 504 638 Number of child-minders voluntarily registered 794 793 Number of children minded 856 854 61 The child-minders who are statutorily registered under the Act are persons—other than relatives—who, during the day look after, for reward, more than two children under the age of five years from different households. Women who look after one or two children may voluntarily register with the Council, receiving a weekly registration fee in return for which they are subject to inspection. Children neglected or ill-treated in their own homes Reference was made in the 1952 Annual Report to experimental conferences which had been held in two health divisions and during 1953 similar conferences were held in the remaining divisions. Representatives of interested Council departments and of other statutory and voluntary bodies concerned with the welfare of the family were invited to these conferences, endeavours being made to bring in everyone who might be helped by, or might be able to help in, a concerted effort to assist the children and families concerned. In each division, a directory of organisations undertaking social casework for children was circulated to all statutory and voluntary bodies in the area. This directory was planned to draw attention to, and include details of, the variety of resources available from national, county and local efforts and to show how they link up with the Council's divisional services. An index has been started in each health division to provide a ready reference to problem families notified from a variety of sources and this enabled those assisting the same family to be informed of each other's interests and so to co-ordinate their efforts. In a number of divisions, standing committees were set up which included divisional representatives of the four official departments concerned (public health, education, children's, welfare) with the co-option of other officers and representatives of voluntary organisations, as necessary, including the N.S.P.C.C. Meetings were informal and their frequency varied from division to division. In some divisions, the standing committee considered matters of general principle only, while in others it dealt with selected casework as well. In divisions where there was no standing committee ad hoc conferences of officers to consider particular cases were held as and when necessary. Medical supervision at residential establishments for children The Public Health Department continued to supervise the health of children in the Council's residential establishments and for this purpose frequent visits were made by members of the central medical and nursing staff. The children in residential nurseries and in nursery schools were under the medical care of the visiting medical officer who saw them on admission and discharge and at other times when necessary. In addition, routine medical examinations and immunisations were carried out. Close co-operation was maintained with the visiting medical officers and also with the Children's Officer. During the year, heavy outbreaks of influenza, measles and whooping cough occurred at many residential establishments. There were also epidemics of sonne dysentery at four of the nurseries and small outbreaks of jaundice at five. Cases of anterior poliomyelitis occurred at three homes. In one there were four cases between 9th June, and 9th July. Two members of the staff (with considerable residual paralysis in one case), and two children (of whom one died) were affected. There was a further non-paralytic case in a member of the staff ten weeks later. Two other homes had one isolated case each, both being members of the staff, one of whom had severe residual paralysis. In all these outbreaks staff from the Public Health department advised on methods of prevention, diagnosis, control and nursing care. Members of the central medical staff advised the Children's Department on the suitability or otherwise of private nurseries offering vacancies to the Council and a list was kept of homes approved for children of various ages. They also advised on the planning and adaptation of new nurseries: for this purpose ten houses were visited during the year. 62 Adoption and boarding-out During the year 767 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 all except three were passed as fit for adoption or for boarding-out. Of the three children who were considered unfit, one was feeble-minded, one mentally backward and the other had a positive Wassermann reaction. The remaining 764 children were grouped as follows : 1. Referred for adoption 188 (a) Normal, fit for adoption 162 (b) Abnormal, but fit for adoption, subject to certain provisions 6 (c)abnormal, unfit for adoption, fit for boarding-out 20 2. Referred for boarding-out 576 Fit for boarding-out 576 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 unmarried mothers and their babies. This duty is performed mainly through the agency of voluntary organisations, as recommended by the Ministry of Health in circular 2866/43 and endorsed by the Council in its proposals under the National Health Service Act, 1946. Some women not admitted to voluntary mother and baby homes, chiefly because of their unsuitability, are admitted to homes under the management of the Welfare Committee. Unmarried expectant mothers in voluntary homes, who are unable to pay for their own maintenance, are paid for through the Welfare Committee. Grants in aid for the maintenance and upkeep of voluntary mother and baby homes are paid annually by the Council under section 22 of the National Health Service Act, 1946. In 1953 20 homes were supported in this way, the total payments amounting to £13,429. The voluntary homes take expectant unmarried mothers during the later stages of pregnancy and for two to three months 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 to ensure that satisfactory standards of diet, staffing and accommodation are maintained. The Medical Officer of Health is represented on the Committees of these voluntary homes. Grants towards their maintenance are made subject to the carrying out by the voluntary bodies of any improvements suggested by the Council. A grant, at present £800 a year, is paid towards the maintenance of a hostel for women in work, which takes women and their babies on discharge from mother and baby homes. Two similar hostels are provided by the Council under the management of the Welfare Committee. The mothers remain in the hostels for periods up to one year. The Council also makes grants under Section 22 of the Act to five moral welfare associations, two Church of England, two Roman Catholic and one Jewish, and in 1953, the grants amounted to £8,610. The headquarters of these associations are visited periodically to review the service provided. A conference is held each year, to which representatives of the moral welfare associations are invited so that the work of the past year may be reviewed and current problems discussed. A survey was undertaken relating to all mothers entering the Council's and the voluntary mother and baby homes between 1st January and 30th June, 1953, to try to obtain information about ante-natal care sought by these mothers. A preliminary look at the data obtained shows that some mothers attend a doctor or hospital to get a medical certificate of pregnancy and the Wassermann test—both of which are essential for admission to mother and baby homes 63 —but have little effective ante-natal care. Closer liaison between moral welfare workers and health visitors may help to improve the position. Case-work for the unmarried mothers during the ante-natal and the immediate post-natal period is undertaken by the moral welfare associations. The voluntary committees and matrons of mother and baby homes also do case-work. DOMICILIARY MIDWIFERY SERVICE the council's domiciliary midwifery service had its origin in the Midwives 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 direction of a doctor, and were encouraged to make the fullest use of the maternity and child welfare services provided by the Metropolitan Borough Councils. The hospitals and voluntary associations received payments 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 national 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 changed 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 of the services which they propose to undertake so that she may know whether to act as a midwife or as a maternity nurse. The midwife reports her findings to the doctor booked for the case on the 1st and 36th week antenatal examination. 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. One general practitioner obstetrician in the county holds a clinic in his own surgery which a Council's midwife attends and it is possible that this practice may be extended. Attached to the form is the analgesia certificate which the doctor fills in and sends to the midwife. The midwife sends the doctor a notice of the delivery of a booked patient within 36 hours of the baby's birth. After discussions with the London Local Medical Committee, the midwife is now asked to notify, with the patient's consent, the list doctor when she has to be booked for a home confinement. The introduction of these forms for the e 64 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 showed a steep increase in 1946-7 (the immediate post-war period) and a big decline since 1948. The table and diagram on page 68 show the number of home confinements attended during the years 1945-53 by the Council's midwives, hospital district midwives and district nursing association midwives. The chief factors effecting the decline in the number of home confinements were (a) the fall in the birth rate (b) the shortage or unsuitability of housing accommodation and (c) the attraction of hospital confinement and the increase in the number of maternity beds provided. It is problematical whether or not the recent increase in maternity benefits, and in particular the introduction of the special grant of £9 for a home confinement, will have any effect in halting the trend towards hospital confinement. Owing to the reduction in the number of home confinements any developments in the domiciliary midwifery service must be looked for in the quality of the service provided by the midwives and the measure of co-operation and integration with other health services and the national medical services provided under the National Health Service Act rather than in any expansion. L.C.C. midwives 541 of the confinements attended by the Council s midwives during 1953 were primi-gravidae, and 5,149 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 94 compared with 98 at the end of 1952 and 111 at the end of 1951; the average number of confinements attended by each midwife was approximately 58 compared with 61 in 1952, and 62 in 1951. Agency arrangements At the end of the year 60 midwives for domiciliary confinements (including supervisory staff) were employed by hospitals and 40 (including supervisory and part-time staff) by district nursing associations. Ante-natal sessions The Council's policy 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 that she may be able to attend her ante-natal session. Each midwife undertakes 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 exhibition 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 also undertake such sessions at a few clinics. Specimens of blood are taken from all mothers attending ante-natally and tested for Wassermann and Kahn reactions and for Rhesus factors. In eight of the nine divisions routine haemoglobin tests are made, further specimens are taken for anti-body 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 first and 36th week examination as mentioned 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. 65 Transport Transport by ambulance cars continues to be available for the use of midwives in emergencies, particularly at night-time and when undertaking relief duties. Housing of midwives Accommodation for domiciliary midwives continued to be provided by the Council. On 31st December, 1953, 53 midwives were housed in 51 houses and flats. Payment to district nursing associations and hospitals Payments to district nursing associations under Section 23 of the National Health Service Act, 1946, continued to be merged in grants made to them for home nursing services provided under Section 25 of the Act. The rate of payment for hospitals providing midwifery services on behalf of the Council continued at the rate of 10 gns. a patient, except in the cases of the Mothers' Hospital (Salvation Army) where the rate, because of special circumstances, was £9 15s. a patient. Maternity outfits Every woman delivered at home under the National Health Service Act is eligible for 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 domiciliary midwifery service. Analgesia Gas and air 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 the 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 77 per cent. in 1953. A similar increase in the use of gas and air analgesia has also been effected in confinements attended by hospital district midwives and district nursing 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 the maternity medical services himself provides the analgesia or anaesthetic. The following table shows the number of administrations of gas and air analgesia: Confinements attended by 1953 L.C.C. Midwives Number 4,406 Percentage 77.4 Hospital District Midwives Number 2,253 Percentage 78.2 District Nursing Association Midwives Number 1,474 Percentage 78.1 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 practice of their profession or employment as midwives. Conditions were laid down which provided that midwives could only obtain supplies of these dangerous drugs by production of a drug book and their personal register of cases. On 1st April, 1953, the Dangerous Drugs Regulations, 1953, came into effect by which the method of obtaining a supply of pethidine was altered. It has now become necessary for a midwife to obtain a midwife's supply order, signed by the Supervisor of Midwives, which she takes to the pharmacist issuing the drugs. E* 66 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 : Confinements attended by As Midwives As Maternity Nurses L.C.C. Midwives 1,186 244 Hospital District Midwives 645 67 District Nursing Association Midwives 369 76 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 midwives service participated in a trial of trilene inhalant in the latter part of 1952 and the first three months of 1953. The results of this trial are being investigated by a joint subcommittee of the Medical Research Council and the Royal College of Obstetricians and Gynaecologists, and on the result of the trial will probably depend the use of trilene by domiciliary midwives in future. Premature infants Premature babies born at home The arrangements outlined in the report for 1952 for nursing premature infants at home were continued and special equipment was lent on 59 occasions. 43 babies were removed to hospital in heated cots and with oxygen supplies provided by the hospital. The following hospitals have special units or cots for the reception of premature infants—Hammersmith, King's College, University College, British Hospital for Mothers and Babies, and the Mothers' Hospital. Some other hospitals 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. 377 babies weighing 5½ lbs. or less were reported to the supervisors of midwives. The following figures are based on their reports: 296 mothers were multi-parae and 51 primi-parae; 27 were under 21 years of age, 58 over 35 years, (including 2 primiparae) and 21 were having their sixth or subsequent pregnancy. Periods of gestation according to the mothers' dates were: Under 32 weeks 16 32 to 36 weeks 63 Over 36 weeks 268 75 received inadequte ante-natal care due to late booking and failure to attend the clinic regularly, and of these 14 were unbooked emergencies (7 primi-parae). Predisposing causes in the mother were: Toxaemia 26 Anaemia (Hb under 70 per cent.) with or without hypertension 21 Respiratory infection 6 Twins 30 The weights of the infants were: Under 3½ lb 25 3½ lb. and under 4½ lb 46 4½ lb. and under 5 lb. 81 5 lb. and over 225 Care of premature infants 292 infants were nursed at home and 4 died. 288 were making good progress when discharged by the midwife, usually at 3 or 4 weeks. 253 of these (88 per cent.) were entirely breast fed. 85 infants were removed to hospital. The usual practice is to transfer 67 immediately all babies under 4 lb., and those showing signs of prematurity, such as cyanosis, impaired respiration or inability to suck. 81 infants were transferred within a few hours of birth and 4 between 6 hours and 10 days, on account of their unsatisfactory condition. 19 of these infants died and 66 were making good progress on discharge. Of these 66, 19 were entirely breast fed. Total Died Survived Breast fed Home 292 4 288 253 Hospital.. .. 85 19 66 19 377 23 354 272 25 babies were under lb. at birth. 12 of these survived, including 7 who were also more than 8 weeks premature. 2 of these were born in the W.C., but after resuscitation and removal to hospital, both did well. Neo-natal deathspremature infants There were 23 neo-natal deaths: 19 in hospital and 4 at home. Hospital cases: 9 infants under 3½ lb. and more than 4 weeks premature 2 infants under 4½ lb. and more than 4 weeks premature 1 infant 5 lb. and more than 4 weeks premature 3 infants over 5 lb. and not premature according to dates All died of prematurity within 48 hours. There were three severely deformed infants who only just survived birth and one mongol who died within a few days of birth. Home cases: 1 very small infant more than 8 weeks premature died within a few hours of birth. 1 infant of 4½ lb. and 1 of 5 lb., whose condition appeared to be satisfactory, died unexpectedly at 3 and 14 hours respectively. 1 infant, previously making good progress, had a cyanotic attack at 12 days and died. Stillbirths and neonatal deaths There were 114 stillbirths in a total of 8,133 domiciliary births. 46 were ante-partum deaths and of these 20 infants showed some congenital deformities, while 23 were under 5½ lbs. in weight. Among the 68 presumably intra-partum deaths 26 babies weighed less than 5½ lbs. and 5 could be considered to be post-mature. The record of neonatal deaths is incomplete. There were, however, 36 deaths in the first week of life of which 7 occurred after the babv had been transferred to hospital. Statistics For the year 1953 and subsequent years the division of domiciliary confinements 5 between midwifery and maternity nursing cases was dropped for statistical purposes at the request of the Ministry of Health. Confinements are now classified as either 'doctor booked' or 'doctor not booked', with sub-divisions of 'doctor present' and 'doctor not present'. Domiciliary confinements attended by London County Council, Hospital and Nursing Association midwives—1953. Number of con finements Number of con finements Doctor not booked Doctor booked L.C.C. District Nursing Association Hospital L.C.C. District Nursing Association Hospital Doctor present Doctor not present Doctor present Doctor not present Doctor present Doctor not present Doctor present Doctor not present Doctor present Doctor not present Doctor present Doctor not present 226 4,241 55 1,601 84 2,586 504 719 86 155 118 97 68 Total number of domiciliary confinements attended by London County Council, Hospital and Nursing Association midwives—1948-1952 Year Maternity Nursing Cases Midwifery Cases Grand Total L.C.C. Hospital District Nursing Association Total L.C.C. Hospital District Nursing Association Total 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 69 Emergency obstetric service A total of 106 calls were made to hospitals during the year for the emergency obstetric service ; 46 of these calls were made by doctors and 60 by midwives. The time intervals between the calling and arrival of the service were : Percentage of total calls Under 10 minutes 2 calls 2% 10 to 20 minutes 34 calls 32% 20 to 30 minutes 58 calls 55% 30 to 45 minutes 12 calls 11% There was no serious delay and in the majority of cases the unit arrived within 30 minutes of being called. The conditions necessitating the use of the service were : Obstetric shock 3 Post partum haemorrhage 26 Retained placenta with post partum haemorrhage 34 Retained placenta 7 Secondary post partum haemorrhage 5 Ante partum haemorrhage 10 Eclampsia 1 Malpresentation 6 Failed forceps 1 Deep transverse arrest 1 Impacted shoulders 1 Cervical and vaginal lacerations 2 Pulmonary embolus 1 Post partum anaemia with collapse 2 Foetal distress 1 Prematurity 1 Abortions 4 Total 106 The action taken by the emergency obstetric service was: Treatment given Removed to Hospital Remained at at Home Total Obstetric shock Blood transfusion – 1 1 Dextrose transfusion 1 – 1 Administration of drugs 1 – 1 Post partum haemorrhage Blood transfusion 5 10 15 Dextrose transfusion 1 – 1 Administration of drugs 3 3 6 No treatment 2 2 4 Retained placenta with post partum haemorrhage Blood transfusion 6 3 9 Dextrose transfusion 1 1 2 Administration of drugs 1 1 2 Manual removal with blood transfusion 1 12 13 Manual expression of placenta 1 2 3 No treatment 5 – 5 Retained placenta Blood transfusion – 2 2 Dextrose transfusion 1 – 1 Administration of drugs 1 – 1 No treatment 3 – 3 Secondary post partum haemorrhage Blood transfusion 2 1 3 No treatment 2 – 2 70 Ante partum haemorrhage Blood transfusion 2 — 2 Dextrose transfusion 1 — 1 Administration of drugs 2 — 2 No treatment 5 — 5 Eclampsia Administration of drugs 1 — 1 Malpresentation Forceps delivery 1 — 1 No treatment 4 1 5 Failed forceps No treatment 1 — 1 Deep transverse arrest No treatment 1 — 1 Impacted shoulders Delivery under general anaesthetic — 1 1 Cervical and vaginal lacerations No treatment 2 — 2 Pulmonary embolus Administration of oxygen 1 — 1 Post partum anaemia with collapse No treatment 2 — 2 Foetal distress No treatment 1 — 1 Prematurity Administration of oxygen 1 — 1 Abortions Blood transfusion 2 — 2 Administration of drugs 1 — 1 No treatment 1 — 1 66 40 106 All 106 cases to which the service was called were true obstetric emergencies. There was only one maternal death and this followed a pulmonary embolus. There were three stillbirths ; one occurred at home and two occurred following admission to hospital. Notification of intention to practise Midwives Act, 1951 The Council, as local supervising authority, has the duty to inspect midwives and maternity nurses practising in its area. These inspections are carried out by four nonmedical supervisors, who maintain a 24-hour supervision of the Council's domiciliary midwifery service. They also 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 stillbirths occurring on district; 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 were received as follows : 1950 1951 1952 1953 As midwives 1,275 1,337 1,331 1,171 As maternity nurses 241 205 232 175 71 An analysis of the notifications for 1953 shows: Midwives Maternity nurses Practising in hospitals 923 — Practising in nursing homes 12 40 London County Council domiciliary 94 — District nursing associations 66 — Hospital districts 67 — Nursing co-operations — 123 Independent 9 12 1,171 175 Summoning of medical aid The number of medical aid notices issued by midwives during 1953 was : By domiciliary midwives 5,885 By midwives in institutions with less than 15 beds and/or no R.M.O. 26 5,911 Doctors' fees 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 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 for which attention is given under the Midwives Acts 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 who is neither the family doctor nor the booked doctor is called in by a 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 1948 1949 1950 1951 1952 1953 Number of claims received 6,354 5,368 4,216 3,932 3,135 3,044 Total payments £15,594 £15,829 £12,682 £12,042 £9,491 £8,662 72 Home visits HEALTH VISITING AND NURSING SERVICES An average of 369 health visitors were occupied during the year in connection with the various health services apart from the tuberculosis service and the school health service. During 1953, these health visitors made 832,504 visits, apart from clinic and other duties. The following table analyses the visits paid since the beginning of 1951 : 1951 1952 1953 Expectant mothers— First 25,439 25,226 24,608 Revisit 19,311 18,708 19,223 Per cent. of notified live and stillbirths 46 47 47 Premature babies— First 1,601 1,834 1,894 Revisit 4,552 5,509 4,476 Still-births— First 918 930 921 Revisit 390 349 335 Per cent. of still births 86 90 87 Children under 1— First 49,605 48,755 46,487 Revisit 180,901 183,816 168,833 Per cent. of live births 92 91 90 Children 1 to 5— First 5,188 4,572 7,485 Revisit 387,383 377,986 368,668 Infectious diseases 26,518 13,396 13,774 Miscellaneous 48,334 51,278 51,676 Unsuccessful 137,108 131,748 124,124 TOTAL 887,247 864,107 832,504 Progress continues to be made in integrating the work of health visiting and school nursing, and in extending the function of the health visitor to cover the care and welfare of the family as a whole. To this end of caring for the family there has been gradually increasing co-operation and consultation between health visitor, general practitioner and voluntary and statutory organisations which serve the family. Experiments are being carried out towards integrating the preventive and curative services where health visitors have been allocated to work with the doctors in two group practices and with specialists at paediatric hospital clinics. Child life protection By arrangement with the Children's Officer, responsibility has been continued for duties under Part XIII of the Public Health (London) Act, 1936, as amended by Part V of the Children Act, 1948. The visiting of foster-children and the inspection of the premises in which the children are living have continued to be undertaken by health visitors designated as child protection officers Towards the end of the year, 690 children were being supervised under these arrangements. Tuberculosis visitors One of the most important functions of the tuberculosis visitor is the visiting carried out in the home. It is now the practice for long-term chemotherapy to be given which involves more frequent visiting, not only to the patient, but also to encourage the regular attendance of contacts at chest clinics. Where conditions are suitable, parents of child contacts are encouraged to take their children to the chest clinics for B.C.G. vaccination. Health education Health visitors have continued to assist in Polytechnics and Institutes in training courses and refresher courses for nursery matrons, nursery nurses, wardens and housemothers and in pre-nursing courses held in schools. There has been an increase in the amount of mothercraft teaching undertaken in schools. 73 The department has continued to co-operate with the nurse training schools in Nurse providing student nurses with theoretical and practical instruction in personal and training communal health and the social aspects of disease. Day nurseries Nurseries The number of nursing and ancillary child care staff employed in day nurseries at the end of the year was 1217. Of these, 276 were students training for the examination of the National Nursery Examination Board. Arrangements continued whereby student nursery nurses from nursery schools exchanged with day nursery nurses to enable them to gain experience with children 0-5 years of age and to give the day nursery students a wider experience of children between 2 and 5 years of age. Facilities were provided for nursery assistants and nursery nurses to attend at senior and supplementary child care reserve courses arranged by the Education Department. A number of nursery matrons attended the short refresher course arranged by the Royal College of Nursing and a number of deputy matrons attended a specially arranged course. During the year there was a slight increase in the number of girls who, on completion of their day nursery training, applied for transfer to residential nursery posts. Residential nurseries The recruitment and selection of all nursery students for residential nurseries continued to be undertaken in the department. Although it was still difficult to recruit the more mature type of nursing staff, the position in regard to existing staff became more stabilised, and it was possible to reduce the number of nurses engaged from nursing agencies during the year. Special boarding-schools and children's homes Recruitment to the nursing service in boarding schools and children's homes improved slightly during the year. The use of non-resident part-time nursing staff was extended and enabled the Council to have the services of experienced nurses who might otherwise have been lost to the profession. By the careful placing and use of trained staff it was possible to reduce the calls made upon the divisional nursing staff for ' Out County relief work'. School camps Three national holiday camps were open from March to the end of October. Six school nursing sisters were seconded for duty with the parties of London schoolchildren sent every fortnight during this period. Large welfare homes It has now been possible to appoint permanent members of the staff to fill 43 places on the approved establishment of these homes. Early in the year following the dense fog there was an increased amount of illness occurring among the old people. As difficulty was still experienced in obtaining admission to hospital, this placed a great strain on the nursing staff who responded splendidly to the additional work involved. The good liaison with the officers of the welfare department has been maintained. 74 HOME NURSING the home nursing service was provided by 27 voluntary district nursing organisations, acting as agents for the Council, for which services they have received (with one exception) grants to the extent of 90 per cent. of approved expenditure. In view of the continued increase of work and rising costs, the associations have found it more difficult year by year to raise the remaining 10 per cent. by voluntary efforts and the Council agreed to the grant being raised to 92 per cent. for the financial year 1953/54. The number of whole-time and part-time nurses employed at the end of 1953 was 490 (whole-time equivalent 444 nurses). This compares with 455 whole-time and part-time nurses (405 whole-time equivalent) employed at the end of 1952. The total number of visits paid was 1,724,302 compared with 1,610,428 in 1952, giving an average of 14 visits daily for each nurse ; the same as for 1952. The average case load of a nurse at any one time was 22.5 (22 in 1952). Treatments completed totalled 63,635 and there were 10,562 patients still in nursing care at the end of the year. The completed treatments related to the following conditions : Percentage Number of total Infectious and parasitic diseases 1,347 2.1 Tuberculosis 2,276 3.6 Cancer and other neoplasms 2,331 3.7 Diabetes 1,455 2.3 Mental and other nervous diseases 708 1.1 Ear, eye and other sense organs 4,348 6.8 Cerebral lesions of vascular origin 1,787 2.8 Heart and arteries 6,451 10.1 Veins and other circulatory diseases 880 1.4 Respiratory diseases 18,189 28.6 Digestive diseases 4,595 7.2 Genito-urinary 3,486 5.5 Pregnancy 635 1.0 Skin 6,632 10.4 Bones and organs of movement 1,320 2.1 Injuries Other diseases or ill defined 1,302 5, 803 2.0 0.3 These patients were referred to the nursing organisations by : Percentages Number of total General practitioners 51,237 80.5 Hospitals 9,823 15.5 Public health authorities 557 0.9 Direct application 1,040 1.6 Chest clinics 978 1.5 Much of the demand for the services of district nurses came from old people ; 44 per cent. of all those whose treatments were completed were over 60 years of age. The expending tendency of the service is shown in the graph on page 75. 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. There was an exceptionally heavy demand for home nursing during the first quarter of the year which was effectively met by the associations ; this was due largely to a sharp rise in the number of respiratory diseases as a result of the severe fogs at the end of 1952 and early in 1953, and to an outbreak of influenza in February. Completed treatments during the quarter numbered 21,570 compared with 15,524 during the first quarter of 1952. 75 76 The supply of equipment on loan to patients being nursed at home was 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 was 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 in purchasing and storing large and expensive items of equipment and in replenishing stocks when articles are on loan for long periods, the Council arranged to supply all loan equipment for tuberculous patients and large articles to all patients. A deposit and a small charge, varying from 3d. to 1s. a week were required from those who could afford to pay. The Council provided cars on loan to those organisations who required them but who were unable to purchase them from their own resources. The Council licensed, insured and periodically overhauled the vehicles, but running costs were borne by the organisations and ranked for grant from the Council. At the end of the year 15 cars were being operated under this arrangement. Every district nursing home was visited during the year by one of the Council's principal medical officers and the Chief Nursing Officer to ascertain the extent of need for improvements in (i) the nurses' homes, (ii) the service and (iii) administration. A number of recommendations for the improved use of accommodation were adopted, involving the installation of additional washbasins, cupboards, airing racks and improved hot water supplies. Suggestions were also made for improving methods of record keeping and for the simplification and reduction of clerical work. Consideration is being given to the question of' staffing standards' for the home nursing service. DOMESTIC HELP SERVICE the domestic help service (provided under Section 29 of the National Health Service Act, 1946, to those requiring it because of the presence of any person who is ill, lying-in, an expectant mother, mentally defective, aged or a child not over school age), has continued to expand over the last three years : age), has continued to expand. The following figures illustrate the extent of the increase over the last three years : 1951 1952 1953 Cases assisted 26,542 27,896 30,335 Hours worked 3,441,152 3,834,688 4,269,408 Home helps employed at end of year 2,663 2,921 2,996 Equivalent of whole-time staff 1,562 1,692 1,866 Of all the cases assisted during the year, 75 per cent. were aged and chronic sick, 6 per cent. were maternity, 4 per cent. tuberculous; 15 per cent. were assisted for other reasons. The very high proportion of aged and chronic sick assisted, to whom service has often to be supplied for several years, accounts for the substantial ' hard core ' of cases remaining on the books at the end of each quarter. This' hard core ' is steadily increasing as the following figures show : On the books at the end of 1949 .. 7,833 1950 10,282 1951 12,177 1952 15,015 1953 17,166 This increase is the combined effect of many factors, including the growing proportion of aged persons in the population, the unwillingness of some relatives to assist if official help is available, the housing position which makes it difficult for aged parents to be 77 accommodated in their children's homes, and a recognition of the fact that it is in many cases in the old people's own interests to be enabled to remain in their own homes. Although the total number of applications for help in 1953 was greater than in 1952, the applications in confinement cases fell. This fall has persisted for several years, and is associated with the falling birth rate and the decline in the proportion of confinements which take place at home. The increase in other applications was probably largely due to heavy demands on the service during the early part of the year as a result of the severe fogs. Number of applications Year Maternity Tuberculosis > Other J Total 1950 3,960 16,763 20,723 1951 2,992 861 14,976 18,829 1952 2,673 804 15,063 18,540 1953 2,454 786 15,540 18,780 In times of heavy pressure it has not always been possible to supply as much service as considered desirable ; as in the past, the policy has been to supply some service to all in need, and this year only 53 applications had to be deferred or refused owing to inability to supply, compared with 215 in the previous year. Might helps Two new extensions of the domestic help service, were introduced during the year The first, which was mentioned in the 1952 Annual Report, was a service of night help to attend chronic sick patients in their own homes to enable the relatives caring for thi patients to get one or two nights' sleep a week. The night helps attend from 11 p.m. t< 7 a.m. and perform those duties, other than nursing, which normally fall to a relative The demand on the service since its inception on 1st January, 1953, was small, but it i possible that the demand will grow as the service becomes more widely known. Child helps The second service, the need for which was touched upon in the 1952 annual report, was the provision of child helps to care for two or more children, in their own homes, who are temporarily deprived of the care of both parents and have no other adult ir the home at night. The object of the service is to obviate the necessity of children ir such circumstances being taken into care, often with consequent emotional disturbances The child help, who must be selected with great care, performs the usual householc tasks normally undertaken by the mother and sleeps in the home. The first year of th< service is on an experimental basis and since its inception on 1st December, 1953, twc cases were assisted. If the father or another adult can take care of the children at night the family is provided with a daytime home help, who if necessary can take over from the father early in the morning and can remain on duty during the evening until he returns from work. IMMUNISATION AND VACCINATION Diphtheria immunisation facilities for the immunisation of children against diphtheria are provided at the Council's child welfare centres, special immunisation clinics, day nurseries, schools and residential establishments in London. Parents may, if they prefer, have their children immunised by the family doctor, who receives a fee of 5s. for each completed record of immunisation sent to the Council. Prophylactic material approved for national free issue is provided by the Council to general medical practitioners on request. The total number of children immunised against diphtheria for the first time in 1953 was 36,004 and in addition 33,172 ' boosting ' doses were given. 78 Reference was made in the report for 1952, to the success of the publicity campaign in checking the fall, experienced during previous years, in the number of children immunised. Notwithstanding continued publicity and personal efforts by clinic doctors and health visitors, the number of primary immunisations during 1953 again fell, and the annual total was less than two-thirds of what it was in 1949. It is estimated that at the end of 1953, the proportion of immunised children under 5 years of age had fallen to its lowest level since the scheme came into full operation, namely 51.5 per cent. For this situation the apathy of parents is largely to blame. The rarity of diphtheria makes it difficult for parents to appreciate the potential danger of the disease, and to this factor must be added fear of possible association with paralysis in poliomyelitis. If the continuation of the present freedom from diphtheria is to be ensured, the number of immunised children under five, and particularly under one, must be substantially increased without delay, and no effort will be spared to achieve this object. Success must however depend ultimately on the parents. In September, 1953, the first batch of children to be fully documented under the National Health Service Act, 1946, entered school. For this and subsequent groups it is hoped to develop a close link between the routine school medical inspections, and the checking of the children's immunisation state. ' Booster ' doses and if necessary, primary immunisations will, subject to parential consent, be arranged. In this way a considerable increase in the proportion of the school population immunised against diphtheria may be achieved. To facilitate the transfer of details of the immunisation history of each child, a combined infectious disease-immunisation record card will be brought into use in child welfare centres, for transfer to school when the child reaches the age of five. 47.7 per cent. of the children in the Council's residential establishments for children in London were fully immunised at the end of 1953. Except for 2.2 per cent. in which parental consent was refused, the remainder were awaiting either parental consent or immunisation, or were unsuitable for immunisation. In out-country establishments, 77 per cent. of children had been immunised, and parental conscnt had been refused for 2 per cent. The following table indicates the number of children immunised against diphtheria during the last five years : 1949 1950 1951 1952 1953 Total No. of Diphtheria Immunisations 57,929 47,605 40,339 42,958 36,004 Estimated percentage at end of year of population 0-4 years who had at any time been immunised against diphtheria 54.7 554 53.7* 53.7* 51.5 *Corrected figure Whooping cough immunisation There is no scheme in London for immunisation against whooping cough corresponding to that for diphtheria. Children may be immunised at the request of their parents by arrangement at the Council's child welfare centres, and the Council pays the standard fee of 5s. for records of such immunisation received from general medical practitioners. Children may, if parents desire it, be immunised against both diphtheria and whooping cough at the same time, by the use of a combined prophylactic. It is however, desirable that a child should be protected against whooping cough before he reaches the age at which the disease is most likely to be dangerous. This results in such children becoming immunised against diphtheria at an earlier age than was formerly the case when immunisation against the two diseases was performed separately. Combined immunisation beginning at the age of about 4 months conforms to modern ideas on the subject. As parental demand for whooping cough immunisation is greater than that for diphtheria 719 immunisation the combined procedure has the effect of increasing the numbers immunised against diphtheria, and is, therefore, to be encouraged. The number of children protected against whooping cough, which had doubled in 1952 compared with 1951, showed a further slight increase. 19,322 children were immunised in the Council's centres and day nurseries, and 3,397 by general practitioners during 1953, compared with 19,447 and 2,786 respectively in the previous year. In 1953, 10,458 children (included above) received combined antigen which protected them against both diphtheria and whooping cough. Vaccination Facilities provided for the vaccination of infants against smallpox are similar to those for diphtheria immunisation. The number of vaccinations of children under 1 year of age has increased steadily over the past five years; the number in 1953 was 76 per cen. above that in 1949. Vaccination of children under 1 1949 13,896 1950 16,836 1951 19,700 1952 23,106 1953 24.434 There was no case of generalised vaccinia or of post-vaccinal encephalomyelitis during the year. Revaccination of older children is undertaken under the Council's scheme. 1,501 schoolchildren were re-vaccinated during 1953, compared with 804 during 1952. 12,284 vaccinations and re-vaccinations were carried out by general practitioners during the year as compared with 14,543 in the previous year. Of children at the Council's residential establishments in London at the end of the year, 51 per cent. had been vaccinated. Parental consent to vaccination was refused for 7 per cent. of children. 59 per cent. of children in out-county establishments had been vaccinated, and parental consent was refused for 2.5 per cent. LONDON AMBULANCE SERVICE the use of ambulance transport in the County of London has increased year by year since the inauguration of the National Health Service and the total of 721,334 patients moved by the general section of the service in 1953 was yet another record, being 9 per cent more than the figure for the previous year. The mileage run and the number of journeys carried out, however, each showed an increase of only 4 per cent., a proof of the success of efforts directed towards reducing the mileage per patient and the number of journeys by co-ordinating the work and by the increasing use of rail transport. This co-ordination was greatly facilitated by development of the policy of decentralisation, under which closer and more direct contact was fostered between certain hospitals and the appropriate ambulance stations. In the case of long out-county removals, hospitals were encouraged to agree to ambulance-train-ambulance arrangements and these not only ensured quicker journeys for the patients but also released ambulances more quickly for other removals. During 1953 5,741 patients were conveyed by this means and the mileage covered by rail was 425,614. 80 The accident section of the service dealt with 81,800 patients in 1953 as compared with 78,692 in 1952, an increase of 3 per cent. Statistics giving details of this total are to be found on pages 84 and 85. Frequent calls are made to the headquarters control room describing emergencies in which it is clear that medical assistance, not an ambulance, is needed and in such a case the caller is either recommended to summon the patient's own general practitioner or is given particulars of other local medical practitioners who may be called upon. 1,167 such calls were dealt with in 1953. Decentralisation Reference was made in the 1952 report to the review of the various clerical and operational procedures employed in the service. Further changes in procedure were adopted during 1953 with the three-fold aim of reducing the pressure upon the central control room, simplifying the control work at the general ambulance stations and promoting still closer association between the hospitals and their local ambulance stations. In furtherance of the last-mentioned aim, more hospitals were brought into the scheme of decentralisation and each general station was provided with an additional exchange telephone line for the use of hospitals in giving orders directly to the appropriate stations for in-county removals, other than those of infectious or mentally-ill patients which continued to be dealt with through the central control room. More hospitals, also, were brought into the arrangement under which ambulance vehicles are stationed at the hospitals for varying periods on weekdays to convey patients to and from those hospitals on the instructions of the hospital transport officers. These developments were of value in reducing delays and have commended themselves to the hospitals they are designed to serve. Coronation of Her Majesty Queen Elizabeth II The Coronation of Her Majesty Queen Elizabeth II on 2ndjune, 1953, brought immense crowds to London for the ceremony and for the attendant celebrations and the arrangements for ensuring the speedy removal of casualties from amongst all these people necessitated careful planning. For Coronation Day itself, special arrangements were made in collaboration with the Metropolitan Police and other authorities and these worked very smoothly. The ordinary work of the general section was greatly reduced on Coronation Day because of the virtual suspension of out-patient treatment work on that day and this enabled a large number of ambulances to be released for special duties : 39 were concentrated at 22 of the dressing stations established by the St. John Ambulance Brigade and the British Red Cross Society at points near the Royal Route and, together with six ambulances provided by the Home Service Ambulance Department, they removed a total of 173 casualties in response to 157 calls. During the Coronation period the number of accident section ambulances on duty throughout the County was increased and their hours of duty were extended. These precautions proved to be well justified for, between midnight on 1st June and midnight on 2nd June, these ambulances dealt with the record number of 440 calls. A special task of the Council on Coronation Day was the assembly of over 30,000 schoolchildren from London and the Home Counties on the Victoria Embankment to see the Royal procession and special arrangements were made for dealing with casualties among them. Happily, casualties were very few and, in fact, only one child had to be removed by ambulance. In recognition of the work of the London Ambulance Service during the Coronation period, Her Majesty the Queen was graciously pleased to bestow the Coronation Medal upon Mr. W. P. Hummerstone, the Assistant Officer-in-Charge, and upon Mr. W. H. Taylor, the Chief Superintendent. 81 Continental tour In response to an invitation from the Director General of Italian Fire Services, and with the valued co-operation and financial help of the British Travel and Holidays Association, the Fire Services Research and Training Trust and certain manufacturers of fire appliances, a contingent representing the London Fire Brigade and the London Ambulance Service carried out a three-weeks' goodwill mission to France and Italy in June, 1953. Eighteen principal cities and towns were visited, including Paris and Rome, and operational demonstrations were given before responsive gatherings of personnel of corresponding services and of the general public. The members of the contingent were received with great enthusiasm and much kindness. Major accidents The number of major accidents occurring in 1953 was much smaller than in the preceding year. The most serious emergency call was a request from the neighbouring West Ham Ambulance Service for assistance at the scene of the underground railway collision at Stratford on 8th April. Four ambulances were despatched and an additional one was sent later to take extra supplies of morphia, together with medical and nursing staff. The Council's ambulances remained at the scene for about 4£ hours during which time they removed a total of 17 casualties to hospital. On the following day an offer of further assistance was made to the West Ham Ambulance Service but no more help was required. Letters of thanks for the assistance given were received from the Chairman of the London Transport Executive and from the Chairman of the North East Metropolitan Regional Hospital Board. Among other major accidents were : 1st May A bus skidded, mounted the pavement and crashed into the fronts of several shops in the Edgware Road ; 12 casualties taken to hospital. 15th June Collision between two coaches at Great Peter Street, junction of Millbank ; 11 casualties taken to hospital. 26th August A private car mounted the pavement in Oxford Street, knocked a pedestrian through the window of a store and continued some way along the street ; 8 casualties taken to hospital. 4th September Train crash at Bethnal Green Junction ; 4 casualties taken to hospital. Flood disaster, 31s< January—lit February, 1953 The first warning of possible flooding was received on 31st January and was followed that night and the next day by a series of messages announcing the closure of certain roads and bridges and summoning ambulances to convey people trapped by the floods near Abbey Wood to hospital. In accordance with pre-arranged plans for meeting such emergencies, additional ambulances and crews were detailed for duty during the peak tide periods and on the request of the Ministry of Health one of the London Ambulance Service tenders was sent to take clothing on behalf of the W.V.S., to Canning Town for flood victims. Home service Ambulance Department Agency arrangements The number of patients conveyed and the mileage run by vehicles of the Home Service Ambulance Department of the Joint Committee of the Order of St. John of Jerusalem and the British Red Cross Society during 1953, in accordance with the agreement between that body and the Council, were respectively 15,272 and 319,869, representing an increase of 11 per cent. over the figures for the previous year. From this it will be 82 seen that the Department has continued to form a valued adjunct to the London Ambulance Service and I am indebted to the officers of the Department for their co-operation and help, particularly with long distance removals which are unsuitable for ambulance-train-ambulance arrangements and with the conveyance of patients to and from the limb-fitting centre of the Ministry of Pensions at Roehampton. Hospital car service The work carried out by the hospital car service decreased again during 1953 when 131,763 patients were carried and 1,424,788 miles were run as compared with 135,523 patients and 1,504,138 miles in 1952. The decline in mileage per patient was due partly to the growing number of ambulance-train-ambulance journeys and the corresponding decrease in long distance car journeys and partly to the co-operation of hospitals in allowing more journeys to be combined. Arrangements in North Woolwich The arrangement under which the West Ham County Borough council undertakes, on behalf of the Council, the provision of ambulance services in the two parts of the Metropolitan Borough of Woolwich which he north of the River Thames continued throughout the year. The co-operation which exists between the London and West Ham Ambulance Service was well illustrated at the Stratford Underground Railway collision already referred to. Premises The year 1953 was marked by considerable progress in the improvement of existing buildings and the construction of new ones. City Accident Ambulance Station was completed in August and the ambulance and crew moved into the new building after having been accommodated for nearly a year within the precincts of the Royal Hospital of St. Bartholomew by the courtesy of the Board of Governors to whom I am most grateful for the facilities they so kindly provided. South-Western General Ambulance Station—Adaptations to increase the vehicle accommodation, to provide a new administrative block and to improve the entrance to the station were commenced in September, 1952, and completed a year later. Eastern General Ambulance Station—Work on Block B in the scheme of adaptation to provide increased vehicle accommodation was finally completed in July, 1953, after modification of the plans, substituting pre-stressed concrete beams for the rolled steel beams originally proposed. Hampstead Accident Ambulance Station—The erection of a new building was commenced in October, 1953. Headquarters Ambulance Station—Adaptation of the Headquarters Ambulance Station in Waterloo Road to serve as the administrative and operational Headquarters of the Service commenced in October, 1953, and the ambulances and crews stationed there were temporarily transferred to premises in Southwark. Vehicles In December, 1952, the Council authorised the purchase of 15 taxi-cab-type vehicles and, during 1953, these were gradually brought into operation for dealing with the growing number of sitting-cases. The revised 1952-53 vehicle replacement programme was completed, 10 single-stretcher ambulances being added to the fleet and 21 large ambulances modified to take either sitting or recumbent patients. Award of resuscitation certificates STAFF It is gratifying to record the award of the Royal Humane Society's Resuscitation Certificate to two drivers in the London Ambulance Service. A boy, 8 years of age, was pulled from the River Thames in an apparently lifeless condition. The ambulance crew performed artificial respiration, using the oxygen apparatus carried in the vehicle. 83 Within a few minutes shallow breathing and ocular reaction were noticed. The boy subsequently recovered and undoubtedly owed his life to the prompt action of the two drivers. Sun-glasses To counteract the reflection of light from the bonnets of ambulances during sunny weather, the issue of one pair of sun-glasses to each member of the operative staff was authorised. Subsequent replacement is to be made, when necessary, on condemnation after not less than 2 years' wear. Supply of victuals Experience during the fog in December, 1952 had shewn that drivers who were on duty for prolonged periods, were unable to secure adequate refreshment at a time when it was most needed. Accordingly, small stocks of coffee or coffee extract, sweetened condensed milk, butter, cream cracker biscuits, cubes of extract of beef and packets of sugar are now held at each of the ambulance stations for consumption in emergency. Attendance at RoSPA House Staff numbers By the end or 1953, two-thirds or the operative stair or the London Ambulance Service had attended a half-day course in advanced safety driving held at the Training Centre of the Royal Society for the Prevention of Accidents. At the end of the year, the numbers of uniformed supervisory staff and station officers remained unchanged at 37 but there was an increase in the operative staff employed from 692 at 1st January to 703 at 31st December. Civil defence It is pleasing to record that two of the first volunteers in the Ambulance Section of the Council's Division of the Civil Defence Corps, both of whom had served in the London Auxiliary Ambulance Service during the war of 1939-45, were awarded the Coronation Medal. They are Miss S.J. Horner and Mr. L. S. S. Humphries. Civil defence training classes and exercises were held under the direction of a Superintendent and two Station Officers, seconded in 1951 for this duty. The training of the operative staff of the London Ambulance Service in basic general civil defence duties was completed during the year. New staff receive this instruction shortly after entry to the service. The instruction of all members of the operative staff in more advanced civil defence ambulance section training was begun. Since 1951, 330 civil defence volunteers have completed the first-aid course. A number proceeded to further ambulance section training, nine courses in which were held during the year. Of these courses, seven were conducted, in the main, by civil defence volunteers who had qualified as civil defence ambulance section instructors at a special course organised by the Council. A new type of course for ambulance section volunteers was introduced during the year. This is a revision course consisting of eight sessions each of two hours, comprising mainly practical work and leading up to two full scale combined exercises held at the Council's Rescue Training Ground. Throughout the year basic general training of volunteers in the Ambulance Section was given, as in the past, by the Metropolitan Borough Councils, with whose officers the closest co-operation continued. Vehicles The establishment of vehicles at the end of the year was : Ambulances 230 Single stretcher ambulances 42 Ambulance buses 10 Sitting-case cars 36 Tenders 2 320 g* 84 Work performed by the directly provided service Accident Section General Section Total Tear 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 1953 81,800 11,387 90,896 458,602 721,334 428,755 3,625,430 803,134 519,651 4,084,032 Work performed by the agency and supplementary services City of London Police Home Ambulance Service Hospital Car Service West Ham C.B.C. Total Tear 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 1953 — — 15,272 319,869 131,763 1,424,788 457 5,358 147,492 1,750,015 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 1953 81,800 458,602 868,826 5,375,445 950,626 5,834,047 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 4 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 supplimentary 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* 85 Statistics Statistics of the work performed by the directly provided service are divided into the Accident and General Sections and are shown in the table (page 84) 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. The Accident Section statistics for 1952 and 1953 are analysed in detail below to show the type of calls received. These include not only street accidents and other emergencies but also the majority of maternity removals and the conveyance of analgesia apparatus to women confined at home. The tables also include statistics of the work performed by the agency and supplementary services on behalf of the London Ambulance Service in 1948 and subsequent years. Analysis of Accident section work [a) Number of patients of various types: 1952 1953 Street accidents 13,655 14,376 Other accidents 18,080 18,887 Assault cases 1,612 1,734 Attempted suicide 591 1,087 Mental 611 521 Epilepsy 1,226 1,322 Other sudden illness 17,625 17,767 Maternity 25,169 25,885 Special journeys with patients 123 221 78,692 81,800 (b) Non-patient carrying journeys: Delivery of analgesia apparatus 5,069 5,013 Special journeys without patients 276 477 Ambulance not required 5,506 5,897 10,851 11,387 The average time taken to reach street accidents in 1953 was 7.0 minutes. PREVENTION OF ILLNESS: CARE AND AFTER-CARE Tuberculosis The services provided by the Council for the care and after-care of tuberculous patients, and for the prevention of tuberculosis, continued on the lines indicated in previous annual reports. During 1953, there were no significant changes which call for special comment. In this report the work of these services is summarised in tabular form, together with corresponding data in respect of the work in 1952. This form of presentation will be continued in future reports as it has the advantage of showing readily any changes which take place over a number of years. Hostels for homeless infective ambulant tuberculous men At the beginning ot 1953, 32 men were in residence at the Council s hostel at Highbury Quadrant, Islington, N.5, and 12 ex-service men were in accommodation made available temporarily at the British Legion Village, Preston Hall, near Maidstone, Kent. On 20th July, 1953, the Council opened part of Hurlingham Lodge, Fulham, S.W.6, as a hostel for 12 men. When adaptations are completed in 1954, the hostel will accommodate up to 27 men. 86 Summary of Statistics, 1952 and 1953 1952 1953 Primary Notifications* Pulmonary 4,713 4,668 Rate per 1,000 living 1.40 1.40 Non-pulmonary 518 410 Rate per 1,000 living 0.15 0.12 Deaths* Pulmonary 933 690 Rate per 1,000 living 0.28 0.21 Non-pulmonary 86 73 Rate per 1,000 living 0.03 0.02 Chest clinics Clinics in London 31 31 Clinic Registers* Total on registers at the end of the year 35,388 36,733 Work of Local Tuberculosis Care Organisers Cases investigated for the first time 5,951 6,091 Patients assisted for the first time with : Extra nourishment 2,559 2,396 Beds and bedding 541 431 Nursing requisites 496 376 Clothing 961 1,089 Other commodities 606 683 Patients at the end of the year receiving : Extra nourishment 2,234 2,451 Home help service 673 618 Home Care and Treatment At the end of the year, patients : Awaiting admission to hospital 738 494 Under treatment in their own homes 808 804 Receiving attention by home nurses 367 466 Rehabilitation At the end of the year the Council was financially responsible for rehabilitants at : British Legion Village, Maidstone 25 25 Papworth Village Settlement, Cambridge 17 17 Enham-Alamein Village Centre, Andover 18 21 Barrowmore Hall, Chester 2 2 Correspondence courses arranged during the year through the British Council for habilitation for patients undergoing prolonged treatment at home 65 113 Boarding Open-Air Schools Children with a history of tuberculosis in these schools at the beginning of the year 33 29 Admitted during the year 47 27 Away at the end of the year 29 34 Awaiting admission at the end of the year 11 7 Boarding-out of Child Contacts Children boarded-out at the beginning of the year 419 440 Placed during the year 490 562 Boarded-out at the end of the year 440 450 Average number boarded-out at any one time 442 486 * Details are given in the comments on page 21 and in tables 9-12, in Appendix. 87 Summary of Statistics, 1952 and 1953—continued 1952 1953 Boarding-out of Child Contacts for Segregation during B.C.C. Vaccination Children boarded-out at the beginning of the year 15 24 Placed during the year 67 38 Boarded-out at the end of the year 24 6 Average number boarded-out at any one time 18 14 B.C.C. Vaccinations Child contacts vaccinated by chest physicians in London 3,034 3,141 Boarded-out child contacts vaccinated by out- county chest physicians during the year 139 161 Child contacts (mainly new-born babies) vaccinated in London hospitals prior to boarding-out 73 77 During the year, 84 recommendations for admission to hostels for tuberculous men were approved and at the end of the year 37 men were in residence at the Islington hostel, 11 men at Hurlingham Lodge, and 11 at the British Legion Village. Domiciliary diversional therapy An experimental diversional therapy scheme for home-bound tuberculous patients was begun in Health Division No. 2 in January, 1953. Part-time occupational therapists were engaged to cover the chest clinic areas in the division and the Council made grants for tools and materials to supplement those provided from the voluntary funds of the local Tuberculosis Care Committee. Patients and chest clinic staff have expressed their satisfaction with the results of the scheme so far. Protection of :hildren against tuberculosis The chest X-ray examinations, on appointment and annually, of certain staff whose employment brings them into close contact with children, was extended from April, 1953, to all teaching staff and also to non-teaching staff at residential educational establishments. During the year arrangements were also initiated for the annual chest X-ray examination of staff and senior pupils at the Council's occupation centres for mentally deficient persons. In the last half of the year 65 staff and 151 pupils were examined under these arrangements and, as a result, one child was admitted to hospital and two referred to chest clinics for observation. Arrangements were also made for the routine X-ray examination of new residents over 15 years of age entering the Council's homeless families' units. Epidemiological investigations were undertaken among the staff and children at Council establishments where cases of pulmonary tuberculosis were notified during the year. The summary (pages 88-9) gives the results of these investigations and demonstrates the great value of careful follow-up of notified cases and, therefore, of full and early notification. Mass miniature radiography I am indebted to the four Metropolitan Regional Hospital Boards and to the Ministry of Health for the figures (page 90) showing the number of persons examined during the year by the Board's mass X-ray units operating in London and among these the number of cases of tuberculosis whose diagnosis was established during 1953. It will be seen that some diagnoses completed during 1953 related to persons X-rayed in 1952. Likewise, some persons X-rayed during 1953 will remain under surveillance until a form diagnosis becomes established in 1954. Tuberculin surveys A scheme for the tuberculin testing and X-ray examination of 5,000 school childrern in Islington, begun in 1952, continued during the year. The survey, which was paralleled by a mass X-ray survey of adults in the borough, has not yet been completed The result will be include in a subsequent report. 88 In some health divisions skin testing of pre-school infants and toddlers at day nurseries and infant welfare establishments has been undertaken with a view to tracing cases of tuberculosis among adult contacts of positive reactors. Summary of investigations made into tuberculosis ' incidents ' at Council establishments in 1953 Establishment Notified case Children Adults Tuberculin tested Positive reactors Xrayed Abnormal Xrayed Abnormal Schools (22) Teacher — — 262 1 23 1 Teacher — — — — 10 — Teacher 390 101 101 1 24 — Teacher 219 — 301 — 30 — Teacher — — 218 — 26 — Teacher — — 638 — 10 — Teacher 87 — 12 — 20 — Teacher 26 — 6 1 40 — Teacher — — 492 2 34 — Teacher — — 177 — 17 — Teacher 101 40 39 — — — Teacher — — 117 1 7 — Teacher — — 251 2 36 — Teacher — — 114 — 1 — Teacher 401 — 401 — 30 1 Pupil 67 — 10 — 11 — Pupil — — 362 1 24 2 Pupil — — 304 2 18 — Pupil — — 261 1 3 — Pupil — — 239 — 15 1 Asst. school keeper 437 — 437 3 46 1 Kitchen helper — — — — 30 3 Polytechnic, training college and evening institute (3) Student — — — — 407 1 Student — — — — 211 2 Teacher — — — — 25 — M.D. Occupation Centre (1) Pupil — — 35 2 5 — 89 Summary of investigations made into tuberculosis ' incidents ' at Council establishments in 1953—continued Establishment Notified case Children Adults Tuberculin tested Positive reactors Xrayed Abnormal Xrayed Abnormal Children's homes (2) Housemother 35 28 28 1 4 — Pupil 35 17 17 2 6 — Residential nursery (1) Nursery Asst. 70 16 15 — 31 — Welfare establishments (homes, reception centres and a lodging house) (?) Resident Attendant — — — — 102 2 Porter — — — — 17 — Porter Receptionist — — — — 65 — Resident — — 6 — 10 — Resident — — — — 4 1 Resident — — — — 14 — Resident — — — — 19 — Totals (36) .. 1,868 202 4,843 20 1,375 15 Foot clinics The demand for chiropody continued to be unsatisfied. There is need, not only for a further expansion of the service at the Council's 27 existing foot clinics, but for the establishment of new clinics in areas which at present are inadequately served. 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 1953 11,464 11,374 180,588 43.5 * Some sessions are attended by more than one chiropodist. The majority of treatments provided at the clinics were for superficial excrescences (corns, callosities, etc.) and malformed nails. Advice was given on shoe fitting, foot hygiene and exercises. 90 Pulmonary tuberculosis mass X-ray units, 1953 Regional Hospital Board unit Total number X-rayed during year (a) Diagnostic classification Metropolitan boroughs visited during 1953 Active Inactive Males Females Total Males Females Total Rate per 1,000 Males Females Total N. W. 5 A Hammersmith, Kensington 44,574 33,293 77,867 79 59 138 1.77 195 102 297 5B Paddington, St. Pancras, Holborn, St. Marylebone 32,627 31,823 64,450 62 44 106 1.64 106 92 198 5D Static—Islington . 13,205 18,093 31,298 107 85 192 6.13 ★ ★ ★ N.E. 6B Stoke Newington, Poplar, Hackney, Bethnal Green 13,377 14,663 28,040 40 27 67 2.39 354 307 661 6D City, Finsbury 33,913 26,312 60,225 55 37 92 1.53 1,591 542 2,133 S.E. 7 A Woolwich, Camberwell, Bermondsey, Southwark 28,250 22,280 50,530 91 59 150 2.97 23 12 35 7D Camberwell, Lewisham, Woolwich, Deptford, Southwark 11,249 7,630 18,879 32 30 62 3.28 39 32 71 7E Co-operates with 7A and 7D in covering S.E. area—Commenced in July, 1953 6,442 8,817 15,259 23 20 43 2.82 5 3 8 S.W.8C Westminster, Battersea, Wandsworth, Fulham, Chelsea 22,332 20,604 42,936 57 35 92 2.14 993 649 1,642 8D Fulham, Westminster Static May-Dec., serving all S.W. London. 11,757 16,713 28,470 159 104 263 9.24 790 789 1,579 Total London Administrative County 217,726 200,228 417,954 705 500 1,205 2.88 * * * Tavistock Square Civil Service 11,605 8,799 20,404 61 40 101 4.95 221 101 323 (a) These are not all Londoners but persons attending units operating in County area. * Figures not available. 91 Venereal disease A summary of the work done in 1953 at the London V.D. out-patient clinics will be found in Table 17, page 159. 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, an increase in the number suffering from gonorrhoea. A large number of persons who were not suffering from venereal disease continued to attend the clinics. I here 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 1953 : Syphilis Gonorrhoea Male Female Male Female Number of patients discharged after completion of treatment and final test of cure 753 702 2,783 609 Number of patients who ceased to attend after completion of treatment but before final tests of cure 440 249 2,147 590 Number of patients who ceased to attend before completion of treatment 108 112 193 74 Number of patients who died from the disease while still undergoing treatment 8 4 — 1 The Council's male and female welfare officers continued to undertake the tracing of contacts of patients, details of whom had been provided by hospitals, by medical services of the British, Dominion and United States Armed Forces, and by local health authorities. The welfare officers were also available to assist clinics in case of difficulty in following up patients who defaulted. The arrangements whereby the services of a full-time welfare officer are made available for attendance at clinics at Holloway Prison and for following up contacts and prisoners on discharge, to which reference was made in my Report for 1952, were continued during the year. Ten notifications were received from the Service authorities' of demobilised men who were under treatment or surveillance for venereal disease and these men were interviewed with a view to persuading them to continue attendance at civilian clinics. Recuperative holidays The demand for recuperative holidays continued fairly steadily throughout the year except that the decrease first noted in 1951 in recommendations for holidays for unaccompanied children continued. The fall in recommendations for unaccompanied children under five years of age was particularly marked, the number sent for holidays in 1953 being less than half that in the peak year of 1950. Unaccompanied children Full use was made throughout the year of the accommodation provided for 36 children aged 3-8 years at the Council's recuperative holiday home at Littlehampton and parties of 30 school children between the ages of 7 and 15 continued to be sent for holidays at a seaside hotel under the Council's Private Hotel Scheme. The Council continued to use the Women's Voluntary Services' Home at Aldeburgh and contributed 90 per cent. of approved maintenance expenditure. On 1st July, 1953, the Council took over the placing of unaccompanied children in recuperative holiday homes from the Invalid Children's Aid Association, which, as the Council's agent, previously made the arrangements in the majority of cases. Since taking over the placings, the Council has received valuable help from the Women's Voluntary Services and from several of the holiday homes in the provision of escorts 92 for the children while travelling. The services of other voluntary organisations, including the Jewish Board of Guardians and the Wandsworth Peace Memorial, continued to be used for the placing of unaccompanied children. Additional facilities were secured during the year for physically handicapped children in need of recuperative holidays. Expectant and nursing mothers, other adults and accompanied children Expectant and nursing mothers, other adults and accompanied children were for the most part placed in recuperative holiday homes direct by the Council but the services of the St. Henry Convalescent Fund were used for recuperative holidays for a small number of adults and children resident in the City of Westminster. Continued assistance was received from the Family Welfare Association in a few particularly difficult cases and from the Spero Fund for the Welfare of Tuberculous Workers in the placing of tuberculous persons in recuperative holiday homes. Additional homes were approved for the placing of epileptic and other physically handicapped adults recommended for recuperative holidays. The scheme introduced last year of placing mothers with their babies, and sometimes a toddler as well, in small private houses proved to be satisfactory and additional homes of this kind were inspected during the year. Statistics A statement showing the number of admissions to recuperative holiday homes during 1953, as compared with 1952, is given below : Unaccompanied children Expectant and Nursing Mothers Accompanied Children Other Adults Total under 5 years School children 1952 686 3,507 190 352 3,308 8,043 1953 550 2,840 194 446 3,120 7,150 Health Education Following the review of activities, both generally and in maternity and child welfare centres carried out in 1952 (pages 99-104 of the report for that year), some expansion took place in organised health education ; details are included in the contributions of the divisional medical officers (pages 132 to 143). Dissemination of good health advice by medical and health visiting staffs in the course of their normal duties continued however, as in the past, to be the main form of health education. The beneficial result of such activity, though difficult to estimate, must be large. Diphtheria immunisation Experience has shown that the intensive campaigns to stimulate awareness of the need for diphtheria immunisation, which are held annually in conjunction with the national campaign organised by the Ministry of Health should, so far as London is concerned, be held well outside the summer months so as to avoid any possible connection between inoculation and paralysis which it has been alleged occurs during poliomyelitis epidemics. Campaigns were held in January (postponed from 1952) and in November. In future it is hoped to hold these campaigns annually in February. The campaigns were supported by illustrated advertisements in local newspapers, displays of posters and distribution of leaflets and bookmarks. The co-operation of the medical officers of health of the metropolitan boroughs in these campaigns was much appreciated. Exhibitions During the two weeks 11th—23rd May a comprehensive health exhibition was organised at the Woodberry Down Health Centre which was attended by several thousand people. Features included film shows, physical exercises displays by local school children and ' Any Questions' forums, the panels consisting of medical, dental and nursing experts. It is certain that the exhibition brought the centre and its normal activities to the attention of many who were in a position to benefit by them. 93 A smaller, but equally worthwhile effort, was the exhibition held at the Health Centre, Amersham Road, New Cross, on 15th and 16th May, and attended by more than 1,000 local residents. A wide range of preventive health services were illustrated by exhibits and by demonstrations (film strips, etc.). A pleasing feature in both of these exhibitions was the way in which the more normal material was supplemented by special exhibits prepared by members of the staff in their own time. Co-operation in an exhibition held by Stoke Newington Borough Council at its Town Hall was eiven bv the provision of a number of the Council's exhibits. Sex education Two courses of talks on sex were organised for youth clubs, the attendances at which totalled 210. In addition talks were given to two parent-teacher associations (attendance 155), and to two young wives' fellowships (attendance 95). Provision of care and treatment for the mentally ill MENTAL HEALTH SERVICES Lunacy and Mental Treatment Acts the work of placing persons suffering from mental illness under care and control continued to be operated centrally from the County Hall on a 24-hour day basis During 1953, 8,081 cases were referred to the mental welfare officers, compared with 7,863 in 1952. The following table shows how they were dealt with : 1953 1952 Male Female Total Admitted for observation to hospitals designated under section 20 of the Lunacy Act, 1890 2,116 2,630 4,746 4,934 Dealt with in their own homes, etc., under sections 14 and 16 of the Lunacy Act, 1890 469 947 1,416* 1,130 Admitted direct to mental hospitals under section 11 of the Lunacy Act, 1890 10 18 28 39 No action under the Lunacy Acts found necessary .. 777 1,114 1,891 1,760 Total 3,372 4,709 8,081 7,863 * Of these 308 male and 625female patients were certified and removed to mental hospitals. f Of these 263 male and 410 female patients were certified and removed to mental hospitals. The ultimate disposal of the patients admitted to observation wards (including 167 patients in wards on 1st January, 1953) is shown below : 1953 1952 Male Female Total Certified and sent to mental hospitals 671 985 1,656 1,806 Admitted as voluntary patients to mental hospitals 504 752 1,256 1,181 Admitted as temporary patients to mental hospitals 7 24 31 43 Discharged to care of relatives (Section 22) 13 13 26 38 No order made by Justice and patient discharged 27 9 36 47 Transferred to general wards 66 40 106 126 Transferred to Tooting Bee Hospital without certification 77 157 234 274 Transferred to Abbots Langley Hospital without certification 5 — 5 12 Transferred to Mental After-Care Association homes — 2 2 2 Died 64 48 112 149 Discharged by medical officer 674 600 1,274 1,233 Dealt with privately 7 7 14 12 Dealt with under Mental Deficiency Acts 4 1 5 11 In ward on 31.12.53 72 84 156 167 Total 2,191 2,722 4,913 5,101 The shortage of accommodation in observation wards has persisted and it has again been necessary to deal with a large number of patients (1,416 compared with 1,130 in 1952) in their own homes or elsewhere than in an observation ward under sections 14 and 16 of the Lunacy Act, 1890. It has been suggested to the Metropolitan Regional Hospital Boards that if additional methods were available to deal with senile patients not only would the problem of accommodation in observation wards be reduced, but the admission of many elderly patients to mental hospitals might be avoided. Unfortunately, although the Boards have plans for the future provision of psychiatric geriatric units, they are handicapped by the financial situation and there does not seem to be any hope of an early solution to this problem. Domiciliary after-care As foreshadowed in the Report for 1952, the work of providing domiciliary care and after-care for persons suffering from psychiatric disabilities, previously undertaken on the Council's behalf by the National Association for Mental Health and the Mental AfterCare Association, was taken over by the Council on 1st April, 1953, two psychiatric social workers being employed for the purpose. social workers being employed for the purpose. Both associations were very helpful in arranging the smooth transfer of 129 current cases. 244 new cases were referred for help during the remainder of the year from the following sources : General practitioners 29 National Assistance Board 18 Mental hospitals 29 Nat. Assoc. for Mental Health \8 Observation wards 6 Mental After-Care Association General hospitals 18 Health visitors, housing wel. offs. etc. 41 Psychiatric O.P. clinics 10 Mental deficiency institutions 2 Patients—Personal applications . . 12 Institute of Social Psychiatry 12 Relatives and friends 11 Other agencies 45 Ministry of Labour 3 Total 244 Employment finding Difficulty in obtaining employment was met in many of the cases referred and this problem was discussed with representatives of Chambers of Commerce in London and the London Association, Engineering and Allied Employers Federation at a meeting on 2nd December, 1953, when the representatives agreed to assist, through their organisations, in finding employment in selected cases referred to them by the Council's officers. Contact will, of course, continue to be maintained with the disablement resettlement officers of the Ministry of Labour. Social clubs and rehabilitation centre The Council continued to make to the Institute of Social Psychiatry a grant of 90 per cent. of the cost in respect of London patients attending the social clubs and rehabilitation centre run by the Institute. Long-term care The Council continued to pay for the maintenance on a long-term basis of a number of chronic and senile patients in homes sponsored by the Mental After-Care Association, the National Association for Mental Health and the Jewish Board of Guardians. At the end of the year, 84 patients were maintained in the Mental After-Care Association's homes, 2 at Moor Place, Windlesham, Surrey, a home administered by the National Association for Mental Health, and 4 in the Jewish Board of Guardians' home at 17 Maresfield Gardens, Hampstead, N.W.3.17 Maresheld Gardens, Hampstead, IN.W.J. The weekly charges tor maintenance were as follows : £ s. d. Homes owned and managed directly by the Mental After-Care Association 3 1 13 6 Homes sponsored (but not owned) by the Mental After-Care Association 3 3 0 Moor Place, Windlesham, Surrey 5 5 0 17 Maresfield Gardens, N.W.3 3 3 0 The patients were assessed according to their means and some contributed towards the cost of maintenance. Others had no means and received 6s. 6d. a week pocket money from the National Assistance Board. 94 95 Short-term care and recuperative holidays The number of recuperative holidays provided during the year again increased, 210 being provided compared with 158 in 1952 and 93 in 1951. 28 patients recuperating from comparatively severe psychiatric illnesses were admitted to Mental After-Care Association homes at Cheam, Surrey and Dartford, Kent, for periods of 3 to 12 weeks. These two homes are intended for patients considered to have good prospects of being able to resume employment, and during their stay they arc assisted in obtaining suitable work. The number of cases in this category has so far been surprisingly few in the London area; this applies particularly to male patients. A further 22 were maintained in homes sponsored by the Mental After-Care Association, usually for a period of 2 to 3 weeks. The remaining 160 were patients suffering from disabilities of a nervous, rather than a mental nature. Many of these had not required specialised treatment and others had been treated in out-patient clinics. This large group of patients was sent to recuperative holiday homes where they mixed with persons who had suffered from physical disability. The average length of stay decreased from 3 weeks in 1952 to a little over 2\ weeks in 1953. A letter was sent to each patient, about 8-12 weeks after returning home, enquiring whether the home chosen had been satisfactory and the holiday beneficial. The replies received have been of value in deciding the appropriate length of stay and the most suitable home in subsequent cases. Statistics Mental Deficiency Acts The following table shows the sources from which cases were brought to notice under the Mental Deficiency Acts and the action taken thereon: Sources of information 1950 1951 1952 1953 Totals from 1.4.14 to 31.12.53 Supervision section 12 8 14 9 1,584 Local education authority 439 453 570 533 16,086 Police authority (section 8) .. 39 31 32 24 1,997 Transfers from prison (section 9) 1 — — — 229 Transfers from approved school (section 9) 2 2 — 2 567 From hospitals and institutions 89 103 124 97 611 Miscellaneous 157 187 222 222 10,744 Total 739 784 962 887 31,818 The position at 31st December, 1953, with regard to the cases referred to in the last column of the preceding table is shown below, together with the position on the same date in the three preceding years: 1950 1951 1952 1953 Detained in institutions 7,767* 7,809* 7,862* 7,842* Discharged from institutional care 2,738 2,902 3,075 3,235 Removed to mental hospitals 522 543 555 572 Not subject for action 9,403 9,668 9,922 10,190 Died 4,380 4,523 4,678 4,853 Total removed from active list 24,810 25,445 26,092 26,692 * 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 : 1950, 366; 1951, 352; 1952, 259; 1953, 236. %  1950 1951 1952 1953 Under guardianship 229 221 222 223 In places of safety awaiting the presentation of a petition 5 8 11 11 Under supervision 4,092† 4,222† 4,556† 4,815† In hospitals, residential nurseries, etc., awaiting the presentation of a petition 45 52 41 59 Still under consideration 4 21 9 18 Total remaining on active list 4,375‡ 4,524‡ 4,839‡ 5,126‡ Grand Total 29,185 29,969 30,931 31,818 The following is a summary of the cases dealt with during 1953, with the comparable figures for the three preceding years: 1950 1951 1952 1953 Placed in institutions 330 303 369 306 Placed under guardianship 9 10 24 21 Placed in places of safety pending presentation of a petition 37 56 70 59 Placed under supervision 591 618 787 735 Discharged from institutional care or guardianship 192 182 203 193 Removed to mental hospital under the Lunacy Acts 19 27 21 26 Ascertained not subject for action 58 68 69 76 Withdrawn from supervision 258 217 201 221 Removed to other areas 44 49 65 60 Died 128 140 165 174 Total 1,666 1,670 1,974 1,871 Petitions The ascertainment of defectives and the oversight of defectives under guardianship has continued to be carried out by medical officers and social workers on the central staff and the supervision of defectives in their homes by social workers employed in four local offices. During the year 19,660 visits were paid to persons under supervision or on licence from hospitals and 804 to persons under voluntary supervision, while 2,128 enquiries were made to ascertain the home circumstances of patients in connection with the statutory review of orders and the consideration of applications for leave of absence or discharge. During the year, 163 petitions for orders for institutional care and 20 for guardianship were presented to a judicial authority under section 6 of the Mental Deficiency Act, 1913. One petition for an order for institutional care raised a point of some interest and importance. The parent of the mental defective concerned refused consent to the order and, after the order had been made, applied to the High Court for a writ of Habeas Corpus. The judicial authority in making the order held that consent had been unreasonably withheld but with an honest but mistaken intention of benefiting the defective. The application was heard by a Judge in Chambers and the learned Judge expressed the view that if the parental intention of benefiting the defective was honest it was held in good faith and that in this case there was no evidence to show that it was vitiated by ulterior motives. He accordingly held that the order under section 6 was bad and granted the apphcation. The implication of this decision is that however misguided or mistaken a parent or guardian may be in withholding consent to the making of an order, the Judicial Authority may not make the order unless satisfied that the parent or guardian is acting in bad faith. It would appear, therefore, to be the local health authority's responsibility in such cases to present in support of a petition such evidence as will show that the parent or guardian is not acting in good faith and is actuated by ulterior motives. † 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: 1950,968; 1951,1,020; 7952,1,040; 1953,1,055. ‡ Of these the following were awaiting institutional care: 1950, 139; 1951, 154; 1952. 169; 1953, 199. 97 As such evidence would not be easy to obtain, the Council decided to draw the attention of the Minister of Health to the difficulties which might arise from this decision and suggested that the point should be considered by the proposed Royal Commission on the law relating to mental illness and mental deficiency. Institutional vacancies The shortage of vacant beds in institutions for the mentally defective continued to cause concern. Although the number of patients requiring institutional care during the year was 33 fewer than in 1952, the number of admissions fell from 369 in 1952 to 306 in 1953, and the number on the waiting list rose to 199 on 31st December, 1953, compared with 169 on 31st December, 1952. In the past, the principal difficulty has been to find beds for children awaiting admission to the Fountain Hospital, but difficulty is now encountered in every type of case. The increased delay in securing admission has resulted in a considerable number of mentally deficient persons being retained in establishments provided under the National Assistance Act and the Children Act and in other accommodation to the detriment of the other persons accommodated. It has been impossible to secure the prompt removal of a number of children from accommodation in which their behaviour has constituted a danger to other infants and young children. No fewer than 22 patients died whilst awaiting vacancies in institutions, 19 while waiting for admission to the Fountain Hospital. Other patients had to remain at home in circumstances of great stress to their families. Placing by parent or guardian 63 children were placed in institutions by their parents under section 3 of the Mental Deficiency Act, 1913. One child for whom such care was requested was found on examination to be educable. Guardianship During 1953, 21 patients were placed under guardianship. Of these, 15 were school leavers whom it was considered would justify a trial in the community as they were likely, with supervision and guidance, to become self-supporting. They were put under the personal guardianship of the Council's inspectors who placed them in foster homes of approved standard and found suitable employment for them within the scope of their abilities. The number of cases being dealt with in this way is increasing and the Council's inspectors are finding it increasingly difficult to obtain suitable foster homes. In February, 1953, the Council approved a special arrangement for a boy under the guardianship of an inspector to be apprenticed to a firm of furniture manufacturers for a period of five years. Reports received during the year indicated that he was doing well. Farm training Two lads were placed during the year under the Y.M.C.A. s British Boys for British Farms Scheme. One proved to be unsuccessful and returned home but the other was placed after training on a farm in Somerset and is reported to be doing well. Another lad who was placed in 1952, is also progressing satisfactorily. At 31st December, 1953, there were 223 patients remaining under guardianship as follows : 47 under the personal guardianship of the Council's inspectors. 68 under the guardianship of nominees of The Guardianship Society, Brighton. 84 under the guardianship of relatives and friends. 16 under the guardianship of superintendents of voluntary homes. Of the remainder, 4 were temporarily in institutions awaiting decisions as to future care. 2 were receiving mental treatment in hospitals under the Lunacy and Mental Treatment Acts, and 2 had absconded from their guardians and were untraced. On 31st January, 1953, a patient and her mother (who was also the statutory guardian), whose home was at Jaywick (near Clacton) died in the flood disaster. Hostel for girls leaving E.S.N, schools Reference was made in the report for 1952 to the proposed provision of a hostel for girls placed under guardianship on leaving special schools for the educationally sub-normal. The Minister of Health sanctioned the Council's proposal to acquire, adapt and equip suitable premises in south-east London for this purpose. Short term care Temporary emergency care was provided by the Council in accordance with the arrangements authorized by Ministry of Health Circular 5/52, for 27 persons for an average period of five weeks and two days. Accommodation was found with nominees 98 of the Guardianship Society, Brighton; at 'Lynsted,' Walmer, and 'Orchard Dene,' Rainhill, Liverpool, homes run by the National Association for Mental Health, the latter on behalf of the National Association of Parents of Backward Children, and at a number of approved homes. The Council recovered contributions towards the cost of maintenance in each case according to the means of the patient's family. 65 London patients were admitted to hospitals under the provisions of the Circular for an average period of five weeks each, the great majority ot these being admissions of children to the Fountain Hospital. This relief has generally been provided for children already awaiting permanent admission to hospital, thus breaking the long waiting period before admission, besides covering the actual emergency. Welfare clinic A special welfare clinic for mentally backward children under five was established in East London during the year as an experiment. Sessions were held once a month, when a medical officer experienced in mental deficiency, as well as maternity and child welfare, attended. She was assisted by a social worker and a nurse. In view of the success of this service, the Council decided to provide similar clinics in other parts of London. Students During the year facilities were given tor a number ot 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 have practical experience in mental deficiency social work. Facilities were also given for some students to witness the presentation of petitions to Judicial Authorities for orders under the Mental Deficiency Acts. Accommodation Occupation Centres An additional occupation centre for elder girls was opened and two centres (one for elder boys and one for elder girls) were moved to better premises during the year. The centres, which were all renamed according to the locality in which they are situated, and particulars of the accommodation available at 31st December, 1953, are as follow : Centre Accommodation Centres Jor children Bcthnal Green 40 Clapton 60 Earlsfield 60 Finsbury 60 Greenwich 45 Hammersmith 40 Lewisham 30 North Kensington (also takes elder girls) 75 Peckham (juniors) 45 Centre Accommodation Centres Jor elder girls Fulham 35 Hackney 40 Islington 30 Peckham (elder girls) 45 Centres for elder boys Archway 35 Battersea 30 Dalston 45 Peckham (elder boys) 60 Total 805 With the growing number of cases to be dealt with it will be necessary for more places to be provided during the next few years. The completion of preliminary adaptations to enable partial use (for elder girls) of the prefabricated former restaurant building in Fulham High Street, is referred to on page 53. When all the work has been completed and full use can be made of the centre, which is expected to be early in 1954, the premises will be used exclusively for children, and the elder girls transferred to other premises. The opening of two replacement centres at Congregational Church Hall, Junction Road, Islington, and St. James' Church Hall, Islington, is also referred to on page 53. The house, No. 9 Spencer Park, Wandsworth Common, referred to in the Report for 1952, is also expected to be ready for occupation in the Spring of 1954. The Council will then have three occupation centres in its own premises. 99 Chest X-ray examinations Arrangements were made for the annual X-ray examination of the chests of all persons attending elder girls' and elder boys' centres. The only active case of tuberculosis discovered was admitted to the sanatorium of a mental deficiency institution. Open days and sales of work Special functions were held at most centres, to which parents and mends were invited, when the general activities were shown and articles made in the centres offered for sale. Sales realised £414s. 7d. at junior centres, £395 15s. 7d. (including £154 12s. 9d. for shoe repairs) at elder boys' centres and £61 15s. 10d. (including £7 16s. 4d. for cookery) at elder girls' centres. Some apparatus was made at elder boys' centres for use at other centres. Holidays and outings Another successful holiday of 2 weeks for 207 children and adults from the centres, in the charge of staff, was spent at a seaside holiday camp. The expenses of the staff were borne by the Council and those of 76 necessitous children and adults were also wholly or partly paid. Day outings were arranged for some centres and four needy children were assisted with the cost. Parties of children attended a free circus dress rehearsal, the cost of transport being paid from private funds. Children and adults from centres were also taken by Council coaches to local parks and open spaces for recreation during the summer months and arrangements were made for the elder boys to play cricket and football. Parties Parties were held at each centre to celebrate the Coronation and each child was presented with a souvenir beaker. In two instances the local Borough Councils included the occupation centre children in their presentations of Coronation souvenirs to school children. Christmas parties and entertainments were also held at all centres. Gifts Several centres received from local parents' groups donations which were expendec on extra treats for the children or on toys and apparatus not normally provided. Staff—Course of training Ten members ot the supervisory start commenced attendance at a two year part-time course of training organised by the National Association for Mental Health. Lectures took place during evenings and vacations. Periods of practical training in centres of other authorities will be undertaken during 1954 and students from other authorities will come to London centres. Some students from the equivalent full-time day course (from other areas) undertook periods of practical training in London centres during 1953. Visits to centres Centres were visited during the year by parties of students from various organised courses and by other interested persons. A routine inspection of each centre was made by Inspectors of the Board of Control and centres were also visited regularly by members of the Health (Mental Health) Sub-Committee; some members of divisional health committees also attended centre functions. 100 Organisation The school health service is, like most of the personal health services, organised on a divisional basis (see pages 132-143 for the reports of the divisional medical officers). The voluntary school care committees continued to be responsible for the follow-up of pupils found at medical inspections to be in need of treatment, and care committee representatives were present at over 90 per cent. of the medical inspections. Medical inspection rooms in schools The standards under the School Premises Regulations, 1951, do not specify separate accommodation for medical inspection purposes, merely requiring that suitable accommodation shall be immediately available at any time during school hours for the inspection and treatment of pupils by doctors, dentists and nurses. In many of the older schools medical rooms are not available, and consequently inspections have to be carried out in halls, classrooms, or other rooms. Matters are being improved by structural alterations, better washing facilities, lighting and heating. However, in the plans for the new comprehensive high schools, now under construction, a well equipped medical suite is being included. This will, in general, contain a doctor's consultation room, a dental surgery, a nurses' treatment room, waiting space with changing cubicles, and a 'rest' room. There will be variations on this basic pattern according to the location of the school, and the availability of school health service clinics in the near vicinity. Pupils on school rolls At the end of 1953 there was a total of 436,921 pupils on the day school roll, 311,637 children of primary and secondary school age were in attendance at County schools and 103,139 at voluntary or assisted schools; in addition there were 14,113 children under five years of age in nursery schools and classes or primary schools and 8,032 children in day special schools. Medical inspection The School Health Service and Handicapped Regulations, 1953, require that (except under special arrangements) general medical inspections shall be carried out at least three times during a child's school life, but it is left to the discretion of the local education authority to fix the ages at which these, and any other medical inspections which may be necessary, are carried out. In London the practice for many years has been to carry out as a routine four general medical inspections at specified ages during school life and this practice is being continued for the present. Such 'routine' inspections, however, constitute only a third of the total number of medical inspections each year. The 're-inspection' of pupils noted for treatment or observation, the 'special' inspection of pupils specifically referred to the school doctor, and general medical inspections at ages outside the four 'routine' age groups, constitute the bulk of the medical inspection work. Details of the medical inspections carried out in 1953, with comparable figures for 1952, are as follows: 1952 1953 General Medical Inspections 'Routine' Age Groups Entrants 58,039 51,814 7 year old 32,902 40,870 11 year old 28,558 33,940 Leavers 26,908 27,768 Total ' routine' age groups 146,407 154,392 Other ages (a) 60,747 56,534 Total general medical inspections (e) 207,154 210,926 101  1952 1953 'Special' Medical Inspections 'Urgents' and 'Specials' (b) 26,061 23,618 Employment Certificates 3,019 3,984 School journeys 20,489 19,375 Miscellaneous (c) 11,905 13,364 Total special inspections (c) 61,474 60,341 Re-inspections 'Nutrition' cases (d) 57,851 62,708 Other re-inspections 121,751 115,622 Total re-inspections 179,602 178,330 Grand Total (e) 448,230 449,597 NOTES (a) Pupils in nursery schools and classes, special schools, secondary and technical schools and colleges, and students in training colleges. (b) Pupils brought urgently to the attention of the school doctor by parents, heads, school nurse, care committee, etc. (c) Handicapped pupils for their special defect, candidates for higher awards, nautical school, etc., children engaged in theatrical employment, T.B. contacts, etc. (d) Pupils receiving school meals, extra milk or halibut liver oil capsules on the recommendation of the school doctor (see page 102) (e) The classification in this table di ffers from that given in the comparable table on page 116 of the annual report for 1952 in that 20,583 inspections of secondary school pupils and 57,851 ' nutrition ' re-inspections were, in that table, classified under the heading 'special' inspections. In addition that table included 8,077 inspections of children in out-county residential schools and children's homes. At general medical inspections about one pupil in six is found to require treatment for defects other than infestation or teeth. The percentages of pupils referred for treatment (other than for infestation or teeth) in the various age groups, with comparable figures for preceding years, are as follows : Pupils referred for treatment. Age group and sex 1950 1951 1952 1953 Entrants Boys 17.8 17.4 15.6 15.1 Girls 16.5 15.3 14.1 13.4 7 years old Boys 20.4 19.8 18.9 17.9 Girls 19.7 18.6 18.4 17.2 11 years old Boys 17.5 16.5 16.1 15.8 Girls 18.8 18.2 18.0 17.6 Leavers Boys 13.6 12.2 12.2 12.7 Girls 16.0 16.6 16.9 16.0 Total Boys and Girls* 17.6 17.0 16.2 15.8 * Exclusive of special schools and training colleges, but inclusive of 'other age' general medical inspections. The following table shows the percentages of delects (other than infestation, teeth or errors of refraction) found in pupils at general medical inspections, and for which the children were referred for treatment or observation, with comparable figures for previous years : 1950 1951 1952 1953 Skin diseases 0.97 1.13 1.14 1.29 External eye diseases 0.57 0.71 0.72 0.75 Defective hearing 0.44 0.51 0.58 0.64 Otitis media 0.69 0.87 0.94 0.97 Enlarged tonsils and adenoids 8.98 8.44 8.26 7.61 Defective speech 0.60 0.63 0.72 0.75 Enlarged cervical glands 1.38 1.67 1.71 1.62 Heart and circulation 0.69 0.80 0.78 0.84 Lung disease (not T.B.) 1.62 1.95 1.83 1.77 Orthopaedic defects 4.84 4.52 4.83 5.25 Defects of nervous system 0.33 0.31 0.41 0.37 Psychological defects 0.70 0.72 0.81 0.86 Anaemia 0.36 0.33 0.34 0.26 H* 102 General condition School doctors carrying out general medical inspections have since 1947, in accordance with Ministry of Education requirements, classified the 'general condition' of the pupils on a 3-point scale, 'Good', 'Fair' or 'Poor'. This replaced a 4-point scale for recording the doctor's assessment of 'nutrition' as 'excellent', 'normal', 'subnormal' or 'bad'. Since all these descriptions are of purely subjective assessments it is obvious that such a change in the system of classification meant that it would be some years before the statistics of assessment on the new scale could be regarded as stable enough to enable significant conclusions to be drawn from year to year comparisons : Year Excellent Normal SubNormal and Bad Percentage referred: Treatment Observation Total 1946 18.0 76.4 5.6 1.3 0.7 2.0 Good Fair Poor 1948 40.8 56.0 3.2 1.0 0.5 1.5 1950 46.3 50.9 2.8 1.0 0.7 1.7 1952 50.5 47.1 2.4 0.9 0.8 1.7 1953 53.3 44.3 2.4 1.1 0.8 1.9 Pupils receiving school meals, extra milk or halibut liver oil capsules on the recommendation of the school doctor are re-inspected each term. During 1953, the number of such re-inspections was 62,708. The classification of general condition recorded at these 'nutrition' re-inspections, with comparable figures for the two previous years, was as follows : Good Fair Poor 1951 10.5 65.5 24.0 1952 10.7 68.0 21.3 1953 12.3 69.4 18.3 School meals, milk and vitamin supplements A return to the Ministry of Education for a typical day in October, 1953, showed that 198,478 pupils, 51.2 of the number in attendance, were provided with school dinners; of these 18,924 received dinners free of charge. On the same day 350,627 children took school milk. This, however, included milk collected from school for children who were absent, so that the consumption cannot, therefore, be related to the number of children in attendance. Halibut liver oil capsules are supplied to pupils either on the recommendation of the school doctor, in which case no charge is made, or at the request of and on payment by the parents. The charge, in the latter case, is ½d. a dose of two capsules, with a maximum charge of 2d. in one week. Approximately, 1,100 schools take part in the scheme. It is estimated that in 1953 some 5,000,000 doses were supplied on payment, and another 3,500,000 doses were supplied free of charge. Between October, 1952, and October, 1953, the number of centres at which school children dined rose from 911 to 932; the number of kitchens of all kinds producing school meals in October, 1953, being 599 (including 573 school and central kitchens). The school meals service aims at concentrating the maximum food value into the quantity of food a child is willing to eat, and has set the following standards: Age group Number of calories (i) Under 7 years minimum of 500 (ii) 7 to 11 years „ „ 650 (iii) over 11 years „ „ 800 Meals for children 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. S. Macrae, O.B.E., D.Sc. To provide a check 103 on the quantities and qualities of served meals, random samples were analysed from time to time by the Council's Chemist-in-Chief (see page 37). Vision All school pupils, other than entrant infants, have their distant visual acuity tested by the school nurse by means of Snellen test charts, those pupils who have them wearing their spectacles for the test. The test is carried out at the time of the routine age group general medical inspection, and in cases of sub-normal vision the result of the test is checked by the school doctor. In testing, the ability to recognise certain letters 9 millimetres square from a distance of twenty feet, is the standard vision. This is termed V=6/6; vision of two thirds that acuity is called V=6/9; vision which only recognises symbols double the normal size is 6/12, and so on. Since vision testing is not objective, the results obtained depend upon the child's response, which involves, inter alia, its knowledge of the types of lettering used on the test chart. The charts now used by the Council are double sided, having lower case script lettering on one side, and plain block capitals, without serifs, on the other; it having been found that children have less difficulty with such types of letters than with the classical Snellen types. The following table gives the results of such vision tests carried out during 1953: Visual acuity (with glasses, if worn) Pcrcent. referred for treatment 6/6 6/9 6/12 or worse % wearing glasses Total Already wearing glasses Not wearing glasses 7 year old Boys 78.5 13.7 7.8 3.1 7.1 0.7 6.4 Girls 76.2 15.8 8.0 3.6 7.4 0.7 6.7 11 year old Boys 81.3 9.4 9.3 7.8 8.5 2.5 6.0 Girls 78.4 11.5 10.1 9.1 10.0 2.8 7.2 Leavers Boys 81.5 8.7 9.8 9.5 8.8 2.9 5.9 Girls 76.6 11.8 11.6 12.6 11.0 4.0 7.0 The constancy of the proportion of pupils recorded with normal visual acuity, about 80 per cent. of those tested, has been noted for many years. In fact the earliest report available, that of the medical officer to the late School Board for London, analysing the results of the testing of the visual acuity of 28,057 pupils in 1902, stated 'The general result is that, while 80 per cent. of the children are found to have normal vision and 10 per cent. have fair vision, the sight of 10 per cent. is bad'. (The 1902 report made it quite clear that the standard of normality then adopted was the same as today, i.e. Snellen 6/6). The above table also shows the proportion of pupils referred to ophthalmologists for specialist examination, and this percentage has also been fairly constant for many years. The table shows that the higher proportion of children referred for treatment at the older ages was mainly due to the need for the adjustment of their glasses with the passage of time. The problem of ensuring that treatment is obtained for pupils with defective vision now that this specialist work is the function of the Hospital Eye service, is discussed on pages 109-110. Personal hygiene inspections and the cleansing scheme For the purpose of assisting at medical inspections, each school nurse is allocated to a group of schools. Each school in the group is also visited by the school nursing sister in accordance with a rota, in order that she can carry out the inspection of the personal hygiene of the children. Each school is visited at least once a term, so that each child is seen at least three times a year. 104 The following table gives the results of the personal hygiene inspections carried out during 1953: Total Number of Inspections Pupils found to be verminous (*) Number Percentage Boys 418,054 3,905 0.9 Girls 447,150 13,916 3.1 Infants 491,401 7,594 1.5 Total 1,356,605 25,415 1.9 * 'verminous', in this context, has a special connotation since it includes cases with only one 'nit' (ovum) as well as cases with live vermin present. For pupils whose personal hygiene is unsatisfactory an 'advice' card is issued, which gives instructions to the parents on cleansing the child at home. A second advice card gives, in addition, a warning of possible statutory action, and invites voluntary attendance at a bathing centre. If, on re-inspection by the nurse, the condition is found to be unremedied, then a statutory notice is sent to the parent. This statutory notice also invites voluntary attendance at a bathing centre. If, on further re-inspection the condition is still unsatisfactory, the pupil is conveyed to a bathing centre for compulsory cleansing. The cleansing is carried out at seven bathing centres run directly by the Council and, by arrangement with the Metropolitan Borough Councils concerned, at 21 borough cleansing stations. During the year the number of individual pupils found by the nurses to be 'verminous' (as defined above) at hygiene inspections, as distinct from the number of occasions on which vermin was found (the same child might be verminous on more than one occasion) was 12,686. The total number of 'advice' cards issued during the year was 16,197. Pupils who attended at cleansing centres after the issue of advice cards numbered 11,507; the number of statutory notices served was 2,142; 627 of the pupils concerned attended voluntarily, and 1,346 were cleansed compulsorily. At the bathing centres individuals treated for scabies totalled 670. The number of verminous cases treated was 14,321, while the total number of treatments given was 21,324. Cases of impetigo treated numbered 2,991. The incidence of scalp ringworm, 38 cases, was higher than in the previous year when 29 cases were reported. Revised approach to problem of uncleanliness The Council's cleansing scheme has operated on the lines described above since the earliest days of the school health service—the two 'advice' cards were first introduced in 1903. The cleansing scheme, coupled probably with a generally more enlightened outlook on the part of parents in recent years, has proved very effective and the numbers of cases reported have steadily declined from year to year. The following table indicates the extent of this decline : Year No. of pupils on school rolls No. of nurses' hygiene inspections No. of occasions oh which pupils were found to be 'verminous' Column (4) as a percentage of column (3) No. of individual children comprising column (4) Percentage of the school population of the individual children in col. (6) (1) (2) (3) (4) (5) (6) (7) 1938 457,253 1,463,634 106,299 7.3 65,292 14.3 1946 334,784 1,532,848 87,668 5.7 40,960 12.2 1947 352,570 1,644,933 80,780 4.9 37,978 10.8 1948 373,090 1,538,187 64,620 4.2 29,970 8.0 1949 379,792 1,366,099 52,382 3.8 26,063 6.9 1950 380,885 1,428,783 46,012 3.2 22,159 5.8 1951 405,548 1,531,418 39,499 2.6 18,503 4.6 1952 425,362 1,439,384 31,905 2.2 17,051 4.0 1953 436,921 1,356,605 25,415 1.9 12.686 2.9 105 Although the cleansing scheme was clearly achieving satisfactory results, the number of pupils cleansed each year was still too great to permit of close investigation of every case. Early in 1953, however, it was decided that the numbers had dropped sufficiently to make it possible to consider whether the existing procedure could be effectively supplemented with a view to securing an even more rapid decline in the incidence of uncleanliness. Hitherto, the cleansing scheme for school-children has been operated by school nursing sisters. The integration of the health visiting and school nursing services should facilitate a more intensive investigation into each case and its linking with existing information on the particular family already in the possession of the health visitor. By approaching the problem at the level of the family, more intensive work might be possible. Accordingly it was decided that if a pupil was found by the school nurse to be dirty, the advice card would be delivered at the home by the health visitor, and that no statutory notice would be issued by the Education Department unless the health visitor requested such action. If the health visitor suspected that adults in the home were verminous, and were the source of the trouble in the school pupil, then, if necessary, she would consult the borough sanitary inspector. It will, of course, be some time before it is possible to assess and report more fully on the results of this more intensive attack on the problem of uncleanliness in school pupils. Comprehensive hygiene inspections The school nursing sisters' personal hygiene inspections of all school pupils each term are primarily concerned with the detection of lice or nits, and therefore can be carried out fairly rapidly, about 50 pupils being seen in an hour. The Ministry of Education suggested to the Council that these inspections should be of a more comprehensive nature, and conducted at a rate of only 20 cases an hour. Accordingly, for a period of twelve months, an experiment was carried out in three of the nine health divisions of the county. The nurses carrying out this comprehensive inspection were given the following notes of guidance as to what they should look for when examining the pupils : (1) Skin—taking care to have clothing turned back from neck, shoulder and arms, presence of rash or vermin, etc., condition of nails. (2) Ears—presence of discharge. (3) Eyes—any blepharitis, conjunctivitis, squint or evident abnormality. (4) Nose and throat—evidence of obstruction other than that caused by acute infection. (5) Orthopaedic—any evidence of orthopaedic defect. (6) Nervous—clear evidence of nervous disease or psychological upset. (7) Mouth and teeth—condition and, in young children, stage of dentition. (8) Head vermin, etc.,—condition—whether clean or uncared for or ' nitty ' or verminous. (9) Clothing and footwear—general standard and suitability. (10) Frequent absence—If the class register shows frequent or prolonged absences not satisfactorily explained, the need for treatment may be brought to light. (11) Any other defect. Pupils for whom further medical care is needed are referred for a special medical examination in school, or for medical examination at a minor ailment or special investigation centre. 106 The following statistical data was compiled of the results of the experiment: School nursing Sisters Doctors Number of pupils inspected 367,164 183,770 Defect Percentage of those pupils in whom defects requiring treatment were noted Skin 1.6 1.2 Head verminous 1.8 0.1 Body verminous 0.009 — Ears—Hearing — 0.5 Ears—Otitis media — 1.0 Ears—Other 0.3 0.3 Eyes—Vision — 9.8 Eyes—Squint — 1.9 Eyes—Other. . 0.8 0.7 N. and T.—Tonsils — 4.7 N. and T.—Adenoids — 0.4 N. and T.—T. and As. — 3.1 N. and T.—Other N. and T. 1.3 0.7 N. and T.—Cervical glands — 1.7 Orthopaedic 0.8 5.1 Nervous 0.2 0.4 Other defects (heart, lungs, enuresis, nutrition, etc.) — - 9.0 Other defects (not specified) 0.6 0.7 In attempting to assess the merits of these inspections by nursing sisters it must be remembered that there is strictly no yardstick of comparability although, in the above table, numbers of defects found by doctors at routine medical inspections are also shown. The routine medical inspections are carried out by age groups (on entry, at age 7, at age 11, and just before leaving school) whereas the nursing sisters' hygiene inspections were of children of all ages three times a year. It might have been expected that the nursing sisters' inspections would disclose the existence of undetected defects among children of ages in the gaps between routine medical inspections, but examination of the figures relating to separate age groups does not support that idea. There can be no doubt that the sooner defects needing treatment can be discovered and the children referred for treatment the better ; and although inspection three times a year by nursing sisters at the rate of less than three minutes a child must be much more of a cursory nature than full routine medical examinations by a doctor four times in school life, the chance of defects coming to light earlier is presumably improved. Nevertheless, hygiene inspections by nursing sisters, however thorough or frequent, cannot satisfactorily replace the routine age group medical examinations. The nursing sisters have appreciated being given sufficient time to make a more thorough inspection, and health education for the children must be relatively more beneficial. Nevertheless, the greater number of school nursing sisters who would have to be allocated to hygiene examinations on the basis of 20 children an hour would not be justified by the results of the experiment. Accordingly it has been decided that, for the whole of the county, the more comprehensive hygiene inspections by the school nurse should be carried out in one only of the three school terms. During the two other terms the normal personal hygiene inspection is carried out. The whole question will be reviewed again after a further period of a year. Re-inspection and 'follow-up' The 'follow-up' of children referred by the school doctors for observation or treatment, which is an essential part of the school health service, is carried out by the children's care organisation. Each child referred is re-inspected by the school doctor a few months after medical inspection, to allow time for treatment to be carried out, and further re-inspections are made, if necessary, to ensure that as far as possible every child gets adequate treatment. 107 During the year 178,330 medical re-inspections were carried out, 62,708 in respect of pupils noted as 'nutrition' cases (see page 102) and 115,622 in respect of other defects. Choice of employment At the general medical inspections of pupils about to leave school, note is made by the school doctors of any physical condition in the pupil which would contra-indicate a particular type of employment, and this information is passed on to the Youth Employment Service. Pupils advised against particular forms of employment formed 16.8 per cent. of both sexes examined. Eye strain, and normally acute vision, followed by heavy manual work headed the list of contra-indications for both sexes. Next came normal colour vision (for boys only), exposure to bad weather, and prolonged standing or quick movement. The following table gives the main contra-indications disclosed at the medical inspections of the 27,768 school leavers during 1953: Contra-indications Boys Girls Occupations, involving: Heavy manual work 273 291 Sedentary work 20 26 Indoor work 10 11 Exposure to bad weather 167 215 Wide changes of temperatures 85 78 Work in damp atmosphere 142 133 Work in dusty atmosphere 136 96 Much stooping 28 41 Climbing 75 55 Work near moving machinery or moving vehicles 59 61 Prolonged standing, much walking or quick movement from place to place 129 199 Eye strain 720 851 Normal vision 812 684 Normal colour vision 249 9 Normal use of hands 10 11 Exposure of hands to moisture, chemicals, etc. 19 31 Handling or preparation of food 59 81 Normal hearing 78 50 Employment of children New bye-laws, governing the employment of children came into operation on 1st December, 1952. The bye-laws require, inter alia, that the school medical officer shall certify that the employment of the child will not be prejudicial to his health and physical development and will not render him unfit to obtain the proper benefit of the education provided for him. Such a certificate is valid only (i) during a period of six months from the date of its issue by the school medical officer, and (ii) for the class of employment referred to in the certificate. During the year 3,984 medical examinations were carried out in respect of the issue of employment certificates. Children under five years of age At the end of 1953 there were 158 nursery classes with accommodation for approximately 4,740 children aged 3 to 5 years. In addition to a mid-day meal, these children had one-third of a pint of milk daily and cod liver oil and other vitamin preparations; medicaments containing iron were also prescribed for those who required them. Nursery class children attend during the ordinary school hours of primary schools, but nursery school children attend between 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 other supplements supplied to the nursery class children. 108 At the end of the year there were 21 maintained day nursery schools with accommodation for 1,250 children from 2-5 years, a nursery centre providing half-time education for two groups of 40 children each, one attending in the mornings and the other in the afternoons, and five assisted nursery schools with accommodation for 230 children. School nursing sisters attended nursery classes and schools frequently, daily when necessary, and each child was examined every term by a school doctor. There was a total of 14,113 children under five years of age on the day school rolls, 12,298 being in the Council's schools and 1,815 in voluntary schools. School journeys Special arrangements for the inspection of pupils before departure on school journeys or visits to holiday camps were continued. The Metropolitan Borough medical officers of health were asked to co-operate by forwarding information when infectious disease occurred in a home from which a pupil had gone on a school journey. 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 head of the school notifies the Divisional Medical Officer and the Borough Medical Officer of Health. The numbers or cases or the principal diseases thus reported during 1953 and the preceding years are as follows: Year Chickenpox German measles Measles Mumps Ophthalmia and Conjuncti vitis Ringworm Scarlet Fever Whooping Cough 1949 5,528 313 7,651 2,113 361 71 2,359 1,814 1950 7,773 312 7,495 7,638 275 79 1,925 4,039 1951 16,756 2,193 15,045 6,127 1,685 138 1,811 3,338 1952 14,281 16,115 13,127 8,391 1,245 138 3,042 2,028 1953 7,143 686 8,282 2,614 526 127 1,703 3,478 These figures are, of course, uncorrected for diagnosis, nevertheless they do indicate the trend of infectious disease in the child community, and are the only figures available in respect of diseases which are not statutorily notifiable. When the number of cases of infectious disease reported from a particular school indicates the possibility of an outbreak, special visits are made by a school nursing sister, and, if necessary, by a school doctor, in order to investigate the situation and take whatever control action is considered desirable. This system of notification by the head, and careful observation of the pupils in the school has been the practice for many years and is an important contribution towards the control of the spread of infectious disease. During 1953 the Advisory Committee on School Equipment had under consideration the supply of towels to schools. It was agreed that the communal roller towel generally in use was not satisfactory, and that alternative methods of drying should be used. The precise type to be supplied would need to vary with the individual school, and a choice of individual huckaback and terry towels, paper towels in fitments, or automatic linen roller towel cabinets should be available. Ringworm outbreak at Our Lady of Dolours School A case of ringworm was found at Our Lady of Dolours School on 17th February, 1953, by the school nursing sister in the course of carrying out her routine personal hygiene inspection of the pupils' heads. The sister found ten more cases in the next fortnight in a systematic inspection of all the pupils in the school. All the infected pupils were in the infants department of the school. The school was visited by medical officers who examined all the pupils under ultra-violet light with a Wood's glass filter. Only one more case was discovered by means of this apparatus. 109 The cases were treated at various hospitals, and St. John's Hospital for Diseases of the Skin carried out the mycological investigations. The infecting agent was found to be M. Audouini. Visits were made by the school nursing sister/health visitor to the homes of cases, and contacts were investigated and treatment arranged when necessary. This example affords a good illustration of the great value of the regular hygiene inspections carried out in schools by school nursing sisters. Outbreak of illness at Brackenbury Road Infants School An outbreak or illness at Brackenbury Road Inrant School started on loth March, 1953, when one pupil was sent home ill. The sequence then ran 23, 20, 9 and 2 cases on successive days. No new cases were reported on 25th March, or subsequently. The pattern suggested a single short exposure to infection, but no diagnosis was made, and all of the affected pupils recovered without after effects. An extract from the school doctor's report on this outbreak is as follows: 'Children became ill in school. All complained of headache and sudden and severe lassitude. Many said they had sore throats, but pain was found to be located about the neck and shoulders. Many had watering and puffy eyes. Some had slight cough. All were feverish with raised temperatures. All complained of nausea. No rash has been reported. There are 8 classes in the infant school—4 of which were affected. 90 per cent. of the cases were in one class, of which 80 per cent. were affected. The pupils work in table groups, and complete tablegroups accounted for the absentees, i.e., no one pupil was left unaffected at any table '. Juvenile Spring Eruption at Sayer's Croft Camp In April, 1953, the children at Sayer's Croft Holiday Camp presented an unusual set of symptoms, the numbers affected, over 90 per cent., giving the appearance of an epidemic. The signs were those of a local dermatitis on the ears, and some glandular enlargement in the associated lymph drainage area. Many more boys were affected than girls, probably as a result of the girls' longer hair giving protection to the ears. The condition was investigated by St. John's Hospital for Diseases of the Skin, as it was thought that it might be a virus infection, but no evidence in support of this theory was discovered. It is likely that a combination of meteorological conditions was responsible, namely, cold strong wind and bright sunshine for many hours. The condition is not uncommon but the unusual feature of this outbreak was the number of cases occurring in a short space of time. There were no after effects and all the children recovered completely within a few days. A fuller account of the investigations carried out has been given by Anderson, Wallace and Howes (Lancet, 10th April, 1954, page 755). Medical treatment Under Section 3 of the National Health Service Act, 1946, it became a duty of the Minister of Health to provide through Regional Hospital Boards and Boards of Governors of Teaching Hospitals, the services of specialists at hospitals, health centres, clinics, etc. The Council, as local education authority, also has a duty under Section 48(3) of the Education Act, 1944 'to make such arrangements as are necessary for securing that comprehensive facilities for free medical treatment are available to its pupils either under this Act or otherwise'. As the provision of specialist services for the school health services in London was, therefore, the concern of both the Council and of the Metropolitan Regional Hospital Boards, it became necessary to determine the extent of the responsibilities of each authority in regard to this matter. Guiding principles on the specialist work carried out at local education authority clinics were laid down in Circular 179 issued by the Minister of Education, and discussions took place in 1950 and 1951 with officers of the Metropolitan Regional Hospital Boards at which it was agreed that responsibility for the provision of specialists at rheumatism, ear, nose and throat, vision and orthoptic clinics lay with the Metropolitan Regional Hospital Boards, while the Council remained wholly responsible for the minor ailment, audiology, special investigation, nutrition and dental clinics. 110 Circular 179 suggested that the Regional Hospital Boards should plan the future organisation and development of services for school-pupils in consultation and agreement with local education authorities, but, in fact, the final word on any growth of the specialist side of the school health service would appear to lie with the hospital boards as is apparent from the extreme difficulty which has been experienced (by the local education authority) in securing from some boards additional specialist sessions for school-pupils. In the area of one of the four hospital boards which serve London, the Council has been endeavouring for some time to secure extra vision sessions, to meet the increased demands which have arisen as the school population has increased. The Board, however, has not, for financial reasons, been able to accede to these requests, although approving in principle the provision of additional sessions. In the meantime, waiting lists become accumulatively longer in the area of that Board. A survey of the position, made by the Divisional Medical Officers concerned, at the end of December, 1953, revealed that the waiting lists, counting both new cases and those old cases due for re-examination, contained the names of 5,152 school pupils. The staff concerned, both Council's officers and Board's specialists, are very conscious of the problem, and, by screening and selecting, endeavour to arrange that the most urgent cases are seen as soon as possible. Nevertheless, the time of waiting for an appointment varies according to the clinic from one to three months for the new cases, and from five to eleven months (after the date due for re-examination) for the old cases. Negotiations with the Board were still proceeding at the end of the year. School treatment centres At the end of the year there were 104 school treatment centres, 80 run directly by the Council and 24 by voluntary committees. The following table shows the number of clinics available in school treatment centres for the treatment of each defect : Type of clinic Minor Ailments 87 †Dental 65 *Vision 42 *Orthoptic 8 *Ear, Nose and Throat 12 Audiology 9 Speech Therapy 26 *Enuresis 1 Special Investigation 12 Nutrition 290 *Rheumatism (Supervisory) 15 † Several of these are ' twin ' surgeries. * Specialists provided in most cases by regional hospital boards. Treatment of school pupils at hospitals The co-operation between the London school health service and the hospitals dates back to the earliest days of the school health service, a Children's Care Organiser being appointed as long ago as 1911 to the London Hospital to direct the flow of patients and act as a liaison officer between the care committees and the hospital authorities. To-day this co-operation between the school health service and the hospitals takes several forms, in all of which the children's care organisers working in the Public Health department play an important role. At some hospitals special sessions are provided for the treatment of school pupils, and organisers make the appointments and attend the sessions. At other hospitals the organiser, although not present at the sessions, undertakes the making of the appointments. At certain other hospitals the organisers attend to carry out the liaison between the children's out-patient department, the specialist clinics, the school health service and the children's care organisation. 111 The following summary of the work carried out at Guy's Hospital illustrates the value of this hospital/school health service co-operation : The total attendances of school pupils in departments of Guy s Hospital covered by the organisers was 6,530. The main details are given in the following table : Department New Cases Attendances Children's 361 1,055 Ear, Nose and Throat 471 770 Vision 230 1,750 Orthoptic 68 675 Orthopaedic 133 312 Skin 249 456 An organiser also works in certain departments of the Evelina Hospital for Children, which is part of the Guy's Hospital Group, and the following is a summary of her report : Department New Cases Attendances Ear, Nose and Throat 535 982 Vision 48 422 Orthoptic 13 332 Medical 108 254 Treatment statistics Ministry of Education returns call for information on all treatment known to have been provided, whether by the Council or otherwise. Such statistics are necessarily incomplete, since no figures are available from general medical and dental practitioners or from opticians. Neither are figures 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. Care should therefore be exercised before attempting to draw conclusions about the incidence of defects or the extent to which treatment has been obtained, from the figures that follow: Type of clinic 1950 1951 1952 1953 *Vision New Cases 32,462 34,231 35,649 35,222 Attendances 85,364 86,758 91,693 92,511 *Orthoptic New Cases Attendances 942 1,435 1,401 1,517 12,745 15,385 15,784 11,564 *Ear, Nose and Throat New Cases 6,974 7,289 7,769 6,301 Attendances 15,138 16,565 17,408 15,291 Audiology New Cases — — 1,206 1,330 Attendances — — 2,407 2,676 Minor Ailments New Cases 163,658 155,080 151,903 169,443 Attendances 1,014,155 1,005,549 954,532 794,263 Dental New Cases 82,650 82,564 93,823 116,499 Attendances 166,874 172,063 202,571 269,061 *Rheumatism New Cases 1,224 1,100 971 959 Attendances 10,088 9,202 7,988 6,936 Nutrition New Cases 1,350 1,380 1,151 1,144 Attendances 10,067 10,984 11,162 10,593 Special Investigation New Cases — — 590 957 Attendances — — 3,027 4,588 *Enuresis New Cases 911 1,267 952 808 Attendances 5,110 6,344 5,449 4,026 * Hospital and specialist services provided by boards of governors or regional hospital boards. Handicapped pupils The place of special schools in the care of handicapped children has been under review since the war. There has been a general movement in mcdicine away from the overcautious attitude that it is said was adopted by the school health service in the nineteen- 112 twenties in the care of the physically handicapped child, e.g. children with symptomless cardiac defects being placed in special schools and left there indefinitely. Whether or not is was true that the school health service adopted this over-cautious view, it most certainly was true of some medical practitioners, and there are many adult neurotics who are able to fall back on alleged cardiac disease diagnosed on the strength of a systolic murmur found in childhood. A healthy distrust of repeating such mistakes today sometimes leads medical practitioners who know little of ordinary schools and less of special schools to tell parents that their child is quite fit to go to the former from the general idea that, once a child has been admitted to a special school, he has been in some way excluded from the ordinary community. In fact a handicapped child may be very effectively excluded from the activities of other children in an ordinary school, only to find his feet in a special school. Children can be very cruel to one another and it is well to appreciate this possibility, but the code of behaviour in schools changes with passing years and children of secondary school age are often more sympathetic towards another child's problems than they were when they were only eight years old. In fact it is wrong to generalise about the educational need of handicapped children ; besides the degree of handicap that each possesses it is necessary to know as much as possible of his intelligence and educational abilities—for many have missed months or years of schooling in hospitals or at home when individual teaching has not been maintained. In addition the child's social background and psychological attitude to disability is important and some knowledge of the available schools is desirable. A recommendation for education in a special school is an important decision but it is never a life sentence, and should be regularly reviewed, for just as it is the aim in partially deaf units to give auditory training to help a deaf child to take his place in the normal environments of an ordinary school and a hearing world, so should it be the aim to try to help a physically handicapped child to return from special to ordinary school as soon as such a change would be of benefit. In London the large numbers of special schools, day and boarding, provided by the School Board before 1904 and by the County Council in the past 50 years have made it much easier to provide special education for those thought to need it. The fall in school population over this period has been accompanied by an even greater proportionate fall in the numbers of places needed for the handicapped, particularly in schools for the physically handicapped. This decline in numbers has however meant that those in the special schools have generally more severe handicaps than previously and the provision of special medical treatment inside the school is more urgently required. In London, physiotherapy is provided at the departments of physical medicine attached to numerous hospitals, and transport is provided between the school and the hospitals. A recent survey showed that a great deal of educational time is wasted by the children in travelling and in waiting in hospitals. Moreover the transport arrangements become complex with children from one school going to three or even more hospitals. In October, 1951, the Director of the Department of Physical Medicine at King's College Hospital accepted responsibility for providing physiotherapy in a nearby school for the physically handicapped and this has had a great effect on the school. The question whether it may be possible to extend this to most or all of the other day schools for physically handicapped children, with the co-operation of the teaching hospitals that have schools of physiotherapy and of the regional hospital boards, is to be explored in 1954. Speech therapy is also now provided in each of these schools but the provision of physiotherapy and speech therapy on their own is insufficient. The Ministry of Health circular 26/53, though it deals only with epileptic and spastic children, underlines a need of all handicapped children—that careful assessment and reassessment of their handicaps and abilities is required if they are to be able to take their proper place in society. If there are fewer handicapped children in our schools the need for help of those that remain is no less. 113 The School Health Service and Handicapped Pupils Regulations, 1953, made certain changes in the definitions of the different categories of handicapped pupils. Notably there is no longer a separate category of 'diabetic' pupils, who are now included in the general category of 'delicate' pupils. This is a residual category covering all handicapped pupils who do not specifically come under the heading of one of the other handicaps, and the new definition takes account of the fact that some delicate pupils (e.g., asthmatics and diabetics) can be educated under the normal regime of an ordinary school, but may need a change of environment to make this possible. Diabetics, however can present special problems and they are not normally placed in open air special schools for delicate children. (See p. 120.) In addition, it is no longer necessary to get a determination from the Minister before a physically handicapped, epileptic or aphasic pupil can be educated otherwise than in a special school, or before a blind or epileptic pupil can be educated otherwise than in a boarding school. During the year 6,194 examinations were made to determine whether special educational treatment should be provided, or whether it could be discontinued. educational treatment should be provided, or whether it could be discontinued. The number of examinations in each category was as follows: Category Pupils not in special school Pupils already in special school Vision 187 51 Hearing 163 84 Educationally sub-normal 1,832 431 Epileptic 28 5 Physically handicapped 400 165 Speech defect 648 146 Delicate 1,220 459 In addition 372 children were considered for special educational treatment as maladjusted pupils and three as diabetic. The recommendations in respect of the 4,478 pupils not already in special schools were as follows: Special School for the: Vision Hearing E.S.N. Maladjusted Epilepsy Physically handicapped Delicate Blind B 3 — — — — — — G 5 — — — — — — Partially sighted B 43 — — — — — — G 42 — — — — — — Deaf B — 30 — — — — — G — 34 — — — — — Partially deaf B — 22 — — — — — G — 8 — — — — — E.S.N.—day B — — 333 — 1(b) — — G — — 243 — 3(6) — — E.S.N.—boarding B — — 60 — — — — G — — 40 — — — — Maladjusted—boarding B — — — 209 — — — G — — — 66 — — — Epileptic—boarding B — — — — 6 — — G — — — — — — — 114 Special School for the : Vision Hearing E.S.N. Maladjusted Epilepsy Physically handicapped Delicate P.H.—day B — — — — 4 137 — G — — — — 5 129 — P.H.—boarding B — — — — 1 9 — G — — — — — 9 — Delicate—day B — — — — — — 238 G — — — — — — 195 Delicate—boarding B — — — — — — 447 G — — — — — — 340 Ordinary school B 13 8 270 — 5(b) 15 — G 9 5 90 — 1(b) 17 — Ordinary school with special treatment B 30 20 445(c) 73(a) — — — G 40 20 219(c) 17(a) — — — Decision deferred B 1 8 13 — — — — G 1 8 9 — — — — Unsuitable for school B — — 74 — 1 — — G — — 36 — — — — Home or hospital tuition B — — — — 1 43 — G — — — — — 41 — N.B. (a) Attendance at special classes part-time. (b) Includes pupils for whom restrictions on certain physical activities {e.g., gymnastics) have been prescribed. (c) Represents those pupils who were recommended after statutory examination to attend ordinary school with special coaching. It does not include pupils for whom special coaching has been provided by the Head on the advice of the Council's educational psychologists. The morbid conditions from which the 316 pupils who were examined regarding physical defects, and recommended to attend school, were suffering are given in the following table: Morbid condition: Day P.H. Boarding P.H. Ordinary B G B G B G Infantile paralysis 21 22 — — 1 2 Cerebral palsy 21 14 3 4 — 1 Various paralyses 7 9 — — — — T.B. bones and joints 12 7 2 — 2 2 Osteomyelitis 5 1 — — 1 2 Perthes disease 5 2 1 — 1 — Congenital deformities 14 15 1 — 4 3 Spinal deformities, scoliosis 4 2 — 1 — — Traumata, amputations 4 2 — — 1 1 Non-T.B. arthritis, synovitis 2 — — — — Rheumatism, chorea 5 2 — — — 2 Heart disease, congenital 7 14 — — — 1 Heart disease, other 7 16 1 — — 1 Other diseases 25 21 1 4 5 2 Total 137 129 9 9 15 17 115 Pupils in attendance at special schools or units are periodically examined to ensure that the special educational treatment they are receiving is still suitable to their particular degree of disability. Details of the results of such examinations during 1953 in respect of educationally sub-normal pupils are as follows: Boys Girls Recommended no longer E.S.N. 61 41 Ineducable 38 35 Transfer from day E.S.N, school to boarding E.S.N, school 19 6 To continue E.S.N, school 64 39 In addition 416 pupils were recommended after medical examination for reporting under section 57(5) of the Education Act, 1944, as requiring supervision after leaving school, and four pupils examined under Section 8 of the Education (Miscellaneous Provisions) Act, 1948, were found to be suitable to attend schools for the educationally sub-normal. Schools for ' delicate children ' Open Air Schools have undergone several re-valuations since their introduction in 1908. For the first years the children referred suffered from 'debility' which figured so largely in the care of children of this period. Anaemia, chronic skin and pyogenic infections were a too frequent accompaniment of the prevailing social and economic conditions. Tuberculosis and the concept of the 'pre-tuberculous' child led in London to the creation of separate schools for these and for non-tuberculous children which persisted until 1939. Several of the schools were destroyed by bombs and the drawing up of the London School Plan and its subsequent revisions have led to critical reassessments of the functions of these schools. They have been attacked on three grounds; first that because of their construction and use it was difficult to develop satisfactory educational techniques; secondly, that the type of child previously recommended for these schools no longer existed in sufficient numbers to justify the continuance of these special schools with their increased costs and staffing requirements; thirdly, that modern school architecture produced schools that were every bit as good as the open air schools. An examination of the grounds of the second criticism shows the seriousness of the first. The kind of child referred by hospital and school physicians has changed and as many as 50 per cent, in some of the day open air schools now have asthma or chronic bronchitis, and it is not to be expected that these children will be ready to return to ordinary schools after a term or two, so that the quality of education that can be provided in the schools becomes of much greater importance. This has been met by the provision of a permanent wall to each of the old open-to-the-elements classrooms and a completely new method of construction for new buildings. As to the second, one can only say that, unfortunate though it is, sufficient numbers of children are still recommended for admission to these schools to provide substantial waiting-lists, though these are composed of younger children than in previous years. The third criticism is rather a matter for the future, for at present it is not possible to discontinue the use of these older schools. Speech therapy Speech therapy sessions are held at 26 school treatment centres and, in addition, sessions are held at 25 day schools for the educationally sub-normal, 15 day schools for the physically handicapped, and at six residential schools. At the end of the year 1,039 pupils were under treatment at these various speech therapy classes. New admissions during the year totalled 531, and 274 pupils were discharged as either improved or cured. 237 pupils, most of whom had shown some improvement, ceased to attend the classes for various reasons. Reviewing the work done by the speech therapists during the year in the schools for the educationally sub-normal, it has been found that fewer children coming into J 116 the senior E.S.N, schools are in need of speech therapy, and this supports the theory that it is in the junior E.S.N, schools that the most effective speech therapy can be done. The senior E.S.N, schools need the speech therapist, but to a lesser degree. Audiometry and audiology Routine group gramophone audiometer testing of school pupils continued throughout 1953, using three sets of Western Electric Type 2120-A and five sets of Western Electric Model 4 equipment. Pupils failing two consecutive group gramophone tests are tested individually with pure tone apparatus, five Amplivox model 61 and three Maico audiometers being available in the divisions. The intention in group gramophone testing is that, each year, all junior school entrants should be tested, and also, if possible, that some of the arrears of older children who have not previously been tested should be tackled. The results of the tests carried out during 1953 are as follows : 1. Estimated Junior School Entrants, age 7 + years 48,000 2. Pupils given first gramophone test 43,972 3. Pupils given second gramophone test 15,456 4. Pupils given second gramophone age of line (2) 35.1 5. Pupils given pure tone test 4,079 6. Pupils given pure tone test-percentage of line (2) 9.3 7. Pupils referred to otologist 1,147 8. Pupils referred to otologist-percentage of line (2) 2.6 The pupils who have failed the individual pure tone test carried out by the school nursing sister on those pupils who fail two consecutive group gramophone tests are referred to an audiology centre for examination by an otologist. The results of the otologist's examinations in 1953 were as follows: Clinical findings Percentage Discharged—no deafness discovered 14.6 —after treatment at audiology centre 33.2 —no improvement likely 24.8 Referred elsewhere for treatment 27.4 100.0 Educational Recommendations Fit for ordinary school 70.1 Fit for ordinary school—to sit in front row 27.3 —with hearing aid 2.6 Referred for ascertainment — 100.0 The fact that only 14.6 per cent. of the pupils referred by the school nursing sister were found not to be deaf by the otologist gives an indication of the efficiency of the pure tone test as a 'screen' for selection of pupils requiring specialist examination. That no pupil was recommended for statutory examination with a view to ascertainment as a handicapped pupil requiring special educational treatment as deaf or partially deaf is noteworthy. It means that such pupils have previously been detected and having had auditory training in a special school and having been supplied, if necessary, with hearing aids, they are able to take their place in the normal hearing environment of an ordinary school. In other words, testing by means of the gramophone is carried out too late, the deaf and partially deaf children requiring ascertainment having already been detected at an earlier age. The problem implicit in all this is one which is exercising the minds of local education authorities generally, and there is a desire to find a technique of hearing testing which can be successfully used on entrants at age five years, or even younger, 117 if possible. Research work, with which Miss Edith Whetnall, the Council's consultant otologist, is closely concerned, is being carried out into various methods of testing hearing at younger ages. The development of the audiology centres to cover the pre-school training of very young children, to which reference was made on page 123 of last year's report, was carried a step further during 1953, by the receipt of the approval of the Ministry of Education. However, the Ministry of Health advised that the procedure of submitting an amendment to the Council's approved proposals under the National Health Service Act, 1946, was required, and the necessary legal formalities were not completed by the end of the year. Epileptic children A central register has been kept since January, 1951, of epileptic school children, and school doctors have been asked to notify all cases of epilepsy that they come across in the course of their work. Where special educational treatment is considered necessary the children are examined at the County Hall. The consultants at hospitals, particularly at the Maudsley and National Hospitals, have been most co-operative in carrying out special investigations on any cases referred to them. At the end of the year there were 416 names on the register. Of these 277 were in ordinary schools, 36 in day schools for educationally sub-normal children, 36 in day schools for physically handicapped children and 36 in boarding schools for epileptics. This probably does not represent all the epileptic children in London schools as there may be some in ordinary schools who have yet to be notified. Enuresis Special enuresis clinics are held at certain hospitals, although some enuresis cases are dealt with through the special investigation clinics. The following summary of the report from the Westminster Hospital (All Saints Urological Centre) is given as an example of the work done at these clinics: Three sessions a week are devoted to London school pupils suffering from enuresis. The figures for 1953 were as follows: New cases 420 Old cases 1,860 Total attendances 2,280 Cases discharged 126 Fewer cases were seen than in previous years, since there are now a number of other clinics treating enuresis, often situated nearer to the patient's homes than the All Saints Centre, which, at one time, catered for the whole of South London, even receiving some cases from North of the river. The waiting list has fallen to an average of one month. The following abstract from the report of the physician in charge of the enuresis clinic in the children's out-patient department of Paddington Hospital illustrates how this problem is dealt with clinically: 'At the first attendance a search for an organic cause of the enuresis is made, the child's home and school background is assessed and the confidence of parent and child is gained as far as possible. The main lines of treatment are to restore the morale of the family by explaining that enuresis is not uncommon, and that it does not mean that the child is seriously 'abnormal' in any way. It is a childish habit which will certainly be grown out of by perseverance and determination. Simple advice is given regarding drinking, charting dry nights, and waking, and an attempt is made to improve any difficulties at school or in the family. Drugs are rarely used. Children are seen at intervals until improvement is satisfactory, and in most cases the results are encouraging and the parent grateful for the assistance given. The liaison with the Council's medico-social worker at the clinic is of great value, as also are the home and school reports obtained from the care committee workers.' J* 118 The following report comes from the enuresis clinic at University College Hospital: 'The clinic is in charge of the Paediatric Registrar, assisted by a medico-social worker who arranges all appointments and attends each session. This history of a new case is obtained from the mother in the absence of the child. Reports from Care Committee workers on the home conditions are brought by the medico-social worker. These reveal any overcrowding in the home, and prove of great value in augmenting the doctor's impression of the parental attitude to the problem and the general atmosphere of the home. School reports are also obtained to help assessment of the child's mentality and behaviour. A general physical examination of the child is made and the history augmented by conversation with the child. An examination of the urine is made in every case. A full urological examination is either carried out initially if the history or physical signs suggest the presence of organic disease, or later in cases showing no response to treatment. The main points in treatment are : 1. An attempt to correct any faulty attitude to the problem on the part of the parents and to improve poor home conditions. 2. An attitude of sympathy, encouragement and optimism is adopted in the clinic. 3. The child is asked to keep a calendar of dry nights. 4. The parents are instructed to waken the child fully to micturate at their bedtime. 5. Drug treatment. Amphetamine is the main drug used, even in children who are said not to sleep deeply. If necessary the dosage is raised to the limit of tolerance— an important point in treatment. In cases made too restless or wakeful by amphetamine, methyl ephedrine is the usual drug employed. For nervous children with unduly frequent daytime micturition a morning dose of phenobarbitone may be used in addition. 6. The assistance of a child psychiatrist is sought for children who show severe behaviour problems. A clinical trial to compare three methods of drug treatment is at present in progress. Only severe cases (wet 6 or 7 nights a week) are included in the trial and are allotted by random selection to one of the three methods of treatment. The doctor will know which treatment a given child received only at the end of the trial. Results.—With these methods of treatment, some children are rapidly and completely cured. Of the remainder, the majority are improved to a varying extent, and only a few are completely resistant to all forms of treatment.' Rheumatism scheme The number of admissions to the acute unit at Queen Mary's Hospital for Children, Carshalton, during 1953 was fewer than in recent years: 1950 1951 1952 1953 Nominations received 270 185 219 178 Outstanding from previous year 5 4 4 4 275 189 223 182 Admitted to rheumatism unit 250 177 216 179 Nominations withdrawn 11 4 2 3 Not suitable for unit 10 4 1 — Awaiting on 31st December 4 4 4 — 275 189 223 182 One encouraging feature of the Council's rheumatism scheme is that a high percentage of the children discharged after treatment at Queen Mary's Hospital remain fit for ordinary school life or for ordinary employment after leaving school. This is some measure of the effectiveness of the preventive side of treatment that is so important in minimising cardiac disablement. minimising cardiac disablement. The condition on admission of the cases admitted during 1953 was as follows : Articular Rheumatism Boys Girls No. admitted 63 72 Percentage with: Carditis 25.4 15.3 Valvular damage: Mitral 30.2 13.9 Mitral and aortic 4.7 4.2 No cardiac involvement 39.7 66.6 Chorea No. admitted 16 23 Percentage with: Carditis 12.5 13.0 Valvular damage: Mitral — 13.0 No cardiac involvement 87.5 74.0 Articular Rheumatism and Chorea No. admitted 1 0 Percentage with: No cardiac involvement 100.0 100.0 Of the 165 cases discharged during the year, 135 (81.8 per cent.) were able to take up normal school life or active employment. There were 2 deaths and 8 who proved to be unfit for school or work, leaving a balance of 20 (12.1 per cent.) who were fit either for light work or continued education at a special school for physically handicapped children. In this latter group, the percentage of boys affected is slightly higher than that of the girls (14.3 per cent. to 10.5 per cent.) whereas in the other groups the number of girls affected is slightly higher: Sex Fit for ordinary school or ordinary employment Fit for P.H. school or light employment Unfit for school or work Died Total No. Percentage No. Percentage No. Percentage No. Percentage Boys 56 80.0 10 14.3 3 4.3 1 1.4 70 Girls 79 83.2 10 10.5 5 5.3 1 1.0 95 Total 135 81.8 20 12.1 8 4.9 2 1.2 165 It is interesting to note that the percentage of cases with cardiac involvement has once again fallen slightly, though the fall is less marked than in the two previous years : 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 67.3 66.7 68.4 60.3 62.4 67.7 70.2 51.7 60.8 49.1 43.7 41.2 The follow-up of the cases after discharge from hospital by school doctors and rheumatism supervisory centres still continues to be an important integral part of the scheme: 1950 1951 1952 1953 Number of children under supervision of school doctors on 31st December 306 186 177 166 Number of children under supervision at rheumatism supervisory centres on 31st December 2,790 2,696 2,218 2,346 Number of supervisory centres 24 24 23 23 Number of sessions at supervisory centres 930 905 877 840 Number of children attending for first time 1,224 1,100 971 959 Total number in attendance at centres 10,088 9,202 7,988 6,936 119 120 Some of the points still being studied and carefully considered by the physicians in charge of the rheumatism supervisory centres are the causes of relapse. It is noted, that, although the number and severity of the new cases that are dealt with seem to be declining, there is still a regrettable number of cases that continue to relapse. Systematic tonsillectomy in selected cases during the convalescent stage certainly seems to mitigate the frequency of these relapses, while another line of attack is to exhibit one of the sulpha drugs in a small daily dose over a prolonged period in order to obviate secondary infection of the upper respiratory passages. The prompt attention to upper respiratory infections and their early treatment by antibiotics does seem to be important, but the value of prolonged administration of such drugs seems open to doubt on grounds other than that of the production of resistant strains of bacteria. A research on the use of sulphanilamide for such cases, carried out by some of the Council's physicians eight years ago did not show favourable results; yet the use of more modern sulpha derivatives seems to be popular in some quarters nowadays. It would be interesting if the relapse rate of those undergoing such treatment could be more fully followed up and perhaps it may be possible to do this in the future. Remedial exercise classes Special classes to correct foot defects, before they develop into permanent disabilities, which were first introduced in 1948, continue to be held mainly in primary schools. They 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. 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. Diabetic children The Council's diabetic unit is housed in the residential school at Hutton, Essex, and at the end of 1953 contained 35 pupils, 16 of whom were from out-County education authorities. 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 again organised a scheme whereby diabetic children from various parts of the country attend holiday camps at Walton-on-the-Naze, Essex; Etton, Nr. Beverley, 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-the-Naze, was provided by the Council and the camp was held in conjunction with the Council's diabetic unit. Child psychiatry In London most child guidance clinics have been provided by or in association with the teaching hospitals and by voluntary associations taken over by the Metropolitan Regional Hospital Boards, and there are now 23 such clinics. They draw their patients, however, from a wide area in the south of England and not exclusively from London. 121 The four child guidance units conducted by the Council continued their work without major changes of staff, though at all of them the waiting lists are constantly growing as the units become better known. The new unit at Woodberry Down health centre has rapidly become established in the neighbourhood and towards the end of the year the North East Metropolitan Regional Hospital Board agreed to increase the number of psychiatrists' sessions from two to four. Earlier in the year an educational psychologist and an additional part-time psychiatric social worker had been appointed. The two clinics which are run in association with the local infant welfare centres continued their work with children under 5 years of age (see page 57). A new boarding school for maladjusted children—Shaftesbury House, Royston— was opened during the year; as at other similar schools a psychiatrist visits regularly and is assisted by a psychiatric social worker. At Bredinghurst School, the psychotherapist is now employed full-time. Two additional part-time psychiatrists were engaged in April to visit the Council's residential establishments and to advise staff on the psychological aspects of child care. The arrangements for psychiatric services at remand homes and reception homes have continued successfully throughout the year. The following table gives details of the work carried out during the year at the four units for which the Council is responsible: Brixton Battersea Earls Court Woodberry Down Total No. of applications received 280 72 112 133 597 No. awaiting first interview at 31st December 43 23 28 47 141 No. interviewed and awaiting treatment Nil 16 12 25 53 Number of patients In treatment at 1st January 144 26 63 9 242 New cases treated 187 58 96 46 387 331 84 159 55 629 In treatment at 31st December 150 35 57 23 265 Discharged 181 49 102 32 364 No. of follow-ups 3 8 78 89 No. of home visits by psychiatric social worker 24 48 23 28 123 No. of school visits by staff 60 50 97 59 266 Disposal of patients Treatment completed 82 19 53 14 168 Transferred to other treatment 25 7 2 7 41 Further attendance impossible 13 9 18 4 44 Unco-operative 58 13 17 7 95 Placed or placement recommended 3 1 9 — 13 Taken into care — — 3 — 3 Total 181 49 102 32 364 Closing status of completed treatments Recovered 39 4 9 9 61 Improved 34 14 30 3 81 No change 9 1 14 2 26 Worse — — — — — Total 82 19 53 14 168 122 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 61). There were seven residential establishments with accommodation for 2,800 children, four approved schools with a total accommodation of of 482, two remand homes with accommodation for 142 children, and a number of other smaller establishments—reception centres, small homes, family homes and after-care 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. Research and investigation Dr. F. A. Nash, Medical Director of the Mass X-Ray service of the South West Metropolitan Regional Hospital Board; Dr. H. C. Price, the Chest Physician for Fulham, and Dr. L. E. Edwards of the Tuberculosis Research Office, United Nations World Health Organisation, Copenhagen, were granted permission to use the school organisation for the purpose of the tuberculin testing of 1,500 children in Fulham. In addition to the investigation forming part of surveys which the W.H.O. are making in different parts of the world, the findings would be of value as part of the tuberculosis control work in the Borough of Fulham. An investigation into the psychiatric disturbances occurring in diabetic children was carried out by Dr. E.J. Anthony, senior lecturer in child psychiatry at Maudsley Hospital, British Post-graduate Medical Federation, University of London, at the unit for diabetic children at Hutton. Dr. L. I. Woolf, of the Institute of Child Health, University of London, was granted permission to investigate the incidence of phenylketonuria in children attending day schools for the educationally sub-normal. A cross sectional study of (i) the volume of the hands and feet, (ii) the length and breadth of the hands and feet, and (iii) the development of the arches of the feet of 50 pupils in each of the age groups from 6 to 10 years, was carried out by Dr. P. Sylvester of the Institute of Child Health, University of London. 123 DENTAL SERVICES the council's Chief Dental Officer reports as follows: Some gratification can be registered with the progress in the dental services in 1953. Graphs of the School Service on page 124 and statistical tables reveal a recovery to approximately the level of 1948, and indicate that the tide may have turned in dental recruitment and attainment. Such satisfaction as is felt, however, can only be with the relative improvement in 1953, as much remains to be done before an efficient dental care programme is in being to meet the Council's statutory obligations. In 1953, the disentanglement of the Council's dental services from Part II (Hospital) Services and from Part IV (General) Services was virtually completed, and it is now possible to look more clearly at the three dental services operated by the Council, namely, the school dental service, the maternity and child welfare dental service and the dental service in boarding schools and residential establishments. It is proposed therefore, to report in separate sections on each of these three services. A tabulation of dental officer staff in school and maternity and child welfare services at the end of the year is given in Table I (below). Table I Total Establish ment Staff Equivalent in Full-time Staff Sessions Total Sessions Total Number employed Fulltime Parttime School Seruice MCW Service School Service MCW Service School Service MCW Service Fulltime Parttime Fulltime Parttime 93 113 52 61 65 9/11 57/11 547 177½ 40 22½ 724½ 623/4 School dental service Towards the close of 1952 the Council adopted as policy the aim of establishing one full-time dental surgery for each 3,000 schoolchildren on the school roll. To attain this ration necessitates the employment of almost 150 full-time dental officers and the provision of a similar number of surgeries. Throughout 1953 efforts were made to reach the authorised interim establishment of 93 dental officers and to acquire, adapt and equip additional premises. Considerable progress was made, but applications for appointments were not numerous and most were for part-time service only. On 28th December, 1953, the ratio attained was 1:6,500 for the county as a whole. Of the nine Health Divisions, the best was Division 2 where the ratio was 1:4,500 and at the other extreme was Division 7 where the ratio was 1:9,000. The considerable progress in 1953 made possible some improvement in the spreadover treatment policy and permitted revisional treatment to a greater extent. It was not yet practical to organise systematically this basic essential of a proper dental care service and during the year revisional treatment was left largely to the discretion and selectivity of individual dental officers. A proportion of children still received ameliorative treatment only and the follow-up of all defaulters continued to be impracticable. In 1953 the number of dental inspections in schools was greatly increased, being two and a half times the number in 1952. At these inspections many parents elected to have treatment carried out elsewhere than at the Council's treatment centres. This factor, plus the increase in the Council's service, undoubtedly resulted in an increased volume of dental attention for children during the year, but the actual amount of dental treatment for children obtained in 1953 from sources other than the Council's is not known. 124 125 Some results in the school dental service are given in Tables II and III, with figures of preceding years for comparison. In Table III there is ground for some satisfaction with the upward trend of conservative treatment. Table II Attendances and treatments 1950 1951 1952 1953 Number of inspection sessions held at schools 544 441 584 1,448 Number of children inspected at schools by Dental Officers 52,931 46,473 59,677 153,293 Number found to require treatment 32,733 29,397 38,069 97,736 Percentage requiring treatment 60.8% 63.2% 63.8% 63.8% Additional number inspected at centres 63,583 65,501 71,452 76,291 Total number found to require treatment 96,316 94,898 109,521 174,027 Total cases treated 82,650 82,564 93,823 116,499 Attendances 166,874 172,063 202,571 269,061 Ordinary treatment sessions 15,890 15,760 19,563 27,366 General anaesthetic sessions 1,559 1,516 1,494 1,725 Temporary teeth extracted 101,066 93,981 96,561 103,922 Permanent teeth extracted 16,247 15,850 17,283 19,727 Temporary teeth restored by fillings 23,960 21,684 26,353 37,787 Permanent teeth restored by fillings 53,388 54,356 66,680 92,576 Fillings in temporary teeth 25,191 24,206 27,556 40,120 Fillings in permanent teeth 58,000 60,568 72,369 102,178 Other operations—temporary teeth 33,489 39,523 45,985 59,863 Other operations—permanent teeth 25,485 28,199 30,291 44,250 Local anaesthetics for extraction 20,557 21,300 24,667 27,020 Local anaesthetics for conservative treatment 1,577 1,607 3,753 7,072 General anaesthetics 35,102 34,097 33,448 37,887 Cases for whom immediate treatment was completed ‡ 8,481* 13,135 15,196 Cases discharged as dentally fit ‡ 40,369* 63,638 81,488 J Figures not available; * Figures for May-December only; Table III Ratio of permanent teeth restored to permanent teeth extracted 1946 4.2 to 1 1947 4.93 to 1 1948 4.8 to 1 1949 3.72 to 1 1950 3.29 to 1 1951 3.43 to 1 1952 3.86 to 1 1953 4.69 to 1 Orthodontics As formerly, the provision of facilities and staff for the correction of malocclusions continued to be a major problem. Clinicians were encouraged to take part in this special form of treatment within their capabilities and the time at their disposal. By this means, 290 patients were accepted for treatment, an increase of 81 on 1952. Most appliances used were of the removable type and all were produced at the Council's Central Dental Laboratory. Results were exceedingly gratifying and dental officers and technicians who undertook this work are worthy of special commendation. In addition to the work undertaken in the routine sessions, 138 cases were accepted by the part-time orthodontist, who continued to devote three sessions a week to this special duty. 126 The following table (IV) summarises his work in these special sessions : Table IV 1950 1951 1952 1953 Sessions 425 245 134 138 New cases 266 117 85 80 Attendances 5,339 3,247 1,816 2,056 Unsuitable for treatment 84 51 17 21 Still under treatment (at 31st December) 491 187 205 195 Fixed appliances fitted 199 155 122 93 Removable appliances fitted 452 127 159 159 Discharged, treatment completed 424 222 50 69 By pre-arrangement, London dental teaching hospitals accepted an additional 100 patients referred from treatment centres, selected on a geographical basis. By these diverse means, a total of 528 cases were undertaken in the year, an increase of 187 on 1952. It is a matter for regret that shortage of staff prevented a larger number from being treated. Discrimination on acceptance or rejection of patients rested mainly with the individual dental officer but parents who pressed their demands strongly were interviewed by me and, if possible, arrangements were made for treatment to be provided. Maternity and child welfare dental service In 1953 the main effort continued to be directed to strengthening the dental service for children but due attention was given, within the facilities available, to building the service to meet the demands of expectant and nursing mothers. Shortage of staff still prevented instigation of routine inspections by dental officers of all new patients attending maternity and child welfare centres, which is envisaged in the National Health Service Act, and requests for dental attention continued to be made only by medical officers. The resultant demand was not great and, as in the preceding year, only about 10 per cent. of the total sessions worked were devoted to this branch of the services. Most expectant and nursing mothers are believed to obtain dental treatment from local practitioners or from hospitals, but there was some growth in demand to the Council for treatment for pre-school children. Results are shown in Table V below. Table V 1950 1951 1952 1953 Number of ordinary sessions 2,238 1,980 2,031 2,505 Number of general anaesthetic sessions 368 333 306 299 Number of appointments offered 26,308 23,342 24,609 30,441 Failed to attend 5,876 5,060 5,614 7,766 Attendances—by appointment 20,432 18,282 18,995 22,675 —other 3,891 3,313 2,162 2,122 Examinations 8,579 7,661 7,362 8,522 Treated—first treatment 5,116 . 4,753 5,444 6,989 —others 11,851 10,216 10,339 12,736 Silver nitrate treatment 2,180 1,818 2,907 4,256 Scalings 859 669 739 994 Prolonged gum treatment 210 214 228 295 Fillings 8,255 7,929 8,852 11,074 Inlays 22 27 18 29 Crowns 11 6 12 13 Number of teeth conserved 7,841 7,507 8,388 10,446 Extractions 11,257 9,289 8,463 9,565 Dressings 2,077 1,687 2,090 2,763 Anaesthetics—local .. 1,457 992 844 1,375 —general 3,372 3,318 2,837 2,938 Number of patients prepared for dentures 2,518 1,822 1,471 1,880 Number of patients supplied with dentures 918 590 476 607 Dentures supplied—new full 655 335 310 373 —new partial 782 536 400 520 Remakes 19 10 10 27 Repairs 84 63 47 51 Number of patients X-rayed 23 65 105 121 Number made dentally fit 5,057 4,654 5,479 6,818 127 Dental service in boarding schools and residential establishments Provision of adequate service to the Council's boarding schools and residential establishments continued during 1953 to be exceedingly difficult, particularly for those lying some distance outside the county boundaries. Alternative methods of remuneration for dental practice and, in some localities, a scarcity of practitioners made recruitment on a sessional fee basis problematical and, in some localities, impossible. Recourse was made to every conceivable arrangement; and to meet individual sets of circumstances use was made of the Council's school dental service; of that of other local health authorities; of local hospitals; or of the services of local practitioners. These various methods, of varying effectiveness, caused repercussions with other authorities responsible for dental services, and were the subject of much discussion and correspondence throughout the year. The coming into force of the Education (Miscellaneous Provisions) Act, 1953, precludes reference of children in educational establishments to local practitioners remunerated under the National Health Service Act and it was not always possible to agree contract terms with them. Wherever possible establishments continued to be visited by Council dental officers and the following table (VI) indicates the sessional attendance and treatment given by them. It is regrettable that a pain relief service was in effect the best that could be given, in the circumstances, at some establishments, but every effort was made during the year to effect improvement. Sodium fluoride treatment and use of dental hygienists The planned investigation on the efficacy of applying a 2 per cent. solution of sodium fluoride to teeth was concluded at the end of 1952. It was found that for twelve months after application there was a considerable reduction in tooth decay in the mouths treated, and during 1953 further investigation was instituted to ascertain whether benefit continued throughout a second year. A full-time hygienist was engaged on this work and devoted herself to careful follow-up of the children in the investigation and to collection of statistical data for examination at the end of the period. In addition, she carried out the routine oral health duties permitted to this class of ancillary operator. A tabulation of hygienists' routine work is set out in Table VII, which shows considerable reduction on the output for 1952, due, of course, to reduction in hygienist staff and to the second part of the sodium fluoride investigation. Table VI 1950 1951 1952 1953 Ordinary treatment sessions 524 449 488 569 General anaesthetic sessions 10 7 2 3 Number of children inspected 5,783 4,635 3,912 4,993 Number found to require treatment 2,355 2,045 1,836 2,452 Percentage requiring treatment 40.7% 44.1% 46.9% 49.7% Attendances for treatment 3,791 3,427 3,622 4,502 Temporary teeth extracted 920 950 690 827 Permanent teeth extracted 172 173 179 231 Temporary teeth restored by fillings 854 699 703 692 Permanent teeth restored by fillings 1,547 1,365 1,936 2,501 Fillings in temporary teeth 976 746 721 767 Fillings in permanent teeth 1,708 1,515 2,037 2,677 Completed scalings 583 346 246 250 Temporary dressings, etc. 511 455 432 612 Local anaesthetics for extraction 666 580 546 652 Local anaesthetics for conservative treatment .. 53 113 103 90 General anaesthetics 272 332 145 140 Cases completed 2,363 1,911 1,909 2,262 128 An additional hygienist was recruited in November, 1953, to give prophylactic treatment, including the use of sodium fluoride. Unfortunately, the meticulous and time-consuming nature of the technique involved in topical application of sodium fluoride prevents the ready adoption of the treatment on a general and widespread scale. The legally essential supervision by qualified professional staff of dental hygienists, and their accommodation and equipment are further obstacles to the use of large numbers of this type of ancillary worker. In present circumstances, the Council has restricted itself to the use of only two hygienists and to authorising the use of 2 per cent. sodium fluoride in the Council's dental services as a commendable treatment. Table VII Dental hygienists—Attendances and treatments 1950 1951 1952 1953 Sessions 1,370 1,499 1,592 189 Number invited to attend for first treatment 2,389 4,188 4,348 535 Number invited to attend tor subsequent treatment 2,851 4,232 1,284 180 Attended—first treatment 2,109 3,365 3,653 489 Attended—subsequent treatment 2,662 3,936 1,237 170 Treated—first treatment 2,104 3,359 3,652 484 Treated—subsequent treatment 2,660 4,033 1,235 166 Discharged—treatment completed 1,834 3,121 3,618 388 Discharged—failed to complete treatment * 104† 72 6 Gum treatments 365 395 495 47 Scalings (cleanings) 3,122 3,986 3,989 624 Polishings (of artificial restorations) 1,823 2,553 1,695 338 Oral hygiene instruction 2,562 4,655 4,137 654 Sodium Fluoride: First application 658 1,220 260 16 Second application 597 1,170 270 13 Third application 559 1,102 262 12 Fourth application 494 1,074 215 9 * Figures not available. † Figures for June-December. STAFF in staff matters the year produced no events of outstanding importance, but a few changes of some interest are touched upon below. Chief Nursing Officer In July Miss Evelyn Robinson, Superintendent of Health Visitors and School Nurses to the Lancashire County Council, was appointed as the Council's Chief Nursing Officer following the resignation of Miss J. M. Calder. Recruitment of dental officers Reference is made on p. 122 to the significant increase in the number of persons dealt with through the priority dental services following a further improvement in the recruitment of dental officers. On 31st December the Council employed 52 full-time dental officers. Part-time officers provided the equivalent of the services of a further 20 full-time officers. The corresponding figures at the end of 1952 were 50 and 10 respectively. Assistant Chief Dental Officer In 1952, as an experiment, administrative assistance for the Chief Dental Officer was provided by four dental officers, each acting for a part of his time as an Area Dental Officer. Owing to the expansion in 1953 of the work of the priority dental services, mentioned in the previous paragraph, it again became necessary to employ an Assistant Chief Dental Officer and the use of Area Dental Officers was temporarily discontinued. Training of student health visitors Queen Elizabeth College had to terminate at the end of the summer term the arrangement under which the college participated in the Council's scheme for training health visitors. The Council was fortunate in being able to arrange for the University of London 129 Institute of Education to provide, commencing in the autumn term, the necessary academic facilities for the student health visitors. Of 155 student health visitors trained since 1948,152 were successful in the examination for the health visitor's certificate, and of these, 87 were still in the Council's service as health visitors at the end of 1953. Night help service Mention is made on p. 77 of the introduction of a new scheme under which staff, designated night helps, 'sit in' all night with aged and chronic sick persons requiring constant attendance. After negotiation with the trade unions concerned the Council prescribed as the appropriate rate of pay for employees in this service, the current rate for home helps working at night, with an allowance at the rate of 4d. an hour in recognition of the special responsibilities borne by them. Child help service The provision of experimental arrangements for taking care, in their homes, of two or more children temporarily deprived of parents or guardians (vide p. 77) involved the negotiation of rates of pay for the staff operating the scheme, who were designated child helps. The amount of time required to be worked by the helps and the responsibility involved varies according to the circumstances in each household and a range of pay (£7 10s. to .£8 8s. 9d. a week) was adopted to enable appropriate remuneration to be applied for each assignment. Staff medical examinations The number of references to the department for medical examination or advice concerning the health of staff, or the fitness of candidates for appointment, was 13,855 compared with 13,436 in 1952. 167 members of the staff were found to be permanently unfit for further duty with the Council and 251 candidates were unfit for appointment. Reciprocal arrangements with provincial authorities for the examination locally of new entrants were continued. Provincial medical officers of health arranged for the examination of 32 entrants to the Council's service and the Council's medical officers examined 43 persons for provincial appointments. The Council's staff medical examiners made 68 home visits to examine members of the staff who were unable to travel, compared with 70 during 1952. Food handlers in contact with infectious diseases In co-operation with the restaurants and catering department arrangements were made for the bacteriological examination of specimens from members of the staff of the school meals service who had been absent from work suffering from illnesses which might have given rise to food-borne infection and those who had been in contact with such illness in their own homes. During the year 141 persons (including 34 contacts) were examined, all but five of whom were allowed to return to work after examination. The five who were regarded as infectious were referred to their private doctors for treatment before being allowed back on duty. During the year this system was extended to cover food handlers employed in the welfare department. FINANCE the total capital expenditure on the health services of the Council in the year ended Capital 31st March, 1953, was .£161,589, details of which are as follows : Ambulance service :— £ Adaptation and extension 9,774 New vehicles 16,043 Children's Holiday Home, Littlehampton—adaptation 2,781 Day nurseries—acquisition, adaptation, erection 46,598 District nursing—purchase of cars 3,439 Maternity and child welfare centres—acquisition and erection 5,234 Occupation Centre—appropriation and adaptation 16,748 Woodberry Down Health Centre 52,824 Other Health Centres 8,148 161,589 130 Maintenance The net cost of the services after allowing for Government grant, expressed in terms of rate in the £ was 10.6d., divided as follows: d. Ambulance service 1.32 Day nurseries 2.25 Domestic help service 1.3 Domiciliary midwifery service .35 General health services .63 Health visiting .6 Home nursing .66 Maternity and child welfare 1.1 Mental Health .3 Prevention of illness (care and after care, health education, tuberculosis, etc.) .73 Vaccination and Immunisation .1 School health 1.26 10.6 The gross cost of the various services in 1952-53—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 723,392 — Day nurseries 1,307,801 135,612 Domiciliary midwifery service 167,605 — General health services (including £163,934 contribution to metropolitan borough councils for salaries of sanitary officers) 177,403 Health centres 6,388 — Health visiting 283,015 — Maternity and child welfare 595,921 50,561 Mental health 154,941 349 Prevention of illness— Home nursing 308,853 — Domestic help 651,403 38,839 Other preventive services 415,451 20,791 School health 745,771 20,561 £5,537,944 £266,713 VISITORS TO THE DEPARTMENT individual visitors to the department (excluding those who went only to Woodberry Down Health Centre) during 1953, totalled 139 from 49 countries, excluding 50 visitors from Great Britain. The foreign countries from which visitors were received with the number for each were : The Argentine 1, Australia 17, Austria 4, Bombay 1, Brazil 1, British Guiana 1, Burma 2, Canada 3, Ceylon 4, China 3, Czechoslovakia 1, Denmark 1, Egypt 1, Fiji 1, Finland 1, France 4, Germany 2, Gold Coast 1, Greece 2, India 18, Indonesia 6, Iraq 1, Israel 4, Italy 1, Japan 3, Jordan 1, Kenya 1, Korea 1, Malaya 1, Mauritius 1, Netherlands 6, New Zealand 3, Nigeria 1, Norway 6, Pakistan 3, Persia 3, Philippines 1, Portugal 2, Rhodesia 2, South Africa 1, Sudan 2, Sweden 3, Trieste 1, Trinidad 2, Turkey 3, U.S.A. 6, U.S.S.R. 2, Yugoslavia 2, Zanzibar 1. These visitors were given programmes suited to their individual needs, consisting of visits in the field and in many cases talks by senior medical, nursing or administrative 131 staff. In addition to these individual visitors, 267 visitors came in organised parties, sometimes for talks and sometimes for visits in the field, or both. These visitors were : 75 Science Masters' Association. 58 Women Public Health Officers' Association. 8 German Directors of Youth Homes. 4 World Health Orgnisation Delegates. 12 St. Margaret's Home Office School. 30 Chiropodists attending Annual Convention. 9 Scandinavian students. 14 Students attending Ministry of Education Course for Teachers at Furzedown College. 24 Surrey County Council Health Visitor students. 20 National Council of Nurses' delegates. 5 from the Emergency Bed Service. An international party of health visitor students from India (1), Sweden (2), Trinidad (1), Eire (1), N. Ireland (1), Britain (2). In addition, large groups of students came from the following organisations : Royal College of Nursing. Institute of Education. Battersea Training College of Domestic Science. National Society's Training College of Domestic Subjects. King Edward's Hospital Fund. Battersea Polytechnic. Bedford College. London School of Hygiene and Tropical Medicine. Queen Elizabeth College of Household and Social Sciencc. National Association of Mental Health. National Children's Home Sisters' Training College. West End Hospital for Nervous Diseases. Small groups of students or individual visitors came from the following hospitals or other organisations : West London Hospital. St. Charles' Hospital. Hammersmith Hospital. Stanhope Institute. Charing Cross Hospital. Philippa Fawcett Training College. Brompton Hospital. Royal Masonic Hospital. National Society for Prevention of Cruelty to Children. St. Bartholomew's Hospital. Family Welfare Association. Institute of Social Psychiatry. Requests for facilities to inspect the Woodberry Down Health Centre have continued since its opening in October, 1952, and during 1953 the following visitors were received there: Overseas visitors and visitors of exceptional importance 347 Medical visitors 233 Nursing visitors 877 Other visitors 785 2,242 E 132 REPORTS BY THE DIVISIONAL MEDICAL OFFICERS Division 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington. Dr. Violet Russell reports: Vital statistics Apart from the continued fall in the birth-rate there were no significant variations in the vital statistics. Welfare of mothers and children There was a general decline in the number of attendances at welfare centres and in the number of visits paid by health visitors; this corresponded with the reduction in the number of births. On the other hand, attendances at health-education sessions rose from 2,167 in 1952 to 2,362 in 1953. Health education To supplement the health education carried on continuously in the welfare centres and other places by doctors, health visitors and school nursing sisters, preparations were made at the end of the year to hold, early in 1954, an exhibition of the divisional health services in co-operation with Borough Councils and the voluntary health organisations. Minor ailments During the year the number of minor ailment sessions at school treatment centres was reduced so as to release the equivalent of 2\ nursing sisters for other duties. Evidence provided by an interim survey suggested that this economy was having no adverse effect on the health of school children; the matter is nevertheless being kept under close observation, and will be reviewed towards the end of 1954. Dental treatment Anticipating the likelihood of dental staff becoming more readily available, arrangements were made to increase the number of dental surgeries. Two surgeries were made available at St. Dunstan's Road centre, Fulham, and additional surgeries were also being provided at the Hammersmith school treatment centre and the former immunisation clinic at Westbourne Grove, Kensington. Day nurseries The demand for day nursery accommodation became less acute, and attendances at the Fulham Babies' Hospital nursery fell so low that it was decided to close it in November; the displaced children being moved to other nurseries. In contrast to the decline in demand, the standard of regularity of attendance rose; it averaged 698 a day in 1953, as against 659 in 1952. Hurlingham hostel The opening of a hostel for men suffering from chronic tuberculosis at Hurlingham Lodge, Fulham is referred to on page 52. The hostel is administered from the Divisional Office, but admissions are arranged centrally from County Hall, since the residents come from any part of the county. The residents were under the care of the Fulham Chest Clinic and on the list of a local general practitioner. Home help service The home help service showed a further expansion, including the provision from 1st January of a night service for the chronic sick. Medical and nursing staff The policy of making staff inter-changeable for school health and maternity and child welfare work enabled an increasing number of medical officers, health visitors and school nursing sisters to gain experience of both branches of the service. Co-operation with other bodies In the report for 1949 it was pointed out that the successful working of the divisional health services depended to a considerable extent on co-operation with many other public and voluntary organisations. It is pleasing to be able to report that this cooperation is not only being maintained but actually grows stronger year by year. Division 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and Westminster. Dr. H. L. Oldershaw reports : Day nurseries and childminders There was a drop in the number of children in the nurseries in the first quarter of the year, but subsequently the position improved and during the last quarter the occupation was 86 per cent. compared with 88.2 per cent. in 1952. At some nurseries it was necessary to admit a number of non-priority cases to ensure that the most economical use was made of the accommodation. The waiting list of priority cases was only 70 at the end of 1953 compared with 195 at the end of 1952. The number of statutorily and voluntarily registered child-minders increased during the year from 132 to 186. 133 Home help service The home help service increased slightly, the number of hours worked by home helps in 1953 being 467,682 as compared with 453,842 in 1952, an increase of about three per cent. The number of cases attended increased by seven per cent. Care of old people It is interesting to note the extent to which the divisional services were allocated to the care of old people. In the home help service approximately 82 per cent of the cases helped were old people, assistance being given, not only in housework, but in shopping and other small services. A number of old people also received assistance under the arrangements for the night service of home helps to 'sit-in' with aged chronic sick persons. In addition almost half of the cases visited by the District Nursing Association were to old persons, and the Council's health visitors included, as a normal part of their duties, the visiting of old people when requested by general practitioners, almoners of hospitals and others. Diversional therapy— tuberculous patients at home The experimental scheme of diversional therapy for tuberculous patients at home, started in Paddington in 1952, was extended throughout the division, and there were at the end of the year three part-time diversional therapists (equivalent to one full-time unit), visiting tuberculous persons in their homes and instructing them in handicrafts, etc. The scheme has been verv well received. Evening sessions— Sessions for working mothers who were unable to attend ante-natal clinics during the day were held in Hampstead, Paddington and St. Pancras. Six evening dental sessions were held in Paddington, Westminster and St. Pancras. Health education Existing activities designed to spread health education in the division were reviewed, and a programme of expansion was approved and commenced. A separate room was made available for health education purposes at all the principal centres in the division. Specialist services (school children) In Westminster and St. Pancras areas there was a long waiting list of vision cases, involving 2-3 months' delay. The provision of additional sessions is under discussion with the Regional Hospital Board concerned. During the year the ear, nose and throat services in St. Pancras and Paddington were transferred from the Council's school clinics to the Royal National Throat, Nose and Ear Hospital and the Paddington Hospital respectively. Premises During the year the following additional accommodation was taken into use : (a) St. Stephen s day nursery, Paddington (51 places) was opened on the 16th February, and replaced the requisitioned premises at Maida Vale, (b) Westminster school treatment centre, Alderney Street, replaced the premises at Rochester Row and Greencoat Place, which were closed by the voluntary organisation on the 18th March. This centre met a real need, and attendances at the various clinics there were very satisfactory. Conclusion I express my sincere appreciation of the loyal co-operation and successful work of all my colleagues in the divisional health services. Division 3, comprising the boroughs of Finsbury, Holborn and Islington. Dr. Bertha E. A. Sharpe reports : Medical officers Six full-time assistant medical officers were employed in the division, two of whom also acted as deputy medical officers of health for the boroughs of Finsbury and Islington. Most of the assistant medical officers and health visitors were engaged in both the maternity and child welfare and school health services. 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 discharged, and reports on patients after their discharge were given to the hospitals on request. 450 aged and infirm persons were referred during the year by hospitals and general practitioners for supervision by health visitors. Close co-operation was maintained with family doctors and regular meetings with hospital almoners were held to improve co-ordination. 134 General Services worthy of special mention were: Problem family conferences—Much concern has been shown in recent years about problem families, and a monthly conference was set up early in the year to help in the solution of these problems. 33 families were dealt with in various ways. A family service unit was established in Islington with one full-time case worker who worked in close co-operation with the divisional officers. Recuperative holidays—Statistics showed that the number of these holidays paid for directly by the Council decreased by 12 per cent. viz. from 951 in 1952 to 833. In addition, 47 other children under five years of age, and 45 school children, were sent for convalescence to the Santa Claus Home in Highgate. Home help service—The total number of households attended increased by 9 per cent. compared with 1952. Vaccination of children under one year—Compared with the total annual live births occurring, the percentage of vaccinations of children under one year increased from 43 per cent. in 1952 to 47 per cent. in 1953. Foot clinic—9 per cent. increase in attendances, from 21,025 in 1952 to 23,054 in 1953. Housing—Requests for grading of applications for priority on medical grounds decreased from 3,954 in 1952 to 3,470. Care of mothers and young children—15 maternity and child welfare centres (including branch clinics) were in full operation in the division throughout the year, and a new centre was opened at Junction Road, Islington, in June, bringing the number of centres in operation at the end of the year to 16. An unsatisfactory building housing a maternity and child welfare centre was closed and the centre transferred to better premises. There were 80,900 total attendances, and first attendance of infants under one year was 87 per cent. of the total live births occurring in 1953. 341 women were referred for advice to the two family planning clinics in the division. Day nurseries—at the end of the year there were nine day nurseries in the division, one of which was opened in February, serving division 4 as well as this division. The number of priority cases awaiting admission on the 31st December was 107 compared with 328 on the 31st December, 1952. One of the two private day nurseries registered under the Nurseries and Child-Minders Regulation Act, 1948 closed in the summer. Vaccination and immunisation A mobile clinic for diphtheria immunisation, equipped with a loud speaker, was again in use and efforts were continued to improve 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 previously been protected. Based on the population figures as at 30th June, 1952, it was estimated that at 31st December, 1953, 50.8 per cent. of children under five years had been immunised against diphtheria; 1,939 schoolchildren were given boosting doses during the year and 2,245 children had a complete course of injections for protection against whooping cough. No case of diphtheria in children occurred, but one adult was reported to be a diphtheria carrier. A further four vaccination sessions were combined with four immunisation sessions, with consequential saving in man-power and sessional fees to medical officers. Sessions for the re-vaccination of school children were continued and 980 children were re-vaccinated. As a precautionary measure the scheme was suspended for about six weeks owing to a rising incidence of poliomyelitis. School health service At the beginning of the autumn term, to save man-power, the hours of opening of certain minor ailment centres were curtailed. One full-time centre opened in the mornings only, children requiring treatment in the afternoons attending a nearby welfare centre and at two other centres the hours of opening were reduced slightly. Arrangements were also made for emergency cases to be seen at welfare centres or the nearest full-time minor ailments centre. The ear, nose and throat clinic is now operated by the North West Metropolitan Regional Hospital Board at the Whittington Hospital. Most of the children seen there were referred by school doctors, and the numbers referred for discharging ears appeared to be declining. The audiology clinic at Islington school 135 treatment centre continued to work very smoothly. Twelve vision sessions a week, devoted to school children only, were held at the Royal London Ophthalmic Hospital (Moorfields), and two at the Westminster Hospital. Tuberculosa Accommodation at the East Islington welfare centre continued to be used by the North West Metropolitan Regional Hospital Board for mass radiography. The unit was also used for the routine examination of the Council's divisional staff. During the year arrangements were put in hand for the mass X-ray of the homeless family units, and of staff at the request of the Divisional Education Officer. A further 2,817 children from 12 schools in Islington had tuberculin skin tests; 366 were positive reactors to the test and 2,451 were negative. Six children were subsequently referred to the local chest clinic for further examination and observation. The Hostel for tuberculous men at Highbury Quadrant was fully utilised and was visted regularly by members of the Divisional Health Committee. Health education Health educational activities at welfare centres in the past year have included talks, discussion groups, film shows, cookery demonstrations and sewing classes, all directed by the health visitors. In addition, parents' clubs at the centres, with the help and encouragement of the Council's staff, have organised 'keep fit' classes, outings to places of interest, 'mannequin parades' of garments made at sewing classes, and talks on many subjects. All establishments, including (by permission of the Metropolitan Borough Councils) local town halls, have displayed a series of posters and leaflets. These were changed each month, and included, not only health education, but allied topics, such as the prevention of accidents in the home. Head teachers of 25 senior schools in the division were invited to co-operate in a scheme to bring home to the children the importance of hygiene in dealing with milk, and to teach them its nutritive value. As a consequence, lectures were given by sanitary inspectors to children in 16 schools covering not only this subject but also some of the wider aspects of food hygiene. General practitioners and hospitals in the area assisted the Council's campaign for immunisation against diphtheria bv displavins posters at their premises. Conclusion Relations with the voluntary services, the Metropolitan Borough Councils, local hospitals, neighbouring divisions, and other departments of the Council have been cordial, and I express my gratitude to them as well as to the Divisional Health Committee and my own divisional staff. Division 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports: Woodberry Down health centre At the beginning of the year 41 sessions of local health authority services were being held each week at the Woodberry Down Health Centre. During the year many services were extended by extra sessions and the following new services were commenced: oral hygiene, 'keep fit' classes, family planning, tutorial class (maladjusted children). By the end of the year a total of 72 sessions were being held. It was estimated that in January approximately 468 persons a week were attending the local health authority sessions and by the end of the year the average weekly attendance had increased to 784. The centre continued to attract considerable publicity and 2,242 visitors were conducted over the premises. Six general medical practitioners commenced to practise at the centre on 1st July, a total of 53 surgery sessions being held each week. A Medical Staff Committee was established to effect liaison between the local health and general practitioner services. The general dental service commenced on 6th August, and one general dental surgeon conducts 11 sessions per week. A successful health exhibition was held during May, which attracted a large public attendance and emphasis has been placed upon health education activities in the health centre. 136 Maternity and child welfare The arrangement made in November, 1952 for expectant mothers from Hackney Hospital to be referred to the Council's clinics for interim ante-natal care resulted in increased attendances at ante-natal clinics. Attendances in 1953 totalled 9,173 as against 7,193 in 1952. 3,516 first attendances of infants under one year of age were made at the welfare centres during the year (equal to 85 per cent. of children born). The total attendances of children at the centres were slightly smaller than in the previous year. Despite the continuing shortage of health visitors the number of home visits made showed improvement. Day nurseries and childminders The total available accommodation in the division remained at 666 child-places. The demand for day nursery accommodation waned and at most nurseries there were some vacant places at the end of the year. As an economy measure the hostel for day nursery students at the Sun Babies day nursery was closed and all resident students were housed at the Kingsland Road welfare centre. Six private day nurseries registered under the Nurseries and Child-Minders Regulation Act, 1948 provided accommodation for 202 children and there were 3 statutorily registered child-minders approved for the care of 13 children. There were at the end of the year 72 approved daily minders. Health education Parents' clubs at the Woodberry Down, Kingsland Road and Richmond Road centres were developed further and mothers' and parents' clubs were inaugurated at Barton House and Milton Grove centres. Arrangements were made for mothers attending the centres at which parents' clubs were not held to be invited to join the club at the nearest convenient centre and mothers of children attending day nurseries were also invited to join. Further equipment was provided for making-up into exhibits and the divisional office library of publications on health subjects was developed. The following comparison of educational sessions and attendances shows the good results obtained during the year. Sessions Attendances 1952 210 2,172 1953 288 5,421 Recuperative holidays Home help service A total of 962 holidays were provided, including 370 for school children and 152 for children under school age. This service was developed as far as financial resources would permit. The following figures illustrate progress during the year. 1932 1953 (i) Total cases given help 2,928 3,293 (ii) No. of home helps employed on 1st January (whole-time equivalent) 178 191 (iii) No. of home helps employed on 31st December (whole-time equivalent) 191 220 Premises and minor improvements During the year, the first programme of redecoration was completed. All health service premises in division 4, for the maintenance of which the Council is responsible, have been renovated and redecorated since 1948. Various minor improvements to premises were made or commenced during the year, such as the laying-out of additional play space to provide grass and hard areas for the children and improvements to the heating and boundary walls at day nurseries and a welfare centre. Conclusion A further programme of works for the year 1954/55 was prepared and approved. I wish to place on record my appreciation of the support and encouragement given by the Chairman and members of the Divisional Health Committee, of the helpful cooperation of the borough medical officers of health and of the good work of the entire divisional staff. 137 Division 5, comprising the boroughs of Bethnal Green, Poplar, Stepney and the City of London. Dr. G. O. Mitchell reports : Premises The centre which had been situated for some years at St. George's Town Hall, Cable F Street, was transferred during September to a new building nearby, (referred to on page 52), which was built by the Stepney Borough Council to accommodate (a) a centre for infant welfare, toddlers and ante-natal sessions, and (b) a branch library, which will be the direct concern of the Borough Council. This new building provides excellent, if small, accommodation for clinic purposes, and is a great improvement on the previous arrangements. The new centre was named the St. George's Maternity and Child Welfare Centre. A welcome extension to University House day nursery, Bethnal Green, was completed (see page 52) and became available from April, providing accommodation for ten infants. In addition, a staff dining-room and a fully-equipped kitchen were included, so enabling the nursery to be independent of outside sources for the supply of meals for children and staff. During the latter part of the year substantial progress was made towards the adaptation of two ground floor flats in Newmill House on the Devas Street extension of the Coventry Cross Estate, Bromley-by-Bow, to serve as a maternity and child welfare centre. This new centre will be a replacement for the clinics which are held, rather inconveniently, at All Hallows Hall, Devons Road and St. Michael's Hall, Ullin Street, Poplar. Sessions The infant welfare sessions in Poplar were increased by the addition of fortnightly sessions at the East India Dock Road and Poplar High Street centres, while a doctor's session was re -instated at the Wellington Way centre; and on the school medical side a weekly orthoptic session was introduced at the East India Dock Road centre. Foot clinic Attendances at the foot clinic increased during the year, and it is already necessary to consider an increase in the number of sessions. The Divisional Health Committee is fully alive to the need for increased chiropody services, particularly for the older members of the community, and would welcome any consent which the Minister of Health might give to the extension of this service. Child-minders The child-minder service continued to expand and proved a useful ancillary to the day nurseries. At the end of the year there were 108 voluntarily registered minders (known to, and recommended by, the health visitors) caring for 83 children as compared with 77 minders caring for 60 children at the beginning of the year. Dental service The position regarding the priority dental services continued to improve and the recruitment of more dentists allowed the establishment of a number of additional sessions throughout the division. At the end of the year the level of the service was 25 per cent. higher than it was in July, 1948. An interesting feature of this expansion was the inauguration of evening dental sessions at the Ida Samuel centre in Underwood Road, Whitechapel; Wellington Way centre, Bow, and the Bethnal Green centre in Lyte Street. Home helps The demand for the services of the home helps continued to increase, and the home help organisers were continually wrestling with the problem of supplying service to urgent and necessitous cases with a staff which was always working to full capacity. Throughout the year the households attended in this division per thousand of the total population exceeded the average for London. District nurses The district nurses also had a very busy year, and this division again showed the highest number of visits per head of population, and the number of visits per nurse was higher than in any other division. 138 Division 6, comprising the boroughs of Deptford, Greenwich and Woolwich. Dr. F. R. Waldron reports: Maternity and child welfare The need for maternity and child welfare services on the recently built Coldharbour Estate in New Eltham, which has over 1,500 dwellings and about 600 children between two and five years old, was met, pending the provision of a comprehensive health centre, by the use of the newly-erected St. Alban's Church hall referred to on page 52. Infant welfare clinics with prophylaxis, toddlers' and ante-natal sessions, were held in these premises from 15th October, 1053. A development in the Blackheath Hill area of Greenwich with its new housing estates, has been the use on certain days each week of the new Division 7 clinic at Merton Place, Greenwich, known as Blackheath Hill Centre, for ante-natal and infant welfare sessions. Special investigation clinics Special investigation clinics were continued at the main centres at Deptford and Eltham. The clinic in Greenwich (temporarily suspended in September) will be resumed in the near future. The purpose of these clinics is to give more thorough examination and guidance to children referred from infant welfare centres and school medical examinations. It is already evident that early attention given to children with minor behaviour problems is well worth while. Foot clinics Home help service Attendances at foot clinics totalled 75,600 as compared with 73,000 in 1952. The number of households attended was 3,197, as compared with 3,286 in 1952. The number of households being attended on 31st December, 1953, was, however, 1,820 as compared with 1,665 on the same date in 1952 and 1,450 in 1951. The work of home helps was particularly appreciated during the influenza epidemic of January and February, when the service worked under considerable pressure. Health Centre, Market Street —rearrangement There was a re-arrangement of accommodation at the Health Centre, Market Street, Woolwich, designed to provide more convenient accommodation on the ground floor for foot clinic patients and for the home help service. The light treatment room was sub-divided to provide a smaller but adequate treatment room and a waiting room for foot clinic patients and the home help service; former physical medicine treatment rooms were converted into a 4-chair foot clinic and a small office for the home help organiser and her staff. By this arrangement, patients for chiropody treatment were saved climbing stairs and had much more satisfactory waiting room accommodation. School health service The unspectacular but exacting work of the school health service, which is of inestimable value to future generations, continued in the closest concert with hospitals, general practitioners, and voluntary workers. The Ormiston Road school treatment centre, Greenwich, after functioning for two and a half years in premises leased from the Welfare Committee, was closed in September, 1953, as the services could be provided satisfactorily at other centres in the locality. The minor ailments and vision clinics were transferred to Chevening Road maternity and child welfare centre which is in close proximity. The speech therapy service was transferred to Fairfield House centre, Charlton. Day nurseries Structural modifications referred to on page 52 were carried out at the Health Centre, Amersham Road, in order to enlarge the 30-place day nursery on the 1st floor of the centre to one of 60 places. The enlarged nursery will, it is hoped, meet the needs of the whole division. Evelyn Street day nursery (40 places), the only other day nursery in the division, which structurally has reached the end of its useful life and is due to be handed back to the Parks Department for providing an outlet from Deptford Park to the main road, will be closed. Health services exhibition A successful health services exhibition, which had as its theme co-operation between the various components of the health service, was held at the Health Centre, Amersham Road, in May. Exhibits displayed features of the Council's maternity and child welfare, domiciliary midwifery, day nursery, home help, chiropody and school nursing services. The activities of other official and voluntary organisations were also prominently featured and a mass miniature X-ray unit was in attendance. During the exhibition a 139 specially arranged party of local medical practitioners, including consultants, was addressed by the Medical Officer of Health. A similar meeting, representative of all branches of the nursing profession, was addressed by the Chief Nursing Officer. The exhibition also aroused great interest among conducted parties of invited adults and school children. Attendance of health visitors at hospital clinics A new out-patient department was opened at the Woolwich War Memorial Hospital in the latter part of the year. At the request of the Paediatric Consultant, a rota of health visitors was formed for attendance at his clinic. The arrangement has worked well and consultants attending other hospitals in the division have asked for similar facilities. It is hoped that it may be possible to extend this very useful linkage. Student nurse training The revised syllabus of training for nurses laid down by the General Nursing Council requires training to be given in the social aspects of disease and personal and communal health. Enquiries were received from five hospitals in the division for facihties for field experience and visits of observation in connection with these studies. In two instances, schemes were agreed and put into practice. Division 7, comprising the boroughs of Camberwell and Lewisham. Dr. H. D. Chalke reports : Accommodation and clinics Many clinics are being held in church halls—accommodation which has very obvious disadvantages, not the least of which concerns the impression they give to the mothers who attend. It is not easy for the health visitors' educational talks to sound convincing in surroundings in which cleanliness, ventilation, heating and so on are of a poor standard. It is indeed fortunate that the zeal of the voluntary and paid staffs who have to work in these clinics never flags, despite the material handicaps. The erection of a prefabricated building (at Blackheath Hill) to replace unsatisfactory accommodation elsewhere and the opening of a new centre in Lordship Lane are referred to on page 52. Owing to the long delay in obtaining the use of premises on the new Kingswood Estate, it was decided to open a child welfare clinic on Saturday mornings in a school on the estate. Despite obvious disadvantages, this experiment met with a good measure of success. An interesting feature of the preventive activities of child welfare centres was the extension of routine tuberculin testing. The children are tested annually. This has already paid dividends by the discovery of unknown cases of tuberculosis of which the positive reactors were contacts—not always among members of the child's family. An ' all purpose ' clinic held in the evening was continued. The attendance was small but it is felt that the clinic served a useful purpose. The use of child welfare clinics There is no little variety of opinion at present as to the functions and value of these centres; it was decided therefore, to obtain the views of a large number of parents on such questions as to why they did, or did not, make use of these clinics. The enquiry also included questions concerned with the public awareness on health matters in general, including immunisation. The results of the enquiry appeared to leave little doubt as to the continued need for these centres, as essential links in the chain of disease prevention and the promotion of health. The questioners for part of the enquiry were medical students from Guy's Hospital, who carried out the work admirably, and it is believed received much benefit themselves, by gaining an early experience of social-medical problems. The results of this investigation are to be published. Health education A number of talks on health matters was given to the public by medical and nursing members of the staff, and considerable use was made of films and film strips. Many additions were made to the film strip library, but there is a real need for better film strips. The response to public lectures was at times rather disappointing; but it is believed that this work has so much value that it should constitute an increasing part of the work of a health department. Lending libraries at the centres were well patronised and it is gratifying to learn that fathers, as well as mothers, made use of books on parentcraft. 140 An exhibition on home accidents was well attended, and the work of the health authority with regard to the domiciliary care of older persons was publicised in an exhibit set up in an 'Old Peoples' exhibition. The incidence of head infestation among children is still far too high, and since the home seems to provide the reservoir, health visitors directed special effort on this aspect of the problem, making insecticides available for use in the home. An investigation as to the value and mode of employment of the preparations of the new contact insecticides is in progress. The home help service and older persons As was anticipated, demands tor this service have increased, and they will continue to do so where older persons are concerned. The plight of many old people in the division demands vigorous action. The domiciliary team under the guidance of the general practitioner consists of district nurses, health visitors, home helps, and voluntary workers, and full effort must be directed towards strengthening this band. In addition, more half-way homes and residential establishments are needed urgently rather than long stay hospital beds. Home helps—including males—are doing praiseworthy work, indeed, without them the expanding problem of senescence would almost be insoluble. For a short period, difficulty was experienced in meeting the demand, but authority for increased recruitment was asked for and obtained. Observations on these matters have been published elsewhere.* School health service Space permits of mention of only one of the many interesting facets of this work— the routine tuberculin testing and mass miniature radiography of pupils and staff in schools in which one of the latter was found to be tuberculous. This method of quenching epidemic foci of the disease is proving well worth while. Day nurseries The numbers of attendances have fallen, particularly in the Lewisham nurseries, and it was necessary to close part of the accommodation and reduce staff in certain nurseries. The number of registrations under the Nurseries and Child-Minders Regulation Act 1948 increased. Experience has shown how valuable a sojourn in the day nursery is proving in the case of children when there are adverse physical and psychological factors in the home. The oft-repeated expression ' the best place for a child is at home ' needs considerable qualification in certain cases, when housing conditions are very unsatisfactory and the parents need education and guidance. The role of the health visitor Much effort has been made to integrate the work of the health visitor more closely with that of the hospital and general medical services, and other statutory and voluntary agencies. The cohesion with hospital almoners was of the closest, in particular where questions of rehabilitation and the care of the aged were concerned. The scope of the health visitors' work has expanded to embrace the family unit rather than the individual, and, in particular with regard to collaboration with general practitioners. It is believed that a good deal of progress has been made in this not-too-easy field. Experiments in the division which have shown already that minor difficulties can be overcome and that the health visitor readily adapts herself to work with general practitioners, bode well for the future. The family health conference which met regularly at the Divisional Office proved valuable in bringing together interested parties and in preventing unnecessary home visiting. Tuberculosis Despite potential difficulties which the National Health Service Act brought into being by its division of responsibilities with regard to prevention and treatment, liaison with the chest clinics has been of the closest. A method of assessing housing priorities for the tuberculous was devised, which it is hoped will be an improvement on the existing system. This has been reported elsewhere, † The extension of tuberculin testing of children was only made possible because the Camberwell Chest Physician co-operated to the full. The mass radiography unit was used very considerably and thanks are due to the Director of the unit and his staff for their help in making the unit available at schools and for undertaking the examination of staff. * The Medical Press, Vol. CCXXXI, No. 5984, 1954. † Public Health, Vol. LXVII, No. 4. 1954. 141 General It is a pleasure to record the excellent way in which the divisional staff have responded to the additional work they have been called upon to do. I should like, also, to thank the members of the many statutory and voluntary bodies whose support and cooperation has been so valuable and, in particular, the Divisional Health Committee for their encouragement. Division 8, comprising the boroughs of Bermondsey, Lambeth and Southwark. Dr. W. H. S. Wallace reports : Premises The redecoration of premises in the division was continued. Two day nurseries and two infant welfare centres were completely redecorated and several minor improvements were made in various premises. Day nurseries There was some decrease in the demand for day nursery accommodation, especially in the Norwood area and parts of Bermondsey; this resulted in the nurseries in these areas not being filled to capacity. Nurseries in the rest of the division were full and there was a waiting list for admission. The overall figure for daily average attendance, however, dropped considerably as a result of the fact that the Norwood nurseries were not filled. Foot clinics The demand for the extension of the chiropody service continued. Adequate facilities existed in Bermondsey and, where possible, patients from parts of Lambeth and Southwark attended the clinics in Bermondsey. The Southwark Old People Welfare Association were given facilities at the Sutherland House welfare centre to provide a foot clinic and this met the needs of many old people in the area. Home help service The demand for the home help service continued to increase. The majority of applicants for the service were unable to pay the full charge and consequently the cost of the service rose as it was extended. It is clear, however, if the problem is viewed on a national basis that economy is being effected by the extension of the service. Large numbers of chronic sick and aged persons who would otherwise need hospital or institutional care were enabled to remain at home as a result of the provision of home helps. Not only is this an economy but it is much better for the old people themselves to remain in their homes whenever possible. Diphtheria immunisation Unfortunately, there was a reduction in the number of children immunised against diphtheria. This was largely due to the fact that propaganda was reduced during the summer months as a precautionary measure on account of the prevalence of poliomyelitis. School health service There was a decline in the number of children attending school treatment centres. Attendances dropped at minor ailment clinics, rheumatism, nutrition and special ear clinics. This change was due in part to the improved health of the school children and in part because more use was made of hospital and general practitioner services. Neglect and ill-treatment of children The problem of the neglect and ill-treatment of children in their homes has been causing concern throughout London. In order to deal with the problem in this division, a joint committee of the chief statutory and voluntary bodies connected with the care of children was set up to consider the problem and the full co-operation of the Children's and Education Departments was obtained. An index of all potentially neglected children was kept at the Divisional Office and the Committee fully consider the steps to be taken to deal with the problems raised in connection with these families. Recuperative holidays There was a noticeable decline in the number of cases sent for recuperative holidays. There was still a large number of cancellations but the number of applications also diminished. The particularly mild weather during the later part of the year may have contributed to a reduction in the incidence of illness and the need for recuperative holidays. 142 Health education The work of health education was carried out throughout the year. The health visitors were the chief workers in this field and a small group of health visitors met together to discuss methods of intensifying propaganda in preventive medicine. Health visitors took turns to arrange the displays in a Brixton shop window and many successful displays, especially those on the protection of food, accidents in the home and cleanliness were shown during the year. Division 9, comprising the Boroughs of Battersea and Wandsworth. Dr. J. T. R. Lewis reports : 1 have much pleasure in reporting on the work of Division 9 for 1953, the second year since my colleagues and I took over our duties in this area. In general the year was uneventful and there was no outstanding matter to which attention need be directed. One of our main concerns was planning the needs of the large increases of population in the division consequent upon the new building programmes in the area. This is a very important subject to which a good deal of attention was given, and to which further reference is made below. Premises At the end of the year negotiations were in progress for setting up a maternity and child welfare centre at St. Peter's Church Hall, Prescott Place, Wandsworth, in place of Clapham Manor welfare centre and St. Margaret's Church Hall, Cricklade Avenue, S.W. The closure of Southfields day nursery in August is referred to on page 52. The premises used for the Tooting school treatment centre had to be vacated and as a temporary expedient the work was distributed between three centres, pending the coming into use of other premises which have been acquired. As mentioned above, consideration was given to the establishment of welfare and school treatment centres mainly in the Roehampton district in anticipation of the large influx of population into the newly-built residential areas, and of a welfare centre in the South Streatham area. Immunisation and vaccination Compared with the year 1952 the number of children immunised against diphtheria showed a decrease of 6.5 per cent. On the other hand, the figures for whooping-cough immunisation revealed an increase of 36 per cent. A slight reduction occurred in the number of persons vaccinated. Research An interesting and important investigation into the efficacy of a combined prophylactic against diphtheria and whooping cough is being conducted, in conjunction with the Medical Research Council. It will probably be some years before the final answer can be given but it is hoped eventually to obtain some definite information as to the value of combined immunisation against these two diseases. Day nurseries There were 639 places in the thirteen day nurseries. Ten of these nurseries are recognised for training students. Special investigation clinics At clinics concerned with the problem of bed wetting there were 1,531 attendances and 210 sessions. These figures showed a decrease of 22 per cent and 5 per cent respectively on the number of attendances and sessions for 1952. On the other hand, the number of new patients, amounting to 253, showed a close approximation to the number recorded in 1952. Recuperative holidays Applications for recuperative holidays placed through the division numbered 946, as compared with 1,019 in the previous year. Direct placing amounted to 44.4 per cent. of the total placing and constituted a slight increase over the percentage for 1952. Home help service Home helps attended 2,790 households, representing an increase of 8 per cent. over the figures of the previous year. Home nursing Equipment was loaned to 29 patients, compared with 24 in 1952. 25 patients were still using the equipment at the end of the year. District nurses paid 197,373 visits; an increase of 7 per cent. over the number of visits recorded in 1952. 143 During the year talks were given by the medical and nursing staff to various organisations, including parent-teachers associations, women's guilds and old people's clubs. One health visitor was employed almost exclusively on health education. Activities included the preparation of exhibits on home safety, to which special attention was given. Special schemes continued in operation whereby officers of the Borough Councils gave talks to school children on milk and food hygiene. Within the limits of the time which the officers can devote to the work it is clear that the schemes were successful. These subjects were also discussed by the school nursing staff during the course of mothercraft talks. Health education Child neglect A conference was held in February between officers of the Council and representatives of organisations concerned with the welfare of children. Neglect, ill-treatment and juvenile delinquency were discussed, and a general understanding was reached on the maintenance of a standing committee on child neglect and of a divisional index of cases. Welfare of old persons Although the combined efforts of the medical staff, health visitors, district nurses and home helps achieved a considerable measure of success in attending to the needs of old people, new problems arose every day, and elderly persons living alone and in a state of neglect often coupled with ill-health, were the source of much anxiety. Co-operation Close co-operation was maintained with individual doctors, the local division of the British Medical Association and the staff of hospitals situated within the division and elsewhere. Similarly, the effectiveness of school health work was enhanced by the close co-ordination which existed between the divisional staff and the staff of the schools and the Divisional Officer of the Education Officer's department. Organisation I made brief reference last year to the importance of team work in all forms of public health administration and practice and to the fact that I had received the greatest possible help and co-operation in our work. I should like to say again how I have appreciated the support and assistance I have received from everyone concerned with the health and welfare of the people in this area, both members of committees and officer colleagues. In particular, I should like to thank my two senior medical colleagues, the Divisional Nursing Officer, the Divisional Administrative Officer, and the Divisional Treatment Organiser. Without their loyal, conscientious and unstinted support it would be impossible to carry out the work in this area with success. 144 APPENDIX A STATISTICS Table 1—Population*—Administrative County of London, 1921-53 Year Mid-year estimate of home population by the Registrar General Average age Total 0-4 5-14 15-24 25-44 45-64 65+ 1921 4,484,500 376,100 809,200 796,600 1,365,500 877,100 260,000 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 J 34.8 1939 4,013,000 211,900 457,500 3,343,600 1940 3,084,100 141,300 232,500 2,710,300 1941 2,320,100 79,200 142,100 2,098,800 1942 2,405,000 137,700 324,500 2,032,800 1943 2,500,600 179,500 282,000 2,039,100 1944 2,462,500 172,000 302,300 1,988,200 1945 2,601,370 189,720 311,440 2,100,210 1946 3,109,240 227,470 353,050 2,528,720 1947 3,245,000 259,000 364,600 2,621,400 1948 3,339,100 269,900 359,500 2,709,700 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 1953 3,343,000 244,000 413,000 410,000 1,072,000 826,000 378,000 37.2 *Civilian population only from 1940 to 1948. 145 145 Table 2—Vital statistics—Metropolitan Boroughs and the Administrative County of London, 1953 (b) Metropolitan boroughs arranged in divisional order Estimated home population mid 1953 Live births Death-rates Notifications of infectious disease Deaths Infant mortality (per 1,000 live births) Heart disease Other circulatory Cerebral vascular lesions Peptic ulcer Pulmonary tuberculosis Pneumonia Other respiratory diseases Cancer Violence Scarlet fever Diphtheria Poliomyelitis Meningococcal infection Acute pneumonia Measles Whooping cough Tuberculosis Paralytic Non Paralytic Pulmonary Nonpul monary Division 1 Chelsea 52,150 15.1 13.3 19 3.47 1.13 1.69 0.12 0.08 0.92 0.96 2.45 0.79 0.94 — 0.04 0.06 0.06 0.56 10.53 4.93 1.92 0.13 Fulham 122,500 13.7 11.5 27 2.93 0.48 1.35 0.22 0.19 0.89 1.27 2.07 0.42 0.57 — 0.06 0.02 0.02 0.37 7.43 4.34 1.31 0.08 Hammersmith 117,600 14.9 10.3 20 2.89 0.37 1.12 0.15 0.26 0.65 1.16 1.90 0.48 0.90 — 0.05 0.02 0.02 0.85 4.55 3.85 1.68 0.14 Kensington 171,500 15.4 10.0 19 2.71 0.55 1.01 0.14 0.15 0.56 0.78 2.00 0.55 0.45 0.01 0.05 0.03 0.03 0.54 4.31 2.83 1.36 0.06 Division 2 Hampstead 97,970 14.5 11.8 16 3.09 0.47 1.13 0.10 0.11 0.50 0.57 4.28 0.42 0.45 — 0.10 0.02 0.03 0.54 12.11 2.19 1.05 0.06 Paddington 123,800 17.0 12.6 24 2.55 0.57 0.96 0.15 0.19 0.53 1.02 4.46 0.65 0.57 — 0.04 0.02 0.03 0.79 6.90 2.60 2.00 0.15 St. Marylebone 73,860 12.2 14.7 21 4.09 1.50 2.40 0.18 0.19 0.58 1.53 2.14 0.66 0.60 — 0.08 0.04 0.01 0.22 5.81 0.96 1.06 0.14 St. Pancras 138,400 15.3 10.1 24 2.60 0.45 0.98 0.20 0.27 0.61 1.16 1.99 0.50 1.27 0.03 0.12 0.04 0.01 0.73 9.87 2.76 1.56 0.22 Westminster, City of 99,380 12.3 10.2 26 2.72 0.44 0.90 0.17 0.28 0.54 0.83 2.18 0.57 0.54 — 0.04 0.05 0.04 0.51 4.96 3.19 1.47 0.07 Division 3 Finsbury 35,640 18.9 9.9 22 2.64 0.31 0.93 0.11 0.31 0.56 1.35 1.68 0.53 1.85 — — 0.03 — 1.71 12.91 9.99 1.77 0.25 Holborn 23,710 11.6 11.5 15 2.66 0.63 0.97 0.17 0.38 0.76 1.69 2.11 0.59 0.42 — 0.38 0.34 0.08 0.17 8.22 2.61 2.02 0.13 Islington 233,500 17.0 11.4 24 3.34 0.50 1.16 0.21 0.16 0.66 1.37 2.18 0.43 1.04 0.00 0.06 0.01 0.01 1.41 11.31 5.00 1.85 0.15 Division 4 Hackney 169,600 14.5 10.2 20 2.93 0.29 1.02 0.14 0.12 0.59 1.20 2.08 0.22 1.72 0.01 0.05 0.02 0.04 0.35 8.89 4.34 1.00 0.09 Shoreditch 45,770 17.8 13.4 22 3.76 0.57 1.68 0.20 0.24 0.76 1.64 2.34 0.44 1.46 — 0.02 0.04 0.02 0.72 8.61 4.63 1.20 0.11 Stoke Newington 51,250 14.7 9.8 24 2.75 0.47 1.05 0.06 0.21 0.76 0.98 1.68 0.20 1.52 — 0.04 — — 0.64 15.10 4.60 1.11 0.14 Division 5 Bethnal Green 56,650 15.9 10.1 14 2.24 0.60 0.92 0.23 0.16 0.58 1.62 2.15 0.37 1.24 — 0.02 — 0.09 0.19 11.23 5.10 1.13 0.07 City of London(a) 5,090 6.1 11.2 32 2.36 0.20 0.59 0.20 0.59 1.77 0.79 2.16 — — — 0.20 1.18 0.20 3.93 0.39 Poplar 72,470 18.0 10.5 34 2.54 0.59 1.09 0.25 0.34 0.44 1.44 2.01 0.33 1.19 — 0.07 — 0.04 0.97 10.76 4.33 1.15 0.14 Stepney 98,570 19.5 12.0 39 2.75 0.72 0.97 0.18 0.40 0.84 1.34 2.40 0.61 0.76 0.01 0.05 0.02 0.08 0.79 6.62 2.53 1.69 0.13 Division 6 Deptford 75,030 15.0 13.0 27 3.85 0.84 1.25 0.19 0.33 0.69 1.71 2.27 0.39 1.05 — 008 0.07 0.01 0.35 5.72 1.48 1.96 0.19 Greenwich 90,440 15.3 9.4 18 2.72 0.57 0.95 0.15 0.18 0.36 1.00 1.86 0.38 1.61 — 0.11 0.01 0.03 0.25 6.19 2.60 0.91 0.18 Woolwich 151,100 13.8 10.4 23 3.22 0.40 1.23 0.15 0.18 0.47 0.85 2.11 0.41 1.42 — 0.07 0.02 0.01 1.04 6.96 2.48 0.94 0.09 Division 7 Camberwell 180,200 15.3 12.1 26 3.11 0.81 1.27 0.12 0.24 0.55 1.54 2.13 0.39 1.22 — 0.08 0.03 0.03 0.45 7.27 2.54 1.59 0.11 Lewisham 225,800 14.4 11.1 22 3.43 0.50 1.25 0.16 0.19 0.53 0.95 2.00 0.33 1.25 0.00 0.16 0.08 0.04 0.84 9.22 2.54 1.36 0.16 Division 8 Bermondsey 59,350 16.3 9.9 29 2.19 0.69 0.99 0.12 0.20 0.71 1.21 2.09 0.27 0.98 — 0.02 — 0.02 0.67 8.66 2.14 1.21 0.17 Lambeth 229,000 15.9 10.5 25 313 0.52 107 0.17 0.20 0.56 1.14 1.86 0.36 0.76 — 0.06 0.02 0.03 0.83 5.69 3.42 1.39 0.13 Southwark 96,870 17.2 12.5 32 3.27 0.71 1.24 0.20 0.22 0.89 1.67 2.25 0.36 1.65 — 0.06 0.01 0.03 0.70 11.10 3.84 1.62 0.08 Division 9 Battersea 114,800 15.5 12.8 19 4.10 0.64 1.69 0.15 0.12 0.72 1.37 2.15 0.39 0.78 0.01 0.09 0.02 0.04 0.64 6.64 3.57 1.32 0.11 Wandsworth 331,000 13.5 14.9 23 4.90 0.76 1.43 0.16 0.20 0.79 1.18 3.21 0.43 0.98 — 0.05 0.02 0.01 0.97 8.61 2.79 1.11 0.10 London, 1953 3,343,000 15.2 11.6 24 3.25 0.59 1.20 0.16 0.21 0.64 1.19 2.34 0.43 1.02 0.003 0.07 0.03 0.03 0.73 8.09 3.30 1.40 0.12 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 (a) Including Inner and Middle Temple. (b) Rates are per 1,000 home population. 146 Table 3—Principal vital statistics—Administrative County of London, 1896-1953 Year(s) Annual rate per 1,000 living Annual mortality per 1,000 living (b) Annual mortality Infant (per 1,000 live births) Maternal (per 1,000 total oirths (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 and enteritis 0—2 Puerperal fever Other child-birth Pulmonary Non-pulmonary 1896-1900 29.7 18.4 18.5 (a) 0.45 0.14 0.14 0.00 0.47 0.57 0.27 1.75 0.69 1.32 1.80 0.35 (a) 0.92 0.07 162 41.3 1.70 1.74 1901-05 28.6 17.7 16.4 (a) 0.20 0.08 0.11 0.07 0.36 0.45 0.17 1.58 0.57 1.46 1.41 0.26 1.31 1.01 0.08 139 30.4 1.64 1.52 1906-10 26.5 17.4 14.9 (a) 0.14 0.04 0.10 0.00 0.29 0.42 0.22 1.39 0.48 1.49 1.22 0.22 1.26 1.11 0.10 114 23.8 1.46 1.47 1911-15 24.0 20.0 14.8 0.02 0.13 0.03 0.05 0.00 0.22 0.43 0.16 1.39 0.39 1.33 1.29 0.21 1.54 1.16 0.11 108 28.0 1.40 1.57 1916-20 20.0 20.1 15.1 0.04 0.17 0.02 0.03 0.00 0.20 0.28 1.01 1.43 0.34 1.38 1.30 0.19 1.71 1.28 0.09 92 15.4 1.64 1.72 1921-25 19.9 17.9 12.3 0.01 0.17 0.01 0.04 0.00 0.15 0.17 0.32 1.01 0.19 1.14 0.97 0.16 1.66 1.38 0.10 71 11.7 1.36 1.63 1926-30 16.2 18.6 12.3 0.02 0.10 0.01 0.02 0.00 0.11 0.16 0.30 0.90 0.14 1.00 0.72 0.16 2.29 1.52 0.12 64 10.2 1.60 1.63 1931-35 13.8 19.5 12.1 0.03 0.08 0.00 0.02 0.00 0.07 0.09 0.26 0.79 0.11 0.85 0.47 0.14 2.99 1.66 0.14 63 11.6 0.99 1.38 (d) 1936-40 13.7 25.4 13.4 0.02 0.04 0.00 0.01 — 0.04 0.04 0.19 0.72 0.09 0.83 0.67 0.13 3.67 1.87 0.16 56 10.9 0.49 0.97 1941-45 15.4 23.3 16.0 0.02 0.02 0.00 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 1953 15.2 19.7 11.6 0.01 — — 0.00 — 0.01 0.00 0.15 0.21 0.02 0.64 1.07 0.12 3.25 2.34 0.07 24 1.4 — 0.40 (a) Comparable figures are not available for this period. (b) Death-rales from 1939 to 1949 relate to the civilian population only. Death-rates for tuberculosis are expressed per 1,000 total population in Table 11(b). (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. 147 Table 4—Civilian deaths by cause—Administrative County of London, 1953 Cause Sex 0— 1— 5— 15— 25— 45— 65— 75+ Total 1953 1952 1. Tuberculosis—respiratory M 1 1 1 9 77 260 126 35 510 684 F 2 1 1 12 73 52 29 10 180 249 2. Tuberculosis—other M 1 2 1 2 10 9 3 1 29 45 F 3 6 2 5 8 9 2 9 44 41 3. Syphilitic disease M — — — — 1 42 52 17 112 144 F — — — — 4 13 23 23 63 69 4. Diphtheria M — — — — — — — — — 1 F — — — — — — — — — 1 5. Whooping-cough M 2 5 — — — — — — 7 6 F 12 1 — — — — — — 13 3 6. Meningococcal infection M 6 7 — — 1 — — — 14 12 F 3 5 — — — 1 1 — 10 17 7. Acute poliomyelitis M — 1 2 3 4 — — — 10 18 F — 2 1 2 3 1 — — 9 5 8. Measles M 2 3 2 — — — — — 7 4 F 1 — 1 — — — — — 2 4 9. Other infective, &c., diseases M 3 3 2 1 10 11 11 3 44 43 F 1 2 — — 5 8 11 8 35 53 10. Malignant neoplasm: Stomach M — — — 1 38 241 225 134 639 593 F — — — — 12 115 160 173 460 506 11. Malignant neoplasm: Lung, bronchus M — — — 2 81 734 475 139 1,431 1,329 F — — — — 18 119 86 53 276 283 12. Malignant neoplasm: Breast M — — — — — 3 — 1 4 9 F — — — — 89 316 179 144 728 736 13. Malignant neoplasm: Uterus F — — — — 35 154 87 55 331 296 14. Other malignant and lymphatic neoplasms M 3 6 12 21 108 596 678 580 2,004 2,067 F 5 2 5 12 113 553 516 555 1,761 1,728 15. Leukemia, aleukemia and Hodgkins disease M 1 6 11 11 12 31 17 10 99 94 F — 4 5 4 14 29 22 12 90 85 16. Diabetes M — — — 3 3 22 31 23 82 84 F — — 1 — 2 33 66 58 160 195 17. Vascular lesions, nervous system M — — 1 3 39 349 500 718 1,610 1,669 F — 1 — 2 50 394 678 1,283 2,408 2,589 18. Coronary disease, angina M — — — — 85 1,055 1,055 732 2,927 3,095 F — — — — 10 292 672 891 1,865 1,880 19. Hypertension with heart disease M — — — — 1 87 146 180 414 414 F — — — 1 5 43 154 307 510 555 20. Other heart disease M — 1 2 11 69 253 495 1,148 1,979 2,388 F 1 — 2 6 85 303 533 2,227 3,157 3,614 21. Other circulatory disease M — — — 1 25 187 244 407 864 938 F — — 1 6 14 128 281 673 1,103 1,132 22. Influenza M 3 1 — — 15 52 53 79 203 86 F 2 1 1 1 16 47 58 185 311 76 23. Pneumonia M 87 21 12 4 11 208 319 445 1,107 1,039 F 74 23 2 1 16 89 238 574 1,017 998 24. Bronchitis M 22 5 1 — 29 614 809 737 2,217 2,341 F 23 4 — 1 15 167 336 819 1,365 1,321 25. Other diseases of respiratory system M 1 1 2 1 19 98 85 51 258 267 F 4 2 4 3 10 26 29 49 127 144 26. Ulcer of stomach and duodenum M — — — — 21 148 134 83 386 427 F — — — 1 3 30 52 77 163 154 27. Gastritis, enteritis and diarrhoea M 39 5 — 1 5 15 8 12 85 68 F 26 3 1 3 7 15 27 36 118 113 28. Nephritis and nephrosis M 2 1 2 5 33 63 47 23 176 176 F — 1 3 2 20 51 43 37 157 185 29. Hyperplasia, prostate M — — — — — 21 92 161 274 366 L 148 Table 4 (contd.)—Civilian deaths by cause—Administrative County of London, 1953 Case Sex 0— 1— 5— 15— 25— 45— 65— 75+ Total 1953 1952 30. Pregnancy, childb.: abortn. F — — — 7 30 — — — 37 50 31. Congenital malformations M 101 9 6 4 11 12 4 3 150 154 F 73 11 1 5 16 18 4 5 133 180 32. Other defined and ill defined diseases M 388 28 19 15 82 244 237 322 1,335 1,517 F 283 15 13 22 82 310 286 578 1,589 1,665 33. Motor vehicle accidents M 1 3 14 31 41 28 22 26 166 139 F — 4 7 4 5 24 19 18 81 82 34. All other accidents M 20 18 23 32 96 92 41 64 386 422 F 17 12 12 4 20 38 53 145 301 308 35. Suicide M — — — 13 75 126 50 24 288 248 F — — 1 4 44 82 36 18 185 136 36. Homicide, operations of war M 2 — 1 5 6 3 1 — 18 19 F 1 2 1 1 3 4 — — 12 9 ALL CAUSES M 685 127 114 179 1,008 5,604 5,960 6,158 19,835 20,906 F 531 102 65 109 827 3,464 4,681 9,022 18,801 19,462 Table 5—Live births and still-births—Administrative County of London, 1931-53 Year(s) Live births Still-births No. Rate per 1,000 total population No. Rate per 1,000 total births (live and still) 1931-35 297,293 13.9 9,824 32.0 1936-40 264,358 13.7 8,416 30.8 1941 33,944 13.5 1,046 29.9 1942 40,654 15.4 1,225 29.3 1943 45,030 16.1 1,137 24.6 1944 44,554 16.2 1,138 24.9 1945 45,532 15.7 1,095 23.5 1946 65,883 20.0 1,598 23.7 1947 71,323 20.9 1,554 21.3 1948 60,934 17.9 1,191 19.2 1949 56,545 16.7 1,134 19.7 1950 53,281 15.7 1,054 19.4 1951 52,387 15.6 1,073 20.1 1952 51,558 15.3 1,008 19.2 1953 50,880 15.2 1,091 ' 21.0 149 Table 6—Infant mortality—Administrative County of London, 1953 Cause of death Age at death Total Rates per 1,000 live births Under 1 day 1 to 7 days 1 to 4 wks. 4 wks. to 1 yr. No. Male Female Total Male Female Measles Leg. — — — 3 3 2 1 0.06 0.08 0.04 Illeg. — — — Whooping-cough Leg. — — — 14 14 2 12 0.28 0.08 0.49 Illeg. — — — Influenza Leg. — — 2 3 5 3 2 0.10 0.11 0.08 Illeg. — — — Tuberculosis Leg. — — — 7 7 2 5 0.14 0.08 0.20 Illeg. — — — Bronchitis Leg. 1 — 1 43 45 22 23 0.88 0.84 0.93 Illeg. — — — Pneumonia Leg. 5 24 27 102 161 87 74 3.16 3.31 3.01 Illeg. — — 3 Diarrhoea Leg. — 1 2 61 65 39 26 1.28 1.49 1.06 Illeg. — — 1 Premature birth Leg. 108 61 6 1 203 113 90 3.99 4.30 3.65 Illeg. 16 10 1 Congenital malformation Leg. 31 36 35 60 174 101 73 3.42 3.85 2.96 Illeg. 3 5 4 Birth injury Leg. 64 45 3 2 138 81 57 2.71 3.09 2.31 Illeg. 10 12 2 Post Natal Asphyxia and Atelectasis Leg. 89 89 4 — 196 121 75 3.85 4.61 3.05 Illeg. 10 3 1 Other diseases of early infancy Leg. 27 33 6 6 72 36 36 1.42 1.37 1.46 Illeg. — — — Other causes Leg. 9 10 4 93 133 76 67 2.61 2.89 2.31 Illeg. 16 1 — All causes Leg. M. 186 184 48 188 1,085 606 479 22.96 24.87 20.92 F. 148 115 42 174 Illeg. M. 31 21 8 19 131 79 52 36.25 41.78 30.18 F. 24 10 4 14 Total, 1953 389 330 102 395 1,216 685 531 23.90 26.09 21.56 Total 1952 403 308 106 372 1,189 690 499 23.06 26.08 19.87 1952 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 L* 150 Table 7—Infant mortality by cause—Administrative County of London, 1931-1953 (Rates per 1,000 live births) Cause of death 1931 to 1935 1936 to 1940 1941 to 1945 1946 to 1950 1951 1952 1953 Measles 1.17 0.79 0.34 0.08 0.13 — 0.06 Whooping-cough 2.17 1.66 1.62 0.54 0.17 0.08 0.28 Influenza 0.36 0.32 0.33 0.19 0.15 0.02 0.10 Tuberculosis 0.73 0.55 0.56 0.25 0.08 0.04 0.14 Bronchitis 2.11 1.80 1.82 0.90 0.95 0.83 0.88 Pneumonia 11.12 9.44 7.56 4.25 2.41 3.05 3.16 Diarrhoea 10.81 10.29 7.76 2.70 0.76 0.80 1.28 Premature birth 14.75 12.56 12.06 6.82 4.71 4.19 3.99 Congenital mal., etc. 7.15 7.29 12.03 11.63 12.35 11.77 11.40 Other causes 13.02 11.12 6.32 3.84 3.72 2.29 2.61 All causes 63 56 51 31 25 23 24 Table 8—Maternal mortality (excluding abortion)—Administrative County of London and England and Wales, 1943-53 (Rates per 1,000 total births) 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 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 0.10 Other causes: London 1.06 0.85 1.09 0.80 0.55 0.37 0.38 0.53 0.39 0.53 0.40 England and Wales 1.44 1.24 1.23 1.06 0.86 0.73 0.71 0.60 0.56 0.50 0.54 Table 9—Tuberculosis—Statutory notifications and deaths—Administrative County of London, 1921-53 (a) Year(s) Pulmonary tuberculosis Non.pulmonary tuberculosis Statutory notifications Deaths Statutory 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 1936-40 24,848 1.29 13,664 0.71 4,510 0.23 1,861 0.09 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 1953 4,668 1.40 690 0.21 410 0.12 73 0.02 (a) Excluding posthumous cases. 151 Table 10(a)—Tuberculosis—Statutory notifications by age groups—Administrative County of London, 1953 Form of tuberculosis notified Sex Number of notifications of new cases of tuberculosis Total all ages 0— 1— 5— 10— 15— 20— 25— 35— 45— 55— 65+ Pulmonary tuberculosis M. 12 93 97 47 175 245 566 431 440 394 249 2,749 F. 11 90 75 56 198 366 551 284 128 77 83 1,919 Other forms of tuberculosis M. 1 17 19 13 13 24 42 18 12 6 5 170 F. — 19 24 13 21 34 57 24 20 10 18 240 All forms of tuberculosis M. 13 110 116 60 188 269 608 449 452 400 254 2,919 F. 11 109 99 69 219 400 608 308 148 87 101 2,159 Table 10(b)—Numbers on the registers, 1943-53 1943 1944 1945 1946 1947 1948 1949 1950 1951 * 1952 * 1953 Cases on the register at the end of the year: Pulmonary— Males 13,608 14,340 15,018 15,695 16,374 17,224 18,203 19,090 19,119 17,336 18,475 Females 10,232 10,990 11,496 12,262 12,862 13,549 14,223 15,031 15,556 14,672 14,930 Other forms: Males 2,847 2,866 2,813 2,821 2,699 2,889 2,752 2,591 2,520 1,530 1,508 Females 3,074 3,185 3,123 3,099 3,142 3,147 3,015 3,068 2,954 1,850 1,820 Total 29,761 31,381 32,450 33,877 35,077 36,809 38,193 39,780 40,149 35,388 36,733 No. per 1,000 of population 11.9 12.7 12.5 10.9 10.6 11.0 11.3 11.7 12.0 10.5 10.9 * On the chest clinic registers. Prior to 1952 numbers supplied by the metropolitan borough councils under the Tuberculosis Regulations, 1930, now rescinded. Table 10(c)—Clinic survey of contacts Men Women Children Total Number of new cases diagnosed as tuberculous at chest clinics during the year 2,522 1,877 534 4,933 Percentage of these new cases found to be 'T.B. plus' (i.e. Infective) 42.1 28.1 3.7 32.6 Number of those who attended as contacts and who were: (a) Diagnosed as tuberculous* 127 (4.6) 127 (3.0) 157 (2.5) 411 (3.1) (b) Not tuberculous 2,469 3,902 5,832 12,203 (c) Not determined (as at 31.12.53) 145 228 416 789 *Figures in brackets are percentages of the total contacts examined 152 Table 10(d)—Occupations of adult notifications Registrar-Central's Short Classification of Employment Population mid 1951 Tuberculosis Notifications— 1951 Tuberculosis Notifications—1953 Males Females Males Females Males Females Number Rate per 1,000 Number Rate per 1,000 Number Rate per* 1,000 Number Rate per* 1,000 1. Fishermen — — — — — — — — — — 2. Agriculture, horticulture, etc. 4,500 400 8 1.8 1 2.5 10 2.2 2 5.0 3. Mining, quarrying occupations — — 2 (1) — — .. — — — — 4. Non-metalliferous mining products 3,700 1,700 10 (1) 2.7 2 1.2 9 (1) 2.4 2 (1) 1.2 5. Coal, gas, coke, chemical workers 6,300 600 2 0.3 — — 7 1.1 — — 6. Metalwork, engineering 131,800 15,000 245 (12) 1.9 16(2) 1.1 258 (8) 2.0 16 1.1 7. Textile workers 1,000 1,600 2 2.0 1 0.6 4 4.0 2 (1) 1.3 8. Tanners, leatherworkers, etc. 6,700 5,000 14 2.1 5 1.0 19 2.8 8 1.6 9. Textile goods and dressmakers 26,500 70,600 45 (2) 1.7 117 (13) 1.7 42 (2) 1.6 96 (12) 1.4 10. Food, drinks, tobacco makers 11,200 8,200 30 (2) 2.7 10 1.2 22 (1) 2.0 7 0.9 11. Wood, cane, corkworkers 36,100 1,100 64 (1) 1.8 2 1.8 41 (4) 1.1 — — 12. Papermakers, bookbinders, printers 24,500 13,700 36 (2) 1.5 12 0.9 24 (1) 1.0 18(1) 1.3 13. Other products (plastics, etc.) 7,200 5,700 12 (1) 1.7 2 0.4 10 1.4 5 0.9 14. Builders and contractors 66,700 — 73 (7) 1.1 — — 173 (7) 2.6 2 — 15. Painters and decorators 35,500 1,300 74 (3) 2.1 1 0.8 61 1.7 2(1) 1.5 16. Administrators, directors, managers, 32,200 7,700 8 0.2 — — 17 (1) 0.5 — — 17. Transport and communications 162,400 16,500 287 (16) 1.8 35(4) 2.1 289 (17) 1.8 31 (4) 1.9 18. Finance, insurance, commerce 107,700 60,600 148(1) 1.4 88 (11) 1.5 156 (3) 1.4 69 (5) 1.1 19. Professional and technical 61,200 54,700 94 (6) 1.5 112(8) 2.0 103 (4) 1.7 87 (6) 1.6 20. Defence services 40,300 1,200 96 (3) 2.4 2 1.7 86 (3) 2.1 2 1.7 21. Entertainment and sport 12,300 5,600 27 (1) 2.2 9(1) 1.6 28 (1) 2.3 9 1.6 22. Personal services (hotels, etc.) 75,700 193,500 218 (10) 2.9 211 (17) 1.1 181 (7) 2.4 173 (23) 0.9 23. Clerks, typists, etc. 94,900 167,300 261 (10) 2.8 307 (21) 1.8 219 (13) 2.3 284 (21) 1.7 24. Packers, warehousemen, etc. 41,100 22,200 69 (1) 1.7 29 (2) 1.3 61 (4) 1.5 16(3) 0.7 25. Stationary engine drivers, stokers 10,700 — 35 (2) 3.3 — — 18(1) 1.7 — — 26. Unskilled workers (not elsewhere specified) 74,500 28,800 202 (18) 2.7 51 (4) 1.8 152 (7) 2.0 49(5) 1.7 27. Other and undefined workers 11,400 2,200 95 (8) 8.3 16(3) 7.3 16 (1) 1.4 3 1.4 Total (1.27) 1,086,100 685,200 2,157 (106) 2.0 1,029 (86) 1.5 2,006 (86) 1.8 883 (83) 1.3 28. Housewives — .. — — 743 (83) .. — — 742 (71) .. Unemployed .. .. 414 (17) .. 230 (31) .. 434 .. 239 (30) .. Retired 83,000 32,300 171 (9) 2.1 36 (4) 1.1 190 2.3 51 (12) 1.6 Students .. .. 29(5) .. 23(4) .. 37 .. 22 (3) .. Children under 15 338,200 323,200 382 (92) 1.1 355 (87) 1.1 304 0.9 293 (55) 0.9 Note.—Numbers in brackets are non-pulmonary cases included in the total. * Rates based on 1951 population distribution. 153 Table 11(a)—Statutory notifications of tuberculosis by age and sex—Administrative County of London, 1947-53 Rates per 1,000 living (i) Pulmonary Sex Age 1947 1948 1949 1950 1951 1952 1953 No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—4 108 0.81 149 1.08 153 1.08 162 1.15 137 0.98 85 0.65 105 0.84 5—14 187 1.01 158 0.87 153 0.82 141 0.75 143 0.74 109 0.53 144 0.69 15—44 1,809 2.56 1,873 2.66 1,886 2.70 1,711 2.46 1,574 2.18 1,549 2.16 1,417 2.01 45 + 973 1.61 957 1.60 1,093 1.84 945 1.59 969 1.91 970 1.88 1,083 2.09 All males 3,077 1.89 3,137 1.93 3,285 2.03 2,959 1.83 2,823 1.80 2,713 1.73 2,749 1.76 Females 0—4 96 0.76 124 0.94 126 0.94 116 0.86 123 0.92 88 0.70 101 0.85 5—14 174 0.96 171 0.96 188 1.04 140 0.77 127 0.68 119 0.61 131 0.65 15—44 1,811 2.41 1,797 2.40 1,821 2.45 1,740 2.34 1,582 1.98 1,501 1.90 1,399 1.80 45 + 263 0.36 244 0.34 279 0.39 234 0.33 242 0.36 292 0.43 288 0.42 All females 2,344 1.32 2,336 1.32 2,414 1.36 2,230 1.26 2,074 1.16 '2,000 1.11 1,919 1.08 Total 5,421 1.59 5,473 1.61 5,699 1.68 5,189 1.53 4,897 1.46 4,713 1.40 4,668 1.40 (ii) Non-Pulmonary Males 0—4 69 0.520 55 0.398 39 0.275 34 0.241 29 0.207 26 0.198 18 0.144 5—14 87 0.472 87 0.479 75 0.404 50 0.265 57 0.294 56 0.275 32 0.152 15—44 118 0.167 116 0.165 109 0.156 114 0.164 103 0.143 103 0.144 97 0.138 45 + 36 0.060 29 0.048 32 0.054 29 0.049 27 0.053 36 0.070 23 0.044 All males 310 0.190 287 0.177 255 0.157 227 0.140 216 0.138 221 0.141 170 0.109 Females 0—4 56 0.444 38 0.289 42 0.312 40 0.296 36 0.269 21 0.168 19 0.160 5—14 71 0.394 69 0.388 68 0.375 49 0.271 48 0.257 34 0.173 37 0.182 15—44 190 0.253 171 0.229 159 0.214 183 0.247 178 0.223 184 0.233 136 0.175 45 + 35 0.048 35 0.049 29 0.041 30 0.042 29 0.043 58 0.085 48 0.070 All females 352 0.198 313 0.176 298 0.168 302 0.171 291 0.162 297 0.165 240 0.135 Total 662 0.194 600 0.177 553 0.163 529 0.156 507 0.150 518 0.154 410 0.123 Table 11(b)—Tuberculosis deaths—by age and sex (i) Pulmonary Males 0—4 12 0.09 8 0.06 3 0.02 7 0.05 3 0.02 — — 2 0.02 5—14 9 0.05 2 0.01 1 0.01 1 0.01 — — — — 1 0.00 15—44 495 0.70 463 0.66 323 0.46 236 0.34 196 0.27 127 0.18 86 0.12 45 + 748 1.24 762 1.27 719 1.21 585 0.99 627 1.23 557 1.08 421 0.81 All males 1,264 0.78 1,235 0.76 1,046 0.65 829 0.51 826 0.53 684 0.44 510 0.33 Females 0—4 13 0.10 7 0.05 4 0.03 — — 3 0.02 — — 3 0.03 5—14 8 0.04 6 0.03 4 0.02 2 001 3 0.02 — — 1 0.00 15—44 527 0.70 487 0.65 342 0.46 238 0.32 171 0.21 125 0.16 85 0.11 45 + 232 0.32 165 0.23 189 0.26 156 0.22 151 0.22 124 0.18 91 0.13 All females 780 0.44 665 0.37 539 0.30 396 0.22 328 0.18 249 0.14 180 0.10 Total 2,044 0.60 1,900 0.56 1,585 0.47 1,225 0.36 1,154 0.34 933 0.28 690 0.21 (ii) Non-Pulmonary Males 0—4 30 0.226 26 0.188 13 0.092 6 0.043 10 0.071 7 0.053 3 0.024 5—14 20 0.109 10 0.055 12 0.065 6 0.032 6 0.031 2 0.010 1 0.005 15—44 44 0.062 38 0.054 36 0.052 25 0.036 29 0.040 19 0.027 12 0.017 45 + 38 0.063 29 0.048 34 0.057 25 0.042 21 0.041 17 0.033 13 0.025 All males 132 0.081 103 0.063 95 0.059 62 0.038 66 0.042 45 0.029 29 0.019 Females 0—4 19 0.151 23 0.175 16 0.119 10 0.074 9 0.067 5 0.040 9 0.076 5—14 16 0.089 11 0.062 7 0 039 7 0.039 9 0.048 2 0.010 2 0.010 15—44 48 0.064 35 0.047 20 0.027 16 0.022 15 0.019 14 0.018 13 0.017 45 + 37 0.051 30 0.042 18 0.025 27 0.038 26 0.039 20 0.029 20 0.029 All females 120 0.067 99 0.056 61 0.034 60 0.034 59 0.033 41 0.023 44 0.025 Total 252 0.074 202 0.059 156 0.046 122 0.036 125 0.037 86 0.026 73 0.022 154 Table 12—Statutory notification of non-pulmonary tuberculosis—distribution according to site— Administrative County of London, 1946-53 Rates per 1,000 living are shown in parentheses against the number of cases Age group Year Site of tuberculosis lesion Bones and joints Abdomen Peripheral glands Meninges Other sites (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) 1953 38 (0.058) 3 (0.005) 33 (0.050) 24 (0.037) 11 (0.017) 109 (0.166) 2. Over 15 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) 1953 87 (0.032) 32 (0.012) 81 (0.030) 13 (0.005) 98 (0.036) 311 (0.116) (a) Includes miliary and genito.urinary. Information not available for 1952 owing to change in the regulations governing the notification of tuberculosis. Table 13—Cases of infectious illness reported from schools in 1953 and preceding years— Administrative County of London Year Chicken-pox Diphtheria Rubella 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 1953 7,143 17 686 195 8,282 2,614 526 81 127 64 1,703 3,478 155 Table 14—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—Administrative County of London, 1933-1953 Year Anthrax Continued fever Diphtheria Dysentery Acute Encephalitis Enteric fever Erysipelas Malaria Measles Meningococcal infection Ophthalmia neonatorum Pneumonia Poliomyelitis Puerperal pyrexia Scabies Scarlet fever Smallpox Typhus WhoopingCough 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 5 0.001 9,557 2.23 31 0.007 22 0.005 164 0.038 2,766 0.645 21 0.005 (b) 216 0.050 527 (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 4 0.0009 11,782 2.79 58 0.014 29 0.007 109 0.026 2,586 0.613 30 0.007 137 0.032 467 8.24 5,569 1.320 74 0.018 758 12.91 18,238 4.32 144 0.034 — — 1935 2 0.0005 3 0.0007 9,294 2.23 199 0.048 15 0.004 187 0.045 1,868 0.448 37 0.009 105 0.025 382 6.87 3,707 0.888 85 0.020 652 11.31 10,954 2.63 — — — — 1936 — — 4 0.001 7,030 1.68 304 0.072 12 0.003 255 0.061 1,815 0.432 35 0.008 113 0.027 462 8.10 4,141 0.986 38 0.009 635 10.92 10,705 2.55 — — — — 1937 3 0.0007 6 0.001 7,810 1.91 916 0.224 8 0.002 216 0.053 1,764 0.432 42 0.010 175 0.043 453 8.26 4,798 1.175 108 0.026 793 13.94 8,455 2.07 — — — — 1938 4 0.001 1 0.0002 7,611 1.88 1,049 0.259 5 0.001 191 0.047 1,829 0.451 16 0.004 (c) 282 0.28 182 0.045 489 9.00 3,962 0.978 134 0.033 853 15.18 8,093 2.00 — — — 1,891 (c) 1.87 1939 3 0.0008 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 0.35 169 0.045 408 8.07 3,733 0.990 98 0.026 704 13.05 5,677 1.51 — — — — 10,537 2.80 1940 3 0.001 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 1.78 839 0.274 303 7.10 2,688 0.876 20 0.007 472 10.66 2,498 0.81 — — — — 669 0.221 1941 1 0.0004 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 4.67 706 0.298 185 6.67 2,518 1.064 41 0.017 340 12.06 2,372 1.00 — — — — 7,944 3.36 1942 1 0.0004 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 8.33 341 0.142 210 5.18 2,246 0.936 25 0.010 505 12.06 4,416 1.84 2 0.0008 — — 6,234 2.60 1943 4 0.002 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 9.18 231 0.093 233 5.19 3,159 1.267 43 0.017 471 10.20 9,689 (d) 9.18 9,477 3.80 — — — — 6,661 2.67 1944 (e) — — — — 758 0.308 1,450 0.589 2 0.0008 30 0.012 916 0.372 78 0.032 7,329 2.98 150 0.061 211 4.74 2,292 0.931 17 0.006 399 8.73 16,450 6.70 3,862 1.57 2 0.0008 — — 7,136 2.90 1945 — — 1 0.0004 801 0.308 1,867 0.718 3 0.001 28 0.011 818 0.314 93 0.036 23,486 9.03 145 0.056 222 4.88 1,930 0.742 63 0.024 515 11.05 14,753 5.69 4,079 1.57 3 0.001 3 0.001 3,264 1.25 1946 — — — — 747 0.240 845 0.272 6 0.002 44 0.014 844 0.271 168 0.054 22,846 7.35 184 0.059 268 4.08 2,125 0.683 29 0.009 553 8.19 11,892 3.84 4,402 1.42 2 0.0006 — — 6,887 2.22 1947 2 0.0006 — — 451 0.136 309 0.093 7 0.002 48 0.015 742 0.224 47 0.014 17,486 5.28 166 0.050 231 3.24 2,110 0.638 702 0.212 441 6.05 5,304 1.60 4,331 1.31 3 0.001 1 0.0003 9,267 2.80 1948 1 0.0003 1 0.0003 335 0.100 704 0.211 1 0.0003 48 0.014 719 0.215 33 0.010 30,608 9.17 110 0.033 224 3.68 1,891 0.566 141 0.042 460 7.40 2,484 0.74 4,568 1.37 — — — — 10,450 3.13 1949 3 0.0009 — — 221 0.065 440 0.130 4 0.001 58 0.017 583 0.173 21 0.006 28,816 8.54 76 0.023 186 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 1950 2 0.0006 — — 81 0.024 960 0.283 18 0.005 63 0.019 566 0.167 20 0.006 22,282 6.57 90 0.027 145 2.72 1,691 0.499 Paralytic Non-par. 371 6.83 (g) 823 0.24 4,157 1.23 — — — — 10,875 3.21 863 0.25 Cases 267 Rate 0.079 Cases 163 Rate 0.048 1951 1 0.0003 — — 30 0.009 4,069 1.212 19 0.006 66 0.020 496 0.148 23 0.007 49,148 14.64 108 0.032 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 — — 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 82 0.024 202 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 1953 — — 1 0.0003 11 0.003 2,639 0.789 18 0.005 45 0.013 408 0.122 89 0.027 27,046 8.09 98 0.029 161 3.16 2,434 0.728 235 0.070 97 0.029 1,712 32.94 527 0.16 3,425 1.02 — — — — 11,027 3.30 1,269 0.38 (a) Rate per 1,000 total births. (b) Comparable figures not available for this period, (c) Cases relate to last quarter only—Rates are adjusted on an annual basis, (d) Cases relate to last 22 weeks only—Rates are adjusted on an annual basis, (e) In order to preserve uniformity with published national figures the 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, (g) For cause of increase since 1950 see page 15. 156 Table 15—Notification of certain infectious diseases—distribution by age and date of notification—Administrative County of London, 52 weeks commencing week ended 10th January, 1953 Fourweekly periods 1953 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 5 5 1 11 54 8 25 87 4,185 2,231 121 6,547 76 39 316 438 1 2 3 6 — 2 — 2 105 192 10 308 326 179 — 506 5—8 9 1 2 12 77 30 25 132 3,402 3,100 100 6,619 44 45 536 632 — 4 1 5 1 1 — 2 77 195 15 287 301 182 2 486 9—12 9 6 1 16 62 65 39 168 3,207 2,207 135 5,561 35 33 160 229 2 3 1 6 2 4 — 6 95 251 17 365 461 355 12 829 13—16 13 — 1 14 86 48 49 183 2,169 1,156 113 3,448 23 28 162 215 5 3 5 13 — 1 1 2 88 171 23 284 426 308 8 743 17—20 4 — 2 6 178 95 72 348 887 482 62 1,433 10 6 92 108 4 1 4 9 2 3 1 6 88 205 17 310 533 387 8 930 21—24 2 1 2 5 150 78 82 310 623 413 26 1,063 6 13 56 75 2 5 3 10 1 1 1 3 84 171 7 262 571 472 10 1,054 25—28 — 1 1 2 157 95 104 358 376 140 14 531 10 5 40 55 12 10 6 28 7 9 6 22 68 189 10 269 852 585 17 1,457 29—32 5 1 1 7 54 25 32 111 176 71 10 258 11 9 40 61 20 12 16 49 9 14 19 42 57 110 6 173 934 550 19 1,509 33—36 1 1 2 4 73 24 24 121 81 14 1 96 8 6 25 39 11 2 10 23 4 7 5 16 47 50 5 103 968 432 14 1,416 37—40 1 — 2 3 64 41 34 139 35 11 3 49 10 12 48 71 14 8 9 31 3 12 8 23 52 131 5 189 524 231 9 767 41—44 6 2 — 8 106 51 58 215 55 17 — 73 21 12 89 123 5 8 4 17 3 7 3 13 89 185 3 277 325 139 8 472 45—48 7 2 2 11 108 73 43 224 43 20 3 66 57 23 89 169 6 1 1 8 1 5 3 9 92 223 8 323 318 144 5 469 49—52 4 1 1 6 129 87 64 282 26 12 — 38 66 29 90 186 2 1 2 5 1 1 2 4 92 152 6 251 241 111 7 360 Total (52 weeks) 66 21 18 105 1,298 720 651 2,678 15,265 9,874 588 25,782 377 260 1,743 2,401 84 60 65 210 34 67 49 150 1,034 2,225 132 3,401 6,780 4,075 119 10,998 Notes: 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 1953. 157 Table 16—Statistics of the administrative work carried out by the Metropolitan Borough Councils in 1953 Borough Dwelling Houses Public Health (London) Act Housing Act, 1936 No. in Borough Erected by borough council Houses inspected Notices served Prosecutions Nuisances abated House to house inspections Section 9 Section 11 Closing Orders (other than underground rooms) Underground rooms Section 25 Overcrowding On complaint On notification of illness* Intimation Statutory Notices served Houses made fit Orders made Houses demolished Found to be unfit for habitation Closed or modified occupation approved Orders determined Houses represented Houses demolished Families overcrowded Families obtained alternative accommodation Houses closed Section 12 By owners By L.A. Under Order Voluntarily Orders made Orders determined City of London 1,100 — 9 1 7 3 1 11 20 — — — 5 — — — — — — — — — — 4 3 Battersea 27,627 242 4,196 1,812 2,058 1,150 86 1,886 — — — — — — — — — — 2 2 — — — 35 44 Bermondsey 17,135 57 3,420 656 2,432 982 72 2,984 47 — — — 7 — — 3 14 — — — — 32 — 17 21 Bethnal Green 15,948 181 2,745 718 2,104 874 80 2,379 123 — — 73 2 15 — 3 — — 4 4 — — 50 39 56 Camberwell 42,101 141 5,385 734 2,661 1,434 116 3,021 — 10 17 5 1 2 — — 8 — 14 17 1 — 4 135 101 Chelsea 16,000 92 871 848 327 123 11 433 44 38 32 — 3 5 — — — — — — — — — 22 31 Deptford 16,898 78 2,188 236 1,398 726 44 1,534 — — — — — — — — — — — — — — — 14 5 Finsbury 9,405 120 1,777 (f) 802 82 9 786 — — — — 2 2 2 5 4 — 30 28 — 53 — 23 58 Fulham 35,138 204 4,601 357 2,567 1,125 152 2,633 309 1 — 1 4 1 — — — — 4 4 — — 43 66 89 Greenwich 22,844 131 1,490 276 918 149 2 1,210 219 — — — 1 8 15 — — — 2 2 1 3 — 53 57 Hackney 40,306 200 5,028 338 4,127 1,946 146 5,862 — 3 11 7 1 5 5 2 6 2 14 14 1 — — 91 89 Hammersmith 25,900 170 4,094 283 1,382 844 136 1,012 — — — — — — — — — — 20 20 14 — 4 178 — Hampstead 21,093 58 2,027 559 1,024 318 1 1,024 166 — 3 — — 1 — — 5 — — — 1 — — 219 53 Holborn 6,248 18 369 351 182 43 1 321 — — — — — — 10 — — — 4 — — — — 11 45 Islington 44,594 234 8,522 (f) 4,631 3,197 216 4,652 986 — 1 — 4 2 9 4 3 1 103 61 2 4 38 163 110 Kensington 37,920 165 4,051 3,221 2,044 1,042 230 1,967 395 — — — 1 2 1 11 2 — 83 80 70 — 4 272 182 Lambeth 53,154 211 6,536 2,725 3,045 1,640 252 3,640 — — — — 8 3 29 — 2 — 5 8 2 25 — 29 84 Lewisham 60,770 415 2,172 424 1,141 602 34 1,015 — 15 38 6 1 11 — — 6 4 — — — — — 39 (a) Paddington 23,581 208 3,648 (f) 1,500 626 31 1,494 — 7 12 2 1 16 2 — 2 2 233 233 21 — — 87 121 Poplar 17,659 235 2,777 123 2,029 943 79 2,818 82 — — — 10 5 — — — — 10 13 — — — 57 35 St. Marylebone 23,114 36 1,247 576 675 318 19 720 73 — — — — — — — 2 — 4,099* 46 12 — — 173 5 St. Pancras 27,759 215 4,670 578 3,646 2,028 165 3,646 238 — — — — — — 1 4 — 85 72 18 — — 326 463 Shoreditch 12,026 372 2,722 1,083 1,924 238 18 2,289 1,451 — — — — — — — 2 — 46 30 6 73 28 33 40 Southwark 24,757 129 4,299 607 2,652 1,294 29 3,215 307 1 81 — 57 6 185 1 10 — 82 95 — 13 2 114 300 Stepney 29,542 218 5,022 374 4,548 1,204 73 2,729 179 — — — 6 6 1 — — — 36 51 — 48 11 112 124 Stoke Newington 8,500 256 1,231 248 574 226 25 1,007 — — — — — — — — 20 — 4 4 — — 9 34 7 Wandsworth 96,917 346 7,987 1,199 2,947 708 31 3,001 — — — — — — — — — — 28 26 1 37 16 93 104 Westminster, City of 24,491 60 1,456 630 287 12 7 1,381 1,000 — — — — — — — — — 37 56 32 — 14 43 42 Woolwich 40,227 216 30,701 743 1,393 880 5 1,236 618 — — — 10 12 — 4 20 1 20 9 — 13 — 40 13 Total 822,754 5,008 125,241 19,700 55,025 24,757 2,071 59,906 6,257 75 195 94 124 102 259 34 110 10 4,965 875 182 301 223 2,522 2,347 * A special survey of underground rooms was carried out during the year. 158 Table 16 (continued) Borough Housing Act, 1936—continued Common lodging houses Slaughterhouses Offensive trades Dairies and milk shops Ice-cream premises Restaurants and eating houses Smoke nuisances Cleansing and disinfection Extra water supply to tenement houses Houses let in lodgings No. in borough Inspections Notices served Complaints remedied Licensed Inspections Licensed Inspections Authorised Inspections Registered Inspections Registered Inspections Number Inspections Complaints received Observations Notices served Persons cleansed Rooms or premises cleansed Intimation Statutory Adults Children After infectious disease For vermin City of London 3 3 — — 1 3 — — 3 30 34 20 78 132 711 1,637 12 120 12 — 490 288 7 86 — Battersea — — — — — — 1(c) — 2 2 143 302 238 302 197 909 13 180 3 1 144 1,943 857 255 — Bermondsey 397 54 — — 2 47 — — 9 28 117 192 180 121 64 576 6 212 4 — 189 1,280 11 165 1 Bethnal Green 181 139 54 34 1 7 — — 4 50 128 433 166 418 123 383 — 7 — — 34 1 36 943 — Camberwell (a) (b) (b) (b) 1 37 3 6 5 10 212 68 426 330 338 373 43 83 1 — 96 773 772 1,495 2 Chelsea 575 (b) 19 17 — — — — — — 43 237 99 413 225 763 17 29 — — 491 686 324 219 43 Deptford — — — — 1 6 2(c) — 1 13 83 126 180 134 110 36 2 10 — — 517 852 153 448 — Finsbury 427 — — — 1 18 — — 3 52 133 196 131 60 289 146 24 145 8 — 126 1,099 378 368 6 Fulham — — — — — — — — — — 120 250 225 224 156 1,152 22 1,362 — — 19 10 184 639 — Greenwich 8 25 — 2 — — — — — — 94 201 230 422 92 502 12 123 2 — 147 627 226 6 1 Hackney — 73 10 12 1 4 1 10 5 12 216 374 351 678 236 674 16 1,500 15 — 154 649 1,030 363 — Hammersmith 9.600 (b) (b) (b) — — 2 1 — — 96 861 299 699 259 490 12 200 6 — 482 932 61 830 6 Hampstead 1,573 607 401 401 — — — — — — 45 174 211 227 201 618 16 75 — — 31 86 233 152 6 Holborn 295 407 4 26 2 7 — — — — 41 66 92 184 550 1,761 27 243 7 — 167 — 100 117 3 Islington (a) (b) (b) (b) — — 5 176 13 38 300 547 509 501 660 1,609 51 257 8 1 143 526 450 1,001 58 Kensington 4,000 (b) 5 5 — — — — — — 178 319 316 121 217 666 14 71 1 1 241 1,242 573 1,272 14 Lambeth (a) (b) (b) (b) — — 1(c) — 2 2 258 489 650 194 253 662 26 94 7 — 253 68 817 2,164 2 Lewisham (a) — — — — — 2 1 — — 85 313 373 579 248 633 9 86 — — 61 723 569 122 — Paddington 5,878 909 112 109 1 5 — — — — 118 318 195 146 143 636 2 19 — — 287 53 317 1,428 46 Poplar 145 18 — — 1 44 3(c) — 1 4 144 338 185 163 262 394 18 85 — — 30 3 348 709 — St. Marylebone 1,812 4,159 24 59 2 43 1 9 — — 169 224 192 254 787 2,026 46 276 21 — 648 439 224 349 23 St. Pancras 16,000 (b) (b) (b) — — 2 13 — — 290 582 452 617 850 1,963 32 148 — — 1,004 1,413 777 547 114 Shoreditch — — — — — — — — 1 4 87 142 176 271 280 569 11 264 4 — 11 — 172 385 10 Southwark (a) (b) (b) (b) 6 43 1 4 5 45 164 348 216 387 477 1,295 12 182 3 — 1,689 2,301 245 1,972 — Stepney 730 56 6 13 5 62 — — 18 133 240 290 285 158 913 990 4 91 — — 506 16 269 812 1 Stoke Newington 12 6 1 1 — — — — — — 42 144 92 132 47 181 12 14 — — 11 286 206 239 3 Wandsworth 3 15 — — — — 3 44 — — 258 1,906 730 1,541 507 1,529 28 75 6 — 117 25 709 184 — Westminster, City of 3,350 3,110 2 2 3 68 — — — — 119 175 229 117 2,979 3,800 120 1,623 5 — 482 189 431 3,789 — Woolwich (a) — — — 2 18 2(d) 307(e) 2 4 131 336 342 1,023 272 1,044 7 292 1 — 129 1,082 416 382 — Total 44,989 9,581 638 687 30 412 29 571 74 427 4,088 9,971 7,848 10,548 12,446 28,017 614 7,866 114 3 8,699 17,592 10,895 21,441 339 Note:—A dash signifies a NIL return; (a) Not available; (b) Included under Public Health (London) Act; (c) Not in use; (d) One not in use; (e) Whole-time supervision by 3 inspectors; (f) Included in previous column. Cowsheds—Camberwell 1 (No inspections). Seamen's Lodging Houses: Total 8—Poplar 3 (45 inspections), Stepney 5 (79 inspections). Prosecutions : Common Lodging Houses—Stepney 7. Offensive Trades—Stepney 1. Ice-cream premises—Southwark 7. Restaurants and Eating Houses—Hackney 7, St. Marylebone 4, St. Pancras 6, Stepney 14, Westminster 10. Water Supply to Tenement Houses—Bermondsey 7, Islington 4, St. Pancras 21. Houses let in lodgings—Hackney 2, Hammersmith 5, Holborn 7, Islington 7, Paddington 6, St. Marylebone 6. 159 Table 17—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 1953 720 401 88 4 6,103 1,546 6,911 1,951 17,615 6,121 220,316 102,365 APPENDIX B STAFF OF THE PUBLIC HEALTH DEPARTMENT (AS AT 31st DECEMBER, 1 953 ) 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. plrrie Epidemiology I. Taylor Tuberculosis W. Hartston Staff examinations and mental health C. W. J. Ingham Chief Dental Officer W. Ritchie Young Chief Nursing Officer Evelyn Robinson 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 160 Senior Officers of the Divisions Division Divisional Medical Officer Divisional Administrative Officer Divisional Nursing 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 The following statement shows the number of staff employed in the Public Health Department in December, 1953 (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) 220 570 74 864 Medical staff 25 155 (b) 180 Dental staff 2 72 (b) 74 Chemists 20 — 6 26 Inspectors 14 — — 14 Nursing staff 9 2,179 103 2,291 Medical auxiliaries (c) 18 144 13 175 Social worker grades (including mental health) 34 171 99 304 Supervisory staff (ambulance service) 3 — 15 18 Manual workers, operative staff (ambulance service), domestic grades, etc. 34 2,613 784 3,431 Totals 379 5,904 1,094 7,377 (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 82 visiting medical officers and 10 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, psychotherapists, dental attendants, dental hygienists, dental technicians and apprentices. 161 INDEX Page Adoption of children 62 Air pollution 38 Ambulance service 79 Analgesia 65 Ante natal sessions 64 Anthrax 17 Analysis of samples 30 Appendix 144 Audiometry 116 Bathing centres 104 Births 6 Blind persons 25 Bronchitis 8 Building materials examinations 35 Building programme 49 Cancer 9 Care of mothers and young children 54 Cerebral hemorrhage 8 Chemical branch 28 Child guidance 57, 120 Child helps 77 Child life protection 72 Child-minders 60 Child welfare 57 Chronic sick 27 Dangerous structures 24 Day nurseries 50, 60, 73 Deaths 8 Degenerative diseases 9 Dental hygienists 127 Dental services 123 Detergents 43 Diabetes 10, 120 Diarrhoea and enteritis 17 Digestive diseases 10 Diphtheria 17, 77 Disinfestation 24 Domestic help service 76 Domiciliary midwifery service 63 Dysentery 17 Emergency obstetric service 69 Enteric fevers 18 Enuresis 117 Epileptic children 117 Erysipelas 18 Expectant and nursing mothers 54 Family planning . . 57 Fertilisers and feeding stuffs 42 Fertility 6 Finance 129 Food poisoning 18 Foot defects 89 General Practitioners 59 Page Handicapped children 111 Health centres 53 Health education 72, 92 Health visiting 72 Heart disease 8 Home nursing 74 Hornless families units 27 Hospital services 59 Housing 23 Hygiene inspection of school pupils 103 Illegitimacy 7 Immunisation 77 Improvement grants 24 Infant mortality 12 Infectious diseases 16 Infectious diseases in schools 22, 108 Insecticides 43 Influenza 18 Introduction 3 Leptospirosis 18 Marriage guidance 58 Mass miniature radiography 87 Maternal mortality 14 Meals for children 37, 102 Meals for invalids 27 Measles 19 Medical inspection of school children 100 Medical treatment of school children . . 109 Meningococcal infections 19 Mental health services 93 Midwifery service 63 Milk sampling 37 Mortality 8 Neo-natal mortality 12, 67 Nephritis 9 Night helps 77 Nurseries, day 50, 60, 73 Nurseries, residential 73 Nursing home registration 26 Occupation centres 53, 98 Ophthalmia neonatorum 19 Orthodontics 125 Pneumonia 12, 19 Poliomyelitis 19 Population 5 Premature babies 66 Premises 49 Prevention of illness 85 Public Health laboratory 24 Psychiatry 120 Puerperal pyrexia 14 162 I N D E X—continued Page Recuperative holidays 91 Remedial exercises 120 Reports of Divisional Medical Officers 132 Rheumatic fever 20 Residental establishments 61, 122, 127 Rheumatism scheme 118 River pollution 33 Road accidents 12 Sanitary inspection 24 Scabies 20 Scarlet fever 20 School dental service 123 School health service 53, 99 School children under 5 years 107 School meals 37, 102 Sewage treatment 31 Sewers 33 Slum clearance 23 Smallpox 21 Sodium fluoride dental treatment 127 Special investigations 58, 122 Speech therapy 115 Page Staff 128, 159 Statistical tables 144 Stillbirths 8, 67 Sunday cinema grants 58 Swimming baths 39 Tuberculosis 21, 85 Tuberculous milk 24 Unmarried mothers 62 Vaccination 79 Venereal diseases 91 Vision tests 103 Visitors 130 Vital statistics 5 Voluntary organisations 56 Water sampling 38 Welfare Committee establishments 25, 27, 73 Welfare foods 58 Whooping cough 22, 78