Litrany LCC 60 LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1954 Published by the London County Council Sold at the County Hall, Westminster Bridge, S.E.1 and, directly or through any bookseller, from Staples Press Limited (Bookshop: 14 Great Smith Street, Westminster, S.W.1) 1955 No. 3914 2s. 6d. Postage extra LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1954 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.1 CONTENTS Page Introduction 3 Vital Statistics 7 Population 7 Fertility 7 Mortality 9 Infectious Diseases 17 Tuberculosis 23 Recent trends 23 London's tuberculous population 25 Preventive measures 27 Services provided 28 Statistics 30 General Public Health 39 Housing 39 Public health laboratory 40 Milk sampling 40 Sanitary inspection 40 Blind and partially-sighted 41 Registration of nursing homes 42 Welfare committee establishments 43 Care of the chronic sick 43 Welfare of handicapped persons 43 Scientific Branch 44 Health Service Premises 51 Co-operation with other Health Services 56 Care of Mothers and Young Children 58 Expectant and nursing mothers 58 Child welfare 60 Marriage guidance 62 Special investigations 62 Day nurseries and occasional creches 63 Unmarried mother and her child 65 Domiciliary Midwifery Service 66 Health Visiting and Nursing Services 70 Home Nursing 71 Domestic Help Service 74 Immunisation and Vaccination 75 London Ambulance Service 77 Prevention of Illness : Care and After Care 83 Foot clinics 83 Venereal disease 83 Recuperative holidays 84 Health education 84 Page Mental Health Services 86 Lunacy and mental treatment Acts 86 Mental deficiency Acts 88 Occupation centres 90 Evidence to Royal Commission 92 School Health Service 94 Organisation 94 Medical inspection 95 School meals, milk &c. 97 Average heights and weights 98 Vision 99 Hygiene inspections 99 Children under five years 102 School journeys 102 Infectious diseases 102 Medical treatment 103 Handicapped pupils 107 Enuresis 113 Juvenile rheumatism 113 Remedial exercise classes 115 Psychiatry 115 Residential schools and homes 117 Research and investigation 117 Dental Services 118 Staff 122 Finance 123 Visitors to the Department 124 Reports by the Divisional Medical Officers 125 Appendices 144 (a) Lung cancer, 1931-54 144 (b) Report of a study group on preventive mental health in the Maternity and Child Welfare Service 156 (c) A Historical sketch of the School Health Service 167 (d) Statistical tables 217 (e) Staff of the Department 228 (W. & s. Ltd. 61283) 10.55. 70742. INTRODUCTION The home population of the County in the middle of 1954 was estimated by the Registrar-General to be 3,322,000, a decrease of 21,000 as compared with the previous year. The average age of the population was 37.4 years and 11.6 per cent. were 65 years of age or over. Vital statistics The live birth-rate (15.2 per thousand population) was slightly lower than in the previous year and, whilst it was well in excess of the pre-war and early war years, it now seems to have stabilised a little below the average over the last 21 years. Of the total live births, 7.2 per cent. were illegitimate, a figure of the same order as those for the past seven years. Since 1948 the still-birth rate has remained relatively stable and in 1954 there were 19.8 still-births per 1,000 total births, the legitimate and illegitimate rates being 19.1 and 29.3 respectively. Since 1951 there has been a steady decline in the death-rate to the lowest figure ever recorded of 10.7 per 1,000 of the population in 1954. Heart disease was still the major cause of death and accounted for nearly one-third of the mortality and, although the death rate from cancer showed a slight decrease from 2.34 per 1,000 to 2.31 per 1,000 in 1954, it remained the second leading cause of death. A detailed analysis of the course of lung cancer in London over the last 25 years is given in Appendix A on page 144. The death rate for the bronchitis and pneumonia group fell sharply from 1.71 per 1,000 in 1953 to 1.14 per 1,000 in 1954. The degenerative diseases, namely, heart disease, other circulatory diseases, cerebral vascular lesions, nephritis and bronchitis continue to be responsible for over half the deaths. There was an increase in the number of fatalities from violence which constituted the sixth leading cause of death. One out of every 24 deaths occurring was attributable to this cause, i.e. accidents in the home and on the road, industrial accidents, suicides, etc. The deaths of children under one year continued to decline and reached the lowest recorded figure of 20.7 per 1,000 live-births. Of these, 15.1 occurred in the first four weeks of life, which was also the lowest figure ever recorded in London and compares with 17.8 for England andWales. The infant mortality rate among illegitimate infants was 30Per 1000 illegitimate births. A new table has been introduced on page 227 giving details of temperatures, rainfall and sunshine during 1954 and the differences from average. Weather The number of cases of diphtheria continues to decline and in 1954 there were only four confirmed notifications of the disease and no deaths. There was a smaller number of notifications of whooping cough (4,691) than for some years past and there were only four deaths from this disease. The notifications of scarlet fever (2,444) was the lowest figure recorded since 1941 and there were no deaths. The fatality rate for measles has declined considerably in recent years and from the 7,445 cases notified only two deaths resulted. Similar remarks apply to diarrhoea and enteritis in children under two years of age and the 24 deaths registered during the year from this cause was the lowest on record. Deaths attributable to influenza fell sharply from 514 in 1953 to 83 in 1954 which was the lowest figure since 1948. There was a comparatively low incidence of poliomyelitis and of the 125 cases notified about one-third occurred in each of the three age groups 0-4 years : 5-14 vears : and 15 vears and over. Infectious diseases Notifications of dysentery (4,268) were the highest recorded, the heaviest incidence being found once again among children of pre-school age. On page 18 reference is made to the results of an investigation into the source and origin of 12 months' notifications of Sonne dvsentery in London. A detailed account and statistical data relating to recent trends in the mortality and morbidity of tuberculosis in London are given on page 23. The routine vaccination by B.C.G. of thirteen-year old school children found, after a tuberculin test, to be susceptible to tuberculosis was inaugurated during the year. It is expected that about 36,000 children of this age will be offered this protection each year in the future. Present experience has shown that in about twenty-five per cent, of cases, parental Tuberculosis 3 consent to vaccination has been withheld, but it is hoped that as the benefits of these preventive measures become more widely appreciated, more and more parents will take advantage of the arrangements. Scientific branch A summary of the work of the former Chemical Branch (which has now been re-designated as the Scientific Branch in order to convey more aptly the scope and nature of its work) will be found on page 44. A fuller report of the work of this branch of the Department has been published separately.* Building programme The need tor economy continued to limit the amount of capital building expenditure. The Minister of Health was unable to sanction the provision of new maternity and child welfare centres except in those areas, such as new housing estates, where no clinic services existed at all, and in consequence the five-year capital building programme for the period 1954-59 approved by the Health Committee during the year included only those projects having the highest priority and deferred for the time being schemes for replacement of existing maternity and child welfare centres. A list of works completed during the year appears on page 52. Co-operation with other parts of the National Health Service Further progress was made towards the closer mtegration of the services provided by the Council with the general medical service provided by the London Executive Council and the Hospital and Specialist services details of which will be found on page 56. Care of mothers and young children The attendances of children at the welfare centres reached a record level, 86 per cent, of children in their first year of life having attended. At the end of the year places were provided for 5,850 children under five years in 105 day nurseries and 1,590 young children were being cared for by child-minders under supervised arrangements. The co-ordination of the various agencies concerned in the problem of protecting children against neglect and ill-treatment by divisional standing committees continued and the results accomplished are recorded in the reports of the divisional medical officers (page 125 to 143). The Central Health Services Council in their report for 1952 drew attention to the desirability of the maternity and child welfare services giving more attention to mental health, concentrating especially on the therapeutic and preventive psychiatry of childhood. It was decided to set up a combined study group drawn from the Public Health Department and the Tavistock Clinic under the chairmanship of Dr. John Bowlby of the Clinic to investigate the possibility of increasing mental health work in this field. Their report is set out in Appendix B, page 156 and steps are being taken to give effect to the main recommendations. The first attendances of expectant mothers at ante-natal clinics in 1954 showed an increase of 2 per cent, compared with the previous year and represented 45 per cent, of all women needing ante-natal care. Attendances at educational sessions showed a further encouraging increase of almost one-third as compared with 1953 and were more than double those of 1950, reflecting the attention now being paid to group education at the welfare centres. The transfer of responsibility for the distribution of welfare foods from the Ministry of Food to the Council was effected smoothly and about 200 distributing points were utilised in London. Domiciliary midwifery service The number of confinements attended under the Council s domiciliary midwifery arrangements, which had been declining since 1948, showed a slight increase during the year, when 10,546 home confinements were attended out of a total of 51,655 live and still-births. There was a further increase in the use of gas and air analgesia. Home nursing The home nursing service provided by the 27 voluntary district nursing organisations, acting as agents for the Council through the Central Council for District Nursing in London, continued and expanded their valuable work. The number of visits paid in 1954 (1,873,881) was about 70 per cent, in excess of those in 1949, i.e., the first full year after the inauguration of the National Health Service. * Annual Report of the Scientific Adviser, 1954. Staples Press Ltd., London. 4 Home helps, of whom 3,124 full-time and part-time were employed at the end of the year, continued to provide a very needful service, particularly in relation to the care of aged and chronic sick persons who comprised about four out of five cases assisted. Domestic help service The volume ot assistance given to all categories has increased by 65 per cent, since 1949. Special efforts were made to utilise the service of child helps outside normal hours to prevent children having to be taken into care outside their home during periods of domestic difficulties. There was a slight though welcome improvement in the immunity state ot children under five years of age due to an increase in the number of primary immunisations against diphtheria from 36,004 in 1953 to 47,621 in 1954. The estimated percentage at the end of the year of children 0-4 years who had at any time been immunised against diphtheria was about 55 per cent. If the continuation of the present freedom from diphtheria is to be ensured, the proportion of immunised children under five years, and particularly under one year, must be substantially increased. No effort is being spared to achieve this object, though the measure of success will depend ultimately on the parents. Prophylaxis In spite of the fact that no publicity is given to whooping cough immunisation, the demand from parents to have their children immunised against this disease continues to grow and during the past four years has increased four-fold. The present generation of parents are undoubtedly familiar with whooping cough and appreciate its potential danger more than in the case of diphtheria. The numbers of children vaccinated in their first year of life against smallpox has almost doubled since 1949 and during 1954 was 49 per cent. of the annual live births. This compares very favourably with the figure of 34.5 per cent. for England and Wales, but the importance of having more infants vaccinated as a routine procedure and revaccinated in later years cannot be over-emphasised. The directly provided and ancillary services of the London ambulance service removed a record number of over one million patients in journeys comprising more than five and a half million miles. To effect the maximum economy in vehicle mileage and to relieve pressure on the central control room the practice of establishing direct contact between hospitals, clinics and local general ambulance stations and the stationing of vehicles at hospitals was further developed. Greater use was made of rail transport for long journeys. A new accident ambulance station was opened in Hampstead and work was commenced on building a further station in each of Wandsworth and Woolwich. The London ambulance service Insufficient accommodation in observation wards for the admission of persons suffering from mental illness and the shortage of institutional accommodation for mental deficiency cases, led the Council to make further representations to the Regional Hospital Boards and the Minister of Health. The accommodation in occupation centres for mental defectives was supplemented and at the end of the year a further 130 places had been provided making total accommodation for 935 persons. A summary of the Council's recommendations to the Royal Commission on the Law relating to Mental Illness and Mental Deficiency is set out on page 92. Mental health services The success of the establishment in East London of a special welfare clinic for backward children under five years of age led to the opening during 1954 of six further clinics to provide such a service throughout the County. As fifty years have now elapsed since the Council assumed responsibility as a local education authority from the London School Board it was thought appropriate to include in this report a historical sketch of the origin, development and present organisation of the School Health Service and this is set out in Appendix C on page 167. School health service During 1954 a further survey of the heights and weights of a sample of school children was carried out. A full report has been published separately* but details as to average heights and weights under age and sex and some data on the relationship of height and weight to the onset of puberty are given on page 98. * Report on the Heights and Weights of school pupils in the County of London in 1954. Staples Press Ltd., London. 5 There was a further decline in the percentage of the school population found at nurses' hygiene inspections to be 'verminous' This figure has reduced from 8 per cent, in 1948 to the record low figure of 2.7 per cent. in 1954. The demand for treatment at the Council's child guidance chnics was such that authority was given for the appointment of two additional whole-time psychiatric social workers and one whole-time and two part-time psychotherapists. Dental services Some slight expansion was possible in the school dental services during 1954, but much remains to be accomplished in this field before the Council's policy of establishing a ratio of one full-time dental officer for each 3,000 children on the school roll can be achieved ; the ratio attained throughout the County as a whole was 1 to 5,600. It is disturbing to note the results of the sample survey (referred to on page 118) which showed that of 2,040 children found to require treatment after dental inspection, over one-third had apparently received no treatment or only partial treatment after six months. This survey was carried out to ascertain the extent to which parents who expressed their intention to have private treatment for their children did so, and in an attempt to estimate the volume of children's dental work done elsewhere than through the Council's dental centres. An encouraging feature of the work generally is the progressive improvement in the ratio of permanent teeth restored to permanent teeth extracted. All applications for treatment of expectant and nursing mothers and pre-school children were met during the year but here again a lot remains to be done, when staff considerations permit, before the aims of the National Health Service Act, 1946, for a comorehensive service can be fully realised. Training of student nurses from hospitals For the purpose of meeting the requirements of the revised syllabus of the General Nursing Council whereby student nurses, from the 1st of January, 1954, were required to have a knowledge of personal and communal health and of the social aspects of disease, arrangements were entered into with the four metropohtan area nurse training committees for the provision of facilities by the Council to the nurse training schools in London for their students to be given field experience and for selected medical officers and health visitors to give lectures. About 3,000 students were granted these facilities during the year. Staff The Department lost by retirement, on reaching the age limit on 14th March, 1954, the services of Mr. C. J. Regan, b.sc., f.r.i.c., Chemist-in-Chief, who entered the Council's service in 1911. Mr. Regan's energy and vision enabled the chemical branch to meet the ever-increasing demands for scientific advice in relation to the Council's activities and his contributions towards developments at the Council's outfall works were of the highest order. His wide knowledge, outstanding ability and qualities of leadership have contributed largely to the present high standing of this branch of the Department. He was succeeded by his deputy, Dr. S. G. Burgess, b.sc., ph.d., f.r.i.c., f.Inst.Pet. During the year Dr. G. D. Pirrie, Principal Medical Officer engaged on school health work, and Miss B. Thom, Divisional Nursing Officer for Division 8, commenced two-year secondments to the World Health Organisation. Dr. Pirrie is now engaged on medical relief work in Formosa and Miss Thom is undertaking pioneer public health nursing work in the Eastern Punjab. I regret to record the death on the 21st of March, 1954, of Dr. H. G. Williams, m.r.c.S., d.p.m., d.p.h., whole-time psychiatrist in the department, who was appointed to the Council's service in March, 1949. The development in recent years of the work of the child guidance clinics, special education for maladjusted children, and the beginnings of mental health education owed much to his interest and industry. 6 VITAL STATISTICS Population the total home population of the County in the middle of 1954 according to the Registrar-General was 3,322,000 compared with 3,343,000 in mid 1953—a decline of 21,000. Corresponding estimates for metropolitan boroughs are shown in Table 3 on page 219 and the rates given in this annual report are calculated on these figures. Table 1 (page 217) 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. The net fall in the population from the middle of 1953 to the middle of 1954 is made up of losses in the 0-4, 15-24 and 25-44 age groups offset partially by gains in the 5-14, 45-64 and 65+ groups. The numbers in the 0-14 age group as a whole have remained relatively stable and the fall in the 0-4 group and the corresponding rise in the 5-14 one are in part a reflection of the higher birth-rate in 1948 and 1949. It is doubtful whether the loss of the younger children is wholly attributable to changes in the birth-rate and, looked at in conjunction with the large decline in the population aged 15-44, it would seem that the newly-established families are still leaving the county for new and expanded towns and the like; the balance of the increase in the 5-14 age group is only explainable in terms of a lesser inward movement of old established families. The increased proportion of the aged and the higher average age of the population are continuations of long existing trends. Fertility The total births allocated to London for 1954 were : Live 50,630 Still 1,025 Total 51,655 The live birth-rate in 1954 was 15.2 per 1,000 total population as compared with 15.3 in 1953. (The figure actually published for 1953 was 15.2 but it has since been adjusted in the light of a later allocation of births from the Registrar-General.) The number of live births registered as occurring in London was 58,442, an excess of some 7,800 over those attributable to mothers residing within the County. The corresponding excess in 1953 of registered births over those allocated was 7,500. The birth-rate in London tends to follow the same trend as for the country as a whole— indeed, since 1947 the rates have been practically identical. The two rates are not however strictly comparable because the proportion of women of child-bearing age in the population is greater in London than in England and Wales. If the London rate is multiplied by the areal/comparability factor (0.87) it becomes 13.3 and hence lower than that for England and Wales. This lower adjusted birth-rate is not however surprising when it is considered that although there are proportionately more potential mothers in London, proportionately fewer of them are married—60.5 per cent. as opposed to 64.0 per cent. in England and Wales, according to the 1951 census. Live births The course of the birth-rate over the last 21 years is shown in the diagram (page 8) from which it will be seen that whilst it now seems to have stabilised a little below the average for the period, it is well in excess of the pre-war and early war years. The actual numbers and rates are given, together with those for still-births, in Table 2 (page 218). For the years 1940 to 1949, the rates will not agree with those published by the RegistrarGeneral because his are based on the civil population whereas those quoted are based on an estimated total population—the justification for this divergence was given in 7 the Report for 1947 and is briefly that births registered in the years in question included those in respect of non-civilians and the rates would have been inflated if fathers in the Forces had been excluded from the calculations. Since 1950 home population has been used as a divisor and the rates shown since that year should be reduced by 0.1 for a strict comparison with earlier years when total population was used. LIVE BIRTH RATE IN LONDON (A.C.) 1934-1954 The number of marriages registered in London in 1954, was 32,876 or 19.8 persons Marriages married per 1,000 of the total population—the corresponding rates for 1953 and 1952 were 19.7 and 19.9 respectively. There were 3,643 illegitimate live births (7.2 per cent, of the total live births). The Illegitimacy percentages in recent years were : Year London A.C. England and Wales Year London A.C. England and Wales 1938-42 6.6 4.7 1949 6.9 5.1 1943 8.2 6.3 1950 7.0 5.1 1944 9.3 7.2 1951 6.9 4.7 1945 11.4 9.4 1952 6.9 4.8 1946 8.0 6.7 1953 7.1 4.7 1947 6.7 5.3 1954 7.2 4.7 1948 7.0 5.4 It will be seen that, after a fall from a peak in 1945, illegitimate births in London have, since 1948, stabilised at about 7 per cent, of total live births while for the country as a whole they have also stabilised but at a lower percentage. Such evidence as is available suggests that the true illegitimate fertility rate in London is lower than would appear from the crude figures because of the understandable wish 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 however allocated to London and consequently increase both its illegitimate and total fertility rates. Deaths under one year among illegitimate infants amounted to 30 per 1,000 illegitimate births compared with a rate of 20 for legitimate births. The corresponding rates for 1953 were 36 and 23 respectively. A detailed comparison of deaths in both groups is given in Table 6 (page 222). 8 There were 1,025 still-births in 1954 or 19.8 per 1,000 total births—the legitimate and illegitimate rates being 19.1 and 29.3 respectively. The number of still-births and rate per 1,000 total births in each year since 1946 and for each of the three preceding quinquennia is shown in Table 2 (page 218). After remaining stable for several years the still-birth rate fell sharply in 1943 and continued to fall until 1948 ; since then the rate has remained relatively stable and somewhat lower than that of England and Wales 123-5). Still-births Mortality The total deaths in 1954 amounted to 35,469 or 10.7 per 1,000 of the population. Detailed figures are given in Tables 3, 4 and 5 (pages 219-221). Mortality from infectious diseases is discussed under the heading of ' Infectious Diseases' on page 17, and tuberculosis is dealt with separately (see page 23). For the latter and other principal causes of death the trend is indicated by the diagrams on page 12.* The death-rate from all causes, which, with the increasing age of the population, had been slowly rising before the war, rose sharply in 1940. This increase was partly due as explained in the footnote below to the exclusion of the young and healthy section of the population from the statistics but the heavy toll of air raids was an important contributory factor. Between 1944 and 1950 there was generally a decline followed by a rise in 1951 attributable largely to an increase in respiratory and heart disease ; since that year there has been a steady decline to the current figure which is the lowest ever recorded. The course of the death-rate over the last 21 years is shown in the diagram (page 11). The leading causes of death in London in 1954 were as follows : Deaths Rate per 1,000 population Diseases of the heart 10,698 3.22 Cancer 7,677 2.31 Vascular lesions of the central nervous system 4,002 1.20 ‡Pneumonia, bronchitis 3,770 1.13 Other circulatory 1,888 0.57 Violent causes 1,470 0.44 Digestive diseases 1,379 0.42 Diseases of early infancy (immaturity, injury at birth, congenital malformation, etc.) 758 0.23 Tuberculosis (all forms) 658 0.20 Nephritis 320 0.10 Hyperplasia of prostate 285 0.09 All other causes 2,564 0.77 Total 35,469 10.68 Leading causes death J Excluding pneumonia of the new bom (under 4 weeks) which is included in 'Diseases of early infancy' * 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† Cause Approximate change as a percentage of those formerly assigned to this cause† Influenza — 11 percent. Bronchitis + 100 ,, ,, Cancer . — 3 ,, ,, Pneumonia + 5 „ ,, Diabetes -30 ,, ,, Other respiratory diseases + 50 ,, ,, Heart diseases — 10 ,, ,, Nephritis. + 12 ,, ,, Other circulatory diseases — 6 ,, ,, 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. 9 The only change in the order of magnitude compared with 1953 is that pneumonia and bronchitis, in which there was a considerable fall, has gone from third to fourth position, below vascular lesions which has maintained the same rate. The diagram on page 12 shows the relative movements of the first four causes, and of tuberculosis, since 1934. While the rates given above present a true order of importance as regards the population at large, they do not give an adequate picture of their effect on the working population as so many of them are diseases which affect mainly the aged. The table below shows the loss of years of 'working life' (taken as ages 15-64) lost per 10,000 total population for certain diseases worked out by the method shown in Appendix C of the Registrar-General's return for the quarter ended 30th June, 1954. It will be seen that, as might be expected, the greatest loss of working life is caused by diseases of early infancy, followed by cancer, diseases of the heart, violent causes and pneumonia and bronchitis. Cause of death Years of working life lost per 10,000 population Male Female Total Diseases of early infancy 162 99 261 Cancer 135 99 234 Diseases of the heart 101 45 146 Pneumonia, bronchitis 69 36 105 Violent causes 88 34 122 Digestive diseases 35 17 52 Vascular lesions of the central nervous system 26 22 48 Tuberculosis (pulmonary) 19 16 35 Nephritis 11 10 21 Other circulatory diseases 12 7 19 Hyperplasia of prostate 1 — 1 All other causes 89 66 155 All causes 748 451 1,199 Bronchitis and Pneumonia The death-rate for the bronchitis and pneumonia group was 1.14 in 1954 compared with 1.71 in 1953. The course of the two components has varied—bronchitis has shown a generally downward trend after its spurious increase in 1940 whereas pneumonia has, since 1946, shown biennial rises and falls. In the year under review both have fallen sharply. Figures for the component diseases are shown in Table 4 (page 220). Cancer The cancer death-rate for all ages in 1954 was 2.31 per 1,000, slightly lower than in 1953. 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. Rates for specified ages since 1948 are shown on the next page : 10 London A.C. : Cancer Mortality Rates per 1,000 living (total population) Age and Sex 1948 1949 1950 1951 1952 1953 1954 Males: 0-14 0.03 0.06 0.11 0.10 0.11 0.12 0.11 15-44 0.30 0.29 0.38 0.35 0.37 0.39 0.34 45+ 5.61 5.81 6.18 7.45 7.35 7.45 7.36 All Males 2.21 2.27 2.45 2.60 2.61 2.68 2.64 Females: 0-14 0.03 0.05 0.07 0.09 0.08 0.07 0.06 15-44 0.36 0.33 0.37 0.35 0.35 0.38 0.32 45+ 4.44 4.42 4.51 4.83 4.87 4.86 4.78 All Females 1.95 1.93 1.98 1.99 2.02 2.04 2.02 All Persons 2.08 2.09 2.20 2.27 2.30 2.34 2.31 It is gratifying to note that for both sexes and for all age groups there has been a fall in 1954. The main contributions on the male side are decreases in cancer of the stomach and 'other' offset partly by an increase in lung cancer ; on the female side decreases in cancer of breast and uterus, again offset partially by an increase in cancer of the lung. These changes no doubt reflect the progress of operative technique. Up to 1953, for England and Wales, the comparative mortality index for females had fallen to 0.92 (1938=1.00), while the male index had remained at 1.13. In London, for both sexes combined, the long-term trend of cancer mortality can be seen from Table 4 (page 220). The increase there shown 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. A more detailed examination of the course of lung cancer in London over the past 25 years is given in Annendix A (Page 144.) The death-rate from vascular lesions of the central nervous system in 1954 was 1.20 per 1,000, the same as in 1953. It would appear that the rate, which had steadily increased from 1.01 in 1948 to 1.27 in 1952, has stabilised at a slightly lower figure than that of the post-war peak year. Cerebral hæmorrhage, etc. DEATH RATE IN LONDON (A.C.) 1934-1954 11 Degenerative diseases YEAR If, as an indication of mortality from degenerative diseases, death from heart disease, other circulatory diseases, cerebral vascular lesions, nephritis and bronchitis are combined, the following trend becomes apparent: Mortality (per 1,000) from cardiovascular, renal disease and bronchitis 1931-40 5.33 1950 5.99 1941-45 7.18 1951 6.82 1946 6.11 1952 6.64 1947 6.27 1953 6.21 1948 5.47 1954 5.75 1949 6.11 The true effects of the war cannot be separated from the statistical influences described in the footnote on page 9. The rates in post-war years still appear to be running higher than pre-war, 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 which is doubtless a reflection of the increasing longevity of the population. 12 Mortality from digestive diseases (other than cancer) in 1954 was 0.42 per 1,000, the same as in 1953. Within this group the death.rate from ulcer of the stomach or duodenum was 0.16 per 1,000 compared with 0.16 in 1953 and 0.17 in 1952. Digestive diseases Diabetes mortality fell steadily between 1939 and 1948, but in the last five years the death-rates have been 0.06, 0.07, 0.08, 0.09, 0.08. As will be seen from Table 4 (page 220) the current figure of 0.06 is lower than that for any quinquennium in the present century, and is in fact the same as in 1948. At ages under 55, where treatment is more effective, the number of deaths in 1954 was 22 which compares as follows with figures for previous years : Diabetes 1936-38 (mean annual deaths) 86 1949 26 1939-41 ( „ „ „ ) 71 1950 39 1942-44 ( „ „ „ ) 42 1951 34 1945-47 ( „ „ „ ) 31 1952 34 1948 27 1953 20 Heart disease, with a death-rate of 3.22 was still by far the major cause of death and accounted for nearly one-third of mortality. There was a very slight fall from the figure of 3.25 in 1953 but it is as yet too early to see whether the figure will stabilise or whether the increasing trend visible from the beginning of the century until the war years has been truly put into reverse. Heart disease The infant mortality in 1954 was 20.7 per 1,000 live births which compares with rates of 23.9 in 1953 and 23.1 in 1952. 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 223). This table has been expanded to separate the major causes previously linked together under the heading of congenital malformation, etc. (and also to agree with the appropriate table in the Annual Report of the Ministry of Health). The diagram on page 14 illustrates the movements in the more important current causes of death. Infant mortality and neo-natal mortality 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 old headings given in the table there has been a pronounced improvement in mortality rates although in 1953 there was a temporary increase, 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. It is noticeable from the diagram, however, that certain of the components previously included in the generic heading of congenital malformations have shown either no improvement, i.e., birth injury, or a worsening, i.e., post-natal asphyxia and atelectasis, but this somewhat gloomy picture must be looked at in conjunction with the explanation given at the beginning of the paragraph, and in the light of the lowest infant mortality on record. The effect of these causes is felt largely in the first four weeks of life and is dealt with in more detail in the succeeding paragraphs. Deaths in various periods of the first year of life during 1954 are shown in detail in Table 6 (page 222). Deaths under four weeks numbered 766 or 15.1 per 1,000 live births —a new low record. Comparative rates for London and England and Wales in past 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 1954 15.1 17.8 13 There is some irregularity in the decline in both sets of rates and the margin between them has varied in extent. In London there was a wartime increase 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 the first four weeks of life, which result largely from immaturity, congenital malformations and birth injury, have been more resistant to reduction. The distribution of causes of death in the first four weeks of life in descending order of magnitude in 1953 and 1954 was as follows : Cause No. of deaths Per cent. of total 1953 1954 1953 1954 Post-natal asphyxia and atelectasis 196 203 23.9 26.5 Immaturity 202 184 24.5 24.1 Congenital malformations 114 121 13.9 15.8 Injury at Birth 136 118 16.6 15.4 Pneumonia of newborn 59 39 7.2 5.1 Other diseases of early infancy 66 31 8.0 4.0 Gastro-enteritis and diarrhoea 4 1 0.5 0.1 All other causes 44 69 5.4 9.0 Total 821 766 100.0 100.0 INFANT MORTALITY MORTALITY PER 1,000 LIVE BIRTHS It will be noted that there are three changes in the order of magnitude between 1953 and 1954—post-natal asphyxia has risen from second to first place, displacing imma- 14 turity; congenital malformations have risen from fourth to third, displacing birth injury; and pneumonia has risen from sixth to fifth displacing other diseases of early infancy. Despite these fluctuations deaths from immaturity, injury at birth and congenital malformations consistently account for some 55 per cent. of neo-natal deaths and it is in these fields that any drastic reduction must be sought. In London, deaths in the first four weeks of life from immaturity 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, have continued to fall to 3.6 in 1954. This comparatively large reduction in the rate is doubtless associated with the contemporary emphasis on the care of immature 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 which compares with 2.3 in 1954 and which is, however, a definite reduction from the figure of 2.7 for both 1953 and 1952. The birth injury death-rate has been under-stated 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. It would appear, therefore, safe to say that in fact the pre-war figure has been regained if allowance is made for the increased precision of diagnosis. The average neo-natal death-rate from congenital malformations was 2.8 per 1,000 live births over the nerind 1936-40. and in 1954 the rate was 2.4 A summary of maternal mortality statistics is given below. Comparative figures for England and Wales in recent years are shown in Table 8 (page 223). Year Live births and stillbirths Deaths in pregnancy or child-birth excluding abortion Post-abortion deaths No. Rate No. Rate 1950 54,335 29 0.53 9 0.12 1951 53,460 24 0.45 18 0.23 1952 52,566 35 0.67 15 0.19 1953 51,971 21 0.40 16 0.21 1954 51,655 28 0.54 6 0.12 Maternal mortality Rales per 1,000 total births, except for deaths following abortion where the rales are expressed per 1,000females (15-44) The maternal mortality rate (excluding post-abortion deaths) in 1954 was 0.54, as compared with 0.40 in the previous year. 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 discussing 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 1951 1952 1953 1954 1951 1952 1953 1954 1951 1952 1953 1954 Sepsis 13 10 8 5 3 8 1 3 16 18 9 8 Other causes 5 5 8 1 21 27 20 25 26 32 28 26 Total maternal deaths 18 15 16 6 24 35 21 28 42 50 37 34 It is interesting to note that the total number of maternal deaths has in fact fallen in 1954 and that the rise in mortality (excluding abortion) has been offset by a reduction in the post-abortion deaths. In England and Wales there were 480 maternal deaths— the lowest figure so far recorded: 76 of them were post-abortion. The maternal mortality rate for the country as a whole was thus 0.70 (0.10 due to sepsis; 0.49 due to other causes; and 0.11 post-abortion): the corresponding London figures were 0.66 (0.06; 0.48; and 0.12). 15 B The trend of maternal mortality in London since 1901 is shown in Table 4 (page 220): it fell slowly and somewhat irregularly—with an upswing during the first world war— until the introduction of sulphonamides in the middle of the '30's; from then on puerperal sepsis has dwindled rapidly away but the fall in ' other causes ' was interrupted by the second world war. The course of maternal mortality since 1934 for both London and England and Wales is shown by the following diagram, which illustrates clearly the effect of war conditions in arresting temporarily the decline in maternal mortality in London. 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. MATERNAL MORTALITY (EXCLUDING ABORTION) MORTALITY PER 1,000 TOTAL BIRTHS Puerperal pyrexia The notification rate of puerperal pyrexia in 1954 was 37.52 per 1,000 total births (1,938 cases) compared with 32.9 in 1953, 35.4 in 1952, 17.0 in 1951 and 6.8 in 1950. This large increase in notifications since 1950 is misleading and is due to the Puerperal Pyrexia Regulations of 1951 which altered the definition of puerperal pyrexia and required the inclusion of cases notified in the hospitals—the revised definition accounting for the major portion of the apparent increase. Respiratory diseases other than bronchitis and pneumonia Road accidents The rate for ' other respiratory diseases' was distorted in 1940 by the revision of causes of death, but thereafter declined fairly steadily until 1951, remaining stable at 0.12 per 1,000 until 1954, when it fell to 0.10. The number of London residents who died in motor vehicle accidents in 1954 was 269 compared with 247 in 1953 and 221 in 1952. In addition there were five deaths from other road accidents. 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 1954—250, for 1953—233, and for 1952—205. As is clear from these figures, some London residents come by their death in motor vehicle accidents outside the confines of the County. Although the number of fatal road accidents in London is still going up, it is not rising proportionately to the number of vehicles currently licensed in the County, i.e., the fatal accident rate per vehicle is going down, albeit too slowly. Violence Other violent causes of death accounted for 1,201 deaths. The corresponding figure for 1953 was 1,190. 16 A detailed analysis of the causes of death from violence (other than road accidents) for the last two years in order of magnitude is set out below: it will be seen that the allocation as between the causes is virtually unchanged. Cause of death 1954 1953 M. F. Total M. F. Total Suicide 315 179 494 288 185 473 Falls 127 178 305 143 167 310 Poisoning 51 62 113 50 41 91 Transport accidents (other than motor vehicles) 34 7 41 54 4 58 Other 157 91 248 157 101 258 684 517 1,201 692 498 1,190 As regards fatal falls, the total of 305 was made up of 117 on the same level, 76 from one level to another, 39 on stairs, 5 from ladders and 68 unspecified; 240 occurred to persons aged 65 and over and of these 186 occurred to persons aged 75 and over— two-thirds being of females. The bulk (74) of the cases of fatal poisoning were attributed to gas in domestic use, the next highest cause (22) being barbituric acid and derivatives. Among the other accidents (248), drowning (58) fire and explosions (52) inhalation of food or other objects causing obstruction or suffocation (25) and homicide (21) were the major causes. INFECTIOUS DISEASES The attack rates and death rates of the principal infectious diseases in London are shown in Tables 3, 4 and 10 (pages 219, 220 and 224): Table 3 shows both types of rates for the constituent Metropolitan Boroughs in 1954; Table 4 shows death rates since 1901 for the County as a whole; and Table 10, attack rates for the County since 1934. 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 10). Table 11 (page 225) 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 10. There was one notification of anthrax during 1954. The person concerned was a male hide sorter and developed a pustule on the finger which quickly improved under chemotherapy. Bacteriological examinations were negative and the diagnosis remains in doubt. Anthrax The number of deaths from diarrhoea and enteritis under 2 years of age was 24, this being the lowest figure ever registered. The number of deaths from this cause was 43 in 1952 and 72 in 1953, the figures in both of these years being increased by the effects of the fog in December, 1952, which resulted in a successive number of deaths from enteritis associated with upper respiratory infections. As will be seen from the diagram set out on page 18, the figure for 1954 is returning towards the point where it would have been expected if the trend from 1947 to 1951 had continued without the disruptive influence of the fog. Diarrhoea and enteritis 17 DEATHS FROM DIARRHOEA AND ENTERITIS (under two years) Diphtheria For the second successive year there were no deaths in London from diphtheria. There were only 4 confirmed notifications of the disease, compared with 11 in 1953 and 18 in 1952. This almost complete freedom from diphtheria during the year is the fruits of the immunisation campaign begun in 1940. In 1939 there were 3,671 (uncorrected) notifications of diphtheria in London and 98 deaths—the contrast with the present state of affairs is obvious from the figures. The scale of the diagram set out on page 19 was chosen to demonstrate the rate of change from year to year. It can be seen that there was an abrupt increase in the rate of improvement in the immunised age groups (0-14 years) after 1941 as a result of the immunisation campaign and that the rate of improvement was steady in subsequent years. In a County as large as London, with large numbers of migrants passing through each year, the possibility of imported infection is always present, and efforts to keep the level of immunisation as high as possible must be maintained. The present low level of incidence of this disease, together with the possibility of imported infection, means that while the present low figures do not justify complacency, a small fluctuation upwards need not cause undue alarm. Dysentery The figure of 4,268 notifications of dysentery was the highest ever recorded. The epidemic was already beginning in the new year and came to its peak in April. Once again the heaviest incidence was among children of pre-school age but there was a slightly increased proportion among schoolchildren compared with last year. Dysentery is often associated in the public mind with food infections, but it should be noted that food-borne outbreaks are at present very uncommon, and there is no evidence that the heavy incidence of recent years is due to food infection. In May, 1952, the Joint Committee of the Borough Medical Officers of Health and the Medical Officer of Health of the London County Council approved the proposals of a sub-committee for an investigation into Sonne dysentery. The investigation in which all the borough medical officers co-operated with the staff of the Department 18 DIPHTHERIA—AGE INCIDENCE NOTIFICATIONS PER 1,000 LIVING IN AGE GROUPS 19 took place between November, 1952 and October, 1953. A report has now been presented to the main committee which contained data on the source and origin of one year's notifications in London. Nearly a half of the cases notified had a clinical illness which was confirmed bacteriologically, less than a tenth were symptomless carriers, and two-thirds of the cases were in outbreaks of two or more associated cases. The secondary attack rate increased steadily with increase in family size above three persons. Children under 15 were more likely to give rise to secondary spread, and more susceptible to secondary spread than those over 15. There was also a suggestion that the child under five gave rise to more spread than the older child, but this was less certain. Secondary spread was greater in homes where cleanliness had been assessed as poor than in other houses. Isolation of the primary case by removal to hospital appeared to have no effect on secondary spread. A clear association was shown between the severity of the primary case and the resulting spread ; in particular it was found that very little spread resulted when the primary case was a symptomless carrier. Trials of the use of sulphonamide to limit the spread of the disease in day nurseries were carried out at the same time; success or failure appeared to depend more upon the number of children involved in the first wave of cases than upon any other factor ; where the infection was widespread sulphonamide appeared to present few advantages. The inquiry produced a great deal of factual information on the above and other aspects of the disease. Of particular interest was the finding of very low secondary family attack rates following exposure to symptomless excreters. Whether or not this can justify some relaxation of the customary practice of excluding such cases from day nurseries is a matter that can only be decided by practical trials in this field. Enteric fevers The number of notifications of enteric fevers in the year (49) showed little change from the previous year (45). There was once again an absence of substantial epidemics. Some of the infections occurred among persons recently returned from visits to the continent, but these formed only a small proportion of the total. The principal method of attack on this type of infection is an intensive investigation into the circumstances of origin of each individual case with a view to bringing to light the healthy carrier of infection. Erysipelas The number of notifications of erysipelas was 368 compared with 408 in 1953, and the number of deaths was one compared with three in 1953. The number of notifications has been decreasing steadily for many years. It is known that the notification of erysipelas is defective to an indeterminate degree and it is therefore not possible to say whether any significance should be attached to this decrease in recent years. It is noteworthy that another streptococcal disease, namely, scarlet fever, has not shown the same tendency towards diminishing incidence. Food poisoning There was a slight diminution in the notifications of food poisoning, 1,060 cases being notified compared with 1,269 in 1953. The sex and age distributions were : Age Males Females Total Attack rateper 1,000 0-4 146 112 258 1.10 5-14 54 46 100 0.24 15-44 178 332 510 0.35 45-64 63 84 147 0.18 65+ 14 31 45 0.12 455 605 1,060 0.32 Influenza The figures show a male excess in childhood and a female excess in adult life. The age specific attack rates would appear to suggest that this condition is notified more frequently in pre-schoolchildren than in schoolchildren and adults. There were only 83 deaths during the year attributable to. influenza, this being the lowest figure recorded since 1948. The influenza epidemic in the early part of the year 20 was of unusually small proportions. Deaths in recent years have been : Year Influenza deaths 1943 726 1944 206 1945 171 1946 371 1947 284 1948 78 1949 372 1950 256 1951 809 1952 162 1953 514 1954 83 The incidence of Leptospirosis in the general population is not known accurately. It is known, however, that the majority of cases occurs in adult men engaged in mining or on sewer work where the infection originates from rats. One case of the disease occurred during the year among the sewer workers directly under the supervision of the Chief Engineer's Department. Leptospirosis The year 1954 being the first of the biennial cycle, incidence of measles was low during the early part of the year. It rose during the summer, and after the customary autumn depression rose steeply during the last part of the year. At the turn of the year incidence was building up to the epidemic peak in early 1955, during which a higher weekly total of notifications was registered than in any previous year since notification began in 1939. The fatality rate of measles has declined considerably in recent years and during the year there were only two deaths from this disease. Measles The incidence of meningococcal infections was again at about the usual interepidemic level at which it has been since the end of the war. There was, as usual, a slight increase in incidence in the Spring but, apart from this, cases were fairly evenly spread both in time and geographically, with no sign of local epidemics. The 28 deaths from meningococcal infection place this disease in an unenviable light when compared with the smaller figures for the other notifiable infectious diseases, but this is largely due to the great reduction in mortality from some of the other infectious fevers in recent years. There is good evidence to show that most of the deaths from meningococcal infection are the result of septicaemic and haemorrhagic attacks in infancy which have always been a formidable therapeutic problem. Meningococcal infections Sixty-two notifications were or children under the age or five years. of the 19 deaths in children under five years of age, 10 were less than a year old. The ratio of notifications to deaths at various ages was as follows : Age Deaths Notifications Deaths as percentage of notifications 0-4 years 19 62 32.2 5-14 years 3 15 20.0 Over 14 vears 6 9 21.4 The incidence of ophthalmia neonatorum which, since 1921, had 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 between 2 and 4 per 1,000 live births. There were 112 cases in 1954 (2.2 per 1,000 live births) of which 101 were those where the mother was a resident of the County of London ; full details of the latter are shown below : Ophthalmia neonatorum Ophthalmia neonatorum Number of cases Domiciliary confinements Institutional confinements Total Notified during the year 45 56 101 Removed to hospital for special treatment 10 — 10 Of the 101 cases, vision was unimpaired in 94 cases at the end of the year and the remaining 7 had removed from the county. 21 Pneumonia The 1,502 notifications of pneumonia in 1954 was the smallest number ever recorded. As only acute primary and acute influenzal pneumonia are notifiable, the notifications can only be a small proportion of the total number of cases of pneumonia which occur: even so there is good reason to believe that the disease is substantially under-notified. In view of the low incidence of influenza in 1954 there is, at first sight, nothing unexpected in the low figure of pneumonia notification. Consideration of the notifications over many years shown in Table 10 on page 224 does, however, raise the possibility of a gradual trend towards less complete notifications through the years. Poliomyelitis The number of notifications of poliomyelitis during the year was 125. Since the first large epidemic in 1947 there have been three years, viz., 1948, 1951 and 1954 which stand out from other years by reason of comparatively low incidence. Incidence showed the usual seasonal pattern and once again the 5-14 age group differed from other ages in having an excess of non-paralytic cases. As a result of this the excess of paralytic cases in other age groups is greater than would appear from perusal of the total figures at all ages. Roughly a third of the notifications occurred in each of the three main age groups. Age No. % 0-4 42 33.6 5-14 41 32.8 15+ 42 33.6 Total 125 100.0 The variations in the proportion of notifications falling in the 0-4 age group in recent years are seen in the following table. 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 1954 33.6 Trials of a vaccine for the prevention of poliomyelitis carried out in the U.S.A. have been watched with great interest. The prospect of being able to prevent this disease, despite the mishaps which attended the administration of the California-prepared vaccine, appears distinctly brighter. Rheumatic fever Deaths in London from rheumatic fever in 1954 were 21, of which 4 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 of persons 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 1954 2 3 275 280 0.133 Under the age of 15 the number of deaths is so small that considerable fluctuation must be expected from random causes. 22 Scabies became notifiable in London in August, 1943. Notifications in 1954 numbered 699, as compared with 527 in 1953. The attack rate (0.201 per 1,000) in 1954, while showing an increase for the first year since notifications began still compares favourably with the rate (6.70) experienced in 1944, the first complete year for which notifications were received after the disease became notifiable. Scabies The number of notifications of scarlet fever in 1954 was 2,444. Only in 1941, when a high proportion of schoolchildren were absent from London, has a lower figure than this been recorded. Although incidence appears to be considerably less than it was 50 years ago the fall in mortality during the same period has been even more striking. At present the disease is a mild illness only rarely giving rise to complications and there were no deaths from scarlet fever in 1954. During the middle of the 18th century scarlet fever was also so mild as to cause the famous physician Thomas Sydenham to describe it as ' a disease in name only '. During the last 200 years scarlet fever has more than once changed its face and become for a period one of the major killing diseases. Should this happen again physicians will find themselves armed with therapeutic weapons not available to their forebears. Scarlet fever There were no notifications of smallpox during the year. Smallpox Details relating to tuberculosis appear in the section which follows. There was one case of epidemic typhus, occurring in a man recently arrived in this country following a journey by air and rail from Eastern Europe. He had been infected before arrival in this country and no secondary spread occurred. Tuberculosis Typhus fever There were 4,691 notifications of whooping cough during the year—a smaller number than for some years past. There were only four deaths, three of them of children under five years of age giving a fatality ratio of 0.085 per cent. Whooping cough The number of cases of certain infectious diseases reported from schools in 1954 and previous years is shown in Table 9, page 223. Infectious diseases in schools TUBERCULOSIS Recent trends During the past ten years, the outstanding change in this disease, in London, has been its greatly reduced mortality. (See Table 4, page 220, the Diagram on page 24 and Tables T1 and T2 on pages 30 and 31.) In 1944 there were 2,073 deaths from lung tuberculosis (representing a rate of 0.75 deaths per 1,000 total population) compared with 596 deaths (a rate of 0.18 per 1,000 population) in 1954. This improvement is undoubtedly due mainly to the advent and increasing use during this period of new and successful specific drug remedies and to more widely available new thoracic surgical measures. A steady improvement in the availability of hospital beds for the treatment of tuberculosis has also exerted a beneficial effect. In 1954 almost 90 per cent, of all tuberculous deaths were due to the pulmonary form of this disease. Mortality Twenty per cent, of the deaths from lung tuberculosis occurred among persons aged between 15 and 45 years. In this age group, in the years 1941-45 pulmonary tuberculosis accounted for 26 per cent, of all deaths (all causes); in the year 1950 its contribution was 18 per cent., while in 1954 the proportionate mortality of this disease had fallen to 5.4 per cent. Nevertheless, in this reproductively and economically important age group, lung tuberculosis remains responsible for more deaths than any other single defined disease of any one organ. Seventy-seven per cent, of the deaths in 1954 from all forms of tuberculosis occurred among persons aged over 45 years and the majority (79 per cent.) of these deaths were in men. In this age group the contribution which tuberculosis made during 1954 to total mortality from all causes in both sexes was 1.6 per cent, compared with 2.2 per cent, in 1950 and 2.6 per cent, in 1940. In the age group 45-65 years, the number of 23 deaths from tuberculosis is exceeded only by those for cancer, bronchitis and cardiovascular disorders. During the year 164 cases of tuberculosis (all forms) came to notice after death, not having been notified during life—this amounts to 25 per cent. of all tuberculous deaths. Morbidity About a century ago nearly one-fifth of all deaths in Londoners was due to tuberculosis; in 1950 the proportion had fallen to a thirtieth and in 1954 to a fiftieth. In relation to morbidity, the picture, while encouraging, is not quite so satisfactory (see Tables T3 and T4 on pages 32 and 33). In 1950 there were 39,780 cases of tuberculosis in London, representing 11.7 per 1,000 of the population. In 1954 the chest clinic registers recorded 37,624 cases, giving a prevalence rate of 11.3 per 1,000 inhabitants. In 1950 the number of new cases (pulmonary and in other organs) notified, was 5,718; in 1954 new notifications were reduced to 4,641 of which 4,231 were pulmonary. In spite of improving facilities for diagnosis there has been a drop of 10 per cent. in the number of new lung cases notified during 1954 as compared with 1953. The occupational grouping of newly-notified cases is set out on Table T6 (page 34). Improved treatment in recent years has not only reduced mortality but has also considerably reduced the infectivity of the registered cases attending clinics. This is TUBERCULOSIS MORTALITY AND MORBIDITY 1934-1954 24 reflected in the smaller numbers and proportion of newly notified lung cases occurring as fresh infections in children under five years of age (Table T3 page 32) and among child contacts (Table T8, page 25). Sixty per cent. of all new notifications in 1954 were in the age group 15-44 years and 30 per cent. n persons over 45 years of age. Since 1950 the proportion of persons over 45 among the new pulmonary notifications has increased from 20 per cent. to 30 per cent., while new cases among those under 5 years of age have dropped from 5 per cent. of lung case notifications to 3 per cent. Notification of non-pulmonary tuberculosis in children aged 5-14 years has shown a steady fall in recent years (see Table T3 (ii) page 32). In 1947 there were 158 new notifications ; in 1950 and 1954 there were 99 and 69 new cases respectively. This is a gratifying fall in incidence and possibly justifies the expectations engendered by the Milk (Special Designations) (Specified Areas) Order made in 1951 which forbade the sale in London of unpasteurised or non-designated milks after October, 1951. Even in this age group, a higher proportion of the non-pulmonary tuberculosis is due to human infection than has hitherto been suspected. There is no doubt, however, that milk-borne bovine type tuberculosis is now a comparative rarity. Table T5 (page 33) gives the distribution according to site of non-pulmonarv lesions notified during the vear. Further evidence of the lessened infective hazard among the general population is seen in comparing the results of tuberculin surveys in various age-groups of London children at different times. Tuberculin surveys In 1929 some 20 per cent. of a tested group of five-year-old London children and nearly 50 per cent. of thirteen-year-olds were found to be tuberculin positive, indicating previous infection. In 1950 the figure among five-year-olds had fallen to 10 per cent, and among thirteen-year-olds to 30 per cent. In 1954 tuberculin positive reactor rates were 18 per cent. among thirteen-year-olds, with some evidence that among five-yearold schoolchildren the rate was about 2 per cent. London's tuberculous population Currently, about 0.3 per cent. of those adult groups thought to be healthy and examined by X-rays in London, are found to have active lung tuberculosis. If this figure is applied to the whole adult population in the County, it would appear that there are about 8,000 undiscovered adult tuberculous persons in the community. Since mass X-ray units tend to concentrate their examinations on those population groups thought likely to contain a relatively high proportion of tuberculous cases, it may be more realistic to reduce this figure by a half and estimate a likelihood of at least 4,000 undiagnosed pulmonary and probably 300 non-pulmonary cases in the County. If the approximate figures of 32,000 known adult lung cases on clinic registers and 2,500 known non-pulmonary cases are added, an estimate is obtained of some 38,800 adult (i.e., over 15 years of age) cases of tuberculosis in the London population. It will be seen from Table T7 (page 35) that at the end of 1954, of the 34,473 lung cases on the clinic registers, 18,897 were males and 15,576 females. One per cent. of these lung patients known to the clinics were under 5 years of age; 6 per cent. were aged 5-14 years; 16 per cent. were aged 15-24 years; 51 per cent. were aged 25-44 years and 26 per cent. were over 45 years of age. From these figures, kindly provided by the clinic chest physicians, it is clear that among the population of London as a whole 0.2 per cent. of children under 5 years are known to have tuberculosis of the lung ; 0.5 per cent. of children age 5-14 years; 1.4 per cent. of persons aged 15-24 years ; 1.6 per cent. of persons aged 25-44 years and 0.7 per cent. of' over 45s'. The Diagram (page 26) shows the numbers of known tuberculous persons per 1,000 of the population in each age and sex group. The chest clinic registers contain the names of 1.2 per cent. of all males in London and 0.9 per cent. of all females. Not all these cases have active disease ; many have responded well to treatment, are 'quiescent' or 'arrested' and are simply kept under medical surveillance until it is felt safe to consider them recovered and very unlikely to 25 relapse. Six per cent, of all cases on the clinic registers in the County were found during the year to excrete tubercle bacilli, i.e., were likely to be infective to others. It is noteworthy also that 33.3 per cent. of males on the clinic registers of lung cases were over 45 years of age. For females in this age group the proportion was 17.2 per cent. During the year, 42 per cent. of the 2,476 newly-notified male pulmonary cases were in the age groups over 45 years, whereas only 16 per cent. of the 1,755 newlynotified female lung cases were in this age group. Almost half of the newly-notified female cases occurred in the age group 20-35 years. 26 Preventive measures Tuberculosis is a widespread infection which progresses to disease only in those susceptible individuals whose physical, nutritional or emotional resistance is inadequate to counteract the destructive activity of the invading germs. Any measures therefore which tend to foster and improve well-being, nutrition and contentment are calculated to increase resistance to tuberculosis. All those general health measures such as ante-natal supervision, child welfare services, school health services, school meals and milk, health education, better housing and food supplies, contribute to improvement in the tuberculosis position. The high standard of diagnostic facilities available from family doctors and at the general and special hospitals, with which London is well endowed, are also valuable preventive aids. Of the more specific preventive measures which are directed against the disease, special mention may be made of the arrangements in London for seeking out, examining and keeping under medical supervision the contacts of known cases. In 1954,13,219 contacts of the 4,534 newly-notified cases were examined at chest clinics and among them were found 338 cases of tuberculosis. The Council provides special services for susceptible children in contact with known cases. ' Boarding out' away from home is arranged either to enable a mother to undertake treatment, to remove a child from special infective hazard in a very crowded and unsatisfactory home, or to protect a child from the risk of infection during the process of B.C.G. vaccination. In 1954 arrangements were made for 450 children to be boarded away from home. Every effort is made to find some alternative form of care for these child contacts so as to avoid separating children from their parents, brothers and sisters and homes before resorting to ' boarding out'. While away with a foster-mother or at a residential nursery, arrangements are made for child contacts to be periodically examined by the Chest Physician of the nearest clinic and he is asked to report periodically on the child's condition and progress. In all aspects of this work the Invalid Children's Aid Association, acting as the Council's agent, provides invaluable assistance. Contacts Mention should be made of the special procedure which was initiated in London a few years ago, of making thorough investigations of the school, nursery, institutional or workplace contacts of cases of tuberculosis notified among the staff or residents in the Council's departments and institutions. A summary of the findings of such 'incidents' is given on Table T9 (page 36). One of the most effective contributions to the prevention of tuberculosis in recent years has been the progressive availability and use of the new specific antibiotic and chemotherapeutic drugs employed alone or in association with bold and drastic surgery. These measures, by reducing or neutralising the infective potential of patients, have made it much safer for children and adolescents to live or work in close contact with most of them. Ten years ago nearly a third of all lung cases attending a chest clinic were ' sputum positive ' ; now the proportion is reduced to less than a tenth of the total. The mass miniature X-ray units of the tour Metropolitan Regional Hospital Boards steadily, albeit incompletely, combing the adult population for undisclosed cases of chest disease, are a preventive resource of undoubted value. The findings reported by these units are set out in Table T10 (page 37). Mass X-ray The Council continued during the year to arrange for a chest X-ray examination of all those newly-appointed members of its staff who were thought likely to come into close or frequent contact with children during the course of their work. B.C.G. vaccination has been provided under the Council s auspices since 1950 at chest clinics in London for those susceptible (tuberculin negative) contacts of known cases, when parental consent is given. Between September, 1950 and December, 1954, a total of 13,156 such children (including boarded-out contacts) had been vaccinated under the Council's arrangements. Since 1953, after special approval by the Minister of Health, the Council has provided facilities for B.C.G. vaccination of those particularly susceptible diabetic children in its care. In June, 1954, a further advance was made in B.C.G. vaccination 27 the active immunisation of children against tuberculosis by instituting routine B.C.G. vaccination for all those tuberculin negative 13-year-old children whose parents had given consent. A new laboratory was established for this work in the County Hall and special equipment designed to meet the needs of the large numbers (approximately 36,000) of children of this age in London who each year will be offered the protection against tuberculous infection which B.C.G. vaccine affords. The special arrangements made for this new service have been carefully planned and, together with the enthusiastic and practical co-operation of parents and head teachers, make this organised preventive measure the largest of its kind in the country. The scheme was introduced gradually in London from June, 1954, and by the end of the year 4,785 children aged 13 years had been tuberculin tested at their schools by a newly-appointed specialist full-time medical officer and the 4,037 negative reactors among them, vaccinated with the specially tested Danish vaccine provided by the Ministry of Health. It is expected that in a full year's working, with two full-time specialist teams visiting all schools, it will be possible for about 27,000 adolescents (i.e., 75 per cent. of all school leavers whose parents accept the proffered service each year) to be tested and those found susceptible to be vaccinated with the best available B.C.G. vaccine. Up to the present time, it has been found that 75 per cent. of the London parents offered vaccination for their 13-year-old children accepted and that only 15 per cent. of these children not in contact with a known case of tuberculosis and who were tuberculin tested were found to be 'positive reactors'—that is, already infected by the tuberculosis germ (though not necessarily actively diseased) and therefore outside the category to which B.C.G. vaccination is applicable. From the findings in the available groups tested, it would appear that in present circumstances some 80 per cent. of 13-yearold London children have not been 'sensitized' by Bacterium Tuberculosis and would safely benefit by that degree of immunity which B.C.G. vaccine affords. As residual parental hesitation and doubt become dispelled by education and example, it is hoped that all susceptible children leaving school will have developed, through B.C.G. vaccination, adequate protection against the markedly increased risks of tuberculous infection which experience shows beset those with such intensity and persistence between the ages of 16 and 25 years. ' Care and after-care' Services provided for the tuberculous patient (see Table T1l, page 38). The Council provides or arranges certain 'Care and After-Care' services for tuberculous Londoners. These are mainly in the nature of nursing, domestic, welfare and rehabilitation provisions designed to assist medical treatment or to augment working capacity and opportunity for the partially disabled or the quiescent case. For the convalescent tuberculous child not yet vigorous enough to return to normal school life, facilities are provided for a stay of some months at day or boarding open-air schools where educational activities are continued at a gentle pace in good surroundings with special emphasis on rest periods, medical supervision and nutritious dietary. For the convalescent adult, ' recuperative holidays 'are arranged in country or seaside surroundings for up to four weeks at homes specially approved as suitable for the tuberculous. For the patient still under treatment at home or at the chest clinic, the Council provides health visitors specially trained in tuberculosis to help the doctor at the clinic and to visit patients in their homes to advise them on details of hygiene, to fortify, instruct and encourage them and to ascertain the home conditions and needs. The Council also provides and maintains at each clinic one or more care organisers who are experienced social workers mostly having a local voluntary Tuberculosis Care Committee from which they can obtain financial and other help for needy patients. Their duties include ascertaining and providing for the patients' material needs. With the health visitors at the clinic they help patients in their anxieties; guide them to agencies (e.g., the National Assistance Board, the Ministry of Labour, the Housing 28 Department, etc.) which will help to solve difficulties; make direct provision to necessitous patients of extra nourishment, clothing, bedding, etc., and arrange for the care of children while mother is unfit or unable to manage. The tuberculosis care organisers make an important contribution to the patients' morale and hope by guidance, counsel and material help. The Council provides home helps to undertake domestic work in the homes of bed-fast patients and to care in the home for the children of mothers undergoing treatment. The Council's domiciliary nursing service provides home nurses who give injections and undertake such other treatment or nursing activities as the family doctor and chest physician request. Nursing equipment such as back rests, air beds, bed pans, urinals, etc., is made available on loan to patients in need. The Council maintains and lends to patients at home, wooden 'chalets' which can be erected in the garden to accommodate a patient in comfort so as to increase the safety of young members of the household by enabling an infective patient to occupy 'a room' by himself. Handicraft classes held at nearly all chest clinics are conducted by instructors provided by the Council's Education Department. These classes become social gatherings at which a group of patients can meet once or twice a week, under the eye of the clinic care organiser, to chat, take tea, make friends and learn and practise embroidery, basketry, leatherwork, weaving, dressmaking, toymaking, painting, etc., to beguile the boredom of disablement. For some bed-fast or homebound patients this diversional therapy is provided in their homes. For the patient too ill to make his own way to the local chest clinic, the Council provides a transport service of ambulances and ' sitting case cars ' to convey such patients to and from their homes for consultation, X-ray, pneumothorax treatment, etc. For homeless infective tuberculous men, whether fit to go out to work or disabled by active disease, the Council continued to provide two hostels as described in previous reports. Hurlingham Lodge, Fulham, had alterations and repainting completed at the end of July when it came into full use accommodating 28 men. The hostel at Highbury Quadrant, Islington, was replaced by better premises at Cromwell Lodge, Hornsey, on 30th September. When adaptations are completed here, the full available accommodation will be for 31 men. (Further reference to these hostels is made in the reports of the divisional medical officers on pages 127 and 133.) In addition, and as a temporary expedient, hostel accommodation was 'borrowed' at Preston Hall, Maidstone, where the British Legion Village undertook to provide board, lodging and diversional therapy for 11 ex-service infective tuberculous men under special fmancial arrangements with the Council. These hostels provide an excellent welfare service of care, comfort, nutrition and control for a group of infective disabled men who might otherwise spend their days and nights in the irregular and precarious health conditions of the poorer type of common lodging houses or similar apartments. During the year 57 recommendations for admission to hostels from chest physicians of clinics and sanatoria were approved. At the end of the year 26 men were in residence at Cromwell Lodge, 26 men at Hurlingham Lodge and 11 at Preston Hall. Maidstone. Hostels Most tuberculous persons who have recovered sufficiently to undertake employment return to their former jobs. So long as the patient is not infective and the physician is aware of the circumstances all may be well. In the case of the tuberculous worker who, in spite of treatment, is still infective but who is physically fit enough and determined to work, the position is not so good. It is seldom practicable for the Medical Officer of Health, the Health Visitor or the Physician to ensure by periodic visits to the work-place, that a particular job is safe for those working in contact with the patient. Since most of the new infections among adolescents and young adults occur at their places of work, the hazard of the actively diseased tuberculous worker in factory, shop and office is manifest. For these cases, special employment under close medical supervision in ' sheltered workshops' easily accessible from the patients' homes in London, is the answer. There is one such factory, run by Remploy, Ltd., under Government aegis, in Tower Bridge Road, Bermondsey, where 100 mostly quiescent and non-infective disabled workers are trained and employed in woodwork. Industrial rehabilitation 29 There is need for at least two more such workshops in the County. For the noninfective worker fit to do medium or light work, new employment is fairly readily found by the local disablement resettlement officers of the Ministry of Labour and National Service. If new employment necessitates special assessment or training this can be provided at the Industrial Rehabilitation Units and Government Training Centres managed by the Ministry of Labour, but at present all are outside the County and for many Londoners this involves too much travel. In present circumstances, therefore, it is still necessary to send disabled London tuberculous adults to residential settlements such as Papworth (near Cambridge), Preston Hall (near Maidstone) and Enham-Alamein colony (near Andover). At the end of 1954, the Council maintained 78 men and women in training or in sheltered employment at these distant institutions. Table T1—Tuberculosis—Statutory notifications and deaths—Administrative County of London, 1921-54 (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 1,861 009 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 0.59 611 019 243 0.07 1947 5,421 1.59 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 1954 4,231 1.27 596 0.18 410 0.12 62 0.02 (a) Excluding posthumous cases. 30 31 Table T.2—Tuberculosis deaths—by age and sex Rates per 1,000 living (i) Pulmonary Sex Age 1947 1948 1949 1950 1951 1952 1953 1954 No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rale 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 46 0.07 45 + 748 1.24 762 1.27 719 1.21 585 0.99 627 1.23 557 1.08 421 0.81 383 0.74 All males 1,264 0.78 1,235 0.76 1,046 0.65 829 0.51 826 0.53 684 0.44 510 0.33 429 0.28 Females 0-4 13 0.10 7 0.05 4 0.03 - - 3 0.02 3 0.03 3 0.03 5—14 8 0.04 6 0.03 4 0.02 2 0.01 3 0.02 - 1 0.00 2 0.01 15—44 527 0.70 487 0.65 342 0.46 238 0.32 171 0.21 125 0.16 85 0.11 77 0.10 45 + 232 0.32 165 0.23 189 0.26 156 0.22 151 0.22 124 0.18 91 0.13 85 0.12 All females 780 0.44 665 0.37 539 0.30 396 0.22 328 0.18 249 0.14 180 0.10 167 0.09 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 0.21 596 0.18 (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 3 0.025 5—14 20 0.109 10 0.055 12 0.065 6 0.032 6 0.031 2 0.010 1 0.005 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 11 0.016 45 + 38 0.063 29 0.048 34 0.057 25 0.042 21 0.041 17 0.033 13 0.025 18 0.035 All males 132 0.081 103 0.063 95 0.059 62 0.038 66 0.042 45 0.029 29 0.019 33 0.021 Females 0—4 19 0.151 23 0.175 16 0.119 10 0.074 9 0.067 5 0.040 9 0.076 2 0.018 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 7 0.009 45 + 37 0.051 30 0.042 18 0.025 27 0.038 26 0.039 20 0.029 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 29 0.016 Total 252 0.074 202 0.059 156 0.046 122 0.036 125 0.037 86 0.026 73 0.022 62 0.019 32 Table T.3—Statutory notifications of tuberculosis by age and sex—Administrative County of London, 1947-54 Rates per 1,000 living (i) Pulmonary Sex Age 1947 1948 1949 1950 1951 1952 1953 1954 No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—14 108 0.81 149 1.08 153 1.08 162 1.15 137 0.98 85 0.65 105 0.84 77 0.64 5—14 187 1.01 158 0.87 153 0.82 141 0.75 143 0.74 109 0.53 144 0.69 104 0.48 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 1,246 1.79 45 + 973 1.61 957 1.60 1,093 1.84 945 1.59 969 1.91 970 1.88 1,083 2.09 1,049 2.02 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 2,476 1.60 Females 0—4 96 0.76 124 0.94 126 0.94 116 0.86 123 0.92 88 0.70 101 0.85 63 0.55 5—14 174 0.96 171 0.96 188 1.04 140 0.77 127 0.68 119 0.61 131 0.65 115 0.55 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 1,291 1.71 45 + 263 0.36 244 0.34 279 0.39 234 0.33 242 0.36 292 0.43 288 0.42 286 0.41 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 1,755 0.99 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 4,231 1.27 (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 17 0142 5—14 87 0.472 87 0.479 75 0.404 50 0.265 57 0.294 56 0.275 32 0.152 30 0.139 15—44 118 0.167 116 0.165 109 0.156 114 0.164 103 0.143 103 0.144 97 0.138 89 0.128 45 + 36 0.060 29 0.048 32 0.054 29 0.049 27 0.053 36 0.070 23 0.044 36 0.069 All males 310 0.190 287 0.177 255 0.157 227 0.140 216 0.138 221 0.141 170 0.109 172 0.111 Females 0—4 56 0.444 38 0.289 42 0.312 40 0.296 36 0.269 21 0.168 19 0.160 17 0.149 5—14 71 0.394 69 0.388 68 0.375 49 0.271 48 0.257 34 0.173 37 0.182 39 0.187 15—44 190 0.253 171 0.229 159 0.214 183 0.247 178 0.223 184 0.233 136 0.175 133 0.176 45 + 35 0.048 35 0.049 29 0.041 30 0.042 29 0.043 58 0.085 48 0.070 49 0.071 All females 352 01.98 313 0.176 298 0.168 302 0.171 291 0.162 297 0.165 240 0.135 238 0.134 Total 662 0.194 600 0.177 553 0.163 529 0.156 507 0.150 518 0.154 410 0.123 410 0.123 Table T.4 —Tuberculosis—Statutory notifications by age groups—Administrative County of London, 1954 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. 10 67 61 43 138 216 501 391 428 376 245 2,476 F. 9 54 57 58 208 327 492 264 132 68 86 1,755 Other forms of tuberculosis M. 2 15 22 8 11 28 33 17 17 14 5 172 F. 3 14 26 13 15 32 60 26 21 12 16 238 All forms of tuberculosis M. 12 82 83 51 149 244 534 408 445 390 250 2,648 F. 12 68 83 71 223 359 552 290 153 80 102 1,993 Table T.5—Statutory notification of non-pulmonary tuberculosis—distribution according to site— 1946-54 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) 1954 27 (0.041) 5 (0.008) 23 (0.035) 28 (0.042) 14 (0.021) 97 (0.147) 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) 1954 88 (0.033) 35 (0.013) 72 (0.027) 16 (0.006) 87 (0.033) 298 (0.112) (a) Includes miliary and genito-urinary. Information not available for 1952 owing to change in the regulations governing the notification of tuberculosis. 33 34 Table T.6—Occupations of persons notified 1951-1954 R[]egistrar-General's Short Classification o Employment Population mid 1951 Tuberculosis Notifications—1951 Tuberculosis Notifications—1953 Tuberculosis Notifications—1954 Males Females 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 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 8(1) 1.8 - - 3. Mining, quarrying occupations — — 2(1) .. — .. — — - - 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 1.4 2 1.2 5. Coal, gas, coke, chemical workers 6,300 600 2 0.3 — — 7 1.1 - - 4 0.6 - - 6. Metalwork, engineering 131,800 15,000 245(12) 1.9 16(2) 1.1 258(8) 2.0 16 1.1 203(8) 1.5 11 (1) 0.7 7. Textile workers 1,000 1,600 2 2.0 1 0.6 4 4.0 2(1) 1.3 2 2.0 2 1.3 8. Tanners, leatherworkers, etc. 6,700 5,000 14 2.1 5 1.0 19 2.8 8 1.6 23 (1) 3.4 1 0.2 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 49(2) 1.8 88 (5) 1.2 10. Food, drinks, tobacco makers 11,200 8,200 30(2) 2.7 10 1.2 22(1) 20 7 0.9 16(1) 1.4 4 0.5 11. Wood, cane, corkworkers 36,100 1,100 64(1) 1.8 2 1.8 41 (4) 1.1 - - 45 (4) 1.2 1 0.9 12. Papermakers, bookbinders, printers 24,500 13,700 36(2) 1.5 12 0.9 24(1) 1.0 18(1) 1.3 29(1) 1.2 12 0.9 13. Other products (plastics, etc.) 7,200 5,700 12(1) 1.7 2 0.4 10 1.4 5 0.9 9 1.3 3 0.5 14. Builders and contractors 66,700 - 73(7) 1.1 — — 173(7) 2.6 2 .. 53 (3) 0.8 - - 15. Painters and decorators 35,500 1,300 74(3) 2.1 1 0.8 61 1.7 2(1) 1.5 52(5) 1.5 - - 16. Administrators, directors, managers 32,200 7,700 8 0.3 - - 17(1) 0.5 - - 17 0.5 5(1) 0.6 17. Transport and communications 162,400 16,500 287(16) 1.8 35(4) 2.1 289(17) 1.8 31(4) 1.9 258(14) 1.6 25(4) 1.5 18. Finance, insurance, commerce 107,700 60,600 148(1) 1.4 88(11) 1.5 156(3) 1.4 69(5) 1.1 140(6) 1.3 67(10) 11 19. Professional and technical 61,200 54,700 94 (6) 1.5 112(8) 2.0 103(4) 1.7 87(6) 1.6 78(4) 1.3 67(3) 1.2 20. Defence services 40,300 1,200 96(3) 2.4 2 1.7 86(3) 2.1 2 1.7 54(1) 1.3 3 2.5 21. Entertainment and sport 12,300 5,600 27(1) 2.2 9(1) 1.6 28(1) 2.3 9 1.6 21(1) 1.7 6 1.1 22. Personal services (hotels, etc.) 75,700 193,500 218(10) 2.9 211(17) 1.1 181(7) 2.4 173(23) 0.9 183(3) 2.4 150(15) 0.8 23. Clerks, typists, etc. 94,900 167,300 261(10) 2.8 307(21) 1.8 219(13) 2.3 284(21) 1.7 230(7) 2.4 252(17) 1.5 24. Packers, warehousemen, etc. 41,100 22,200 69(1) 1.7 29(2) 1.3 61(4) 1.5 16(3) 0.7 45(1) 1.1 31(1) 1.4 25. Stationary engine drivers, stokers 10,700 — 35(2) 3.3 — — 18(1) 1.7 - - 31(1) 2.9 - - 26. Unskilled workers (not elsewhere specified) 74,500 28,800 202(18) 2.7 51(4) 1.8 152(7) 2.0 49(5) 1.7 252(15) 3.4 48(3) 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 13 1.1 2 0.9 Total (1-27) 1,086,100 685,200 2,157(106) 20 1,029(86) 1.5 2,006(86) 1.8 883(83) 1.3 1,821 (79) 1.7 780(60) 1.1 28. Housewives - .. - - 743(83) .. - .. 742(71) .. - - 772(78) .. Unemployed .. .. 414(17) .. 230(31) .. 434 .. 239(30) .. 461(29) .. 185(28) .. Retired 83,000 32,300 171(9) 2.1 36(4) 1.1 190 2.3 51(12) 1.6 191(4) 2.3 40(8) 1.2 Students .. .. 29(5) .. 23(4) .. 37 .. 22(3) .. 45(2) .. 28(6) .. Children under 15 338,200 323,200 382(92) 1.1 355(87) 1.1 304 0.9 293(55) 0.9 236(46) 0.7 277(57) 0.9 Note.—Numbers in brackets are non-pulmonary cases included in the total. * Rates based on 195/ population distribution. The figures stated are based on weekly (uncorrected) notifications and therefore differ slightly from the Reg. Gen. Total (Table T.1). Information not available for 1952 owing to change in the Regulations governing the notification of Tuberculosis. Table T.7—Numbers on the registers, 1944-54 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 Cases on the register at the end of the year: Pulmonary— Males 14,340 15,018 15,695 16,374 17,224 18,203 19,090 19,119 17,336 18,475 18,897 Females 10,990 11,496 12,262 12,862 13,549 14,223 15,031 15,556 14,672 14,930 15,576 Other forms: Males 2,866 2,813 2,821 2,699 2,889 2,752 2,591 2,520 1,530 1,508 1,442 Females 3,185 3,123 3,099 3,142 3,147 3,015 3,068 2,954 1,850 1,820 1,709 Total 31,381 32,450 33,877 35,077 36,809 38,193 39,780 40,149 35,388 36,733 37,624 No. per 1,000 of population 12.7 12.5 10.9 10.6 11.0 11.3 11.7 12.0 10.5 10.9 11.3 Since 1952 figures are taken from Chest Clinic registers; for earlier years they represent Borough M.O.H. registers. Table T.8—Condition of new cases and their contacts Men Women Children Total Number of new cases diagnosed as tuberculous at chest clinics during the year 2,426 1,696 412 4,534 Percentage of these new cases found to be 'T.B. plus'(i.e. Infective) 38.6 25.1 4.6 30.5 Number of those who attended as contacts and who were : (a) Diagnosed as tuberculous* 104(4.2) 125(3.3) 109(1.6) 338(2.6) (b) Not tuberculous 2,195 3,479 6,104 11,778 (c) Not determined (as at 31.12.54) 172 231 700 1,103 *Figures in brackets are percentages of the total contacts examined 35 Table T.9—Summary of investigations made into notified tuberculosis ' incidents ' at Council establishments in 1954 Establishment Notified case Children Adults Tuberculin tested +ve reaction X-rayed Abnormal X-rayed Abnormal Day schools Teacher 210 37 37 - 13 - Teacher 143 * - - - - Teacher and Pupil - - 457 9 14 - Teacher - 518 10 - - Teacher 29 12 20 - - - Teacher 255 25 25 - 6 - Teacher 606 24 20 3 23 1 Teacher 180 8 8 - 4 - Teacher 370 20 78 - 10 - Teacher 198 113 144 1 - - Teacher - - 238 - 14 - Teacher 196 15 191 - 7 - Teacher 29 5 30 - - Pupil - - 304 - 18 - Pupil - - 295 1 18 - Pupil - - 17 - 1 - Pupil 866 1ll 218 - 11 1 Pupil - - 296 - 15 - Pupil 37 11 11 - 38 - Assistant schoolkeeper - - - - 40 - Meals supervisor 431 3 3 - 9 - Meals supervisor 551 45 45 - 23 - Kitchen helper 302 23 24 - 16 - Totals (23) 4403 * 2979 24 280 2 Residential schools for handicapped children (2) Pupil - - 43 - - - Teacher 106 15 107 1 40 1 Children's department residential schools and nurseries (2) Nursery student 11 * - - 87 - Nursery warden 60 6 6 - - - Welfare establishments, reception centre and halfway house (3) Resident - - - - 200 12 Resident 18 * - - 29 - Resident - - - - 240 4 Divisional health office and day nurseries (1) Cleaner 43 6 6 - 15 - Supplies department (1) General clerical officer - - - - 79 - Grand Totals (32) 4641 * 3141 25 970 19 * Figures not available. 36 Table T.10—Mass X-ray units—Activities reported in London A.C.—1954. Metropolitan Regional Hospital Board Unit London areas included in ambit of unit Numbers X-rayed during year (a) Cases of active tuberculosis diagnosed Male Female Total Male Female Total Rate per 1,000 N.W. 5A Hammersmith, Kensington and Paddington * * 10,301 * * 27 2.62 5B Holborn, Paddington, St. Marylebone and St. Pancras * * 49,385 21 12 33 0.67 5C Static(Islington) * * 33,299 * * 182 5.47 N.E. 6A Stepney 9,702 5,486 15,188 20 12 32 2.11 6B Bethnal Green, Hackney, Poplar and Stoke Newington 23,673 27,386 51,059 40 34 74 1.45 6D City, Finsbury and Shoreditch 36,239 25,432 61,671 51 46 97 1.57 S.E. 7A Bermondsey, Camberwell, Deptford, Lambeth and Southwark 26,741 21,479 48,220 107 63 170 3.53 7D Greenwich and Woolwich 14,531 11,878 26,409 49 23 72 2.73 7E Lewisham 16,177 14,900 31,077 89 33 122 3.93 S.W. 8C Battersea, Chelsea, Fulham, Wandsworth and Westminster 33,990 26,540 60,530 47 36 83 1.37 8D Static(Wandsworth) 12,870 17,020 29,890 116 88 204 6.83 Total * * 417,029 * * 1,096 2.63 Tavistock House Civil Service, etc. * * 68,179 * * * * (a) The numbers given are of persons attending the units, normally whilst they were operating in London : such persons are therefore not necessarily London residents. The total number of London residents examined throughout the country during the period July to December (excluding examinations during July and August by the Ministry of Health unit at Tavistock House) was 117,680 (60,490 male and 57,190 female) but pathological findings are not yet available. * Figures not available. 37 Table T.11—Summary of services provided for the tuberculosis patient, 1952-54 1952 1953 ###] Clinic registers Total on registers at the end of the year 35,388 36,733 37,624 Work of local tuberculosis care organisers Patients assisted for the first time with:— Beds and bedding 541 431 435 Clothing or footwear 961 1,089 1,334 Patients at the end of the year receiving:— Extra nourishment 2,234 2,451 2,391 Home help service 673 618 729 Home care and treatment At the end of the year, patients:— Awaiting admission to hospital 738 494 209 Under treatment in their own homes 808 804 930 Receiving attention by home nurses 367 466 530 Rehabilitation At the end of the year the Council was financially responsible for rehabilitants at:— British Legion Village, Maidstone 25 25 33 Papworth Village Settlement, Cambridge 17 17 23 Enham-Alamein Village Centre, Andover 18 21 22 Barrowmore Hall, Chester 2 2 2 Correspondence courses arranged through the British Council for Rehabilitation for patients undergoing prolonged treatment at home 65 113 80 At boarding open-air schools Children convalescent from tuberculosis:— At the beginning of the year 33 29 34 Admitted during the year 47 27 23 At the end of the year 29 34 22 Awaiting admission at end of year 11 7 1 Boarding-out of child contacts Children in nurseries and foster homes at the beginning of the year 419 440 450 Placed during the year 490 562 411 Boarded-out at the end of the year 440 450 365 Average number boarded-out at any one time 442 486 417 Boarding-out of child contacts for segregation during B.C.G. vaccination Children in nurseries and foster homes at the beginning of the year 15 24 6 Placed during the year 67 38 39 Boarded-out at the end of the year 24 6 11 Average number boarded-out at any one time 18 14 10 B.C.G. vaccination schemes Child contacts vaccinated by chest physicians in London 3,034 3,141 3,851 Boarded-out child contacts vaccinated by out-county chest physicians 139 161 48 Child contacts (mainly new-born babies) vaccinated in London hospitals prior to boarding-out 73 77 64 13-year-old school children - - 4,037 Diabetic children in the Council's care - - 26 38 GENERAL PUBLIC HEALTH Housing during the year 14,544 houses and flats were erected by the Council and the Metropolitan Borough Councils. Of these 11,567 were in London (5,171 erected by the Council and 6,396 by the Borough Councils) and the remainder (2,977) were erected by the Council outside the County. At the end of the year the total number of permanent dwellings erected or acquired by the Council for housing purposes was 165,106 (an increase in the year of 8,148) of which 80,047 were situated in London and 85,059 outside the County. In addition there were 7,812 temporary prefabricated bungalows erected by the Ministry of Works but managed by the Council. The number of applications registered on the Council's waiting list at the end of the year was 164,559 compared with 170,225 in 1953. New applications registered during the year totalled 27,588. 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 (a) urgent cases, (b) cases with some housing need, but not of an urgent character, (c) no basic housing need. During the year 32,732 (580 fewer than in 1953) requests for preference in rehousing on health grounds were considered and suitable recommendations made to the Director of Housing. 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 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 the Medical Officers of Health of Metropolitan Boroughs and of out-County authorities, by hospitals and by family doctors in providing reports is gratefully acknowledged. Of the applications considered 4 per cent. were recommended for special preference because rehousing was urgently necessary to reduce the danger of infection arising from active pulmonary tuberculosis, 14 per cent. were classified as 'most urgent' and 35 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 47 per cent. Preferential rehousing During the year the survey of areas included in the five-year programme of slum clearance was continued and 37 areas containing 1,953 houses were represented to the Housing Committee under section 25 of the Housing Act, 1936. In addition, preliminary surveys of a further 32 areas containing 1,776 houses were completed. Slum clearance The Minister of Housing and Local Government arranged 23 public local inquiries into Orders made by the Council and by the end of the year ten of the Orders had been confirmed ; the results of the remaining 13 inquiries were awaited. One Order was confirmed without the holding of a local inquiry. The Housing Repairs and Rents Act, 1954, repealed, as from 31st August, 1954, section 33 of the Housing Act, 1936 under which the Metropolitan Borough Councils had to notify the Council of their intention to deal with an area by way of slum clearance. During the first eight months of the year notifications were received from ten boroughs of 17 areas containing 306 houses. Surveys were made in respect of 47 applications to the Council for improvement grants under section 20 of the Housing Act, 1949 (as amended by the Housing Repairs and Rents Act, 1954). In addition 122 investigations were made in connection with applications for such grants made to Metropolitan Borough Councils. Improvement grants During the year 1,446 searches were made in connection with enquiries concerning premises scheduled as dangerous structures. Dangerous structures 39 Public health laboratory Full use was made of the facilities available at the Medical Research Council Public Health Laboratory at the County Hall and the close liaison which is possible with the staff of the laboratory has proved of great value. Milk sampling The following are details of the sampling for biological examination of milk coming into London : Source of sample Designation Samples Percentage positive of completed samples Total Positive Incomplete Negative 1954 1953 (a) Supplied to London by road and rail in churns and bottles Ordinary 383 14 38 331 3.7 4.1 Accredited 27 6 1 20 * * Tuberculin tested 75 - 6 69 - - Tuberculin tested (farm bottled) 13 - - 13 - - (b) Residential schools Tuberculin tested 2 - - 2 - - Total 500 20 45 435 4.0 3.8 * A percentage would be unreliable owing to the few samples taken. The 20 positive samples were obtained from milk sent by 12 farmers, ten supplying ordinary and two accredited milk. As a result of investigations by the Ministry of Agriculture and Fisheries into the origin of positive samples in 12 herds, ten tuberculous cows from seven herds were slaughtered under the provisions of the Tuberculosis Order, 1938. The source of infection in one herd was assumed to be a cow disposed of before investigation into the origin of the positive samples was complete, and investigation was still proceeding at the end of the year into three other 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. Dried milk Samples of dried milk powder taken for analysis totalled 88 and of these 18 contained more than 100,000 organisms per gram, and staphylococci aureus were isolated in three samples. Disinfestation Sanitary inspection Reports of 153 instances of infestation were received from establishments controlled by the Council, e.g., school meals centres, schools, welfare establishments and parks. Infestation by rats, mice, pigeons, cockroaches, bugs, ants, silver fish, flour and clothes moths, furniture beetles, clover mites, plaster beetles, wasps, hornets and flies were dealt with and the control measures carried out have proved effective. Talks on the most effective measures for controlling and eliminating pests were given to volunteer squads of the London Fire Brigade. School meals More than 700 visits of inspection were made to school meals centres and 30 reports of illness following the consumption of school meals were investigated. In no instance could the cause of the illness be confirmed as due to the food. Welfare establishments Complaints Regular inspections relating to hygenic conditions were made at least once a quarter of 75 homes, hostels and other welfare establishments. A large number of complaints of insanitary conditions was received from residents in London and referred to the health departments in the appropriate Metropolitan Boroughs. 40 In connection with the development of an estate in Lambeth the Council obtained powers in the London County Council (General Powers) Act, 1953 to enable it to remove a quantity of human remains from a disused burial ground. This work was carried out in accordance with conditions imposed by the Secretary of State and Regulations made by the Medical Officer of Health. All exhumations and re-interments were supervised by the Inspectorate of the Department and a total of 201 cases containing the remains of about 802 persons were removed. Re-interment took place at Tottenham. Exhumation of human remains Advice was given to other departments of the Council on problems relating to sanitation, drainage and other public health matters in connection with the preparation of plans for new buildings and the adaptation of existing premises. Advisory and research work 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. The installation of' single pipe' systems of plumbing was extended during the year. The Chief Inspector continued to represent the Council on a number of committees of the British Standards Institution and as 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 was also a member of the Plumbing Research Committee of the Building Research Board of the Department of Scientific and Industrial Research. Representation on committees of outside bodies Blind and partially-sighted persons During the year, 1,741 examinations were made in connection with certification under the National Assistance Act, 1948, of blind and partially-sighted persons. In addition, 297 certificates were accepted from other local authorities, hospitals and private ophthalmologists. The results of examinations of persons newly registered during the year, and of the re-examination of those previously recommended to obtain treatment are given in tables (i) and (ii) below; 52 of those examined were found to be neither blind nor partially-sighted. Re-examinations to confirm certificates given in previous years, and certificates accepted from other authorities relating to persons already registered (transfers into London) are omitted from the tables. TABLE (i) Number of new registrations during the year with percentage recommended to obtain treatment Principal cause of defective vision Total Cataract Claucoma Retrolental fibroplasia Other conditions (a) No. of persons 581 120 4 804* 1,509* (b)No. recommended to obtain treatment 253 44 - 169 466 (b)as percentage of (a) 43.5 36.7 - 21.0 30.9 * Includes eight schoolchildren examined under the Education Acts. The principal cause of defective vision was frequently associated with a secondary condition, e.g., cataract with glaucoma. Recommendations for treatment are generally made where some improvement of vision may be expected, though improvement may be insufficient to lead to removal from the register of blind and partially-sighted persons. Persons recommended to obtain treatment are re-examined at intervals after the initial registration. The number of persons re-examined for this reason in 1954 is shown in the following table. 41 TABLE (ii) Re-examination of persons recommended to obtain treatment Principal cause of defective vision Total Cataract Glaucoma Retrolental fibroplasia Other conditions No. of persons re-examined 123 26 - 114 263 No. found to have had treatment 80 21 - 75 176 Percentage treated 65.0 80.8 65.8 66.9 These figures are a measure of the extent to which treatment was obtained. Since most of the blind and partially-sighted are elderly or old people, many of whom are reluctant to accept treatment, an effective treatment rate of 67 per cent. cannot be regarded as unsatisfactory. As a consequence of successful treatment, 26 persons previously registered as blind were found, on re-examination, to be partially-sighted, and 16 persons previously certified as blind or partially-sighted were found to be improved to such an extent as no longer to be registrable. Figures for ophthalmia neonatorum are given on page 21. Registration of nursing homes At the end of the year there were 42 nursing homes on the register, six fewer than in 1953. In the 42 homes there were 836 beds distributed as follows : Number of beds in home Number of homes Patients accommodated Maternity† Others* Total 25 or over 9 238 189 427 20 to 24 6 27 104 131 15 to 19 4 20 49 69 10 to 14 12 43 97 140 5 to 9 8 31 31 62 Under 5 3 2 5 7 Total 42 361 475 836 † Each bed is registered for a maternity, medical or surgical case. * Numbers include beds for medical and surgical patients which cannot be used if a maternity patient is accommodated in the same room. Close over-all supervision of the homes was maintained and visits of inspection made at regular intervals by medical officers (72 inspections) and public health inspectors (192 inspections). 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. 39 exemptions from the operation of Part XI of the Public Health (London) Act, 1936, were granted. In July, 1954, all executive work connected with the registration of nursing homes, including co-ordination of action by other departments concerned, was transferred from the Clerk of the Council to the Medical Officer of Health. 42 Welfare Committee establishments The Medical Officer of Health is responsible for the medical arrangements in all types of establishments under the control of the Welfare Committee. These include large and small homes for the aged and infirm, mother and baby homes, hostels for mothers at work, reception centres for persons without a settled way of life and homes for the blind. At the end of the year 167 mothers and 343 children (of whom approximately 60 per cent. were under five years of age and 15 per cent. under one year of age) were accommodated in the five homeless families' units. Regular visits were made 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. Weekly visits were made by health visitors to advise mothers on the care of their children and to give talks on mothercraft. Mothers were also encouraged to attend sessions at neighbouring maternity and child welfare centres and a weekly child welfare session was held at one large unit. Nursery classes for children aged between three and five years were conducted under the direction of the Education Officer at two units. Homeless families' units Medical supervision of two hostels for mothers at work and one mother and baby home was given by medical officers on the central staff. In one of the hostels the children were cared for by the staff while their mothers were at work and a medical officer on the divisional staff made routine visits to the children as if they were in a day nursery. In the other hostel children were taken by their mothers to day nurseries in the area. Mother and baby home and hostels for mothers at work Care of the chronic sick A considerable number of chronic sick persons remained in the Council's homes because of the shortage of hospital beds. Consultations were held with the Ministry of Health on the problem, but although arrangements were made for a number of chronic sick to be exchanged for infirm persons in hospital who could not be discharged to their own homes, the number of chronic sick accommodated in the homes at the end of the year was 559 (149 men and 410 women), an increase of 53 compared with the previous year. These patients all complied with the definition of chronic sick laid down by the Minister of Health. In some homes sick bays were provided for the care of the aged suffering from temporary illnesses for whom hospital beds were not available. Invalid Meals (formerly Invalid Kitchens) of London provided (year ended 30th Spetember, 1954) 166,165 meals for invalids and sick people compared with 128,211 in the previous year ; 135,042 of the meals were delivered to houses and 31,123 were served in the dining centres belonging to the organisation. The Council made a grantin-aid of £8,000 during the year. Invalid Meals of London Welfare of handicapped persons Medical advice as to eligibility for registration under the Council's scheme for the welfare of handicapped persons other than the blind and partially-sighted was given in five cases during the year. 43 SCIENTIFIC BRANCH the work of the branch is carried out in three groups of laboratories. At the County Hall headquarters work is undertaken on foods, meals, trade effluents, atmospheric pollution, detergents, laundries, paints and decorative materials, statutory work on many Acts and Orders, fuels and all types of oils, building materials, waters of many kinds, etc. The Northern and Southern Outfall laboratories, situated at Beckton and Crossness respectively, are concerned with obtaining scientific data for the control of the sewage treatment processes and ancillary plant and, in addition, at all laboratories research on important 'domestic' matters is undertaken. It may be noticed that the branch has been renamed because its field of activity has, in the interests of the Council, extended beyond that normally considered as chemistry and the more general title conveys more readily the scope and the nature of the advice available. The Scientific Adviser submits the following summary of his annual report: The ever-increasing demand for scientific advice resulting from the growing appreciation of the financial advantages to be gained has its repercussions in local government and officers of the Council consult the branch more frequently than in the past in an increasing range of subjects. Although a wide range of experience is available in the branch, it could not be claimed that advice on any question can always be given immediately but generally the senior officers have means whereby in a relatively short time authoritative information can be obtained, if necessary, from sources outside the service by utilising the government and other research associations, consulting specialists in the particular field and disentangling claims and facts. Research work on a problem is pursued when the financial aspects warrant it and a strict watch is maintained to utilise the available scientific manpower in the service to the very best advantage. The research projects pursued in all the laboratories, the advice given on processes and methods and the watch maintained on deliveries and materials used on sites, constitute a considerable financial asset to the Council whilst figuratively providing an insurance premium against low standard products and claims against the Council and, furthermore, the branch provides the evidence to ensure the compliance with the requirements of the many Acts and Orders which the Council has to administer. Synopsis of work done The total number of samples examined was 26,562, which exceeds by 1,294 that of the previous year. This number does not indicate the full extent of the work because it takes no account of the advisory and consultative work undertaken by the senior officers which may not require the examination of samples and, furthermore, for the most part research projects cannot be numbered, except to assist in their subsequent identification. This advisory service has developed rapidly in the last few years and, serving as it does to give an opinion, frequently informally, on materials to be used, must tend to reduce maintenance costs appreciably. It is important that this liaison with user departments should be encouraged for the use of unsuitable materials can cause, in the future, considerable replacement costs and so frequently only by scientific appraisal can they be known to be unsuitable. The following sections of this report deal in greater detail with many aspects of the work done and the following table summarises the number of samples examined. Air—tunnels 260 Air—miscellaneous 6 Bacteriological, miscellaneous 160 Building materials 498 Chemicals, drugs and medical supplies 105 Clay, sub-soils and borehole waters 1,597 Compost 2 Detergents and soaps 148 Disinfectants 25 Fertilisers and Feeding Stuffs 110 44 Fire extinguishers 5 Floor oils 69 Fuel (coal and coke) 33 Foods 403 Gases :— Degreasing and rubber spreading works 22 Flue 92 Sludge digestion plant 280 Grit (from Power Stations) 4 Inks (marking, drawing and writing) 4 Insecticides 10 Instrument sets (ambulance) for sterilisation 26 Insulating materials for hot water systems 17 Lamps, gas detector 405 Laundry tests 46 Liquor (effluent from Beckton Gas Works) 360 Meals 86 Metals (various) 46 Milk, liquid 86 Milk, condensed and powdered 26 Miscellaneous 110 Oils, lubricating and fuel, etc 82 Paints, varnishes and distempers 1,590 Petroleum and allied samples 116 Plastics 7 Rain-water (atmospheric pollution deposit gauges) 92 Rubber and rubber substitutes 17 Scale from boilers, etc 5 Scouring powders and lavatory cleaners 36 Sewage and effluent 3,173 Sludge, primary and digested 2,581 Sludge, activated 734 Smoke in air, determinations 1,694 Sulphur gases in air, determinations :— Lead peroxide cylinder method 138 Volumetric method 1,694 Water, etc., from steam raising plants 1,330 Water, drinking, chemical 63 Water, drinking, free chlorine tests 638 Water, drinking, bacteriological 758 Water, swimming bath, chemical 303 Water, swimming bath, free chlorine tests 364 Water, swimming bath, bacteriological 455 Water, river, chemical 3,308 Water, river, bacteriological 296 Water, miscellaneous 56 Trade wastes 149 Research and investigation samples at Northern and Southern Outfall Works 1,842 26,562 The following paragraphs give a general indication of the source of origin of these samples and of the consultative and advisory duties carried out for the various services and departments of the Council. Rivers and drainage Throughout 1954 the whole of the sewage flow to the Northern Outfall Works was treated by sedimentation and approximately one-quarter of it subsequently by the activated sludge process. At the Southern Outfall Works the whole of the flow continued to be treated by primary sedimentation only. In the case of both outfall works, the plants functioned satisfactorily throughout the year and achieved as large a saving of B.O.D. (biochemical oxygen demand) load on the water of the River Thames as could be expected. 45 The sludge digestion plants at the Northern Outfall Works worked satisfactorily and some 550,000 cu.ft. of the resultant gas per day containing about 70 per cent. methane was used as a source of power at the works. Regular sampling and examination was undertaken from all sections of the plant and its ancillaries and the scientists and engineers were constantly in touch to consider what modification in plant or its operation could be made to improve efficiency. Good progress has been made on the new sedimentation tanks which will be in operation in 1955, and will further reduce the B.O.D. loading on river. In addition to plant control work to advise the Chief Engineer, many research problems were examined and brief details of a few examples are as follows : (a) Tests were made at a 12 foot depth of water on the efficiency of aeration of rectangular flow diffusers, 4 in. and 7 in. dome diffusers. It was found that at normal operating pressures the 7 in. dome was the most efficient but at slightly greater pressures the flat tile gave the best results. (b) Experiments with synthetic detergents showed that they retarded the aeration of water by diffusers, even in low concentrations of 1 to 10 parts per million. There is a possibility therefore that they may retard the self-purification of a river by reducing the oxygen uptake from the air and may also reduce the efficiency of the activated sludge process. (c) Work on de-watering of sludge at temperatures about 35°C. showed that with the Northern Outfall sludges the separation of water was unreliable and the cost not justified. (d) Experiments made of outflowing sludge from the digestion plant showed that the extension of the primary tank would not be a satisfactory financial proposition. (e) Mixtures of gas liquor and sewage were purified in a laboratory plant with activated sludge to establish the ratio of the relative difficulty of the oxidation of sewage and the particular gas effluent received. This work is continuing and the results will be of financial importance and have a bearing on river pollution considerations. (J) Research has continued on the estimation of sulphide in river water, especially when small amounts of both oxygen and sulphide are present together, as has been shown to occur. Trade wastes The London County Council General Powers Act, 1953, which came into force on 1st April, 1954, enables the Council to exercise a closer control over the discharge of trade wastes into the London sewerage system. Industrial discharges have increased in volume and complexity over the past few years in view of the many new processes using a wider range of chemicals than formerly. The analysis of samples frequently presents difficulty to ensure that (i) the matter is neither, alone or in combination with the contents of the sewers, dangerous, a cause of a nuisance or injurious to the health of persons entering the sewer (ii) the matter will not injure the sewer, interfere with the free flow of the contents of the sewer or be likely to be prejudicial to the treatment and disposal by the Council (iii) the material does not contravene any act, order or agreement in force. Cases have been examined where a discharge of synthetic resin adhesive completely blocked a local pipe sewer and also where a manufacturer wished to discharge large quantities of the powerful sterilising agent phenyl mercuric acetate. These examples show the diversity of the problems presented. Safety Regular examination of inflammable gas detector lamps of the expanding metal spiral 46 type and those based on selective diffusion is made to ensure that all lamps are in good order and advice is given as required on the use of self-contained oxygen respirators. Experiments have continued on methods of improving sewer ventilation. River Thames The work on the assessment of pollution of the River Thames continued ; weekly samples were analysed from 26 points between Teddington Weir and the Black Deep (the sludge dumping area) and in addition the water off the two outfalls is sampled daily at both high and low tides. The condition of the river is obviously worst in the summer ; in 1954, the average daily fresh water flow over Teddington Weir was 502 million gallons for the July— September quarter which was more than double that of the previous year. The effect of this increased flow, coupled with the recorded lower average air and water temperatures, produced an improvement in general river conditions. The dissolved oxygen level improved and the area where sulphide was detected was smaller and of shorter duration and the actual concentrations were much reduced. The necessity for the reduction of the pollution load on the river is apparent and the Council's additional treatment works now under construction or being planned will, when in operation, make a substantial contribution to this end. It should be emphasised in this connection that there are many sources of pollution gaining access to the river, as well as the effluent from the Council's works ; for example, other sewage effluents, trade waste discharges, water from impure tributaries and contamination from shipping. The Scientific Adviser continued to be a member of the Thames 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. Mention should be made of research work done at the Southern Outfall works laboratory on the iron salts in the river water. The amount varies from 0.4 p.p.m. to 2.5 p.p.m. (average 1.4 p.p.m). Normally they are present in the ferric state but when sulphides become established they are reduced partially or wholly to the ferrous state. Throughout 1954 a regular examination of high and low tide samples was made to determine the changes of the ferrous and ferric balance. Housing The work done by the Scientific Branch for this service covers a very wide field. The largest section, that concerned with paints and other surface coatings, is of considerable economic importance, since the total expenditure of the Council on these products and their application is round about £4 million. The Inter-departmental Paint Committee and Sub-Committee continued their regular meetings and played an important part by ensuring that good-quality products only were used and by taking all possible steps to avoid site difficulties. The approved paint lists comprised hard gloss, semi-gloss, flat, oil and emulsion paints and chlorinated rubber and black protective bitumen. In this range, 61 new brands were approved during the year and 87 were found not to be of the quality required. The faults to which a paint is prone are many and varied but several exterior hard gloss paints were rejected because their pigments contained excessive quantities of calcium carbonate or lithopone, sometimes as much as 50 per cent. In one case, a pigment for a paint recommendecf for Grade A exterior contained 63 per cent. of china clay. A common fault found on the site was the inadequate sealing of porous surfaces and, in some instances, complaint was made of slow drying and the difficulty of application. Special laboratory investigations were necessary in connection with some site troubles and advice notes were sent to user departments on— 47 D (a) the advisability of using only certain 'Archrome' colours for exterior work, semi-gloss and flat finishes; (b) the decoration of Bellrock panels; (c) the use of emulsion paints; (d) anti-condensation paints; and (e) the preservation of iron and steel under severe conditions, etc. Increasing demands were made on the facilities provided by the branch for the examination of building materials. These samples covered a wide range and included floorings, floor sealers and polishes, plasters, building boards, fire retardants, concrete, hardcore, slates, asphaltes and bitumen felts. A prolonged series of tests were made during the year on many different types of floor polishes and sweeping compounds and recommendations, which effected economy in labour, time and materials and enabled a good non-slip floor surface to be obtained, were made for the maintenance of (i)thermoplastic floors and (ii) wood floors. A large number of subsoil samples were examined and recommendations made as to desirable type of cement required, having due regard to economy and the 'aggressiveness' of the clay present towards Portland cement. Materials for eradicating wood destroying beetles and fungi were examined and advice given on affected sites. On the planning side, the advice of the Scientific Branch was sought in many cases in regard to the Use Classes Order, 1950, relating to the Town and Country Planning Act, 1947; guidance was sought as to the exact classification of proposed industries with respect to the possible causation of nuisance and effect on the amenities of the areas involved. Public health During the year, the water supplies to 25 establishments served by wells were regularly examined. The 758 bacteriological samples, 63 chemical and 638 free chlorine tests ensured that the water was efficiently chlorinated and at all times in satisfactory condition. The air in the Council's vehicular tunnels under the River Thames was regularly examined in order to ensure that carbon monoxide, nitrous fumes, lead and soot contents remained within safe and desirable limits. The volume of motor traffic was the greatest yet recorded but the forced ventilation was efficiently adjusted and, of 208 samples taken, only two were above the specified limit of 250 parts per million. There was, however, some increase in the amount of black suspended matter, which is considered to be related to the increase in diesel-engined vehicles. Considerable work was done during the year on air pollution; estimation was made of total deposit tarry matter, sulphur gases and smoke in connexion with a scheme sponsored by the Department of Scientific and Industrial Research. A new form of electrically-operated automatic sampler was devised by an officer of the branch enabling measurements to be made over six consecutive periods without attention, thereby saving labour. This improved type of instrument is being installed at six sites. Seasonal fluctuations were clearly marked at all sites and the overall picture showed some reduction in the amount of sulphur dioxide present in the air as compared with recent years ; an important factor here was the rainfall, which was unusually persistent during several months of the year. Other work included consideration of various types of disinfectants and the use of quaternary ammonium compounds in washing-up water. Although the latter compounds do reduce the bacterial content of the water being used, handhng and the condition of the wiping cloth are very important and the recommendation of a sterilising sink maintained at 170 degrees Fahrenheit is being continued, where possible. On questions of industrial hygiene, problems such as discharges from factories, the hazards of certain synthetic resin dusts, the dangers of a hair restorer and leakage of petrol vapour were all the subject of reports. 48 Public control Under the Fertiliser and Feeding Stuffs Act, 1926, for which the Scientific Adviser is the Official Agricultural Analyst to the County, of the 111 samples examined, 51 varied, in some way, from the Statutory Statements or Voluntary Warranties given by the vendors, but only in four cases were the variations to the disadvantage of the purchaser. Many samples were examined under the Petroleum (Consolidation) Act, 1928, the provisions of which govern licences for storage and safety precautions regarding petroleum spirit and petroleum mixtures. Of these, 47 samples were found to come within the provisions of the Act. Advice was sought in several instances on premises and processes employed to which the London Building Acts, 1930.39, applied. The means of escape clause and the danger of fire and/or explosion are matters frequently requiring scientific consideration. The officers of the branch were also concerned with the Bread Order, S.I. 1283/1953, the Prepacked Food Order, 1950, the L.C.C. (Celluloid, etc.) Act, 1915, etc. Parks Although some work was done for this department on fertilisers, soils and other matters of horticultural interest, the major item related to the open.air swimming baths provided for public use. The Council has under its control 15 open.air swimming baths and 20 indoor baths situated at various institutions. In conjunction with the officers of the Chief Engineer's department, considerable research on the subject of control has been done in the branch and, of the 127 bacteriological samples taken from open.air baths, only one showed any coliform pollution ; the lowest clarity recorded was 25 feet, the greatest above 100 feet and the mean was 60 feet. Research is proceeding on this subject on the lines of even better control at less cost. School meals, education and children's departments The work done in co.operation with the School Meals and Catering Department was continued and 82 meals were analysed for fat, protein, carbohydrate, mineral contents and calorific value in order to ascertain that the standards aimed at were being provided by the kitchens. The results showed a good approximation to the requirements of the various nutritional factors for the age groups concerned. Visits to the laboratories of kitchen supervisors were organised in order to demonstrate how the work in the kitchen and the analytical results obtained in the laboratory are related. Swimming bath waters and drinking waters at residential schools were examined and the improvised treatment of the former worked well and will be continued until authorisation by the appropriate Ministry for the expenditure for installing automatic treatment plants is obtained. Instructional visits of school parties to the County Hall continued and the application of many branches of science directly to human needs and problems was demonstrated. Supplies More than 2,000 samples were examined, either directly or indirectly, for this department, and their wide range is shown by the fact that in the list of samples given in this report they fall into about 16 groups. Particularly close liaison was maintained with officers of all branches of the Supplies Department which facilitated discussions on matters on which a scientific aspect could be helpful. The foodstuffs, which are divided into 17 classes, were generally of a high standard of quality and a careful watch on contamination from the container, preservatives and general adulteration was maintained. AO complaints on these and other purchases are carefully investigated, new preparations assessed for potential value to the Council and tenders assessed to ensure that the cheapest satisfactory material is recommended. Careful attention is given to the development of synthetic detergents and new types are examined when they become commercially available. The field of work for this department includes paints, fuels, lubricating oils, foods, soaps, plastics, solders, chemicals, drugs and general medical supplies. 49 Fire brigade Much of the work in this field was of a consultative and advisory nature. An officer of the branch serves on British Standards Institution Technical Committees on fire resistance and incombustibility and the inflammability of cinematograph films. Investigations were made of cases in which spontaneous ignition was suspected and three examples of hazardous materials that were encountered were wood impregnated with silver nitrate, fine metal turnings and fibres from buffs containing grease and metallic dust. The merits of an automatic foam producing system were assessed, fire. retarding compounds were investigated and reports were made on suitability for use of rubber hose, foam producing compounds and chemical extinguishers. Steam raising, heating, etc., plants, laundries In collaboration with the Chief Engineer's or Architect's Departments many plants under this heading were examined. Twenty.eight steam raising plants were regularly visited and a further 21 must be added to the list shortly. Sixteen softener plants and 14 hot water systems are tested periodically and 10 others from time to time. The Council maintains 19 large laundries with commercial type equipment and numerous small ones with domestic appliances. With the scientific staff available every effort is made to visit these establishments, determine the efficiency of the processes and advise on difficulties arising. Economically, this is a very important branch of the work, in view of the value of the goods involved and the damage that can be done by incorrect washing procedures. Special methods are often recommended, taking into account the circumstances, equipment available, financial considerations and staff. Miscellaneous Many interesting matters could be mentioned under this heading of which a few examples are given below : (1) Investigation of plastic lampshades, deterioration temperature and overcoming static electricity difficulties. (2) Report on mixtures of different fibres in brushes. (3) Experiments to determine the force exerted by a child stumbling and its effect on glass panels. (4) Recommendations on the destruction of large quantities of chemicals which could not be discharged as such into the sewer. Attention was paid to the development of new analytical methods and close liaison was maintained with many Research Associations, Government Scientific Establishments, etc. The Scientific Adviser served on one Government Committee, two of the Department of Scientific and Industrial Research and eleven of the British Standards Institution, and acted as an expert witness for the Board of Trade in a series of prosecutions connected with the sale of turpentine substitutes. Publications and lectures during the year were : (<j) Sewage sludges and their utilisation—S. G. Burgess and G. S. Clements. (b) Detergents—S. G. Burgess. The staff numbered 57, which included 26 graduates, 27 ancillary staff and 4 in the clerical section. 50 HEALTH SERVICE PREMISES Building programme the health committee approved a five.year capital building programme for the Five.year building period 1954.59, which had been prepared with the object of securing that future proposed programme building works should be carried out, as far as practicable, in order of urgency and pnased 1954.59 so that they might become available at the time they were required. Advice had previously been received from the Minister of Health that the need for economy continued to limit the amount of capital building expenditure which could be authorised each year, and that he was unable, for the present, to sanction the provision of new maternity and child welfare centres except in those areas, such as new housing estates, where no clinic services existed at all. In the light of this advice it was necessary to include in the five.year building programme only those projects having the highest priority and to defer for the time being schemes for replacement maternity and child welfare centres. These deferred schemes were included in a reserve list of works from which the most urgent could be brought forward if changed circumstances permitted. During the year the procedure introduced in 1950 whereby the Council submits an Submission of annual annual capital building programme to the Minister of Health with a view to obtaining building his approval of schemes to be carried out during the following financial year, was programmes modified. Under the revised procedure particulars of both the capital building programme for the year 1955.56 and the projects proposed for the year 1956.57 were submitted to the Minister and as starting dates for building works were no longer required, only schemes costing more than 10,000 were required to be included. The programme for 1955.56 included two new schemes and six other projects brought forward from earlier programmes. In addition, it was proposed to carry out during 1955.56 seven other schemes which no longer required individual approval by the Minister. Five schemes requiring his sanction were proposed for the year 1956.57, including one previously included in the programme for 1954.55. Particulars of outstanding schemes which had previously been submitted to the Minister for approval, and of projects included in the programmes for the years 1955.56 and 1956.57 are given below : Division 3—Charles Lamb (Popham Road) School, Islington—Adaptation as a maternity Scheme and child welfare and school treatment centre. The adapted premises were intended to abandoned replace a centre in a decontamination shelter in Tibberton Square but as other premises in Clephane Road (formerly used as a day nursery) became available, the scheme was abandoned. The following schemes for replacement maternity and child welfare centres included Schemes in earlier programmes were excluded from the five.year building programme, 1954.59 : Division Premises Work involved 1 129 Fulham Palace Road Adaptation 3 Drayton Hall, Islington Extension of maternity and child welfare facilities and addition of school treatment centre 6 Bumey Street, Greenwich New building Division 1—Westway, Hammersmith—Day Nursery—This scheme was held in abeyance Scheme in owing to a diminishing need for day nursery places. abeyance Division Premises Service Work involved Schemes 3 Basire Street (Coleman Fields), Day nursery New Building deferred until Islington later in five . South Eastern ambulance station General ambulance Extension Year station programme 51 Works Division Premises Service Work involved completed 1 St. Quintin welfare centre, High. Maternity and child New building lever Road, Kensington welfare centre 1 Eridge House day nursery, Fulham Day nursery Repairs on acquisition 5 Mary Hughes Centre, Underwood Maternity and child Extension to form a child Road, Stepney welfare centre welfare centre in association with the London Hospital 6 Amersham Road health centre, Day nursery and Adaptation Deptford office ation 7 Kinsey House, Kingswood Estate, Maternity and child Adaptation of existing Camberwell welfare centre accommodation . 9 Spencer Park, Wandsworth .. Occupation centre Conversion of existing premises . Hampstead ambulance station, Accident ambulance New building Heet Road station . Hurlingham Lodge, Fulham .. Hostel for tubercu. Adaptation for full occupation lous men . Cromwell Lodge, 55 Cholmeley Hostel for tubercu. Initial adaptation on Works in Park, Hornsey lous men acquisition hand at 2 86 Carlton Hill, St. Marylebone .. Day nursery Repairs on acquisition end of year 5 Peel Grove, Bethnal Green .. Maternity and child New building welfare centre 9 193 Mitcham Road, Wandsworth School treatment Adaptations centre . Cromwell Lodge, 55 Cholmeley Hostel for tubercu. Completion of adaptations Park, Hornsey lous men to premises Dover Lodge, Wood Vale, Hostel for mentally Adaptation on acquisition Camberwell deficient girls London ambulance service head. Ambulance service Conversion of fire station quarters, Waterloo Road, Lambeth . Pear Place, Lambeth Headquarters ambu. Additional accommodation lance station . Brook ambulance station, Green. General ambulance Reinstatement of war damage wich station . Upper Richmond Road ambulance Accident ambulance New building station, Wandsworth station . Mottingham ambulance station, Accident ambulance New building Scheme Woolwich station approved but 5 1a Wellington Way, Stepney .. Maternity and child Reinstatement of war damaged work not welfare centre block as offices and resi. commenced at dential accommodation for end of year staff Programme The programme submitted to the Minister of Health for the year 1955.56 included for 1955.56 the following projects : Division Premises Work involved 3 Muriel Street, Islington Erection of day nursery 5 Galbraith Street, Poplar Adaptation of premises as maternity and child welfare and school treatment centre 9 Stormont Road, Battersea Erection of maternity and child welfare centre 9 67 Victoria Drive, Wandsworth.. Completion and adaptation of premises as maternity and child welfare and school treatment centre to serve new housing estates 9 Roehampton Lane, Wandsworth .. Erection of maternity and child welfare and school treatment centre as first instalment of a comprehensive health centre to serve new housing estates 9 ' Southlands,' Shuttleworth Road, Bat. Reinstatement and adaptation of premises to tersea provide additional accommodation for maternity and child welfare centre and office purposes and severance from Borough Council's premises . Grafton Hall, Camberwell . Adaptation of existing building to provide new occupation centre . Foxley Road, Lambeth Conversion of former fire station to provide new accident ambulance station 52 53 Arrangements were also made for the undermentioned schemes, which no longer required individual approval by the Minister to be dealt with in the year 1955.56 : Division Premises Work involved 2 283a Harrow Road, Paddington .. Extension of premises to provide additional accommodation for maternity and child welfare, school treatment, and office purposes 2 Daleham Gardens, Hampstead Erection of building as a combined maternity and child welfare and school treatment centre 2 Hampstead Health Institute, Dynham Adaptation of existing premises to provide Road accommodation for maternity and child welfare centre 5 Rochelle Street School, Bethnal Green . . Adaptation of building to provide maternity and child welfare centre 7 Queen's Road centre, Camberwell .. Second stage works of adaptation, including provision of hot water and heating systems . Shoreditch ambulance station . . . . Improvements to entrance of existing building . Cornwall Avenue, Bethnal Green .. Adaptation of premises as occupation centre The following projects requiring the approval of the Minister were proposed for Projects for inclusion in the building programme for the year 1956.57 : 1956.57 Division Premises Works required 1 Walmer Road, Threshers Place, Ken. Erection of day nursery to form ultimately a sington maternity and child welfare centre as the first instalment of a comprehensive health centre 6 Abbey Wood, Woolwich Erection of maternity and child welfare and school treatment centre as first instalment of a comprehensive health centre to serve new housing estate . Highlever Road, Kensington Erection of occupation centre to replace unsatisfactory temporary accommodation and provide additional places . Iceni Sports Ground, Ickburgh Road, do. Hackney Shaftesbury School, Perry Rise, Lewisham do. Day nurseries The continued gradual diminution in the demand for day nursery places and the strict application of a priority system of admission enabled the day nursery service to be maintained without serious difficulty, despite the closure of four nurseries, but the extent to which the service depended on the use of premises held on insecure tenure or under requisitioning powers due to expire in December, 1957 continued to give rise for concern. The level at which the service would need to be maintained to meet the anticipated future demand for places was accordingly reviewed to enable steps to be taken, where necessary, to secure the continued availability of requisitioned nurseries and other premises held on insecure tenure by means of acquisition or long.term leases. Division 6—Amersham Road Day Nursery, Deptford—Adaptations to provide additional Works accommodation were completed to permit the closure of Evelyn Street day nursery complete which was demolished. Division 1—St. James' Day Nursery, Maxwell Road, Fulham—The tenancy of these premises Nurseries was terminated by the freeholders and the nursery closed. No replacement was available closed but the children displaced were accommodated in neighbouring nurseries. Division 4—Sylvester Day Nursery, Sylvester Path, Hackney—This day nursery, which was accommodated in unsatisfactory requisitioned premises, was closed without replacement. Arrangements were made for the children to be transferred to other nurseries in the locality. Works completed Division 9—Balham Day Nursery, Old Devonshire Road, Wandsworth—This nursery was closed because of serious defects in the structure of the building and the children placed in other nearby nurseries. Maternity and child welfare centres Division 1—St. Quintin Welfare Centre, Highlever Road, Kensington—This purpose designed building was completed and the centre opened in July. Further reference to this new centre is made on page 126. Replacements Division 5—Mary Hughes Centre, Underwood Road, Stepney—Adaptation of these premises to provide improved facilities, in association with the London Hospital, was completed and the new centre opened. The enlarged centre replaced the temporary centre at 52 Ashfield Street, Stepney. Division 5—Bromley Welfare Centre, Newmill House, Devas Street, Poplar—New purpose designed accommodation was provided in flats on the Coventry Cross housing estate extension to replace unsatisfactory centres at St. Michael's Church Hall, Ullen Street, and All Hallows Church Hall, Devons Road, which were closed. Division 9—St. Peter's Church Hall, Prescott Place, Wandsworth—A centre was opened in newly rebuilt premises to replace a centre in inadequate accommodation at the Public Baths, Clapham Manor Street. Division 9—St. Margaret's Church Hall, Cricklade Avenue, Wandsworth—These premises were brought into use as a welfare centre to replace unsatisfactory accommodation at the Baptist Church Hall, New Park Road. Division 7—Kingswood Welfare Centre, Kinsey House, Bowen Drive, Camberwell—A new centre was opened in premises adapted for clinic purposes to serve a newly.developed area in which no welfare services existed. Division 9—Streatham Vale Welfare Centre, Church Hall, Churchmore Road, Wandsworth— A temporary centre was opened in these premises to provide improved facilities in the South Streatham area. Division 9—Woodlands Welfare Centre, West Hill, Wandsworth—These premises were rented to provide a temporary centre to meet the needs of new housing estates pending the provision of a purpose built maternity and child welfare and school treatment centre at 67 Victoria Drive, Wandsworth. Division 5—Peel Grove, Bethnal Green—The erection of a temporary purpose designed centre, which had been sanctioned by the Minister of Health, was nearing completion at the end of the year. Accommodation for tuberculous men Hurlingham Lodge, Hurlingham Road, Fulham—Major works of adaptation were completed to bring the hostel into full occupation by 28 men. Further reference is made to this hostel on page 127. Provision of additional centres Works in progress Works completed Replacement Cromwell Lodge, Cholmeley Park, Hornsey—Preliminary works to allow occupation of these newly.acquired premises by 27 men were completed and the hostel opened to replace the one at Highbury Quadrant, Islington. The completion of second stage works of adaptation, which were well advanced at the end of the year, will provide full occupation by 31 men. Further reference to this hostel is made on page 133. Additional centres Occupation centres for the mentally defective Details regarding premises used as occupation centres for the mentally defective will be found on page 90. 9 Spencer Park, Wandsworth—The adaptation of these premises was completed and the building brought into use as an occupation centre for junior mixed children. 54 Moatside, 86 Fulham High Street—Adaptation of this building, begun in 1953, was completed and the premises brought into full use as an occupation centre for junior mixed children. St. Peter's Church Hall, Cranfield Road, Deptford—This centre was opened for junior Replacement mixed children who were transferred from the Methodist Church Hall, Albion Way, Lewisham. Use of the latter premises as an occupation centre was discontinued. Hostel for mentally defective girls under guardianship ' Dover Lodge,' Wood Vale, Camberwell—Adaptation of an existing building as a hostel Work in for girls placed under guardianship on leaving special schools for the educationally Pro8ress sub.normal was well advanced at the end of the year. School health service Division 9—193 Mitcham Road, Wandsworth—Adaptation of these premises for use as a Works in school treatment centre, speech therapy centre and health visitors' office was nearing progress completion at the end of the year. This centre will replace the one formerly at 1071 Garratt Lane. Office accommodation The following changes in office accommodation were made during the year : Division 4—Accommodation at Hackney Town Hall was vacated at the request of the Hackney Metropolitan Borough Council and arrangements made for the staff to be transferred to the Elsdale Road Welfare Centre. Division 5—Office accommodation at Poplar Town Hall, rented from the Poplar Metropolitan Borough Council, was relinquished and the staff transferred to temporary accommodation at Wellington Way welfare centre. Division 7—The health visitors at 1, 2 and 12 The Arcade, Catford, were transferred to the Rushey Green day nursery and to the Shaftesbury House day nursery, Perry Rise. Health centres During the year the London Executive Council agreed to the Council's proposals for Reservation the reservation of a further two sites for health centres. of sites The view was expressed in the Report of the Committee on General Practice within Committee on the National Health Service* that many of the advantages of health centres, both to general practice doctors and to patients, might more easily be secured through the evolution of group practices consisting of doctors who chose to work together in communal premises which they themselves owned and the Committee welcomed the scheme approved by the Minister of Health whereby interested general practitioners were invited through Executive Councils to apply for interest free loans to help them to establish group practice premises which would normally be regarded as permanent medical facilities. Although not a substitute for comprehensive health centres, group practices may, in many areas, prove to be a satisfactory alternative. While it will be some years before sufficient group practices can be estabhshed to assess their value, their estabhshment in any substantial number in London would have obvious repercussions on the Council's policy for the provision of health centres to which reference was made in the Reports for 1951 and 1953. It is, however, too early to consider any radical modification of this policy in the light of the Report of the Committee on General Practice. * Enclosed u/ith Ministry of Health Circular 17/54 (2281/6/5) Acquisitions and leases Opportunities were taken whenever possible to acquire suitable properties and sites for health service purposes or to secure long term leasehold tenancies. The following leasehold tenancy and acquisition were completed during the year : Division Property Interest obtained Service 5 532.4 Commercial Road, Stepney Leasehold Divisional health sub.office . Cromwell Lodge, 55 Cholmeley Freehold Hostel for tuberculous men Park, Hornsey 55 CO.OPERATION WITH HOSPITAL AND MEDICAL SERVICES General liaison Ante and post.natal care Employment of general practitioners Local meetings with general practitioners in the report for 1952 reference was made to the machinery for co.ordination and the general field of co.operation with the various branches of the Health Service in London. The constitutions of the Health Committee and the divisional health committees provide for the representation of many bodies concerned with the Health Service including the London Executive Council and the Local Medical Committee for the County of London. Conversely, the Council has the right to nominate eight members of the London Executive Council and the Medical Officer of Health is a member of the Local Medical Committee for the County of London. There are periodical conferences at officer level with the senior administrative medical officers of the four Metropolitan Regional Hospital Boards, the medical officers of health of the Home Counties, representative house governors of Teaching Hospitals and representative metropolitan borough medical officers of health. Each of the nine divisional medical officers is a member of at least one hospital management committee and they and other senior divisional staff also serve on many voluntary committees concerncd with health. Hospital staffs co.operate fully with the divisional organisation and there is a strong link between the hospital maternity and paediatric departments and the ante.natal and child welfare clinics at welfare centres. The joint use of staff in the hospital and local authority services and the employment by the Council of general practitioners on a sessional basis in the maternity and child welfare and school health services encourage a closer working together in the field. The composite nature of the tuberculosis services in London calls for continuous liaison between all those concerned. Information about the health services is disseminated through many channels, e.g., directories, guides, leaflets, local information centres, etc. Efforts were made during the year to develop further the ties with other parts of the National Health Service and attention was focussed particularly on general practitioners by the publication of the report by the Committee on General Practice within the National Health Service under the Chairmanship of Sir Henry Cohen and by the issue by the British Medical Association in conjunction with the Society of Medical Officers of Health of the statement entitled ' The General Practitioner and the Health Visitor'. Reference has also been made in previous reports to measures adopted to foster co.operation with general practitioners ; the present position is summarised below. Both ante.natally and post.natally the doctor and domiciliary midwife work together to give the mother advice and attention. Indeed in some instances midwives attend doctors' surgeries and this kind of co.operation has been encouraged. General practitioners are employed in the Council's health services on a sessional basis for many types of work, e.g., ante and post.natal, child welfare, vaccination, immunisation, and in the school health service. At the end of the year an average of 700 sessions a week in the school health and maternity and child welfare services were being conducted by 360 medical officers employed sessionally, about half of whom were engaged in general practice. Co.operation has been furthered also by the presence in the service of sessional medical officers holding appointments in hospitals, industry, or working as private specialists or in other capacities. Meetings with general practitioners have been arranged locally at which the part of the health visitor was given prominence and the wide range of her duties stressed. The fact that there are only some 400 health visitors in London and over 2,200 general practitioners on the Local Medical Committee's list limits the amount of effective help which the health visitor can give, but in some instances consultation is frequent. Co.operation has been very fruitful in dealing with the medico.social problems of families where difficulties have not come singly : the family doctor in giving treatment and influencing the family to accept specialised local authority services and to follow the skilled guidance of the health visitor. In some districts there are experimental schemes whereby a health visitor is allocated to a group practice. 56 The Cohen Committee in their review of the question of the provision of health Woodberry Down centres referred, to the Woodberry Down Health Centre but concluded that the centre Health had not been in use long enough for positive lessons to be learnt from it. The general Centre practitioner service at this comprehensive health centre was introduced on 1st July, 1953, and joint use of the centre by general practitioners and Council's staff has undoubtedly facilitated co.operation between them as the centre superintendent is in daily contact with the practitioners and the health visitors are at hand for consultation on family problems and to undertake follow.up visits. Co.operation between the Council's medical officers and general practitioners in School health the field of school health is of long standing, and dates back to the early days of the service school health service when, in several districts of London, local practitioners grouped themselves together to set up voluntary committees administering and operating school treatment centres ; several of these organisations are still flourishing today. During the course of a child's school life comprehensive records in a pattern approved by the Ministry of Education are kept about his state of health, and, both during and after school life, these records can be made available, upon request, to the family doctor. Arrangements exist in the school health service (and also in the maternity and child welfare service) for the family doctor to be consulted when a child is found to need special investigation or treatment. In the home nursing service the traditional close co.operation with the general Homc practitioner was maintained and more than three.quarters of the patients were referred nursmg to the district nursing associations by them. A similar close liaison with general practitioners has developed in connection with Domestic the provision of home helps, including, in appropriate cases, the special types of service hclp servlce such as the night home help and, for the particular assistance of the family with young children, the early morning and evening home help. Throughout the Council's mental health services the closest co.operation has been Mental health maintained with general practitioners and the results of examinations by the Council's services medical officers or any action taken by social workers or other officers at their request have been communicated to general practitioners. As would be expected, only a small proportion of alleged mental defectives were referred by general practitioners (the majority being referred through the Education service or by hospitals) but in these cases full information of any action contemplated has been supplied to the general practitioner. A very large proportion of the cases referred for action under the Lunacy and Mental Treatment Acts was referred by general practitioners who, in addition to being informed of the result of the enquiries made by the mental welfare officers, were advised whether any other action, either within the mental health services or other services (such as the provision of home helps, admission to establishments maintained by the Council's Welfare department, etc.) was considered appropriate. It has been the practice of the psychiatric social workers engaged in psychiatric care and after care service to get into touch with the general practioner regarding every new patient referred and secure his co.operation in the course of action decided upon. Shortly after the inception of the National Health Service a booklet was prepared Information setting out the various health services administered by the Council. This booklet has to general been revised and contains for each division details of the facilities available at local Practltloners clinics, etc. The Health Committee authorised the distribution of approximately 6,000 copies to general practitioners and social workers free of charge. In some divisions street lists giving the location of the respective clinics and names and addresses of health visitors for the various street addresses have been sent to general practitioners. When staff are absent from duty owing to ill.health and unable to travel to the Medical County Hall for medical examination, and in other cases where for any reason this course appears to be indicated, it is a long.established practice of the Council's Staff 57 Medical Examiner to consult, with the prior consent of the patient, the general practitioner or, where the member of the staffis in the care of a hospital as an in.patient or an out.patient, the hospital doctor. Medical reports from the hospital or chest physician concerned must be obtained in respect of teachers suffering from tuberculosis to enable the statutory medical reports required by the Ministry of Education to be completed and reports giving confidential diagnoses are particularly helpful in cases of staff suffering from this and certain other diseases to enable recommendation for additional sick pay to be made by the Medical Officer. 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 51. Expectant and nursing mothers First attendances at ante.natal clinics represented 45 per cent, of all women needing ante.natal care compared with 44 per cent, in 1953 and attendances at post.natal clinics increased. Educational activities at welfare centres (see page 85) continued to expand and there was a substantial increase in attendances. The following tables give 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 1950 114 910 26,979 176,993 50 1951 112 905 24,819 162,667 45 1952 113 895 21,959 145,088 41 1953 114 976 22,713 129,451 44 1954 116 911 23,204 126,270 45 58 Year Post.natal 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 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 1954 4 9 612 3,717 912 4,629 Year — Special breast feeding Educational sessions per month Total attendances Sessions per month Total attendances 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 1954 .. 25 1,596 328 45,322 Relaxation exercise classes for expectant mothers were conducted either by health visitors or physiotherapists at some welfare centres. Examination of blood specimen for theWasserman and Kahn reactions and for the Tests Rhesus factor was a service available to each expectant mother who attended the Council's ante.natal clinics and haemoglobin estimates were made. Hospital laboratories and the Medical Research Council's laboratory at County Hall continued to provide services free of charge to the Council. 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. Arrangements for routine chest X.ray examination by means of mass X.ray units or Chest X.rays at chest clinics of women who were to be confined at home were further extended. Six mothers with their young children were sent for periods of six to eight weeks Rehabilitation to rehabilitation centres for training in mothercraft and housecraft. A review of families of mothcrs sent during the past two years for this form of rehabilitation has shown that, if it is to be successful, families must be selected in which the father is reasonably stable and interested in the family. Subsequent follow.up by health visitors must be closely maintained and any necessary rehousing arranged shortly after the return of the mother and her children. The residential unit maintained at the Violet Melchett infant welfare centre, a voluntary Mothercraft organisation providing services on behalf of the Council under section 22 of the National training 59 Health Service Act, 1946, continued to provide treatment for mothers and babies experiencing breast.feeding difficulties, and for babies with dietetic upsets. Comparative figures are :— Mothers 1953 1954 67 62 Accompanied Unaccompanied infants infants 73 75 66 72 Clinics Exchange of medical officers Voluntary organisations Family planning Similar non.residential facilities were continued at the North Islington Infant Welfare Centre, another voluntary organisation providing services on behalf of the Council under Section 22. Attendances totalled 837 compared with 994 in 1953. The tables on pages 58, 59 and 60 show attendances at sessions of various types held at maternity and child welfare centres. An average of 300 sessions a week were being conducted at the end of the year by medical officers employed on a sessional basis. 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. Maternity and child welfare services were provided by 17 voluntary organisations who entered into agreements with the Council in accordance with Section 22 of the National Health Service Act, 1946. In addition, child welfare centres were maintained on behalf of the Council by the medical schools of four teaching hospitals acting as voluntary organisations and grant.aided by the Council. Family planning sessions totalling seven 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. 877 women were referred to the Association during 1954 compared with 978 in 1953. At the end of the year 34 weekly sessions were being held by the Association, some in the Council's centres, where accommodation was made available free of charge. Child welfare As will be seen from the table below attendances at child welfare centres in the first year of life reached 86 per cent., the highest figure yet recorded. Those infants who attend in their first year, do so about 14 times. Thereafter attendances tend to fall off rapidly but all mothers are encouraged to bring their children to the child welfare clinics or toddlers' clinics and special invitation cards to the latter are 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 Attendances Percentage of infants attending a centre at least once in the first year of life Clinics at end of year {including toddlers) Session* per month Under I year Over1 year Special toddlers First Total First Total 1949 165 1,784 48,489 683,089 6,641 282,202 35,500 84 1950 169 1,815 43,916 649,983 5,496 245,484 41,817 79 1951 169 1,893 45,534 626,164 4,540 235,942 43,145 82 1952 169 1,925 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 1954 175 1,927 44,061 614,369 4,653 211,634 42,683 86 Mental health in the maternity and child welfare services The study group of medical officers and health visitors under the chairmanship of Dr. John Bowlby, of the Tavistock Clinic, completed their investigation into the 60 possibility of increasing mental health work in the maternity and child welfare services, Their report, which appears in Appendix B, page 156, was considered by the Council's Health Committee towards the end of the year and steps are being taken to give effect to the main recommendations of the group. Reference is made in the section dealing with the mental health services (page 90) to the provision of special child welfare services for backward children. The indexes already started in each health division to provide a ready reference to Children problem families have been developed, and meetings have continued of the divisional neglected or standing committees consisting of the divisional medical officer, area children's officer, ill.treated in their own divisional officer (education), divisional nursing officer, divisional administrative officer, homes district care organiser, together with co.opted members for special purposes. The arrangements for the protection of children against ill.treatment and neglect were reviewed during the year, with particular emphasis on such matters as the degree of success achieved through the co.ordination of the services ; the means by which cases are brought to light ; the most fruitful action when difficulty is found in gaining access to homes where neglect is suspected ; adequacy of the powers for dealing with cases where neglect has occurred and the advantages, and comparative costs, of avoiding the need to take children into care by the use of day nurseries, home helps, child helps, and other health services. The health of children in the Council's residential nurseries is supervised by medical Medical officers of the Public Health Department. Children admitted to these homes are medically supervision at examined by the visiting medical officer who also does routine medical examinations establishments at intervals according to the age of the child. Where appropriate every child is immunised for children against diphtheria, whooping cough and smallpox. Dental inspections are made at the nurseries, usually by local dentists, and treatment is given at the dentists' surgeries. Monthly visits are made by a psychiatrist to advise the child care staff on the management and care of children who are, to a greater or lesser degree, emotionally disturbed. Primarily these visits are made for the education of staff, and children who are sufficiently disturbed to require psychiatric treatment are referred to the local child guidance clinic. In two nurseries case conferences are used as a means of health education for the staff. These conferences are attended by a medical officer of the central staff, a psychiatrist, a child care inspector and the area children's officer, as well as those members of the nursery staff who are closely associated with the child, whose problem is presented by the psychiatrist as a basis of discussion. There were small outbreaks of Sonne dysentery and gastro.enteritis, particularly in two large nurseries which admit the majority of children taken into care who are under three years of age. In one of these nurseries there was a major outbreak of food poisoning which affected some 60 children, ten of whom became seriously ill. Minced ham served to the children for breakfast had been contaminated with Staphylococcus Aureus from an infected burn on the finger of the cook. The visiting medical officer called in a consultant paediatrician and his team from the nearby hospital to assist him with the treatment of the children, all of whom recovered within 48 hours of the onset of symptoms. Most of the nurseries had outbreaks of mumps and chickenpox, but the incidence of measles and whooping cough during the year was low. There were no cases of poliomyelitis. A number of nursery students resident in one nursery had infective hepatitis, and gamma globulin was given to new students entering the nursery as a protective measure. On the whole the prevention of the spread of infection did not present any major difficulty except in the two admission nurseries where the high turnover rate, as well as the size of the nurseries, increase the risk. The Medical Officer of Health advises the Children's Officer on the suitability on Adoption and medical grounds of children for adoption and boarding.out in accordance with the boarding.out duties placed upon the Council by the Children Act, 1948. 61 All children offered for adoption or boarding.out are medically examined either by the visiting medical officer of a nursery or by a family doctor, and blood reports are obtained. Many children present no particular problems, but in some cases family background or medical history may require special consideration before the child can be placed. Prospective adopters may be interviewed by a medical officer so that the implications of hereditary factors or a handicap may be fully explained. Advice may also be sought on the suitability on medical grounds of prospective adopters to adopt a child. 642 children were referred by the Children's Officer for opinion as to their suitability on medical grounds for adoption and boarding.out. Three children were considered unfit and the remainder were grouped as follows : 1. Referred for adoption 203 (a) Fit for adoption 178 (b) Fit for adoption subject to certain provisions 7 (c) Unfit for adoption but fit for boarding.out 17 (id) Case still under consideration 1 2. Referred for boarding.out 436 Fit for boarding.out 434 (two cases withdrawn by Children's Officer) Drugs, medicaments, welfare foods, etc. Since the Ministry of Food first began to provide welfare foods, i.e., national dried milk, orange juice, cod liver oil compound and vitamin A and D tablets, distribution has taken place at welfare centres as well as at the local food offices, but on the closing of the latter in the middle of 1954 the Council, in common with other local health authorities, undertook the entire local distribution on behalf of the Ministry of Food. Considerable reorganisation was necessary to provide transport, storage, distribution and financial arrangements, but the transfer was effected smoothly and the needs of the public were fully met through approximately 200 distributing points. Valuable assistance was given by the Women's Voluntary Services, in providing 11 distributing centres and help elsewhere, and by other volunteers. In addition to those distributed on behalf of the Ministry of Food, other welfare foods continued to be made available for children on the approval of a medical officer, at fixed charges, subject to abatement where necessary. Drugs and medicaments according to an approved list were provided free of charge when recommended by the clinic medical officer. Sunday cinema grants The Council continued to receive contributions from 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 were administered by small voluntary committees. Marriage guidance The Council decided, in 1951, to give financial aid over a period of five years to each of the three marriage guidance organisations operating in London, and grants were accordingly paid during 1954 to the London Marriage Guidance Council, the Catholic Marriage Advisory Council and the Family Discussion Bureau of the Family Welfare Association. Special investigations Investigations continued into the following matters, which were referred to in the report for 1953 :— Registration of rubella cases for the Ministry of Health enquiry into virus infections during pregnancy. 62 Investigation being conducted by Mr. H. J. B. Atkins, Director of the Department of Surgery, Guy's Hospital, into the health history of female children who have never received human milk. Survey of illegitimate children. The investigation being conducted by Dr. W. F. Dunham, of the Department of Physical Medicine at Charing Cross Hospital, into the early detection of infantile cerebral palsy had extended by the end of the year to five of the nine health divisions. Day nurseries and occasional creches The Council's policy since 1951 has been to maintain day nursery accommodation Day substantially at the level at that time but to watch for any indication of redundancy Nursenes which might occur, despite efforts to secure full occupation within the limits set by the scheme of priorities for admission. During 1954 one grant.aided and four maintained day nurseries were closed and the accommodation was reduced at three others. The loss of places was partly offset by increasing the accommodation at one maintained nursery by 30 places. The net loss was 208 places. At 31st December, 1954, there were 100 maintained and 5 grant.aided day nurseries providing 5,850 places. Comparison with the previous year is shown in the following table:— Age Group Maintained Grant.Aided Total 31.12.53 31.12.54 31.12.53 31.12.54 31.12.53 31.12.54 0.2 years 2,006 1,956 50 50 2,056 2,006 2.5 years 3,813 3,690 189 154 4,002 3,844 5,819 5,646 239 204 6,058 5,850 The priority waiting list for admission at the end of the year was 916 as compared with 621 at the end of 1953. This increase was due to the introduction of the third priority group referred to later. One training day nursery was closed and one was reduced to non.training status. The number of training day nurseries at the end of the year was 59 (56 maintained and 3 grant.aided). The rules governing eligibility for admission to day nurseries are as follows:— 1. The first priority for admission shall be given equally, subject to the other rules, to the children (including adopted children) of:— (<j) mothers who are widows, separated or divorced wives, or wives whose husbands are totally disabled or in prison, or unmarried mothers, provided they are maintaining an independent home and are employed at least 35 hours a week including meal times ; (b) parents where the mother is in ill.health and cannot care adequately for the children, or during the mother's confinement; (c) parents who are living in housing conditions detrimental to health, or where other environmental factors are such that it is desirable for the health of the child that it should be admitted to a day nursery ; and (d) widowers or where the mother has left the home. 2. The second priority for admission shall be given, subject to the other rules, to the children of parents where, because the father is unemployed or his earnings are so low, the mother is compelled to go to work as an economic necessity and is employed at least 35 hours a week, including meal times, provided the joint net income of the parents as calculated in accordance with approved rules does not exceed a week. 3. Vacancies not required for children in the first and second priority classes shall be offered to other children in a third priority class whose parents are both working, if able to do so (the mother being employed for at least 35 hours a week, including meal times), and whose joint net income, as calculated in accordance with approved rules, exceeds £9 a week. 63 4. In assessing applications for all admissions an over.riding consideration shall be that the parent(s) is/are unable to make other satisfactory arrangements for the care of the children. 5. The Divisional Medical Officer, with the approval of the Chairman of the Divisional Health Committee, is authorised at his discretion, to admit in appropriate cases, the children of mothers working fewer hours than stipulated in the foregoing rules, 1, 2 and 3. 6. Places offered to children in the third priority class referred to in rule 3, shall be initially for six months (unless a temporary admission for a shorter period is required), subject to review after that time as in rule 8 below and renewals for subsequent periods of six months shall be permitted, provided that vacancies are not required at the time of review for children in the higher priority classes. 7. The Divisional Medical Officer shall have over.riding discretion to admit any other cases presenting special features and any appeal from his decision shall be considered by the Chairman of the Divisional Health Committee. 8. A review of the circumstances of the parents of all children admitted to day nurseries, including, where appropriate verification of parents' incomes, shall be made at six.monthly intervals from the date of admission. Where a child no longer falls within the first or second priority classes, a third priority vacancy shall be offered wherever possible in accordance with the rules. During 1954, the demand for places for children in the first and second priority groups continued to show signs of falling, but admissions under the third priority averted a decline in total attendances. As stated in the report for last year, the third priority group and the scale of supplementary charges were introduced on 2nd November, 1953, but application to children already on the registers was deferred until 4th January, 1954, to enable the parents' circumstances to be reviewed. As a result of this review a total of 1,520 children were re.classified as third priority. During the first six months of the year 199 children were withdrawn from the nurseries because of the supplemental charge ; of these 13 started school, 93 were cared for by the mother, who had either given up work or was working at home, and 35 were placed in the care of relatives. In the case of the remaining 58 children it was verified that other satisfactory arrangements, such as their care by child.minders, had been made. Experiments were conducted over a considerable period to investigate the advantages of the use of washing machines in day nurseries. It was found that a financial saving, albeit small, could be anticipated in respect of the cost of washing and ironing, and that this would be enhanced by the longer life of the articles. Other advantages included the opportunity to reduce the stock carried because of the more rapid turnover and the avoidance of the accumulation of large quantities of soiled linen, etc., on the premises. In consequence washing machines and drying cabinets were provided at a number of day nurseries where the installations could be carried out without considerable structural alterations. Voluntary With the Council's concurrence, the voluntary committee administering the St. Paul's Organisations day, nursey Stepney, decided to close the nursery because of falling attendances. This nursery which provided 35 places closed on 16th July, 1954. Arrangements with five other voluntary associations providing day nurseries continued throughout the year and a grant was made towards the maintenance costs of one part.time day nursery. The provision of facilities at occasional creches remained at the level existing in the previous year. Nurseries and Child Minders (Regulation) Act, 1948 In addition to those child.minders who are required to register under the Act, the Council has encouraged others, i.e., those who mind one or two children, to register voluntarily with the Council, and a small weekly registration fee is paid in return for which their homes are subject to inspection. Occasional Criches Child. minders 64 The numbers of child.minders, both statutorily and voluntarily registered, as compared with 1953, were as follows :— At 31 st December 1953 1954 Number of child.minders statutorily registered 112 110 Number of children minded 638 590 Number of child.minders voluntarily registered 793 925 Number of children minded 854 1,000 The number of private day nurseries registered under the Nurseries and Child Private day Minders (Regulation) Act, 1948, and the number of places provided, as compared with nurseries 1953, were :— At 31st December 1953 1954 Private day nurseries statutorily registered 60 61 Places provided 1,795 1,795 Care of the unmarried mother and her child The Council's duties for the care of expectant and nursing mothers and young General children include the care of unmarried mothers and their babies. This duty is performed arrangernents 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 unmarried mothers 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 1954, 21 homes were supported in this way, the total payments amounting to £13,057. The Medical Officer of Health is represented on committees of voluntary homes by the appropriate divisional medical officer, who ensures that local services are readily available to the unmarried mother and health visitors call regularly at mother and baby homes in their districts. When the mother and baby leave the home notice of the new address of each is sent to the Medical Officer of Health of the area concerned whether the mother and baby remain together or not. It was estimated that of 684 mothers admitted to mother and baby homes during Ante.natal a period of six months, 39 per cent, had no effective ante.natal care, 28 per cent, had medicaI care ante.natal care for less than three months before the expected date of confinement while 11 per cent, had no ante.natal care at all. Eighty.five per cent, of the total of 684 women were primiparae and nearly two.thirds of the latter cases were between 18.24 years of age. An attempt has been made to meet the needs of unmarried mothers for antenatal care by holding evening clinic sessions in some divisions at which any mothers who go to work and find it inconvenient to get to a clinic during the day may attend. In January, 1954, the Council introduced a punch.card system for recording details Statistics of each unmarried mother dealt with by the welfare workers of the associations. These cards are designed to serve the dual purpose of providing the Council with accurate statistics of the volume of work carried out by each association, and also assist the voluntary organisations by reducing their clerical work and informing them of the case load of individual welfare workers. E* 65 DOMICILIARY MIDWIFERY SERVICE Number of births and home confinements Organisation and staffing Ante.natal arrangements Maternity nursing associations Still.births details relating to births appear on page 7 from which it will be noted that the number of live and still.births in London in 1954 was approximately the same as in 1953, that is, 51,655 as against 51,971. The number of home confinements, which are set out in the table on page 68, rose slightly from 10,458 to 10,546. The duty to secure provision of an adequate domiciliary midwifery service under Section 23 (2) of the National Health Service Act, 1946, is discharged through the Council's own full.time salaried midwives (98), mid wives employed by district nursing associations (33, including supervisory staff) and district midwives employed by the hospitals (60, including supervisory and part.time staff). The service is centrally administered and is supervised by four non.medical supervisors. The average annual case load of each midwife is 64. The fullest co.operation with other local health authority services, statutory and voluntary bodies, and with general practitioners providing maternity and ante.natal services is encouraged. A few midwives now attend ante.natal clinics in the surgeries of general practitioners ; but since, in the main, general practitioners are prepared to send mothers for intermediate ante.natal care to the Council's centres there is a system of exchange of reports for the majority of cases between the booked doctor and the midwife, supplemented by personal contact. Blood tests, including Wasserman, Kahn, Rhesus and haemoglobin, are carried out for all expectant mothers attending the Council's centres and chest X.ray is offered through the mass X.ray service. There was one major change in the domiciliary midwifery service during the year. At the request of the North West Metropolitan Regional Hospital Board, the district midwifery work of the Maternity Nursing Association was transferred to the Council on 1st April, 1954. The Maternity Nursing Mission, as it was then known, opened its first district midwives' home in King's Cross Road in 1896. The Association was taken over by the Royal Northern Hospital in 1930, and carried out the latter's district midwifery work, in association with the City of London Hospital. In 1938 the Maternity Nursing Association became an all.district second period training school, probably the largest in the country and certainly one of the best known. During the long years of its existence, the Maternity Nursing Association gave much valuable service in the field of domiciliary midwifery. Both the Maternity Nursing Association and the City of London Hospital came under the jurisdiction of the Northern Group Hospital Management Committee on 5th July, 1948, and the arrangements for providing domiciliary midwifery in agreement with the Council continued. The three district homes used by the Maternity Nursing Association have now been given up and an alternative home for the midwives has been provided in a former hostel for day nursery students and in flats converted from surplus health service accommodation or made available by the Housing Committee. A superintendent has been appointed to take charge of the home at Scholefield Road. Facilities offered for Part II training of pupil midwives are being continued. The transfer has resulted in a simpler and more economical service. Of the 10,546 mothers who were confined at home 922 were primiparae, 9,624 multiparae and there were 101 still.births. In England and Wales the still.birth rate was 23.5 per 1,000, but whereas in London the still.birth rate in hospital was 21.5 per 1,000 the still.birth for domiciliary confinements was only 10.3 per 1,000. The still.birth rate for home confinements in London has remained at about this level since 1951. It is to be expected that, since confinements likely to be abnormal are taken into hospital, the still.birth rate would be lower for domiciliary confinements. The markedly lower figure for domiciliary confinements would, however, suggest that arrangements made for the ante.natal care of mothers by the clinic doctors and midwives at maternity and child welfare centres by which women are selected as 66 suitable for home confinement, together with medical aid and the ready availability of hospital services, if necessary, does ensure a reasonable margin of safety for the baby born at home. The following is an analysis of the 101 still.births : (a) Ante.partum 57 ; Intra.partum 41 ; Unknown 3. (b) Predisposing causes of the 41 intra.partum deaths were Complicated vertex deliveries 11 Breech delivery 8 Prematurity 5 Short cords . 5 Congenital defects 5 Unknown 7 (c) Full term 68 ; Premature 33. (d) 17 of the still.born infants had congenital defects. The record of neo.natal deaths is incomplete because midwives visit for periods Neo.natal varying from 14 days to, occasionally, 21 or 28 days after the end of labour. There were deaths 56 neo.natal deaths reported in the first three weeks of life, 52 of these occurring within the first 7 days. Thirty.five of the 56 neo.natal deaths were premature infants, the deaths of 24 being attributable to prematurity alone. The causes of death of the remaining 21 full.term infants were as follows : Cerebral haemorrhage .. 4 Gastro.intestinal abnormalities 4 Congenital heart lesions .. 3 Pneumonia .. .. .. 3 Atelectasis 2 Acute peritonitis and salpingitis 1 Unknown . 4 During 1954, 519 babies weighing 5£ lbs. or less were born to 492 mothers in the Premature care of domiciliary midwives [53 mothers were primiparae, 439 were multiparae of bables which 46 were having their sixth or subsequent baby, 14 mothers—parity unknown], 36 mothers were delivered as unbooked emergencies and had no ante.natal care, 32 mothers had a previous history of premature babies. Babies weighing 4 lbs. or less, or those showing signs of immaturity, are transferred to hospital immediately after birth ; 353 babies were nursed at home and of these 346 were well and thriving when discharged by the midwife at two to four weeks ; 283 babies were fully breast.fed on discharge. 139 calls were made to hospitals during the year for the emergency obstetric unit. Emergency In the majority of cases the unit arrived within 30 minutes of being called.obstetric unit Conditions necessitating the use of the service were : Post.partum haemorrhage—46. Eclampsia—3. Post.partum haemorrhage with retained placenta—43. Medical aid for the baby—3. Ante.partum haemorrhage—13. Cervical and vaginal lacerations—2. Retained placenta—12. Failed forceps—2. Foetal distress—8. Obstetric shock—1. Mal.presentation—6. There was one maternal death, due to collapse following post.partum haemorrhage and manual removal of placenta. There were eight still.births. The use of gas and air analgesia by the Council began in 1946. The apparatus is held at Gas and air selected ambulance stations throughout the county and transported to the patient's analgesia home on the request of the midwife. All midwives employed by the Council are qualified to administer gas and air analgesia. Its administration shown as a percentage of all domiciliary confinements rose again to 79 per cent, in 1954. 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. It is not administered when the patient refuses it, when she is considered medically unfit or when labour is too far advanced when the midwife is called. Certified midwives, who have notified intention to practise to the local supervising pethidine authority, are authorised to possess and administer pethidine, so far as is necessary for the practice of their profession. 67 Summoning of mcdical aid The number of medical aid notices issued by midwives during 1954 was: By domiciliary midwives . 5,708 By midwives in institutions with less than 15 beds and/or no R.M.O. 16 5,724 Total number of domiciliary confinements attended by London County Council, Hospital and Nursing Association midwives—1950.1954 Year Maternity Nursing Cases Midwifery Cases Grand Total L.C.C. Hospital District Nursing Association Total L.C.C. Hospital District Nursing Association Total 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 Year Number of confinements Number of confinements Grand Total 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 1953 226 4,241 55 1,591 85 2,595 504 719 86 155 114 87 10,458 1954 247 4,537 72 1,635 44 2,019 667 837 104 160 93 131 10,546 68 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 still.births occurring on the 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 1954 As midwives 1,275 1,337 1,331 1,171 1,142 As maternity nurses 241 205 232 175 168 Notification of intention to practise The following is an analysis of the notifications for 1954 : Midwives Maternity nurses Practising in hospitals 914 — Practising in nursing homes 11 45 London County Council domiciliary 96 — District nursing associations 60 — Hospital districts 50 — Nursing co.operations — 113 Independent 11 10 1,142 168 As in previous years, two courses of six lectures each were given to midwives working Lectures to in London, Middlesex and Surrey, who had notified their intention to practise. The mldwivcs syllabus for 1954 was : Lecturer Subject 1. Miss Lois E. Beaulah, ' Health Education and the Midwife ' S.R.N., D.N., S.C.M., M.T.D. Principal of Midwives Teachers' Training College 2. Dr. Mavis Gunther, ' Breast Feeding and Ante.natal Care ' M.R.C.S., L.R.C.P., B.Chir., M.B. 3. Miss Josephine Barnes, ' Recent Advances in the Use of Drugs in B.M., M.R.C.P., F.R.C.S. Labour ' 4. C. W. F. Burnett, Esq. ' Thrombosis' F.R.C.S., M.D., F.R.C.O.G. 5. E. Robert Rees, Esq., ' Stillbirths and Post.Maturity ' M.D., M.R.C.S., L.R.C.P., M.R.C.O.G. 6. A. Melvin Ramsay, Esq., ' Infections in Early Infancy ' M.A., M.D. 69 The annual lecture.demonstration course was attended by 45 midwives from London, Middlesex and Surrey, the syllabus being : Subject Lecturer ' Care of Premature Babies' Bernard E. Schlesinger, Esq., O.B.E., M.A., M.D., F.R.C.P. ' Preparation of the Mother for her Confinement' W. C. W. Nixon, Esq., M.D., F.R.C.S., F.R.C.O.G. ' Ante.natal Cases'—demonstration Miss Gladys H. Dodds, F.R.C.S., F.R.C.O.G., G. A. Silley, Esq., M.R.C.S., L.R.C.P., M.R.C.O.G. H. Reiss, Esq., M.A., B.M., B.Ch. Film on ' The Siamese Twins Operation ' — Post certificate residential courses for midwives arranged by the Royal College of Midwives were attended by 19 of the Council's midwives at Oxford, Cardiff and Bristol. One non.medical supervisor of midwives attended summer school and another attended the International Congress of Midwives and acted as Chairman of the Executive Committee. HEALTH VISITING AND NURSING SERVICES the average strength of health visitors available during the year for health visiting duties, apart from the tuberculosis and school health services, was the equivalent of only 372 full.time units. In addition to their clinic and other duties, these health visitors made 836,045 home visits. 1952 1953 1954 Expectant mothers— First 25,226 24,608 24,739 Revisit 18,708 19,223 19,428 Per cent, of notified live and still.births 47 47 47 Premature babies— First 1,834 1,894 1,624 Revisit 5,509 4,476 4,033 Still.births— First 930 921 887 Revisit 349 335 366 Per cent, of still.births 90 87 89 Children under 1— First 48,755 46,487 47,337 Revisit 183,816 168,833 178,262 Per cent, of live.births 91 90 94 Children 1 to 5— First 4,572 7,485 7,182 Revisit 377,986 368,668 369,948 Infectious diseases 13,396 13,774 5,320 Miscellaneous 51,278 51,676 58,864 Unsuccessful 131,748 124,124 118,155 TOTAL 864,107 832,504 836,045 Home visits Progress continued to be made in extending the function of the health visitor to cover the care and welfare of the family as a whole and is referred to more fully in the section dealing with co.operation with other parts of the National Health Service (page 56). 70 Home visiting and medical follow.up of children attending the Council's schools has for nearly fifty years been the duty of voluntary children's care committee workers trained and organised by salaried staff employed by the Council. Following upon the transfer to the Council in 1948 of responsibility for providing the health visiting service, the Council's policy in recent years has been towards integrating this service with the school nursing service. The Council has now amended the duties of the voluntary care committees to enable health visitors to participate in the medical care of schoolchildren in London and authority has been given for experiments to be conducted with a view to ascertaining how the services of health visitors can best be used in conjunction with the voluntary workers. By arrangement with the Children's Officer, responsibility has been continued for Child life duties under Part XIII of the Public Health (London) Act, 1936, as amended by Part V protection 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'. At the end of the year 647 children were being supervised under these arrangements. A most important function of the tuberculosis visitor comprises health education Tuberculosis and advice carried out in the home. Chemotherapy involves more frequent visiting visitors and requires more careful regulation of the patient's home life. Parents of child contacts are encouraged to take their children to the chest clinics for B.C.G. vaccination and for general surveillance. Details of the Council's scheme for the training of student health visitors are given Training of on page 123. student r ° health visitors HOME NURSING the home nursing service was provided, as hitherto, by 27 voluntary district nursing organisations, acting as agents for the Council, liaison being maintained through the Central Council for District Nursing in London. These associations (with one exception, where a block grant is paid) were grant.aided to the extent of 90 per cent, in 1952.53 and 92 per cent, in 1953.54 ; in 1954.55 increased work and rising costs increased the total expenditure on the service so that it became more difficult for the voluntary associations to raise the balance. The grant for 1954—55 was therefore increased to 93 per cent, of approved expenditure. The number of whole.time and part.time nurses employed at the end of 1954 was 558 (whole.time equivalent 508). This compares with 490 whole.time and part.time nurses (444 whole.time equivalent) employed at the end of 1953. Twelve of the district nursing organisations undertake district nurse training. The total number of visits paid was 1,873,881, compared with 1,724,302 in 1953, giving an average of 13 visits daily for each nurse (14 in 1953). The average case load of a nurse at any one time was 23 (22.5 in 1953). Treatments completed totalled 61,352 (63,635 in 1953) and there were 11,792 patients still in nursing care at the end of the year (10,562 in 1953). The completed treatments related to the following conditions : Number 1953 Percentage of total Number 1954 Percentage of total Respiratory diseases 18,189 28.6 14,904 24.3 Heart and arteries 6,451 10.1 7,425 12.1 Skin 6,632 10.4 6,297 10.3 Digestive diseases 4,595 7.2 4,609 7.5 Genito-urinary 3,486 5.5 3,859 6.3 Ear, eye and other sense organs 4,348 6.8 3,544 5.8 Cancer 2,331 3.7 2,455 4.0 Tuberculosis 2,276 3.6 2,400 3.9 Cerebral lesions of vascular origin 1,787 2.8 1,671 2.7 Diabetes 1,455 2.3 1,560 2.5 71 Loan of home nursing equipment  Number 1953 Percentage of total Number 1954 Percentage of total Injuries 1,302 2.0 1,450 2.4 Bones and joints 1,320 2.1 1,291 21 Veins and other circulatory diseases 880 1.4 1,186 1.9 Infections and parasitic diseases. 1,347 2.1 890 1.5 Mental and other nervous diseases 708 1.1 758 1.2 Pregnancy 635 1.0 666 1.1 Other diseases or ill.defined 5,893 9.3 6,387 10.4 These patients were referred to the nursing organisations by : Number 1953 Percentage of total Number 1954 Percentage of total General practitioners 51,237 80.5 48,514 79.1 Hospitals 9,823 15.5 10,328 16.8 Direct application 1,040 1.6 1,102 1.8 Chest clinics 978 1.5 1,035 1.7 Public health authorities 557 0.9 373 0.6 Taking both sexes together, 68 per cent, of all patients whose treatment was completed were 40 years of age and over, and 47 per cent. 60 years of age and over. Females formed 62 per cent, of the total number of patients treated. Children under the age of five years accounted for 6 per cent, of the total, while the proportion of patients suffering from tuberculosis who were nursed at home by the district nursing organisations amounted to some 4 per cent, of all patients treated. The increased use of the service is shown in the graph on page 73. The numbers of visits paid and of treatments commenced rose to a peak in the March quarter ; otherwise the average number of completed treatments per nurse employed remained fairly constant. There was no serious epidemic in the first quarter of 1954, but the total of completed treatments reached 18,102. This compares with 15,524 in the first quarter of 1952 and 21,570 in the corresponding period of 1953, when there was an influenza epidemic. The Council provided cars on loan to those district nursing organisations who required them but 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. At the end of the year 17 cars were operated under this arrangement. The Council's direct concern in running a home nursing service made it appropriate to appoint a supervisor of home nursing who was to take up her duties on 1st January, 1955, for an experimental period of one year. A survey of the work of the district homes and of the nurses engaged in general duties is being made as well as certain advisory work in connection with the service as a whole. It is hoped that liaison between the home nursing service and the other services of the local health authority will be strengthened. Facilities for the training of student nurses from hospitals are working smoothly and are being developed at divisional level. Both written and oral evidence was submitted to a working party which was set up by the Ministry of Health to consider the training of district nurses. Under arrangements made by the Council for the care and after.care of sick persons, nursing equipment may be lent to patients being nursed in their own homes. A deposit and a small charge, varying from 3d. to Is. a week according to the cost of the article, are required from those who can afford to pay. This is a continuation and extension of services run by voluntary organisations before the National Health Service Act, 1946, came into operation. In London the British Red Cross Society have continued to run their medical loan depots, as agents of the Council, and are given block grants for the 72 HOME NURSING IN THE ADMINISTRATIVE COUNTY OF LONDON 73 purpose. The district nursing organisations have also continued to maintain their 'loan cupboards', from which they lend equipment to their own patients, and their expenditure on this account is approved for grant purposes. Since January, 1953, the Council has undertaken the responsibility for supplying large and expensive items of equipment and all loan equipment needed for tuberculous patients, as the voluntary organisations were experiencing difficulties in storing and maintaining the extensive stocks of equipment needed for long-term loans to tuberculous patients. The voluntary organisations now supply only such small articles as rubber sheets, enamel bowls, bedpans, etc. The demand for expensive and unusual equipment continued to increase during the Year, possibly due to the fact that many chronic sick and disabled persons, who were formerly considered to be 'hospital' cases, can now be nursed at home. Striking examples of this are the many paraplegic patients who are able to live and care for themselves as a result of the work of the National Spinal Injuries Unit at Stoke Mandeville, and who need a large selection of equipment, including special beds and mattresses, which is lent by the Council. Various types of hoist are needed for some patients, and in addition to those which can be used by partially paralysed patients to move themselves a few hoists which can be used by the district nurse or relatives to lift heavy immobile patients were purchased. Hospital authorities, general practitioners and the Council's Welfare Department are also empowered to provide various types of equipment and appliances, the dividing line between the various responsibilities is not always easy to determine, and close liaison with all three and with the Ministry of Health is maintained in order to ensure that the patient obtains the necessary equipment from the correct source with the least possible delay. 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. The following figures illustrate the extent of the increase over the last three years: 1952 1953 1954 Cases assisted 27,896 30,335 32,503 Hours worked 3,834,688 4,269,408 4,601,168 Home helps employed at end of year 2,921 2,996 3,124 Equivalent of whole-time staff 1,692 1,866 1,992 Of all the cases assisted during the year, 77 per cent. were aged and chronic sick (75 per cent. in 1953), 5 per cent. were maternity (6 per cent. in 1953), 4 per cent. were tuberculous (4 per cent. in 1953), and 14 per cent. were assisted for other reasons (15 per cent. in 1953). The substantial 'hard core' of aged and chronic sick cases assisted, which was referred to in the 1953 report, continued to increase, as the following figures show : On the books at the end of 1949 7,833 1953 17,166 1954 19,417 These cases often remain on the books for many years and the regular supply of adequate help to the large numbers of aged and infirm persons who live alone and are entirely dependent on the home helps for shopping as well as housework, is a great problem, particularly in the winter when many old people become housebound and 74 there is increased pressure on the service due to illness of both recipients and home helps. A small number of male home helps is employed to care for elderly men. In times of heavy pressure it has not always been possible to supply as much service as was considered desirable ; as in the past, the policy has been to supply some service to all in need, but this year 161 applications had to be deferred for a time or refused owing to inability to supply. The figures for the previous two years were 53 (1953) and 215 (1952). An extension of the domestic help service which is used mainly for the aged chronic sick is the provision of night helps to sit with patients in their own homes to enable the relatives to get one or two nights' sleep a week. The demand on this service, which was started in January, 1953, has been small, 65 cases only being supplied with help during the year. Night helps Particular efforts were made to use the health services wherever possible to prevent children being taken into care during periods of domestic difficulty, such as the illness or confinement of the mother. Where there is no adult sleeping in the home at night, as for example when the mother is in hospital and the father is on night work, a child help may be supplied to sleep in the home and perform the usual household tasks normally undertaken by the mother. Twelve families, in which were 34 children, were supplied with the services of child helps during the first experimental year ended 30th November, 1954. Where children have to be cared for during the daytime only, specially suitable home helps are supplied and their hours of duty are adjusted to fit in with parents hours of work and day nursery and school hours. Help was supplied for the care of children outside normal working hours, i.e., between 7 and 9 a.m., and 5 and 7 p.m., to 185 families in 1954. Child helps. 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 1954 was 47,621. This was a most encouraging increase on the figures of the last three years as is shown in the table below, and the number of reinforcing doses given increased at a similar rate. Of the 47,621, however, only 33,671 were immunised before they were two years old. []###[(All ages) 1949 1950 1951 1952 1953 1954 Primary immunisations 57,929 47,605 40,339 42,958 36,004 47,621 Reinforcing doses 38,312 27,579 22,908 27,820 33,172 45,802 Estimated percentage at end of year of children 0-4 years who had at any time been immunised against diphtheria 54.7 55.4 53.7 53.7 51.5 54.9 The principal cause of the fall in the annual number of children immunised against diphtheria from 1950 onwards was the fear of a possible association between inoculations and poliomyelitis. The possibility that paralysis might follow an inoculation was always very small; with the new prophylactics in use during the last two years it is probably infinitesimal. Moreover, a close watch is always maintained by the divisional medical 75 officer during poliomyelitis prevalence, and where the possibility of infection exists action is taken to protect the interest of those who may be due for inoculations. The very success of the immunisation campaign brings its difficulties. The modern generation of mothers has not seen diphtheria and learnt to fear it as did their parents. For their benefit it is necessary to repeat that unless a high level of immunisation is maintained epidemic diphtheria will return, as it has already done in certain other countries. As improved methods of immunisation become available they are introduced into the Council's scheme ; investigations are in progress, both on the Council's behalf and also in co-operation with other interested bodies, to compare the results of new methods with those of the older methods. 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. In spite of the fact that no publicity is given to whooping cough immunisation the demand from parents continues to grow and this is undoubtedly due to their familiarity with whooping cough and their appreciation of its potential danger. The following figures show the increase in the number of children immunised against whooping cough in the past four years, including those receiving the combined antigen which protected them against both diphtheria and whooping cough. 1951 1952 1953 1954 No. of children immunised against whooping cough (a) under Council arrangements 8,874 19,447 19,292 31,985 (b) by general practitioners 432 2,786 3,427 5,449 Total 9,306 22,233 22,719 37,434 Vaccination Facilities provided for the vaccination of infants against smallpox are similar to those for diphtheria immunisation. The number of vaccinations of children under one year of age has increased steadily over the past six years : Vaccination of children under 1 Number vaccinated Percentage of annual live births 1949 13,896 25 1950 16,836 32 1951 19,700 38 1952 23,106 45 1953 24,434 48 1954 24,995 49 There was no case of generalised vaccinia or of post-vaccinal encephalomyelitis during the year. Re-vaccination of older children is undertaken under the Council's scheme. The numbers of school children re-vaccinated during the past three years are shown below : Re-vaccination of children aged 5 to 14 years 1952 804 1953 1,501 1954 2,944 13,621 vaccinations and re-vaccination were carried out by general practitioners during the year as compared with 12,284 in the previous year. 76 LONDON AMBULANCE SERVICE during 1954 the directly provided and ancillary services removed more than one million patients over five and a half million miles, thus setting up another record. The full significance of the growth of the work represented by these figures can be appreciated when it is remembered that in 1947, the last complete year before the inception of the National Health Service, the total number of patients carried, excluding accident and emergency cases, was 182,206. The increase in the number of patients carried by the General Section in 1954, as compared with 1953, was 76,603, representing a rise of 10.6 per cent., whilst the increase in the mileage run was 179,114 or 4.9 per cent. These disproportionate rates of increase are largely accounted for by the extension of the practice of decentralisation, described later in this report, and by the growing use of rail transport for long journeys. During 1954, ambulance-train-ambulance arrangements were made for 5,867 patients and the rail mileage covered was 425,599. The Accident Section conveyed 82,850 patients in 1954, as compared with 81,800 in 1953, an increase of 1.3 per cent. These figures are analysed in the statistical tables on pages 81 and 82. Many calls for emergency ambulances are received in the control room at headquarters in circumstances in which it is clear that medical assistance, rather than ambulance transport, is required and in such cases the caller is advised to summon the patient's own general practitioner or is given particulars of other local medical practitioners who may be called upon; 2,126 such calls were dealt with in 1954. On 1st October, the responsibility was undertaken for providing transport required by the mental welfare officers. Ancillary services During the year the Ambulance Department of the Joint Committee of the Order of St. John of Jerusalem and the British Red Cross Society removed, on behalf of the Council, 17,493 patients over a distance of 371,372 miles, an increase over the previous year of 14.5 per cent. in the number of patients and 16 per cent. in the number of miles. The work undertaken by the Department, especially on the longer journeys, affords an appreciable measure of relief to the directly provided service and, again, I would like to place on record my very warm appreciation of the willing co-operation which is invariably shewn by the Department and of the excellent relations which have continued to exist between the Director and his staff on the one hand and the London Ambulance Service on the other. Joint mittee of the Order of St. John of Jerusalem and the British Red Cross Society During the year the Hospital Car Service carried, on behalf of the Council, 125,352 patients over 1,320,582 miles as compared with 131,763 patients conveyed over 1,424,788 miles in 1953. Closer integration of the directly provided service with the Hospital Car Service was achieved during the year by strengthening the liaison between the superintendents of the general section ambulance stations and the area officers of the Hospital Car Service. This has enabled the interchange and combination of certain orders to be effected locally without reference to headquarters, so economising in both vehicles and staff. The Hospital Car Service has continued to make a valuable contribution to the work of the service as a whole and I am indeed grateful for the help and co-operation received from the County Organiser and her staff. Hospital Car Service There was no change during the year in the standing arrangement between the Council and the West Ham Borough Council whereby the latter undertakes, on behalf of the Council, to provide ambulance services in the two parts of the Metropolitan Boroueh of Woolwich which he North of the River Thames. Arrangements in North Woolwich The ever-growing demand upon the service has constituted a challenge to administrative and operative staff alike and has been largely met by the development of the practice of decentralisation. This takes two forms : by the end of the year 66 major hospitals and clinics were passing all transport orders for in-county removals, other than those for infectious or mentally ill patients, directly to the appropriate local general 77 Decentralisation ambulance station, whilst 48 of these hospitals were also benefiting from the arrangement whereby one or more ambulance vehicles are stationed at the hospital for varying periods on weekdays to convey patients to and fro on the instructions of the hospital Transport Officer. The aim of these developments has been both to relieve the pressure on the central control room and to economise in vehicle mileage and they have been well received and indeed welcomed by the hospital officers concerned, for whose co-operation I am most grateful. Homecoming of Her Majesty the Queen after her tour of the Commonwealth The only Royal occasion during 1954 calling for special arrangements to ensure the speedy removal of possible casualties from large crowds was that of the return on 15th May of Her Majesty the Queen and His Royal Highness the Duke of Edinburgh after their tour of the Commonwealth. The Royal Party arrived at Westminster Pier in the afternoon and drove to Buckingham Palace via Whitehall, Trafalgar Square and the Mall. Twelve ambulances, each with a double crew, were posted for duty at eight St. John Ambulance Brigade dressing stations near the Royal Route but, fortunately, these were called upon to remove nine casualties only. The number of accident section ambulances on duty throughout the County was also increased on that day and the duty hours of crews extended. Visits of inspection by the Chairman of the Health Committee During the summer recess, the Chairman of the Health Committee paid a series of visits of inspection to establishments, including each of the six general section stations, eight of the 18 accident section stations, the headquarters station and ' The Fourth Arms,' the civil defence training centre. In her subsequent report the Chairman recorded her pleasure and pride in the general state of efficiency of the service and commented upon the smart bearing and alertness of the supervisory officers and of the ambulance crews, the cleanliness of the vehicles and the clean and orderly appearance of the premises generally. She took the opportunity of speaking with members of the operative staff from whom she gained a further appreciation of the operational difficulties arising from the ever-increasing pressure of work and of the problem of keeping in good order premises which, in many cases, are very old and far from ideally suited to the present day needs of the service. The Chairman also spoke with a number of volunteers in the ambulance section of the Civil Defence Corps whom she met at stations where they were receiving practical training. Exhibitions In addition to taking part in numerous Road Safety campaigns, the Service contributed towards the interest of the Islington Health Exhibition, held in October. One fully-equipped reserve accident ambulance was made available for inspection by visitors throughout the period of the exhibition. There was also a stand devoted to photographs and statistics relating to the work of the Service. Major accidents One of the most serious accidents attended occurred on 9th January when 11 persons suffering from severe gas poisoning were removed to hospital from a private address in Battersea. Four ambulances were sent to the call and one attendant in particular earned special commendation for his diligent administration of artificial respiration. There were two fatalities. Among other major accidents were : 8th January Outbreak of fire at the Polish Club, Knightsbridge; five casualties taken to hospital. 5th February Explosion at private premises in Stour Road, Poplar; five casualties taken to hospital. 30th April Collision between a trolleybus and a car outside Finsbury Town Hall ; five casualties taken to hospital. 7th May Collision between a bus and a lorry outside Bow Railway Station ; four casualties taken to hospital. 6th July Outbreak of fire in Adelaide Road, Hampstead ; eight casualties removed, one of whom had been fatally injured. 78 1st October Collision between a bus and a lorry at the junction of Roman Road and Grove Road, Bethnal Green ; fourteen casualties taken to hospital. 3rd October Collision in Harrow Road, Westbourne Terrace, as a result of which a coach crashed into the wall of a house ; eight casualties taken to hospital. 4th October Multiple collision in Sidcup Road, Eltham; six casualties removed, of whom one had been fatally injured. During 1954, more than a hundred visitors were received by or on behalf of the Officer-in-Charge and shown over the headquarters control room. A number of these were also given the opportunity of inspecting ambulances and of visiting one or more stations. Many of the visitors came from abroad, e.g., Persia, Ceylon, New South Wales —while others were from various parts of the British Isles. Talks and demonstrations on the general organisation and operation of the Service were given to a number of parties of home and overseas students pursuing courses of study at the Royal College of Nursing. Visitors Hampstead Accident Ambulance Station—The principal event of the year was the completion of the first new accident ambulance station to be built in London since 1932. The new station is situated in Hampstead and was formally opened by the Chairman of the Health Committee on 8th December, 1954. From the commencement of operations on 15th November to the end of the year the three ambulances at the station dealt with 1,248 calls, of which 562 were emergency calls. Upper Richmond Road and Mottingham Accident Ambulance Stations—The erection, in Wandsworth and Woolwich, respectively, of two new accident ambulance stations, each designed to accommodate three ambulances, was commenced in June and December, respectively. Headquarters Ambulance Station—The ambulances and crews attached to this station were accommodated in temporary premises in Southwark throughout the year whilst work continued on adapting the former fire station in Waterloo Road to serve as the administrative and operational headquarters of the service. Brook General Ambulance Station—Work on the alteration and reinstatement of this station after war damage commenced in March and proceeded throughout the remainder of the year. Primarily it is designed to provide additional accommodation for ambulances but the scheme also covers the erection of a new kitchen, messroom and workshop and various other works to modernise the premises and to lessen the risk from fire. Despite the extent of the building operations the work of the station has continued day and night, often in the face of considerable difficulties. Premises The vehicle replacement programme has been influenced by the ever-mcreasmg demand upon the service for the conveyance of out-patients to and from hospital and the present trend is towards a higher proportion of vehicles adaptable for the conveyance of patients able to walk and sit. During the year, 11 taxi-type cars were added to the establishment and one car beyond economic repair was replaced. Three new singlestretcher, sitting-case ambulances were acquired and these have proved of particular use in decentralised work at hospitals. Vehicle strength at end of 1954 : Ambulances 230 Single-stretcher, sitting-case ambulances 45 Sitting-case cars 47 Ambulance buses 10 Tenders 2 334 79 Vehicles Award of resuscitation certificate Staff for the second successive year a driver in the London Ambulance Service was awarded the Royal Humane Society's Resuscitation Certificate. By a ladder which reached only to within 4 ft. of the window he entered a room some 30 ft. above the ground where a man had committed suicide by inhalation of coal gas. A police constable had collapsed whilst trying to rescue the man and the driver commenced artificial respiration and administration of oxygen to the constable in the gas-filled room. The driver continued artificial respiration while the constable was conveyed to hospital where he subsequently recovered. Staff numbers During the year the number of ambulance station officers was increased by two, one to take charge of the newly-opened Hampstead ambulance station and one for Civil Defence duties, bringing the total of uniformed supervisory staff and ambulance station officers to 39. The number of operative staff employed on 31st December, 1954, was 701. Safe driving and first aid It is gratifying to record that a very large percentage of the drivers continue to qualify for awards in the National Safe Driving Competition and that numbers attend classes and examinations to gain further knowledge and certificates in rendering first aid to the injured. New duties Civil Defence during the year the Ambulance Section of the Civil Defence Corps assumed new duties and a new name. The section was reconstituted as the ' Ambulance and Casualty Collecting Scction ' and it took on new duties of stretcher bearing, loading and unloading of ambulances at ambulance loading points and hospitals and ambulance trains at railheads. These duties, which might involve the carriage of stretcher cases over rubble, are not considered suitable for women and will be carried out by fit men. Publicity Efforts to recruit volunteers into the Civil Defence Corps were intensified. A column comprising vehicles from all sections of the Civil Defence Corps and ancillary services drove through the Metropolitan Boroughs in four ceremonial ' drivesIn all of these drives Superintendent R. E. Ridgwell of the London Ambulance Service was the Column Commander. The Ambulance Section was well represented in these drives by volunteers and civil defence ambulances. In addition, in conjunction with the Metropolitan Borough Councils, the Ambulance Section took part in exhibitions, demonstrations and houseto-house canvasses, all of which helped in the recruitment of volunteers. Armistice Day ceremony An Ambulance Section volunteer, Mr. L. A. Lyall, represented the County of London Division of the Civil Defence Corps at the Armistice Day Ceremony at the Cenotaph on 7th November. Training The strength of the Ambulance Section increased by nearly 400 volunteers from 1,662 on 1st January to 2,060 on 31st December. To keep pace with this progress the training programme was considerably expanded. The instructional staff under the Superintendent seconded for these duties was increased to three station officers by the employment of an additional station officer on civil defence duties. Fourteen introductory, fourteen first aid, fifteen ambulance section and seventeen other types of courses, making a total of sixty, have been held since training began in 1951 ; 569 volunteers have taken the full first aid course and passed the examination. Volunteers who reached an advanced stage of training took part in exercises, including a number at the Council's Rescue Training Ground, Hackney Marshes, in which up to fifty volunteers and five vehicles were involved. Operative staff of the London Ambulance Service received training in the duties of the Civil Defence Ambulance Section in wartime. New staff, in addition, attended for basic general training already completed by other members of the staff. 80 Selected officers of the Public Health Department were trained in the duties of group ambulance officers and deputies and a revision course was held for those officers who had received this training in 1952. Driving instruction commenced during the year when volunteers who already held driving licences received instruction and practice on three types of ambulances including the Daimler. Plans were also completed for the commencement of driving tuition for selected volunteers who cannot drive and wish to learn. Driving instruction Statistics Statistics for the directly provided service are divided into two sections—the Accident Section and the General Section—and are shown in the table on page 82 for 1938 (the last full year before the war), 1947 (the last full year before the inception of the National Health Service) and 1950-54 inclusive. The table also includes annual statistics of the work performed by the agency and supplementary services on behalf of the London Ambulance Service during the period 1950-1954. The Accident Section statistics for 1953 and 1954 are analysed below to show the types of calls received. Analysis of Accident Section work (a) Numbers of patients : 1953 1954 Street accidents 14,376 15,282 Other accidents 18,887 19,450 Assaults 1,734 1,783 Attempted suicide 1,087 1,167 Mental 521 526 Epilepsy 1,322 1,348 Other sudden illness 17,767 17,278 Maternity 25,885 25,772 Special journeys with patients 221 244 81,800 82,850 (b) Non-patient carrying journeys : Delivery of analgesia apparatus 5,013 5,517 Special journeys without patients 477 289 Ambulance not required 5,897 6,004 11,387 11,810 The average time taken to reach a street accident in 1954 was 7.1 minutes. 81 82 Work performed by the directly provided service Year Accident Section General Section Total Patients Non-patient carrying journeys Total journeys (calls) Mileage Patients Journeys Mileage Patients Journeys Mileage 1938 54,070 4,126 56,318 293,166 217,908 171,000 (est.) 1,930,172 271,978 227,000 (est.) 2,223,338 1947 61,136 5,007 64,560 362,880 182,206 155,122 1,768,550 243,342 219,682 2,131,430 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 1954 82,850 11,810 92,401 466,415 797,937 448,004 3,804,544 880,787 540,405 4,270,959 Work performed by the agency and supplementary services Year Home Ambulance Service Hospital Car Service West Ham C.B.C. Total Patients Mileage Patients Mileage Patients Mileage Patients Mileage 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 1954 17,493 371,372 125,352 1,320,582 434 5,008 143,279 1,696,962 Work performed by both sections of the directly provided service and by the agency and supplementary services Year 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 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 1954 82,850 466,415 941,216 5,501,506 1,024.066 5,967,921 NOTES :—1. The figures are based on the Council's definitions of* patient ' and 'journey ' which differ from those adopted by the Ministry of Health. 2. The agreements with the agency and supplementary services have been in operation only since 5th July, 1948, the ' appointed day * under the National Health Service Act, 1946. 3. The work carried out by the agency and supplementary services is almost entirely analogous to the 'General Section' work of the directly provided service and has been included in the table for * Total General Section Work.' PREVENTION OF ILLNESS : CARE AND AFTER-CARE Foot clinics the chiropody service which the Council is able to provide is generally inadequate to meet demands upon it and is very unevenly distributed. There is no service in 13 of the metropolitan boroughs and the City of London, while in Finsbury 18.47 chiropodist sessions a week per 10,000 population are provided compared with an average of 1.38 for the County as a whole. Residents from adjacent boroughs, however, attend the clinic in Finsbury and this, and similar arrangements which apply to a limited extent in other areas, help to spread the available service more evenly. The inadequacy and uneven distribution of the service, due to the diversity of the arrangements taken over from the Metropolitan Borough Councils in 1948, must continue until the Minister of Health can see his way to approve the Council's proposals for expansion of the service. In Kensington a foot clinic staffed by student chiropodists from Chelsea Polytechnic was established before 1948. This arrangement continued until July, 1954, when it was suspended by the Polytechnic authorities because of a change in the training curriculum. The service has, however, been maintained at the same level by the employment of qualified chiropodists. The following are particulars of new cases and attendances : [###Year New cases Attendances Staff at the end of the year (in terms of whole units) 1949 9,446 129,682 35 1950 10,165 153,687 44 1951 10,348 162,163 43.5 1952 10,828 169,598 43.2 1953 11,374 180,588 43.5 1954 10,143 185,614 44.8 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. Venereal disease A summary of the work done in 1954 at the London V.D. out-patient clinics will be found in Table 13, page 227. Approximately 77 per cent. of the patients were resident in the County of London. The figures showed a continued decline in the number of patients suffering from syphilis and the increase in the number suffering from gonorrhoea noted in recent years appears to have been arrested. A large number of persons who were not suffering from venereal disease continued to attend the clinics. There was no appreciable change in the defaulter rate. The table below gives the number of patients completing treatment and of defaulters as shown by analysis of the returns from the clinics for 1954. Syphilis Gonorrhoea Male Female Male Female Number of patients discharged after completion of treatment and final test of cure 788 624 2,951 650 Number of patients who ceased to attend after completion of treatment but before final tests of cure 424 257 2,195 695 Number of patients who ceased to attend before completion of treatment 107 119 147 70 Number of patients who died from the disease while still undergoing treatment 9 1 - - 83 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, Commonwealth and United States Armed Forces, and by local health authorities. Information of 431 contacts was received but in 309 instances there was insufficient information for following-up. Of the remaining 122 cases, 64 were traced of whom 36 were successfully brought to treatment. 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 the Reports for 1952 and 1953, were continued during the year. Six 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 following figures show that there was a revival in demand for recuperative holidays for school children during the year, but that recommendations for unaccompanied children under 5 years and for adults, continued to decline. Admissions to recuperative holiday homes Year Unaccompanied children Accompanied children Expectant and nursing mothers Other adults Total Under 5 years School children 1952 686 3,507 352 190 3,308 8,043 1953 550 2,840 446 194 3,120 7,150 1954 486 3,404 424 197 2,954 7,465 Parties of children continued to be sent to a seaside hotel under the Council s private hotel scheme, to the Council's recuperative holiday home at Littlehampton and to the home administered by the Women's Voluntary Services at Aldeburgh in respect of which the Council contributed 90 per cent. of approved expenditure. The placing of unaccompanied children in many other recuperative holiday homes continued satisfactorily. Applications included those relating to physically handicapped, maladjusted and educationally sub-normal children and accommodation, although not always easy to obtain, was found for all these children. The scheme for placing mothers with their babies in small private homes continued and a number of additional homes of this kind were approved for use during the year. In most cases all the arrangements for the holidays were made direct by the Council, but assistance was received from the Jewish Board of Guardians, the Wandsworth Peace Memorial, the St. Henry Convalescent Fund, and from the National Association for the Prevention of Tuberculosis (Spero Fund) in respect of tuberculous persons. Health education During recent years special attention has been given to the development of health education as an essential part of the health services, and, following a review of activities referred to in the 1952 Report, further progress was made in extending this field of the department's activities. As in previous years, the main emphasis was placed on the individual approach by medical and health visiting staffs, but attention was also given to developing group instruction of mothers attending at welfare centres and to the 84 provision of the means and methods of such instruction. A panel of officers was formed to advise on health education programmes generally and, in liaison with a small committee of field workers, proved to be a means of stimulating and encouraging the medical and nursing staff concerned with health education. The growth of the department's library of film strips has been of material assistance in providing visual aids in connection with the various talks given by medical and nursing staff, and during the year 30 new film strips were appraised by a panel of officers formed for this purpose. A new film strip dealing with B.C.G. vaccination against tuberculosis was produced in the department, and proved useful in the instruction of teachers and public health personnel in the technique and procedure relating to the Council's scheme for the vaccination of 13-year-old children in schools. All film strips available within the department were classified for easy reference by the staff concerned, and during the year film strips were shown to various audiences on over 600 occasions. The department owns 14 films which were used on 120 occasions and in addition 276 showings were arranged of films hired from various organisations. The new film 'Sensitivity to Antibiotics' made by the Ministry of Health was purchased for use in the department, and was shown throughout the County area to medical staff, district nurses and midwives. Films and film strips The growth in educational activities at welfare centres is exemplified by the increase in the number of educational sessions from 133 per month in 1949 to 328 per month in 1954. Further attention was given to the need to provide more demonstration material for mothercraft training and a basic list of requirements for this purpose was approved for implementation during 1955. Educational activities at welfare centres An intensive campaign to stimulate awareness of the need for diphtheria immunisation was held in February. The campaign was supported by illustrated advertisements giving addresses and times of immunisation sessions in local newspapers, displays of posters, distribution of leaflets and bookmarks, and press publicity. Diphtheria immunisation campaign In view of the unnecessary loss of life and incalculable harm resulting from accidents in the home, the Council decided to hold an annual intensive campaign to supplement the everyday effort of public health and other workers in their endeavours to reduce the number of accidents occurring and to make people more aware of accident hazards. The first of such campaigns was held in December when local programmes were implemented in each division, and the co-operation of many official and voluntary organisations enlisted in an endeavour to reach as many people as possible. Posters were widely distributed on public information panels, London underground stations and on noticeboards at schools and health service premises throughout the County area. Leaflets were distributed through welfare centres, schools and other establishments, and head teachers were invited to co-operate in making school-children aware of the more common causes of home accidents and in the formation of habits for their prevention. Advertisements inserted in local newspapers and a press release drawing attention to the campaign and to the subject generally were further means used in bringing this problem to the notice of as many people as possible. Films, film strips and exhibits dealing with home safety were shown at welfare centres and group talks to parents of young children were arranged. Accidents in the home campaign In addition to the exhibitions staged by the Council in Division 1, details of which will be found on page 125, the department co-operated in other exhibitions organised by Borough Councils and in a special exhibition dealing with the work done in the field of special education for handicapped pupils held at County Hall in July. The Council gave consideration to the desirability of holding larger exhibitions as opposed to the existing practice of holding small exhibitions with varied presentation in the several health divisions and it was decided that the present policy should be continued. Exhibitions The classification of all posters and leaflets used within the department for health education purposes has facilitated the selection of suitable material in support of health Posters and leaflets 85 education programmes, and during 1954 about 10,000 posters and 300,000 leaflets were supplied to divisions. About 2,800 copies of the Central Council for Health Education's publication ' Better Health ' were also distributed each month from welfare centres. Exhibits There is now a wide variety or materials available for visual education, and steps were taken during the year to acquire further models, photographs and exhibits for display purposes. Use was made of the health education topic service organised by the Central Council for Health Education and exhibits on various health subjects were shown throughout the year at welfare centres and other establishments. Lectures Fifteen evening public lectures on health topics were given during the year by medical and nursing staff who also gave instruction to student nurses at hospitals in personal and communal health and the social aspects of disease. About 120 members of the staff attended two lectures given by Dr. Emrys Davies of the Central Council for Health Education dealing with aids in health education. j Press publicity statements issued through the Council s Press Officer to local newspaper editors dealing with various health aspects received favourable press publicity, particularly those dealing with accidents in the home, diphtheria immunisation and B.C.G. vaccination of school children against tuberculosis. 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 ; 8,690 cases were referred to the mental welfare officers, compared with 8,081 in 1953. The following table shows how they were dealt with : 1954 1953 Male Female Total Admitted for observation to hospitals designated under section 20 of the Lunacy Act, 1890 2,163 2,459 4,622 4,746 Dealt with in their own homes, etc., under sections 14 and 16 of the Lunacy Act, 1890 505 1,176 1,6811 1,416* Admitted direct to mental hospitals under section 11 of the Lunacy Act, 1890 5 29 34 28 No action under the Lunacy Acts found necessary 947 1,406 2,353 1,891 Total 3,620 5,070 8,690 8,081 * Of these 308 male and 625 female patients were certified and removed to mental hospitals. † Of these 281 male and 649 female patients were certified and removed to mental hospitals. The ultimate disposal of the patients admitted to observation wards (including 156 patients in wards on 1st January, 1954) is shown below : 1954 1953 Male Female Total Certified and sent to mental hospitals 612 804 1,416 1,656 Admitted as voluntary patients to mental hospitals 650 851 1,501 1,256 Admitted as temporary patients to mental hospitals 3 33 36 31 Discharged to care of relatives (Section 22) 9 18 27 26 No order made by Justice and patient discharged 13 6 19 36 Transferred to general wards 51 39 90 106 Transferred to Tooting Bec Hospital without certification 77 85 162 234 Transferred to Abbots Langley Hospital without certification 1 1 5 Transferred to Mental After-Care Association homes 1 3 4 2 Died 45 38 83 112 Discharged by medical officer 702 583 1,285 1,274 Dealt with privately 7 11 18 14 Dealt with under Mental Deficiency Acts 4 3 7 5 In ward at end of year 61 68 129 156 Total 2,235 2,543 4,778 4,913 86 The position as regards accommodation in observation wards continued to deteriorate and there was again an increase in the number of cases referred to the mental welfare officers. Fewer patients could be admitted to observation wards, with the result that it was necessary for more patients (1,681 compared with 1,416 in 1953) to be dealt with in their homes or elsewhere than in an observation ward under sections 14 and 16 of the Lunacy Act, 1890. Further difficulty was caused by the fact that at some mental hospitals there was a waiting period between certification and admission which sometimes extended for more than a week. This caused beds in observation wards to be immobilised or necessitated the retention of patients in their homes in circumstances of potential danger for this period. Representations were again made to the four Metropohtan Regional Hospital Boards expressing the Council's concern about the urgent need for the provision of accommodation for the mentally ill and the Minister of Health was urged to give special consideration to any plans which the boards might have for the alleviation of the situation. Owing to financial and other difficulties, however, there appeared to be little hope of any early improvement. During the year 330 new cases of persons suffering from psychiatric illness were referred for help in domestic, social and unemployment problems from the following sources: General practitioners 15 National Association for Mental Health 16 Mental hospitals 58 Mental After-Care Association Observation wards 11 Health visitors, housing welfare officers, etc 45 General hospitals 9 Psychiatric clinics 34 Institute of Social Psychiatry 1 Citizens Advice Bureaux 12 Patients—Personal applications 23 Army (discharged personnel) 19 Relatives or friends 13 Other agencies 50 Ministry of Labour 5 National Assistance Board 19 Total 330 Domiciliary after-care The increase in the work necessitated the appointment of an additional psychiatric social worker on 1st January, 1954. Three psychiatric social workers were employed full time on these important duties throughout the year. They were based at the County Hall, and each dealt with all cases in one area of the County. Patients were interviewed privately at the County Hall or at home. One psychiatric social worker held a weekly session at Woodberry Down Health Centre. The Council continued to make 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 of Social Psychiatry for persons suffering from mental illness. The number of chronic and senile patients maintained by the Council in homes sponsored by voluntary organisations increased from 90 at 31st December, 1953, to 107 at 31st December, 1954. Of these, 99 were maintained in homes sponsored by the Mental After Care Association ; three at Moor Place, Windlesham, Surrey, a home run by the National Association for Mental Health; three at the Jewish Board of Guardians' home which was removed from 17 Maresfield Gardens, N.W.3 to 1 Daleham Gardens, N.W.3 ; one at a home sponsored by the National Association for the Paralysed and one at a small private home. The weekly maintenance rate at the homes sponsored by the Mental After Care Association was increased from ₤3 3s. to ₤3 12s. 6d. a head, but other maintenance rates remained unchanged during the year. Social clubs and rehabilitation centre Long-term care Recuperative holidays were arranged for 205 persons recovering from psychiatric illness, compared with 210 in 1953 and 158 in 1952. These included 34 persons sent for periods up to 12 weeks to assist in their rehabilitation, to the Mental After Care Associations' homes at Cheam, Surrey and Dartford, Kent, where there were special facilities for younger patients capable of work, and 40 persons sent for periods of two or three weeks to other homes sponsored by the Mental After Care Association. The Recuperative holidays 87 remainder, whose illnesses were of a milder character, were sent to general recuperative holiday homes accommodating patients recovering from all types of illness. 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 1951 1952 1953 1954 Totalsfrom 1.4.14 to 31.12.54 Supervision section 8 14 9 16 1,600 Local education authority 453 570 533 502 16,588 Police authority (section 8) 31 32 24 18 2,015 Transfers from prison (section 9) - - - - 229 Transfers from approved school (section 9) . 2 - 2 4 571 From hospitals and institutions 103 124 97 91 702 Miscellaneous 187 222 222 229 10,973 Total 784 962 887 860 32,678 The position at 31st December, 1954, 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: 1951 1952 1953 1954 Detained in institutions 7,809* 7,862* 7,842* 7,799* Discharged from institutional care 2,902 3,075 3,235 3,428 Removed to mental hospitals 543 555 572 592 Not subject for action 9,668 9,922 10,190 10,549 Died 4,523 4,678 4,853 5,006 Total removed from active list 25,445 26,092 26,692 27,374 *This figure includes cases on licence who were visited at regular intervals by officers of the Council on behalf of the regional hospital boards as follows : 1951, 352 ; 1952, 259 ; 1953, 236 ; 1954, 247. Under guardianship 221 222 223 217 In places of safety awaiting the presentation of a petition 8 11 11 11 Under supervision 4,222† 4,556† 4,815† 5,007† In hospitals, residential nurseries, etc., awaiting the presentation of a petition 52 41 59 61 Still under consideration 21 9 18 8 Total remaining on active list 4,524‡ 4,839‡ 5,126‡ 5,304‡ Grand Total 29,969 30,931 31,818 32,678 †In addition to the cases under supervision, persons known to the local authority to be mentally defective but not subject to be dealt with, were visited on a voluntary basis, as follows: 1951, 1,020; 1952, 1,040; 1953, 1,055; 1954, 986. ‡Of these the following were awaiting institutional care : 1951, 154 ; 1952, 169 ; 1953, 199 ; 1954, 205. The following is a summary of the cases dealt with and comparable figures for the three preceding years : 1951 1952 1953 1954 Placed in institutions 303 369 306 284 Placed under guardianship 10 24 21 28 Placed in places of safety pending presentation of a petition 56 70 59 45 Placed under supervision 618 787 735 688 Discharged from institutional care or guardianship 182 203 193 216 Removed to mental hospitals under the Lunacy Acts 27 21 26 25 Ascertained not subject for action 68 69 76 111 Withdrawn from supervision 217 201 221 247 Removed to other areas 49 65 60 62 Died 140 165 174 153 Total 1,670 1,974 1,871 1,859 88 The ascertainment of the majority of defectives and the oversight of defectives under guardianship 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, the duty of making the social inquiries for the purposes of ascertainment in respect of defectives reported to them was undertaken from the local offices. During the year 20,749 visits were paid to persons under supervision or on licence from hospitals and 765 to persons under voluntary supervision, while 1,932 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. Ascertainment and supervision During the year 160 petitions for orders for institutional care and 25 for guardianship were presented to a Judicial Authority under section 6 of the Mental Deficiency Act, 1913, and 54 children were placed in institutions by their parents under section 3 of the Act. Three of the petitions were dismissed and in one case an order for guardianship was made after a petition had been presented for institutional care. In addition, 27 applications for Varying Orders were made as a result of which 15 patients who had become unsuitable for guardianship were admitted to institutions, ten patients were transferred to other guardians and two patients were transferred from institutions to guardianship. One of the applications for transfer from an institution to guardianship was made by another local health authority on behalf of the Council. Eight children whose names were on the waiting list for institutional care were found at special reexaminations to have improved to such an extent that they could be considered educable and their names were removed from the hst. Petitions The Council's medical officers continued to attend at magistrates' courts, as required, to give evidence as to the mental condition of alleged defectives charged with criminal offences. During the year 30 such defectives were ordered to be sent to institutions under section 8 of the Mental Deficiency Act, 1913. Magistrates' courts The shortage of vacant beds in institutions continued to cause concern. The number of admissions fell from 306 in 1953 to 270 in 1954 and the number on the waiting hst rose from 199 on 31st December, 1953, to 205 on 31st December, 1954. 21 patients on the waiting hst, of whom 15 were children awaiting admission to the Fountain Hospital, died during the year before vacancies could be obtained. Of the 205 patients who were awaiting admission to institutions 89 lived in south-east London in the area of the South East Metropolitan Regional Hospital Board whose institutional resources are the least adequate of all the four Metropolitan Regional Hospital Boards, notwithstanding that a number of patients from that area were admitted during the year to institutions not previously available to London patients. The need for more hospital accommodation for persons suffering from mental deficiency was included in the representations made to the Metropolitan Regional Hospital Boards and the Minister of Health referred to on page 87. Institutional accommodation i c During 1954, 28 patients were placed under guardianship of whom 11 were school leavers with no satisfactory homes of their own who were considered suitable for life in the community. They were placed under the personal guardianship of the Council's inspectors who found them foster homes of approved standard and suitable employment within the scope of their abilities. At 31st December, 1954, there were 219 patients remaining under guardianship as follows:— 48 under the personal guardianship of the Council's inspectors. 66 under the guardianship of nominees of The Guardianship Society, Brighton. 74 under the guardianship of relatives and friends. 22 under the guardianship of superintendents of voluntary homes. Of the remainder, five were temporarily in institutions awaiting decisions as to future care, two were receiving mental treatment in hospitals under the Lunacy and Mental Treatment Acts and two had absconded from their guardians and were untraced. 89 Guardianship Hostel for mentally defective girls under guardianship In June, 1954, the Council approved a scheme for the adaptation of premises in south-east London as a hostel for mentally deficient girls leaving special E.S.N, schools who have no suitable homes of their own. Considerable alterations and adaptations to the premises were to be carried out and it was anticipated that the hostel would be ready for occupation in May, 1955. The hostel will accommodate 12 girls at first but this number may be increased later up to 18. Short-term care In accordance with the provisions of Ministry of Health circular 5/52, temporary care was provided by the Council for 47 patients (7 adults and 40 children) at various approved and private homes because of family difficulties or emergencies. The weekly cost of this accommodation varied from approximately £2 to £6 6s. a patient. Patients or relatives were assessed to contribute towards the cost according to their means. It is hoped that more accommodation for children under 16 years of age will become available nearer London in due course if proposals of the Middlesex County Council to open a short-stay home at Hillingdon, Middlesex, are implemented. The Middlesex County Council has offered to allow a number of beds at the home to be used for London children needing temporary care on payment of the cost by the Council. In addition to the 47 patients mentioned above, 72 patients (19 adults and 53 children) were admitted to mental deficiency institutions for temporary care under the provisions of Circular 5/52. The total number of London defectives provided with short-term care was 119 during 1954 compared with 92 during 1953. Home tuition In March, 1954, the Council authorised the engagement of a qualified teacher to provide tuition for three sessions a week in her own home for a child aged 14 years. The child who had been reported by the Council's Education Committee as ineducable, was deaf and dumb as well as mentally deficient, and had been found after trial to be unfit for attendance at an occunation centre. Welfare clinics for backward children under five During the year it became clear that the special welfare clinic for mentally backward children which had been established in east London as an experiment was successfully meeting a need and it was decided therefore to set up similar clinics in other parts of London. Six additional clinics were opened during the year and the whole of the County thereby provided with this service. A medical officer experienced in mental deficiency and in maternity and child welfare work is in charge of each clinic, assisted by a nurse and a social worker. The service will be reviewed during 1955 and any necessary adjustments made to ensure a comprehensive service. Investigation into effects of mental deficiency In January, 1954, the Council authorised the granting of facilities to the Institute of Psychiatry, Maudsley Hospital, S.E.5 to conduct a family survey of the conditions under which low grade mentally defective persons, whose homes are in London, were living. The inquiry will be concerned primarily with the social and psychological problems imposed on families with a grossly defective member and will cover the families of defectives living at home and of those in institutions. It is understood that the Institute proposes to arrange for the results of the inquiry to be published in due course. Students During the year facilities were given for a number of students taking university courses of training in social science to spend short periods in the district offices of the supervision section to enable them to gain 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 The completion of the adaptation of premises at No. 9 Spencer Park, Wandsworth Common, and at 86 Fulham High Street (referred to in the Report for 1953) enabled both buildings to be brought into full use for juniors, and provided increased accommodation for children from the former Earlsfield and Hammersmith junior centres. The new centres are known respectively as the Wandsworth and Fulham centres. The rented accommodation at Earlsfield was taken into use for the elder girls' centre, which had been temporarily accommodated at 86 Fulham High Street, and the Hammersmith 90 premises were used to provide an additional elder boys' centre. These changes took place in May. In September the junior centre at Lewisham was transferred to larger and better premises at St. Peter's Hall, Brockley. Particulars of the accommodation available at 31st December, 1954, were as follows:— Centres Accommodation Centres Accommodation Centres for children Centres for elder girls Bethnal Green .. 35 Earlsfield 45 Brixton .. 40 Hackney 40l Islington 35 Brockley .. 50 Peckham (elder girls) 45 Clapton .. 60 Centres for elder boys Finsbury .. 60 Archway 40 Fulham .. .. 75 Battersea 30 Dalston 50 Greenwich also take elder girls 45 Hammersmith 30 North Kensington 70 Peckham (elder boys) 60 Peckham (juniors) 45 Wandsworth .. 80 Total 935 Arrangements were put in hand for the opening in 1955 of an experimental industrial training centre at 52 Ashfield Street, Stepney for approximately 20 elder boys. The Council approved the preparation of schemes for the erection of new permanent centres on sites at Hackney, Kensington and Lewisham and proposals were initiated to provide for the replacement of the unsatisfactory elder girls' centre at Peckham and for the transfer of the Bethnal Green and Hackney centres to permanent premises at Cornwall Avenue. Bethnal Green. During the year it was possible to extend the provision of special transport for occupation centres to include the conveyance of all persons attending junior and elder girls' centres by means of four adapted ambulance coaches, operated through the transport section of the Education Officer's Department, and 12 coaches hired from contractors. Transport Parents and friends were invited to functions showing the work and activities at the majority of centres. Articles made at the centres were offered for sale, the receipts amounting to £543 10s. 5d. (including £164 l1s. l0d. for shoe repairs) at elder boys' centres, £127 6s. 1d. (including £6 7s. for cookery) at elder girls' centres and £43 9s. 9d. at junior centres. Elder boys' centres also made some apparatus and domestic equipment for use at other centres. Open days and sales of work Arrangements were continued for the annual chest X-ray examination of the staff at all centres and for elder boys and men and elder girls and women attending centres. No active cases of tuberculosis were discovered. Chest X-ray examination The annual organised holiday at a seaside camp was again an unqualified success. 198 children and adults took part, including 81 necessitous cases whose expenses were wholly or partly borne by the Council. Day coach outings to the sea or country were arranged at some centres and transport provided for visits to local parks for recreation. Facilities were given for elder boys to play cricket and football at recreation grounds, and local parents' groups provided transport from certain centres to visit a free circus matinee. Christmas carries were held at all centres. Holidays, outings and parties Gifts, including radio sets, a gramophone and other small items, and money to provide extra amenities, were given to centres by local parents' groups. Gifts Centres were visited frequently by parties of students taking organised courses of training and by other interested persons, including representatives of provincial local authorities and visitors from other countries. Routine inspections of each centre were made by Inspectors of the Board of Control. Centres were also visited by members of 91 Visits to centres the Mental Health Sub-Committee and some centre functions were attended by members of divisional health committees. National Association of Parents of Backward Children Facilities were given to the Hampstead and District section of the National Association of Parents of Backward Children to enable them to include sequences showing activities of children and adults at some of the Council's occupation centres in a film they were producing. Staff—course of training Members or tne supervisory statt attending tne two-year part-time course or training organised by the National Association for Mental Health (mentioned in the Report for 1953) were given leave of absence to undertake periods of practical training in centres and institutions of other local or hospital authorities, and students from other authorities participating in the course spent periods at London centres. Practical training will be completed early in 1955. Students from the Association's full-time day course also undertook training in London centres. Royal Commission on the Law relating to Mental Illness and Mental Deficiency During the year the Council submitted written and oral evidence to the Royal Commission set up under the Chairmanship of Lord Percy of Newcastle to enquire into the existing law and administrative machinery governing the certification, detention and care of persons suffering from mental illness or mental defect. The following is a summary of the Council's recommendations to the Royal Commission:— Mental illness (i) All persons of unsound mind needing compulsory removal should in the first instance be admitted to an observation unit, which should not be a part of a mental hospital. (ii) No person over 65 years of age, unless so grossly disturbed as to require immediate psychiatric care, should be admitted to an observation unit. Psychiatric geriatric units, to which all such persons should be referred for assessment and admission, if necessary, should be established. These units should be linked with general hospitals. (iii) Medical staff of mental hospitals should consider on the discharge of patients whether they would benefit by after-care and, if so and if the patient is willing, should arrange for such care to be provided either by the hospital or the local authority. (iv) Future planning of hospital requirements should include adequate provision for neurosis hospitals or units separate from, although grouped for staffing purposes with, mental hospitals. Meanwhile, patients suffering from neuroses who need to be admitted to mental hospitals should be admitted without formality and should, as far as possible, be kept separate from psychotic patients. (v) In order to remove fears in the minds of neurotic patients, endeavour should be made to distinguish between neurosis and insanity. Mental deficiency (vi) Psychopaths and other social misfits should not be included in the legislative provisions for mental defectives. (vii) The present classification of defectives should be revised. (viii) The inclusion of ' moral defectives' in the classes of defectives should be discontinued. (ix) The formalities for the admission to institutions of defectives whose parents desire it should be reduced to a minimum and in such cases the parents should have the right to direct discharge. 92 (x) Compulsory admission to and detention in institutions should be effected by judicial order in cases in which the defective is not under proper care or control and the consent of the parents or guardians cannot be obtained. The judicial authority should not be debarred from making an order even if the consent of the parent is withheld with the bona fide intention of benefiting the defective. Power should be given to enforce the attendance of a defective and his parents before a judicial authority, if necessary. (xi) The period of detention of defectives ordered to be sent to institutions as a result of criminal offences should be subject to limitations in relation to the maximum term of imprisonment which could have been imposed. (xii) Feeble-minded persons should be accommodated in institutions separate from those for the lower grades. (xiii) The cases of feeble-minded persons in institutions should be subject to review at yearly intervals. (xiv) The continuation of institutional care for defectives accommodated with the consent of their parents should be effected by the issue of a certificate in appropriate terms by the medical officer of the institution. (xv) Persons under compulsory detention should receive independent review at the prescribed intervals. (xvi) Parents of defectives should have the right to submit their views to the reviewing tribunal, which should have the power to discharge the defective. (xvii) The power to discharge should be vested also in hospital management committees. (xviii) The reasons for decisions made contrary to their wishes should be given to parents. (xix) The term 'supervision' as a form of care should be discontinued and replaced by 'community care.' (xx) Community care should normally be a service offered on a voluntary basis by local authorities. Additional powers should be granted to local authorities to enable them to pay maintenance allowances to defectives not living with their parents and to provide hostels for defectives receiving such care. (xxi) Power to enforce admission to a hostel or to other suitable accommodation away from home should be given to local authorities in cases in which the parents are opposed to this action under the same conditions as for the enforcement of institutional care. (xxii) Defectives receiving community care should be medically examined at prescribed intervals when consideration should be given to the advisability of discontinuing such care. (xxiii) Defectives of school age in institutions and occupation centres should be reexamined at regular intervals to ascertain whether they are educable. (xxiv) Attendance of defectives at occupation centres should be compulsory up to the age of 16 years. (xxv) All the services provided for school children, i.e., medical, dental, milk and meals, should be available to children attending occupation centres and, where applicable, to defective children, under community care, not attending occupation centres. 93 SCHOOL HEALTH SERVICE. the 1st may, 1954, was the fiftieth anniversary of the day upon which the Council became the Local Education Authority for the County of London. One of the ways in which the Council marked this jubilee was by holding at the County Hall a special exhibition and display of the work done in the field of special education for the handicapped pupil, a field in which there is of necessity the closest collaboration between the education and school health services. An account of the growth and development of the school health service over the past fifty years will be found in Appendix C, page 167, whilst the following paragraphs deal with the details of the work done during 1954. Organisation Like most of the personal health services, the school health service is organised on a divisional basis (see pages 125-143 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. In 1952 the Education Committee, jointly with the Health Committee, reported to the Council on a number of suggestions made by the then Minister of Education in relation to the school health service. This report referred to the inter-departmental working party of officers which had been set up to consider certain matters relating to the duties of health visitors in connection with the complete integration of the school health and maternity and child welfare services and also the duties of the medical treatment organisers (children's care organisers in the Public Health department). The outcome of the prolonged deliberations is not yet known as, during the year the Council decided that experiments should be held and that no decision on the working party report would be made until the reports on their experiments were available. The experiments will involve the withdrawal of the Public Health children's care organisers from certain school treatment centres where health visitors/school nurses will take over part of their duties. This will include liaison with the voluntary care committees on which the Council still relies for the medical following-up for school children. To help towards cementing the desired co-operation between the care committees and the health visitor/school nursing staff, the Education Committee have added a clause to the constitution of care committees which reads as follows:— 'To co-operate fully with the school nurse/health visiting staff on all cases where specialised nursing knowledge appears essential in securing the most effective treatment'. In bringing this addition to the notice of the care committees the Education Officer said 'The specific function of the Care Committee is to endeavour to make sure that nothing in the child's mental or physical make-up or his home surroundings shall hinder him from obtaining full benefit from the education provided. 'In pursuance of this aim, Care Committees will be at pains to enlist the specialised knowledge of health visitors who, through their responsibilities in the field of family health, will already be in touch with many of the families'. Since the National Health Service Act, 1946, came into force, giving additional responsibility to the Council, it has become increasingly clear that the paramount need is for a still closer co-operation between all field workers. The drawing together still closer of the care committees and the health visitor/school nursing staff will, therefore, only be a development of a principle already well known and the value of which is beyond dispute since it can only result in a more effective service to the community. 94 Medical inspection rooms in schools The Standards for School Premises Regulations, 1954, do not specify separate accommodation for medical inspection purposes but merely require 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. Financial limitations imposed by the Ministry of Education severely restrict the amount of money that can be spent upon 'minor improvements' at schools, so that improvements such as structural alterations and better washing, lighting and heating facilities for medical inspection purposes are necessarily proceeding slowly. On the other hand, in the plans for the new comprehensive high schools now under construction, well-equipped medical suites are being included. These will, in general, contain a doctor's consultation room, provision for 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. The first of the Council's comprehensive high schools was opened at Kidbrooke in south-east London in September, 1954. It contains a complete medical suite on the ground floor in the administration block. The medical services, which may need to be revised in the light of experience, provide for a full-time school nursing sister, three doctor's sessions and two dental officer's sessions weekly. Pupils on school rolls At the end of 1954, there were 442,129 pupils on the day school roll, 313,908 children of primary and secondary school age were in attendance at County schools and 104,480 at voluntary or assisted schools; in addition there were 15,584 children under five years of age in nursery schools and classes or primary schools and 8,157 children in day special schools. Medical inspection The School Health Service and Handicapped Pupils 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. 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 1954, with comparable figures for the two previous years, are as follows : 1952 1953 1954 General Medical Inspections 'Routine ' —Entrants 58,039 51,814 44,415 Age — 7 years old 32,902 40,870 44,604 Groups —11 years old 28,558 33,940 34,312 —Leavers 26,908 27,768 27,892 Total 'routine' age groups 146,407 154,392 151,223 Other ages (a) 60,747 56,534 54,866 Total general medical inspections 207,154 210,926 206,089 g 95  1952 1953 1954 'Special' Medical Inspections 'Urgents' and 'Specials'(b) 26,061 23,618 27,262 Employment Certificates 3,019 3,984 4,604 School journeys 20,489 19,375 19,503 Miscellaneous (c) 11,905 13,364 8,223 Total special inspections 61,474 60,341 59,592 Re-inspections 'Nutrition ' cases (d) 57,851 62,708 64,909 Other re-inspections 121,751 115,622 107,131 Total re-inspections 179,602 178,330 172,040 Grand Total 448,230 449,597 437,721 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 vitamin capsules on the recommendation of the school doctor (see page 97). 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 1951 1952 1953 1954 Entrants Boys 17.4 15.6 15.1 13.8 Girls 15.3 14.1 13.4 11.9 7 years old Boys 19.8 18.9 17.9 16.8 Girls 18.6 18.4 17.2 15.4 11 years old Boys 16.5 16.1 15.8 14.5 Girls 18.2 18.0 17.6 15.9 Leavers Boys 12.2 12.2 12.7 11.7 Girls 16.6 16.9 16.0 15.6 Total Boys and Girls* 17.0 16.2 15.8 14.8 * Exclusive of special schools and training colleges, but inclusive of 'otherage' general medical inspections. The following table shows the percentages of defects (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: 1951 1952 1953 1954 Skin diseases 1.13 1.14 1.29 1.39 External eye diseases 0.71 0.72 0.75 0.72 Defective hearing 0.51 0.58 0.64 0.59 Otitis media 0.87 0.94 0.97 0.74 Enlarged tonsils and adenoids 8.44 8.26 7.61 6.92 Defective speech 0.63 0.72 0.75 0.72 Enlarged cervical glands 1.67 1.71 1.62 1.45 Heart and circulation 0.80 0.78 0.84 0.87 Lung disease (not T.B.) 1.95 1.83 1.77 1.55 Orthopaedic defects 4.52 4.83 5.25 5.10 Defects of nervous system 0.31 0.41 0.37 0.37 Psychological defects 0.72 0.81 0.86 0.97 Anaemia 0.33 0.34 0.26 0.19 Enuresis * * 1.76 1.56 * Not available. 96 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', 'sub-normal' or 'bad'. Since these are descriptions 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: Sub- Normal Percentages referred: Year Excellent Normal and Bad 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 1954 57.6 40.4 2.0 1.0 0.8 1.8 Genera Condition Pupils receiving school meals, extra milk or vitamin capsules on the recommendation of the school doctor are re-inspected each term. During 1954, the number of such re-inspections was 64,909. The classification of general condition recorded at these 'nutrition' re-inspections, with comparable figures for 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 1954 13.0 70.1 16.9 School meals, milk and vitamin supplements A return to the Ministry of Education for a typical day in October, 1954, showed that 207,051 pupils, 52.8 per cent. of the number in attendance, were provided with school dinners ; of these, 18,995 received dinners free of charge. On the same day 353,192 children had school milk. This, however, included milk collected from school for children who were absent, so that consumption cannot therefore be related to the number of children in attendance. Vitamin 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 event, is Is. 3d. a term for a daily dose. Between October, 1953, and October, 1954, the number of meals centres at which schoolchildren dined rose from 932 to 960, the number of kitchens of all kinds producing schools meals in October, 1954, being 595 (including 583 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 the following standards have been set:— Minimum Age group number of calories (i) Under 7 years 500 (ii) 7 to 11 years 650 (iii) Over 11 years 800 Meals for children are planned to contain, as a minimum, 20 grammes of protein, 25 grammes of fat and 400 milligrammes of calcium. The diet of the children taking meals was under the supervision of the Council's Honorary Nutritional Consultant, 97 * Dr. T. S. Macrae, O.B.E., D.Sc. To provide a check on the standards of meals served, random samples were analysed from time to time by the Council's Scientific Adviser (see page 49). Average heights and weights of school pupils During 1954 a survey of the heights and weights of a sample of school pupils was carried out and a full report of the survey has been published separately*. Schools were chosen at random within the nine health divisions thus ensuring that the sample was geographically and socially representative. The schools selected actually yielded records for 21,003 children (10,904 boys and 10,099 girls), and the distribution of records was adequate for the calculation of averages. It should be mentioned that the children were measured and weighed in their ordinary indoor clothing but without footwear—heights were recorded to the nearest centimetre and weights to the nearest 1 /10 kilogramme. The County averages were as follows:— Age Years Average height at stated age Average weight at stated age cm. in. kg. lb. Boys 5.5 •• 111.1 43¾ 19.90 43¾ 6.5 •• 117.1 46 22.21 49 7.5 •• 123.7 48¾ 25.01 55¼ 8.5 •• 129.1 50¾ 27.64 61 9.5 •• 133.8 52¾ 30.33 66¾ 10.5 •• 139.0 54¾ 33.23 73¼ 11.5 •• 143.4 56½ 36.38 80¼ 12.5 •• 148.8 58½ 40.36 89 13.5 •• 154.0 60¾ 44.32 97¾ 14.5 •• 161.2 63¾ 50.82 112 15.5 •• 167.9 66 57.48 126¾ Girls 5.5 •• 110.2 43½ 19.38 42¾ 6.5 •• 116.4 4¾ 21.89 48¼ 7.5 •• 122.4 48¼ 24.30 53½ 8.5 •• 127.7 50½ 26.92 59¼ 9.5 •• 133.2 52½ 29.88 65¾ 10.5 •• 138.5 54½ 33.16 73 11.5 •• 144.5 57 36.83 81¼ 12.5 •• 150.2 59¼ 41.73 92 13.5 •• 155.4 61¼ 46.21 101¾ 14.5 •• 159.2 62¾ 50.88 112¼ 15.5 •• 161.4 63½ 54.18 119½ NOTE.—The averages at the stated age intervals are obtained by simple linear interpolation of the crude data. It was considered desirable to extend the scope of the survey to obtain some data on the relationship of height and weight to the onset of puberty. The attainment of sexual maturity is a long process and in the case of girls, for example, can be recorded by the time sequence of changes in the development of breast, pubic hair and axillary hair, as well as by the occurrence of the menarche; development changes in the first three can be still further sub-divided. As an initial step, therefore, it was decided to regard the breaking of the voice among boys and the commencement of menstruation among girls as broad indications of the onset of sexual maturity and pupils were asked whether the appropriate event had occurred. From many points of view it would have been desirable to have known the age and not merely the fact of maturity but had the question been asked the answer would have been merely the child's recollection which might well have been inaccurate and any deductions therefore misleading. *Report on the heights and weights of school pupils in the County of London in 1954. Staples Press Ltd., London. 98 The findings are summarised in the following table :— Age Years ' Mature ' Mean height c.m. ' Immature ' Mean height c.m. ' Mature ' Mean weight h- ' Immature ' Mean weight kg- Boys 9-5 — 133-8 — 30-33 10-5 — 139-0 — 33-23 11-5 143-1 143-4 34-54 36-42 12-5 151-7 148-5 42-49 40-05 13-5 157-8 152-5 48-24 42-79 14-5 164-2 157-2 53-83 46-80 15-5 169-0 163-5 58-78 51-84 16-5 171-7 — 61-45 — Girls 9-5 — 133-2 — 29-88 10-5 — 138-5 — 33-16 11*5 152-5 144-0 45-99 36-31 12*5 154-7 148-8 47-91 39-74 13-5 157-5 152-6 49-09 42-33 14-5 159-8 156-5 51-99 45-11 15-5 161-4 — 54-27 — 16-5 162-7 — 56-28 — 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. 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, as it has been found that children have less difficulty with such types of letters than with the classical Snellen tvces. The following table gives the results of such vision tests carried out during 1954 :— Visual acuity (with glasses, if worn) Percentage referred for treatment 6/6 6/9 6/12 or worse % wearing glasses Total Already wearing glasses Not wearing glasses 7 years old Boys 80-1 13-0 6-9 3-0 6-6 0-6 6-0 Girls . 79-2 13-8 7-0 3-5 6-7 0-6 6-1 11 years old Boys . 82-2 9-0 8-8 8-0 8-3 2-2 6-1 Girls . 79-3 11-0 9-7 9-5 8-9 2-8 6-1 Leavers Boys . 81-5 8-9 9-6 9-9 8-4 3-2 5-2 Girls . 76-9 11-3 11-8 13-8 10-9 4-5 6-4 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. 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 103-4. Hygiene inspections and the cleansing scheme For the purpose of assisting at medical inspections, each school health visitor is allocated to a group of schools. Each school in the group is also visited by the school health visitor in accordance with a rota, in order that she can carry out the inspection as to 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. The hygiene inspection of all pupils is, in two terms out of three, concerned 99 primarily with the detection of lice or nits. As was explained in the 1953 report (pages 105-6) in the third term of the school year a more comprehensive inspection is carried out. The nature and extent of both types of hygiene inspection were under review at the end of the year. The following table gives the results of the personal hygiene inspections carried out during 1954 :— Total Number of Inspections Pupils found to be verminous* Number Percentage Boys 406,941 3,267 0-8 Girls 441,337 11,718 2-7 Infants 451,080 6,887 1-5 Total .. 1,299,358 21,872 1-7 * ' 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, 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 eight bathing centres run directly by the Council and, by arrangement with the Metropolitan Borough Councils concerned, at 21 borough cleansing stations. The following table shows the results of the operation of this ' cleansing scheme' during 1954 :— 1. Number of pupils on school roll 442,129 2. Number of hygiene inspections 1,299,358 3. Number of occasions on which pupils were found to be' verminous ' (as defined) 21,872 4. Number of individual pupils comprising item 3 11,801 5. Number of advice cards issued 13,135 6. Number offamilies involved in item 5 5,225 7. Number of pupils found to be clean after issue of advice card .. 2,228 8. Number of pupils voluntarily attending bathing centre after advice card 8,827 9. Number of statutory notices issued 1,839 10. Number cleansed voluntarily after statutory notice 632 11. Number compulsorily cleansed after statutory notice 1,123 The cleansing scheme, coupled probably with a generally more enlightened outlool on the part of parents in recent years, has proved very effective and the numbers of case: reported have steadily declined from year to year. The following table indicates th< extent of this decline. Year No. of pupils on school rolls No. of nurses' hygiene inspections No. oj occasions on 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 1948 373,090 1,538,187 64,620 4-2 29,970 8-0 1950 380,885 1,428,783 46,012 3-2 22,159 5-8 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 1954 442,129 1,299,358 21,872 1-7 11,801 2-7 100 Early in 1953 it was decided that the numbers had dropped sufficiently to make it possible to consider whether the existing scheme could be effectively supplemented to secure an even more rapid decline in the incidence of uncleanliness. By approaching the problem within the family as a whole, more radical work might be possible. Accordingly it was decided that if a pupil was found by the school health visitor to be ' verminous' the advice card would be delivered at the home by the family health visitor, and that no statutory notice would be issued by the Education Officer 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. From the family health visitors' records it is possible, for the first time, to measure the size of this problem in terms of families, and 5,225 different families were involved during 1954. It must be remembered, however, that this figure includes cases of accidental infestation from school contacts, and a better measure of the ' hard core ' of uncleanliness in London is probably the 1,123 cases that required compulsory cleansing. 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. During the year 172,040 medical re-inspections were carried out, 64,909 in respect of pupils noted as' nutrition ' cases (see page 97) and 107,131 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 indicate against a particular type of employment, and this information is passed on to the Youth Employment Service. Pupils advised against particular forms of employment formed 15-5 per cent, of both sexes examined. Eye strain and normal vision again headed the list of contraindications for both sexes. Next came normal colour vision (for boys only), heavy manual work, 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 27,892 school leavers during 1954 :— Contra-indications Boys Girls Occupations involving : Heavy manual work 253 254 Sedentary work 19 22 Indoor work 10 4 Exposure to bad weather 127 223 Wide changes of temperature 55 56 Work in damp atmosphere 130 118 Work in dusty atmosphere 140 93 Much stooping 21 34 Climbing 74 58 Work near moving machinery or moving vehicles 39 41 Prolonged standing, much walking or quick movement from place to place 105 206 Eye strain 639 896 Normal vision 772 771 Normal colour vision 257 2 Normal use of hands 7 9 Exposure of hands to moisture, chemicals, etc. .. 31 40 Handling or preparation of food 68 64 Normal hearing 63 43 101 Employment of children The bye-laws governing the employment of children require, inter alia, that the Principal 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, and (ii) for the class of employment referred to in the certificate. During the year 4,604 medical examinations were carried out locally in respect of the issue of employment certificates. In addition, 399 medical examinations were carried out at the County Hall of children concerning their employment under licence in public entertainments, comprising 120 boys and 279 girls. Children under five years of age At the end of 1954 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 can attend between 8.30 a.m. and 4.30 p.m. and have dinner (and breakfast and tea when necessary), and two-thirds of a pint of milk daily in addition to other supplements supplied to the nursery class children. At the end of the year there were 21 maintained day nursery schools with accommodation for 1,250 children from 2-5 years, three nursery centres each providing half-time education for two groups of 40 children each, one group attending in the mornings and the other group in the afternoons, and five assisted nursery schools with accommodation for 230 children. Health visitor/school nursing sisters attend nursery classes and schools frequently and each child is examined every term by a school medical officer. There were 15,584 children under five years of age on the day school rolls, 13,160 being in the Council's schools and 2,424 in voluntary schools. School journeys Arrangements for the medical and hygiene inspection of pupils before departure on school journeys or visits to holiday camps were continued. During the year 19,503 such examinations were carried out. 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. Holidays for diabetic and epileptic children During the summer the Diabetic Association again organised holidays for diabetic children and the British Epilepsy Association, under a similar scheme, organised for the first time a holiday for epileptic children. A small number of London diabetic and epileptic children, who would otherwise have been denied a holiday because of the problems associated with their handicaps, were provided with holidays at Walton-on-the-Naze, Kingsdown, Kent ; Barrow, Lancashire (diabetic children), and Brockley, Northants (epileptic children). 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. 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 of cases of infectious diseases thus reported during 1954 and the preceding years are given in Table 9, page 223. 102 These figures are, of course, uncorrected for diagnosis, but they 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. The 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. In March, six cases of clinical tonsillitis occurred in a residential school for educationally sub-normal boys. They were found to have been caused by a mitis strain of diphtheria bacillus. The boys at the school had been immunised in the past and therefore had very mild symptoms. Swabbing of all boys in the school brought to light 27 healthy carriers. Some of these were admitted to hospital but the remainder were treated at the school with erythromycin, with outstanding success. Diphtheria at Bishopswood Farm School In the following term two boys suffered from throat infection with diphtheria bacilli, one of whom had quite a sharp attack. On this occasion 15 carriers were discovered, all of whom responded to erythromycin. There were no further incidents of this nature at the school. There was a small outbreak of ringworm of the scalp in the children s home at Hutton in May. One boy was noticed to have a suspicious patch on his scalp which proved to be ringworm. Next day all the children living in the home and all the children coming into the junior school from the area around—Hutton and Shenfield—were examined by ultra violet light. Six more cases were found amongst children living in the home, in four separate houses ; all these children were isolated and later transferred to Goldie Leigh Hospital for treatment together with another child who was confined to the sick bay with whooping cough, when found to have ringworm also. Ringworm at Hutton There was no further spread, cither in the home or among the Essex children—none of whom was found to be infected. In January, two children in Langley House reception centre were reported as being treated with Castellani's paint. On enquiry as to which part was being treated it was found to be the temple region and that the condition was considered to be ringworm of the skin. The two children were then examined by Woods glass filter and ultra violet light, when it was established that the condition was ringworm of the head. As a result all the children in Langley House were examined in the same way and two more found to be infected. The necessary treatment was arranged and epilation carried out at Lambeth Hospital. Ringworm of the head at Langley House reception centre The children at Langley House attend several different schools; these were visited and the children in the classes to which the Langley children belong were all examined by the Woods glass filter and ultra violet light. Three schools in all were visited but no positive cases were found. Another case was found in Langley House—a child re-admitted to Langley House from hospital who was a brother of two of the infected children Subsequently there was another case in Langley House—a child who had spent a lot f the time between December, 1953, and May, 1954, in hospital. He was diagnosed as having ringworm on 4th May. Six children in all were affected, three of whom were brothers and it seems very likely that this family was the source of the infection. 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 103 securing that comprehensive facilities for free medical treatment are available to its pupils either under this Act or otherwise'. 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 after discussions with the Boards 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. 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 Regional Hospital Boards. In the 1953 report reference was made to the fact that in the area of one of the four Regional Hospital Boards which serve London, the Council had been endeavouring to secure extra vision sessions, to meet the increased demands which had arisen as the school population had increased. For financial reasons, however, the Board had not been able to accede to these requests, though approving in principle the provision of additional sessions. In June, 1954, the Council approved the direct employment by the Council of ophthalmologists, temporarily, to deal with waiting lists of about 5,000 cases, without prejudice to the principle that the provision of this service was the responsibility of the Board. In July, the attention of the Minister of Health was drawn, both by letter and by deputation, to the unsatisfactory position which had led the Council to make this decision. In October the Council was informed that, though the Board had agreed in principle to the need for an increase in this service, the Board felt unable to accept any additional financial commitments. In June the Minister of Education had been asked to approve the Council's proposed expenditure on the employment of ophthalmologists. In December, 1954, the Council was informed that the Minister of Education had consulted the Minister of Health who agreed that the arrears might be dealt with under the supplementary ophthalmic services. This decision of the Ministers implies that the Minister of Health accepts the Council's contention that the provision of vision treatment for school pupils is the responsibility of the National Health Service and not of the local education authority. However, the Minister apparently prefers not to direct a Regional Hospital Board on the details of its expenditure on specialist services, and accordingly has decided to meet the additional expenditure through the Supplementary Ophthalmic Services provided under Part IV of the National Health Service Act, 1946. From the point of view of the welfare of the school pupils it is immaterial whether their glasses are obtained under Part II or Part IV of the National Health Service Act, 1946, so long as they can be obtained without delay. However, from the point of view of the practical implementation of the expedient that the Minister has devised, a wide range of administrative complexities necessarily arise at the clinics. 'Normal' sessions remain the responsibility of the Hospital Eye Service, so that the Ophthalmologist is remunerated by the Regional Hospital Board, prescriptions are on white form H.E.S.I, and the optician is paid by the local Hospital Management Committee. The 'extra' sessions (held at the same clinic, with the same staff) come under the supplementary service, so that the Ophthalmologist is remunerated by the Council, prescriptions are on green form O.S.C.2, and the optician is paid by the Executive Council. Little wonder that all concerned, staff, parents, opticians, teachers and care committee workers are bewildered. Moreover, it will be noticed that there is, as yet, no final solution of this problem of obtaining extra sessions for school pupils, though the school roll continues to rise and will reach its peak in about 1958-59. 104 At the end of the year there were 105 school treatment centres, 81 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 83 †Dental 63 *Vision 41 *Orthoptic 8 *Ear, Nose and Throat 12 Audiology 9 Speech Therapy 35 *Enuresis 1 Special Investigation 15 Nutrition 29 *Rheumatism (Supervisory) 14 School treatment centres †Several of these are ' twin' surgeries. *Specialists provided in most cases by regional hospital boards. 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 takes several forms, in 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 departments, the specialist clinics, the school health service and the children's care organisation. Reference has already been made on page 94, to the Council's decision to hold experiments in the field in connection with the integration of part of the duties of the organisers with those of the health visitor/school nursing sisters. Treatment of school pupils at hospitals The report of the children's care organisers working in the out-patient department of Guy's Hospital, illustrates the wide scope of this liaison between the school health service and the hospitals. The following is a short statistical summary of the report :— Hospital department New Cases Total attendances Discharged— treatment complete Children's 345 1,027 128 Ear, Nose and Throat 376 676 275 Vision 267 1,519 999* Orthoptic 63 647 19 Orthopaedic 119 293 73 * Spectacles either obtained or not needed. The total number of attendances of school pupils seen in departments of the hospital attended by the organisers was 5,332. The following note has been contributed by Dr. E. E. Gourlay, who has been responsible for a nutrition centre for the past twenty years:— 'Nutrition centres were started in five centres in London in 1935, because it was felt that there were many children in the Council's schools who were not up to standard Nutrition centres 105 physically and yet were probably not under any investigation or treatment. At that time of wide-spread unemployment and misery in Hoxton it seems strange that in the beginning we were at a loss to know how to choose the children for the clinic when so many would have been suitable. The school nursing sisters soon came to our help as they knew the children who were constantly attending the minor ailment clinics with septic sores, boils and other such complaints. The school doctors and the care committees also brought forward children who had failed to make progress from free school dinners and milk. 'On further enquiry it often appeared that the school food was just about all of a body-building kind which the children obtained and it was not enough. In those days these children suffered from all the minor ill-health associated with poverty and poor food, such as septic boils, respiratory infection and a certain amount of iron deficiency anaemia (16.4 per cent. of children were below Hb 85 per cent. in 1936-37). Their clothing was wretched, often consisting of many layers of poor cotton in mid-winter and broken boots or only Wellingtons were common. Of 68 children seen in 1936/37, 23 came from families of unemployed men and 8 were children of widows or came from broken families. ' Although it is impossible to make accurate comparisons owing to the alteration in the value of money, it is certain that those families living on Public Assistance or Unemployment Assistance before the war had not enough money for food. When the war came accompanied by full employment a great change came over the scene in Hoxton and it was our compensation to see a little comfort come into these homes. Many children needed to attend the clinic in the period just after the war when " lease lend " had ceased, and, in spite of all the levelling up and down, only poor food was available for all who could not afford expensive supplements. We actually have more iron deficiency anaemia amongst the children now than before the war (25 per cent, of children seen in the last 2 years were below Hb 85 per cent.) probably due to lack of meat. We have now full employment and of 63 children seen in the past two years only five came from families where the father was unemployed, four of these being cases of chronic ill-health or physical disability. 'The housing question rather than the money shortage is the great problem now. To my personal knowledge the housing is no worse now than it was 20 or 30 years ago, shocking as it is in some cases, and yet before the war we never heard these present bitter complaints about it. Probably it is the fact that better accommodation is available for some which causes discontent. Also before the war it was possible to move even if only to another slum which suited the family better; now there is no place to go. 'Our children now come well-dressed, the little girls in their bright warm best cloth coats and the boys in their favourite lumber jackets. Poor shoes are rare and many television sets have come to Hoxton. Yet in a lower income group with a large young family living in a new Council flat it is a fact that unless the mother goes out to work the income is such as to qualify the children for free dinners in school. Some families in Hoxton do not seem to be entirely above the poverty line and many mothers are still glad of the help of the nutrition centre team. 'Quite indispensable to the running of the clinic is the Sister-in-charge of the centre, who knows the local children and many of the mothers and who is able therefore to bring forward cases which would benefit by advice. If possible we arrange a home visit by the Care Committee visitor which gives a picture of the social circumstances and often many interesting sidelights if the Care Committee Secretary knows the family well. Some of the children who benefit most from the clinic are those living under indifferent housing conditions with chronic respiratory infections. 106 'We give these children three doses of High Potency Ostelin 200,000 Int. units at two-weekly intervals, if possible, combined with a course of ultra-violet light treatment. If this can be followed by a period of convalescence or at a boarding open air school in the good weather the improvement in these cases is remarkable. In all this work we should accomplish little without the help of the Children's Care Organiser who is always there to explore all possibilities of help or to use to the utmost the vast facilities which the Council has available for the benefit of the children.' 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, opticians or 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 hospitals, 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 1951 1952 1953 1954 *Vision New Cases 34,231 35,649 35,222 34,420 Attendances 86,758 91,693 92,511 94,176 *Orthoptic New Cases 1,435 1,401 1,517 1,410 Attendances 15,385 15,784 11,564 11,643 *Ear, Nose and Throat New Cases 7,289 7,769 6,301 6,439 Attendances 16,565 17,408 15,291 15,056 Audiology New Cases — 1,206 1,330 1,153 Attendances — 2,407 2,676 2,954 Minor Ailments New Cases 155,080 151,903 169,443 166,173 Attendances 1,005,549 954,532 794,263 757,220 Dental New Cases 82,564 93,823 116,499 129,712 Attendances 172,063 202,571 269,061 300,912 *Rheumatism New Cases 1,100 971 959 786 Attendances 9,202 7,988 6,936 5,681 Nutrition New Cases 1,380 1,151 1,144 1,090 Attendances 10,984 11,162 10,593 10,594 Special Investigation New Cases — 590 957 904 Attendances — 3,027 4,588 5,626 *Enuresis New Cases 1,267 952 808 592 Attendances 6,344 5,449 4,026 3,466 * Hospital and specialist services provided by boards of governors or regional hospital boards. Treatment statistics Handicapped pupils During the year 6,702 examinations were made to determine whether specialExaminations educational treatment should be provided or whether it could be discontinued. The number ot examinations in each category was as follows:— Category Pupils not in special school Pupils already in special school Vision 175 36 Hearing 152 64 E.S.N 2,355 265 Epileptic 110 14 Physically handicapped 348 142 Speech defect 138 732 Delicate 1,302 462 Maladjusted 351 56 107 The recommendations in respect of the 4,931 children not already in special schools were as follows:— Special School for the:— Vision Hearing E.S.N. Maladjust ment Epilepsy Physically handicapped Delicate Blind B 5 — — — — — — G 5 — — — — — — Partially Sighted B 38 — — — 1 — — G 24 — — — — — — Deaf B — 22 — — — — — G — 14 — — — — — Partially Deaf B — 12 — — — — — G — 10 — — — — — E.S.N.—day B — — 565 — 11(b) — — G — — 390 — 10(b) — — E.S.N.—boarding B — — 67 — — — — G — — 30 — — — — Maladjusted—boarding B — — — 159 2 — — G — — — 51 1 — — Epileptic—boarding B — — — — 3 — — G — — — — 2 — — P.H.—day B — — — — 2 135 — G — — — — 1 101 — P.H.—boarding B — — — — 1 9 — G — — — — 1 5 — Delicate—day B — — — — — — 248 G — — — — — — 175 Delicate—boarding . . B — — — — — — 521 G — — — — — — 358 Ordinary school B 36 19 280 — 39(b) 24 — G 24 8 109 — 30 (b) 12 — Ordinary school with special treatment B 23 40 508(c) 117(a) — — — G 20 27 288(c) 24(a) — 1 — Decision deferred B — — 11 — — — — G — — 10 — — — — Unsuitable for school B — — 51 — 3 — — G — — 46 — 3 — — Home or hospital tuition B — — — — — 30 — G — — — — — 31 — (a) Attendance at special classes part-time. (b) Includes pupils for whom restrictions on certain 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. 108 The morbid conditions from which the 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 14 13 1 — 4 5 Cerebral palsy 20 19 1 2 1 — Various Paralysis 8 7 — — — — T.B. bones and joints 5 5 3 — — 1 Osteomyelitis 2 2 — — 1 — Perthes disease 10 2 1 — 3 1 Congenital deformities 16 10 — — 3 3 Spinal deformities, scoliosis — 3 — — — — Traumata, etc. 1 1 — — 1 — Non T.B. Arthritis 1 3 — 1 1 — Rheumatism, chorea 3 4 — — 1 1 Heart disease, congenital 13 8 1 — 1 — Heart disease, other 3 3 1 1 — 1 Other diseases 39 51 1 1 8 — Total 135 101 9 5 24 12 Pupils 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 such examinations during 1954, in respect of Educationally Sub-normal pupils are as follows:— Boys Girls Recommended no longer E.S.N. 65 42 Ineducable 51 46 Transferred from day E.S.N, school to boarding E.S.N, school 25 10 In addition, 360 pupils were recommended after medical examination for reporting under Section 57 (5) of the Education Act, 1944, as requiring supervision after leaving school. Routine examinations for ascertainment of E.S.N, children continues to be carried out divisionally. A medical officer experienced in ascertainment work is in charge of: these examinations and is responsible to each divisional medical officer, not only for the actual ascertainment but also for the supervision of children attending E.S.N.schools and the completion of the statutory examinations under Section 57 (5) (leaver). In cases of children recommended by the Principal School Medical Officer for ascertainment under Section 34 (1) or for reporting to the Local Health Authority under Section 57 (3) and (4) where the parent has exercised his right to appeal to the Minister of Education, a further investigation takes place at the County Hall. It has been found in a large number of appeal cases that the parents are not disputing the fact that the children are backward and are not progressing under ordinary school education, but that they do not understand the exact nature of special school education or they have become confused with what ascertainment really means. This further consideration of the case and in many instances, further examination, has enabled the parents to express their opinion and in many instances to put forward fresh points which were not disclosed at the original examination. The results obtained from this further consideration in disputable cases has been very satisfactory. Numerous appeals have been withdrawn and, in some 109 Educationally sub-normal pupils instances, the further information from either the Head or the parent has resulted in the child being allowed a further extension of trial in an ordinary school. Specialist investigation and examination of difficult cases such as multiple defects, and cases referred by the Divisional Medical Officer for special reasons is carried out centrally at the County Hall under the direct supervision of a principal medical officer. When necessary these children are seen in consultation with various visiting consultant specialists, e.g., ophthalmic surgeon, ear, nose and throat surgeon or psychiatrist. Detailed figures of the ascertainment and general supervision of E.S.N, children are given in the tables on pages 108-109. It will be noted that the over-all figures show a considerable increase on the numbers quoted in preceding years. This does not mean that there is in fact a big increase in the incidence of sub-normal intelligence but is due more to the modern feeling that children of I.Qs. of 75 per cent.—80 per cent., or in some instances 85 per cent., whose educational attainments are low, progress more rapidly under special school education than in backward streams in the ordinary schools, and also that in certain types of combined E.S.N, and maladjustment, admission to an E.S.N, school has been found preferable to admission to a school for maladjusted. Day open-air schools A survey was initiated in April, 1953, with the object of comparing the heights, weight and sickness absence of pupils attending day open-air schools, and thus being able to assess the merits of the different types of such schools in relation to the physical progress of the pupils. The observations were designed to be recorded over a period of one year, to take account of seasonal variation, beginning with the summer term of 1953. A record form was designed for recording monthly heights and weights and sickness absence, but special inspections and measurements were not required. The schools included in the survey consisted of: Type 'A'—old 'open' type, i.e. classroom shelters with 3 foot wooden walls. Type 'B'—new type, i.e. brick and glass classrooms electrically heated. Type 'C'—folding screen type. Type 'D'—half wall type, i.e. openable upper wooden walls. Type 'E'—Type 'A' after enclosure (see below). Two difficulties arose during the currency of the survey which prevented the original comparison of progress over a year being effected. First, because of initial staffing difficulties, the survey did not start at Type 'D' until the autumn term of 1953, and second, and more important, all Type 'A' were enclosed during the period from November, 1953, to January, 1954, thus becoming Type ' E and Type ' D ' were heated at the same time. Although record forms were submitted for 1,680 pupils, 412 were rejected because the child concerned was not a pupil for the whole of one or other of the various periods selected for comparative purposes. Sickness absence As there were so few children over the age of ten years at Type 'C' it was decided to restrict the survey to those under that age. The average number of absences at Type 'E' was found to be of the same order, and there was no difference between the sexes (boys 1.74 ± 0.40, girls 1.72 ± 0.40), consequently it was thought reasonable to combine the sexes in order to draw conclusions from a larger sample. It was only possible to compare four types over the Easter term, 1954, for reasons already stated: Average days' Type absence 'B' 7.5 'C' 7.7 'D' 9.3 'E' 8.3 110 By extending the period to two terms, the number of schools in the survey became restricted: Average days' Type absence 'A' 9.8 'B' 11.3 'C' 13.0 In only two types of school was it possible to extend the period over a whole year : Average days' Type absence 'B' 18.6 'C' 17.1 It was decided to confine the comparison of heights and weights to a minimum of two terms because it was felt that one term only was an insufficient period. In fact, no conclusions could be drawn from an examination of the height and weight of the children. Comparisons were made between boys and girls attending Types 'A', 'B' and ' C but no significant change was observable. It is doubtful if any valid conclusions of the effect of the type of building can be drawn from this survey. A much longer observation period and a larger sample would be needed. Heights and weights These schools, of which there are seven, are intended to help debilitated children to achieve the normal state of health and as a result to become able to profit by their education and to lead happier lives. The important word is debilitated, i.e., children who are 'run down', or 'under the weather.' The cause of the debility may be serious illness and slow recovery or a poor standard of home, or anything between. The limits are wide, and the degree of ill-health variable. The reduced ability of the ill child is plain to see but it is not always so obvious that a child not in the full bloom of health, but yet not one that could be rated as ill, is capable of better work and a fuller life than is achieved. It is this less tangible state of ill-health that is attacked in an open-air school and boarding is arranged because in so many homes there is inability to give the children a secure, regular, full life. In a boarding school habits of living a full life, having adequate rest, proper sleeping time and a diet which is balanced and appetising all play a part in raising standards for the child. Most of the children remain for two terms as experience has shown that the gains of the first term are consolidated by a second. Some need a longer stay and a very few spend most of their school life away. In all cases-they are seen regularly by the visiting medical officer and reports are made to the Principal School Medical Officer if any need for special consideration arises. In addition the schools are visited regularly by experienced medical officers of the central office staff. Any person who is aware of a child thought to be in this debilitated condition can suggest that he or she be seen as a 'special' at a school medical inspection. Many children are recommended from the special investigation clinics, but more might well be recommended from the school itself, where the closer, regular, contact of teacher and child gives great opportunity for observing the day-to-day variations in the 'less well' child. Some parents have doubts and find it hard to accept that their child can do well away from home but it is not unusual to find, after a term or two, that these parents are amongst the strongest supporters of the boarding open-air schools, to such an extent that other children in the family are sometimes put forward for examination in the hope that they too will obtain benefits as valuable as those which accrued to the child who went away. 1ll h Boarding open-air schools The social service side of the work is of great importance to these parents; understanding preparation by the Care Committee worker can make the whole prospect brighter and less worrying to them. Many of the children return home for the holidays, but many can be and are kept at the school for all or part of the holiday period. When the time for discharge comes the child usually returns to his previous school but in some cases the easier regime of the day open-air school is recommended for an intermediate spell. Physically handicapped pupils— physiotherapy Since 1950, physiotherapy at the Venetian special school for physically handicapped children has been given at the school by physiotherapists working under the supervision of the Director of Physical Medicine from the nearby King's College Hospital. This arrangement has proved so successful, both in the treatment of the children and in the saving of time as compared with children at other schools who have to travel to hospitals during school hours for their treatment, that efforts are being made to effect similar arrangements at other special schools for physically handicapped children. Speech therapy Speech therapy sessions were held at 28 school treatment centres and, in addition, sessions were held at 25 day schools for the educationally sub-normal, 15 day schools for the physically handicapped and at four residential schools. At the end of the year, 1,135 pupils were under treatment at these various speech therapy classes. New admissions during the year totalled 628, and 348 pupils were discharged as either improved or cured. 241 pupils, most of whom had shown some improvement, ceased to attend the classes for various reasons. Plans were formulated to extend the work and to increase the number of staff. Audiometry The routine audiometer testing of pupils continued during 1954, using the group gramophone test technique. The aim is that, each year, all entrants to junior schools should be tested, and for this purpose eight sets of apparatus are in use in the divisions. Pupils failing two consecutive group gramphone tests are tested individually with pure tone audiometers, and pupils who fail this individual pure tone test are referred to an audiology centre for examination by an otologist. The results of the audiometer tests carried out during 1954 were as follows : Percentage of Number first tests Estimated Junior School entrants age 7+ years 56,000 — Pupils given first gramophone test 46,159 — Pupils given second gramophone test 13,462 29.2 Pupils given pure tone test 3,805 8.2 Pupils referred to otologist 1,120 2.4 Reference was made in last year's report to the need for methods of testing the hearing of children at younger ages than is possible with the group gramophone device. 'The Health of the School Child', the report of the Chief Medical Officer of the Ministry of Education for the years 1952 and 1953, contains the recommendation, made by the Medical Research Council's Committee on the Education Treatment of Deafness, that the sweep frequency method of testing was preferable to the group method. Towards the end of the year it was decided that it would be desirable to carry out field trials in London of the rapid pure tone sweep method on school entrants of age 5 + years. The necessary apparatus was ordered, and during 1955 pilot schemes will be operated in two of the nine health divisions. Diabetic pupils Under the School Health Service and Handicapped Pupils Regulations, 1953, there is no longer a separate category of 'diabetic' pupils; they are now included in the general category of 'delicate' pupils. The new definition takes account of the fact that some delicate pupils (e.g., diabetics) can be educated under the normal regime of an ordinary school, but may need a change of environment to make this possible. During the last war, as part of the special evacuation arrangements for handicapped pupils, the Council started a diabetic unit in the curtilage of the residential school at Hutton, Essex. The scheme was so successful that it continued after the war, until April, 1954, when the unit was closed, and a residential hostel for diabetic pupils was opened at Palingswick House, Hammersmith. Children suffering from diabetes mellitus, 112 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, and the children are trained to make their own insulin injections and to guard against the accidents of a diabetic life. A visiting medical officer provides the day to day care, and a consultant visits regularly. Laboratory work, to ensure control, is undertaken by a technician under the direction of the consultant. The nature of the hostel is such that a wide variety of children of several age groups may be in residence. The children attend nearby schools, except for a few who, already attending grammar schools, continue to travel to the same school. Those children attending the infant school return to the hostel for their midday meal, the others have part school meal and part food taken with them from the hostel. While many of the children go home for the school holiday periods, a few must remain for various reasons and these are given a change of air elsewhere. Since January, 1951, a central register of epileptic schoolchildren has been kept at the County Hall and all school doctors have been asked to notify any children suffering from epilepsy ; if any of these children are considered to be in need of special educational treatment they are examined at the County Hall. The consultants at hospitals have been most helpful in carrying out special investigations on any cases referred to them. Since January, 1954, 130 names have been added to the register. Of these, 89 were in ordinary schools, 25 in day special schools, 11 in boarding special schools, including 5 placed at epileptic colonies, and 6 were found to be ineducable. This probably does not represent all the epileptic children of school age in London, as there may be some in ordinary schools who have yet to be notified. Enuresis At the Westminster Hospital (All Saints Urological Centre) the number of new applications for enuretic school pupils has been decreasing for some time, owing to the provision of other facilities elsewhere, and in consequence the number of sessions for school pupils was reduced from three to two a week from January, 1954. The number of new cases seen throughout the year fluctuated from 110 in the first quarter to 80 in the third quarter, rising again to 108 in the last quarter. The waiting period has averaged one month and has not risen above two months throughout the year. There was a total attendance of 1,759 and 137 children were discharged as cured. A number of former pupils who failed to re-attend were, necessarily, removed from the current file, which, • at the end of the year, totalled 314. Enuresis is now dealt with at a number of other hospitals in London, and, in addition, is among the conditions dealt with at the Council's own special investigation clinics. Juvenile rheumatism The number of children with acute rheumatism referred through the Council's rheumatism scheme for admission to Queen Mary's Hospital for Children, Carshalton, has shown a slight fall during the past three years, thus bearing out the trend that has been noticeable for some time past throughout the whole country, and indicating that acute rheumatism is becoming progressively less prevalent. 1951 1952 1953 1954 Nominations received 185 219 178 151 Outstanding from previous year 4 4 4 — 189 223 182 151 Admitted to rheumatism unit 177 216 179 146 Nominations withdrawn 4 2 3 1 Not suitable for unit 4 1 — 2 Awaiting admission on 31st December 4 4 — 2 189 223 182 151 113 H* Epileptic In the same way the number of children with cardiac involvement also shows a steady decline, which seems to indicate that the disease, in addition to being less widespread, is also becoming less severe and that the cardiac complications are becoming milder. The percentage of children with cardiac involvement on admission during recent years has been : 1947 1948 1949 1950 1951 1952 1953 1954 67.7 70.2 51.7 60.8 49.1 43.7 41.2 34.5 Chemotherapy and the wider use of antibiotics has probably been a factor in speeding up a process which in part seems due to an attenuation in virulence in the infecting organisms, but the use of cortisone and its congeners does not seem to prevent the onset of carditis in cases of established disease. The condition on admission of the cases admitted during 1954, was as follows: Boys Girls Articular Rheumatism Number admitted 64 38 Percentage with : Carditis 28.1 31.5 Valvular damage: Mitral 9.4 10.5 Mitral and aortic 3.1 — No cardiac involvement 59.4 58.0 Chorea Number admitted 12 17 Percentage with : Carditis 8.3 23.5 No cardiac involvement 91.7 76.5 Articular Rheumatism and Chorea Number admitted 4 4 Percentage with: No cardiac involvement 100.0 100.0 N.B. seven children were diagnosed ' not rheumatism . An analysis of the figures available for the past year suggests that, whereas the numbers of boys and girls developing carditis as a result of acute rheumatic infection are almost equal (boys 28.1 per cent.—girls 31.5 per cent.) and the numbers with mitral involvement are similar (boys 9.4 per cent.—girls 10.5 per cent.), the boys have been more liable to aortic disease. When the cases of chorea are considered, however, it is noticed that the girls are more frequently affected and that the percentage of carditis amongst them is considerably higher (boys 8.3 per cent.—girls 23.5 per cent.). Unfortunately it cannot be claimed that these figures are complete as it has not been possible to follow up all the cases. Changes at Queen Mary's Hospital, Carshalton, during the past two years have ended the 'Acute Rheumatism Unit' as a separate entity. No longer are the children under the care of a single consultant in separate wards; they now come under the care of three separate consultants in general wards. This seems to cause considerable delay before discharge reports reach the County Hall, and makes the correlation of reports somewhat arbitrary and the follow-up more difficult. A solution of these difficulties should not prove insuperable and should certainly be attempted, for with reasonable co-operation it is thought that re-entry into school life at a satisfactory level of activity could be expedited. In the past year 88 per cent. boys and 84.5 per cent. girls were considered fit for ordinary school or employment; 8.4 per cent. boys and 8.6 per cent. girls suitable for school for the physically handicapped or light employment; 3.6 per cent. boys and 6.9 per cent. girls unfit for school or work: Fit for ordinary Fit for P.H. Sex school or ordinary school or light Unfit for school Total employment employment or work No. Percentage No. Percentage No. Percentage Boys 73 88.0 7 8.4 3 3.6 83 Girls 49 84.5 5 8.6 4 6.9 58 Total 122 86.5 12 8.5 7 5.0 141 114 The follow up of the children, after discharge from hospital, by school doctors and rheumatism supervisory centres, is an important part of the rheumatism scheme but, as explained above, difficulties have occurred in ensuring that such follow-up is initiated : 1951 1952 1953 1954 Number of children under supervision of school doctors on 31st December 186 177 166 147 Number of children under supervision at rheumatism supervisory centres on 31st December 2,696 2,218 2,346 1,840 Number of supervisory centres 24 23 23 23 Number of sessions at supervisory centres 905 877 840 780 Number of children attending for first time 1,100 971 959 786 Total number in attendance at centres 9,202 7,988 6,936 5,681 For some time past the prophylactic use of chemotherapy during convalescence has become popular in the hope of reducing the relapse rate and more recently the exhibition of daily doses of penicillin has been started in some quarters. It seems too early to pronounce a judgment on the effectiveness or otherwise of this procedure at present. The final assessment can only be made after a considerable time lag has allowed the relapse rate to be compared with an earlier pre-prophylactic period and then be weighed against the possibility of producing penicillin resistant strains of infecting organisms. So far as can be seen at present, however, that risk does not seem to be a high one, though the use of brisk intermittent dosage at the slightest sign of upper respiratory infection may eventually prove to be a more effective method of prevention than prolonged mild medication. 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 and the senior inspectors of physical education of the Education Department. The general medical supervision of the classes is undertaken by the consultant in postural defects who visits each class at least once each year. An assistant medical officer in each Division is responsible for selecting the children and for their discharge on improvement. Psychiatry The demand for treatment at the Council's four child guidance units has continued to increase and the ever-growing waiting lists made it necessary to seek authority for an increase of staff at each unit. Approval was given to the appointment of two additional whole-time psychiatric social workers and one whole-time and two part-time psychotherapists, as well as additional sessions at one of the units by an educational psychologist. Some of these vacancies had been filled by the end of the year. It is envisaged that these staffing increases will enable the units to function more effectively and to undertake the treatment of a larger number of children. A study group which had been set up under the chairmanship of Dr. John Bowlby to consider mental health in the maternity and child welfare services published its report, which caused widespread interest, and is set out in Appendix B on page 156. It is planned to extend psychiatric services to more maternity and child welfare centres, in addition to the work which continues to be carried out with children under five at the two child guidance clinics run in conjunction with the local infant welfare centres. Child guidance units 115 The following table gives details of the work carried out during the year at the four units: Brixton Battersea Earls Court Woodberry Down Total No. of applications received 237 62 95 137 531 No. awaiting first interview at 31st December 52 20 29 43 144 No. interviewed and awaiting treatment 11 21 12 13 57 Number of patients In treatment at 1st January 150 35 57 23 265 New cases treated 159 47 95 91 392 Total 309 82 152 114 657 In treatment at 31st December 136 35 56 40 267 Discharged 173 47 96 74 390 No. of follow-ups 9 2 61 — 72 No. of home visits by psychiatric social worker 16 26 21 19 82 No. of school visits by staff 41 56 57 64 218 Disposal of patients Treatment completed 86 11 45 33 175 Transferred to other treatment 13 5 12 6 36 Further attendance impossible 15 10 16 7 48 Unco-operative 42 17 18 28 105 Placed or placement recommended 15 4 5 — 24 Taken into care 2 — — — 2 Total 173 47 96 74 390 Closing status of completed treatments Recovered 33 1 3 17 54 Improved 35 8 29 7 79 No change 18 2 13 9 42 Worse — — — — — Total 86 11 45 33 175 Psychiatric services at boarding special schools and residential establishments A new boarding special school for maladjusted children—Pine End—was opened by the Education Officer and arrangements were made for it to be visited by a psychiatrist and a psychiatric social worker. Similar arrangements continued at the other schools for maladjusted children, and it is considered that they play an important part in the work of these schools. Other special boarding schools and residential establishments continued to be visited by the Council's psychiatrists. It is ever more widely recognised that the separation of young children from their families and homes creates difficulties and problems of which the psychiatrist has a particular and specialised knowledge and understanding. In the course of their visits to the various establishments the psychiatrists give the staff general advice and guidance on the management of difficult children, discuss points of general interest and also examine individual children. It has been found that their advice and help have been generally appreciated by the staff and have led to a better understanding of the problems and needs of children deprived of a normal home life. Day school for maladjusted children The Lilian Baylis School, the first day school for maladjusted children in the county, was opened in January, and much interest has been aroused in this experiment in the 116 education and treatment of maladjusted children living in their own homes. A psychiatrist visits the school frequently and takes part in discussions and case conferences, while care committee workers visit the children's homes. Even in the short time that the school has been functioning its success has been evident. Residential schools and homes In accordance with the Memorandum prepared by the Home Office on 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 2,935 children, four approved schools with a total accommodation of 468, two remand homes with accommodation for 142 children, and a number of other smaller establishments—reception centres, small homes, family homes and aftercare hostels. At the large establishments a visiting medical officer, appointed by the Council attended for routine medical examinations, and also accepted the children on his national health service 'list'. Periodic visits were made by senior medical and nursing officers from the County Hall. Arrangements were made for the dental treatment of the children, and visits were made by the Council's psychiatrists. Research and investigation For the last eight years a record has been kept of the health, growth and development of 6,000 children in all parts of Great Britain, born in one week of March, 1946. This survey, which is undertaken by a Joint Committee consisting of the Institute of Child Health, the Society of Medical Officers of Health and the Population Investigation Committee, was continued in 1954, and health visitors again supplied the relevant information in respect of London children in the survey. Professor Arnold Sorsby, Director of the Research Unit of the Royal Eye Hospital was given facilities to carry out an investigation into the changes occurring during the normal growth of the eyes of 2,000 London school children. An investigation was started into the nutritional state of the children in one E.S.N, school, to determine whether the provision of breakfasts at the school would assist these children to overcome their lack of vitality, general clumsiness of movement and poor muscular co-ordination. Dr. W. J. J. de Sauvage Nolting, a psychiatrist at a mental hospital at the Dolder, Holland, was granted permission to consult the Council's records of the dates of birth of educationally sub-normal children born since 1942. He wished to discover whether there was any interrelation between the monthly birth rate of educationally sub-normal children and the vitamin C content of the blood of mothers during pregnancy. The diet of the mothers, unless supplemented, would vary in vitamin C content according to the season of the year. In England, mothers are provided with vitamin supplements during pregnancy and the intention was, therefore, to compare the rate of births month by month of educationally sub-normal children in this country with the monthly birth rate in Holland, where extra vitamins are not supplied. Permission was granted to Dr. Fisch, of the Audiology Unit, Royal National Throat, Nose and Ear Hospital, to conduct hearing tests of children suffering from cerebral palsy attending schools for the physically handicapped. The Council, together with other local authorities, co-operated in a follow-up, sponsored by the Ministry of Health, of children who had attended the Audiology Unit at 309 Gray's Inn Road. 117 DENTAL SERVICES the council's Chief Dental Officer and Principal School Dental Officer reports as follows:— Hopes that the expansion effected in the Council's dental services during 1953 would continue throughout 1954 were not fully realised but the year was one of all-round slight improvement. Graphs of dental inspections at schools and of treatment sessions worked (page 120) show some upward trend in the school dental service and this improvement is also reflected in tables V and VI dealing with the maternity and child welfare dental service and the dental service in boarding schools and residential establishments. The improvement was not progressive throughout the period, however, and at the close of the year the staffing position was only slightly better than in December of the preceding year. Financial provision had been made and plans prepared for several additional treatment centres to be equipped and opened but some of these were held in abeyance owing to lack of staff. Table I gives staffing and sessional figures compared with the preceding year but does not reveal the disconcerting factor of the frequency of staff changes. Replacements, however, continued to balance resignations of both full-time and part-time officers. A number of evening sessions worked by individual officers as overtime augmented the sessional figures. Table I Total Establish ment Staff Equivalent in Full-time Staff Sessions Total Sessions Total Number employed Fulltime Parttime School Service MCW Service School Service MCW Service School Service MCW Service Fulltime Parttime Fulltime Parttime 1953 (Dec.) -93 113 52 61 65 9/11 5 7/11 547 177½ 40 22} 724J 62 3/4 1954 (Dec.) -93 114 54 60 68 6 2/11 569 179 41 27 748 68 Throughout the year, the Council's policy to establish in the school dental service as soon as possible a ratio of one full-time dental officer for each 3,000 schoolchildren on the school roll (i.e., 142 full-time dental officers) was pressed forward but, as shown in the above table, even the interim establishment of 93 was not reached. The ratio attained throughout the county as a whole was 1 to 5,600 (in December 1953 the figure was 1 to 6,500) and ranged from 1 to 4,000 in Health Division 4 to 1 to 9,500 in Health Division 9. It was not possible, therefore, to give a full and comprehensive dental care programme to all who sought advice at the Council's dental surgeries but the spreadover policy of former years continued. In the three dental services (school, maternity and child welfare and boarding schools and other residential establishments) much useful work continued to be done and results are tabulated under their respective headings. School dental service For another year systematic revisional dental treatment for many children had to be postponed and some could receive (or desired) only ameliorative treatment. As formerly, not all defaulters could be followed up. At dental inspections in schools, considerable numbers of parents continued to express their intention to have private treatment and it was decided to investigate what proportion did indeed do so, and to attempt to estimate the volume of children's dental work done elsewhere in addition to the Council's work. 118 A survey was held in eight representative surgeries in four health divisions; children were dentally inspected, treatment required was noted and 2,190 children were referred in the ordinary way for treatment. About six months later, as many of the same children as were available (2,040) were re-inspected and the results were tabulated. It was found that 51 per cent. had obtained treatment from the Council, 9.7 per cent. from private sources, 1 per cent. from hospitals and 38.3 per cent. had received no treatment, or only partial treatment. It is known that the same children do not from year to year comprise the 50 per cent. who avail themselves of the Council's service, a factor which makes proper dental care highly improbable for many individual children. The proportion of children—38 per cent.—who apparently are dentally neglected between inspections is disturbing and much requires to be done by personal dental health education, enlargement of the Council's dental service and co-operation with the dental profession elsewhere before much professional satisfaction can be registered. Table II gives figures for the year under review and comparison with the three preceding years. Table II Attendances and treatments 1951 1952 1953 1954 Number of inspection sessions held at schools 441 584 1,448 2,056 Number of children inspected at schools by dental officers 46,473 59,677 153,293 199,041 Number found to require treatment 29,397 38,069 97,736 139,955 Percentage requiring treatment 63.2% 63.8% 63.8% 70.3% Additional number inspected at centres 65,501 71,452 76,291 67,604 Total number found to require treatment 94,898 109,521 174,027 207,559 Total cases treated 82,564 93,823 116,499 129,712 Attendances 172,063 202,571 269,061 300,912 Ordinary treatment sessions 15,760 19,563 27,366 29,022 General anaesthetic sessions 1,516 1,494 1,725 1,939 Temporary teeth extracted 93,981 96,561 103,922 108,825 Permanent teeth extracted 15,850 17,283 19,727 21,095 Temporary teeth restored by fillings 21,684 26,353 37,787 46,256 Permanent teeth restored by fillings 54,356 66,680 92,576 112,226 Fillings in temporary teeth 24,206 27,556 40,120 49,148 Fillings in permanent teeth 60,568 72,369 102,178 124,974 Other operations—temporary teeth 39,523 45,985 59,863 65,280 Other operations—permanent teeth 28,199 30,291 44,250 57,086 Local anaesthetics for extraction 21,300 24,667 27,020 21,216 Local anaesthetics for conservative treatment 1,607 3,753 7,072 8,352 General anaesthetics 34,097 33,448 37,887 43,899 Cases for whom immediate treatment was completed 8,481* 13,135 15,196 17,474 Cases discharged as dentally fit 40,369* 63,638 81,488 86,957 * Figures for May-December only. In Table III, an encouraging factor is the progressive improvement in the ratio of permanent teeth restored to permanent teeth extracted. This is considered to be symptomatic of the improved quality of treatment given generally, consequent upon the stabilised sessional case-load in operation more firmly throughout the year. Table III Ratio of permanent teeth restored to permanent teeth extracted 1946 4.2 to 1 1947 4.93 to 1 1948 4.58 to 1 1949 3.72 to 1 1950 3.29 to 1 1951 3.43 to 1 1952 3.86 to 1 1953 4.69 to 1 1954 5.32 to 1 119 120 Orthodontics The treatment of mouths deformed by badly positioned teeth is important dental work of a rather dramatic character which is sometimes more readily appreciated and understood than is the prevention of such conditions. The main difficulty in 1954, as in former years, was to strike a balance between the two lines of treatment. Every effort continued to be made to provide as much orthodontic treatment as possible but the correction of malocclusions requires considerable skill and the treatment is frequently very extended and time-consuming. Staff were encouraged to undertake in their own surgeries as many cases as time and pressure of routine work would permit and removable appliances of a high standard continued to be provided for them by specially trained technicians at the Council's central dental laboratory. By these means a considerable advance in numbers treated within the Council's service was achieved. It was not possible to increase the three sessions per week devoted exclusively to orthodontic treatment at Hammersmith treatment centre, where a full-time officer has displayed particular aptitude for this work. All dental teaching and general hospitals known to undertake orthodontic treatment were again invited to give their assistance. Use continued to be made of such hospitals who undertook to accept an agreed number of orthodontic patients per annum. The numbers for whom particulars were sent to divisional offices for reference to hospitals were controlled in order to conform to the acceptance number agreed with each hospital or orthodontist. Unfortunately, not many cases could be accepted. Table IV gives figures for comparison with the preceding years. Table IV 1950 1951 1952 1953 1954 Number of special orthodontic sessions 425 245 134 138 134 Number accepted at special orthodontic sessions 266 117 85 80 98 Number accepted at routine sessions — — 209 290 389 Number referred to hospitals — — — 100 127 Total number of patients accepted 266 117 294 470 614 In view of the difficulties of recruiting dental officers, some satisfaction may be registered with the growth of this section of the service during the year and I would record my appreciation of the dental officers and technicians who assisted. Maternity and child welfare dental service The demands on this service continued during the year to be less than expected. Sessions devoted to the work were about 10 per cent. of the total effort but with the help of a number of evening sessions it was possible to deal with all applications for treatment. Not all mothers and children were inspected, however, nor were reluctant patients followed up or firmly persuaded to accept treatment. Much remains to be done, when staffing permits, before an efficient and comprehensive dental health service for preschool children and their mothers, as visualised in the National Health Service Act, 1946, is in being. Comparative figures in Table V show increases under most headings and are indicative of a healthy, if slow, growth. Table V 1951 1952 1953 1954 Number of ordinary sessions 1,980 2,031 2,505 2,780 Number of general anaesthetic sessions 333 306 299 253 Number of appointments offered 23,342 24,609 30,441 33,797 Attendances—by appointment 18,282 18,995 22,675 24,692 —other 3,313 2,162 2,122 1,873 Silver nitrate treatment 1,818 2,907 4,256 4,433 Fillings 7,929 8,852 11,074 12,312 Extractions 9,289 8,463 9,565 10,157 Dentures supplied—new full 335 310 373 461 —new partial 536 400 520 646 Number made dentally fit 4,654 5,479 6,818 6,802 121 Dental service in boarding schools and residential establishments Recruitment to this section of the service, particularly in rural areas, showed improvement in 1954 and some stabilisation was brought to the problem by arrangements made under the Education (Miscellaneous Provisions) Act, 1953. At establishments of a size which justified the provision of a dental surgery on the premises, though used only part-time, arrangements were made for a dental officer to attend for inspection and treatment sessions at specified frequencies. At other establishments, arrangements were made, if possible, with the local authority's school dental service or with local practitioners to visit the schools for inspections and to provide sessions in their own surgeries for treatment, on payment of agreed sessional rates. Less comprehensive arrangements were made for short-stay establishments. The figures shown in Table VI are indicative of some improvement but refer only to sessions in the Council's surgeries. Table VI 1951 1952 1953 1954 Ordinary treatment sessions 449 488 569 611 General anaesthetic sessions 7 2 3 4 Number of children inspected 4,635 3,912 4,993 5,097 Number found to require treatment 2,045 1,836 2,452 2,654 Percentage requiring treatment 44.1% 46.9% 49.7% 52.1% Attendances for treatment 3,427 3,622 4,502 5,794 Temporary teeth extracted 950 690 827 1,222 Permanent teeth extracted 173 179 231 291 Fillings in temporary teeth 746 721 767 680 Fillings in permanent teeth 1,515 2,037 2,677 2,880 Cases completed 1,911 1,909 2,262 2,060 It is satisfactory to note that the pain relief service, which was all the Council was able to provide for some years at certain establishments, was replaced in 1954 by a more comprehensive form of dental care. Dental hygienists The second part of the sodium fluoride investigation commented upon in previous annual reports was concluded in 1954 and results indicated that the beneficial effect of applying 2 per cent. sodium fluoride to the teeth persists during the second vear after the application. On 31st March, 1954, a detailed report on dental use of sodium fluoride and employment of dental hygienists was submitted to the appropriate committees, as a result of which the continued temporary engagement of two hygienists was approved. At two twin-surgery establishments where full-time dental officers functioned, the hygienists assisted within their legal limitations by making use of equipment set up in recovery rooms. Joint appointments with the Metropolitan Borough Councils STAFF the staff employed in the public health department is set out in Appendix E on page 228. A further development in the sphere of co-operation between the Council and the Metropolitan Borough Councils on public health matters was the appointment of Dr. H. D. Chalke, Divisional Medical Officer for Division 7, and Dr. M. Cran, Deputy Divisional Medical Officer for that division, to be in addition Medical Officer of Health and Deputy Medical Officer of Health respectively of the Metropolitan Borough of Camberwell. Four of the Council's divisional medical officers were then acting, in addition, as borough medical officers of health and eight other members of the Council's medical staff as deputy borough medical officers of health. 122 The University of London Institute of Education continued to provide the theoretical instruction for the majority of the Council's health visitor students, some of the remainder receiving it at Battersea Polytechnic and the others at the Royal College of Nursing. During the course, field experience was provided by the Council. Of 195 of the Council's student health visitors trained since 1948, 191 have been successful in the examination of the Royal Sanitary Institute for the health visitors certificate and, of these, 102 are still in the Council's service while a further 40 students are in training. Training of student health visitors Importance is attached to the necessity of keeping the health visitor abreast of developments in her field and of affording her the opportunity for some revision of the theoretical basis of her skills. Accordingly, having regard to the recommendations of the Whitley Nurses and Midwives Council adopted by the Council, it is the Council's policy to enable its health visitors to attend a fortnight's post-certificate refresher course five years after qualifying and every subsequent five years. These courses are held both in and outside London, some being organised by the Women Public Health Officers Association and the others by the Royal College of Nursing. The Council meets the cost of the fees, travelling expenses and, when held outside London, a substantial part of the cost of board and lodging. Refresher courses for health visitors The number of references to the department for medical examination, for advice concerning the health of staff and for the fitness of candidates for appointment totalled 14,040, compared with 13,855 in 1953. 207 members of the staff were found to be permanently unfit for further duty with the Council and 220 candidates unfit for appointment. Reciprocal arrangements with provincial authorities for the local examination of new entrants were continued. Provincial medical officers of health arranged for the examination of 57 entrants to the Council's service and the Council's medical officers examined 53 persons for provincial appointments. The Council's staff medical examiners made 84 home visits to examine members of the staff who were unable to travel, compared with 68 during 1953. Staff medical examinations In co-operation with the welfare department and the school meals and catering department arrangements were made for the bacteriological examination of specimens from members of the food handling staff 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 195 persons (including 46 contacts) were examined, all but seven of whom were allowed to return to work after examination. The seven who were regarded as infectious were referred to their private doctors for treatment before being allowed back on duty. Food handlers in contact with infectious diseases FINANCE the total capital expenditure on the health services of the Council in the year ended Capital 31st March, 1954, was £98,236, details of which are as follows: Ambulance service:— £ Adaptation and extension 15,977 New vehicles 17,950 Children's Holiday Home, Littlehampton—adaptation 857 Day nurseries—acquisition, adaptation, erection 18,332 District nursing—purchase of cars 769 Maternity and child welfare centres—acquisition and erection 10,746 Occupation Centre—appropriation and adaptation 9,239 Woodberry Down Health Centre 10,519 Other Health Centres and establishments 13,847 98,236 123 The gross cost of the various services in 1953-54—including central administrative charges but excluding debt charges—and the contributions recovered from recipients of the services were : Service Amount recovered in Cost charges £ £ Ambulance service 765,120 Day nurseries 902,697 188,315 Domiciliary midwifery service 169,691 — General health services (including ,£160,519 contribution to Metropolitan Borough Councils for salaries of sanitary officers) 184,642 - Health centres 14,927 — Health visiting 298,287 — Maternity and child welfare 557,632 42,893 Mental health 177,582 Prevention of illness— Home nursing 352,952 - Domestic help 697,646 37,973 Other preventive services 448,648 24,218 School health 787,553 17,581 £5,357,377 £310,980 Maintenance The net cost of the services after allowing for Government grant, expressed in terms of rate in the / was 10-17d., divided as follows : d. Ambulance service 1.4 Day nurseries 1.32 Domestic help service 1.4 Domiciliary midwifery service .36 General health services .76 Health visiting .63 Home nursing .74 Maternity and child welfare 1.02 Mental Health .36 Prevention of illness (care and after care; chest clinics, foot clinics, etc.) .78 Vaccination and Immunisation .11 School health 1.29 10.17 VISITORS TO THE DEPARTMENT numerous requests are received each year for programmes to be arranged for visitors from home and abroad consisting of visits to the Woodberry Down Health Centre, maternity and child welfare centres, day nurseries, school treatment centres, occupation centres, etc., and talks by senior medical, nursing or administrative staff. Apart from those visitors who went to Woodberry Down Health Centre only and to which reference is made on page 134, there were 159 individual visitors from 51 overseas countries during 1954, the largest number being (in numerical order) from India, Australia, France, U.S.S.R., Yugoslavia, Japan, New Zealand and U.S.A. In addition, programmes were arranged for 130 visitors from Great Britain. Facilities have continued to be given to groups of medical, nursing and social science students from various training centres to undertake visits of observation and to be given talks connected with the Council's services and, apart from visits by student nurses from hospitals which are referred to below, students were received during the year from the following colleges, etc.:— 124 Whitelands College. Bedford College. St. Bartholomew's Medical School. London School of Economics. National Association of Mental Health. Convent of the Holy Child Jesus. N.S.P.C.C. London University. Stepney Jewish Girl's Club and Settlement. Charing Cross Hospital. North Western Polytechnic. West End Hospital for Nervous Diseases. St. Margaret's House, Bethnal Green. Royal College of Nursing. National Children's Home. The revised syllabus of the General Nursing Council for the training of student nurses became operative on the 1st January, 1954, and during the first year following the revision, about 3,000 student hospital nurses were given facilities for visits of observation in the field to acquire a knowledge of personal and communal health and of the social and preventive aspects of disease. Post-graduate medical students studying for the Diploma in Child Health and the Certificate in Public Health were given facilities, as in previous years, under the supervision of the medical staff for visiting many different types of services administered by the Public Health and other departments of the Council. During the year 1,143 visits were arranged for 72 students studying for the Diploma in Child Health and about 150 visits were arranged for some 30 doctors studying for the Certificate in Public Health. Interviews with senior staff of the department were arranged for students studying for the Diploma in Public Health. REPORTS BY THE DIVISIONAL MEDICAL OFFICERS Division 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington. Dr. Violet Russell reports : The birth rate continued to fall, the total births being 11 per cent, less than last year. The major part of this decrease was reflected in a lower number of hospital confinements ; domiciliary confinements were only 2.5 per cent, lower than in the preceding year. Vital statistics Consequent upon the lower birth-rate there was a decrease in the number of antenatal and infant welfare attendances at welfare centres and slightly fewer visits were made by health visitors. Nevertheless the popularity of the welfare centres continued to grow and it was encouraging to note that mothers were calling at centres more often on their own initiative to discuss their problems with the medical officers and health visitors. Welfare of mothers and children Among the activities carried on at the welfare centres health education made noteworthy progress and attendances at the special sessions arranged increased from 2,362 Health education in 1953 to 3,146 in 1954. At these sessions and elsewhere lectures, demonstrations and film shows were given and these were supplemented by various forms of display equipment and publicity. Early in the year a health exhibition was staged at the Hammersmith Town Hall, when representative examples of the wide range of services available were shown by photographs, models, graphs and other devices. All major aspects of health work undertaken by the Council, the Borough Councils and the voluntary agencies co-operating with them were represented in an attractive series of exhibits which included some shown by other public services. The exhibition was mentioned in a broadcast by 125 the B.B.C. and had good publicity in the Press and by a wide distribution of invitations, printed programmes and handbills. It was opened by the Chairman of the Health Committee and was very well attended by the general public and by senior boys and girls from schools who arrived in parties at 15-minute intervals throughout school hours. Several hospitals sent carries of student nurses and other officers. Vaccination and immunisation While there was a slight fall in the number of children vaccinated against smallpox there was a substantial increase in the number receiving primary immunisation and reinforcing doses against diphtheria. Even so, despite continued efforts by all available means of publicity to persuade parents to have their babies immunised, the number who were protected remained regrettably low. St. Quintin welfare centre The delightful new St. Quintin welfare centre in North Kensington was opened in July. This centre replaced the Dalgarno Gardens centre which was destroyed by bombing. It is designed and decorated on modern lines and is a most attractive, spacious and well-equipped centre which is greatly appreciated by the mothers. The opening of this centre provided a further opportunity of integrating the maternity and child welfare and school health services as the doctors and health visitors working at the centre also attend the local schools. Welfare clinic for mentally defective children A welfare session for mentally defective children was opened during the year at the Campden Hill welfare centre, Kensington. The doctor is specially experienced in mental deficiency as well as in infant welfare, and mothers attend with their children for advice, information and help in their special problems. The number of applications from mothers for appointments at this session shows that it is fulfilling a real need. Day nurseries Endge House day nursery, Fulham, was only in partial occupation during the first half of the year owing to extensive repairs on acquisition of the premises and the measures which had to be taken to eliminate dry rot. Reference is made on page 53 to the closure of the St. James day nursery, Fulham ; fortunately the work at Eridge House was completed about this time and many of the children could be transferred, the remainder being accommodated at other nurseries in the area. In order to provide more nursery accommodation in Fulham it was decided that a scheme should be drawn up to bring the upper floor of Grove House day nursery, Fulham, into use for children between two and five years of age. Work to provide the additional sanitary accommodation which will be necessary is to be undertaken in 1955. It was learned with great regret that St. Charles day nursery, Kensington, would have to be closed early in 1955 and that it could not be replaced. To offset this loss to some extent, it was decided that the annexe at Kensal House day nursery, Kensington, should be reopened. This will provide accommodation for about six babies and ten children between one and two years of age but considerable adaptations and improvements will be necessary and a scheme to be carried out as early as possible in 1955, was prepared during the year. Arrangements have also been made to accommodate, so far as space permits, some Kensington children in neighbouring nurseries in Paddington (Division 2). There has been a marked change in the demand for nursery accommodation, that for babies having increased while there have been vacancies for older children. At the end of the year about 25 per cent, of the available accommodation was occupied by children of families in the third priority group whose income exceeds -£9 a week, but in no case has this resulted in the exclusion of children in the higher priorities. School health To increase the facilities for dental treatment of school children at the Hammersmith centre, the rheumatism, vision, orthoptic and ear, nose and throat sessions were transferred to the Milson Road welfare centre, Hammersmith. Dental treatment The two dental surgeries at St. Dunstan's Road centre, Fulham, are now working full-time. The adaptation of the Westbourne Grove centre, Kensington, as a dental surgery was completed, but it could not be brought into use owing to lack of dental staff. 126 For the first time in London a scheme was introduced for inoculating with B.C.G. all children in secondary schools in the division in the year preceding their 14th birthday. The arrangements for the testing and inoculation of the children ran very smoothly thanks to the co-operation of the teachers and parents. Consents for the test were given for about 75 per cent, of the children and of those approximately 84 per cent, were found to give a negative reaction to the test and were given an iniection of B.C.G. vaccine. B.C.G. vaccination against tuberculosis The adaptation of Hurlingham Lodge hostel for tuberculous men to allow full occupation was completed and the number of beds was increased from 12 to 28, including two in garden chalets. The hostel is in a charming setting with a large garden overlooking Hurlingham sports grounds and provides excellent living accommodation for men with chronic active pulmonary tuberculosis. It continued to attract a large number of doctors, students and other visitors from this country and overseas. Hurlingham Lodge Hostel 1 for ; tuberculous men I he root clinics continued to provide a very valuable and popular service. I he arrangements for staffing the one at the Raymede centre, North Kensington, by chiropodists and students from the Chelsea School of Chiropody had to be discontinued owing to shortage of students, and two whole-time chiropodists were appointed by the Council. Foot clinics The expansion of the home help service continued and, despite the difficulties of recruiting sufficient staff, all essential demands were met. Two families were provided with child helps during the year. In both cases a suitable home help was willing to live with the fatherless family for a short period while the mother was in hospital. Home help service Child helps Six persons were supplied with night help for two nights a week for periods of one to six weeks to give some relief to relatives during the illness of old people. The number of home nursing visits continued to increase and there is no doubt that the magnificent work of the district nurses enabled many patients to be nursed at home instead of in hosoital. Night attendance on the chronic sick Home nursing Much time and thought have been given to means of ensuring the closest co-operation between various field workers in this and other departments of the Council and other authorities and voluntary agencies in measures for preventing the ill-treatment and neglect of children and juvenile delinquency. I should like to pay a tribute to the tact, zeal and good judgment of the health visitors in dealing with these very difficult cases. In the report for 1952 reference was made to the general conference which was attended by representatives of various departments of the Council concerned with these questions together with representatives of borough housing departments, the police, the probation service, the hospitals, family doctors and some 25 voluntary organisations. This conference has met each year and in 1954 discussed problems connected with housing. The Standing Committee, consisting of principal officers of the Council in the division (with power to co-opt members of other social agencies as necessary) which was then set up has met from time to time and has proved a useful supplement to the close and all-important collaboration which already existed among the numerous workers in the field. Meanwhile, efforts are being made by all concerned to utilize the available services to the full in order to avoid the breaking up of families which so often provides the background of the delinquent child. Ill-treatment and neglect of children and juvenile delinquency Attention was also directed to the question whether juvenile maladjustment and delinquency could not be controlled if greater attention were given to the mental and emotional health of the child at the Council's welfare centres and school inspections. At the request of the Divisional Health Committee I prepared a report on the subject which shows that the doctors are aware of the problem and are dealing with it constructively but that the problem is not only a medical one. It is in many cases associated with family difficulties, the solution of which lies in the endeavours of all people in touch with the family to bring the whole family as a unit back into community life. As the physical health of children improves, the question of mental health comes more into prominence and it is hoped that there will be increasing opportunities for developing this aspect of the welfare centre doctors' and health visitors' work in the future. 127 j Mental health in the child Prevention of accidents in the home To ensure that there was unison in the division in efforts to educate the public on the need for precautions to be taken for the prevention of accidents in the home, a conference was arranged between representatives of the various statutory and voluntary organisations concerned, including the borough medical officers of health, the Divisional Officer (Education) members of the British Red Cross Society, Women's Voluntary Services, Old People's Welfare Associations, health visitors, home help organisers and senior divisional staff. In addition to propaganda in connection with the Home Safety Week arranged by the Council in December exhibits were on show at the divisional health exhibition and at clinics at various times throughout the year. In addition posters were displayed and pamphlets were distributed at clinics and offices. Welfare foods The distribution of welfare foods was taken over from the Ministry of Food in July and the transfer operated without difficulty. Welfare foods were already being distributed by the divisional staff at a number of welfare clinics and care was taken to arrange the new scheme in such a way as to maintain a service no less convenient to the public than that previously provided jointly by the Council and the Ministry of Food. With one exception the service is now concentrated in establishments associated with other maternity and child welfare services and, apart from the manifest advantage and convenience of this association to the mothers, the changes enabled some administrative economies to be effected. Co-operation with general practitioners I have kept in close touch with the secretaries of the local divisions of the British Medical Association and the local representatives of the Local Medical Committee with i view to further strengthening and improving the relationship and co-operation between :he general practitioner and health visitor. Any request from a general practitioner for :he help of a health visitor for one of his patients has immediate attention and personal :ontacts between health visitors and local doctors are encouraged. In conclusion I must give my very sincere thanks to the Chairman and members of :he Divisional Health Committee for their constant support and interest. I should also ike to acknowledge with gratitude the co-operation of the medical officers of health }f the four Metropolitan Boroughs, of the staff of all other departments of the Council ind the members and staff of the many voluntary committees and associations in the division. Finally it is a pleasure to pay a tribute to the loyal and able help of all my :olleagues on the divisional staff. The year closed with the retirement of the Divisional Administrative Officer, Mr. LWelsh, and I should like to place on record my sincere appreciation of his outstanding ibility, energy and wisdom which contributed so much to building up the divisional Drganisation and service since its inception in July 1948. Division 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and Westminster. Dr. H. L. Oldershaw reports : Day nurseries and child-minders I here was very little change in the number ot children in the nurseries during the year and the occupation during the last quarter was 88 per cent, compared with 86 per cent, in 1953. About one-third of the children were in each of the first, second and third priority groups, and the waiting list at the end of the year for all groups was 107, as against 70 at the end of 1953. The number of statutorily and voluntarily registered child-minders at the end of the year was 171, compared with 186 at the end of 1953. School medical treatment Most of the school medical treatments advised were given with little delay. There has been a long waiting list for vision cases at the Westminster school treatment centre, but authority was given for an extra session to be held. The transfer of the rheumatism supervisory clinic from St. Georges Hospital to Victoria Hospital for Children took place very smoothly in October, and the new arrangements are proving satisfactory. A special investigation clinic was opened in Marylebone in April and the attendances remained at a satisfactory level. An increasing number of enquiries were dealt with each week by the Organiser who attended the audiology unit at Grays Inn Road. 128 Continued emphasis was given to the importance of vaccination and immunisation. During the year 4,741 children were vaccinated against small-pox ; 7,531 children completed a primary course of diphtheria immunisation and 7,056 children received re-inforcing injections ; in addition 4,408 children were immunised against whooping cough. Vaccination and immunisation Throughout the year particular attention was given to problem families. Coordination of this work was achieved by means of frequent informal conferences convened by medical officers and health visitors at welfare centres. The unfailing co-operation with officers of the Council of all welfare workers and representatives of organisations concerned with this aspect of the work was of inestimable value in helping to alleviate difficulties encountered and to improve the state of many families. By the end of the year the index register contained information of over 100 families who were receiving careful supervision and help. In three instances during 1954, in which it was considered that a period of training would be beneficial, arrangements were made for mothers, accompanied by their children, to be sent to a rehabilitation centre. Problem . families Commencing on 5th February, 1954, a monthly session was held at Barnes House welfare centre, St. Pancras, to which parents of any mentally-backward children under five years of age, known to the medical or health visiting staff in the division, and who were not attending a hospital for the treatment of their special defect, were invited to bring their children to discuss their difficulties and to be given advice and practical help by the medical officer in charge. Attendances were good and the clinic has proved most successful. Special advisory clinic for backward children ocuciany, uic nuiiiuci ui iiumc ncips cnipiuycu. was sumciciic tu meet rcasunauic demands made on health grounds. The great majority of those assisted were the chronic sick, including aged and infirm. The use made of the special services attached to the home help service was limited, although 96 hours of night help and early morning and evening service were provided in 20 households. Home help : service Weekly foot clinic sessions were held at four welfare centres and, in Hampstead, Paddington and St. Marylebone, the local old people's welfare committees continued to provide chiropody facilities for aged folk in Council premises. Foot clinics Group teaching has always been a feature or the health visitors work and is still developing, as shown by the following activities. Health education (a) Film strip projectors were used at a number of centres and loaned to district nursing associations ; sound films have been used at one or two centres. (b) Portable exhibits on various topics were circulated to all maternity and child welfare centres. (c) All centres have had an initial supply of equipment for teaching purposes, and it is hoped that further supplies will be available in 1955. Posters, leaflets and booklets on health topics were distributed to all centres and schools. (d) Mothercraft talks took place at seven centres and demonstrations of gas and air analgesia were given by a local midwife. (e) Special demonstrations on cooking and sewing were given at eleven centres. Eight health visitors have taken a recognised course in parent-craft teaching and several members of the staff compose and paint their own posters. Frequent renewal of displays on topical subjects, such as, ' Accidents in the Home ' is effected. A fathers' club, recently started at one centre (University College Hospital), is flourishing, with 20-24 attendances and two or three mothers' clubs have entertained speakers on varying subjects. There are 12 schools where either a health visitor or school nursing sister is teaching mothercraft and it is hoped that this number will increase in 1955. Special meetings were held with the general practitioners working in the division sc that they could have an opportunity of meeting, personally and informally, the council'! medical officers and health visitors. Separate meetings were held for each of the five divisions of the British Medical Association operating in division 2. 129 Co-operation with general practitioners Conclusion I would again like to 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 One of the six whole-time medical officers formerly employed in the division left the Council's service during 1954. This officer was not replaced, the opportunity being taken to bring in more general medical practitioners as part-time officers, thus maintaining the service to the public and increasing liaison with the general medical services at the same time. All five whole-time medical officers are doing combined maternity and child welfare and school work. Four whole-time and three part-time medical officers are also approved for the ascertainment of educationally sub-normal children. Co-operation with hospitals and general practitioners Interchange between the Council's medical officers and medical staff of the Hospital for Sick Children, Great Ormond Street, continued with mutual benefit. Throughout the year the special arrangements whereby this hospital sends reports on children discharged from the hospital have continued, and there have also been some reports from the Queen Elizabeth Hospital for Children, Hackney, and other hospitals. All cases have been followed up by health visitors or school nursing sisters. Reports have been supplied to hospitals on request covering both the home conditions of patients whom it was proposed to discharge and the physical condition of patients after their return home from hospital. Where housing conditions were poor, action was taken to remedy defects or, in particularly bad cases, to assess medical priority for rehousing. Regular meetings have been held with hospital almoners to improve co-ordination, and I have continued to be a member of the Central Group Hospital Management Committee of the North East Metropolitan Regional Hospital Board. I was invited to serve on the National Health Service Liaison Committee for the North Central Area of London, and acted as Convenor and Chairman of the Paediatric Working Party set up by that Committee. Very useful discussions were held and the Working Party produced a report with recommendations which it is hoped will form the basis of even closer co-operation between local health authorities (London and Middlesex), hospitals and general medical practitioners. A further measure of cooperation effected during the year was the introduction of the health visiting service to the general medical practitioners in the division, which was done by means of a personal letter suggesting possible ways of getting together and urging the doctors to estabhsh personal contact with the centre superintendents and the health visitors covering their areas of practice. The introduction by the General Nursing Council of the revised syllabus of training for hospital student nurses has been the means of securing even closer co-ordination with the hospital services. During the year 558 student nurses from nine hospitals were introduced to the work of the local health authority, and lectures were given and discussions attended bv the divisional nursing officer and her staff. Problem families Charles Booth's 'Submerged Tenth' smote the consciences of our forbears: we have now to do equally intensive and vital rehabilitation work for families fewer in numbers—about 2 per cent, of the population in a recent check in the north—but certainly beset by no less serious problems and constituting just as great a menace to themselves, to their neighbours and to the nation. We in the mid-twentieth century have dubbed them 'problem families,' and the whole of our work for them is aimed at making them independent, responsible members of the community. They are generally characterised by lackadaisical disorder, squalor, absence of elementary hygiene, and bad household management, and against each and every one of these enemies we must give battle. Oddly enough, many of these families lead—according to their lights—happy family lives, and overt ill-treatment of children is but rarely met. Frequent divisional conferences are held—usually monthly—to determine the best ways of helping problem families and preventing the degeneration of potential problem families. The conferences are attended by statutory and voluntary workers, and their 130 membership was extended during the year by the inclusion of a Free Church minister. Of the 206 families known, 44 were found in 1954 to present particularly intractable problems and intensive case work for these families was undertaken. The method has been to decide which of the field workers concerned could best act as co-ordinator of services for the particular family, so as to establish the necessary personal, friendly relationship and avoid multiplicity of visiting, and then to consider periodical reports from the worker selected. Any of the Council's services may be called in to keep the family going—day nurseries to care for the children and relieve a worried mother ; recuperative holidays where there has been a breakdown in health ; home nursing for sick members of the family ; home helps to cope with the household chores. Every endeavour is made to ensure that the family have regular meals, that they receive adequate medical attention and that their housing is brought up to a reasonable standard, and the borough medical officers of health are most co-operative in requesting sanitary inspectors, at short notice, to deal with defects, etc. within their province. The increasingly intensive case-work has made big demands, particularly on the time of the health visitors, and the Islington Family Service Unit had to take on a second field worker. The care of old people formed a particular feature of the work of the division during the year. Of the 2,599 households provided with home help, no less than 1,850 were for chronic sick, aged and infirm people, an increase of 13-6 per cent, over the figure for 1953 (1,628 out of 2,452) and more home helps had to be employed. Care of the aged root ciimc attendances, over ou per cent, or wnicn were estimated to oe oy aged persons, again rose, from 23,054 in 1953 to 25,264 in 1954, and arrangements have been made through the North London District Nursing Association for the existing domiciliary chiropody service, financed from voluntary funds, to be made available at a nominal charge to home-bound old people recommended by the health visitors. Close touch has been maintained with the Medical Officer of Health for Islington about his Council's new scheme for a laundry service for chronic sick old people, which will be an inestimable advantage to them, and cases have been recommended to him. In association with the health visitors and home help organisers I have reviewed the question of provision of meals by the Invalid Kitchens of London and have recommended a number of extra persons for this service now that some expansion is contemplated. Old people continue to form a large proportion of the cases on the books of the district nursing associations, and there has been a marked increase in the amount of home nursing equipment (particularly commodes) lent to these old people. Of the 956 persons who were provided with recuperative holidays during the year (itself an increase of 14-8 per cent, over the 1953 figure of 833), 386 were adults (other than expectant and nursing mothers and mothers with young children) and 75 were over 70 years of age. «^ne or tne 10 wenare centres in operation at tne Degmmng or tne year naa to be vacated at the end of March. Additional sessions were arranged at a nearby centre so that the public should not be deprived of the services, and a diligent search for new premises has been made—so far without success. Many of the services in the other centres such as special toddlers' clinics, were expanded during the year. First attendances of children under a year old (4,331) represented 90 per cent, of the live births for the year. With the transfer to the Council on 1st April of the work of the former Maternity Nursing Association, additional combined doctors' and midwives' ante-natal clinics were established at three of the welfare centres. The additional clinics gave an opportunity to introduce into the service the general practitioner obstetricians who would be called in by the midwives to give medical aid if required. These doctors had no previous experience of working in welfare centres and thus another link was forged with the general medical services. Living accommodation for three midwives and six pupils was provided in the staff hostel forming part of a day nursery and two more midwives with pupils were housed in adapted rooms over another day nursery. The two family planning clinics continued to function satisfactorily and 275 women were referred there for advice during the year. Fewer dentures were provided this year for expectant and 131 Care or mothers and young children nursing mothers (44 as against 52 for 1953), but as the facilities seem to be less well known among the population than could be desired, everything possible is being done to publicise them. I Physiotherapy Physiotherapy work has been cxtended and the equipment at tne Council's centres improved. However, despite an increased number of sessions in 1954 compared with previous years, total attendances of children fell from 11,742 in 1953 to 8,159 in 1954. Against this must be set the welcome increase in attendances at ante-natal classes for relaxation exercises, etc. Attendances numbered 2,014 in 1954 compared with 1,107 in 1953. Child guidance There were fewer attendances at the child guidance clinic for the under-fives at John Street welfare centre—243 against 292 the year before. Joint use has, however, been made with division 2 of a new special unit at Barnes House welfare centre, Camden Town, where parents can be advised on the handling of difficult children, and seven cases were referred there during 1954. Welfare foods When the local rood Unices were closed at the end ot June, arrangements were made for orange juice, cod liver oil, vitamin tablets and national dried milk to be distributed from the welfare centres, including the two voluntary ones. Minor alterations had to be made in a few centres, but on the whole the transfer of functions was effected very smoothly. There had of necessity to be some small reduction in the hours at which foods were sold, but as the number of distribution points was trebled, the public suffered no inconvenience. Quantities distributed were about the same as before the changeover but the diversion of purchasers from Food Offices to welfare centres has not resulted in any marked increase in attendances at the welfare centres for advice. Day nurseries ine mne day nurseries operated tnrougnout 1 ine numoer or nrst and second priority cases awaiting admission at 31st December was 18. There is one private day nursery in the division registered under the Nurseries and Child Minders Regulation Act, 1948, and one voluntary day nursery which is grant-aided by the Council. There was a marked increase during the year in the number of child-minders approved under the Council's scheme for the care of less than three young children, the figures being 150 at the end of 1954 as against 115 for 1953. It is not certain how far this may be due to increased day nursery fees, but it cannot be purely coincidental. The number of unregistered child-minders is not accurately known. Vaccination and immunisation I he division s mobile clinic, towed by a loudspeaker van, was again in use during 1954, when efforts to improve the immunity of the child population against diphtheria were continued at high pressure. Primary courses of immunisation were completed for 3,432 children, representing 71 -3 per cent, of the live births. Boosting doses were given to 3,843 schoolchildren to reinforce their primary immunisation. This figure compares with 1,939 for 1953, showing a gratifying increase of nearly 100 per cent. Sessions for schoolchildren were arranged on Saturday mornings and during school holidays thus avoiding interruption of school work and were well attended, 3,343 children had complete courses of immunisation against whooping cough, a further increase on previous years (2,380 in 1953). 2,894 primary vaccinations and 2,742 re-vaccinations were completed, the latter figure including 2,377 schoolchildren. These figures were the highest ever recorded in the division, and compare with 2,685 primary vaccinations and 1,332 re-vaccinations (including 982 schoolchildren) in 1953. One adult case of diphtheria occurred during the year. The incidence of poliomyelitis was so slight as to make unnecessary any precautionary cessation of prophylactic work. School health service Three new (rebuilt) schools have been re-opened in the division, involving the usual medical services. Over 80 per cent, of the health visitors are now doing combined maternity and child welfare and school work. In one school a teacher was found to be suffering from pulmonary tuberculosis. The children were X-rayed and no abnormalities were found. Vision clinics have presented no untoward problems. In addition to the facilities provided at the treatment centres, large numbers of children were dealt with at Moorfields Eye Hospital. Essential dental work was being coped with satisfactorily until the end of 132 the year, when two dentists left the service. This affected the northern part of the division. The mobile dental unit was in service from May to November and was very useful in the Finsbury Park area. Special investigation clinics which were held in two treatment centres functioned very satisfactorily and met a great need, especially for enuretics. The results of these cases are more and more encouraging. Chronic discharging ears, such a feature of schoolchildren before the war, seem almost to have disappeared as a problem. This welcome improvement is probably due largely to the early treatment by antibiotics which can now be given, coupled with generally improved living standards. The number of verminous schoolchildren has continued its steady decline. 2,895 were found to be verminous in 1954, the figures for the four years preceding being 3,561 (1953) ; 4,477 (1952) ; 5,107 (1951) ; 8,318 (1950). The Islington cleansing station closed for a short time during the year for renewal of boilers and arrangements for the cleansing of children were made at the Finsbury, Stoke Newington and St. Pancras cleansing stations, with the willing co-operation of the borough medical officers of health concerned. There were at the end of the year 522 children in the various schools for the handicapped, and there was no waiting list. The provision of a day open-air school in the division, when practicable, will be advantageous in reducing travelling time for the children needing a spell at this type of school. Tuberculosis Tne mass radiography unit of the North West Metropolitan Regional Hospital 1 Board, situated in the Council's premises at 32 Drayton Park, was used throughout the year for routine examination of the Council's staff, including teachers. The unit also participated in the completion of the special tuberculin survey of Islington schoolchildren, the results of which were being investigated at the end of the year. In all, 5,075 children of school age living in Islington were given skin tests, 615 being positive reactors. 4,138 of the children attended the mass X-ray unit for chest X-ray. The hostel for tuberculous men at Highbury Quadrant was closed at the end of September and the residents transferred to new premises at Cromwell Lodge, Cholmeley Park, Highgate, in the borough of Hornsey. Various works of adaptation and improvement were in progress at the end of the year, but notwithstanding the inconvenience caused by the constant presence of the workmen, the residents quickly settled down in their new surroundings. Frequent visits were paid to the hostel by members of the Divisional Health Committee ; complaints were dealt with and suggestions for improvement considered and, where practicable, acted upon. The hostel has been fully occupied. During the year the scale of extra nourishment which chest physicians could recommend for supply to tuberculous persons was increased to a maximum of 14 pints of milk, J lb. butter and 7 eggs weekly. Recuperative holidays were provided for 61 tuberculous persons, slightly fewer than in 1953. In July the North West Metropolitan Regional Hospital Board opened a new chest clinic in the grounds of St. Mary's Wing of the Whittington Hospital, the Council accepting responsibility for furnishing the offices for a superintendent, the health visitors and the care organiser and her staff. The new clinic replaced two smaller clinics in the City of London Chest Hospital and the Royal Northern Hospital respectively. The Council was invited to participate in a Health Exhibition organised by the Islington Borough Council, which was held between 4th and 9th October in the Islington Town Hall. Despite bad weather, a total of some 5,000 persons attended during the week. The Council's contribution included stands devoted to maternity and child welfare and day nurseries ; the school health service ; the work of the health visitors ; and services in the home, including home nursing, midwifery, and the home help service. Diphtheria immunisation and audiometric sessions for schoolchildren were held each day both forming 'live' exhibitions of the Council's health services. Thanks to the co-operation of the School Meals and Catering Department and the Divisional Education Officer and teachers, typical school meals, specimens of the work of handicapped children and posters designed and produced by pupils were included. The Health education 133 divisional staff designed the settings and made posters and special exhibits such as a layette, toys, etc. Professional staff were on duty until 9 p.m. to give interested visitors an account of the local health authority services. Special educational sessions held at the welfare centres totalled 757 and the attendances 6,640, both figures being a considerable advance on any previous year. Activities directed by health visitors included individual talks and discussion groups, cookery demonstrations and sewing classes, film shows, etc. Kindred activities were organised by parents' clubs attached to some of the centres, which received every encouragement. Posters and leaflets on seasonal topics, changed at monthly intervals, were displayed at all divisional establishments, at Town Halls (by permission of the Borough Councils) and, in some instances (e.g., vaccination and immunisation propaganda) in doctors' surgeries. Articles on health subjects were written by the divisional staff and published in the Islington Public Libraries Bulletin. The three Borough Councils agreed to stock, in the public libraries, books recommended as being valuable for expectant mothers and mothers of young children, and a list of the books, with library reference numbers, was posted in each welfare centre. Following lectures on the value of milk and the importance of food hygiene given by sanitary inspectors (by permission of the borough medical officers of health) to children in 16 of the senior schools, five of the head teachers were able to arrange for pupils to visit large dairy depots. The visits were reported to have been both instructive and beneficial. The aim will be to repeat the lecture and visiting programme annually, so that the propaganda may reach successive batches of children. Conclusion At me end of the year, owing to i11-healtn, the services of Mr. Laurence wilKes, who had been divisional administrative officer since the inception of the division and had built up and co-ordinated its administrative organisation were lost to the department. I should like here to pay tribute to his qualities of judgment, good humour and commonsense, which were of inestimable advantage to his colleagues. Relations with voluntary and statutory organisations and their officers continued to be most cordial and I am grateful to them, to the Divisional Health Committee, and to the divisional staff, for their courtesy, hard work and loyal co-operation. Division 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports : Woodberry Down Health Centre During the year many services were extended at the Woodberry Down Health Centre by additional sessions, while the following new services were commenced: speech therapy, psychiatric community care and civil defence ambulance section training. By the end of the year facilities were provided for 139 local health authority sessions in all. The estimated weekly average number of persons attending these sessions at die centre in January was 784 ; this had increased to 1,339 at the end of the year. The centre continued to enjoy considerable publicity and some 2,130 visitors were conducted round the premises. It is worthy of note that no less than 1,502 of these visitors were either trainee or post-graduate students in the professions concerned with public health. They included doctors, nursery and hospital nurses, health visitors, midwives, psychiatric and other social workers, social science students and teachers. The considerable number of visitors from the dominions, colonies and foreign countries who have continued to visit the centre has included a large number of medical officers concerned with public health services. The six general medical practitioners who commenced to practise at the centre in July, 1953, continued to do so and have achieved a large measure of co-operation. Their surgery sessions have been slightly increased to 55 a week, and through the Medical Staff Committee, they have made representations for the provision of technical assistance in the clinical side room on the premises and for the provision of physiotherapy facilities. 134 The school minor ailment clinic has been combined, with advantage to both services, with the nursing treatment provided on each week day for such of the general practitioners' patients who need it. The Dental Surgeon who conducts the general dental service has continued to be fully employed for 11 sessions a week and has made representations, which have been supported by the Council and were still under consideration at the end of the year, for the appointment of a second Dental Surgeon. Facilities at the centre have continued to be used for the training of the Council's medical and nursing staff and health visitors. The National Blood Transfusion Service held two blood donor sessions at the centre during the year and a voluntary association was allowed to use accommodation once a month for the meetings of a club for diabetics resident in the division. Arrangements were made under which, as from 1st January, 1954, expectant mothers attending for the first time at the Council's ante-natal clinics in the division were referred for X-ray examination of the chest by mass radiography. An additional ante-natal session was commenced at the welfare centre, 28 Lower Clapton Road ; a weekly family planning session conducted by the Council's own medical officer was inaugurated at the Richmond Road welfare centre and a Saturday morning diphtheria immunisation session was started at the Hoxton school treatment centre. I Maternity and child ' welfare There were 8,164 ante-natal and 386 post-natal attendances at divisional clinics. 3,487 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 during the year which was the same proportion as in the previous year. The demand for day nursery accommodation continued to wane and at most nurseries there were some vacant places at the end of the year. In consequence of the smaller demand, the approved accommodation for children at the Fernbank and Hillside day nurseries was reduced and the Sylvester Path day nursery was closed. The total number of child-places was thereby reduced from 666 to 603. Day nurseries and child-minders Six private day nurseries registered under the Nurseries and Child-Minders Regulation Act, 1948, provided accommodation for 202 children and there were three statutorily registered child-minders approved for the care of 11 children. At the end of the year there were 70 approved daily minders. The following comparison of educational sessions and attendances shows the good results obtained during the year. 1 Health education sessions Attendances 1952 210 2,172 1953 288 5,421 1954 414 6,494 The advertising of health education subjects in the centres and day nurseries has been greatly facilitated by the provision of many additional display boards. Further equipment was provided for making-up into exhibits. The divisional establishments all participated in the county-wide campaign in December concerning the prevention of accidents in the home. A total of 985 holidays were provided, including 400 for schoolchildren and 139 Recuperative for children under school age. holidays This service was developed as far as financial resources would permit. The following Home help figures illustrate progress during the year : service 1952 1953 1954 (i) Total cases given help 2,928 3,293 3,645 (ii) No. of home helps employed on 1st January (whole-time equivalent) 178 191 220 (iii) No. of home helps employed on 31st December (whole-time equivalent) 191 220 249 135 The Hackney Borough Council kindly agreed that its laundry facilities for incontinent persons should be extended to cases coming to the notice of home help organisers. Problem families and help for children A standing Committee, consisting ot omcers ot ail departments ot the Council concerned, representatives of the N.S.P.C.C., and other voluntary agencies met regularly to consider assistance for problem families in the division. All possible action was taken through the personal health services to avoid the necessity for children being taken into care. In cases where, for example, mothers went into hospital or to prison, or where desertion or matrimonial discord occurred the children were looked after through the home help service, child-minders, or foster mothers or were admitted to day nurseries. One problem family was assisted by sending the mother and some of her children to a rehabilitation centre for a lengthy period of training. Premises and minor improvements The use of the Homerton store of the Hackney Metropolitan Borough Council was discontinued and a saving was made by the use of vacant accommodation at the Sun Babies day nursery as a divisional store and workshop for handymen. Various minor improvements to premises were made or commenced during the year, such as the acquisition of a strip of land adjoining, and the widening of, the side entrance at the welfare centre at 186 Upper Clapton Road, and improvements to heating arrangements and the layout of grounds at day nurseries. Conclusion 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 co-operation of the borough medical officers of health and of the good work of the entire divisional staff. Division 5, comprising the boroughs of Bethnal Green, Poplar, Stepney and the City of London. Dr. G. O. Mitchell reports: Premises Reference is made on page 54 to the adaptation of two ground floor flats in Newmill House, Bromley-by-Bow. This new maternity and child welfare centre came into use on 3rd May and replaced the clinics held hitherto in the St. Michael's and All Hallows Church halls. The new centre is excellent in every way and has four health visitors. It is a notable addition to the maternity and child welfare facilities in this part of Poplar. Early in 1953 the Council adopted a report for the adaptation of the derelict first floor of the Mary Hughes building in Underwood Road, Whitechapel, as an infant welfare centre in co-operation with the London Hospital. The work was completed during the summer of 1954 (see page 54) and the first clinics were held there in June. This new centre which is already flourishing, is an interesting experiment in liaison with a teaching hospital, the chief feature being the teaching of medical students in a local health authority clinic by a paediatrician from the London Hospital. The opportunities thus afforded for medical students to see something of normal babies and children and to have the health visitors at hand with their intimate knowledge of the families and home conditions, are most valuable. In conjunction with the opening of this centre, the Ashfield Street clinic ceased and was transferred to the new centre. During the latter part of the year good progress was made in the construction of a new maternity and child welfare centre adjacent to Bethnal Green Town Hall to replace the present centre in Cornwall Avenue. Day nurseries since tne extension to tne university fiouse day nursery, wnicn was reterred to m the 1953 Report, it has provided ideal facilities for training purposes; this nursery has accordingly been designated a training nursery. During the year Miss Reilly, matron of the St. Paul's (Voluntary) day nursery, Wellclose Square, resigned after many years of devoted and self-sacrificing service to the children in her charge. Owing to the relatively few numbers of children then attending, the voluntary committee decided to close the nursery. The children thus displaced were accommodated in other Stepney nurseries. 136 With the closing of the local offices of the Ministry of Food, responsibility for the distribution of welfare foods passed to Local Health Authorities on 28th June. A scheme was drawn up for the distribution of these foods at all infant welfare and toddlers' sessions in this division and at a few other places which the anticipated public demand seemed to justify. The changeover worked quite smoothly and only minor variations in ooening hours were subseauentlv made. Welfare foods All clinic sessions are reviewed periodically, and alterations in their frequency and duration are made as circumstances demand. Several such adjustments were made during the year, and in this connection I regret to record that it was found necessary to reduce the weekly immunisation and vaccination session at the Wellington Way centre from a ' long ' to a ' short' session. Despite the constant efforts of the health visitors, the number of infants vaccinated in this division continues to be lower than that in any other. Sessions In April the first relaxation classes for expectant mothers in this Division were started at the Cornwall Avenue centre with the co-operation of the staff of the Maternity Department of Bethnal Green Hospital, and are continuing most successfully, thanks to the enthusiasm of the health visitor concerned. The improvement in the priority dental services which was welcomed last year has, unfortunately, failed to continue, and during 1954 the total weekly dental sessions were reduced by nine. Dental service A further expansion was noted in the child-minder service, there being 128 voluntarily registered minders caring for 89 children at the end of the year as compared with 108 minders with 83 children at its commencement. These child-minders were under constant supervision by the health visitors and attended the clinics regularly with the children in their care. Child-minders The demand for the services of home helps steadily increased and the constant endeavour was to expand the service sufficiently to meet the demand. During the year the households attended in this division, per thousand of the population, again exceeded the London average. riome helps The calls on the district nursing associations continued to be heavy, and during thi year the number of visits per nurse was again higher than in any other division. ; District nurses A good deal of work was done by the health visitors during the year in health education, both in the clinics and in the homes. I hope for an expansion of this very useful contribution to preventive medicine. In addition to their other routine duties, the extensive and painstaking case-work which they continue to do in connection with the problem families, deserves mention. Health visitors Division 6, comprising the boroughs of Deptford, Greenwich and Woolwich. Dr. F. R. Waldron reports : Special investigation clinics, at which more thorough examination and guidance is given to children referred from infant welfare centres and school medical examinations, were held at the principal centres in Deptford, Eltham, Greenwich and Woolwich. Special investigation clinics The revised syllabus of training for nurses, which requires training to be given in the social aspects of disease and personal and communal health, was implemented by granting facihties for field experience and visits of observation to student nurses from hospitals in the division. Lectures were given periodically at these hospitals by divisional medical and nursing officers. Student nurses' training The closest link between hospital staff, general practitioners, voluntary workers officers of other departments and the school health service continued with resultam benefit to all concerned. The Kidbrooke school (accommodation for 2,210 girls) openec in October. Medical inspection, minor ailments, dental and vision sessions were held ir the school's suite of medical rooms. School health service Speech therapy classes for an increasing number of children were held at nine centres 2,519 children were treated during the year at cleansing stations, compared witl 2.297 in 1953. Speech therapy Bathing and cleansing 137 Day nurseries and child-minders Reference is made on page 53 to the closure of the Evelyn Street day nursery, the site and building of which passed to the Parks Department on 1st April, 1954. It was found practicable to transfer all the children to the enlarged Amersham Road day nursery (60 places). The amenities of this nursery were greatly improved by providing excellent playground facilities on an adjoining piece of land. There were 83 statutorily and voluntarily registered child-minders at 31st December, 1954, as compared with 69 at 31st December, 1953. Foot clinics Attendances at foot clinics totalled 73,732 and the number of treatments given to schoolchildren and the aged continued to rise. Home help service The number of separate households attended by home helps was 3,295, compared with 3,197 in 1953. Households attended at 31st December, 1954, were 1,989, compared with 1,820 on the same date in 1953, and 1,665 in 1952. This service is much appreciated by an ever-increasing number of aged persons of both sexes. Health visitors at hospital clinics Continuing the policy of fostering co-operation with local hospitals, health visitors attended out-patient paediatric, asthma and diabetic clinics on a rota system, at three local hospitals. This action has been most effective in developing and increasing the good relationship between Council officers, members of the hospital staff, general practitioners, and other interested parties. It is hoped that these arrangements will be continued and developed. B.C.G. vaccination The Council s central team or medical start began visiting schools in the division in December, to carry out where appropriate, B.C.G. vaccination of children in the year preceding their 14th birthday. The response has been very good. Ante-natal exercise and mothercraft classes were held weekly at nine centres. Health education X-ray of expectant mothers Routine chest X-rays were arranged for 1,032 expectant mothers during the year. Of these 44 were abnormal and further investigations were needed. District nursing associations The Charlton and Blackheath District Nursing Association, the Nursing Sisters of St. John the Divine, the Ranyard Nurses, the Silvertown and North Woolwich District Nursing Association, and the Woolwich and Plumstead District Nursing Association, rendered most valuable and co-operative service. Prophylaxis rvaaiuonai sessions ior propnyiaxis were mauc avanauic uuimg uic ycai anu 11 ib hoped that these increased facilities will encourage parents to have their children immunised. Apart from the immunisation sessions held at the schools in the division, full or part-time sessions were held weekly at 14 centres. 4,456 children (0-15 years) received a primary course of immunisation and 3,076 reinforcing injections during 1954, and these figures compared very favourably with 3,263 and 1,928 respectively for the vear 1953, which were on the low side because of the outbreak of Poliomyelitis. Cerebral palsy investigatior Dr. Dunham of the Department of Physical Medicine, Charing Cross Hospital, extended his survey into the early detection of infantile cerebral palsy among selected babies at special sessions at certain maternity and child welfare centres in the division. The survey is continuing and it is hoped that considerable interest will be fostered and benefit derived. Mentally backward children In co-operation with the local Mental Welfare Organiser clinics tor mentally backward children under five years of age were held experimentally at one centre. Mothers were given advice and special help with welfare problems. Tne scheme proved worth while and sessions were arranged at an additional centre so that the travelling of parents and children could be reduced to a minimum. Mothercraft— rehabilitation of mothers Two mothers, both with complicated family problems, were sent, together with certain of their children, to Spofforth Hall Recuperative Centre. The break-up of the home was prevented in each case, and it is hoped that the improvements in the homes and in the general demeanour of the famihes already noted, will be maintained and strengthened. Distribution of national welfare foods The distribution of national welfare foods was taken over from the Ministry of Food in June, 1954, and a total of 104 sessions weekly were held at 28 centres throughout the division. 138 Lecture room accommodation was made available at two health centres for the training of civil defence ambulance section volunteers. I acknowledge most sincerely the good work of everyone associated with the health service in the division. Division 7, comprising the boroughs of Camberwell and Lewisham. Dr. H. D. Chalke reports: Civil defencc Space only permits of mention of some of the more important activities. The popularity of the child welfare clinic was undiminished. While the number of children attending however remained high, far too many were brought once or twice only. Enquiry of all mothers attending the centres during one week (1,360)* confirmed the continuing need for making advice, reassurance and guidance available there : these were the main reasons why children (especially first children) were brought. Unfortunately there was a much less appreciation of the desirability for continued attendance when the child appeared to be doing well. Many mothers still disbelieved in supervision of this sort, others said they could not attend because they were at work during the day, though an early evening clinic to cater for these mothers was poorly patronised. It has not yet been possible to improve many of the unsuitable clinic premises in Church Halls. Great importance is attached to the use of voluntary workers at the centres and fortunately they continued to help, although unavoidable circumstances necessitated the resignation of one or two. Emphasis has been laid on the establishment of an easy friendly atmosphere at the clinics. ' Maternity and child welfare centres Evening talKs and film shows were increased tnougn attendances were variable. Special effort was directed towards the instruction of schoolchildren and young persons. The health visitors' duties are widening rapidly, and to accomplish the new tasks with the present staff, a careful selection of work is necessary with elimination of the unessential. . Health education S Health visitors Great strides have been made in tightening the liaison with hospitals and more and more requests are being received for help. Home supervision of asthma and diabetic patients was undertaken for the special departments concerned and also for premature baby units. The health visitors attended hospital social resettlement units and geriatric departments. There was improved collaboration in respect of educational and relaxation sessions for ante-natal women and the hospital almoner and health visitor worked more closely together than ever. 1 Hospitals The new duties of health visitors as members of the domiciliary team are closely bound up with the work of the general practitioner. Every effort is being made to make the health visitor service more available and acceptable to the family doctor. Regular visits by health visitors to doctors' surgeries have been well worth while. The results, though slow in appearing, are encouraging.- General practitioners There was some falling off of attendances in the higher priority groups at da) nurseries but the position in the division now seems to have stabilised itself. Day nurseries The work of preventing mental ill health has been expanding slowly but surely. The divisional family health conferences at which problem families were discussed by representatives of voluntary and statutory organisations continued to be of value. A home making course for inexperienced mothers is about to commence. The day nurseries are playing a necessary part regarding the child with unsatisfactory home conditions or adverse family background. Prevention of mental ill health Routine tuberculin testing of pre-schoolchildren has been extended to school entrants. The results so far suggest that the conversion rate is falling rapidly. Careful search among relatives and neighbours can reveal the infecting source of the positive reactor in a large percentage of cases. Tuberculosis Despite the increase in the number of home helps, the demands were heavy, particularly during the winter months—a time when the sickness rate among the home helps was * Results about to be vublished. Home helps 139 also High. As before, the greatest call on the service was from old persons who continued to present very difficult problems, especially when help was not sought early. The old person living alone, with no relatives in the neighbourhood, who is often not on a doctor's hst and refuses medical attendance presents particular difficulties. Fortunately, it was not found necessary to ask for compulsory removal of an old person, under the provision of Section 47 of the National Assistance Act. Tribute must be paid to the way in which the voluntary agencies co-operated with the divisional and borough staff in helping to solve the many problems that arose. Afternoon courses of instruction for home helps proved well worth while ; they were given short talks by members of the staff and made to realise that they are members of the health team. Conclusion Many thanks are due to my medical and lay colleagues in the area tor their cooperation and to the members of the divisional staff for their loyalty and support. Division 8, comprising the boroughs of Bermondsey, Lambeth and Southwark. Dr. W. H. S. Wallace reports : Day nurseries The demand for day nursery accommodation remained steady and the average daily attendance was well maintained. Good use was made of the nurseries to provide for children whose mothers were ill or in hospital, or during confinement. Children from 187 families in this category were admitted to day nurseries during the year. Extensive renovation was carried out at Tenda Road nursery, where structural failure resulted in the re-roofing of the building being necessary. Unfortunately this necessitated the nursery being closed for nearly three months while the work was in progress. Lady Alexandra Metcalfe, who has a fund at her disposal for the benefit of the children of Lambeth, very kindly offered to effect some improvements at the Cynthia Mosley and Chestnut day nurseries. She kindly provided covered verandahs at both these nurseries, thus giving the children more opportunity to remain in the open air in wet weather and be protected from the sun in hot weather. She has also provided many toys and equipment for all the day nurseries in Lambeth. Our grateful thanks are due to her for the valuable help she has given. Diphtheria immunisation 1 am glad to be able to report an increase in the number ot children immumsed 1 against diphtheria. 5,741 children received a full primary course of immunisation in 1954, compared with 5,106 in 1953. Health visitors Efforts were made to ensure full co-operation between the general practitioners and health visitors. A meeting of the Lambeth and Southwark Branch of the British Medical Association was held during the year to which health visitors were invited, and the integration of the work of the general practitioner with the preventive services was fully discussed. Neglect and ill-treatment of children The work of the Standing Committee on the Neglect and Ill-Treatment of Children has continued throughout the year. The committee was of great value in bringing together the members of all interested sections in this work. In addition to the committee meetings there was full co-operation between field workers of the care committees, health visitors, the N.S.P.C.C. and other voluntary bodies. Day nursery vacancies, home helps, re-housing, have been obtained in many cases and workers have done everything possible to prevent the break-up of families. Every effort was made to avoid the necessity of children being taken into care. 102 families in need of assistance were referred during the year by the Children's Officer and were found day nursery vacancies, home helps, etc. Welfare foods In consequence of the closure of the food offices the distribution of welfare foods was taken over by the Council. The transfer was effected smoothly and no difficulties arose. Foods were supplied at welfare centres, at a kiosk in the former food office in Bermondsey and at the sub-office at Lambeth. School health service The premises at Pages Walk school, where treatment sessions were held, were required by the Education Department, and consequently alternative arrangements were made for these services. The nutrition session was transferred to Sutherland House 140 centre, the rheumatism session to Southwark health centre and the vision session to Villa Street centre. A second dental surgery was installed at St. George's dispensary and both the dispensary and Lambeth treatment centre were fully re-decorated. As a result of the diminution in the number of children attending physically handicapped schools the Lilian Baylis School was closed for physically handicapped children and opened as a school for maladjusted children. It has been felt that many mothers with backward or mentally deficient children may not wish to attend an ordinary infant welfare clinic and that they may be in need of special advice on the care of their children and the facilities that are available to help them. It was therefore decided, as an experiment, to hold a special session for such children once a month at the Sutherland House welfare centre. Children from anywhere in the division can be seen there, and in view of the special attention required cases are seen at each session by appointment only. A medical officer with special experience in the care of these children is in charge and the clinic has already proved successful. 1 Clinic for i mentally backward 5 children Division 9, comprising the boroughs of Battersea and Wandsworth. Dr. J. T. R. Lewis reports: I have much pleasure in reporting on the work of division 9, for 1954, the third year during which my colleagues and I have been working in this area. The year was a busy one and many matters of importance were dealt with. Of these perhaps the most important were concerned with planning the needs of the large housing estates which are rapidly being built in the area. In addition to these specific needs, however, steps have also been taken to improve the existing health service facilities. The maternity and child welfare centre at St. Peter's Church Hall, Prescott Place, Clapham, to which brief reference was made in the 1953 Report, came into operation on the 13th March and has proved a great success. A new maternity and child welfare centre was opened in August at the church hall of the Church of the Holy Redeemer, Churchmore Road, to cover the needs of the Streatham Vale area and a similar centre was also opened in April at St. Margaret's Church Hall, Cricklade Avenue, in place of the former centre in New Park Road. As a temporary measure and to do something to cover the needs of some of the new estates in Wandsworth, a maternity and child welfare centre was opened in October at ' Woodlands' in West Hill. While these new centres do not, of course, accord with modern ideas and needs, they have proved popular and are providing a very valuable service. Premises In the report for 1953, reference was made to the acquisition of premises to take the place of the Tooting school treatment centre. At the end of the year the work of adapting premises at 193 Mitcham Road was virtually completed. It is hoped that in the near future, work will be started on a number of projects, namely the new combined maternity and child welfare and school treatment centre on the Argyle/Ackroydon estates, a similar new centre on the Ashburton estate, the possible start with yet another similar centre on the Roehampton Lane estate, the commencement of work on a new maternity and child welfare centre in Stomont Road. Battersea, and the improvements at 'Southlands,' Shuttleworth Road, Battersea.When these projects are completed in the next two or three years, there will be a very considerable strengthening of the public health facilities available. Compared with the year 1953, the number of immunisations against diphtheria showed an increase of 46 per cent. This was quite a satisfactory increase over the previous year, probably explained by the fact that there was less need in 1954 to restrict immunisation because of the prevalence of poliomyelitis. The figures for whooping cough immunisation also revealed an increase of 1.7 per cent, and there was a slight increase in the number of persons vaccinated. , Immunisation . and vaccination 141 Research The investigation, in conjunction with the Medical Research Council, into the efficacy of a combined prophylactic against diphtheria and whooping cough has continued as has also the investigation into the early diagnosis of cerebral palsy. During the year two further investigations likely to break new ground, were instituted. Firstly, in conjunction with the Family Welfare Association, a home-making scheme for the mothers of problem families was started. A group of mothers, referred by various agencies, met weekly and by group discussion gained some insight into housekeeping, child management and similar questions. It is too early to assess the value of the scheme but it is hoped it will provide a means of helping mothers, particularly those belonging to the border-line group of potential problem families. Some thought has also been given to the preventive aspects of mental illness by paying more attention in infant welfare centres to early deviations from normal. This work has been carried out in very close association with Dr. W. Warren, the Medical Director of the Brixton child guidance unit, whose help and guidance has been invaluable. Dr. Warren is now running one of the pilot discussion groups formed in accordance with the recommendations of the L.C.C. Study Group on this subject. Day nurseries inuring uic year, x>ainam aay nursery was ciosea, leaving a total 01 day nurseries providing places for 599 children. Of these 12 nurseries, eight were recognised for training students. Special investigation clinics At clinics concerned with the problem of bed wetting there was a total of 1,390 attendances at 214 sessions. This showed a slight decrease in the number of attendances compared with the figure for the previous year although the number of sessions was slightly more. There were 235 new cases compared with 253 in 1953. Applications for recuperative holidays placed through the division numbered 886 as compared with 946 in the previous year. Direct placing amounted to 31 per cent, of the total and constituted a decrease compared with the percentage (44-4 per cent.) for 1953. Recuperative holidays Home helps The home helps attended 3,231 households during 1954 representing an increase of 15 per cent, over the previous year. This is in line with the increasing use made of the home help service which is now firmly established as one of the most important of the social services. Home nursing Equipment was loaned to 40 patients compared with 29 in 1953. 23 patients were still using the equipment at the end of the year. The home nurses paid 207,150 visits during 1954, an increase of 4-9 per cent, over the number of visits recorded in 1953. There was a similar increase in 1953 compared with 1952 and I should hke to say how important a place the home nursing service has come to play in the care of the domiciliary patient. Working on the one hand in close conjunction with the family doctor and on the other gaining constantly closer contact with the other services provided by the local health authority, and particularly with health visitors and home helps, its social as well as its more strictly medical value is undoubtedly increasing. I should like to express appreciation for the help and co-operation received from the district nursing associations in this area, some of whom are facing new problems. The large estates which are being built, particularly in the Roehampton area where previously there were comparatively few residences, means that a large expansion of the home nursing services for that area will be essential. This is well recognised and I have no doubt that the demand will be efficiently met. Health education During the year the giving of talks by the medical and nursing staff to various organisations continued and one health visitor still devoted a large proportion of her time to problems of health education. With the cordial co-operation of the Borough Librarians, to whom I would like to express our thanks and appreciation, literature on public health matters, particularly relating to mothers and young children has been made available to the public. Special leaflets have been prepared which are available at centres and suitable books suggested by the divisional staff have been made available for loan in the libraries. There is reason to think that good use is made by many of the mothers of these facilities. 142 During the year also, arrangements were made for the display of public health posters in various business premises. The most potent factor in health education undoubtedly remains the individual approach by members of the health department. Thus health visitors, school nurses, home nurses and indeed all members of the staff who come into contact with the members of the public have an important part to play. Close co-operation with statutory and voluntary bodies concerned with child neglect continued throughout the year. I should like to express my appreciation of the help which I have received from other departments, particularly the Children's Care Organisation, the Divisional Education Officer, the Area Children's Officer and also from the staff of voluntary organisations. Child neglect Reference is made above to the expansion of certain of the infant welfare clinics and to the improvement in others. During the year, consideration was given from time to time to 'selective' visiting by health visitors. This is a subject which at the moment is being discussed extensively, particularly as it relates to problem families and the prevention of child neglect. 'Selective' visiting, certainly on a small scale, has been in operation for some considerable time but the extent to which such visiting by health visitors should or can be extended requires careful thought. Health visiting During the year the distribution ot welfare roods was taken over from the Ministry of Food. The necessary arrangements entailed a large amount of careful planning and I should like particularly to express my appreciation for the work of the Divisional Administrative Officer, Mr. F. E. Willson, for planning the take-over, which is working extremely smoothly. Welfare foods Reference was made last year to the combined efforts of everyone to tend to the needs of old people. This work has continued. Welfare of old persons Co-operation I am again happy to refer to the close co-operation and liaison which exists with the individual doctors, the local division of the British Medical Association and the hospitals in the area. A similar liaison exists between the divisional staff and other Council departments concerned with health and welfare, particularly the Divisional Officer of the Education Officer's Department, the Welfare Department and the Borough Councils' staff. A very useful meeting was held during the year with the local division of the British Medical Association to discuss, specifically, liaison between the health department generally and the local doctors. This took the form of a discussion opened by myself and my colleagues and it was generally agreed that a very useful and constructive evening was spent and many useful contacts established. It is a pleasure again to thank all my colleagues in the Division for the great help and support which has been accorded to me during the year. I am especially grateful to my senior colleagues—Dr. W. G. Harding, Dr. A. Garland, Mr. F. E. Willson, Miss W. M. Winch and Miss G. U. Cox. It was particularly pleasant in the early part of the year to welcome back Mr. F. E. Willson, the Divisional Administrative Officer, after a serious illness. Organisation In March, Miss E. M. Woods, the Divisional Nursing Officer, retired. She had spent most of her professional life firstly in the service of the Metropolitan Borough of Wandsworth and then with the Council and had rendered, during many years, yeoman service to the mothers and children of the area. She left the Division with the good wishes of everyone. Fortunately, her place was very adequately filled by Miss Winch who very soon settled in and took up the reins of her office. It is with great pleasure that I welcome Miss Winch to the staff of the Division. At the end of the year, Miss S. M. Jones, one of the Assistant Divisional Nursing Officers, also left after more than 30 years' service with the Council, mainly 011 the school health side. Her services to the schoolchildren of this area of London have been manifold. 143 APPENDIX A LUNG CANCER 1931—54 in recent years deaths from lung cancer have attracted increasing attention. There is little doubt that there is a statistical association between smoking and lung cancer and that extensive cigarette smoking is accompanied by higher lung cancer death rates. Without entering into the controversy that rages between those who argue that excessive cigarette smoking causes an increase in the rate of lung cancer, those who argue that excessive smoking determines merely the site of a cancerous growth without increasing the over-all risk, and those who deny any association whatever, it was thought desirable to bring together the available data about lung cancer mortality, incidence and prevalence relating to the Administrative County of London during the last 25 years. General Mortality Since 1931 the over-all death rate for cancer has risen from 1-48 to 2-04 in England and Wales and from 1-64 to 2-31 in London. The greater proportion of this apparent rise in importance of cancer as a cause of death is due to changes in the age structure of the population ; people no longer die as readily from other causes in early life and the increasing survival rate coupled with changes in the birth-rate has left relatively more aged persons to be killed by cancer—a disease of mature age. If the age and sex structure had remained as it was in 1931 the current death rates would by 1-55 for England and Wales and 1-73 for London—net increases of-07 and -09 respectively. During the same period, however, the lung cancer death rate has risen from 0-05 to 0-37 in England and Wales and 0-12 to 0-54 in London ; on adjustment for age and sex changes during the period the figures become 0-30 and 0-43 respectively—net increases of 0-25 and 0-31. The following table illustrates the point :— Cancer death rates in England and Wales and London A.C. 1931 and 1954 (adjusted to 1931 populations) [####] Lung cancer Other cancer All cancers. England and Wales 1931 .05 1.43 1.48 1954 .30 1-25 1.55 Increase or decrease + .25 - .18 + .07 London A.C. 1931 .12 1.52 1.64 1954 •43 1-30 1.73 Increase or decrease + .31 — .22 + .09 It can be seen that while there has been a slight increase in cancer mortality over the country as a whole and a somewhat greater one in London, these are in fact a reflection of greater increases in mortality from lung cancer partially offset by decreases in mortality from cancers of other sites. The reduction in the rates for other forms of cancer can possibly be attributed to improved methods of diagnosis and treatment during the period under review but it will be noted that London has a higher death rate than elsewhere whether one looks at lung cancer or other cancers. This fact cannot be attributed to marked differences in population structure between the two areas as the Area Comparability Factor for London deaths in 1954 was -99. Regional and local differences in cancer death rates have been investigated by Stocks (1947) who found that during the years 1921-30 London rates at specified ages from cancer of all sites were above national level, particularly for men, although they were exceeded by those in Manchester ; that mortality from cancer of the respiratory organs was higher in urban areas than in rural ; and that there was a significant negative correlation between hours of bright sunshine and lung cancer. Figures 144 showing the mortality from lung cancer during the year 1953 for certain types of area in England and Wales arranged in order of descending mortality are set out below. The rates for each male age group decrease with decreasing urbanisation despite the higher proportion of persons aged 65 and over in the rural areas. Death rates per 1,000 living from lung cancer—England and Wales, 1953 ###]s Males Females Percentage of Popn. 65 and over in Popn. 25 and over 25- 45- 65- 75 and over Total 25 and over 25- 45— 65- 75 and over Total 25 and over M. F. All conurbations 0.12 0.11 1.71 3.69 2.45 1.15 0.03 0.20 0.44 0.57 0.18 13 18 Urban areas 100,000+ 1.55 2.97 2.06 1.04 0.83 0.17 0.42 0.38 0.16 14 19 50,000100,000 0.10 1.35 2.79 1.53 0.92 0.03 0.15 0.25 0.32 0.12 15 21 Less than 50,000 0.08 1.24 2.27 1.53 0.84 0.02 0.14 0.29 0.37 0.13 16 20 Rural areas 0.05 1.02 1.67 1.15 0.65 0.02 0.13 0.29 0.25 0.12 17 21 E. and W. 0.10 1.43 2.78 1.81 0.96 0.03 0.17 0.36 0.42 0.15 15 19 It seems evident that, whatever the reasons, urban areas have higher mortality rates for cancer, and London accordingly has higher rates than England and Wales as a whole. This pattern also seems to hold good abroad—the United States census of 1951, for example, disclosed that 53-5 per cent, of lung cancer cases occurred in cities of over 100,000 which accounted for only 29-3 per cent, of the population. The table set out hereunder shows the average death-rate from lung cancer per 1,000 of the population aged 15 years and over for each of the Metropolitan Boroughs for the years 1950-54 inclusive, which it will be seen range from 0-79 in Bethnal Green to 0-47 in Kensington with a mean for the County of 0-60. Various environmental and social factors were examined and the table also shows the degree of overcrowding in the boroughs as assessed by the percentage of persons living at a density of more than 2 persons per room, and the percentage of social classes IV and V in their populations, according to the 1951 census; the amount of existing open space according to the London Development Plan Analysis and the average amount of atmospheric pollution as measured by the solid deposit and sulphur dioxide concentration recorded by all the stations within each borough during 1954, according to the Atmospheric Pollution Bulletin of the Department of Scientific and Industrial Research. Effects of certain environmental and social factors The correlation coefficients of the lung cancer death-rate with the various factors are + 0.431 for overcrowding; + 0.599 for percentage in social classes IV and V ; — 0.417 for the amount of open space + 0-085 for atmospheric solid deposit and + 0.262 for atmospheric sulphur dioxide concentration. The first three are significant and the last two are not. The highest correlation is that with the percentage in social classes IV and V, and it is therefore not surprising to find some degree of correlation with overcrowding and lack of open space which are frequently associated inversely with social class. This finding of an association between lung cancer and social class is in keeping with Logan's (1954) description of the social class gradient in lung cancer. He noted that the gradient was not found in married women or in men over the age of 65 years. The correlation between lung cancer and atmospheric pollution was not significant in this analysis, but this in itself does not preclude an association between them. 145 K1 Lung cancer death-rate—Overcrowding, social class, open space and atmospheric pollution Lung cancer D.R. per 1,000 aged 75+ 1950-4 (Average) Percentage of persons living at a density of more than 2 per room 1951 Percentage of social classes IV & V 1951 Existing open space per 1,000 persons (Acres) 1951 Atmospheric pollution Solid deposit to 1954 Sulphur dioxide concentration (b) 1954 Division 1 Chelsea 0.53 1.9 23.2 1.20 19.8 2.73 Fulham 0.60 2.7 27.3 0.92 28.8 2.76 Hammersmith 0.61 3.9 30.0 2.30 14.0 1.76 Kensington 0.47 4.6 23.1 0.95 16.1 2.32 Division 2 Hampstead 0.51 2.7 15.4 3.75 20.5 1.18 Paddington 0.63 5.2 26.9 1.13 18.8 2.31 St. Marylebone 0.55 2.2 21.7 4.88 21.1 3.40 St. Pancras 0.76 4.4 32.0 3.98 21.3 1.80 Westminster, City of 0.48 2.3 26.7 7.15 28.9 3.67 Division 3 Finsbury 0.72 3.4 39.0 0.43 20.7 3.20 Holborn 0.61 2.3 29.9 1.17 19.8 3.95 Islington 0.68 3.8 31.0 0.26 26.3 2.64 Division 4 Hackney 0.59 1.5 26.0 3.68 14.4 2.49 Shoreditch 0.78 3.5 38.5 0.22 (c) 3.25 Stoke Newington 0.53 1.7 22.0 1.19 15.5 1.65 Division 5 Bethnal Green 0.79 2.8 38.0 1.75 (c) 3.55 City of London 0.52 0.8 43.4 1.90 24.0 3.82 Poplar 0.69 3.5 44.0 1.45 35.2 3.60 Stepney 0.64 3.4 46.0 0.44 20.3 3.31 Division 6 Deptford 0.64 1.7 34.7 0.46 (c) (c) Greenwich 0.53 1.9 31.5 4.85 38.0 2.65 Woolwich 0.56 1.3 25.0 7.00 18.9 2.89 Division 7 Camberwell 0.58 1.6 29.7 1.47 15.8 1.76 Lewisham 0.48 1.4 21.8 2.83 16.3 1.86 Division 8 Bermondsey 0.64 2.7 45.1 1.29 (c) 2.47 Lambeth 0.58 2.1 28.7 1.25 17.6 2.73 Southwark 0.73 2.9 41.8 0.36 35.8 3.58 Division 9 Battersea 0.57 2.1 29.7 3.30 28.8 1.99 Wandsworth 0.63 1.3 21.1 3.77 (c) 1.64 London County 0.60 2.5 28.8 2.47 22.4 2.67 (a) In tons per square mile per month. (b) As measured by the mean rate of sulphuration of a standard lead peroxide candle expressed in milligrammes of sulphur trioxide fixed per day per 100 cms. of Batch A standard lead peroxide. (c) Not recorded. 146 General death-rates, however, do not reveal the whole picture for which a detailed examination of the rates for various sex and age groups is necessary. Table A on page 153 sets out the number of deaths from lung cancer in London Administrative County by age and sex for each year from 1931, and Table B on page 154 reproduces the same information in the form of rates. It should be mentioned that during the period 1939 to 1949 inclusive, the Registrar-General did not give an age break-down of the London population aged 15 and over and only a partial one in 1950—hence the figures on which the death-rates for these years are based are the result of interpolation ; another complication arises from changes in 1938 and 1948 in the code numbers of the international classification of causes of death—lung cancer has been taken as Nos. 162 and 163 in the current hst (i.e., malignant neoplasm of trachea, and of bronchus and lung) and by interpolation cancer of the larynx and mediastinum has been isolated and removed from earlier and less specific classifications. [ Effects of age From Table B, it will be seen that lung cancer is of negligible importance until the 35— age group is reached ; that from then on its incidence increases steadily with age up to and including the 65— age group and that over the period there has been an increasing incidence in both sexes although the male rates are well in excess of the female. For ease of comparison graphs of the rates for each sex in the age groups 35—, 45—, 55— and 65— are set out on page 151; the aged 75 and over group is excluded merely because its rates come between those of the 55— and 65— groups and would render the graphs less clear. The effect on the 35— male group of the removal of the fitter members during the war years is noticeable, as are the fluctuations due to small numbers in the rates for the 35— and 45— females. The graphs have been plotted on semi-logarithmic paper which is equivalent to plotting the logarithms of the death rates on ordinary paper. This type of graph has the effect of flattening the curve but it has been adopted in order to focus attention on the proportional rate of increase rather than the absolute—a straight line representing a constant proportional increase. Broadly they show a steady proportional increase in the rates with a higher rate of increase in the male than in the female and in the older males than in the younger. The all-male and all-female rates in 1954 on the basis of the 1931 age structure would have been 0-76 and 0-13 respectively—increases of 262 per cent, and 160 per cent. It is interesting to note that in New York State (Symposium (1952) ) the age-standardised mortality from cancer of the lung between 1930 and 1950 increased by 385 per cent, for males and 68 per cent, for females. In order to ascertain which of the sexes has the greater rate of increase the sex-ratio of the deaths from age 55 onwards has been extracted for the period. For comparative purposes, the ratios for all causes, all cancer (International List Nos. 140-205) and bronchitis (International List Nos. 500-502) have also been extracted and the numbers, rates and sex ratios are shown in Table C (page 155). It is appreciated that there was an apparent increase in bronchitis from 1940 onwards owing to the abandonment of the former method of selection in multiple causes of death and to the revision of the International List of Causes of Death, but it was felt that the sex-ratio should not thereby be unduly affected, and it was desired to compare lung cancer with another disease which might be attributable in whole or in part to the inhalation of irritants. Crudely there has been an increase in the ratio over the period of 25 per cent, for all causes ; 36 per cent, for all cancer, presumably a reflection of the changes in lung cancer incidence ; 73 per cent, for lung cancer and 164 per cent, for bronchitis—for ease of comparison the rates have been plotted (also on semi-logarithmic paper) and are shown on page 152. The graphs are by no means as regular as might have been anticipated even in the ' normal' years from 1931-38, particularly in the case of lung cancer although the irregularities of the war years are understandable in the light of migration and (perforce) estimated populations. The general similarity in the slopes of the lung cancer and bronchitis graphs since the end of the war is noticeable although their earher courses are different : the close association of the ' all causes ' and ' all cancer * graphs is also noticeable though Effects of sex 147 K2 here a divergence occurs in recent years which reflects the movement of the lung cancer ratio within the cancer group. Incidence and prevalence While the facts about lung cancer mortality are relatively straightforward, it is more difficult to assess the incidence and prevalence of the disease. As Doll (1953) points out no figures are available for assessing the incidence of lung cancer other than the Registrar-General's mortality figures, but because of its great fatality the number of persons dying from it is nearly equal to the number affected and, from this point of view, mortality statistics provide a reasonable estimate of incidence, although they are subject to the inaccuracy inherent in the certification of causes of death. Any such estimate of incidence to be of current application needs amendment in the light of the time interval between the onset of the disease and death, which is in turn affected by the effects of treatment. Interval between symptoms and treatment Until the cancer registration scheme reaches a higher degree of completeness information on timing can only be a guess and even if it were complete it would be less reliable in the case of lung cancer because of the greater rapidity and fatality of this type than of many other cancers. However, isolated studies have been made of this question—Harnett (1952) shows the number of lung cancer patients in the London hospitals during the years 1938 and 1939 distributed according to the interval from the appearance of first symptoms to first consulting a doctor. There were 1,024 such patients of which 842 were males and 182 females, but in 216 of these cases no interval was recorded. According to these statistics the average duration between the appearance of first symptoms and date of first consulting a medical practitioner was, on the average, 78 days. In 80 per cent, of these cases the interval was less than 3 months. The same survey shows 417 of these patients distributed according to the duration of symptoms at the time of commencement of treatment. According to the table, the average duration was 171 days. The results of a later study by Edwards (1954) of a small sample of 38 consecutive cases admitted to the Liverpool Thoracic Surgical Centre were as follows : Average number No Less than 8 days Total of days delay 8 days and over cases Interval between onset of symptoms and first visit to doctor 46.6 5 21 12 38 Interval between first visit to doctor and X-ray of chest 55.8 2 11 25 38 Interval between first X-ray of chest and surgical advice 46.7 0 9 29 38 Interval between surgical consultation and admission to unit 9.6 3 19 16 38 Total 1587 It is not clear whether there is any difference in definition between the ' commencement of treatment' in the London cases and the ' admission to unit' in the Liverpool area, and in any case the longer time interval in Liverpool may merely reflect regional differences in available accommodation, especially if incidence is rising also. The more interesting fact is the reduction by about a month of the time between the onset of symptoms and the consultation of a doctor. It is understood from Mr. Edwards that the Liverpool study was carried out in 1953, from which it would be reasonable to assume that, over the period of some 14-15 years between the collection of the two sets of data, patients have become less unwilhng to seek medical advice at an early stage in the onset of the disease. Possible reasons are numerous and it does not seem practicable 148 to suggest any form of study which would establish the prime cause beyond any shadow of doubt. The total time lag between onset and first symptoms and start of treatment does not seem markedly different as between lung cancer and cancer of other common sites as breast, rectum and uterus. To state a truism, the success or failure of treatment depends in large measure on the timing of diagnosis and unfortunately lung cancer, more often than not, remains clinically unobserved during most or all of the period when surgical treatment, which holds out the only real prospect of a cure, is most likely to be successful. It is, therefore, to be hoped that as middle-aged men (and women) become more "cancer conscious" they will consult their general practitioner when they have a persistent cough or other symptoms. Fortunately, as the Minister of Health said in part answer to a Parliamentary question on 21st October, 1954, 'diagnosis has been improved by the introduction of cytological methods and the wider use of radiography, particularly mass miniature X-rays'. Cytological examination of sputum (Brit. Med. J., 1954) appears to give better and earlier results than bronchoscopy but relatively few pathologists in this country have as yet the necessary training. As regards case finding through the medium of mass miniature radiography, certain figures have been received for the years 1943-53 through the good offices of Dr. Norman Smith of the Ministry of Health. These figures, some of which are set out in Table D on page 155, relate to cases of intrathoracic malignant disease found by the units operating in the areas of the four Metropolitan Regional Hospital Boards plus the Ministry's own unit—thus they do not relate wholly to London or wholly to lung cancer, although as regards the latter out of 2,501 cases of intrathoracic malignant disease mentioned in the annual Report of the Chief Medical Officer of the Ministry of Health for 1953 2,226 (89 per cent.) had lung cancer. It will be seen from the Table that the increased rate of case finding far exceeds the increase in mortality in the comparable or similar age groups shown in Table B; to what extent this excess is due to improvements in diagnostic technique, to greater willingness to be X-rayed or to a real increase in incidence it is impossible to say, but the inferences are that improved technique leading to earlier diagnosis plays a substantial part. In support of such an inference there is evidence of a greater proportion of cases now being found suitable for surgical treatment and, incidentally, of a greater prospect of survival after treatment—here again improved techniques must have played a part. As regards the practicability of radical surgery, Harnett shows that of the 1,024 patients in hospital in 1938-9, only 1.5 per cent. received this treatment, while in addition 3.6 per cent. had a transthoracic exploration but pneumonectomy was abandoned. He goes on to say that figures published by Brock (1948) showed that an operability rate of 11 per cent. in 666 cases had recently increased to 21 per cent.; Holmes Sellors (1955) gives figures showing that between 1940 and 1950 out of 689 thoracotomies, 446 (65 per cent.) were resected. It should be added that suitability is often surmised—of 723 cases explored, according to Ochsner, Ray and Acree (1954), 254 (23 per cent.) were non-resectable in fact. Another factor influencing mortality is the type of growth, prognosis being relatively good for the squamous-cell type, more doubtful for adenocarcinoma and very poor for the oat-celled type (Lancet, 1955). According to Harnett, of 1,012 cases which could be traced out of the 1,024 occurring in 1938-9, 931 (90.9 per cent.) died in the first year after coming under treatment, 54 (5.3 per cent.) in the second year, 8 (0.8 per cent.) in the third and fourth years and 1 (0.1 per cent.) in the fifth, leaving 10 survivors—a five year survival rate of 0.98 per cent. or an average expectation of 0.69 years of life during treatment. Stocks (1950) shows that in 1945-6, of 1,711 traceable males, 1,501 (87-7 per cent.) died in the first year, the corresponding figures for females being 243 and 211 (86.8 per cent.). Stocks (1952) gives crude survival rates for three years as being:— 149 Diagnosis and treatment Survival Crude survival rates (per cent.) 1945 Early Late All primary primary primary Male 1 year 33 9 11 2 years 12 2 3 3 years 9 1 2 Female 1 year — 11 13 2 years — 5 5 3 years — 4 3 1946 Male 1 year 32 9 11 2 years 19 3 4 3 years 15 2 3 Female 1 year — 10 13 2 years — 4 6 3 years — 3 5 NOTE. 1 year figures are corrected; 3 years' figures are provisional. It can be argued from these figures that the general prospects of survival have become less meagre, especially if the case is an early primary lesion—the prospects of survival of those undergoing pneumonectomy seem somewhat brighter; according to Raven (1953) Taylor and Waterhouse found in 1950 that the five year survival rate in a total of 1,134 cases was 13.7 per cent.; the survival rate for 133 cases operated on by Sir Clement Price Thomas (of whom 33 were resectable but not strictly operable) was 25.5 per cent. (Brit. Med. J., 1954); Holmes Sellors (1955) states that cases operated on prior to 1948 showed 21 per cent. alive after five years and in a 1949-50 series 34 per cent. alive after three years; of 149 out of the 469 resectable American cases mentioned earlier when the disease had not spread beyond the lung, the five year rate was 31 per cent. The lack of complete figures makes it difficult to assess in advance but it would appear that it is still broadly true to say that mortality is a reflection of incidence a little over a year previously (1.16 years in 1938-9 made up of 0.47 years to the commencement of treatment and 0.69 years expectation of life during treatment)— currently, the time interval between the onset of symptoms and the receiving of treatment seems to have lessened but the expectation of life as the result of earlier and better treatment has increased, although, so far as can be ascertained from Stocks' figures (admittedly for nine years ago) not radically. It should be noted however that his figures do show a very marked difference between the survival rates of early and late cases, which should in due course be reflected in the overall rates, as the collective results of the earlier seeking of advice and advances in diagnostic and surgical skill. From the public health aspect one can only emphasise the fact that the crude survival rate of the early primary male cases is three to four times that of the late ones for one year and eightfold for three years. References Brit. Med. J. (1954), 2, 582. 'Detecting Lung Cancer.' Brock, R. C. (1948). 'Diseases of the Chest.' Lancet, 2, 70. Doll, R. (1953). 'Bronchial Carcinoma; Incidence and. Aetiology.' Brit. Med. J., 2, 521 and 585. Edwards, F. R. (1954). 'Detecting Lung Cancer.' Brit. Med. J., 2, 752. Harnett, W. L. (1952). 'A Survey of Cancer in London.' London. Holmes Sellors, T. (1955). 'Results of Surgical Treatment of Carcinoma of the Lung.' Brit. Med. J., 1,445. Lancet (1955), 1, 954. 'Cell Type in Bronchial Carcinoma.' Logan, W. P. D. (1954). Brit. J. Prev. Soc. Med., 8, 128. Ochsner, Ray and Acree (1954). American Review of Tuberculosis, 70. Raven, R. W. (1953). 'Handbook on Cancer.' London. Stocks, P. (1947). 'Studies in Medical and Population Subjects—No. 1.' H.M. Stat. Office, London. Stocks, P. (1950). 'Studies in Medical and Population Subjects—No. 3.' H.M. Stat. Office, London. Stocks, P. (1952). 'Studies in Medical and Population Subjects—Supplement to No. 3.' H.M. Stat. Office, London. 'Symposium of the Endemiology of Cancer of the Lung.' Council for International Organisation of Medical Science, Louvain. (1952). 150 LUNG CANCER DEATH RATES 1931-54 MALES, BY AGE (PEP. IOOO LIVING) LUNG CANCER DEATH RATES 1931-54 FEMALES, BY AGE (pen iooo living) 151 RATIO OF MALE/FEMALE DEATH RATE AGE 55+IN L.A.C. 1931-54 ALL CAUSES, ALL CANCER, LUNG CANCER AND BRONCHITIS 152 Table A—Lung cancer deaths in London A.C. 1931-54 by age and sex Age Sex 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 0— M - 1 - - - 1 - - - - - - - - - - - - - - - - - 1 F 2 - - - - - - - - - - 1 - - - - - - 1 - - - - - 5— M 1 - - - 1 1 1 1 1 1 1 - 1 - - - - - 1 - - - - - F — 1 1 1 - - - - - - - - 1 - - - - - - - - - - - 15— M 1 - 2 2 - 1 - 2 2 3 2 1 3 - 2 1 2 1 3 - 2 3 2 1 F — 2 1 2 2 1 1 — 1 2 — — 1 — — 2 1 — — — 7 — — 1 25— M 7 3 14 7 7 9 14 10 12 7 5 6 7 7 3 8 11 12 7 11 8 8 6 6 F 6 3 4 4 4 5 3 5 4 3 7 1 2 6 6 2 2 1 3 4 3 1 2 6 35— M 30 29 26 36 36 34 36 41 41 46 34 44 32 38 48 43 75 54 50 60 55 65 75 58 F 11 10 10 8 14 13 11 10 13 11 7 11 18 9 10 11 16 15 13 16 14 18 16 13 45— M 106 107 123 110 129 154 137 146 138 138 108 129 147 149 159 179 198 192 217 249 250 233 276 272 F 14 23 37 23 25 27 42 25 34 20 24 25 21 27 25 19 39 36 27 32 34 39 38 62 55— M 147 163 202 208 231 213 236 265 248 262 263 289 271 272 316 325 353 365 384 444 446 440 458 501 F 33 40 36 46 39 47 42 58 53 42 36 36 35 52 45 53 61 59 60 54 57 88 81 75 65— M 100 95 108 119 130 148 178 157 189 169 152 181 220 185 240 239 302 313 350 364 401 439 475 468 F 26 28 26 29 32 49 46 46 52 53 38 38 50 37 45 59 74 75 91 69 87 72 86 95 75 and over M 39 33 36 36 35 47 42 47 50 44 36 46 59 58 60 61 71 113 107 110 122 141 139 157 F 13 10 18 23 21 24 20 24 28 24 17 27 27 23 28 36 25 38 42 45 57 65 53 69 All ages M F 418 118 431 777 511 133 518 136 569 137 608 166 644 765 669 768 681 185 670 155 601 729 696 139 740 155 709 154 828 759 856 782 1,012 218 1,050 224 1,119 237 1,238 220 1,284 253 1,329 283 1,431 276 1,464 321 153 Table b—Lung cancer death.rates in London A.C. 1931-54 by age and sex (per 1000 living in the age/sex group) Age Sex 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 0— m . 0.01 - - - 0.01 - - - - - - - - - - - - - - - - - 0.01 F 0.00 - - - - - - - - - - 0.01 - - - - - - 0.01 - - - - - 5— m 0.00 - - - 0.00 0.00 0.00 0.00 0.00 0.00 0.01 - 0.01 - - - - - 0.01 - - - - - F — 0.00 0.00 0.00 - - - - - - - - 0.01 - - - - - - - - - - - 15— M 0.00 - 0.01 0.01 - 0.00 - 0.01 0.01 0.01 0.02 0.01 0.03 - 0.02 0.01 0.01 0.01 0.02 - 0.01 0.02 0.01 0.01 F — 0.00 0.00 0.01 0.01 0.00 0.00 — 0.00 0.01 — — 0.01 — — 0.01 0.00 — — — 0.00 — — — 25— M 0.02 0.01 0.04 0.02 0.02 0.03 0.04 0.03 0.04 0.03 0.04 0.04 0.05 0.06 0.02 0.03 0.04 0.04 0.02 0.04 0.03 0.03 0.02 0.02 F 0.02 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.03 0.00 0.01 0.03 0.03 0.01 0.01 0.00 0.01 0.01 0.01 0.01 0.01 0.02 35— M 0.11 0.11 0.10 0.14 0.14 0.13 0.14 0.15 0.15 0.21 0.19 0.24 0.17 0.21 0.23 0.16 0.27 0.20 0.19 0.22 0.21 0.25 0.31 0.24 F 0.03 0.03 0.03 0.02 0.04 0.04 0.03 0.03 0.04 0.04 0.04 0.06 0.09 0.04 0.05 0.04 0.06 0.05 0.05 0.06 0.05 0.07 0.06 0.05 45— m 0.43 0.42 0.51 0.46 0.55 0.66 0.60 0.64 0.65 0.73 0.71 0.81 0.89 0.86 0.87 0.94 1.08 1.02 1.14 1.30 119 1.08 1.27 1.23 F 0.05 0.08 0.13 0.08 0.09 0.09 0.15 0.09 0.13 0.09 0.15 0.15 0.12 0.16 0.14 009 0.16 0.16 0.11 0.13 0.14 0.16 0.15 0.25 55— m 0.78 0.87 1.06 1.10 1.23 1.13 1.25 1.42 1.40 1.64 2.19 2.13 1.92 1.96 2.15 2.02 2.31 2.33 2.42 2.79 2.86 2.80 2.90 3.23 F 0.15 0.18 0.16 0.20 0.17 0.21 0.18 0.25 0.24 0.23 0.27 0.26 0.24 0.36 0.30 0.29 0.32 0.30 0.30 0.27 0.28 0.44 0.40 0.36 65— m 1.02 0.96 1.07 1.17 1.28 1.42 1.70 1.48 1.77 1.67 1.99 2.29 2.34 2.00 2.45 2.34 2.83 2.85 3.15 3.26 4.01 4.35 4.75 4.68 F 0.29 0.21 0.19 0.21 0.23 0.35 0.33 0.33 0.37 0.46 0.44 0.43 0.47 0.40 0.41 0.45 0.53 0.54 0.64 0.48 0.58 0.47 0.57 0.61 75 and over m 0.81 1.01 1.10 1.08 1.05 1.38 1.22 1.34 1.41 1.52 1.65 1.36 1.67 1.67 1.64 1.39 1.55 2.40 2.25 2.30 2.90 3.28 316 3.57 F 0.22 0.17 0.30 0.38 0.34 0.38 0.32 0.38 0.47 0.49 0.46 0.71 0.51 0.44 0.51 0.55 0.36 0.54 0.59 0.63 0.73 0.80 0.65 0.79 All ages M 0.21 0.21 0.26 0.26 0.29 0.32 0.34 0.35 0.38 0.46 0.55 0.62 0.63 0.61 0.68 0.59 0.66 0.67 0.71 0.78 0.82 0.85 0.92 0.94 F 0.05 0.05 0.06 0.06 0.06 0.08 0.08 0.08 0.09 0.09 0.10 0.11 0.12 0.12 0.12 0.11 0.13 0.13 0.13 0.12 0.14 0.16 0.15 0.18 154 Table C—Deaths in London A.C.—1931-54 Population aged 55 and over.—Numbers, rates and sex ratio for certain causes Cause(s) Sex No., rate, etc. 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 All causes m No. Rate 16,392 16,427 16,789 16,112 15,734 16,955 17,955 16,129 16,764 19,668 15,604 3,541 14,585 14,978 13,997 14,971 15,802 14,470 15,678 15,735 17,354 16,658 15,796 14,646 51.61 50.77 51.83 49.58 48.85 51.82 52.55 49.11 52.42 68.82 71.58 54.47 53.96 56.27 49.77 48.78 51.79 46.11 49.42 49.38 58.23 55.34 52.30 48.98 F No. Rate 17,557 17,244 17,517 16,856 16,555 17,446 18,274 16,078 16,949 19,784 14,404 12,656 14,271 13,908 13,174 14,284 15,632 13,820 15,704 15,509 17,394 16,546 16,024 14,581 42.71 41.25 41.67 39.87 38.95 40.65 42.35 36.92 40.28 57.65 55.76 47.29 46.82 48.44 41.54 37.69 39.51 33.95 38.17 37.53 40.45 37.95 36.67 32.47 m/f Ratio 1.21 1.23 1.24 1.24 1.25 1.27 1.24 1.33 1.30 1.18 1.28 1.15 1.15 1.16 1.20 1.29 1.31 1.36 1.29 1.32 1.44 1.46 1.43 1.51 All cancer M No. Rate 2,699 2,779 2,760 2,773 2,782 2,933 2,915 2,926 2,766 2,685 2,345 2,405 2,593 2,431 2,601 2,654 2,781 2,945 2,953 3,135 3,251 3,250 3,312 3,276 8.50 8.50 8.52 8.53 8.64 8.96 8.91 8.65 8.65 9.26 10.76 9.67 9.59 9.13 9.25 8.65 9.12 9.38 9.31 9.84 10.91 10.80 10.97 10.96 F No. Rate 2,710 2,559 2,631 2,829 2,709 2,766 2,798 2,788 2,712 2,422 1,978 2,106 2,320 2,151 2,232 2,405 2,636 2,692 2,711 2,758 2,757 2,856 2,865 2,811 6.59 6.12 6.26 6.69 6.37 6.44 6.48 6.40 6.44 7.06 7.66 7.87 7.61 7.49 7.04 6.34 6.66 6.61 6.59 6.67 6.41 6.55 6.56 6.26 m/f Ratio 1.29 1.40 1.36 1 28 1.36 1.39 1.38 1.39 1.34 1.31 1.40 1.23 1.26 1.22 1.31 1.36 1.37 1.42 1.41 1 48 1.70 1.65 1.67 1.75 Lung cancer m No. Rate 273 294 346 363 396 408 456 469 487 475 451 516 550 515 616 625 726 791 841 918 969 1.020 1.072 1.126 0.86 0.91 1.97 1.12 1.23 1.25 1.39 1.43 1.52 1.64 2.07 2.08 2.03 1.93 2.19 2.04 2.38 2.52 2.65 2.88 3.25 3.39 3.55 3.77 F No. Rate 85 78 80 98 92 120 108 128 133 119 91 101 112 112 118 148 159 172 193 168 201 225 220 239 0.21 0.19 0.19 0.23 0.22 0.28 0.25 0.29 0.32 0.35 0.35 0.38 0.37 0.39 0.37 0.39 0.40 0.42 0.47 0.41 0.47 0.52 0.50 0.53 m/f Ratio 4.10 4.79 5.63 4.57 5.59 4.46 5.56 4.93 4.75 4.69 5.91 5.47 5.49 4.95 5.92 5.23 5.95 6.00 5.64 7.02 6.91 6.52 7.10 7.11 Bronchitis m No. Rate 962 756 796 806 630 872 835 600 763 2,387 1,627 1,275 1,463 1,370 1,469 1,534 1,833 1,377 1,682 1,466 2,126 2,091 2,006 1,326 3.03 2.34 2.46 2.48 1.96 2.67 2.55 1.83 2.39 8.23 8.46 5.13 5.41 5.15 5.22 5.00 6.01 4.39 5.30 4.60 7.13 6.95 6.64 4.43 F No. Rate 1,134 887 846 795 556 756 746 449 595 1,860 1,091 825 1,104 843 953 970 1,156 782 1,077 930 1,372 1,249 1,287 688 2.76 2.12 2.01 1.88 1.31 1.76 1.73 1.03 1.41 5.42 4.22 3.08 3.62 2.94 3.01 2.56 2.92 1.92 2.62 2.25 3.19 2.86 2.95 1.53 m/f Ratio 1.10 0.10 1.22 1.32 1.50 1.52 1.47 1.78 1.70 1.52 1.77 1.67 1.49 1.75 1.73 1.95 2.06 2.29 2.02 2.04 2.24 2.43 2.25 2.90 Table D Mass Radiography Intrathoracic malignant diseases found by the four Metropolitan R.H.Bs. and Ministry's Unit Aggregated figures of rates per 100,000 examined Period Total number of persons examined Males Females 45— 60 and over All ages 45— 60 and over All ages Oct.' 43—Dec.' 45 320,550 29 39 4 6 — 1 Jan.—Dec. 1946 124,171 38 154 17 — — 1 „ 1947 248,028 43 98 14 9 71 2 „ 1948 356,282 47 73 12 12 108 3 „ 1949 403,872 69 180 23 26 111 5 „ 1950 624,984 55 146 19 6 101 3 „ 1951 845,836 56 186 22 13 32 4 „ 1952 960,829 100 334 41 18 50 6 Jan.—June 1953 495,101 108 483 52 13 12 3 155 APPENDIX B REPORT OF A STUDY GROUP ON PREVENTIVE MENTAL HEALTH IN THE MATERNITY AND CHILD WELFARE SERVICE 1. The Medical Officer of Health decided in July, 1953, to set up a Study Group to investigate the possibility of increasing preventive mental health work in the Maternity and Child Welfare service and invited Dr. John Bowlby, Tavistock Clinic, to head it. This Study Group consisted of professional staff of the Public Health Department of the London County Council and of the Tavistock Clinic.*Regular weekly meetings were held over a period of six months and the conclusions of the group are presented in the report which follows. The report was edited by Dr. Wilfrid G. Harding; its findings do not necessarily express the views and the policy of the London County Council. 2. The Report for 1952 of the Central Health Services Council contained the following recommendations: Preventive psychiatry Further consideration was given to this subject during the year, in relation more particularly to childhood. It was felt that there were in mental illness certain predisposing factors, i.e., heredity, personal relationships (especially during childhood and adolescence), emotional, economic and physical stresses, in regard to which preventive measures could be organised. In so far as many of the conditions originated in the early years of life, it was advisable that they should be treated before patterns of behaviour became set. The Committee accepted the recommendations of the Expert Committee on Mental Health of the World Health Organisation regarding 'the desirability of concentrating especially on the therapeutic and preventive psychiatry of childhood' and endorsed its opinion that the application of preventive hygiene measures has particular value during the period of infancy and childhood. The Committee believed that there was great need for the spread of information about the principles of mental health, especially among those whose work brings them constantly into contact with large groups of the community, e.g., maternity and child welfare personnel. The Minister was advised: 'That it is desirable that the Maternity and Child Welfare Service should give more attention to mental health It is to the implementation of these proposals within the County of London that the Study Group has addressed itself. *Membership of the Study Group L.C.C. Dr. D. F Dr. G. D. Pirrie Principal Medical Officers Dr. H. G. Williams— Psychiatrist (deceased) Dr. F. R. Waldron— Divisional Medical Officer Dr. W. G. Harding— Deputy Divisional Medical Officer Dr. E. Chappie Dr. M. S. Gillatt Dr. S. B. Moss-Morris Medical Officers Dr. A. A. V. Smyth Miss F. A. Carter Miss K. J Carden Mrs. D E. Marrin Health visitors Miss M. M. Oldfield J Tavistock Clinic Dr. J. Bowlby Dr. M. Mackenzie Mrs. E. Irvine—Psychiatric Social Worker 156 Extent of problem 3. Mental ill-health constitutes about one-third of all ill-health in Britain today. This is shown by the following figures: (a) About 40 per cent. of all hospital beds are mental hospital beds. (b) During the 1939-45 war, 40 per cent. of all medical discharges from the Army were for psychiatric disorders. (c) In an investigation carried out for the Medical Research Council, Russell Fraser (1947) found that neurotic illness caused between a quarter and a third of all absence from work, due to illness, in a random sample of 3,000 factory workers. 4. Not only is mental ill-health a substantial proportion of all illness, but it affects in some degree about one person in every three of the population. This is shown by the results of three surveys carried out in the late 1940s, one fairly large and the other two very small. (i) Russell Fraser in the investigation referred to above† found that 9 per cent. of the men and 13 per cent. of the women had suffered from definite disabling neurotic illness during the six months prior to the examination, and that a further 19 per cent. of men and 23 per cent. of women had suffered from minor degrees of neurosis during the same period. The totals are 28 per cent. of men and 36 per cent. of women. (ii) In a recent paper Logan and Goldberg (1953)‡ report their study of the physical, mental and social health of the 18-year-old males who registered for National Service in a Borough of outer London in May, 1949. Of the total of 85 youths, 74 co-operated fully. Of these 74, 12 were found to be severely maladjusted* and another 19 mildly disturbed. Expressed as percentages these represent 16 and 26 respectively—or a total of 42 per cent. (Even if all the 11 youths who failed to co-operate are assumed to have been stable, the percentages remain as high as 14 and 22—with a total of 36 per cent.) (iii) Also in 1949 and in a Borough of outer London a survey (unpublished) was made by a psychiatrist on the staff of the Tavistock Clinic of all the eight-yearold boys in a primary school. Of a total of 40 boys, the parents of 33 co-operated fully. Of these boys 14 were judged to be maladjusted*—or 42 per cent. (Again, if it is assumed that the 7 who did not co-operate were all stable the percentage remains as high as 35.) 5. Thus at three age levels—the working population as a whole, eighteen-year-olds and eight-year-olds—the overall incidence of emotional disturbance is found to be in the region of 30 per cent., with fairly severe disturbances in the region of 10-15 per cent. These figures are far higher than is generally assumed. 6. Whereas the incidence of physical ill-health has dropped very strikingly in the last 100 years and continues to do so, there is no reason to suppose that there has been any reduction in the incidence of mental ill-health. Unfortunately, there are no figures available by which these trends can be judged. Some origins of psychological disturbances 7. The old maxim that the influences present during the first seven years of a child's life remain with him for the rest of his existence has been confirmed during the last 50 years by evidence derived from the psychological treatment of adults and children †FRASER, Russell {1947) The Incidence of Neurosis among Factory Workers. M.R.C. Industrial Health Board Report No. 90, H.M.S.O. ‡LOGAN, R. S. L. and GOLDBERG, E. M. (1953) Rising Eighteen in a London Suburb. (Brit. J. Socio1. 1953, 4. pp. 323-345.) (*In this context the term 'maladjusted' indicates that a child or youth is either unable to make satisfactory and satisfying relationships with others or suffers from neurotic symptoms or both.) 157 and more recently through the work of child guidance clinics. For instance, in the opinion of the psychiatrists working in the Council's child guidance units in 1952, in 80 per cent. of their new cases the genesis of the disorders lay in the pre-school years. For 1953, the figure was 87 per cent. As the seeds of so much mental ill-health are sown in infancy and early childhood it follows that action should be taken during those years to prevent their growth. This constitutes an important part of preventive mental health work. 8. Of the common sources from which difficulties may arise during infancy and early childhood, there are three which are particularly relevant to preventive work: (a) action based on false norms of development and behaviour; (b) separation of infant and child from the family such as occurs when they are taken into hospital or residential home; (c) emotional disturbances in the parents, stemming from the parents' own life-history, disturbances in which the child becomes entangled. The first class of case can be corrected by the dissemination of better knowledge, and the second by a combination of better knowledge with more wisely conceived medical and social services; the third, which represents a large proportion of cases, requires assistance of a more specialised and skilled kind. 9. Sound knowledge of norms of infant and child development, especially in respect of behaviour, still needs dissemination. In particular there is insufficient recognition that there is an extraordinarily wide range within which development is normal. A typical example is the well-known fact that the range for the development of walking is about 15 months—between about 9 and 24 months. Similarly wide ranges occur in the normal development of such things as age of weaning, toilet training, obedience, partial independence of mother. 10. Unfortunately false norms have got into currency. These false norms are not infrequently the result of assuming that the earliest time at which such a function develops in any child is the age at which all children should develop the function. These false norms, being quite unrealistically optimistic for the great majority of children, have led to much harm. Mothers have become disheartened because their infants fail to conform to their expectations and, by trying to force the pace, have often created difficulties which would never have existed had there been better understanding of the true norms of development. Thus the acceptance of wrongly based standards of behaviour and achievement prevents some mothers from following their natural good sense with confidence. By trying to make their children conform to unsuitable patterns they create situations out of which conflicts and behaviour problems can arise. Unfortunately, these false norms are still wide-spread in the community so that there is the task not only of spreading knowledge of better based norms, but of correcting the belief in false norms. This is a big educational task, the basic nature of which, nevertheless, is easy to understand. 11. In the second class of case where emotional disturbances of all degrees of severity are caused by separation of infant or child from the family, it should be possible to adapt medical and social services in the majority of cases, once the basic facts and the seriousness of the matter are fully appreciated. 12. However, the third very prevalent source of difficulty arises out of the emotional disturbances of the parents, so that action quite other than education or reform of medical and social services is required. These disturbances, in which deep human emotions such as love, hate, fear and guilt are involved, are of a kind which have hitherto been ignored in the training of health personnel who not only are as a rule unfamiliar with these problems but, because of the nature of the problems, often reluctant to tackle them. Experience of the teaching of this work to members of many professions, medical and non-medical, shows that it is often a slow and laborious process for the student to 158 grasp the essential problem, and any attempt at rapid training is doomed to failure. It may be useful to consider the type of problem concerned in a little more detail. 13. During his early years a child and his mother are to be regarded as a unit. It is only very gradually that he grows out of the environment provided by her and becomes relatively independent. The lack or interruption of an intimate and warm relationship with the mother encourages the development of a child's ordinary anxieties to a pathological degree and these anxieties have been found to underlie a great variety of mental ill-health in later life. Thus the child's mental development and mental health can be affected, not only by premature separation, but also by the nature of the general emotional environment provided, first by his mother and later also by his father and others in the family. Thus he can become deeply upset by experiences such as frank rejection, a covert rejecting attitude underlying his parent's love, by a parent's excessive demand for love and reassurance from him, or by a parent's need for vicarious satisfaction from his difficult behaviour which he or she consciously condemns. 14. In most cases the parents are not fully aware of the nature of these disturbances in their relationship with their children, and the reason for this is commonly that the disturbances have their roots in the parents' own childhood, especially in their relationships with their own parents, brothers and sisters. For instance, a parent who has developed hostility or jealousy towards one of her own parents or siblings may, unwittingly vent her feelings on one of her children who happens to remind her of the original object of her feelings. Equally, a parent who has grown up to feel guilty in regard to some personal failing may see such failing in her child and seek by rather violent measures to correct it, or may even turn from the child in horror. Thus problems of behaviour which do not exist in the child are imagined, and the importance of those which do exist exaggerated and thereby exacerbated. 15. In cases of this kind, advice, often given in excess, is seldom found to be of any value. On the other hand, if the right kind of help can be given quickly, the problem can be dealt with in its early stages before a vicious circle has had time to develop. At present insufficient skilled help is given and sooner or later a very difficult problem is referred to a child guidance clinic. These clinics have in the past been conceived as providing a preventive service, but this has never in reality been the case. It may be that the therapeutic work done in them often prevents even greater problems arising in adolescence and adult life but on the whole child guidance clinics today are inundated with severe problems of many years' standing. The present position in the maternity and child welfare services of the Counity 16. Although it is true that in child guidance work carried out in the Council's clinics and elsewhere the average age of children referred has materially decreased in recent years and that in some clinics appreciable numbers of pre-school age children are nowadays receiving treatment, a radical improvement can only be achieved if the public health staff working in child welfare centres are themselves encouraged to take a live interest in mental health problems and to concern themselves actively with preventive mental health work. 17. The conception that preventive mental health has a place in the maternity and child welfare service is, of course, by no means new. Psychiatrists working in child guidance clinics which have in the past dealt mainly with children of school age have become increasingly conscious of the inevitability of failure in a large proportion of their cases, simply because they were not seen sufficiently early. In London, two child guidance clinics have been established in child welfare centres for periods of 9 and 8 years respectively, and children of pre-school age have been directly referred to them by the centre doctors. The Council's first comprehensive health centre at Woodberry Down, opened in 1952, also includes a child guidance clinic. 159 L 18. In recent years the need for preventive mental health work has been increasingly realised by doctors and health visitors in the Council's service. A survey carried out by one of the Council's psychiatrists in one Health Division during 1952 shows that 3.5 per cent. of young children seen in child welfare centres during a period of six months were sufficiently disturbed to require some form of treatment. In the two centres which have child guidance clinics on the same premises, the corresponding figure was even higher, i.e., 5.6 per cent. 19. A child psychiatrist from the Brixton child guidance unit has paid regular visits to selected child welfare centres during the last two years for the dual purpose of seeing cases referred by the centre doctors and of giving centre staff some insight into the psychological aspect of their work, by regular contact and discussion. Group discussions between child psychiatrists and local divisional medical staff were held concurrently. 20. During the autumn of 1953 two child psychiatrists held courses on preventive mental health with a strong emphasis on pre-school age problems. Attended by doctors, nurses and social workers from all parts of the County, they were conducted on the basis of group seminars, and aroused considerable interest and comment. 21. Concurrently with our meetings experimental case conferences were held regularly each week in a child welfare centre. These were attended by a medical officer and a health visitor, a psychiatrist and a psychiatric social worker, all of whom were members of the Study Group. At these conferences the clinic doctor and health visitor brought up cases for discussion with the consultant team; the latter did not themselves interview the mother or examine the child, but discussed the information contributed by the centre staff. One of the cases which came before this conference was also followed through by our Group and we discussed the technique which was employed by the case conference for this and other cases. 22. The experience gained in this pilot experiment has convinced us that the use of the child welfare centre as a base for preventive mental health work has many advantages because of the established relationship between staff and mothers and the knowledge concerning individual families which has accumulated there over a period of time, often as far back as the mother's first pregnancy. We believe that the normality of the setting in a child welfare centre is important, for mothers of well babies are as welcome as those of disturbed babies so that medical officer and health visitor are not regarded by the mothers as people who are only interested in failures. In such a setting it is possible to employ a flexible technique which is not dependent on regular appointments, but takes maximum advantage of those occasions on which a mother's anxiety leads her to seek help and renders her most receptive to it. The mother's feeling of independence can also be more readily preserved in that the choice of coming is her own. Conversely, the health visitor can bring before the case conference problems of families who, for one reason or another, rarely, if ever, attend the centre. 23. The medical officer and health visitor who took part in the case conference found that the insight gained by this method was not confined to the cases actually discussed, but could be generally applied in their day-to-day work in the centre. This experience was borne out by other members of the Group, both doctors and health visitors, working in the field, who found that they were quite spontaneously devoting increasing attention to mental health factors in their day-to-day contacts in the centre and the home. We were concerned about the time factor which would undoubtedly arise if work of this nature were added to the established functions of the centre. The field workers among our members, however, found that the expected difficulties did not materialise in practice to the extent to which they had been anticipated and that the mental health features of their work became increasingly merged with the traditional approach. 160 Programme of action 24. In the Public Health service of London then, a number of tentative approaches have been made which have prepared the ground for the introduction of preventive mental health work into the maternity and child welfare field, and we believe that the time has now come to prepare a programme of action. Prevention has traditionally been the main function of the public health services and a widening of the range of preventive work, in the light of modern thought, to include the field of mental health should on first principles be the concern of the maternity and child welfare service. 25. Two methods present themselves for the introduction of such a programme : in the first, the child psychiatrist himself—assisted by the other members of his specialist team—would be directly responsible for most of the work, and the staff employed in maternity and child welfare work would act merely by referring any cases which they may recognise as requiring speciahst guidance. The second method is to offer to the maternity and child welfare staff themselves an active and growing share in this work. 26. It is the considered and unanimous opinion of the Group that, because of the size of the problem, it cannot possibly be tackled effectively by child guidance staff alone; their number is at present—and is likely to remain for some considerable time— far too small for a radical extension of services. Besides, it would in any case be entirely impractical to depend on psychiatrists for the recognition of all potential problems in mothers and children attending child welfare centres, and doctors and health visitors would, therefore, have to acquire considerable knowledge in this field. We believe that the only practical solution is not only to accept preventive mental health as the responsibility of the existing public health service, but also to recognise it as a proper sphere of interest for non-specialist staff engaged in the maternity and child welfare field. How then can this new approach be introduced into the existing service and public health personnel assisted to acquire the insight which they will need for their fresh tasks. 27. It is already noticeable that many of the more recently trained health visitors show an increased understanding of human relationships and a lively interest in the psychological aspects of their work. This, no doubt, is due to the greater emphasis which is nowadays being placed on such studies during their training, and a further extension of such activities might well be considered by the Working Party on the Training of Health Visitors which was recently set up. 28. In the training of the public health doctor, on the other hand, child psychology and psychiatry have not so far been given their proper share, though there seems no reason why more systematic post-graduate training in this field should not be offered, e.g., as an elective subject in courses for the Diplomas of Public Health and Child Health. 29. Our immediate problem, however, concerns the large body of existing personnel within the service, both doctors and health visitors. Naturally, not all of them will be equally interested to develop this side of their work, and any training must obviously be based on the principle of voluntary acceptance. We have already referred to the wide interest with which the subject has recently been received within the service and have confidence that the offer of training facilities would receive a ready response. We go further into questions of training and administrative aspects in later sections of this report. 30. No plan of action can be envisaged which does not include close co-operation with the family doctor. This, in any case, is very much on the increase in the present-day practice of preventive medicine and without it not only may essential etiological factors be overlooked but also confusion and misunderstanding aroused. 161 h* 31. We are convinced that preventive mental health activities carried out within the maternity and child welfare service will be welcomed by the general public. Here we would again stress that the proposal that such work should be done by public health staff and in child welfare centres constitutes no more than an extension of accepted principles and existing practice. Those who make use of the maternity and child welfare services expect advice to be given sympathetically and in terms which are readily understood; in the practice of preventive mental health there is no need and indeed no place for 'jargon' and unfamiliar terms, which may frighten rather than help those who seek advice. Moreover, in cases which may have to be referred to child guidance clinics previous contact with child welfare staff who are well known to the mothers may induce encouragement and confidence, and conversely may enable the specialist team to call on the centre doctor and health visitor for continuity of care and follow-up. Increased responsibilities of public health staff 32. The ways in which preventive mental health work can be developed as an integral part of a maternity and child welfare service must now be considered in somewhat greater detail. From the point of view of the broad dissemination of principles a great deal has been and is being done already. Both centre doctors and health visitors— particularly those more recently qualified—have become increasingly alive to the necessity of making parents aware of certain principles of mental health, such as the child's basic need for security, but much more of such work will be required in the future. 33. It is the function of the health visitor to help parents in the care and management of their children in the widest sense. Home visits enable her to make a first assessment of each family. In giving advice, she must bear in mind important principles of mental health. Thus, when it falls to her in an emergency, such as the mother's admission to hospital, to make practical arrangements, she must realise their far-reaching implications for emotional adjustment. For instance, through team work with her colleagues in the field, e.g., home help organisers, children's officers, hospital almoners, etc., she may, by suitable arrangements to keep the child within its home environment, lessen the impact of physical separation from the mother. 34. In a programme of preventive mental health, however, even more will be expected of the health visitor. She has the earliest opportunity to help the mother to deal wisely and confidently with the normal problems of emotional development, and in her contact with the mother during the ante-natal period can anticipate stresses and strains arising from new situations, such as the advent of a new baby, and help the family to find health adjustments. She can help the mother to face the anxiety which inevitably arises from time to time in bringing up young children, and in particular she can give valuable support to the mother who suffers from conscious or unconscious over-anxiety. 35. The basic function of public health activities in the maternity and child welfare field is health education. Centre doctors and health visitors in dealing with problems such as feeding difficulties, toilet training, temper tantrums, etc., are constantly called on to give guidance and advice which demand a preventive mental health approach. The discussions within the Study Group, as well as frequent comments of colleagues, have revealed a very general desire on the part of members of the public health staff to understand fundamental principles of causation and management of such problems, so that they may undertake with confidence the dissemination of broad principles relating to normal developmental phases. 36. A wider understanding may be achieved not only by individual contact with mothers and discussion of their anxieties, but on a broader front through group discussion in the centres. Initially, this will cover only a small proportion of young parents, 162 but this limitation we must accept, knowing that this work, if successful, will gain force, and that, moreover, members of such discussion groups themselves may act indirectly as 'educators' by influencing their friends. 37. Reading matter is being increasingly employed in health education. It is hardly possible, however, to find approaches which will suit all—or even a majority—and such impersonal methods are not without danger. To some extent health education journals are already concerning themselves with mental health. For the understanding of common developmental phases, there may be a case for well-designed pamphlets—some of them reduced almost to picture strips. Some parents, on the other hand, may be referred to more comprehensive reading, and joint schemes with public libraries already exist in some parts of the County. There is as yet little experience in this country of concerted mass approach methods but it is known that they have caused difficulties elsewhere and any development of such methods should be considered with reserve. In-service training of public health staff 38. We have already expressed our view that improvements in the basic training of public health staff, with proper emphasis on mental as well as physical preventive medicine, are necessary and urgent, but they can only gradually come into being even if agreement in principle is reached on them. Moreover, existing staffs will not benefit directly from any improvements of basic training and ways must be found to enable them to play their full part in a programme of Preventive Mental Health. It is the unanimous opinion of the Group that the key to success of such a programme lies in the promotion and maintenance of close ties between individual child welfare and child guidance teams. We believe that such a link-up would be of the greatest mutual advantage and represent the only sound basis for a scheme of this nature. There are, of course, cases which are so profoundly disturbed that they are beyond the scope of preventive methods and early treatment. Such cases will require to be referred to the child guidance team. Close liaison, however, will ensure continuity of treatment and minimise the alarm often felt by parents when psychiatric advice is recommended. 39. In the training of public health staff in preventive mental health, two lines of approach may be distinguished; first, the broad orientation of medical and nursing staff and, secondly, the more intensive training of a smaller number of doctors and health visitors on the basis of individual cases. 40. In dealing with the first line of approach reference has already been made to seminars on preventive mental health which have revealed wide-spread interest among medical officers, health visitors and social workers. Such orientational courses should be frequently held, wherever possible on the basis of local discussion groups. We consider it essential that the Council's midwives should be given every opportunity to participate in such activities. 41. The second approach must be on a much smaller scale. Its keystone must be a more intensive training of a necessarily much smaller number of doctors and health visitors by giving them the opportunity of discussing individual cases with a psychiatrist and psychiatric social worker from a child guidance clinic. In this way they will acquire insight, experience and clinical skill in recognising factors which may give rise to emotional disturbance and maladjustment and in dealing with them in their very early stages. 42. We have referred to experimental work of the Brixton child guidance team in child welfare centres and to the further development of this technique by introducing a regular weekly case conference into a child welfare centre. By using this type of case conference at some of the early meetings of our own Group, we gained insight into the kind of problems likely to be met in child welfare work. We are agreed that this is an extremely valuable method of training. It constitutes the most practical means of 163 introducing techniques of preventive mental health into the maternity and child welfare service and offers at the same time the advantage of facilities for expert consultation. 43. At regular case conferences in child welfare centres, cases will be presented by centre doctors and health visitors and discussed between them and the psychiatrist and psychiatric social worker from a child guidance clinic in such a way that the principles of taking a psychiatric history, the technique of elucidating important factors and the understanding of underlying patterns will gradually become established. In the normal way neither psychiatrist nor psychiatric social worker will actually see mothers and children but, by discussion of the problems, will guide the centre staff in their own handling of the case. There is no reason, of course, why the psychiatrist should not sometimes be asked to see a case himself at the centre, in order to assist the centre staff in its further management without referral to the child guidance clinic. 44. Cases which are found to require closer attention and follow-up than can be given by case consultation in the child welfare centre will be referred to the child guidance clinic, but with the great advantage of continuity of information and attention, both at the stage of referral from child welfare centre to child guidance clinic and later on in the course of treatment and after its conclusion. 45. The scheme would allow the inclusion of non-attenders of our welfare centres whose problems may be noticed by the health visitor in the course of home visits, and who, though unwilling to take part in organised centre activities, may yet welcome the health visitor into their own homes. The health visitor will find the method of case discussion of great value in the handling of such problems. 46. We have already stressed that the scheme must in its early stages be limited to a relatively small number of centres. If it is successful, it can gradually be extended to cover them all. Approaches and techniques are bound to vary in different groups and no attempt must be made to standardise them for some considerable time—if ever. On the other hand, the pooling of experience gained by the different groups will undoubtedly be of mutual benefit. At first the case conferences at the centres will have to be held frequently, probably once a week, but as the child welfare team gains experience and closer links between child guidance clinic and centre begin to be formed it may be possible to reduce the frequency of organised meetings, and the child guidance staff may then be able to extend their contacts to other centres. However, the personal link between centre doctor and health visitor on the one hand and psychiatrist and psychiatric social worker on the other will always be maintained, even when formal meetings take place less frequently. Administrative implications 47. Consideration must be given to the practical implementation of the suggestions made in preceding sections. As far as medical and nursing staff entering the public health service are concerned, it is to be hoped that the need for more intensive training in the field of preventive mental health will be recognised in revised syllabuses for the D.P.H., D.C.H., and Health Visitor Certificate courses. 48. A programme of orientational training for public health staff within the County's service presents no great difficulty. It seems desirable, particularly in view of our proposals for intensive training in the centres, to conduct orientational activities at the local level as far as possible and thereby to establish contacts between public health field staff and the local child guidance units which will facilitate the introduction of intensive training schemes. For the planning of the latter, one of the limiting factors will be the number of child guidance teams which are both willing and adequately staffed to accept such training commitments. It may also be possible to establish closer ties between the two child guidance clinics which already exist in maternity and child welfare centres in Divisions 2 and 3 and the child welfare staffs working in these centres. 164 49. The arrangement of regular case conferences will not present major organisational problems. It is not envisaged that these need occupy a full morning or afternoon session; weekly meetings lasting from an hour to an hour and a half should be adequate and can be fitted into the centre time-table without undue difficulty. 50. While the case conference will provide clinical guidance to the public health staff, the actual management of the case will be in the hands of the centre medical officer and health visitors in the course of their normal activities. At routine child welfare sessions, however, a continuous flow of mothers and babies usually arrive for consultation and this is not a suitable setting for intensive work. For such work, neither mother, doctor nor health visitor must have the feeling of being pressed for time. Already centre doctors often discuss 'special problems' by appointment, either towards the beginning or end of their ordinary sessions, or during special sessions, e.g., at 'Toddler Clinics'. Undoubtedly similar arrangements will have to be made for preventive mental health work. In those child welfare centres where case conferences are introduced the medical officer must have the opportunity of arranging special appointments so that he can devote sufficient time for discussion with the mothers without disturbing the routine work of the centre. 51. We refer in paragraph 36 to the formation of parents' discussion groups. Mothercraft classes which are at present being conducted by health visitors in many child welfare centres in the County form a useful nucleus, but they could be further developed to allow for the attendance—at least at times—not only of the centre doctor but also of members of the child guidance team. For afternoon meetings it would seem possible to time such discussions so that they either precede or follow the regular case conference. Evening meetings similar to those of parent-teacher associations should also be arranged at not too infrequent intervals in order to give the father as well as the mother an opportunity for discussion. 52. A programme conducted on these lines would cause least disturbance of existing services. As training and consultation could proceed side by side the scheme would provide for the extension of centre activities to include preventive mental health work from its inception, though, of course, on a very limited scale at first. The scheme is capable of modification and adaptation to local circumstances and of development in the light of experience, and one of its great advantages is that it allows preventive mental health work to be carried out as part of the normal activities of the child welfare centre and by the centre staff themselves. Thus the mother will be advised by those who may, in many instances, have assisted her already in the ante-natal period and in whom she has gained confidence. Summary of recommendations 53. (1) Preventive mental health is a proper field of development for the maternity and child welfare services. A large measure of this work can be carried out by suitably trained medical officers and health visitors. The need of including more intensive training in preventive mental health in revised syllabuses for D.P.H., D.C.H., and Health Visitor Certificate courses has been stressed. In-service training schemes for doctors and health visitors employed at present on the maternity and child welfare services of the County are recommended. These include: (a) Broad orientation of all professional public health staff through seminars and group discussions. Such training should be conducted at divisional level by the staff of local child guidance clinics. (b) Intensive training of a limited number of medical officers and health visitors. Such training should also be conducted by the staff of local child-guidance clinics, in the form of weekly case conferences during which problems of mental health arising in the course of maternity and child welfare work are discussed on an individual case basis and guidance is given on their management. 165 (2) Preventive mental health is a proper field for health education measures : (a) Group activities at mothercraft sessions should include the full discussion of such problems; evening sessions are desirable at not too infrequent intervals in order to afford both parents an opportunity to attend. (b) Reading matter, film strips and films may be useful media for the propagation of the principles of preventive mental health and there is scope for the preparation of suitable material. Mass approach methods, such as periodic bulletins, etc., merit further study before the value of their inclusion in a programme of preventive mental health can be properly assessed. Such measures can, in any case, be considered only as subsidiary to methods of individual and personal approach which are essential in the field of preventive mental health. The Study Group wish to record their appreciation to Dr. W. Warren, Brixton Child Guidance Unit, Dr. A. Bolton (lately of that Unit) and Mrs. Kahn Freund, psychiatric social worker, Woodberry Down Child Guidance Unit, who attended some of the meetings of the Group. 166 APPENDIX C A HISTORICAL SKETCH OF THE ORIGINS, DEVELOPMENT AND PRESENT ORGANISATION OF THE SCHOOL HEALTH SERVICE Foreword by Dr. C. J. THOMAS, Senior Medical Officer, School Health Service from 1902-1941 'There is cause here for pride 'said Sir Gwilym Gibbon speaking of the school health service in his monumental survey of the Council's activities issued to mark its Jubilee in 1939. This will be the verdict too, of all who read the following pages. They will bring home how earnest is the solicitude of the Council for the care and well-being of the children and young people in the schools of the Metropolis. There are two names that stand out in the history of the service; one is that of Dr. James Kerr, the first school medical officer, who initiated the medical inspection of school children and who had a vision of a great preventive service and the faculty of kindling enthusiasm in his colleagues and helpers, and the other is that of Miss Morton, the first principal organiser of school care committees. The establishment in every school of a care committee to which is delegated certain powers of the central authority is the unique feature of the London system. Representatives of the care committees attend hospitals and centres where school children are treated and send a stream of information which enables the care committees to aid the parents in carrying out the advice given and to secure such modifications of social conditions as are necessary in the interests of the child concerned. A comprehensive school dental service, preventive in outlook, is one of the pillars of a complete national health service. The aim should be that every child leaving school should enter industry with sound teeth and a healthy mouth. The disruption of the school dental service was an unforeseen result of the establishment of the national health service. It was a late example of 'the cart before the horse' and of the baffling antithesis which so often makes itself apparent between preventive and curative medicine. The saving to the community of a complete and flourishing school dental service is great and no effort should be spared to ensure it. To one whose fortune it has been to experience at first hand from the beginning all the horror of the contact with the condition of the children in the first years of the century, the frustration and despair engendered by the lack of means and power to remedy matters and the dawn of expectation as the conscience of the community was aroused and empowering legislation initiated, the steady growth of the service is the fulfilment of hope and a dream come true. The London School Board and the transfer of its powers to the Council The Elementary Education Act of 1870 laid the foundation of a national system of elementary education. The Act provided that there should be one school board for London, which first met on 15th December, 1870. The Board found that more than half the children of London had no school to attend, and it provided a school place for every child needing one, created a system to enforce school attendance, and built up a body of competent teachers. It did not, however, build up a school medical service. In its final report, the London School Board stated: The London School Board 167 'it has always been a question how far the Board is authorised to spend public money on the medical care of children. On the one hand suggestions have been made for the inspection of their teeth, and the treatment of cases of anaemic condition and arrested development. On the other hand a legal opinion has been expressed that the Board is not entitled to do anything, or to take any measures except such as spring from the fact that the attendance of the children is compulsory. On this account it has been thought right to take action only in those cases in which on account of contagious disease, it is necessary to exclude children from school.' The Board did, however, make provision for the teaching of handicapped children about which more information is given later in this report. In 1890, the Board appointed a medical officer to report on candidates for permanent appointment and generally to advise the Board on any matters on which his special knowledge might be useful and in 1898 two assistant medical officers were appointed to examine defective children, each medical officer giving an equivalent of half-time to the work. One of these medical officers was a woman who also had the duty of examining female candidates for appointment by the Board. In 1901 it was decided to appoint oculists to test the eyesight of the children in senior departments of schools of the Board and, to counteract the severe incidence of chronic infections and parasitic disease, of which ringworm alone kept thousands of children away from school for long periods, the Board in October of that year, appointed the first school nurse, who was soon nicknamed the 'ringworm nurse'. In 1902, Dr. James Kerr, who was a Bradford ear and eye surgeon and who had acted as adviser to the Bradford School Board, was appointed whole-time Medical Officer to the Board. Two half-time assistants were appointed for work in connection with the special schools, and, shortly afterwards, an additional half-time assistant was appointed for a special measles enquiry projected by the Medical Officer. A laboratory was provided and the oculists' duties were tacitly extended to include a great deal more than mere vision testing; five additional nurses were appointed and systematic records of all observations were kept. The field of work entered into by the medical department was the investigation of all conditions affecting or tending to affect the health of those working in the schools. At that time, conditions were appalling—the vision of 60,000 children was so bad that they could not see the blackboard; there were 20,000 cases of ringworm; and a third of the girls had verminous heads. The Medical Officer to the Board wrote in his report for the year 1903: 'The maintenance of sanitary conditions as regards heating, lighting, ventilation, and cleanliness both of the buildings and persons of the pupils, the detection of early cases of illness . . . ill-health from any causes . . . come under the daily work of the teacher, and there is no requirement that any knowledge of such matters should be possessed by him. It is left to his own common sense . . . ' In his report for the following year, the Medical Officer wrote: 'The provision of medical oversight for school life is rapidly becoming a necessity.' The following work was undertaken by the School Board in the year 1904: A cleansing scheme for the schools was established. A complete report was obtained on the visual condition of the children. The method of bacteriological control of diphtheria was established. The measles enquiry was extended. All the children in the special schools were reviewed. Enquiries were commenced to elucidate conditions of congenital aphasia. 168 During 1903-1904, work had so rapidly extended that it could not be systematically carried out for want of staff, and what had been done showed the serious conditions existing in various directions. The Education (London) Act, 1903, which applied the Education Act of the previous year to London, abolished the School Board and transferred its powers to the London County Council. On the 1st May, 1904, the London County Council took over from the School Board for London 521 schools, having an aggregate average attendance of 485,343 pupils, and also became to some extent responsible for 438 voluntary schools with 175,408 pupils. Sir Shirley Murphy, then Medical Officer of Health to the Council, stated in his report: 'The year 1904 will always be notable in the sanitary history of the Metropolis for the reason that by the transfer of the administration of the Education Acts to the London County Council, a health authority is brought into direct relation with a large proportion of the child population of London. This change in administration gives opportunity for the study by a health authority of the conditions which affect the growth and development of the young, and for the application of measures which tend to promote improvement in their physical condition. It gives greater opportunity, moreover, for the study of the behaviour of communicable maladies which affect the whole population, but which have their greatest incidence upon children, and for the application of knowledge thus obtained to the limitation of risks which are inseparable from the aggregation of young and susceptible persons, and which have in the past been productive of regrettable results upon the prevalence of disease, not only among school children but among the population at ages other than those of school life.' It is always salutary to reflect upon the words of the early workers in any field, and such applies particularly to the above quotation by Sir Shirley Murphy. By this transfer of the administration of the Education Acts to the Council, the health authority was brought into direct relation with a large proportion of the child population of London. From the start, much attention was paid to the care of handicapped children and the welfare of pupils in general. A scheme was prepared for dealing with the general condition of the pupils, the prevention of diffusion of infections, the promotion of cleanliness, and the sanitary conditions of school buildings. To carry out this work, one permanent 'half-time' assistant and twenty 'quarter-time' temporary assistants were appointed. For dealing with ringworm and securing personal cleanliness in the schools a superintendent and twenty-six nurses were added to the staff. In 1904, as a result of the revelations of the Army Recruiting Boards about the number of remediable physical defects found in recruits during the South African War, a Departmental Committee on Physical Deterioration was appointed. Both this body, and an Inter-departmental Committee on Physical Training, reported strongly in favour of the institution of a medical service in schools. By the end of May, 1905, the Education Committee had reported upon each of the 438 non-provided schools, suggesting that 92 schools, accommodating about 69,000 pupils, were so defective that closure seemed the only remedy, and that 282 schools required material alterations. By 1907,77 of these had been closed, six transferred to the Council, and all except 56 brought up to the Council's requirements. Care committees and children's care organisers Care committees were first formed in July, 1907, when two temporary social workers (a man and a woman) were appointed to form the care committees in poor schools and to report on the methods of selecting necessitous children. In submitting his report the chairman of the Education Committee's Sub-Committee on Underfed Children, said: Assumption of responsibility by the Council Care committees 169 'The Council has created children's care committees whose province it should be to deal with all matters which affect the welfare of the child outside the curriculum —home conditions, medical treatment and after-care should be part of the work and should all be brought into close connection with the feeding problem.' In 1909 the Council recognised care committees in all elementary schools (and later all day special schools) and extended the scope of their work to after-care and advice to school-leavers on the choice of employment in co-operation with the local juvenile advisory committees appointed by the Board of Trade in 1910 under the Labour Exchange Act (1909). A care committee was formed for every elementary school; members were appointed by the Children's Care (Central) Sub-Committee of the Education Committee. The link between the individual care committees and the Central Care Sub-Committee was through the local associations of care committees which were formed for each borough. The first care committees had, in poor neighbourhoods, to struggle with want and disease and a great deal of prejudice in parents. The part played by those committees when the treatment centres were established is described in the section on 'Medical inspection and treatment'. page 177. A small body of paid social workers was appointed by the Council to assist in the formation of care committees, to recruit, train and advise voluntary workers and to interpret the rules and policy of the Council. These children's care organisers are employed in both the Education and Public Health Departments. The division in the organising staff between the two departments was necessitated by the growth of the school health service. At the present time there are approximately 65 children's care organisers in the Education Department, working from offices in each of the nine administrative divisions, and a Principal Organiser (and her assistant) at the County Hall. There are also about 84 children's care organisers and a Principal Organiser in the Public Health Department, and a District Care Organiser and a Divisional Treatment Organiser in each division. The organisers in the Public Health Department co-operate with those in the Education Department in the recruitment and training of voluntary workers and the training of students. They attend the school health service clinics and many hospitals, and they control the appointments and are present at the doctors' sessions, talking to the parents and children, when possible explaining the routine of the individual treatment involved, and hearing personal problems with which parents do not like to bother the doctor. The organisers 'follow-up' after the session, arrange for any further treatment and re-appointments, and report to both the Care Committee and to the school doctor on what has been done or decided for the child at hospital clinics. There is continual exchange of information between care committee workers (some 2,400) and the organisers. In the hospitals the organiser's position is unique. She attends the clinics specially provided for London children, works in the same room as the physician or surgeon and interviews every mother and child personally. As such her work differs from that of an almoner who, generally speaking, is not present at examinations and can, therefore, normally only meet the problems referred to her by the medical staff. The organiser is regarded as the link with the Council. At the request of the Ministry of Education, the Council now has under consideration the question whether some modifications should be made in the duties of organisers in the Public Health Department. The need for such a review was emphasised by the opportunity provided by the National Health Service Act for the Council to bring together for the first time its health visiting and school nursing services. Children's care organisers 170 Nutrition Before 1906, the teachers of London, faced with the difficulties of endeavouring to educate children who were obviously suffering from lack of food, undertook extensively to give some nourishment to such children with the aid of voluntary funds. The meals given varied widely but were restricted in scope and in nutritional value by the inadequacy of the funds contributed to cover the whole of the needs of the schools. The School Board had made special enquiries, in 1889,1895 and 1898-99, into the subject of feeding children who could not profit from teaching through lack of food. As a result of the 1889 enquiry, the number of school children in want of food was estimated to be 55,000 and it was decided that a central organisation was required to prevent waste and overlapping of voluntary effort, and the London School Dinners Association came into being. After the more extensive enquiry of 1898, when it was recorded that, in addition to the London School Dinners Association, there were four associations operating in various parts of London, a Committee of the Managers was appointed for each 'necessitous' school to draw up lists of necessitous children and to apply to the Central Associations for funds for meals if these were found to be needed. A Permanent Joint Committee of Underfed Children was appointed in 1900 and dealt with applications for assistance from the school committees. In 1904 the voluntary or non-provided schools came within the sphere of the Joint Committee and the scope of the 'Relief Committees', as they were then known, was enlarged to include the provision of boots, clothing and other kinds of assistance in addition to food. In 1905 the Council decided to seek powers from Parliament to provide food when necessary for children attending rate-supported schools in London. The Education (Provision of Meals) Act, 1906, gave powers to local education authorities to provide meals for children who were 'unable by reason of lack of food to take full advantage of the education provided for them', and care committees (first formed in July, 1907) were made responsible for the work. It was not until 1908 that (as voluntary subscriptions were beginning to fail) it was decided to utilise public funds for the purchase of food. The system then introduced for the feeding of necessitous children continued for over thirty years with little alteration. During the winter of 1909-1910, the school doctor at Wolverley-street school, Bethnal Green (Dr. Hawkes), finding so many children in the school at that time suffering from malnutrition, suggested that they should be given milk in school. The head teachers and the care committee of the school took up the suggestion and milk was provided. The results were so good that the practice of giving milk on the school doctor's advice, spread, first to neighbouring schools, and eventually to the whole of London. Before the second world war, voluntary milk clubs existed in most schools to enable the children to buy milk as cheaply as possible. During that war, the Government sponsored a nation-wide campaign to encourage children to have meals at school which resulted in a very rapid expansion in London, as elsewhere and the Government also introduced a scheme whereby one-third of a pint of milk was supplied at a reduced price for children attending school. Present legislation is embodied in the Education Act, 1944, under which local education authorities are required to provide meals of a high nutritional standard for those children who want them and for which parents pay a standard charge fixed by the Minister of Education which may be remitted partly or wholly. Over 200,000 school children in London received subsidised school dinners in 1954, as compared with about 10,000 before the war. Since 1946 milk has been issued free and nine out of ten children in London take advantage of the scheme. Vitamin capsules are purchased by the Council for school children and a charge is made to cover the cost unless they have been prescribed by the school doctor. Children under five may have cod liver oil and orange juice free. School meals and milk 171 It was decided to include in the three-year programme, 1935-38, additional provision for full investigation at special investigation centres of under-nourished children referred from the ordinary school medical inspections and to have five centres, one in each medical administrative division. The divisional medical officers each nominated, from the staff engaged in their divisions, an assistant medical officer (part-time), specially qualified in this work. To each centre, an experienced nurse was allotted and a specially selected organiser with experience in social economics. Careful investigation was made of the family budgets and dietaries, and advice on the latter was given to the parents. The Organiser at the centre was in touch with the School Care Committee, who in turn kept in touch with the children both at home and in school, and reported to the Organiser for the doctor's information. When a period of observation in hospital was desired, this was arranged at the Council's special hospitals for children. The clinics started in 1935 and from the outset, children other than those suffering from malnutrition were examined, the true function of the clinics being that of further inspection and advice. The control of infectious and parasitic diseases Before 1891 (when the passing of the Public Health (London) Act made it compulsory for the Medical Officer of Health to send a copy of the notification relative to certain infectious diseases to the teacher of any school attended by children from infected houses) there was no attempt to prevent the spread of infectious disease by precautionary measures at school. In those days the schools were regarded as hotbeds for the dissemination of infectious disease, and the only remedy the health authority could think of was to close them during epidemics. However, as a report to the School Board for London in 1900 pointed out: 'The closing of schools, besides leading to grievous educational waste, is an admittedly ineffectual system of dealing with the spread of infection. The children, healthy and infectious alike, are only driven out of school to associate freely together in the streets.' The Annual Report of the Medical Officer of the School Board for London for the year ended 25th March, 1904, stated that, when the Head Teacher received the copy of the notification of infectious disease from the Medical Officer of Health, 'all affected children (whether suffering or coming from the home in which the disease exists) are excluded from school'. If a child showed symptoms of measles, mumps, whooping cough or chicken-pox (which were non-notifiable diseases) he was excluded. The experience of the school medical service in London has been that the control of infectious diseases occurring among school children' is best secured by a system of immediate exclusion from school of individual scholars, who are themselves suffering or suspected to be suffering from illness of an infectious or contagious character, and the prompt notification by head teachers of such exclusion to the Divisional Medical Officer and the Borough Medical Officer of Health concerned. Generally speaking, routine disinfection of schools is considered to be valueless. Constant touch is kept with the medical departments of the Borough Councils to ensure that children who have been excluded do not spread infection by mixing with others. When the number of cases of infectious disease reported from a particular school indicates a high prevalence, special visits are made by a school nursing sister, and, if necessary, by a school doctor. 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. At the time when the powers of the London School Board were transferred to the Council, measles and whooping cough were often fatal diseases to very young children. In his Annual Report for the year 1908, Dr. Kerr reported that the measles enquiry which he had proposed to the School Board had been conducted in the district of Woolwich by Dr. C.J. Thomas in co-operation with Dr. Davies, the Borough Medical Officer of Health. The enquiry gave much valuable information in regard to the distribution and methods of treating measles outbreaks in schools, resulted in a great Nutrition centres General Measles 172 saving in school attendance and showed also that the measles death-rate might be minimised. By means of advice cards there had been accomplished a gradual education of parents to a sense of their responsibility and to the seriousness of the disease. The principles deduced from the enquiry were of sufficient weight and importance to justify their application to all the infants' departments of the public elementary schools in the Metropolitan area. They were also recommended generally by the Local Government Board. The procedure adopted was that the infants' head teacher made enquiry as to the measles history of each pupil on the roll, and of every child newly admitted to the department, if a child had already had measles, this was recorded in the attendance register by the letter 'M'; if the child was not known to have suffered, this was noted by the letter 'O.' If a child with a negative measles history contracted the disease before leaving the infants' department, a suitable alteration was made in the register. The record thus established served to show at any time the proportion of children protected by previous attack to those who were unprotected and liable to attack when exposed to infection, and it was upon this knowledge that any action was based. Immediately a case of measles occurred in the department, a card was distributed to each of the unprotected children in the classroom in which the patient was attending. This card informed the children's parents or guardians that, as a case of measles had occurred among the pupils in the children's class, it was possible that they might have contracted the disease, and the parents were requested to pay particular attention to the state of the children's health during the following three weeks, and upon the slightest sign of illness to abstain from sending them to school. The case was then reported to the Medical Officer (Education) with particulars as to the relative numbers of protected and unprotected children in the room. The measles returns from all schools were reviewed daily at the head office, and when, in the opinion of the doctor, closure of a classroom would tend to check the spread of the disease, instructions were given to the head teacher, who immediately sent home the children in the affected classroom, after distributing a card of warning to parents. Unfortunately, when closure took place, all subsequent events passed out of knowledge and the control of the outbreak by home visiting and advice on the part of the local Medical Officer of Health ceased. The school remained the one channel of information concerning measles and in the absence of school attendance the control over the death-rate given by this knowledge was lost. The control of measles in London schools continued to be the subject of serious consideration. For example, a scheme was devised in 1913 by which it was sought, with the co-operation of attendance officers and head teachers, to secure notification of the first case in school within a week after the sufferer's last day of attendance. In accordance with an Order of the Local Government Board dated 27th November, 1915, measles and German measles became compulsorily notifiable diseases on 1st January, 1916. With the object of deriving full benefit from compulsory notification in connection with the control of measles in the schools, an arrangement was made with Dr. Davies, the Medical Officer of Health of Woolwich, whereby full particulars of all cases of measles notified under the Order were at once reported to the School Medical Officer in order that immediate steps might be taken at the school concerned to limit the spread of infection. As a tentative measure the principle of class closure for short periods, instead of merely excluding those children who had not previously suffered from measles, was adopted in Woolwich with a view to discovering whether by such means a greater control over the spread of measles in school could be secured. The Order relating to compulsory notification of measles was rescinded by the Ministry of Health in December, 1919, and, while this action was no doubt justifiable, it became the more necessary that close watch should be kept upon measles in the schools, and special measures were approved by the Council having this object in view. The Ministry of Health pointed out that various criticisms had reached them as to the ineffectiveness of the Order of 1915 and that it had been concluded that compulsory notification was not the best method of dealing with the problem of the control and 173 treatment of measles. On the other hand, it was pointed out by the Ministry that there were many other channels of information through which medical officers of health received information of cases of measles, i.e., from school teachers, school attendance officers, health visitors, etc., and it was expected that the withdrawal of the Notification Order would leave local authorities free to organise their existing resources with a view to combating the spread of the disease and the mortality arising therefrom. In this connection the School Medical Officer circularised the borough medical officers of health to ascertain what measures were being taken to provide for nursing assistance in cases of measles and whooping cough and the replies received indicated that, generally, the provision of nursing care was being dealt with in London. A scheme was drawn up in consultation with the Education Officer for the more effective control of measles in public elementary schools by expediting where possible the ' voluntary ' notification of cases of the disease (in addition to compulsory notification in those London boroughs which had decided that this should remain in force) thus enabling local sanitary authorities to put into operation their arrangements for nursing provision and ' following up ' at an earlier date than would otherwise have been possible in many instances. The scheme involved close co-operation between the school nurse, head teacher, school attendance staff, and the public health staff of the borough. It was proposed in the scheme to pay special attention to the children under five years of age. As time passed, experience showed that the policy of school or class closure was valueless, as closure was not resorted to until the outbreak had become well-established, and by that time the damage had been done, all the ' susceptibles' having already been exposed to infection. The need for utilising to the fullest possible extent the administrative powers and machinery, both central and local, for securing the fuller control of measles led to concerted action by the Council and the Metropolitan Borough Councils. At a conference, on 25th February, 1921, there was a general measure of agreement with the Council's scheme for dealing with measles, which on the one hand, involved the fullest utilisation by the Borough Councils of their powers under the Public Health (London) Act, 1891 and the Maternity and Child Welfare Act, 1918, for giving all possible assistance in the matter of providing nursing and medical treatment in co-operation with the Central Council for District Nursing and local voluntary nursing associations, and by the Council, on the other hand, in providing all possible facilities of its school organisation, involving the co-operation of head teachers, school attendance staff and school nurses in bringing cases of measles to light and reporting them to the Medical Officer of Health of the borough concerned. It was reported by the School Mcdical Officer in the annual report for the year 1925 that this procedure had been applied in successive epidemics in recent years and that there had been a concurrent decline in mortality from the disease. It was also stated in the same report that the most effective of the administrative steps taken to reduce the mortality from measles had been the attention to, and nursing of, sick children in hospitals or in their homes. Owing to the 1914-18 war, conditions were very adverse in the poor quarters of London and the mortality from measles in particular was excessive in these areas in the winter of 1917 (before the food supply was brought under control) and it is probable, but for these adverse conditions, that the reduction in the measles mortality would have occurred earlier. With rationing of food and the decline of the birth-rate conditions altered for the better, both for the children and the mothers. Although, therefore, a good deal could be accomplished in reducing mortality, experience showed that, in spite of all efforts, little could be effected in the way of checking the incidence of the disease when it became epidemic. As a result of observations of the working of the scheme inaugurated in 1921 the principle was adopted of concentrating upon the crowded, insanitary and slum areas, where, owing to want of medical attention and proper nursing, measles mortality was notoriously high, and paying less attention to the better-class residential areas where parents were better able to afford the services of a private doctor. 174 By 1931 the following conclusions could be drawn from previous experience : (i) Measles epidemics occurred every two years in London, commencing in the autumn and lasting for six or seven months. (ii) The only means of preventing a measles epidemic was by the use of serum, but, owing to practical difficulties, this preventive could, at that time, only be applied in very restricted communities (hospitals, residential schools, etc.). (iii) The incidence was greatest in the age groups 1-5, and the deaths highest in the age groups 1-3. (iv) Practically all measles deaths resulted from complications (bronchopneumonia especially) which were to a very large extent avoidable if patients obtained adequate medical and nursing care. (v) Children were not sent to hospital until complications had arisen. (vi) The younger the child, the greater the risk of serious illness from complications. Measles again became notifiable in London in 1938 and for control purposes the results were immediate. Before any records of epidemiological value could be accumulated however, the normal biennial rhythm of attack was disturbed by the evacuation movements of 1939 and subsequent war years and in the years after 1940 the attacks were annual and of the same order of magnitude every year. In 1951, it was reported that the rhythm of measles epidemics was then moving towards a biennial period such as had existed in the period 1923-38. Before 1938, records of incidence were built up from reports of absences from school, from hospital admissions and from mortality records. Up to the outbreak of the 1939-45 war, biennial epidemics were of such magnitude that more than 70 per cent. of children suffered an attack before the age of 15. In 1949, it was stated that the overall incidence had been reduced to such an extent that the risk of attack before the age of 15 had fallen to 60 per cent. Most deaths from measles are due to respiratory complications, and the more recent reduction in mortality can largely be attributed to the use of the sulphonamides and anti-biotics in the prophylaxis and treatment of the respiratory complications. Like measles, whooping cough was often a fatal disease for very young children at the time of the transfer of the powers of the London School Board to the Council. The fatality from this disease, which has been declining since the end of the last century, has fallen with dramatic rapidity in more recent times. Immunisation against whooping cough is kept under close watch with a view to the establishment of arrangements similar to those for diphtheria as and when medical developments justify it. Parents who ask to have their children immunised against whooping cough can have it carried out free at a session in one of the Council's centres by arrangement, and the Council pays the standard fee for records of such immunisations received from eeneral practitioners. Whooping cough Mention has already been made of the appointment by the London School Board, in October, 1901, of the first school nurse, who was soon nicknamed the ' ringworm nurse'. At that time, ringworm kept thousands of children away from school for long periods and was one of the diseases considered by the Special Sub-Committee on the Treatment of School Children (referred to in the section on ' Medical inspection and treatment'). The disease was the chief trouble the nurses had to contend with, the resources of the hospitals being inadequate to deal with the problem. In 1906 it had been shown that ringworm cases corresponded to a school absence involving a loss of fee grant of between £5,000 and £6,000 annually and this meant an average of 2,950 children out of school. Subsequently, the Attendance Department ascertained that the average number absent at any time was about 3,500 to 4,000. In his annual report for the year 1911, the School Medical Officer stated that, in recent years, there had been about 6,000 new cases annually. When the treatment scheme became established, an enquiry by the nurses, who filled up a card for each case, showed 3,542 cases, of which 446 were being treated by Roentgen rays. 175 Ringworm It was also stated in the annual report for 1911 that ringworm was costing the Council not less than £7,000 per annum in the service of doctors, nurses and hospitals and in the loss of fee grant entailed. Details of each case of ringworm as it became known were entered upon a special card and the school nurse followed up the case to the best of her ability. If any child was alleged to be under treatment by a doctor, no further consideration was given and children said to be treated by a chemist or at home were offered X-ray treatment but if this was refused no action was taken. This was the weak part of the scheme. Certain other cases, however, were followed up and treated under the Council's schemes. About 20 per cent. coming under treatment in 1911 were being treated by Roentgen rays but up to the end of that year, there had been no noticeable diminution in the number of cases reported. The Council's laboratory rendered all assistance possible in the diagnosis of the disease. By 1919, however, the number of cases of ringworm discovered in the schools had been diminishing steadily for several years, and, although there was some retrogression in 1919 and 1920, the number dropped again in 1921 and the following years, so that, in his annual report for the year 1924, the School Medical Officer was able to refer to the success achieved in the prevention of the disease among elementary school children in recent years, and to state that this success might be ascribed to the efficiency with which new cases were promptly discovered by the school nurses and the increasing number of children treated by means of X-rays. In 1911, when 6,214 fresh cases had been discovered, only 30 per cent. had received X-ray treatment, and this percentage had progressively increased year by year until, in 1924, as many as 70 per cent. of the cases were X-rayed. A great advantage of the X-ray treatment was the avoidance of much loss of school attendance, for whereas a child treated in this way was ordinarily able to return to school in two months or less, children receiving ointment and other forms of treatment might have been away from school for years, to the detriment of their whole career. By 1933, the number of schoolchildren suffering from ringworm of the scalp had sunk to the comparatively insignificant total of 178, and the incidence of the disease continued to be comparatively rare up to the outbreak of war in 1939. Throughout the war years, the incidence of the disease in London was small, but extensive outbreaks were reported from other parts of the country. With the cessation of hostilities the return of children from all over the country was almost certainly the cause of a marked increase in the number of cases in London. Treatment by X-ray continued to be the method of choice and, in addition to arrangements made with certain voluntary hospitals, facilities were provided by the Council for out-patients at Hammersmith Hospital and for in-patients at Goldie Leigh Hospital. During 1946, there was again an increase in the number of cases of scalp ringworm, when there were 311 new cases, but there was a marked falling off in 1947 to 150 cases and this trend has continued. Favus A number of cases of favus, a parasitic disease of the hair which chiefly affects the scalp, though occasionally found on other parts of the body, were found to exist among the school population of East London in 1904. The disease was almost entirely of foreign importation, and occurred chiefly among the alien population of the East End. At that time, there were 79 known cases of favus in one small area of the East End, of about one square mile in extent, and 34 cases outside that area. A detailed inspection of the pupils in 21 schools, situated chiefly in the affected area, resulted in the detection of 51 further cases. The opportunity was thus presented for making a new departure in the method of prevention of the disease by forming a special class or school for children suffering from favus, where treatment could be supervised while, at the same time, school work could be carried on. On 28th February, 1905, the Council agreed to establish a favus school, and on 6th June, 1906, the school was opened, with a roll of 61 children, in a temporary building situated in Finch Street, Whitechapel. At first, treatment was not included in the scope of the work, but the school was supervised by a medical officer who arranged for the heads of the children to be cleansed and disinfected daily, and for the treatment 176 School children at Snowsfields Primary School in 1894 School children at the same school in 1952 School medical inspection in 1913 School medical inspection in 1953 prescribed by a hospital or private doctor to be effectually carried out. Very little progress was made in actual cures until the Board of Education, in August, 1907, agreed to recognise this school as a ' special school' under the Elementary Education (Defective and Epileptic Children) Act, 1899, as this gave the Council power to carry out treatment of the children. In May, 1908, an X-ray apparatus was installed, and thenceforward the cases were cured with comparative rapidity. By the summer holidays, 1909, only three cases remained uncured and the school was closed as a teaching centre. With one exception, all the children treated were of alien descent. With a view to preventing the further ingress of favus into the country through the Port of London by immigrants, the Public Health Department worked in co-operation with the Medical Officer to the Port of London Authority and London Immigration Board. Medical inspection and treatment In 1905, without waiting for legal powers (which it was clear would shortly be enacted) school medical inspection was started and in January, 1906, a complete system of medical supervision was extended to all the non-provided schools, and large numbers of children who should have been in special schools were discovered. Section 13 of the Education (Administrative Provisions) Act, 1907, provided that ' the powers and duties of a local education authority under Part III of the Education Act, 1902, shall include—(b) the duty to provide for the medical inspection of children immediately before, or at the time of, or as soon as possible after their admission to a public elementary school, and on such other occasions as the Board of Education direct.' With the inauguration of a scheme of medical inspection it soon became evident that there was need for further facilities for treatment of some of the ailments discovered. As the result of inspection the numbers of children attending the hospitals were so seriously increased that many of the larger hospitals were compelled to limit the attendance of school children to certain numbers of children to be seen on any appointed day. In the introduction to the Annual Report of the Medical Officer (Education) for the year 1907, it was stated that a point had been reached when it had to be decided whether the greater part of the medical inspection work should remain fruitless or whether the Council should take steps which would justify its later interference to see that its younger dependents had a fair chance of benefiting properly from the education offered. On 25th July, 1911, the Council resolved that school medical work, including medical treatment, should be placed under a new Medical Officer of Health to be appointed, who should also be the Medical Officer and on 1st January, 1912, Sir William Hamer became both Medical Officer of Health and School Medical Officer. Early developments A Special Sub-Committee on the Treatment of School Children was appointed in July, 1907, which included thirteen representatives of the Council and representatives of outside interests such as the chief medical bodies, hospitals and charities. The SubCommittee reported that the resources of the hospitals were inadequate and recommended that agreements should be made with existing voluntary bodies, including hospitals, and that, where these arrangements were not sufficient, the provision of voluntary school treatment centres should be stimulated. Dr. Kerr was not wholeheartedly a supporter of the voluntary system, and it was not until 1910 that (a) the Council made arrangements with six hospitals about the treatment of children and (b) two treatment centres were opened, the first in July at Hampstead, on the premises of the Kilburn Provident Medical Institute and the second in September at Norwood. A third treatment centre was opened in Wandsworth in January, 1911. Under the arrangements made the hospitals assumed the whole of the responsibility for treatment. No arrangements were made for after-care, and the only information concerning children who had ceased attendance before treatment was completed was received as an accompaniment to the claim for payment, and was too late to be of service. The difficulty of the position caused the London Hospital, in February, 1911, 177 M* Treatment at hospitals and voluntary school treatment centres to ask the Council for an officer to visit the hospital to regulate the attendance of the children and this duty was undertaken by one of the organisers of children's care work. The experiment was so successful that it was extended to other hospitals. The system of treatment centres (institutions for the treatment of children's ailments only) was established with the co-operation of local committees of medical practitioners. The treatment centres were of great benefit to children living in areas remote from hospitals. Attendance for treatment was regulated by the Council's organisers of children's care work, records of the children treated were kept at the centres, and the care organisation followed up to see that treatment was completed. During 1912 and 1913, the system begun at the London Hospital in 1911 was extended to cover all the treatment arrangements of the Council. In the course of development the school care committees, advised by the Council's organisers, were in a position to note the course of treatment step by step to a successful conclusion. The immense influence that this arrangement exerted on the harmonious working of the treatment scheme was reflected in the very high percentage of treated cases. By the end of 1912, arrangements had been made with eleven hospitals and seventeen treatment centres providing for the treatment of 54,208 children. Decentralisation to school health divisions Sir William Hamer in 1912 induced the Council to commence an experiment with whole-time officers in one division in the East End and Dr. Menzies was appointed as a divisional medical officer with six whole-time assistants. After six months this experiment was declared a success, the whole-time system was adopted throughout London and three more divisional medical officers were appointed. The Eastern Division proved rather too bulky and was divided into two, so that the County was organised on a basis of five school health divisions, with a divisional medical officer and an assistant superintendent of school nurses at each office. In the same year record cards based upon the Board of Education's schedule were introduced and machinery was set up for transmitting results of inspections to the Central Office. While the Board of Education directed that two age groups in every school should be examined every year, the Council decided to carry out inspection of three age groups, including one at eight years of age. The improvement in health of the children in school threw into relief the neglected state of infants at entry, but in 1918 the Maternity and Child Welfare Act entrusted to the Metropolitan Borough Councils the safeguarding of the health of children under school age and, by the supply of health records, the child welfare centres were able to furnish a full account to the school doctors of the health of many children on entering school. The Education Act. 1918 The passage of the Education Act, 1918, altered the conception ot the duties ot the local authority with regard to treatment. The earlier Act gave an optional power to make arrangements for the medical treatment of elementary school children. Section 2(1) (b) of the new Act made this optional power a duty as regards elementary school children, and Section 18 extended the optional power to include the provision of facilities for treatment in respect of children attending any school or educational institution, whether aided or not by the local authority. These powers and duties were later incorporated in the consolidating Education Act of 1921. The Council made arrangements for the medical and dental treatment of scholarship holders at secondary and trade schools and extended the facilities to fee-paying pupils, subject to the actual cost of treatment being recovered. Necessitous children were treated free, if the Care Committee so advised. By this Act, too, the provision of schools for physically defective children was made compulsory. In 1920, examination of a fourth age group—the leavers—was established. The Council's Economy Committee abolished this examination two years later but it was, however, restored in 1925. The Education Act, 1944 The Education Act, 1944, came into operation in 1945. The relevant sections of the Act materially altered the previous practice both as regards the medical inspection of, and the provision of medical treatment for, school pupils. Under the Act the certification 178 by medical officers of children as mentally or physically defective was abolished and it became the duty of the local education authority (i.e., at member level) to ' ascertain ' which children in their areas required special educational treatment. For this purpose the local education authority have power to examine medically any child in their area who has attained the age of two years. For the first time, therefore, the local education authority was expected to examine medically, in the circumstances mentioned, children below compulsory school age, and parents who, without reasonable excuse, refused to submit their child for such medical examination rendered themselves liable to a penalty. A similar procedure to that indicated above was also prescribed by the Act to determine which children in the area of the local education authority over the age of two years were suffering from a disability of mind of such a nature or to such an extent as to make them incapable of receiving education at school, with a view to such children being referred for necessary action by the local authority under the Mental Deficiency Acts. Similar provision was made for ensuring that children in attendance at a special school who were suffering from a disability of mind should, if necessary, receive supervision after leaving the special school. In pursuance of the duty placed upon the Council under the 1944 Act to make arrangements for securing that medical treatment should be free, the Council arranged for free medical treatment in its hospitals, at school treatment centres and at voluntary hospitals with which the Council, under previous enactments, already had arrangements for the treatment of certain specified defects or illnesses. Steps were also taken during 1945 to ensure the free supply and repair of surgical appliances (including artificial limbs) and spectacles and the free supply of insulin prescribed at voluntary hospitals for pupils for whom the Council, as education authority, was responsible. Authority was also given for the cost of emergency dental treatment by private practitioners for the relief of pain during the evenings, weekends, and at other times when clinics were not open, to be borne by the Council. In consequence of the coming into operation on 5th July, 1948, of the National Health Service Act, 1946, the Council's municipal hospital service was transferred to the new hospital authorities, which allowed special arrangements for schoolchildren's clinics to continue. Under this Act every child became entitled to free general practitioner services. National Health Service Act, 1946 Although the duty of the Council to secure the provision of free medical treatment for school pupils was not statutorily modified by the National Health Service Act, 1946, administrative decisions by the Ministry of Health and the Ministry of Education have indicated the principles upon which the responsibility for the treatment of school pupils should be shared between the Council and the hospital and specialist services of the National Health Service. The essential underlying point is the freedom of choice of the individual parent. In London, the following categories of pupils are now submitted for medical inspection :— (a) ' Entrants', who are presented to the doctor as soon after admission as possible. (b) Seven-year-old age group, who are seen in the term in which their seventh birthday falls. (c) Eleven-year-old age group, who are seen in the term in which their eleventh birthday falls. (d) Twelve-year-old age group. These pupils are seen in the term in which their twelfth birthday falls only if medical records showing that they were inspected at 11 years of age are not available. (e) 'Leaverswho are seen in the term prior to that in which they will be leaving school. (f) Any pupils who were due for examination in an age group the previous year but who were, for various reasons, not seen. 179 Routine medical inspections— current procedure Special inspections Headmasters and headmistresses are required to bring before the school doctor : (a) any pupil about whose well-being (physical or mental) the parents, care committee, nursing sister or teaching staff are in doubt. (b) pupils for whom special educational treatment is suggested. Re-inspections Pupils who at previous inspections were referred for treatment or observation are brought forward for re-inspection as required by the school doctor. This group includes any pupils receiving school meals, extra milk, or vitamin capsules on the recommendation of the school doctor. Parents are invited to be present at all medical inspections (except those of a casual nature and most re-inspections) Nurses' hygiene examinations Hygiene examinations are carried out once each term by the school health visitor but one of these three annual inspections is carried out more intensively and an average of 20 children an hour are dealt with instead of 50 an hour. History of earlier developments in dental inspection and treatment School dental service Interest in the case of children's teeth grew towards the end of the last century. The British Dental Association, from its incorporation in 1880, pressed for the institution of frequent examination and, where necessary, treatment of children's teeth. In 1885, W. M. Fisher of Dundee carried out the first detailed examination of a number of schoolchildren's teeth, his published results pointing to the urgent necessity for regular examination and treatment and in 1898 the School Dentists' Society was formed. In 1900 Dr. Wm. Hunter of London insisted on the importance of oral sepsis in general medicine. His statements about the intensity of scarlatinal angina being proportionate to the amount of dental sepsis made the subject of prime importance in schools. Dunfermline and Cambridge were among the leaders in elementary school dental work. Cunningham of Cambridge in 1908 established a dental treatment centre in that Borough. Operated in the first instance through local benevolence, the centre was later taken over by the local authority. In December, 1905, the School Dentists' Society asked for the appointment of properly-qualified dental surgeons for all elementary schools so that dental inspection, advice and preventive treatment might be given regularly from the earliest age. At that time, in London, both among children and the younger teachers, toothache and neuralgia were fruitful causes of absence from school. Neglect of the teeth was almost universal and it was exceptional to find children who used tooth brushes. Only two children among six thousand had had conservative treatment. During 1906 dental care was instituted for children over ten years of age in the Council's schools for the deaf; this was a matter of special educational importance in connection with the teaching of articulation. In the same year too, Mr. C. E. Wallis wrote a report to the Council upon the state of the mouths and teeth of the schoolchildren and was the first detailed dental investigation made of London elementary schoolchildren. In his report, he said : ' The most striking feature observed is the neglect of dental cleanliness and absence of any evidence of dental treatment, beyond a few instances in which teeth have been extracted or broken. Only three of these 245 children possessed tooth brushes, and showed signs of having used them regularly . . . Bacterial deposits, tartar, remains of food and every degree of malodorousness and sepsis were evident. Many children were suffering from undue retention of temporary teeth.' Mr. Wallis then described briefly the results of such foul mouths on the general health and the undermining of the child's natural resistance to disease. At the same time Dr. Wm. Hunter at Charing Cross Hospital was showing scientifically that local concentrated sepsis caused anaemia and that removal of local sepsis cured this and many other complaints. After a Sub-Committee on the Medical Treatment of School Children, appointed by the Council, had made certain recommendations about teeth in 1907, the Council decided that the problem was one to be dealt with separately from medical treatment. 180 With some small exceptions, no arrangements could be made with any hospitals for the dental care of children. The professional dental associations refused to consider any co-operative arrangements for establishing dental surgeries on the lines of the school treatment centres. The Council's dental scheme may be said to date from January, 1910, when advantage was taken of the offer of Dr. R. A. Kirby to provide dental treatment free of charge at St. George's Dispensary, Blackfriars Road, for a period of one year. In order that the utmost benefit should be derived from this offer, a scheme was devised by the assistant medical officer who advised on dental matters, and it is from this scheme that the subsequent dental treatment organisation developed. In October, 1910, a comprehensive report on the dental treatment of children attending public elementary schools stated that it was undesirable to attempt an immediate and complete settlement of the problem. The Council accordingly adopted the policy suggested in the report, namely, to enter into an agreement with the authorities of two institutions to provide treatment for 6,000 children for a period of one year, as from January, 1911, with a view to accumulating experience as to how best to deal with the matter. In connection with these two schemes, lectures on dental hygiene were given in five schools in the vicinity of each treatment centre by one of the assistant medical officers and general information on the care of the teeth was disseminated among teachers, parents and pupils by means of pamphlets, etc. The Council decided in principle that, wherever possible, existing voluntary agencies should be utilised and that where provision of facilities was lacking arrangements should be made for the establishment of voluntary committees for the purpose. This policy guided the later decisions of the Council. Whenever the need for a centre in any particular district was proved, it became necessary to secure the cooperation of some local voluntary body who were either actively engaged in the provision of some form of treatment and therefore in possession of premises, or who were willing to secure, by renting or purchase, premises which could be adapted for the purposes of a centre. In this way centres came into existence throughout London of no particular standard and all varying according to the conditions at the time of their establishment. It would, of course, have been very difficult for the Council to establish its own treatment centres in all parts of London without delay, and it was fortunate in obtaining the co-operation of the voluntary bodies. To secure the attendance of children at centres, it was found necessary to appoint ' dental inspectors', as the purely medical inspection did not cover the age group of children amongst whom cases suitable for conservative treatment were especially to be found. The appointment of ' dental inspectors' was of great benefit, as, in addition to their work of inspection, they devoted the last half-hour of their time to advising the parents who had been assembled for the purpose. At the end of 1913 arrangements had been made for the dental treatment of 31,240 children a year as against 18,850 at the end of the previous year and further centres were being established. It was not obligatory until 1921 for local education authorities to provide dental treatment, but under Section 80 of the Education Act, 1921, it became their duty to do so for children attending elementary schools. The service was also permissive for higher education and other schools. By 1922, a great improvement had been brought about. Between 1913 and 1919 the improvement resulted in roughly five per cent. more children leaving school with sound teeth ; in two years, from 1919 to 1921, another five per cent. was added, and in 1922 still another five per cent., making fifteen per cent. in all in nine years. The remarkable improvement noticed during 1921 and 1922 was due to the fact that children began to leave school who, from an early age, had come under dental inspection. In 1923 the Council agreed to a scheme by which the dental inspections should be largely increased in number. By this scheme all the schools were placed on a dental rota and dental inspection of the children was to be carried out by the school dentists annually for all age groups of children except those due for examination during the year 181 by the school doctors, who saw them in the course of the routine medical inspection; overlapping between dentists and doctors would thus be avoided. Developments after the inauguration of the National Health Service In the latter half of 1948 and in 1949 staffing problems became increasingly difficult as dental surgeons resigned to transfer to the General Dental Service under the Local Executive Councils where their earning capacity on a scale of fees method was substantially greater. As a result of loss of staff during 1948, 1949 and 1950, the Council's dental services for schoolchildren were curtailed and routine dental inspections in schools were greatly reduced to prevent severe congestion at the surgeries, 58 of which were closed or partly closed. Local dental surgeons attended at most of the Council's residential establishments on a sessional basis prior to 5th July, 1948, and, as their private commitments increased after the introduction of the National Health Service, many of them resigned. At the end of 1949 a number of these establishments had local pain-relief services only, and no systematic examination and treatment was being carried out. In 1951 perhaps the most important development in the Council's dental services was the adoption of the agreed Whitley Council scales of remuneration for wholetime dental officers serving with local authorities. During that year, in the Council's dental services, a staff of approximately 50 dental officers continued to deal with numbers which would have been completely overwhelming but for a system of control of patients' appointments brought into force in 1950. In 1952, for the first time in several years, it was possible to increase the number of dental inspections and of treatment sessions and towards the close of that year the Council adopted as policy the aim of establishing one full-time dental officer for each 3,000 schoolchildren on the school roll. To attain this ratio necessitates the employment of almost 150 full-time dental officers and the provision of a similar number of surgeries. Considerable progress with efforts to reach the authorised interim establishment of 93 dental officers and to acquire, adapt and equip additional premises was made in 1952 and 1953, but applications for appointments were not numerous and most were for part-time service only. In 1954 the ratio attained was 1:5,600 for the County as a whole. There was also some improvement of the dental services for boarding schools and residential establishments. Children are admitted to schools in each of the three school terms and in very few schools is the number of new entrants in any one term, or even in a full year, enough to constitute one full dental inspection of 120 children. Dental inspection sessions, therefore, arranged to cover all new entrants, have to include children in other age groups as well as infants. Subject to dental treatment waiting lists being small enough to permit of dental inspections being held, all new school entrants are dentally inspected, if possible, in the first year at school. So far as it can be arranged, however, dental inspections other than those in infants departments are directed to cover children aged 9 years and 13 years and any dental inspections conducted in excess of the number required to cover these three age groups are directed at school leavers in the term before that in which they leave school. Annual inspection of every school child in London would require well over 4,000 inspection sessions a year which is not attainable at present. Orthodontics An experimental orthodontic scheme was inaugurated in September, 1934, by Mr. Bertram Samuel, who was then the Council's consulting dental surgeon. Before that time, no special facilities had been provided by the Council for dealing with orthodontic cases. Any children found at the school inspections or at the treatment centres to require treatment had been referred to the dental hospitals or to the Eastman clinic. The Council felt that the cost of equipment and staff for a special dental workshop for the purpose of the school medical service alone was not justified. The position had altered after the transfer to the Council in 1930 of the general hospitals as a special workshop for dentures and dental appliances was maintained primarily for its general hospitals. 182 Under the experimental orthodontic scheme inaugurated in September, 1934, special orthodontic centres were established in different parts of London. The construction of orthodontic appliances was undertaken at the Council's dental laboratory, then at St. James's Hospital, Balham, and provision was also made for X-ray photographs to be taken when necessary at certain of the Council's general hospitals. Owing to the great pressure of work at the dental laboratory in providing dentures for patients at the general hospitals, however, it became impossible to obtain, within reasonable time, the increased number of apphances required by the orthodontic centres. The scheme consequently was held in abeyance until March, 1936, so far as the special orthodontic centres were concerned, but about the same time, Major-General J. P. Helliwell, then the Council's Consulting Dental Surgeon, ascertained that the Dental Surgeon at the Bermondsey Medical Mission Hospital dental centre (Miss E. M. Still, L.D.S.), who had considerable experience in orthodontic work, was able to undertake orthodontic treatment by means, to a large extent, of the fixed type of appliance which did not necessarily require the services of a dental mechanic and which she was usually able to make in her own laboratory. Arrangements were therefore made for suitable cases in the district to be dealt with at the centre, and the first session was held at the Bermondsey Medical Mission Hospital on 22nd April, 1936. One session a week was at first allowed for this work, but from 1st September, 1936, two sessions a week were necessary. This method proved so successful that the Council decided to extend the work and a second orthodontist was appointed. Both orthodontists worked five half-days a week as from 1st April, 1937. Eight centres were equipped for the work, including the one already in operation at Bermondsey Medical Mission Hospital, four south of the river and four north of the river. A central workshop was also equipped at 123 Peckham Road, S.E., where the orthodontists attended each on one session a week to deal with the construction of the apphances, which were mainly made of stainless steel. A special trained nurse assisted each orthodontist at the centres and in the workshop, and helped in the making of the plaster moulds, etc. In certain instances, where removable apphances were necessary, the models were forwarded to the Council's central dental laboratory (opened in 1938) where it was then possible for the mechanics to construct a limited number of orthodontic apphances in addition to their normal dental work for the general hospitals. The scheme continued, broadly on the same lines, during and after the war. In 1948, as the demand for orthodontists to treat malocclusions far exceeded the potential supply, clinicians were encouraged to treat cases themselves and the reference of orthodontic cases to the orthodontists was controlled. This revised method for obtaining treatment of dental deformities resulted in an increased number of children being given orthodontic treatment without reference to the specialist orthodontists. Throughout 1949, the four part-time orthodontists employed by the Council completed 318 cases while, in addition, 649 (compared with only 229 in 1948) were treated by the dental surgeons, and 67 children were accepted by hospitals ; a total of 1,134. In the ordinary treatment centres, most orthodontic cases were treated by means of removable appliances, all of which were fashioned at the Council's Central Dental Laboratory. The Council's Hospital Dental Service had been transferred to the Ministry of Health's control on 5th July, 1948, but the increased demand on the laboratory for this highly skilled service offset the decreased demand for dentures consequent upon the transference of much of the adult dentistry to the Regional Hospital Boards. Two part-time orthodontists resigned in 1950 and the services of only two orthodontists continued on a part-time basis during 1951 when one of these resigned in November of that year. At the close of 1951, only three sessions a week were expressly reserved for the urgently required service for the correction of malocclusions. Since then it has not been possible to augment this service but clinicians continued to be encouraged to take part in the correction of malocclusions. Most apphances used were of the removable 183 type and all were produced at the Council's Central Dental Laboratory. In addition, by pre-arrangement, London dental teaching hospitals accepted additional patients referred from treatment centres. Dental hygienists and sodium fluoride treatment The Government Inter-Departmental Committee on Dentistry, under the Chairmanship of Lord Teviot, presented their final report on 18th October, 1945. The recommendation was made inter alia ' that a scheme for the training of dental hygienists should be initiated forthwith on such a scale as would provide an adequate test of their value'. On 26th July, 1949, the Council authorised the appointment of four female dental hygienists to the staff of the Public Health Department, to be recruited from the women trained under arrangements by the Ministry of Health. In addition to the duties prescribed in Paragraph 192 of the Teviot Report, the Council, in October, 1949, obtained the authority of the Ministries of Health and Education for the Council's dental hygienists to apply a 2 per cent. aqueous solution of sodium fluoride to the teeth of schoolchildren. This treatment had in recent years been developed in America and was advocated as a measure to reduce the incidence of dental decay. It was found that for twelve months after application of the sodium fluoride solution there was a considerable reduction in tooth decay in the mouths treated, and during 1953 further investigation confirmed that there was continuing benefit throughout a second year. 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 of dental hygienists by qualified professional staff and their accommodation and equipment are further obstacles to the use of large numbers of such ancillary workers. 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. School nurses and the cleansing scheme, etc. As previously stated, in order to counteract the severe incidence of chronic infections and parasitic disease, of which ringworm alone kept thousands of children away from school for long periods, the London School Board appointed, in October, 1901, the first school nurse. In 1903, Dr. Kerr reported ' numerous children, the back of whose heads was encrusted with a thick mass of scabs, exudation and lice ' and by September, 1904, the School Board and the Council, as its successor, had appointed eleven nurses whose duties specifically included the supervision of the general hygiene of the children. There was then no explicit statutory sanction for dealing with conditions of personal uncleanliness, and the nurses were compelled to carry out their duties in face of much opposition from irate parents. With the passing of the Council's General Powers Act, 1907, and the Children Act, 1908, the Council was given powers to arrange for the compulsory cleansing, under certain conditions, of verminous children. Between 1904 and the passing of these Acts, the Council had sought and obtained the co-operation of several of the borough councils in cleansing the bodies and clothing of verminous children. These arrangements were, however, voluntary the parents being invited to avail themselves free of charge of the facilities for bathing and disinfestation provided by the borough councils at their stations, which had been erected under the Cleansing of Persons Act, 1897. The Council in 1910 established and equipped three cleansing centres and it was at these stations that arrangements were made for the compulsory cleansing of children in accordance with the powers conferred upon the Council by the Children Act, 1908. These arrangements were later extended by agreement with the various borough councils, so that by the year 1911 a fairly comprehensive scheme was in operation for almost the whole of London. 184 Dental treatment in 1911 Dental treatment in 1952 Personal hygiene examination in 1951 By 1910 there were 90 school nurses with a superintendent and two assistants to the superintendent. Their duties consisted chiefly in assisting at the medical examination of schoolchildren ; making systematic visits under the direction of the Council's medical officer to the schools allotted to them, paying due regard in all such work to the necessity of using as much tact as possible with teachers, parents and children ; examining children for all forms of obvious uncleanliness and disease ; advising the teachers in regard to the exclusion from school of doubtful cases ; applying the cleansing schemes ; visiting the children's homes and advising the parents about treatment. For the purpose of carrying out the schemes for personal cleanliness each nurse was placed in charge of a district containing from seven to fifteen schools. A rota was arranged so that every school was visited at least once a month. The homes of children with verminous bodies and clothing were visited, and, if found to be unclean, the Medical Officer for the district was asked to deal with them under the London County Council (General Powers) Act, 1904, Part IV. Reports were made on children found in circumstances which might render it desirable for them to be dealt with under the Children Act, 1908, with a view to action being taken for their safety and protection, and for the punishment of the parent or guardian. The arrangements which were in force by 1911 for the compulsory cleansing of children in accordance with the powers conferred upon the Council by the Children Act were amended from time to time by agreements with the Borough Councils (particularly with regard to the enlargement of the stations) and, as occasion demanded, the Council itself established more ccntres. In order to deal better with the cases where infestation was confined to nits only, the Council decided in 1920 that special arrangements should be made for the treatment of such children in premises apart from the ordinary cleansing centres. Powers had been given to the Borough Councils (as local sanitary authorities) in 1904 for cleansing, purifying or destroying articles and cleansing verminous dwellings. Under the cleansing scheme, local boroughs were notified of all children bodily infested and of persistent head infestation. Thus, while the school child was being dealt with under the cleansing scheme, the local sanitary authority was given the opportunity of dealing with other members of the family, the bedding and clothing, and also with the actual dwelling. Extended powers to deal with verminous bedding and clothing, etc., were given to the Borough Councils in the London County Council (General Powers) Act, 1922. Under Section 126 of the Public Health (London) Act, 1936, powers were conferred upon the Council, as local education authority, to examine the person or clothing of any child, for vermin or other foul or filthy condition, attending any school provided or maintained by the Council. The school nursing sisters examine all pupils of compulsory school age once a term under this provision and more frequently if necessary. A similar provision in Section 54 of the Education Act, 1944, is applied to pupils over compulsory school age, who are also examined once a term by the school nursing sisters. When a child is found at these examinations to be in a verminous condition, the parents are advised, and if they elect they may send the child to one of the 32 bathing centres made available either by the Council or by agreement between the Council and the Borough Councils. If parents fail to have their child cleansed to the satisfaction of the school nursing sister, statutory provisions exist to enforce cleansing. In addition to the termly hygiene inspections, school nursing sisters note all departures from normal health and report children deemed to require medical examination ; assist school doctors in their work ; weigh and measure the children, and test their vision on entrance to school and at the ages of seven and eleven, and finally in the term before that in which the children attain the age of 15 years. The work of the school nursing sisters in connection with audiometer testing is described in the section dealing with deaf and partially deaf children on page 192. 185 General Ascertainment, special education and care of handicapped pupils From small beginnings the facilities for handicapped children have been improved during the years. Just before the last war the children for whom special education had to be provided were those who were blind, epileptic, deaf or defective, that is, either mentally or physically defective. The present law relating to the education of handicapped children is contained mainly in the Education Act, 1944, and in the Handicapped Pupils and School Health Service Regulations, 1953, since made thereunder, in which it was determined that the handicaps requiring special educational treatment, were to be blind, partially sighted, deaf, partially deaf, educationally sub-normal, epileptic, maladjusted, physically handicapped, pupils suffering from speech defect, and delicate. In London there already existed special arrangements for children in all these categories except the maladjusted. Examinations under Section 34 of the Education Act 1944 are in the main arranged divisionally for children considered to be educationally sub-normal, physically handicapped or delicate, and at County Hall for children thought to be blind, partially sighted, deaf, partially deaf or epileptic. Examinations are also carried out with a view to recommending special educational treatment for children suffering from speech defects, diabetes and maladjustment. Consultants advise the Principal School Medical Officer on ophthalmology, ear, nose and throat conditions, orthopaedics, child psychiatry and juvenile rheumatism. Education in hospital or at home Before the National Health Service came into operaton, the Council had seven schools in its own hospitals, and the total roll was over a thousand children. The children in these hospital schools suffered from pulmonary and non-pulmonary tuberculosis, juvenile rheumatism, orthopaedic defects, chronic skin disease, and diseases of the eyes and ears. All except one of these schools were in hospitals outside the County of London, and after the Regional Hospital Boards were set up, the out-county schools were handed over in 1949 to the appropriate local education authorities. Since then, new schools have been opened in a number of London hospitals. The aim of these schools is to reduce to the minimum the interruption to the children's education caused by their stay in hospital. There are now five schools, including the one school not transferred in 1949, and the average total roll in the year 1953-54 was 319. Section 56 of the Education Act, 1944, gave local education authorities power to provide education otherwise than at school and, as a result, it has been possible to give instruction to individual pupils and small groups of children in hospitals where the numbers do not justify the establishment of a school. Under the same section it is also possible to provide tuition for severely handicapped children who cannot leave their own homes. This tuition can be provided up to the age of 18, and the type of tuition varies in each individual case. For older children some vocational training may be given and some have been enabled to obtain the General Certificate of Education. Blind children The first school for the education of the blind in England was established in Liverpool in 1791. Before that date, the provision which had been made for the blind had been in the nature of care rather than of instruction, as the names of the oldest schools— 'asylums'—indicated. The school at Liverpool was soon followed by two other institutions, and many more were established during the first half of the nineteenth century. The teaching given in these schools during the first part of the century was hampered by the fact that as yet no embossed type had been generally adopted ; the different institutions sponsored different types and, as a result, books were limited in number and costly. Nevertheless, these institutions did fine pioneer work. In 1829 Louis Braille devised the six-point system which bears his name and made both reading and writing possible for the blind, and which eventually made its way into every blind school and institution in England. The British and Foreign Blind Association (now the Royal National Institute for the Blind) was founded in 1868. 186 The early schools for the blind were residential and little was done in the way of providing day schools until in February, 1872, the London School Board passed their first resolution relating to blind and deaf children, instructing the Statistical Committee to ascertain what provision existed for the education of such children. That resolution was, in due course, followed by the adoption of schemes to provide instruction for both blind and deaf. The Board's first great difficulty was that of types. The earliest plan was the appointment of a peripatetic teacher to visit the various schools once or twice a week to give a lessson to blind children by aid of the Moon type, and this teaching was supplemented by an occasional lesson at home from the agent of a voluntary society. In 1876 it was found that the Moon type was unsuitable for teaching the young blind, so after trying Roman type, the Board decided to adopt the Braille type for reading and writing. The Board's first day school for the blind was started in 1879. No legislative changes were effected, but the work was carried on with the formal sanction of the Education Department. These schools were at first conducted without Government grant, but in 1890 the School Board brought to the notice of the Education Department the unsatisfactory state of things that existed with regard to the day classes for the blind and deaf and obtained as a concession the recognition of these classes for purposes of grant. The Royal Commission on the Blind, the Deaf and Dumb, etc., was appointed in July, 1885, and in its Report (issued in 1889) recommended the compulsory education of the blind from the age of five until the age of sixteen. The recommendations of the Commission were embodied in the Elementary Education (Blind and Deaf Children) Act, 1893, which cancelled the permissive powers (except in regard to pauper children) of the Poor Law Guardians to teach and maintain blind and deaf children, and laid the duty on the school authority of providing education for blind children between the ages of five and sixteen resident in their area in some school certified for the purpose by the Education Department. The Act also enabled the School Board to place blind children in residential schools, and until the Board could provide such schools, they utilised places in voluntary institutions. By this means, the Board reduced the number of its schools for the blind from 26 in 1893 to 10 in 1903. This reduction facilitated the better classification of pupils. The School Board in 1897 acquired the Royal Normal College for the Blind as a residential school but, owing to many difficulties in working a school, the main object of which was to teach adults, the Board in 1899 re-transferred that institution to the voluntary committee from which they had taken it over. In 1900 the Board decided to acquire two residential schools for the older blind children between the ages of 12 and 16, one for girls and one for boys, both of which were opened in 1902. Special attention was paid in these schools to industrial and manual work in order to teach the children during their final years of school life some occupation by which they might become, to some extent, self-supporting. The schools for the blind and deaf were under a separate superintendent until the end of 1900, when one superintendent of both classes of schools was appointed, with an assistant superintendent for the blind schools. After 1904, the Council, as education authority, continued the work begun by the School Board for London. The majority of children remain in a school for the blind until they are 16 years of age or older, and in addition to the usual subjects, a full handwork course is followed. The boys receive instructions in woodwork, basketwork and modelling, and the girls study housecraft, knitting, simple sewing, light basketry and modelling. Typewriting is taught to all boys and girls when they reach the age of 13. Those children who qualify for Grammar School education receive a liberal academic education, which enables them to take up professional courses. The Education Act, 1944, required blind children to be educated in boarding schools. London has two boarding establishments (Linden Lodge and North House) which are recognised as one school under the control of one headmaster. 187 Linden Lodge was one of the two residential blind schools opened by the London School Board in 1902. Numbers, which were very small at first, gradually increased. The functions of the school remained unchanged until 1934, when, upon the closure of all day schools for the blind in London, it had of necessity to widen the scope of its work by taking in the displaced blind boys. Henceforth it became an all-age school for blind boys, the majority of whom were resident. Elm Court School, West Norwood, the corresponding school for girls (also opened by the London School Board in 1902) then completed the Council's school provision for the blind. During the war of 1939-45, both schools were evacuated. After the war, the boys returned to Linden Lodge, but as Elm Court had been bombed, the girls, who had been evacuated to the Barclay School for the Blind at Brighton (later removed to Sunninghill in Berkshire) were without a home. Upon the reorganisation of schools for the blind and partially-sighted after the war, the Barclay School became exclusively a school for partially-sighted. The blind girls therefore sought hospitality with the Royal London Society, which during the war had moved its school from Swiss Cottage to Dorton in Buckinghamshire. Here they remained until 1949 when the Council purchased North House near Wimbledon Common to which they returned. Henceforth the boys' and girls' schools were amalgamated administratively and educationally as one all-age mixed school for the blind under one Principal. The older girls live at North House but are conveyed daily by a special bus to join the boys at Linden Lodge for lessons. The younger boys and girls up to the age of about ten years both live and have their lessons at North House. The Council has recently purchased Clevedon, a private house near North House, for use as a hostel by the older girls. An ophthalmic surgeon visits Linden Lodge and North House every term and sees each child at least once in six months and the younger children three times a year. As a general rule any child in need of treatment is referred back to the hospital to which his parents may have been taking him prior to his admission to the school. Should he have no such hospital, he is referred to the Council's consultant ophthalmologist who makes the necessary arrangements. Partially- sighted children Under the Elementary Education (Blind and Deaf Children) Act, 1893, the expression 'blind' meant' too blind to be able to read the ordinary school books used by children.' Included in the category of blind children were semi-blind, high myopes, etc. Before the establishment of special schools for the partially-sighted, the only specialised form of education available for partially-sighted children was given in the schools for the blind. Mr. N. Bishop Harman (later the Council's consultant opthalmologist) was appointed as an oculist by the London School Board on 29th May, 1903. As a result of examining the eyes of the children in the London schools for the blind he found that many of the pupils were not in fact, blind, but had been placed in these schools because of high myopia. Dr. Kerr requested that a copy of the findings should be presented to the Second International Congress of School Hygiene, held in London in 1907. In his report, Mr. Harman stated that since these children were not blind, they should not be in a blind school, but, rather, should be given special educational facilities adapted to their needs. This report aroused great interest. A differentiation in the educational curriculum of blind and of partially-sighted children was first made in 1907 when the Council arranged to give instruction in reading and writing from large types at a distance of one metre, instead of in Braille, to children in their schools for the blind who were suffering from high myopia, but who were not actually blind. The first special class for high myopes and children suffering from severe degrees of defective vision was established in 1908 by the Council in Boundary Lane School, Camberwell. This special class of 24 children constituted an intermediate group whose education was carried on jointly by the staffs of the elementary school and of the adjacent blind school. For oral work the partially-sighted children joined with fully sighted children ; for manual work they received instruction from the staff of the blind 188 school ; while literary work was taught in the blind school, and included such part of the 3-Rs as required the use of script and writing materials. The success which attended this scheme of special education for the partially-sighted led the Council to extend it to other districts, and in 1911 the Council received sanction from the Board of Education to establish special classes for an additional hundred partially-sighted children. In applying for sanction the Council expressed the opinion that classes for these children should be held either in or in close proximity to the elementary school premises, as it was essential that the oral work should be taken with the fully-sighted children. The Council pointed out that this arrangement would have the further advantage of rendering less likely the impression, which might otherwise be created, that the myopic child, although ' educationally blind ', was a blind child. By this proposal the Council showed that it had definitely adopted the policy of educating the partially-sighted child as a sighted and not as a blind child. The initiation and development of this system of special education for partially-sighted children in London, which gave the lead to the whole country, was due to Dr. Kerr and Mr. Harman. Under Section 69 of the Education Act, 1921, the expression 'blind' still meant 'too blind to be able to read the ordinary school books used by children', so that partially-sighted children still came within the educational definition of blindness. However, the Handicapped Pupils and School Health Service Regulations, 1945, included the new category of 'partially-sighted pupils' among the list of handicapped children requiring special education treatment. In London the selection of pupils needing education in schools for the partiallysighted is based on visual acuity and capability. It thus differs from the criteria used originally for many of the schools, to which myopic children were admitted in the belief that easy educational methods controlled the progress of myopia in a child. The partially-sighted school serves the child whose corrected vision is 6/18 or less, for such a child cannot usually follow the ordinary curriculum without detriment to his educational development. If the vision is 6/60 or less, the child cannot, as a rule, be educated by sighted methods, and requires admission to the blind school. Co-operation between the teachers responsible for the education of the borderline case and the ophthalmologist is very necessary if the child is to be properly placed and given the best chance ; in some cases the opinion of a psychiatrist has to be sought before a final decision is possible. The tendency is to keep the child in the ordinary school as long as he is making satisfactory progress, and, similarly, at the other end of the scale, education should be by sighted methods so long as the child is able to profit by them. This applies to cases of retinitis pigmentosa, progressive macular dystrophy and some cases of buphthalmia. With the change in views there has been a considerable fall in the number of myopic pupils attending London partially-sighted schools. In 1953, of the 450 pupils attending the six London schools, 43 per cent. were myopic, with degenerative or other changes, 15 per cent. were aphakic, 12 per cent. had nystagmus, and 8 per cent. were albinos ; only 3 per cent. were defective from the result of inflammatory diseases, and the remainder were divided among a miscellany of other congenital and hereditary defects, optic atrophy of known and unknown origin. It is to be expected that the number of myopics will diminish still further in the future and that retrolental fibroplasia will provide a small increase, though regrettably most of these are likely to be of blind standard. On the whole there is a slow but steady proportionate increase in the number of pupils suffering from congenital defects of various kinds. A partially-sighted school should consist of 5 or more classes, each of 15 pupils, and catering for the appropriate age-groups. The methods of teaching, especially for the older pupils, have undergone much change in recent years. They no longer have the aim of saving sight, but seek to provide as full an education as possible within the limits of the visual capabilities of the child, regulating close work by interspersing oral 189 lessons or handwork, thus avoiding undue fatigue. The purpose of the partially-sighted school is to overcome the handicap of defective sight which hampers the pace of learning. Because of the risk of retinal haemorrhages and detachment of the retina, the nature and amount of physical training has been carefully regulated in the partially-sighted schools. Swedish exercises, excluding those in which the head is lowered below the waist, are practised, as also are eurythmics and dancing. The use of gymnastic apparatus which requires violent muscular action and head-down postures is excluded. Swimming is taught to all pupils, but diving is forbidden. Outdoor ball games are encouraged under strict supervision by a teacher ; heading the ball is not allowed. Partially-sighted pupils are examined by an ophthalmologist twice yearly and a number, whose sight is considered to have improved sufficiently, pass on from the schools for the partially-sighted to normal grammar schools, technical colleges and secondary modern schools. Partially-sighted pupils are reviewed, shortly before they leave school, by the ophthalmologist, who completes a certificate indicating the nature of the visual defects, vision with glasses, the prescription of the glasses, whether the disease is progressive, and whether lifting of weights and stooping are prejudicial. This certificate is sent to the Youth Employment Officer to assist in the choice of suitable employment. Children who are deaf or partially deaf, as well as being partially sighted, may be received at the Council's school (Rayner's) at Penn. Formerly, a doubtful case attending the ordinary school was put on ' easy treatment which meant placing the child in the front row of the class, forbidding fine close work such as mapping, fine sewing, and homework. If glasses were worn, a second pair was provided against loss or breakage. The interpretation of the restrictions applied to ' easy treatment' varied from teacher to teacher, and it was decided to abolish the term in the London area. Such cases are termed 'care' to ensure that they come for examination by an ophthalmologist at intervals of six months, and their progress is reviewed. No restrictions are placed on close work or homework, but a second pair of glasses is provided. Deaf and partially-deaf children The first orgamsed effort on public lines to educate the deaf and dumb in this country took shape in 1792, when the Asylum for the Deaf and Dumb Poor in the Old Kent Road was founded. (It is now the Royal School for Deaf and Dumb Children, Margate.) Other foundations followed, which also came to be known as ' asylums,' and such they were, in the best sense of the word. The children admitted to the first asylums were those most in need. Deaf and dumb children who could manage by self-teaching alone through their eyes to make themselves useful and a source of income to their parents did not often find their way into the asylums. The children who were admitted were those who were useless to their families. All the early institutions followed much the same pattern. The children were isolated from the world and no means were provided whereby deaf children might share in the life of a normal school. A feature of the early asylums was the annual examination. The patrons had to be satisfied of the children's progress, and this was often done by faked results. A steady income for the schools depended on passing the whole thing off as a ' modern miracle'. Apart from donations and subscriptions there were also the fees from private pupils. It was a problem to protect these children from infection brought in by charity children, so that the first attempt to gain some sort of a medical history of handicapped children was made by the charity schools. The 1834 Poor Law Act and the Act of 1862 both empowered Boards of Guardians to pay for deaf and blind children in asylums and in 1870 statutory authorities began their task of educating normal children. In February, 1872, as stated above, the London School Board passed their first resolution about blind and deaf children, instructing the Statistical Committee to ascertain what provision existed for such children. In 1874, the School Board's first class for the teaching of deaf children was set up. In doing this, the Board was acting in advance of legislative action. The work was carried on with the formal sanction of the Education Department, but no grant was received. 190 The Royal Commission on the Blind, the Deaf and Dumb, etc., already referred to above in connection with blind children, was appointed in July, 1885, and its report was issued in 1889. This report recommended legislation, the need for which had already been pointed out to the Education Department by the London School Board. The recommendations of the Royal Commission were embodied in the Elementary Education (Blind and Deaf Children) Act, 1893, which cancelled the permissive powers (except in regard to pauper children) of the Poor Law Guardians to teach and maintain deaf children, and laid down the duty of the school authority to make special provision for blind and deaf pupils, and gave power to enforce attendance, which was compulsory for deaf pupils from the age of seven years up to the age of sixteen years. In 1902, a residential school for deaf pupils who also had another handicap was established at Homerton and by 1905 there were ten special schools or special classes in ordinary schools, and two deaf boarding schools and a boarding school for deaf children who were suffering from some second defect. Many of those children admitted to the classes and schools as deaf would not require admission today, because (i) the advances of medicine and surgery and their availability to school children have eliminated much of the deafness which was then due to discharging ears, the after-results of respiratory infections, and partly because of (ii) improved treatment and of changed classifications in what constitutes deafness from the educational point of view. The Homerton School for the Deaf instituted for many years a holiday camp at Osea Island, with great benefit to the pupil. The removal in 1921 of the Homerton School (now Rayner's School) to Penn in Buckinghamshire was part of the same policy of trying to mitigate the disadvantages of deaf children by giving them a healthy and happy environment. It has long been appreciated that if the partially deaf child is to retain and develop speech he should have educational methods different from those for the deaf, and separate facilities provided, about which more information is given later. Before 1947 these children attended special 'hard of hearing classes' but since that year they have attended special' partially deaf units' in ordinary primary schools. The aim is to return these children, if possible, after six months to two years in the unit, to the ordinary day school, where, with hearing aids, they may become almost normal pupils. Partially deaf pupils did not form a separate category of handicapped pupils for whom local education authorities had to provide special educational treatment until the Handicapped Pupils and School Health Service Regulations (1945) came into force. As ' special school pupils', partially deaf children remain at school until the age of 16. Earlier Education Acts did not specify the category of 'partially deaf pupils' and so, even when such children attended a 'hard of hearing class', their school leaving age was the same as that of normal school pupils. In London there are four day schools for deaf children of both sexes from the age of 5 to 13 years, and at each of the schools there is a nursery section for children from the age of 2 to 5 years. At the age of 13 the children are transferred to boarding schools, one for boys and one for girls, where all children remain until the age of 16 years. Some continue to the age of 18 or 19 years. The size of each class is limited to 10. The majority of deaf children now attend school from 2 years and upwards, and there is a growing appreciation on the part of parents of the value of early education. As already stated, at the age of 13 years the children are transferred from the day schools to separate boarding schools for senior boys and girls up to the age of 18 or 19. The Council maintains two boarding schools, one for each sex. Vocational (trade) training for children up to the age of 16 is gradually being discontinued so that full-time classwork (speech, lipreading and development of language) may be maintained. Provision is made, as in secondary schools for hearing children, for practical subjects— handicraft for boys and housecraft and needlework for girls. Upon leaving school, employment is found in any appropriate type of work not involving normal hearing. 191 N The oral system, speech and lipreading, is used throughout the nursery, primary and secondary schools. Those children with sufficient residual hearing make full use of group hearing aid apparatus for group work in specially equipped classrooms and are provided with individual hearing aids for personal use in and out of school. Measurement of hearing loss The measurement of hearing loss began a century ago with calibrated tuning-forks designed to lose what would now be called 1 bel after 5 seconds. By careful timing of the period during which the fork remained audible, the amount of hearing loss could be computed. Before the use of the audiometer was introduced into London schools, two common methods (which are still used) of testing hearing were the watch-tick test and the whisper test. For the watch-tick test, it was usually accepted that a normal hearing person could hear the tick of a watch at a standard distance. Only one child was tested at a time ; the child held his finger in one ear while the other ear was being tested. The watch was placed at the child's ear and was slowly withdrawn until he ceased to hear it. The same procedure was then followed in testing the other ear. The scores were averaged to secure the child's degree of hearing. There were three difficulties : (i) the tester was never sure that the child actually ceased to hear, or began to hear, at the instant he gave his report ; (ii) it was doubtful that a measure of the child's ability to hear speech was secured from the watch-tick test ; (iii) only about fifteen children could be tested in an hour. For the whisper test, the whisper had to be made after emptying the lungs of all normal air and then whispering distinctly with the residual air. Only one child could be tested at a time. The tester was twenty feet from the child, who stood with his back to the tester. The child had to repeat what was said. If he did not do so, the tester gradually came closer until the child did repeat the words whispered. If what was said could be repeated at 15 feet, the score was 15-20. The test had several difficulties : (i) it was not definitely standardised ; some testers claimed that persons of normal hearing could hear a whisper at 30 feet ; (ii) voices differed, and this prevented satisfactory standardisation ; (iii) only 15 children could be tested in an hour. The ordinary methods of medical inspection failed to detect slight and early defects of hearing and, to a considerable extent, defective hearing in one ear only. In 1930 the Council provided a gramophone audiometer. This mechanism was a gramophone playing a record of strings of numbers spoken at graded levels of intensity, each usually being three decibels stronger than the next. A common range was from 30 decibels above the normal threshold down to zero. The record was played over, and the persons being tested recorded on a form the numbers which they heard until the numbers became inaudible. The score was then checked and the approximate decibel loss of hearing for speech assessed. This instrument was at first used in the London schools by an assistant aurist giving only one half-day a week to the work. The children with hearing defects were followed up and the great majority were found to be amenable to treatment with consequent improvement of hearing and arrest of conditions which might have led to permanent and progressive deafening. While useful information was obtained, it was not possible to examine any large proportion of the children in the schools and the best use from the instrument was not obtained. Provision was therefore made for an extended use of gramophone audiometers for the testing of hearing of children and for their subsequent treatment where necessary. The services of a full-time nurse and the services of an aurist for one additional session a week were sanctioned in order that full use could be made of the one audiometer still authorised. The full use of the instrument began on 1st November, 1934. About 40 children could be tested at one time and the use of the audiometer was at first confined to senior departments. The first testing was done under the direction of the nurse, who travelled from school to school with the apparatus ; those children failing to reach a certain standard of hearing were given a second test. Those failing in the second test were then 192 examined clinically and the parent was invited to be present. If the aurist at this examination found any defect which accounted for the loss of hearing for which treatment was indicated, the position was explained to the parent, whose agreement was obtained to the prescribed treatment which might be given at one of the special ear inspection centres or at a minor ailment centre. The case was then followed up by the school care committee, who notified the nurse when the treatment was completed in order that a third test could be made. Many of these children with hearing defects were found to have abnormal conditions of the nose, which were wholly or in part responsible for the defect of hearing. These cases also were referred to the school treatment centres where amongst other methods of treatment ' diastolisation ' was undertaken. The 'audiometer unit' scheme was at first confined to the North Western Division. The 'audiometer unit' consisted of one gramophone audiometer, one full-time nurse and an otologist giving two sessions (one for clinical examination and one for treatment) weekly. To obtain a correct diagnosis of the hearing capacity of children, referred as deaf or suffering from defective hearing to such an extent that special education was required, a pure-tone audiometer was purchased and used mainly at the County Hall. It was also used for recording periodically the condition of the auditory function of the children in the deaf and partially deaf schools. By 1939 there was a gramophone audiometer in use in each of the five divisions, and the working arrangements provided for the testing of pupils of 7 years of age and over within a period of five years. The war interrupted the scheme but it was partly resumed in 1947. There is now a gramophone audiometer in each of the nine divisions. The work is carried out by eight school nursing sisters each using a gramophone audiometer in the schools. Pupils failing in two consecutive gramophone tests are referred to the audiology clinic at a local school treatment centre for pure tone testing by the same sister (except in the case of those sisters who use a portable pure-tone audiometer and who can therefore carry out pure-tone testing at the schools). Any pupils failing their pure tone test are referred to an otologist. The sisters are engaged exclusively on this work, being responsible for the clinical work, home visits, transport of equipment, arrangements with schools, pure tone sessions and attendance at audiology sessions. Since the gramophone test implies that the pupils must be old enough to write from dictation, the tests are carried out on entrance to junior schools at the age of 7+ years. The great advantage of the gramophone audiometer is that it allows group testing, so that, out of a large body of children, it is possible quickly to select those whose hearing loss is such that further individual tests on the pure-tone audiometer is desirable. Furthermore, the gramophone audiometer shows actual response to speech. There may, however, be normal hearing for speech and yet considerable losses outside the speech frequencies. The gramophone audiometer cannot reveal all defects (of medical importance) which are shown up clearly by the pure-tone audiometer. On the other hand, the pure-tone audiometer does not give a clear picture of likely response to speech. As it is desired to have routine audiometer tests carried out at as young an age as possible, investigation is now being made into the possibility of the use of the pure-tone sweep technique on entrants to schools at the age of 5+ years. (Other hearing tests involve the use of percussion sounds, pitch pipes, etc.) Many cases of suspected hearing defect are referred to the Principal School Medical Officer by school doctors (through the divisional medical officers) or may be brought to light as a result of a statutory E.S.N, examination. Many other cases are referred to him direct by hospitals. A few cases are referred by parents and private doctors, and some are disclosed as a result of an examination under the Mental Deficiency Acts. 193 N* Very young deaf children If a child is suspected to have some defect of hearing when he is examined at an infant welfare centre, or is seen by a health visitor, the child's name is referred to the local Council audiology clinic and arrangements are made for an examination at a convenient place. If, as a result of this examination, it is confirmed, or still suspected, that there is some defect of hearing, the child's name is referred to the Audiology Unit of the Royal National Throat, Nose and Ear Hospital, Gray's Inn Road, where further investigation is carried out, and, if necessary, pre-school training (which is intended to benefit the parent as much as the child) is provided. If the child concerned is two years of age or more, the hospital audiology unit informs the Principal School Medical Officer (usually after training has continued for about six months) whether special educational treatment is recommended. (Liaison between the School Health Service and the Audiology Unit of the Royal National Throat, Nose and Ear Hospital is particularly close, as Miss E. Whetnall, the Council's consultant otologist, is in charge of the audiology unit.) Recommendations received in this way from the hospital are, of course, reconsidered, and re-examination at the County Hall may be carried out if this is considered to be necessary. Although a number of children attend the Council's schools for the deaf from the age of two, many other children, for various reasons, do not attend the nursery classes of these schools until the age of three. By the age of three, however, valuable time has been lost unless a child has been receiving special training. This training in speech and understanding should begin when a child begins to talk, i.e., at about 10 months, and should be given continuously at home by the parents, who should be under instruction from a certificated teacher of the deaf. Pioneer work on these lines has been carried out at certain London hospitals, and it is felt that there is now scope for expansion, and that local centres would avoid the problem of travelling long distances, and thus encourage attendance. Accordingly, therefore, the Council has established two special clinics for training very young deaf children and their mothers, and it is the intention to establish up to a maximum of one in each of the nine health divisions of the County. These clinics are held in the existing audiology centres, and the training is given by a certificated teacher of the deaf, working under the advice of the otologists attached to the centres. The centres are equipped with pure tone audiometers and other special equipment. The work is under the general supervision of the Council's consultant otologist. Diabetic children The present arrangements for the treatment of diabetic children are the result of experience gained during the war. Most of the diabetic children for whom the Council was responsible were evacuated in one party to Hutton Residential School. The unit was staffed by nurses and the children were taught how to test for, and how to control, the symptoms of their disease. Apart from this the children lived the same life as other children and they attended local schools. This educational aspect of the work was successful in helping the children to return home and to order their lives in accordance with their disability. It is not, of course, necessary for all diabetic children to spend part of their school lives in such a hostel, but, as in the case of all types of handicap, the social and psychological problems of each child must be considered in assessing what is his need. After the war, a unit for diabetic children was retained at Hutton. The Council thus became the first authority to provide residential care for diabetic pupils under the Education Act, 1944. Early in 1954, the unit was moved to Palingswick House, Hammersmith. The children live together in the unit, but go out each day to ordinary primary and secondary schools. Educationally sub-normal children The Handicapped Pupils and School Health Service Regulations (1945) established the concept of ' educational sub-normality' to replace that of mental defect so far as educable children were concerned. In speaking of this type of child in the period before these Regulations came into force, it will therefore be necessary to use the term ' mentally defective'. A certain amount of training for mentally defective children was given in the asylum for idiot children at Earlswood (1847) and the Royal Lancaster Asylum (1864). In July, 194 1891, the School Management Committee of the London School Board decided that the Sub-Committee on the Blind and Deaf should also undertake the provision of special instruction for mentally and physically defective children. The name of the subcommittee was altered to the 'Special Schools Sub-Committee Combined centres for mentally and physically defective children were first set up by the School Board in 1892, at which time there were no statutory arrangements governing the conduct of the classes. In 1898 the Medical Officer of that day was directed to supervise the classes and in the following year two part-time assistants were given the task of visiting the schools and examining entrants. The Elementary Education (Defective and Epileptic Children) Act 1899, gave powers to school boards to maintain special schools for mentally and physically defective children from the age of 7 to 16 and laid down that, where this was done, medical officers were required to certify the children. The medical work in the Board's schools of this type (which had, until then, been on a 'voluntary' basis) was thus placed on a statutory basis. The selection of children for these schools was made jointly by a medical officer and the superintendent of schools for the physically and mentally defective (or an assistant) who accompanied the medical officer at his examination. So far as can now be judged from the records, some children were admitted and remained on trial for long periods who would now probably be considered imbecile, while there were others who would now probably be regarded as merely dull. At that time, the schools for the mentally defective were 'schools of recovery' and the term 'mental defect' had not its later connotation suggestive of a need for permanent care, supervision and control. Gradually, in the years up to 1909, various tests of intelligence and capacity were being attempted, but there was no established scale and each of the medical officers was making his own separate experiments and investigations. About 1912, Binet scales became part of the recognised procedure of ascertainment. If, in the early days of the 1899 Act, it became necessary to enforce attendance, proceedings were taken before a Court whose decision on the facts was final. A decision of the High Court, however, based on the Elementary Education (Administrative Provisions) Act, 1909 (Section 6) was that a magistrate was bound to act on the certificate, signed by a duly qualified practitioner approved by the Board of Education, to the effect that the child was defective. Later the position changed somewhat; by the Education Act, 1921, it was laid down that in a case of doubt the matter should be determined by the Board of Education. The Education Act, 1921, defined mentally defective children as those who were incapable, on account of their mental defect, of receiving 'proper benefit from the instruction in the ordinary public elementary schools; but not incapable by reason of such defect of receiving benefit from instruction in special schools.' Under this Act the schools for mentally defective children had to provide for children between the ages of 5 and 16 years. Under the Education Act, 1944, the certification of children as mentally defective was abolished and it became the duty of every local education authority to ascertain which children in their area required special educational treatment. One of the categories into which these children were divided by the Handicapped Pupils and School Health Service Regulations (1945) was ' educationally sub-normal pupils'. The Education Act, 1944, also required the local education authority to determine which children in their area were suffering from a disability of mind of such a nature or to such an extent as to make them incapable of receiving education at school, with a view to such children being referred for necessary action by the local authority under the Mental Deficiency Acts. Similar provision was made for ensuring that such children in attendance at a special school and suffering from a disability of mind should if necessary, receive supervision after leaving the special school. 195 Under Regulation 53 of the Handicapped Pupils and School Health Service Regulations, 1945, it was required that medical officers should be approved by the Minister of Education if they were to be employed for the ascertainment of pupils needing education in a special school as educationally sub-normal. This requirement was slightly modified by Regulation 11 of the Handicapped Pupils and School Health Service Regulations, 1953, so as to make it unnecessary for an authority to ask the Minister's approval in the case of a medical officer who has already been approved for similar employment by another authority. Intelligence and intelligence quotients Intelligence is measured by well-standardised tests, that is, tests which have been given to such a large number of children under identical conditions that the performance of any individual child can be reliably compared with the normal performance level of other children of the same age group. These tests aim at assessing natural ability rather that acquired attainment. The units of measurement are: (a) Mental age. This is the standard that at least 50-60 per cent. of children of a given age reach on a well-standardised intelligence test and is therefore taken as the mental age of that group. If a child reaches a level that is average for children of 10 years his mental age is said to be 10 years, regardless of his actual age. (b) Intelligence quotient. In order to compare the intellectual capacity of children at different ages, the ratio between a child's mental age and his actual or chronological age is expressed as a percentage. In terms of the educational provision they require at different intellectual levels, physically normal children may be grouped roughly as follows: I.Q. under 50: defective and ineducable. Provision in day occupation centres, or residential homes and institutions for mental defectives. I.Q. 50-75: very inferior ability. Provision in day or boarding schools for educationally sub-normal children. I.Q. 75-84: inferior ability. Provision in ordinary schools with special educational treatment, or, in special circumstances where home circumstances or behaviour problems make it desirable, in E.S.N, boarding schools. I.Q. 85-94: low average ability I.Q. 95-104: average ability I.Q. 105-114: high average ability provision in ordinary schools. The dividing lines in this classification can vary in individual cases. For example, a child with an I.Q. of 70 to 75 may well succeed in an ordinary school, with special educational treatment, if he is a stable personality and other circumstances are favourable. Considerable statistical evidence exists to show that for the vast majority of children, the I.Q. fluctuates very little, and that it is a reliable predictive measure, at least over a period of two or three years. The following arc the types of intelligence test: Verbal tests: The main test of intelligence normally used by school medical officers for the routine assessments of the I.Q.'s of children of school is the StanfordBinet intelligence scale as revised by Terman and Merrill. Performance tests: A performance test, such as the Porteous Maze, does not involve use of words and it is not covered by school knowledge. Non-verbal tests: Raven's progressive matrices involve neither use of words, acquired knowledge nor manipulation of material. The Weschler scale, which is both verbal and non-verbal, is being considered for increased use. It is with children who are found to be educationally sub-normal that most of the appeals to the Minister of Education against the Council's decision arise. Between the ages of five and seven years an appreciable number of children are ascertained and enter primary special schools. Doubt is sometimes expressed at the accuracy or the validity of 196 tests when a child is very young, but an experienced medical officer can make allowances for emotional or other disturbances, and, where there is any doubt whatever, re-examination can be carried out. However, in children showing evidence of educational sub-normality, a limited period in a special school with small classes may result in better educational attainment and a return to the ordinary school later. Maghull Institution, Liverpool, was the first in this country to provide (in 1888) for the training and care of epileptics. Epileptic children In 1896, the London School Board made representations to the Education Department respecting 'defectives'. These representations drew particular attention to children capable of receiving education who, by reason of severe epilepsy, were excluded from ordinary and special schools, and the Departmental Committee on Defective Children recommended that special provision should be made for such children by means of residential schools. The Elementary Education (Defective and Epileptic Children) Act, 1899, gave permissive powers to school authorities to make such arrangements as they thought fit for (1) ascertaining 'what children in their district are epileptic children, that is to say, what children, not being idiots or imbeciles, are unfit by reason of severe epilepsy to attend the ordinary public elementary schools', and (2) for making provision for the education of such children, between the ages of 7 and 16. The obligation to educate a defective or epileptic child between 7 and 16 was only imposed upon the parent' where a special class or school is within reach of the child's residence.' A parent was given the right to bring his child to the school authority for medical examination, and could also be compelled to do so under a penalty not exceeding five pounds. A child was not 'ascertained' under the Act to be epileptic until it had been so certified by a qualified medical practitioner. The School Board decided not to avail themselves of the provision of the 1899 Act with regard to the education of epileptics, because the limitation which the Act contained as to the size of homes was unsatisfactory. No establishment could consist of more than four homes, each for fifteen children. A special Sub-Committee was appointed by the London School Board to consider the matter, and the Board's Medical Officer was requested to examine all the children in London reported as epileptic, in order that trustworthy information might be available both as to the number and the severity of the cases. The Medical Officer's report, showing 114 cases fit for residential school, was forwarded to the Board of Education, together with a memorial from the School Board objecting to the limitation contained in the Act, on the ground that it would ultimately require five establishments to deal with the epileptic children in London. The Act remained a dead letter so far as epileptic children were concerned. In 1903, an amending Act was passed, giving the Board of Education power to submit Rules to Parliament under which schools might be certified without regard to the limit of size imposed by the Act of 1899. After this amendment, the School Board decided to make provision for epileptics, and they asked the Board of Education for their sanction to provide the accommodation needed. The National Society for the Employment of Epileptics was also approached about the possibility of the provision required being made at their colony at Chalfont St. Peter. After the transfer of the powers of the London School Board to the Council, arrangements were made for sending children suffering from chronic epilepsy, and who were unfit to attend an ordinary school but who could benefit from education, to epileptic colony schools if the children were between the ages of 7 and 13 years, subject to the parent's consent. The authorities of the epileptic colonies had the right of selection. If admitted, the children might be retained until the age of 16 years. Thus, until the transfer to the council, in 1930, of the Hackney Branch Home at Brentwood (later known as St. Faith's) and the Edmonton Colony for Epileptics, the Council had not itself provided a school for epileptic children. It had secured 197 modation at the Lingfield Epileptic Colony, and other London children were sent to the Chalfont St. Peter Colony. Roman Catholic children were sent to the Much Hadham School. When the Hackney Branch Home at Brentwood and the Edmonton Colony were transferred to the Council there was a small number of educable epileptic children being maintained in each of these institutions. The school at Edmonton was discontinued in August, 1932. There are a number of epileptic children in different types of schools and it is hoped, in the course of time, that the occurrence of fits will provoke less comment. In London and other big towns the presence of day schools for physically handicapped or educationally sub-normal children helps greatly, for the children can be transported by bus and the staffs are accustomed to such problems. It is impossible and unnecessary to consider special boarding school education for all children who have had fits at one time or another. If a child is incapable of deriving benefit from the education provided because of the frequency or severity of fits, the head of the school may ask at any time for him to be considered with a view to admission to a special school for epileptics. It was agreed in 1950, in consultation with the Ministry of Education, that all epileptic children considered for special educational treatment should be examined by the same medical officer, who would make contact with the schools, hospitals and family doctors to ensure care. The purpose of seeing these children at the County Hall is that they may be treated according to their individual needs. Figures concerning epileptic children cannot be taken as accurate because many children attend ordinary schools who suffer from mild epilepsy, whose parents have not revealed the fact to the head master, school nurse or doctor. The truth emerges only when the child happens to have an attack in school. A large number of epileptics are educationally sub-normal, and some are found to be ineducable. The average I.Qs. of epileptics range around 70-75, though there are a few with high I.Qs. who are of grammar school or even University standard. Deterioration of mental condition takes place in some cases, especially in children suffering from mild forms of fit lasting only a second or so: the I.Q. may tend to become lower as time passes, and some children may even become ineducable. Epilepsy is a long-term illness. Medicines need time, patience and care to produce good results. The exact dosage and even the time of day at which they are taken is of importance, and the doctor's orders must be carefully carried out. Further, they have to be continued for long after the fits have ceased. It is because of the long term treatment that hospitals find it so difficult to treat epileptics. They cannot spare beds for the necessarily long period of observation. The Lingfield Epileptic Colony maintains the policy of giving the London County Council each suitable vacancy that arises for a school child, irrespective of the length of time that the child has been on the waiting list. It is rare for a London child to be on the Lingfield waiting list for more than two months. The special school at Lingfield (which is recognised by the Ministry of Education) is the largest special school for epileptics in the country, and uses special methods of approach for children in the lower I.Q. groups. The pupils are from five to sixteen years of age. The colony (which also caters for adult epileptics) has grown from a single building purchased by the Christian Service Union in 1895, and it first received epileptics of school age in 1899. Lingfield reports that up to 40 per cent. of their patients are discharged either with their fits arrested or so infrequent that they are considered fit to attend ordinary school or to take up employment. Other boarding establishments to which London children may be admitted are St. Faith's Hospital School, Colthurst House School, St. Elizabeth's (R.C.) School, Much Hadham, and Chalfont St. Peter Colony. 198 The Handicapped Pupils and School Health Service Regulations, 1945, included the new category of' maladjusted pupils' as a defect to be ascertained and for which provision had to be made. Maladjusted children and child guidance This category is new so far as special educational provision is concerned, although child guidance clinics had dealt with such children for many years, and there was a permissive clause in the Education Act, 1921, by which authorities could, as part of medical treatment, accept financial responsibility for such children in certain schools thought to be successful in dealing with such children. London did not avail itself of this clause of the Act. As an organised movement, and in the particular sense that the words are now used, 'child guidance' was introduced into this country in 1927 through the generosity of a private trust, the Commonwealth Fund of America. However, the general idea of child guidance work was not altogether new, and had been carried out in London and elsewhere in increasing measure during the preceding half-century. In this country, the need for this special type of service had been felt mainly in the educational field, where it was seen that even with the various types of special schools, there still remained the type of problem which seemed to baffle all the available agencies. The first attempt to treat maladjusted children in this country as a separate category was made by the Tavistock Clinic, where the pioneer work in the treatment of adult neurotic cases, began in 1921, was soon extended to a special department for children. Nevertheless, as stated above, 'child guidance' as an organised movement, and in the particular sense in which the words are now used, was not introduced into this country until 1927. In that year, the Child Guidance Council was established in London as the central voluntary organisation of the movement 'to encourage the provision of skilled treatment of children showing behaviour disturbances and early symptoms of disorder.' An immediate approach was made to the London County Council to obtain its support to the establishment in London of a child guidance clinic of the kind widely established in the U.S.A. and Canada. At the expense of the Commonwealth Fund, the Council's principal organiser of children's care committees and an assistant medical officer visited America to report on the methods followed by the child guidance clinics there. Shortly afterwards, leave was given to four assistant organisers of care committees to spend a year in America also at the expense of the Fund, in order to take a course of training as psychiatric social workers. In 1928 the Council accepted the offer of the Child Guidance Council to open a clinic in London:— (a) for the investigation of difficult, maladjusted or deliquent children; (b) to treat symptoms so as to prevent further trouble; and (c) to establish harmony between the child and his environment, home life, school and play. The Council appointed representatives on the Child Guidance Council and on the provisional committee of the clinic, but decided that the matter was to be regarded as an experiment for three years, without any cost falling on the Council. The number of children treated was to be determined by the Council, and they were to be selected by the School Medical Officer. The proposal received the approval of the Board of Education. This first clinic—the London Child Guidance Clinic—materialised in 1929 and Dr. Wm. Moodie was appointed director. One of the assistant organisers of children's care committees who had taken the course of training was appointed as chief psychiatric social worker. A course in mental welfare was arranged at the London School of Economics for the training of psychiatric social workers, the Canonbury Clinic being used for demonstration and practice. Four of the Council's children's care organising staff were granted one year's leave of absence to take this course. The whole expense was bome by the Commonwealth Fund. 199 In 1929 the Council recognised the East London Child Guidance Clinic opened by the Jewish Health Organisation and in 1931 the children's clinic for out-patients at the Council's own Maudsley Hospital was recognised by the Education Committee. In 1932 the three years' experimental period was completed but the Education Committee postponed the question of paying grant to the Child Guidance Council or to the clinic and deferred their review of the position of child guidance in relation to the Council's educational and medical services until they could have before them reports on the work done at the East London and Maudsley Clinics as well as at the Canonbury Clinic. The Commonwealth Fund continued to finance the movement and indeed continued to do so on a generous, but diminishing scale, until the outbreak of war. In 1933 the Board of Education informed local authorities that the financial position did not permit of any payments of grants in respect of child guidance at that time. In July, 1933, the Education Committee entered into an arrangement with the Director of the London Child Guidance Clinic (Canonbury) for the psychological examination of children and young persons in the remand home and for the supply of special reports required by the juvenile courts. This arrangement was not regarded specifically as a 'child guidance' service. (It was not being done under the Education Act.) Payment was sanctioned at the rate of £300 a year and this was later increased to £400 a year. In 1934 three more clinics were recognised by the Council, viz., Tavistock Clinic (Institute of Medical Psychology), West End Hospital for Nervous Diseases and North Western Child Guidance Clinic and in 1936 two further clinics were recognised, viz., The Institute of Child Psychology and the Department of Psychological Medicine, Guy's Hospital. The last clinic to be recognised by the Council was the Creighton House Child Guidance Clinic in 1938. In 1936 the Education Committee had the first real opportunity of reviewing the child guidance movement in London in the light of the work being done at Maudsley Hospital and also at six recognised voluntary clinics. In the course of a long report the Special Services Sub-Committee stated: 'We are of opinion that, in a limited number of cases, a great deal of good is done by the special methods of investigation and treatment known as child guidance we think, however, that there are undoubtedly instances where an accurate diagnosis of the root of the trouble and a recommendation for treatment could have been reached without the elaborate technique of child guidance. We think, however, that for selected cases, child guidance is a useful and beneficial part of a school medical service. In certain cases, child guidance treatment given in time may often prevent the appearance of a child in a juvenile court.' Until 1936 the Council had not committed itself to any monetary grant in aid of child guidance treatment under the Education Acts. In that year, however, it received applications for financial assistance from the London Clinic (Canonbury) and from the Institute of Child Psychology. The Committee decided to recommend a grant for one year of £400 to the London Clinic in recognition of its services and also, in view of the fact that it was proposed to terminate the arrangement, to pay £400 a year for the special examinations at the remand home. No grant to any other child guidance clinic was sanctioned that year. In the years 1937, 1938 and 1939 the grant of £400 to the Canonbury Clinic was continued and small grants were made to five other clinics. These grants could not be regarded as anything more than tokens of the Council's formal recognition of the clinics as school treatment centres. It will be apparent that whilst the Council co-operated with the Child Guidance Council from the inception of the movement, its policy up to 1939 was marked by 200 caution. Other authorities who had given official recognition more recently to child guidance had been similarly hesitant to commit themselves very far in this field. Child guidance, as it had become known in this country up to that time, was imported with very little modification from America. It was to be questioned whether its range and technique fitted in as well in this country as in some parts of America with the other provisions for education and mental health of children which had already been made in this country by local authorities and voluntary societies. In 1934 the Child Guidance Council and the National Council for Mental Hygiene had agreed to explore the possibility of a closer co-ordination between the various bodies engaged in voluntary mental health work. This led to the formation by five of the principal societies (with the help of the Commonwealth Fund) of a joint committee under a lay chairman (Lord Feversham). This Committee undertook to review the provisions of mental health services and to make suggestions for eventually bringing together, on a rational basis, all the voluntary services in this particular field in the United Kingdom. The Committee's Report was issued in 1939 and in it was formulated a scheme for the amalgamation of the principal voluntary societies. The outcome was the formation of a new body, the Provisional National Council for Mental Health, in 1943. This amalgamation did not call for any particular action from the Education Committee in regard to their relations with the Child Guidance Council. A constant feature of the work of most of the child guidance clinics in London was the extraordinarily wide range of conditions which were regarded as suitable for their particular methods of guidance or treatment. As already stated, the Special Services Sub-Committee observed in 1936 that cases of a kind that did not need the elaborate technique of child guidance were referred to the clinics, and emphasised the need of careful selection. The Feversham Committee in their report remarked that at first the child guidance clinic dealt with every type of behaviour difficulty in children. 'No doubt,' they said, 'some pioneers of child psychology had been guilty of overstatement and there was a danger lest incursion into the normal province of the teacher and the family doctor might bring the child guidance movement into disrepute They also called attention to the difficulty of estimating the results of child guidance methods so long as clinics dealt with children who were fundamentally normal but merely reacting to environmental difficulties. The types of cases dealt with by the clinics in pre-war years were of great variety. This variety must have been to some extent due to the diverse channels through which the children were referred. In 1928 the Council laid down that the School Medical Officer should select the cases to be referred from the schools. By 1936 the report of the Special Services Sub-Committee showed that the usual channels of reference for school cases had become the district organiser of school care committees on requests by head teachers or the school care committees, presumably with the concurrence of school doctors carrying out the routine or special medical inspections of the children. In addition to the cases referred from the schools, however, the clinics were dealing with other children referred direct to them by various people such as probation officers, clergymen, family doctors and others. It was not unusual for the clinics to enlist the help of the care committee organisers in enquiries into school and home environment and in other ways in dealing with cases not referred to them from the schools. In 1943, it was suggested by the Education Officer that, since child guidance was only recognised under the Education Act as a form of school medical treatment, it seemed important that children should be referred through the school organisation only on the authority of the School Medical Officer. It was also suggested that it seemed desirable that the selection of cases should be made on reports of medical practitioners with special experience of children, such as the assistant (school) medical officers already in the service of the Council who were approved by the Board of Education for selecting 201 children for special schools. These 'certifying officers' would have before them reports from the Council's lay officers on the family and home circumstances, the school medical records and school reports from the head masters. They would personally see the children with the parents and the teachers as they did in considering special school cases. It was considered that any such arrangements for the more systematic sifting of children for reference to child guidance clinics would probably bring to notice a number of children who had presented problems to their teachers on account of some minor abnormality in behaviour or educability. Some such cases already came to light in the examination of children for special schools. Other cases would merely constitute problems of simple training or discipline. The kind of guidance required for these cases was, in the opinion of the Feversham Committee, part and parcel of the statutory education system and a matter for an educational psychologist. The Feversham Committee recommended that every local education authority should, when possible, appoint a Psychologist to advise them on their education programme and to examine and advise on the treatment of backward children and those presenting difficult problems of behaviour and education, referring suitable cases to a child guidance clinic for further advice and treatment. As early as 1913 the Council had appointed (half-time) to the Education Officer's Department a leading psychologist (Dr., afterwards Professor Sir Cyril Burt). Dr. Burt divided his time between reporting on individual delinquent and problem children referred to him (mainly from the juvenile courts) and in advising teachers about backward children. He stimulated great interest in the London Education Service in the testing of children's intelligence and educable capacity. His memoranda on his work in this matter were published by the Council. When Dr. Burt resigned in 1932, the Council did not fill his post and temporary arrangements were made for continuing the psychological work within the Education Inspectorate. The School Medical Officer and the Education Officer suggested in 1943 that it would be an advantage if the Council could take a more active part in shaping the sphere of psychology in statutory educational provision. They suggested that, as a first step to organising better the Council's resources in the matter, there should be set up, in each of the administrative divisions of the Education Officer's Department, a small standing conference to meet as required. These conferences (known as Problem Cases Conferences) began work in the divisions in March, 1944. They meet once a month, or more frequently, and consist of the District Inspector of Schools, the Divisional Medical Officer, the District Organiser (or an assistant organiser) of Children's Care Work, and the Divisional (Education) Officer or his representative. The educational psychologists also attend whenever possible. Teachers and officers are free to refer to this conference or to consult them personally on children who present problems from the educational or social angle, whether or not medical considerations appear to be involved. Some may be children whose need of special schools is in question, whilst others may be children from bad homes who are on the way to becoming in need of statutory care. Such conferences have the merit of team work, the importance of which had been so much stressed in child guidance clinics, and they have become the means of co-ordinating much of the special children's case work formerly diffused in different sections of the Council's education administration. Heads of schools are kept informed of decisions taken by the conferences. The case conferences sometimes forward to the School Medical Officer those cases which seem prima facie to qualify for special schools or to need expert child guidance or other specialist medical treatment. Sometimes, the conference itself is able to dispose of problems by advice, and, where necessary, by enlisting the appropriate official help. The setting-up of these conferences, in March, 1944, was approved in principle as an experiment, to be reviewed after one year's work. The first year's work was seriously interrupted by evacuation on account of flying-bomb and rocket attacks on London. In July, 1948, in considering the reports on this interrupted year's work, the 202 Special Education Sub-Committee reported that there appeared to be no doubt that the conferences performed an essential function in difficult problem cases, and that they were arranging for their continuance. One of the principal aims of the child guidance clinics was to investigate delinquent children. The experience of the Council in employing the London Child Guidance Clinic and also Dr. Burt in reporting on children in remand homes was that it did not work altogether smoothly. There were instances where the psychological and the medical reports either overlapped or did not harmonise. The Council therefore decided to employ at the remand home a Medico-Psychologist who could undertake both the physical and mental examination of the children. This arrangement had, by 1943, been in operation for about nine years and the general opinion was that it was more satisfactory than having the two examinations done by different practitioners reporting independently. By 1943, however, it had come to be recognised by the School Medical Officer and the Education Officer that the services of the Medico-Psychologist would be enhanced if he were brought into closer collaboration with experienced teachers who could undertake the tests of educable capacity and also contribute reports on the characters and behaviour of the children from the personal observations over a continuous period of weeks. The employment since 1941 at the Stamford House Remand Home of an experienced headmaster and the retention of many boys there for longer periods than usual through lack of vacancies in the approved schools, had fortuitously given the necessary conditions to try out informally such a collaboration. The results were so encouraging that they led the Chief Inspector of the Children's Branch of the Home Office to agree with the Education Officer's view that such work might be developed at Stamford House in such a way as to constitute it an observation centre as well as a remand home. In this way it was hoped that valuable assistance could be given to juvenile court magistrates in deciding how best to deal with their cases. Before the war, the Special Services Sub-Committee consistently declined recommendations made by child guidance clinics that certain London children they had been dealing with (but not necessarily on reference from the school organisation) should be sent at the Council's expense to voluntary residential schools or homes for maladjusted children. The Special Services Sub-Committee, however, authorised continuance by the Council of payment for children who had originally been sent to such schools by other local authorities before their parents moved to London. During the war, many hostels had been opened by billeting authorities under the Evacuation Scheme for 'difficult' children, some of them (with the assistance of the Mental Health Emergency Committee) for children designated 'maladjusted'. There were a few evacuated London children who had been admitted to voluntary schools for maladjusted children at the instigation of the local authority of the reception area. In 1941, when considering a suggestion that provision should be made for residential special schools for maladjusted children, the General Purposes Sub-Committee felt that the matter required further examination before an opinion could be expressed in favour of separate special schools, but were of opinion that in any revision and extension of special schools the opportunity should be taken for bringing within their scope children needing personal or social adjustment who had hitherto been committed by juvenile courts to schools for delinquent or difficult children, which were under the general direction of the Home Office. The Council conducted, for most of the war years, a hostel for children in its care under the Poor Law who did not do well on being transferred from a large children's home to private billets. This hostel was signally successful in improving behaviour. The Council also conducted under the evacuation scheme a residential school for about 100 boys from two of its institutions who were considered to be 'unbilletable and the staff encountered no exceptional difficulties in getting the children, after a short settlingdown period, to conduct themselves much like ordinary healthy children of their age. 203 Before the war, it was not uncommon for boys who were giving trouble at home to be admitted as 'care committee cases' to the Training Ship 'Exmouth'. Several boys on probation from juvenile courts and others giving trouble at home were sent for some weeks' stay at the King's Canadian School, Bushy Park. During 1945 several proposals were received for individual children to be boarded away from their homes. When such proposals were supported by inspectors of schools and by the School Medical Officer, some of these children were sent, with the sanction of the Ministries of Health and Education, to hostels for unbilletable or difficult children established under the evacuation scheme. It became evident soon after the passing of the Education Act, 1944, that the Council would need to provide some establishments of its own for maladjusted children. The first of these, Bredinghurst, was set up in South-East London to take boys of all ages, although the age range has since been narrowed. The establishment is both school and hostel, and boys who make reasonable educational progress soon begin to attend local schools. At any one time, less than half the boys go out to school. Psychotherapy of a specialised nature is provided for those children who need it, but a most important feature is the work with parents, carried on both by the head master and the psychiatric social worker. This work is designed to help the parents to understand the problems of their disturbed children and to show them how the homes may be prepared to receive the children once more whenever that is possible. One such school was not enough and so, in May, 1950, a second school and hostel, Dromenagh, was opened at Iver Heath, in Buckinghamshire. It is for boys and girls of primary age and is smaller than Bredinghurst. Buckshaw House, near Sherborne, in Dorset, has similar aims; but here the majority of the children, girls from 5 to 15, and boys under 11, go out to local schools. Because of its distance from London, Buckshaw House is not to be a permanent hostel-school. Five other Council boarding schools for maladjusted children have also been opened. The Council, in addition to providing places in its own boarding schools, also places a considerable number in voluntary special schools and independent boarding schools. When they are so placed the Council keeps in touch with their progress either by visits by a Council inspector or by means of reports obtained on its behalf by the local authority in whose area the school is situated. Special educational treatment of maladjusted children must depend, not so much on the nature of the symptoms shown, but on the underlying causes of the lack of adjustment to the community in which the child lives. It is not easy to determine what these causes are and only patient observation of the children concerned can give insight into them. The Council's first full-time day school for maladjusted children was opened at Lilian Baylis School, S.E.1, on 11th January, 1954. Those maladjusted children who do not require boarding education, and who do not attend the Lilian Baylis School, attend day special classes. These classes are not, as a rule, held on school premises and the children come to them usually for only part of the week, attending their own school for the remainder. Their names remain on the rolls of their ordinary schools. Where parents are reasonably co-operative, attendance at a special day class may be very helpful to the child. Quite often maladjustment in the home situation is accompanied by backwardness and unhappiness at school. Sometimes the main symptoms may show themselves at school either in inability to get on with other children or to accept any sort of teaching of the basic skills. As the child improves, the attendance at the special class can diminish until the child is back 'full-time' in the ordinary school, with increased confidence in his ability to learn, improved skills and great ability to make friendly relationships with others. Classroom technique for maladjusted children must be based entirely on the needs of the individual. Remedial teaching is commonly needed and is accompanied by the 204 utmost encouragement and sympathy. Every method known for the teaching of reading is attempted; if one fails another is tried and the teacher must be experienced and resourceful. Ample opportunity is given for creative work; painting, pottery, general handicrafts help different children to achieve satisfaction. However well the environment may be planned, however free and encouraging the atmosphere and sympathetic the teacher, a small minority of children still do not respond. For them psycho-therapeutic treatment is necessary, and this can only be undertaken extensively as a rule in child guidance units and clinics. At the Maudsley Hospital the Council provides a hospital school for children and adolescents who because of the intensity of their psychological disturbance need in-patient treatment. There, teachers work in close co-operation with doctors and occupational therapists; lessons are voluntary, but generally popular with the small patients. The work in the school is considered to play a very definite role in the treatment of the children and young people. A considerable amount of home visiting is undertaken by care committee workers and psychiatric social workers attached to child guidance clinics with a view to bringing about a better understanding by the parents of maladjusted children: if this can be attained, the chances of readjustment are improved. As from 1st January, 1948, the Council took over full administrative and financial responsibility for the voluntary clinic at Bishop Creighton House, and on 6th September, 1948, a further centre (part-time) was opened in the Putney Health Centre. The Council on 13th May, 1947, decided that the Education Committee would make arrangements for the medical treatment of school children through the Health Committee, and accordingly the Education Committee on 16th June, 1948, delegated to the Health Committee so much of its child guidance duties as involved treatment in clinics. Circular 179 (4th August, 1948) of the Ministry of Education, paragraphs 18 and 20, recognised the duty of local education authorities to provide child guidance centres closely linked with the school and home and that these centres should include a psychiatrist, psychiatric social worker and an educational psychologist and, as a rule, in addition, a paediatrician. Part of the work of these centres would be concerned with the ascertainment of maladjusted pupils under Section 34 of the Education Act, 1944. The circular also stated, however, that the Minister of Education, in agreement with the Minister of Health, considered that children needing psychiatric treatment should be referred to the new clinics to be set up by the regional hospital boards. The School Medical Officer, with the concurrence of the Education Officer, reported to the Health Committee and to the Education (General Purposes) and (Special Purposes) Sub-Committees in September, 1948, on Circular 179 generally, and mentioned that on the appointed day the regional hospital boards took over twelve child guidance clinics in the London area to which pupils were officially referred by him. The School Medical Officer also stated that the Council had two centres functioning and that proposals with regard to six others were under consideration, and added: 'The main difficulty lies in deciding at what point a child is in need of psychiatric treatment as opposed to social and educational adjustment. It is also questionable whether it is good for a child under investigation or treatment to be transferred from one team of workers to another after initial investigation or during the course of his or her treatment. In a memorandum to the Chairman of the Health Committee dated 24th September, 1948, the School Medical Officer set out the stages in dealing with a maladjusted child— (a) reference to a problem case conference on which the Education Officer and the School Medical Officer were both represented; (b) arrangements for attendance at what used to be called a child guidance clinic, where necessary advice and treatment were given. The Ministries of Health and Education had differentiated between child guidance centres, where no treatment was given, and child guidance clinics, where treatment was provided. 205 Ill October, 1948, the School Medical Officer headed a deputation to the Ministry of Education from the School Health Group of the Society of Medical Officers of Health and stated their objections to the separation of child guidance work into diagnosis and treatment and its division between the hospital side and the local education authority side, and stated that it would be preferable to do the work of both child guidance centres and clinics in ad hoc centres administered by the local education authority. Within the proposed new set-up child guidance clinic sessions could be held in the same building and by the same staff as that provided by the 'centres.' The regional hospital boards would pay the staff for the child guidance clinic sessions. The School Medical Officer stressed the need for co-operation between local education authorities and hospital authorities to ensure that adequate information should be mutually available, and said that he would need to know the names of children in attendance at schools of the local education authority who were referred to hospital child guidance clinics. At a meeting between the senior administrative medical officers of the metropolitan regional hospital boards, which the School Medical Officer attended in November, 1948, there was general agreement on the lines on which the child guidance service was to be worked in future, namely, that it was undesirable and uneconomic for parallel 'centres' and 'clinics' to be established, the former by local education authorities, the latter by hospitals. The same staff should work in the same building and be responsible for both diagnosis and treatment. A neutral title such as a child guidance unit should be used to cover both child guidance centre and child guidance clinic. In November, 1948, a report was prepared on the position with regard to child guidance in London for discussion with the regional psychiatrists at a conference held in January, 1949. General agreement was reached on the following points: it was felt that clinics should not be separated from centres; that it would be too complicated to work out for allocation of cost between the regional hospital boards and the Council how much time was spent on diagnosis and how much on treatment, and that as an alternative the psychiatrist should be appointed and paid by the regional hospital boards, but that the local education authorities should be associated with the appointment; the psychologists and the psychiatric social workers should be appointed and remain on the staff of the local education authorities; the premises should be provided and maintained by the regional hospital boards, if they were in hospitals, or by the local education authority, if they were in ad hoc premises. It was appreciated that difficulties would be encountered in established clinics and in clinics provided by the teaching hospitals, which would not wish to transfer existing psychologists and psychiatric social workers to the local education authorities. It was decided, however, to defer further discussions pending a decision about to be given on these suggestions by the regional hospital boards and the Council. A further survey of psychiatric services in London was completed in April, 1949, and was followed by a conference on 3rd June, 1949, with the psychiatrist of the metropolitan regional hospital boards. The School Medical Officer outlined the plan which it was proposed to submit to the Council for the provision of six additional child guidance units in London. It was considered that one unit should be provided for each 30,000 school children where existing facilities were inadequate. It was agreed that the scheme, as outlined, would not embarrass the regional hospital boards and that no further child guidance clinics to serve London school children would be established at regional hospital boards' hospitals without prior consultation with the Council. It was also agreed that the teaching hospitals concerned should be informed of the discussions that had taken place and of the Council's plans for development and, further that they should be asked to inform the Council of any plans which they might have for development. There are now four Council child guidance units—Battersea, Woodberry Down, Brixton, and Earls Court. 206 Child learning how to speak Partially sighted children reading through magnifying glasses School for the physically handicapped in 1908 School for the physically handicapped in 1951 In 1838, the Royal National Orthopaedic Hospital was founded for the surgical treatment of cripples. In 1851, a Cripples' Home and Industrial School for girls was founded in St. Marylebone, and in 1865 the National Industrial Home for Cripple Boys was established at Kensington. Physically handicapped children In 1891, the London School Board considered the recommendations of the Royal Commission on the Instruction of the Blind, the Deaf, etc., and resolved 'that special schools for those children who, by reason of physical and mental defect, cannot be taught in the ordinary standards or by ordinary methods, be established, and that the schools be designated "schools for special instruction In July, 1891, the School Management Committee of the Board decided that the Sub-Committee on the Blind and Deaf should also undertake the provision of special instruction for mentally and physically handicapped children. The name of the sub-committee was altered to the 'Special Schools Sub-Committee Combined centres for mentally and physically defective children were first set up by the Board in 1892, at which time there were no statutory arrangements governing the conduct of the classes. Although physical as well as mental defect was mentioned in the scheme approved by the Board in 1891, children suffering only from physical defect were not then looked upon as a separate class, but they were from that time onward frequently admitted to the special classes with the mentally defectives. A Departmental Committee (of the Education Department) on Defective and Epileptic Children, appointed in 1896, issued its Report in 1898. The report included a section on physically defective children in which it was stated: 'We recommend that physically defective children shall be admitted to special classes if, owing to chronic ill-health, they are not capable of receiving proper benefit from instruction in the ordinary school while capable of benefiting from instruction in the special classcs.' Later in the same report a class for physical defectives then being carried on at Southwark was referred to as 'a fair field for voluntary effort' but for which the recognition of the Board was not recommended. The Departmental Committee had come to the conclusion that one per cent. of the children between the ages of 7 and 14 needed special instruction. The London School Board accepted this estimate, but declared that it was not expedient at once to make provision for this number of children. It was agreed that the accommodation to be provided should be considered on the basis of the needs of the locality. It was further agreed that no class should contain more than twenty scholars; but no centre should, if possible, be for fewer than two classes or more than five; that if only one class could be formed in any locality, it should be conducted in the ordinary school building and not in a specially erected centre. The commencement of this work was not unattended with difficulties. No child was taken out of the ordinary school and sent to a centre unless it had been examined by the Board's Medical Officer and the Superintendent and had been certified by them as requiring special treatment. Parents were often unwilling to admit the deficiency of their children; more particularly in mental cases. It was a question, too, whether the Board, although it had power to compel a child's attendance at school, was empowered to compel it to attend any particular school. It not infrequently happened, therefore, that parents protested against the classification of their children as defectives, and demanded, as of right, that they should continue their education in the ordinary school. The cost of the education of defective children was necessarily greatly in excess of the cost of the education of the normal child, but at first the Government did not recognise this fact and the centres for defectives could earn no greater grant than the ordinary schools. These difficulties were overcome by the Elementary Education (Defective and Epileptic Children) Act, 1899. This Act was framed upon the same principles as the 207 o Blind and Deaf Children Act, 1893. The most striking difference between the two Acts was that, while the Blind and Deaf Act made the education of the blind and deaf compulsory upon the education authority and upon the parent, the Defective and Epileptic Act was merely permissive. The school authority was at liberty to adopt its provisions or not as it saw fit, and the obligation to educate a defective or epileptic child between 7 and 16 years of age was only imposed upon the parent' where a special class or school is within reach of the child's residence.' The school authority (in London, the School Board) had power to ascertain the number of children in its district who, without being either imbecile, on the one hand, or merely dull and backward, on the other, were, by reason of physical or mental defect, incapable of receiving proper benefit from the instruction given in the ordinary schools. A parent was given the right to present his child to the school authority for medical examination and also could be compelled to do so under a penalty not exceeding five pounds. A child was not 'ascertained' under the Act to be defective or epileptic until it had been so certified by a qualified medical practitioner. After the passage of the Defective and Epileptic Children Act, the medical work in the Board's schools for mentally and physically defective children (which had, until then, been on a 'voluntary' basis) was placed on a statutory basis. In 1898, a committee connected with the Passmore Edwards Settlement in Tavistock Place had made an application to the Special Schools Sub-Committee for the establishment of an invalid children's school in rooms belonging to the settlement. They pointed out that some invalid children's classes already existed in London, carried on by voluntary societies. The Board agreed to the proposal, which involved purely educational expenses only, the Settlement Committee providing the ambulance and nursing. The sanction of the Education Department was given on 26th January, 1899, and the school was opened on 28th February, 1899. In 1900, a committee composed of members of the School Board and specialists reported in favour of the establishment of separate schools for the physically defective of normal intelligence. This recommendation was accepted by the School Board; the Board of Education accepted the proposal, and consented to the provision of such schools in districts where the accommodation was required. Cripple or invalid children who were also mentally defective were not admitted to these schools, but it was decided, where possible, that children suffering from the double handicap should be taught in the schools for the mentally defective, to which they were to be taken by ambulance. Each cripple school was managed by a local committee and there were a trained nurse and helper, and one or two ambulances, according to the number of children to be collected. The work of the cripple schools was supplemented by a voluntary society called the 'Cripple Children's After-Training and Dinner Societywhich, in addition to arranging for a midday meal in each school, endeavoured to provide special training for cripples when they reached the age of 16 years or to apprentice them to suitable trades. The Council's day schools for physically handicapped children are intended for those children whose handicap is not so severe as to necessitate boarding accommodation. These children live at home and are conveyed to and from school by the Council's buses specially adapted for the purpose. In the day school every child is examined by the school doctor on admission, and thereafter once a year. Arrangements are also made for any ailing child to be specially examined. In addition each child suffering from an orthopaedic defect is examined at the school by the Council's Consulting Orthopaedic Surgeon once every six months. Before leaving, a special report is made giving advice as to future occupation and notes of any contra-indications. The Council's boarding schools are intended primarily for those children whose handicap is so severe that they should live and be taught on the same premises. Of the two boarding schools at present maintained by the Council one provides for girls and the other for boys. The age range at both schools is from 5 to 16. 208 Arrangements for medical inspection in boarding schools are similar to those in day schools. A visiting medical officer is available for emergency examination, and supervisory visits are paid by doctors from County Hall. The Orthopaedic Surgeon also visits these schools and a school nursing sister is in residence. The size of classes is limited to 20 but for practical classes the maximum is normally 10. It follows from the definition of physically handicapped children given in the Regulations that the purpose of special schools for such children is to provide a physical environment appropriate to their needs, an environment where their particular disabilities may receive proper and continuous care and attention, where their education, academic and practical, is conditioned by their physical and mental capacity, and where their emotional development may find harmonious expression. In other words, the care, maintenance (and where possible the restoration) of health, education and the development of normality in outlook and behaviour, all form one integrative process in the schools for the physically handicapped. Consequently, each school has a nursing sister on the staff, special equipment, furniture and apparatus are provided to meet the needs of special cases and physiotherapeutic treatment, remedial exercises and speech therapy are given to those requiring them. The teaching staff is specialised in its task; the curriculum is designed to fill in the gaps caused by illness, to cover the full range of general and cultural subjects, and to provide varied forms of practical work. The boys learn woodwork, metalwork, and leatherwork; the girls learn dressmaking and receive secretarial training. The tempo of work is slower than that in the ordinary schools. Pupils may remain at school for a period after reaching the age of 16 years if they so desire. Others, whose ability, progress and state of health justify such a course, may be nominated for special courses at technical schools or polytechnics at an earlier age. The Youth Employment Service tries to find suitable employment for all leavers and keeps in touch with them afterwards. When employment is chosen, care is taken to ensure that there is a minimum of travelling. For the majority, sedentary occupations are found, the type of work depending on educational attainment and a very small number work at home. The number of physically handicapped children has declined in recent years. A number show sufficient improvement to justify their transfer to the ordinary schools and many such transfers take place at the age of 11 years. The number of physically handicapped children needing provision is substantially less than was envisaged in the London School Plan, in which provision was made for the building of new schools for such children away from the centre of London. Except at a few schools where more satisfactory arrangements prevail, children at day schools for the physically handicapped whom a consultant recommends for physiotherapy now go by ambulance between school and the hospital giving the treatment. The loss of school time and the expenditure on the ambulance service would be reduced, and a better service would be provided, by giving the physiotherapy at the schools. A satisfactory scheme has been in operation experimentally at one school for nearly three years and is in process of being extended to others. Under this scheme each school has been linked with a hospital and receives regular visits from members of a physiotherapist team acting under the direction of a specialist in physical medicine at the hospital. Arrangements on these lines are at present being negotiated with hospitals for the remaining day schools for the physically handicapped which have not already an adequate service. At the end of 1953, just over twenty per cent. of the children in London schools for the physically handicapped were ' spastics Another 10-20 children were placed in boarding schools maintained by other authorities or by voluntary societies and payment in respect of these children is made by the Council. 209 o* The Council appointed an orthopaedic consultant to the schools in September, 1905. Children were referred to hospitals for treatment as the Council has never maintained its own clinics for orthopaedics. The fact that in London so many teaching and other hospitals are within easy access has meant that suitable hospital and specialist services have always been readily available for school pupils referred to them from the school health service. Children suffering from speech defects During the later years of the last century, it was recognised, especially on the Continent, that stammering was a serious disorder which required treatment, but very little was done in this country until a few years before the 1914-18 war. The many speech disorders which are now recognised under separate categories were not formerly considered to be due to definite causes. In 1911 a speech clinic started work at St. Bartholomew's Hospital, another at St. Thomas's Hospital in 1913 and a London County Council evening institute group for stammerers began work in 1914. During the 1914-18 war it became more widely recognised that stammering was a nervous disorder. (The theory of psychological causation of stammering was first formulated in England in a paper read in 1912 at the first Conference on Speech Training, held in London.) Many 'shell-shocked' men developed a stammer, and its incidence was increased among children living in air raid shelters. In 1917 an experimental clinic for stammerers was opened in Westminster by Miss Elsie Fogerty. The experiment was successful, and in 1918 the Council opened its first four school centres for stammerers. During the next few years the number was increased. In 1934 the Association of Teachers of Speech and Drama formed a section for remedial speech, later known as the Association of Speech Therapists. In 1935 the British Society of Speech Therapists was formed. Both these societies were recognised by the Board of Registration of Medical Auxiliaries. In 1945 the two societies completed their amalgamation to form the College of Speech Therapists, upon which Royal Patronage was conferred in 1948. The College is the official examining body for entry into the profession. In 1945 speech therapy for schoolchildren suffering from speech disabilities was made a statutory obligation under the Education Act, 1944, and in 1947 the first residential school for children suffering from certain speech disorders was opened at Moor House, Surrey. Speech difficulties in children can be considered under three headings: a. Those who stammer—these children are easily recognised, and should be brought for examination and treatment without delay. There is no difference between stammering and stuttering. b. Those who confuse sounds, or who substitute one sound for another, or who fail entirely to make the wanted sound—this is not usually a matter of any urgency unless there is no improvement in the speech between the ages of six and seven. c. Those with some organic defect which interferes with speech. Any child with such a defect should be brought for examination without delay. It is particularly necessary in cases of cleft palate; the longer the delay in treatment, the more difficult it is to obtain correct speech. There are also special cases, for example, spastic children, who are naturally spastic all over. Physiotherapy directed to the general muscular state is likely to aid the muscles of speech too. Teaching those spastic children who dribble, to swallow, is sometimes the first stage in gaining proper speech. It is advisable to refer these children to a centre if they are of normal intellect. Those children whose defect of voice or articulation is due to lack of hearing, whereby they cannot properly appreciate the sound of speech made by others, are excluded from this category and fall into that of partially deaf or deaf pupils. Aphasic 210 children arc those who show no defect of hearing, preferably after testing with an audiometer, yet do not speak, or speak very little and very indistinctly. They usually exhibit a certain amount of confusion in their expression of written language, showing that the defect is not merely one of speech. The defect is rare, but children who are deaf to high notes while hearing low notes are sometimes mistakenly called aphasic because their hearing has not been scientifically charted. It is sound practice that all children with speech defects should have an audiometer test, and this is being done to an increasing extent. Occasionally children who fail to talk do so for psychological reasons, and the aid of a child guidance clinic may be necessary as well as otological examination, in order to classify them properly. Before starting treatment, arrangements are made for any other defects, such as carious teeth, defects of vision, unhealthy tonsils and adenoids, etc., to be treated. The general principles of the treatment of stammering comprise the teaching of relaxation, correct breathing, and rhythmic speech. In the treatment of other speech defects the ear is trained to make a well-defined distinction between closely similar sounds and the vocal organs to reproduce such sounds accurately. As constant practice is essential to success, good results are mostly confined to cases where parents and therapists co-operate. Before 1st January, 1948, pupils suffering from speech defect formed the only category of pupils requiring special educational treatment under the Education Act, 1944, in respect of whom arrangements for accommodation and placing were made in the Public Health Department. As from 1st January, 1948, the Education Officer undertook the administration of speech therapy centres, while the School Medical Officer continued to supply medical supervision and the services of speech therapists. Speech therapy work is at present carried out by a staff of one head, ten whole-time, three part-time and five sessional qualified therapists who work in 34 clinics (some of these clinics being held in ordinary schools, some in welfare centres, and some in school treatment centres). In addition to these 34 clinics where children from ordinary schools are treated, speech therapy clinics have been established in the day schools for educationally sub-normal children and in all but two of the day schools for physically handicapped children. Clinics have also been established in some boarding schools and in some Children's Department residential establishments. Though progress is slow, the correction of speech defects is particularly important in helping physically handicapped and educationally sub-normal children to take their place in the community. Occasional visits are paid by speech therapists to children receiving home tuition who have speech defects. Nominations of children for speech therapy are sent to County Hall on the appropriate cards, which are scrutinised by the medical officer responsible for this work. Where a detailed examination appears to be necessary, children are called to County Hall. The Medical Officer's recommendations for speech therapy are passed to the Education Officer. Arrangements are then made for the children to be ascertained formally and admitted to suitable centres. Each centre consists of groups for stammerers, who sometimes need to be taken individually, and for other children who generally are taken individually. The period of treatment is about 40-50 minutes. Pupils selected for admission to speech therapy clinics attend once or twice weekly, according to their needs, and attend their ordinary school meanwhile. Each speech therapist's session is of three-hours duration. Vacancies are filled normally at the beginning of the term, but vacancies occurring during the term are, if possible, filled immediately. New cases are usually called for the 211 second week in the term. At this first attendance of new cases, the parents are invited and interviewed by the therapist to ascertain the child's history. The medical officer in charge of this work visits all centres from time to time to see the children (and, if necessary, the parents) and gives advice and help where necessary. A senior speech therapist began duty on 1st September, 1949, acting as leader of the team of therapists. She advises on general matters relating to speech therapy and is available for consultation by teachers and others in addition to performing clinical duties. The clinics in the day schools for educationally sub-normal children, referred to above, were established in 1951, and those in day schools for physically handicapped children in 1952, after the senior speech therapist had made a survey of speech therapy needs in boarding schools and in day schools for educationally sub-normal children, and had also ascertained the requirements of the day schools for physically handicapped children from the head teachers. Delicate children The term open-air school' or 'class' is often applied to the type of school organisation which provides for the education of delicate children. The first such school to be established was an open-air recovery school at Charlottenburg, a suburb of Berlin. It was opened in 1904 for schoolchildren who had ' lung trouble, heart disease, anaemia and scrofula Sanatoria for children had been established in Germany before this time, and they may be regarded as the parents of the first openair school because they provided a little schooling. The Council's open-air school at Bostall Wood, Plumstead, for 100 anaemic or otherwise unhealthy children was the first school of this type organised by a local education authority in this country. The school was opened in 1907, and was attended by children from Woolwich, Greenwich and Deptford. The lines of the Charlottenburg school were closely followed; organised rest was included in the curriculum. Other schools of the same type followed, but until 1912 the schools were open only from April to October. In that year they were continued throughout the winter months, and the results upon the health of the children were reported as ' uniformly good Tuberculosis and the concept of the 'pre-tuberculosis' child led in London to the creation of separate schools for these and for non-tuberculous children which persisted until 1939. Several of the day open-air schools were destroyed by bombs during the war, and the drawing up of the London School Plan and its subsequent revision have led to critical reassessments of the functions of these schools. The kind of child referred by hospital and school physicians has changed. For the first years, the children referred suffered from ' debility', which figured so largely in the care of children of that period. (The number of children suffering from debility has increased somewhat recently, but these children arc now usually admitted to boarding open-air schools.) Today, as many as 50 per cent. in some of the day open-air schools have asthma or chronic bronchitis. A permanent wall has been provided for each of the old open-to-the-elements classrooms and a completely new method of construction for new buildings has been adopted. 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 used to be the case. The Council's special schools for the delicate cater chiefly for the needs of those suffering from asthma, bronchitis, debility, malnutrition, primary tuberculosis, anaemia and chronic catarrh. A careful check is kept upon the health of the children who are examined by the school doctor each term. The day schools are for those whose handicap is not so severe as to necessitate boarding education. A school nursing sister is in attendance at each school. 212 The size of classes in schools for the delicate is limited to 30, and the curriculum is the same as that of schools for normal children. All children receive three meals a day, rest for one hour at midday, and whenever possible, work in open-air conditions. The Council's boarding schools are intended primarily for those children for whom a change of air is necessary. Treatment and education are similar to those given in day schools. The average length of stay at a boarding school is two terms, but this period can be prolonged if it is considered advisable. If pronounced fit, the pupil returns at the end of that time to the day school he formerly attended: however, if it is considered advisable, he may be admitted for a time to a day open-air school. In addition to providing places in its own boarding schools, the Council accepts places in voluntary schools. The Rheumatism scheme In London, the beginning of an organised effort to combat rheumatism, on a scale commensurate with the magnitude and importance of the problem, dates from the latter end of 1926, when a special unit of 60 beds was established by the Metropolitan Asylums Board at Queen Mary's Hospital, Carshalton, for the treatment of rheumatic children in the early acute stages of the disease. Until that time, acute rheumatism in its various manifestations was dealt with by the special children's hospitals as well as the general and special hospitals in London. The length of time spent in a hospital bed in the case of rheumatism was prolonged as compared with other diseases. Poor Law cases were admitted to the infirmaries. There was very little special provision for convalescent treatment of rheumatic children other than that provided by the Poor Law. Impressed by the urgent need for such provision, the Invalid Children's Aid Association had established two small homes, but the waiting lists were very long and the need for further accommodation was manifest. Early efforts to combat rheumatism Interest in the problem of rheumatism in children was not really aroused (although a good deal of pioneer work had been done in America) until about 1923, when the question was discussed at the annual meeting of the British Medical Association. After this, Sir George Newman in his annual report to the Board of Education in 1924, and Dr. Poynton in a memorandum on behalf of the Invalid Children's Aid Association to the Public Health Committee of the London County Council urged the necessity for the provision of more institutional beds for rheumatic children where it would be possible to continue the child's education during the latter part of its stay in hospital. A report by Dr. Gordon Pugh to the Metropolitan Asylums Board followed the same lines and the establishment of the unit of 60 beds referred to above was the result of the cumulative effect of these representations. It was quickly recognised that this could only be regarded as a beginning. A comprehensive scheme was therefore organised with gradual increase in the accommodation in special rheumatism units, until beds in sufficient number were available to provide for an average period of treatment of at least six months for all children showing signs of active disease. Rheumatism supervisory centres were established and staffed by specialists, for the purpose of early diagnosis of doubtful cases and supervision of quiescent cases. A system of supervision of children after discharge from rheumatism units was started. Investigation and amelioration, if necessary and possible, of the child's home environment was attempted and the various branches of the scheme were co-ordinated centrally. Although the provision of hospital accommodation fell far below requirements, a step forward was made in 1930 in that fifty more children received treatment at Queen Mary's Hospital, Carshalton, or High Wood Hospital, Brentwood, than was the case in 1929. 213 The supervision of children who had received hospital treatment under the scheme was extended to include the years immediately after their leaving school. From the information supplied it was possible to ascertain the effect of child rheumatism in adolescence, to estimate the handicap which the disease inflicted on the young worker, and to assure that the children were supervised or treated if this was necessary after they had passed out of the care of the school medical service. In his annual report for 1924 the Chief Medical Officer of the Board of Education had urged on local authorities the need for the establishment (inter alia) of special rheumatism clinics for the purpose of supervising the rheumatic child. In 1936, 20 such centres were in existence and during 1935, 6,199 children were under supervision. Ten of these centres were staffed and equipped by the Council; the remaining ten were organised at the out-patient departments of certain of the voluntary hospitals, the Council making a contribution to the hospital, and in some cases paying the specialist in charge of the centre. The arrangements for the supervision of children after discharge from the rheumatism units consisted of: (a) Supervision at rheumatism supervisory centres. (b) Supervision through the school medical service by the school doctors. (c) Supervision in the out-patient departments of the voluntary hospitals. The particular method of supervision to be adopted in any individual case was decided by the supervising medical officer of the scheme when the case was reviewed on discharge. The arrangements provided for a minimum period of two years' supervision after discharge from the unit. The rheumatic child is particularly susceptible to an unhealthy environment, and it was realised that much of the good done by prolonged institutional treatment under ideal conditions would be nullified if the child had to return to a damp, ill-ventilated, overcrowded home. Arrangements were therefore made for obtaining a detailed report on the home conditions of all children who received institutional treatment under the scheme. Structural or sanitary defects were reported to the borough medical officer of health, who could thus take immediate action. In desirable cases where the family was on the waiting list of applicants for a house or flat on one of the Council's housing estates a recommendation that preferential consideration should be given to the application was passed to the appropriate department. The selection, grading and allocation of the cases for the special rheumatism inpatient units were dealt with by the supervising medical officer and the decision as to when a child was fit to return home was made by the medical superintendent of the unit. When a child was discharged, the superintendent sent a discharge report to the supervising medical officer. A copy of the report was also supplied to the doctor who originally nominated the patient for treatment under the scheme. Periodical visits were made by the supervising medical officer to the various units and a full record was kept at the County Hall of every child who received treatment under the scheme. The essential function of a rheumatism unit is to give the rheumatic child the prolonged treatment and nursing the disease requires, but, ancillary to this, is the provision of facilities for education during the latter stages of treatment. This helps the child to re-enter the ordinary school world without any great and sudden change in its mode of life. Provision was therefore made to deal with this aspect in units permanently allotted for rheumatic cases which, for this purpose, were recognised as ' hospital schools' by the Board of Education and staffed by suitably qualified teachers. The essence of treatment is rest, under the best possible hygienic conditions; and the rest must be physiological, rest of the body and mind. As regards acute cases, a stay in hospital of six months is probably the shortest period that can be regarded as of real value. 214 Except in uncomplicated cases of chorea, the blood sedimentation rate has proved of value in dealing with the question of anticipation and prevention of relapses, as it frequently makes it possible to anticipate a relapse and put the child back to bed before clinical manifestations of trouble appear. Apart from this, the clinician has to rely mainly on careful observation of the child's general condition, especially as regards gain in weight and response to graduated exercises. At the outbreak of war in September, 1939, there were in existence five rheumatism units for the institutional treatment of rheumatic children, with accommodation for 900 patients and a turnover of more than 2,000 annually; 15,000 to 16,000 attendances of rheumatic children at 21 rheumatism supervisory centres were recorded each year, and about another 2,500 rheumatic children were kept under supervision by the school doctors. These activities as well as ancillary ones connected with the home environment and education of the rheumatic child came to an abrupt end on the declaration of war. Nevertheless, the machinery of the scheme was tentatively re-started after two months, although the scope of the work done was necessarily much restricted. Effect of the war years In January, 1940, the essential fabric of the Scheme had been reconstructed. The only important change in the organisation of the scheme during this period was the abandonment of the system described above as a preliminary to the acceptance of cases for admission to the units. Since the specialists formerly employed in this branch of the work were unavailable, full clinical reports on the cases nominated for admission were obtained instead from the doctors nominating them, and this method, which on the whole has proved satisfactory, is still in use. In July, 1944, owing to the 'flying bomb' attacks, it was decided that the Queen Mary's and Downs Hospitals should be evacuated (the only remaining unit at High Wood Hospital had already been cleared of rheumatic children) and transferred to the Scotton Emergency Hospital, near Knaresborough in Yorkshire. The total number of rheumatic children transferred was 156 and the combined Unit was placed under the medical charge of Dr. C. E. Thornton, the Supervising Medical Officer of the Scheme. An assistant medical officer and nursing personnel from Queen Mary's Hospital accompanied the Unit, and after a few weeks teaching staff followed and the usual educational curriculum of the hospital school was resumed. Dr. Thornton, in a special report on the work of the Unit while at Scotton, stated that on the whole the children did well and benefited greatly, consequent on escaping from the strain and disturbance of air raids, although it was impossible at Scotton to obtain anything approaching an open-air regime. The Unit returned to Queen Mary's Hospital on 26th May, 1945. The return of peace-time conditions brought about no great changes either in the working of the scheme or in the numbers dealt with during the later years of the war. The number of children admitted for treatment was at its lowest in 1941 (248). Subsequently, the numbers admitted each year were rather higher, but even in 194-6 only 545 admissions were recorded. The number of attendances at the supervisory centres, however, steadily increased. In 1941 only 1,446 attendances were made, but in 1946 the number had increased to 8,117. Of the five rheumatism units with room for 900 children only one—the Queen Mary's Hospital Unit—survived the war, but now accommodating only some 240 children and, even so, being a little overcrowded. On the other hand, all the supervisory centres survived—in fact an additional one was opened in 1946, making 22 in all, and the number of children under supervision rapidly increased. A comparison of the incidence of juvenile rheumatism in 1946 (when conditions had become stabilised) with that in pre-war years seemed to indicate a substantial diminution, but it did seem likely that one important factor was the dispersal of a large proportion of the child population of London to 'safe' areas. A considerable section of these evacuated children were between six and eleven years of age, i.e., the age of the greatest incidence of rheumatic infection, and by the time they returned to London they were less liable to contract the disease. 215 The net effect of six years of war conditions on juvenile rheumatism among London children appeared to have been negligible. Perhaps, in those affected, the disease assumed a severer form; possibly rheumatism became more prevalent among the children who were not evacuated (but of this there is no proof); perhaps chorea was rather more common as a result of emotional disturbances. Nevertheless, it seemed that such maleficient effects were on the whole more than offset by the general dispersal of the juvenile population to less overcrowded areas. Post-war years Although, in the post-war years, the incidence of acute rheumatism has greatly diminished, it is felt that the Scheme still fulfils an essential purpose. The great changes in the Council's Public Health service brought about by the National Health Service Act left the organisation of the scheme very much the same as it was before 1930. Although Queen Mary's Hospital, Carshalton, is situated within the area of the South West Metropolitan Regional Hospital Board, any child under sixteen years of age with acute rheumatism who is resident within the Council's administrative area can be considered for acceptance. Conclusion The term 'school health service' covers a very wide range of medical facilities and perhaps an even wider range of complex administrative problems. In a broad historical survey of this kind many subjects, though each important in varying degrees, have been only mentioned in passing or are of such recent introduction as not to be mentioned at all. Development of the service, improvements and the search for efficiency with economy are continuous, and such matters as the periodical surveys of the heights and weights of schoolchildren, the provision of recuperative holidays, remedial foot exercises for the correction of postural defects in primary schoolchildren are only a few of the matters of which little or no mention has been made. The half-century of the service here reviewed has seen very great changes in the everyday world, particularly in science and engineering, but even those changes are possibly of less vital importance to the nation than the tremendous improvement in the living conditions and general enlightenment of the working class of the London population. The social changes and the enlightenment among parents of children that followed have had their effect on the school health service. Far higher proportions of parents are not only willing to accept but are anxious to secure the medical treatment their children need than was the case 50 years ago. There are still problem families, often referred to as 'the hard core', but there are now far fewer of them. There is no complacency, however. On the contrary, the smaller numbers offer encouragement to try to raise them to the generally prevailing level. 216 APPENDIX D STATISTICS (a) Table 1—Population (b)—Administrative County of London, 1921-54 Year Mid-year estimate of 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 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 3,375,470 276,200 367,000 2,732,270 1950 3,389,620 276,200 370,000 1,437,960 1,305,460 1951(c) 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 1954 M. 1,551,000 120,000 216,000 175,000 520,000 376,000 144,000 35.9 F. 1,771,000 114,000 209,000 219,000 536,000 451,000 242,000 38.7 3,322,000 234,000 425,000 394,000 1,056,000 827,000 386,000 37.4 (a) The statistics given are based on the latest information available from the Registrar-General: instances have occurred in the past in which figures have been subsequently corrected so that data for a previous year may differ from that published in the Annual Report for that year. (b) 1921-38—Total population. 1939-49—Resident civilian population. 1950-51—Home population, i.e., resident civilian population, members of the Merchant Navy at home and overseas and members of the Armed Forces stationed in the area. 1952- —Home population, i.e., resident civilian population, plus any British, Commonwealth or Allied Armed Forces stationed in the area. (c) From 1951 onwards the figures have been corrected to the nearest thousand. 217 Table 2—Live births and still.births—Administrative County of London, 1931.54 Year(s) Live births Still.births No. Rate per 1,000 population* No. Rate per 1,000 total births (live and still) 1931.35 297,293 13.8 9,824 30.2 1936.40 264,358 13.6 8,416 30.9 1941.45 209,909 15.4 5,652 26.2 1946 66,023 20.0 1,597 23.6 1947 70,685 20.7 1,540 21.3 1948 60,805 17.9 1,188 19.2 1949 56.547 16.5 1,129 19.6 1950 53,660 15.8 1,055 19.3 1951 52,387 15.6 1,073 20.1 1952 51,443 15.3 1,000 19.1 1953 50,992 15.3 1,088 20.9 1954 50,630 15.2 1,025 19.8 *1931.49—Total population. 1950— Home population. 218 219 Table 3—Vital statistics—Metropolitan Boroughs and the Administrative County of London, 1954 (a) Metropolitan Boroughs Estimated home population mid 1954 Live birth rate Death.rates Notifications of infectious disease Deaths Infant mortality (per 1,000 live births) Heart disease Other circus latory Cerebral vascular lesions Peptic ulcer Pulmonary tuberculosis Pruumonia Other tory diseases (inc. Bronchitis) Cancer Violence Scarlet fever Diphtheria Poliomyelitis Meningococcal infection Acute pneumonia Measles ing cough Tuberculosis Paralytic Nm Paralytic Pulmonary Non. pulmonary Division 1 Chelsea 52,060 15.1 14.1 27 3.78 117 1.82 0.10 0.17 0.81 0.73 2.79 0.94 0.50 . 0.02 . 0.02 0.54 2.00 1.79 1.04 0.17 Fulham 120,700 14.1 10.2 19 2.91 0.46 1.04 0.17 0.22 0.70 0.69 2.07 0.44 0.39 . 0.01 . 0.02 0.22 0.52 0.96 0.94 0.10 Hammersmith 116,500 15.2 9.2 21 2.51 0.38 0.91 0.16 0.15 0.33 0.73 2.03 0.58 0.61 . 0.01 . 0.02 0.63 1.29 1.47 1.43 0.11 Kensington 170,600 15.9 9.6 23 2.91 0.52 1.19 0.14 0.12 0.44 0.39 2.06 0.61 0.30 . 0.03 . 0.01 0.32 0.55 0.80 1.28 015 Division 2 Hampstead 98,210 14.7 9.1 17 2.94 0.50 1.05 0.10 0.10 0.36 0.54 1.77 0.51 0.51 . 0.02 . 0.02 0.48 0.37 1.72 0.98 0.06 Paddington 123,100 17.4 9.7 17 2.72 0.42 0.99 0.16 0.13 0.49 0.47 2.36 0.59 0.38 . 0.04 0.02 0.01 0.24 0.45 1.65 1.58 0.14 St. Marylebone 73,930 11.6 14.3 32 4.57 0.89 1.95 0.08 0.12 0.50 0.96 3.02 0.68 0.26 . 0.03 0.01 0.05 0.22 0.43 0.72 0.72 0.16 St. Pancras 136,400 15.9 9.8 18 2.79 0.43 0.89 0.18 0.26 0.44 0.80 2.20 0.59 0.60 . 0.03 . 0.04 0.46 2.90 0.78 1.37 0.12 Westminster, City of 98,870 11.5 9.3 27 2.34 0.59 1.20 0.17 0.28 0.52 0.55 1.89 0.45 0.30 0.02 0.02 0.03 0.07 2.71 0.84 1.25 0.10 Division 3 Finsbury 35,490 19.7 8.8 30 2.56 0.37 0.68 011 0.34 0.37 0.51 2.11 0.37 0.85 . . 0.03 . 1.16 8.71 2.62 1.52 0.11 Holborn 23,340 10.8 10.2 32 2.14 0.39 1.29 0.34 0.21 0.34 0.73 1.97 0.69 0.21 . 0.09 0.04 0.04 0.17 1.63 0.26 1.37 0.17 Islington 230,500 17.6 10.5 17 3.11 0.55 1.11 0.24 016 0.53 0.82 2.42 0.41 0.82 0.004 0.03 0.01 0.01 0.45 5.05 1.08 1.64 0.12 Division 4 Hackney 168,600 14.2 10.2 19 3.11 0.46 1.03 0.10 017 0.42 0.88 2.34 0.36 0.78 . 0.02 0.02 0.02 0.45 4.74 1.30 0.79 011 Shoreditch 45,960 16.6 12.2 22 3.13 0.57 1.35 0.37 0.24 0.35 1.15 2.81 0.59 0.41 . 0.02 0.02 . 0.35 10.01 0.70 0.94 0.11 Stoke Newington 51,260 15.8 9..9 18 3.00 0.53 1.19 0.18 012 0.37 0.98 1.81 0.27 0.35 . 0.02 . . 0.68 5.54 0.84 0.82 0.06 Division 5 Bethnal Green 55,530 17.0 9..9 15 2.72 0.49 1.01 0.22 0.25 0.43 0.86 2.38 0.36 0.63 . 0.04 0.02 0.02 0.04 6.07 1.58 1.15 0.14 City of London (b) 5,180 4.2 12.5 . 3.28 0.58 0.77 — 0.19 0.77 1.74 3.09 1.35 0.39 . . 0.19 . 0.39 1.35 0.77 2.51 . Poplar 71,690 17.7 10.0 25 2.50 0.45 102 0.22 0.18 0.42 0.96 2.47 0.22 0.84 0.01 . . 0.06 0.77 0.56 1.41 0.86 0.13 Stepney 97,900 18.9 11.5 22 2.94 0.62 1.06 0.16 0.31 0.63 1.13 2.67 0.46 0.61 0.01 0.03 . 0.06 0.66 1.47 1.28 1.63 0.23 Division 6 Deptford 73,820 14.8 12.0 17 3.82 0.69 1.54 0.09 0.27 0.49 107 2.57 0.31 1.04 . 0.08 0.03 0.04 0.28 3.20 1.23 2.11 0.16 Greenwich 90,600 14.9 8.8 22 2.84 0.51 0.93 0.12 0.17 0.30 0.53 1.93 0.41 0.76 0.01 0.03 0.03 0.04 0.18 0.31 2.46 0.99 0.14 Woolwich 149,700 13.6 96 18 2.91 0.47 1.20 013 0.11 0.51 0.62 2.04 0.43 103 . 0.03 0.03 0.02 0.57 0.36 1.56 1.24 0.08 Division 7 Camberwell 179,500 14.8 10.1 22 2.96 0.69 1.13 0.18 0.13 0.35 0.79 2.19 0.41 0.77 . 0.03 0.02 0.04 0.25 2.42 2.06 1.85 0.18 Lewisham 224,200 14.2 10.0 21 3.32 0.50 1.32 0.12 0.16 0.41 0.71 1.92 0.28 1.48 . 0.02 0.05 0.03 0.34 2.32 2.00 1.02 0.12 Division 8 Bermondsey 58,590 16.5 9.8 24 2.36 0.73 0.89 0.20 0.24 0.61 0.82 2.20 0.36 1.09 . . . 0.07 0.32 3.11 2.30 1.08 017 Lambeth 226,200 16.3 10.2 23 3.04 0.54 1.24 0.14 0.15 0.52 0.86 1.97 0.34 0.59 . 0.02 . 0.03 0.59 2.13 1.42 1.56 0.08 Southwark 95,370 17.8 11.5 21 3.34 0.57 1.21 0.19 0.23 0.75 1.01 2.26 0.38 1.01 . 0.01 . 0.03 0.57 2.44 2.40 1.59 0.14 Division 9 Battersea 114,300 15.2 10.1 19 3.23 0.48 1.25 0.18 0.17 0.39 0.63 1.95 0.45 0.60 . 0.01 0.03 0.02 0.33 1.68 1.01 1.12 0.10 Wandsworth 333,900 13.3 14.6 19 5.12 0.83 1.65 0.16 0.19 0.58 0.75 3.39 0.43 1.01 . 0.01 0.01 0.02 0.81 0.91 1.29 1.06 0.11 London,1954 3,322,000 15.2 10.7 21 3.22 0.57 1.20 0.16 0.18 0.48 0.76 2.31 0.44 0.74 0.001 0.02 0.01 0.03 0.45 2.24 1.41 1.27 0.12 London, 1953 3,343,000 15.3 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 (a) Rates are per 1,000 home population. (b) Including Inner and Middle Temple. 220 Table 4—Principal vital statistics—Administrative County of London, 1901.1954 Year(s) Annual rate per 1,000 living Annual mortality per 1,000 living (a) Annual mortality Infant (per 1,000 live births) Maternal (per 1,000 total births (b) Live births Marriages Deaths (all causes) Meningococcal infection Diphtheria Enteric fever Scarlet fever Smallpox Whooping cough Measles Influenza Tuberculosis Pneumonia (all forms) Bronchitis Other resp. diseases Heart disease Cancer Diabetes Infants 0—1 Diarrhoea and enteritis 0-2 Puerperal sepsis Other child.birth Pulmonary Non.pulmonary 1901.05 28.6 17.7 16.4 (c) 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 (c) 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 0.04 017 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 0.15 017 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 1936.40 13.6 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 0.48 0.96 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 0.27 1.04 1946.50 18.2 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 0.07 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 0.15 0.51 1953 15.3 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 0.02 0.38 1954 15.2 19.8 10.7 0.01 — 0.00 — — 0.00 0.00 0.02 0.18 0.02 0.48 0.66 0.10 3.22 2.31 0.06 21 0.5 0.06 0.48 (a) Death.rates from 1939 to 1949 relate to the civilian population only. Death.rates for tuberculosis are expressed per 1,000 total population in Table 7 7. (ib) 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. From 1931 deaths from abortion are excluded. (c) Comparable figures are not available for this period. Table 5—Civilian deaths by cause—Administrative County of London, 1954 Cause Sex 0- 1- 5— 15— 25— 45— 65— 75+ Total 1954 1953 1. Tuberculosis—respiratory M — — - 3 43 220 119 44 429 510 F 2 1 2 8 69 50 32 74 167 180 2. Tuberculosis—other M 1 2 1 7 4 9 5 4 33 29 F 1 1 - 1 6 12 7 1 29 44 3. Syphilitic disease M - - - — 3 34 58 17 112 112 F - - - _ 2 21 26 22 71 63 4. Diphtheria M - - - _ - - — - — - F - - - - - - - — - — 5. Whooping cough M 2 - - - - - - - 2 7 F 1 — — - - - — 1 2 75 6. Meningococcal infection M 7 7 3 1 1 - 1 - 20 14 F 3 2 - - - — 1 2 8 70 7. Acute poliomyelitis M - - 1 - 1 - - - 2 10 F - 1 1 1 1 - — — 4 9 8. Measles M 1 - 1 - - - - - 2 7 F - - - - - — — — — 2 9. Other infective, &c., diseases M 3 4 1 1 9 19 4 5 46 44 F 1 1 1 3 72 7 8 5 38 35 10. Malignant neoplasm: Stomach M - _ - - 24 224 197 119 564 639 F — — — — 19 119 140 167 445 460 11. Malignant neoplasm: Lung, bronchus M - 1 - 1 64 773 468 157 1,464 1,431 F - - - 1 19 137 95 60 321 276 12. Malignant neoplasm: Breast M - - - - - 4 1 - 5 4 F - - — - 58 301 158 158 675 728 13. Malignant neoplasm: Uterus F - - - - 24 137 79 46 286 331 14. Other malignant and tic neoplasms M 1 8 10 17 101 591 673 556 1,957 2,004 F 5 5 6 11 102 567 540 538 1,772 1,761 15. Leukemia, aleukemia and Hodgkins disease M 1 6 9 1 22 30 24 8 107 99 F - 2 4 5 8 25 20 21 81 00 16. Diabetes M - - - - 6 12 15 18 51 82 F - - - 1 4 27 57 40 132 160 17. Vascular lesions, nervous system M — - 1 4 39 392 545 654 1,635 1,610 F — - - 1 52 405 606 1,233 2,367 2,408 18. Coronary disease, angina M - - - - 100 1,138 1,042 807 3,087 2,927 F — - - 1 14 314 688 892 1,909 1,865 19. Hypertension with heart disease M - - - - 6 63 166 185 420 414 F — - — - 3 55 152 318 528 510 20. Other heart disease M 1 - 1 8 56 268 450 1,086 1,870 1,979 F 1 - 2 3 S4 500 451 2,045 2,884 3,157 21. Other circulatory disease M - - - 1 21 179 255 355 811 864 F - - 1 2 12 727 205 648 1,077 1,103 22. Influenza M 1 1 - 1 6 17 12 9 47 203 F - - — - - 7 11 24 36 577 23. Pneumonia M 56 17 4 1 13 150 211 352 804 1,107 F 48 8 6 2 13 70 180 475 802 7,017 24. Bronchitis M 20 6 5 - 18 370 509 541 1,469 2,217 F 13 2 — - 72 86 770 442 734 7,565 25. Other diseases of respiratory system M 2 3 1 - 7 70 56 55 194 258 F 2 1 2 - 5 26 27 52 115 127 26. Ulcer of stomach and duodenum M - - - - 7 127 125 106 365 386 F - - - - 5 50 48 75 167 163 27. Gastritis, enteritis and diarrhoea M 13 2 - 1 4 20 15 18 73 85 F 9 - - 2 6 75 27 55 90 118 28. Nephritis and nephrosis M - 1 5 7 25 70 25 29 162 176 F 1 3 3 11 27 50 42 38 158 157 29. Hyperplasia, prostate M - - - - 1 18 85 181 285 274 30. Pregnancy, childb. : abortn. F - — - 6 28 — 34 37 31. Congenital malformations M 105 9 4 5 8 12 7 5 155 150 F 73 70 3 3 11 16 5 5 126 133 32. Other defined and ill defined diseases M 397 15 20 20 93 280 243 261 1,329 1,335 F 256 8 7 12 107 282 270 499 1,441 1,589 221 Table 5(contd.)—Civilian deaths by cause—Administrative County of London, 1954 Cause Sex 0— 1 — 5— 15— 25— 45— 65. 75+ Total 1954 1953 33. Motor vehiclc accidents M — 6 15 21 55 32 12 34 175 166 F . 8 3 8 7 25 24 79 94 81 34. All other accidents M 13 9 17 19 71 88 49 85 351 386 F 6 3 3 7 20 46 62 779 326 301 35. Suicide M . . . 9 94 135 52 25 315 288 F . . . 7 51 79 29 13 179 185 36. Homicide, operations of war M 3 1 . 4 1 9 . . 18 18 F . 7 4 7 3 2 1 . 12 72 ALL CAUSES M 627 98 99 138 903 5,354 5,424 5,716 18,359 19,835 F 420 57 48 95 758 3,309 4,342 8,081 17,110 18,801 Table 6—Infant mortality—Administrative County of London, 1954 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 ale Whooping Cough Leg. — — . 3 3 2 1 0.06 0.08 0.04 Illeg. — — — Tuberculosis .. Leg. — — 1 3 4 1 3 0.08 0.04 0.12 Illeg. — — . Measles Leg. — — — 1 1 1 — 0.02 0.04 — Illeg. — — — Convulsions Leg. — 1 — — 1 — 7 0.02 — 0.04 Illeg. — — — Bronchitis and Leg. 5 18 13 98 137 76 61 2.71 2.94 2.46 Pneumonia Illeg. — 2 1 Gastro Enteritis Leg. — — — 21 22 13 9 0.43 0.50 0.36 and Diarrhoea Illeg. — — 1 Congenital Leg. 31 45 37 57 178 105 73 3.52 4.07 2.94 Malformation Illeg. — 5 3 Immaturity, etc. Leg. 97 53 11 4 188 107 81 3.71 4.14 3.26 Illeg. 13 8 2 Injury at Birth Leg. 54 45 5 1 119 78 41 2.35 3.02 1.65 Illeg. 7 6 1 Post.natal Asphyxia Leg. 112 70 1 3 206 126 80 4.07 4.88 3.22 and Atelectasis Illeg. 13 6 1 Haemolytic disease Leg. 17 7 3 — 28 15 13 0.55 0.58 0.52 Illeg. 1 — — Accidental Mechanic Suffocation Leg. Illrg. 1 . . 1 5 6 4 2 0.12 0.15 0.08 . . . Other causes Leg. 15 30 13 85 154 99 55 3.04 3.84 2.24 Illeg. 8 1 2 All causes Leg. M. 192 168 50 143 936 553 383 19.92 23.09 16.62 F. 139 101 35 108 Illeg. M. 26 19 6 23 111 74 37 30.47 39.53 20.89 F. 16 9 5 7 Total, 1954 373 297 96 281 1,047 627 420 20.68 24.28 16.93 Total, 1953 389 330 102 395 1,216 685 531 23.85 26.06 21.50 Leg. M. 186 184 48 188 1,085 606 479 22.92 24.85 20.87 F. 148 775 42 174 Illeg. M. 31 21 8 19 131 79 52 35.94 41.60 29.78 F. 24 10 4 14 222 Table 7—Infant mortality by cause—Administrative County of London, 1931.1954 (Rates per 1,000 live births) Cause of death 1931 to 1935 1936 to 1940 1941 to 1945 1946 to 1950 1951 1952 1953 1954 Whooping cough 2.17 1.66 1.62 0.54 0.17 0.08 0.28 0.06 Tuberculosis 0.73 0.55 0.56 0.25 0.08 0.04 0.14 0.08 Measles 1.17 0.79 0.34 0.08 0.13 . 0.06 0.02 Bronchitis 2.11 1.80 1.82 0.90 0.95 0.83 0.88 2.71 Pneumonia 11.12 9.44 7.56 4.25 2.45 3.05 3.16 Gastro.enteritis 10.81 10.29 7.76 2.70 0.76 0.80 1.28 0.43 Immaturity 14.75 12.56 12.06 6.82 4.71 4.19 3.99 3.71 Influenza 0.36 0.32 0.33 0.19 0.15 0.02 0.10 (a) Other causes 13.02 11.12 6.32 3.84 3.72 2.29 2.61 (b) Congenital mal., etc. 7.15 7.29 12.03 11.63 12.35 11.77 11.40 (b) Congenital malformations . 3.52 Injury at birth Post-natal asphyxia and atelectosis Previously included in Congenital malformations, etc. 2.35 4.07 Haemolytic disease 0.55 Convulsions — — . . . . . 0.02 Accidental mechanical suffocation — — — — — . . 0.12 Other causes — — — — — — — 3.04 All causes 63 56 51 31 25 23 24 21 (a) Now included in other causes. (b) Now re.grouped. Table 8—Maternal mortality (excluding abortion)—Administrative County of London and England and Wales, 1944.54 (Rates per 1,000 total births) 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 Puerperal sepsis: London 0.18 0.26 1.12 0.12 0.13 — — 0.06 0.15 0.02 0.06 England and Wales 0.27 0.24 0.18 0.16 0.13 0.12 0.12 0.10 0.09 0.10 0.10 Other causes: London 0.85 1.09 0.80 0.55 0.37 0.40 0.53 0.39 0.51 0.38 0.48 England and Wales 1.25 1.23 1.06 0.86 0.74 0.70 0.60 0.56 0.50 0.54 0.49 Table 9—Cases of infectious illness reported from schools in 1954 and preceding years— Administrative County of London Year Chicken.pox Diphtheria Rubella Impetigo Measles Mumps Ophthalmia and conjunctivitis Poliomyelitis Ringworm Scabies Scarlet fever Whooping cough 1938 11,018 3,576 2,383 1,018 31,852 4,805 342 . 278 2,718 3,988 4,067 1946 5,602 290 349 381 8,291 5,296 251 5 245 1,488 1,654 2,421 1947 7,423 263 1,571 264 6,684 2,845 233 153 180 650 1,974 3,660 1948 7,745 187 491 243 11,545 9,162 297 34 119 323 2,078 3,691 1949 5,528 135 313 178 7,651 2,113 361 132 71 120 2,359 1,814 1950 7,773 63 312 151 7,495 7,638 275 91 79 106 1,925 4,039 1951 16,756 26 2,193 212 15,045 6,127 1,685 29 138 73 1,811 3,338 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 1954 13,891 7 567 402 2,439 13,051 452 28 110 81 1,292 1,587 223 (a) Rate per 1,000 total birtk (b) relate to last 22 weeks only. Registrar.General has been followed corrections were not availablt (f) Rate per 1,000 live births. Table 10—Notifiable infectious diseast —Annual number of notifications and numbers per 1,000 of population—Administrative County of London, 1934.1954 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 Whooping Cough Food poisoning Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate 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 (f) 8.24 5,569 1.320 74 0.018 758 (a) 12.91 18,238 4.32 144 0.034 — — 1935 1936 2 0.0005 3 4 0.0007 0.001 9,294 7,030 2.23 1.68 199 304 0.048 0.072 15 12 0.004 0.003 187 255 0.045 0.061 1,868 1,815 0.448 0.432 37 35 0.009 0.008 (b) 105 113 0.025 0.027 382 462 6.87 8.10 3,707 4,141 0.888 0.986 85 38 0.020 0.009 652 635 11.31 10.92 10,954 10,705 2.63 2.55 — — — — (b) 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 — — — — (c) 1,891 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 (b) 8,093 2.00 — — — — 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 0.22 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 (b) 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 (d) 9,689 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 9.18 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 .68 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 Paralytic Non.par. 1950 2 0.0006 81 0.024 960 0.283 18 0.005 63 0.019 566 0.16? 20 0.006 22,282 6.57 90 0.027 145 2.72 1,691 0.499 Cases 267 Rate 0.079 Cases 163 Rate 0.048 371 6.83 {g) 17.04 823 0.24 4,157 1.23 — — — — 10,875 3.21 863 0.25 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 0.015 911 572 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 1954 1 00003 1 0.0003 4 0.001 4,268 1.285 15 0.005 49 0.015 368 0.111 53 0.016 7,445 2.41 86 0.026 112 2.21 1,502 0.452 79 0.024 46 0.013 1,938 37.52 669 0.20 2,444 0.74 — — 1 0.0003 4,691 1.41 1,060 0.32 Comparable figures not available for this period. (c) Cases relate to last quarter only—Rates are adjusted on an annual basis, (d) Cases Rtes are adjusted on an annual basis, (e) In order to preserve uniformity with published national figures the practice of the in producing this table, namely in taking full account of any known changes in diagnosis after the receipt of the original notification. These or to 1944. Comparable figures can be obtained by the method given in the footnote to this table in previous annual reports. (g) For cause of increase since 1950 see page 16. 224 d Table 11—Notification of certain infectious diseases—distribution by age and date of notification—Administrative County of London, 52 weeks commencing week ended 9th January, 1954 Four. weekly periods 1954 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 m 5 2 2 9 100 49 34 183 24 6 2 32 13 12 65 90 2 - - 2 - 4 - 4 45 55 3 103 122 48 1 171 F 3 — — 3 72 39 60 176 10 8 1 19 14 8 88 110 - - 1 1 1 - - 1 20 60 3 84 119 48 1 168 5— 8 m 7 2 2 11 73 78 32 184 21 22 2 45 7 6 99 112 1 - 1 2 - - 2 2 22 71 1 94 68 34 1 103 f 3 1 — 4 79 75 52 208 25 24 3 52 4 8 55 67 - - 1 1 - - - - 24 66 4 94 91 51 7 149 9—12 m 7 2 2 11 106 89 35 232 39 43 1 83 15 8 71 94 - - 1 1 - - - - 25 100 3 130 112 66 2 180 f 4 — 1 5 85 89 89 267 33 40 5 78 5 6 47 53 1 1 - 2 - - 1 2 37 78 6 122 106 70 5 181 13—16 m 4 — — 4 143 113 74 331 62 56 3 122 6 10 43 59 - - - - - - 1 1 39 86 9 135 98 53 - 151 F 4 — — 4 113 108 133 359 80 55 4 139 9 6 29 45 - - - - - - - - 32 91 5 128 115 69 - 184 17—20 m 4 1 2 7 104 83 52 240 85 41 1 129 5 9 63 78 - - 1 1 - - - 28 60 3 91 190 75 - 185 F 3 — — 3 113 64 87 264 83 44 4 131 1 9 41 51 - - 1 1 1 1 2 22 48 2 72 114 66 3 187 21—24 m 2 1 — 3 66 83 33 182 75 74 2 152 5 9 32 46 - - 2 2 1 - - 1 27 56 3 87 87 4.4. 2 134 F — — — — 77 70 65 215 59 67 6 132 5 5 29 39 - - 2 2 - - 2 2 30 66 6 103 94 TT 55 4 153 25—28 m 3 1 4 68 82 16 166 117 126 3 246 6 14 30 50 2 1 1 4 1 - 1 2 26 69 5 101 103 70 5 178 F - — — — 58 107 56 221 109 125 6 240 5 5 16 26 - - 2 2 - - - 4 24 79 7 111 128 76 4 208 29—32 m 1 1 1 3 54 29 26 109 148 137 1 287 5 6 19 30 - 1 - 1 1 3 2 6 27 58 - 86 98 54 2 156 F 3 — 1 4 44 31 54 131 149 127 2 278 1 1 24 26 — 2 - 2 - 7 1 2 16 43 3 63 119 85 3 209 33—36 m 2 — — 2 44 15 24 84 115 44 6 165 4 4 16 24 2 - 2 4 1 3 - 4 16 25 3 44 130 74 2 206 F 1 1 — 2 41 12 32 87 103 33 4 140 1 3 20 24 2 7 1 4 1 6 - 7 23 20 3 46 125 72 5 202 37—40 m - 1 1 2 38 21 16 75 135 112 - 247 6 9 20 35 1 - - 1 1 1 - 2 22 53 3 78 81 41 5 123 F 1 — 1 2 31 15 29 75 101 99 5 205 3 5 23 31 1 2 2 5 - 1 1 2 13 47 4 64 100 50 4 154 41-44 m 4 3 — 7 34 21 11 66 239 229 2 472 6 3 43 52 3 1 2 6 1 - 1 2 33 64 3 100 91 72 1 164 F — — — — 42 18 22 83 237 213 2 452 3 5 40 48 2 - - 2 1 - 1 2 21 50 1 1UU 72 112 65 8 185 45—48 m 1 — — 1 36 28 13 77 350 250 3 604 10 17 32 59 7 2 3 12 - 4 3 7 41 58 1 101 123 101 - 224 F — — 1 1 35 23 21 80 291 235 3 530 (5 9 39 54 4 1 2 7 1 2 - 3 35 81 2 118 156 119 6 281 49—52 m — 1 — 1 52 42 14 108 536 754 5 1,297 24 20 61 106 2 1 2 5 - - 2 2 28 59 4 91 116 79 1 197 f 1 — — 1 37 31 25 93 553 696 6 1,261 11 12 73 96 2 - 2 4 — 2 2 4 25 75 3 106 129 87 7 225 Total m 40 15 10 65 918 733 380 2,037 1,946 1,894 31 3,881 112 127 594 835 20 6 15 41 6 15 12 33 379 814 42 1,241 1,338 811 18 2,172 52 week f 23 2 4 29 827 682 725 2,259 1,833 1,766 5/ 3,657 68 82 518 670 12 7 14 33 5 17 9 37 325 804 49 7,755 7,505 913 57 2486 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 10 which relates to tht calendar year 1954. pi 225 Table 12-Statistics of the administrative work carried out by the Metropolitan Borough Councils in 1954. Borough Dwellings CLEARANCE AREAS DWELLING HOUSES SMOKE NUISANCES CLEANSING AND DISINFECTION LICENSED OR REGISTERED PREMISES Restaurants, eating houses and canteens SANITARY OFFICERS Erected by the Borough Council | Erected by other persons Total number in the Borough Inspections Repaired as a result of informal action Defects remedied after service of formal notice Housing Act 1936 Local Govt. Miscellaneous Provisions Act 1953 Sec. 10 (I) Water supply provided to tenement houses Complaints Observations Intimation notices served Nuisance notices served Adults cleansed Children cleansed Premises disinfected Premises disinfested Licensed slaughter houses < Other offensive trades Dairies and milk shops Ice cream premises Common Lodging Houses Establishment Employed at end of year Assistants employed at end of year Unfit Houses Other Houses On complaint On notification of illness House.to.house Other reasons Section II Section 12 At home At a cleansing station Demolished Persons displaced Demolished Persons displaced Public Health (London) Act Housing Act Demolished Closed by undertaking Rooms closed Undertakings accepted By owners By local authority By owners By local authority Number Persons displaced Number Persons displaced ground rooms other rooms ground rooms other rooms Closing Orders made Number Persons displaced Number Persons displaced Number Persons displaced Number Persons displaced Number Persons displaced Male Female Total Male Female Total Male Female Total Division I 46 101 - 222 7 2 9 7 2 9 - - - Chelsea 70 73 16,267 — — — — 822 366 58 — 374 93 1 30 — 4 4 1 — — — 4 4 — — — — — - 36 11 7 — - - 487 632 112 159 - - 133 254 - 159 15 1 16 11 1 12 2 — 2 Fulham 104 10 31,337 — — — 2,744 514 269 — 27 2,204 12 — 1 — — - — 3 10 1 2 — — — — 4 16 7 19 1,063 - - - 71 18 106 422 - - 98 301 - 267 14 1 15 11 1 12 - — — Hammersmith 59 67 26,238 — — — — 3,972 266 - 1,200 391 515 4 1 — — — - — 6 19 — — — — — — 13 81 2 15 189 2 — — 507 887 39 233 2 - 184 332 - 217 19 - 19 16 - 16 - — — Kensington 181 176 38,397 — — — — 4,309 1,798 7,213 2,708 1,041 680 1 — — — — - — 83 26 4 — 8 — 9 — 2 — 7 12 41 — — - 265 1,288 333 1,412 - - 299 - - Division 2 206 - 203 11 1 12 11 1 12 - - - Hampstead 66 309 21,468 - - - 2,141 469 116 946 1,109 256 - - - - - - 10 5 47 40 - - - - - - 22 31 411 4 — — 34 20 211 99 — - 47 214 - 141 17 1 18 14 1 15 2 - 2 Paddington 72 17 24,255 - - - - 4,066 † 1,514 1,312 1,308 589 6 8 2 - - - - 34 - - - 3 - - - 1 12 13 4 — — — — 219 36 158 896 - - 487 2 817 - - 13 10 3 13 - - - St. Marylebone 171 43 24,232 — — — — 1,282 450 579 263 329 235 - - - - - - 58 30 7 8 2 — — — 1 2 31 49 328 10 — — 641 373 184 436 1 2 - 298 233 - ‡850 21 1 22 20 1 21 — — — St. Pancras 392 23 31,461 — — — — 4,800 438 239 3,406 1,610 1,979 8 — — 1 — - — 79 — 8 — — — — — 1 — 140 24 264 — - - 866 792 651 538 - - 121 135 3 3,044 19 1 20 18 1 19 — — — Westminster, City of 216 163 26,000 — — — — 1,219 329 1,598 4,182 19 273 - - - - - - - 51 47 41 38 - - - - - - 8 69 1,414 2 — — 406 169 292 1,738 - - 103 Division 3 540 1 449 8 - 8 6 - 6 3 - 3 Finsbury 201 16 9,622 - - - - 2,000 - - 2,381 785 41 - - - - - 1 5 33 11 4 — 10 6 2 — 1 2 15 20 192 — — — 105 1,019 318 321 - 2 124 2 468 5 - 5 5 - 5 - - - Holborn 56 25 6,190 — — — — 150 132 — 171 151 17 — — — — — — — 19 1 2 — — — — — — — 3 30 135 — — — 52 — 53 88 - 5 68 540 - 651 31 3 34 21 2 23 3 — 3 Islington 397 390 45,518 — — — — 8,682 † — — * 3,506 42 — — 6 16 9 34 106 151 19 14 16 14 — — 8 36 44 42 315 8 2 26 172 470 353 556 1 13 319 369 1 Division 4 175 228 28 - 28 24 - 24 - - - Hackney 225 334 40,182 — — — — 5,041 233 - 1,975 2,853 2,610 35 — — 3 9 1 — 28 15 13 11 12 — — — 8 29 — 33 1,936 19 2 — 221 505 535 278 2 5 226 96 289 9 - 9 7 - 7 2 - 2 Shoreditch 366 248 12,458 42 170 6 33 2,910 914 1,639 3,167 1,822 210 — 1 — 3 18 — — 17 — 3 3 8 — — — 1 8 8 6 375 7 — — 20 4 139 550 - 1 87 165 47 7 - 7 6 - 6 - - — Stoke Newington 120 1 11,386 — — — — 1,256 117 — — 210 182 12 - - - - - - - 17 - - - - - - - - - - - - - - 34 270 103 107 - - 44 74 Division 5 117 186 129 9 - 9 9 - 9 - - - Bethnal Green 25 159 17,340 39 112 17 59 2,627 415 190 1,204 858 571 1 — 126 4 3 — — — — 1 — — — — — 4 20 — 13 — — — — 32 5 74 626 1 4 30 286 959 20 - 20 20 - 20 1 - 1 City of London — — 1,100 - - - - 6 3 54 1 13 3 — — — — — — — — — — — — — — — — — — 10 150 13 — — 499 234 11 49 - 3 172 293 - 9 9 - 9 - - - Poplar 243 92 17,966 8 20 5 24 2,493 103 100 536 1,396 746 — — — 11 32 — — 30 3 3 3 53 10 43 — — — 39 9 370 764 3 1 264 875 18 1 19 17 1 18 - - - Stepney 269 4 29,784 12 26 — — 4,495 350 57 1,252 2,601 789 — — — 6 16 — — 42 — 18 6 — — — — 4 — 3 25 108 1 — 45 497 27 221 641 - 20 Division 6 9 - 9 8 - 8 - - - Deptford 7 106 16,939 .— — — 2,186 226 - 1,354 911 509 - - - - - - - - - - - - - - - - - - - - - 444 983 134 440 2 1 83 111 9 1 10 7 1 8 - - - Greenwich 32 39 23,185 — — — 2,224 220 239 947 1,012 184 — 1 — 2 14 — — 2 1 — — — — — — — — 9 18 15 3 — 28 251 663 249 404 — 146 18 1 19 16 1 17 - - - Woolwich 164 130 41,647 — 17 — — 1,955 1,143 2,647 8,166 1,038 484 — 2 — 1 5 — — 8 2 3 1 — — — — 16 58 — 7 25 1 — 21 103 860 331 149 390 359 - - Division 7 340 19 - 19 19 - 19 - - - Camberwell 615 418 41,535 2 9 — — 5,560 321 334 569 2,737 2 8 1 2 9 1 3 16 29 35 43 — — 11 6 2 8 — 40 127 3 — — 116 712 586 1,507 3 5 233 20 - 20 17 - 17 - - - Lewisham 591 128 61,120 — — — — 3,255 38 247 2,314 37 §993 — 7 3 6 19 2 5 1 5 33 20 — — — — 8 31 — 2 — — — 2 69 490 535 94 1 ‡250 Division 8 14 - 14 13 - 13 - - - Bermondsey 109 53 15,160 2 10 - 3,463 439 565 5,819 1,492 904 5 4 2 43 3 2 — 6 2 7 24 — 6 439 5 1 — 160 665 13 153 — 8 121 188 2 305 17 19 17 2 19 - - - Lambeth 586 538 53,578 — — — — 6,449 1,527 - - 1,171 1,722 118 — — 4 — 3 6 7 18 3 11 9 16 4 11 8 29 — 17 13 4 — — 256 67 763 1,870 — 2 269 511 231 - - 20 16 1 17 6 - 6 Southwark 168 215 24,977 46 186 — — 4,232 289 3,673 2,214 2,230 1,471 32 2 — 21 41 6 11 216 5 20 3 — — — — 4 3 — 15 179 8 — — 1,583 1,223 141 1,605 5 161 480 - Division 9 12 14 - - - Battersea 110 248 27,862 — — — — 3,138 736 - 2,036 825 738 34 — — — — — — 7 1 — — — — — — 6 8 — 17 207 3 2 — 214 2,499 599 212 1 2 145 264 — 196 14 2 23 21 2 21 - - - Wandsworth 672 1,892 101,452 23 65 — — 7,876 1,140 — 7,306 2,017 626 — — — — — — — 14 9 — — 8 3 — — — — 4 30 93 13 1 — 62 23 684 174 3 251 513 23 - - - LONDON 6,287 5,917 838,656 174 615 28 116 95,353 12,976 20,997 55,194 28,199 25,867 313 60 133 74 186 24 64 917 407 312 210 78 39 32 19 99 367 405 581 8,069 106 9 122 8,425 14,943 8,298 16,521 22 77 4,290 8,147 27 13,239 410 18 461 388 21 409 19 - 19 * included in next column. †included in previous column. ‡estimated. § includes informal action under Public Health (London) Act. Notes:—(i) Housing Act, 1949. One Demolition Order was determined and a Closing Order substituted in Finsbury (5 person* displaced). st. pancras-11 (2) Local Government (Miscellaneous Provisions) Act, 1953. Two Closing Orders were determined in Woolwich and in Hackney five were revoked and Demolition Orders made. (3) Licensed cowsheds. Camberwell—1. (4) Seamen's lodging houses. Poplar—3, Stepney—6. (5) Prosecutions. Inadequate water supply to tenement houses ( convictions) (8 convictions). Dairies and milk shops : St. Pancras—1 (1 conviction), Westminster—4 (1 conviction). Common lodging houses : Stepney—1. Restaurants, eating houses and canteens : City of London—1 (1 conviction), Hampstead—17 (17 convictions), Islington—8 (8 convictions), St. Pancras 2 (2 convictions), Stepney 5 (5 convictions), westmmster 5 226 Table 13— 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 1954 651 340 64 2 5,816 1,422 6,531 1,764 17,875 6,304 219,258 100,554 Table 14 Weather during 1954 (as recorded at Kew Observatory) Month Temperature Rainfall Sunshine Mean (a) °F Difference from Average (b) °F Total ins. Difference from Average (c) ins. Total hrs. Difference from Average (d) hrs. January 38.7 .1.8 0.91 .0.85 60 +16 February 37.6 —3.1 1.73 +0.19 55 . 6 March 43.4 +0.3 1.57 .0.12 88 -15 April 46.6 -0.5 1.10 -0.35 211 +62 May 53.8 -0.9 1.57 -0.15 143 -60 June 58.0 -1.5 3.94 +1.79 157 -42 July 58.9 -4.1 2.56 +0.39 170 -25 August 59.4 -2.8 3.15 +0.91 135 -48 September 57.2 .0.3 1.61 -0.26 194 +49 October 54.7 +3.7 1.42 -1.28 90 -3 November 46.8 +3.0 2.99 +0.77 50 -3 December 45.4 +3.9 2.91 +0.62 60 +23 Year 50.0 .0.4 25.46 +1.66 1,410 -55 (a) Average of the weekly means of daily readings. (b) Average over the 30 years 1906 to 1935 published in 'Averages of temperature for the British Isles for periods ending 1935 (c) Average over the 35 years 1881 to 1915 published in Section I of the ' Book of Normals'. (d) Average over the 30 years 1901 to 1930 published in 'Averages of bright sunshine for the British Isles for periods ending 1930'. 227 p1 APPENDIX E STAFF OF THE PUBLIC HEALTH DEPARTMENT Medical Officer of Health and Principal School Medical Officer J. A. Scott Deputy Medical Officer of Health and Deputy Principal School Medical Officer A. B. Stewart Senior Principal Medical Officer M. MacGregor Principal Medical Officers Maternity and child welfare Dorothy F. Egan School health G.D. Pirrie (seconded to the World Health Organisation) Evelyn A. MowerWhite (from 1/9/54) Epidemiology I. Taylor Tuberculosis W. Hartston Staff examinations and mental health C. W. J. Ingham Chief Dental Officer and Principal School Dental Officer W. Ritchie Young. Chief Nursing Officer Evelyn Robinson Chemist.in.Chief C. J. Regan (Retired (Re.designated—Scientific Adviser) March, 1954) S. G. Burgess (from 16/3/54) Chief Inspector J. Croft Administrative Administrative Officer C. R. Geere Establishment Officer R. H. J. Stronge Principal Clerks G. Berridge D. J. B. Cooper W. H. Joyce Officer.in.Charge, London Ambulance Service A. G. Hellman Senior Officers of the Divisions 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 Eveline 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 Katharine M. Roe 6. F. R. Waldron L. R. T. Coward Lilian Berry 7. H. D. Chalke G. J. Newton Flora E. Frederick (Retired 22/5/54) Kathleen L. Sewell (from 1/6/54) 228 The following statement shows the number of staff employed in the Public Health Department in December, 1954 (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) 224 616 73 913 Medical staff 25 151 (b) 176 Dental staff 2 74 (b) 76 Chemists 21 9 — 30 Inspectors 15 — — 15 Nursing staff 9 2,116 101 2,226 Medical auxiliaries (c) 16 141 20 177 Social worker grades (including mental health) 34 164 108 306 Supervisory staff (ambulance service) 2 — 16 18 Manual workers, operative staff (ambulance service), domestic grades, etc. 36 2,783 732 3,551 Totals 384 6,045 1,059 7,488 (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. 229 Senior Officers of the Divisions—continued Division Divisional Medical Officer Divisional Administrative Officer Divisional Nursing Officer 8. W. H. s. Wallace W. H. C. Bishop Bessie Thom (Seconded to W.H.O.) Margery D. Butler (from 29/6/54) 9. J. T. R. Lewis f. e. wlllson Ethel E. K. Woods (Retired 1/5/54) Winifred M. Winch (from 3/5/54) INDEX Page Accidents in the home 85 Adoption of children 61 Ambulance service 77 Analgesia 67 Ante.natal sessions 58, 65,66 Anthrax 17 Analysis of samples 44 Appendix 144 Audiometry 112 Backward children under five 90 Bathing centres 100 B.C.G. vaccination 27 Births 7 Blind and partially.sighted persons 41 Boarding.out 61, 27 Bronchitis 10 Building programme 51 Cancer 10,144 Care of mothers and young children 58 Cerebral hæmorrhage 11 Child guidance 115 Child helps 75 Child life protection 71 Child.minders 64 Child welfare 60 Chronic sick 43 Civil Defence 80 Co.operation with other Health services 56 Cleansing scheme 99 Dangerous structures 39 Day nurseries 53, 63, 65 Deaths—Leading causcs 9 Deaths from violent causes 16 Degenerative diseases 12 Delicate children 111 Dental hygienists 122 Dental services 118 Diabetes 13,112 Diarrhœa and enteritis 17 Digestive diseases 13 Diphtheria 18,75,85,103 Disinfestation 40 Divisional medical officers' reports 125 Domestic help service 74 Domiciliary midwifery service 66 Drainage 46 Dysentery 18 Educationally sub.normal pupils 109 Emergency obstetric service 67 Employment of children 101 Enteric fevers 20 Enuresis 113 Epileptic children 113 Erysipelas 20 Exhibitions 78, 85 Exhumation of human remains 41 Expectant and nursing mothers 58 Page Family planning 60 Fertility 7 Finance 123 Food poisoning 20 Foot clinics 83 General Practitioners 56 General public health 39 Handicapped pupils 107 Health centres 55, 57 Health education 84 Health visiting 70 Heart disease 13 Heights and weights of school pupils 98, 111 Home nursing 71 Homeless families units 43 Hospital car service—co.operation 77 Hospital services 56 Housing 39 Hygiene inspection of school pupils 99 Illegitimacy 8 Immunisation 75 Improvement grants 39 Infant mortality 13 Infectious diseases 17,123 Infectious diseases in schools 23, 102 Influenza 20 Introduction 3 Juvenile rheumatism 113 Lectures 86 Leptospirosis 21 Loan of home nursing equipment 72 Lunacy and Mental Treatment Acts 86 Lung cancer 10,144 Maladjusted children 116 Marriages 8 Marriage guidance 62 Mass miniature radiography 27, 59 Maternal mortality 15 Meals for schoolchildren 49, 97 Meals for invalids 43 Measles 21 Medical inspection of schoolchildren 95 Medical treatment of schoolchildren 103 Meningococcal infections 21 Mental Deficiency Acts 88 Mental health services 86 Mental health in maternity and child welfare services 60,156 Midwifery service 66 Milk sampling 40 Mortality 9 Mothercraft training 59 Neo-natal mortality 13, 67 Night helps 75 Nurseries, day 53, 63, 65 Nurseries, residential 61 Nursing home registration 42 Nutrition centres 105 230 INDEX—continued Page Occasional creches 64 Occupation centres 54,90 Open.air schools 110,111 Ophthalmia neonatorum 21 Orthodontics 121 Physically handicapped children 112 Pneumonia 10, 22 Poliomyelitis 22 Population 7 Preferential housing 39 Premature babies 67 Premises 51,79 Prevention of illness 83 Public health laboratory 40 Psychiatry 115 Puerperal pyrexia 16 Recuperative holidays 84, 87 Refresher courses 123 Rehabilitation 29, 59, 87 Remedial exercises 115 Reports of Divisional Medical Officers 125 Report of study group on mental health 156 Research 41,117 Residental establishments 61, 116, 117, 122 Respiratory diseases 16 Rheumatic fever 22 Rheumatism scheme 113 Ringworm 103 River pollution 47 Road accidents 16 Royal commission—evidence 92 Sanitary inspection 40 Scabies 23 Scarlet fever 23 School dental service 118 School health service 94 Page School health service.—Historical sketch 167 Schoolchildren under five years 102 School journeys 102 School meals 40 Scientific branch 44 School treatment centres 105 Sewage treatment 46 Slum clearance 39 Smallpox 23, 76 Sodium fluoride dental treatment 122 Special investigations 62,90,117 Speech therapy 112 Staff 80, 92,122, 228 Statistical tables 217 Stillbirths 9, 66 Sunday cinema grants 62 T.B. hostels 29, 54 Training of student health visitors 123 Tuberculin surveys 25 Tuberculosis 23 Tuberculous milk 40 Typhus fever 23 Unmarried mothers 65 Vaccination 76 Venereal diseases 83 Vision tests 99 Visitors 79,91,124 Vital statistics 7 Voluntary organisations 60, 64 Weather during 1954 227 Welfare Committee establishments 40, 43 Welfare of handicapped persons 43 Welfare foods 62 Whooping cough 23, 76 231