1 LCC 61 LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1955 Published by the London County Council Sold at the County Hall, Westminster Bridge, S.E.I and, directly or through any bookseller, from Staples Press Limited (Bookshop: 14 Great Smith Street, Westminster, S.W.I) 1956 No. 3950 2s. 6d. Postage extra LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1955 By J. A. SCOTT, O.B.E., M.D., M.R.C.P., Q.H.P. county medical officer of health and principal school medical officer ERRATA Page 2 (contents) Appendices (B) page 164 not 179 (C) page 179 not 164 Page 19, last para., line 2, Table 13 is on page 189 Page 155, line 10, for '25 to 49' read '25 to 47' Page 187, Table 10, note 2 should refer to Table 9 THE COUNTY HALL WESTMINSTER BRIDGE, S.E.i CONTENTS Page Statistical Summary 3 Introduction 4 Vital Statistics 8 Population 8 Fertility 10 Mortality 12 Infectious Diseases 20 Tuberculosis 25 Recent trends 25 London's tuberculous population 27 Preventive measures 28 Services provided 30 Statistics 36 General Public Health 48 Housing 48 Public health laboratory 49 Milk sampling 49 Sanitary inspection 50 Blind and partially-sighted 50 Registration of nursing homes 52 Welfare committee establishments 53 Care of the chronic sick 54 Welfare of handicapped persons 54 Scientific Branch. 54 Health Service Premises 63 Care of Mothers and Young Children 67 Expectant and nursing mothers 67 Child welfare 69 Marriage guidance 71 Special investigations 72 Day nurseries and occasional creches 73 Unmarried mother and her child 74 Domiciliary Midwifery Service 75 Health Visiting and Nursing Services 79 Home Nursing 80 Domestic Help Service 83 Immunisation and Vaccination 84 London Ambulance Service 86 Prevention of Illness : Care and After Care 92 Foot clinics 92 Recuperative holidays 92 Venereal disease 93 Health education 93 Page Mental Health Services 95 Lunacy and mental treatment Acts 95 Mental Deficiency Acts 97 Occupation centres 100 Co-operation with general tioners 102 School Health Service 103 Organisation 103 Medical inspection 103 School meals, milk See. 105 Vision 106 Hygiene inspections 107 Children under five years 109 Audiometer testing 109 Audiology centres 110 Very young deaf children 110 School journeys Ill Medical treatment 112 Infectious diseases 114 Handicapped pupils 115 Enuresis 117 Juvenile rheumatism 117 Remedial exercise classes 118 Psychiatry 118 Residential schools and homes 120 Bed time for school children 120 Research and investigation 121 Dental Services 121 Staff 125 Finance 130 Visitors to the Department 131 Reports by the Divisional Medical Officers 132 Appendices (a) Review of Mortality in this Century 153 (b) Vital statistics of the County of London in the years 1901 to 1951 179 (c) Statistical tables 164 (d) Staff of the Department 190 (W.&S. Ltd. 61283) 12.56. 274514. LONDON ADMINISTRATIVE COUNTY VITAL STATISTICS, 1955 Figures in brackets are for 1954 Population :— Males 1,540,0001. 3,295,000 (3,322,000) Females 1,755,000 Areal comparability factors :— Births .0.87 (0.87) Deaths 0.99 (0.99) Live births:— Legitimate .45,999 (47,130) 49,826 (50,745) Illegitimate 3,827 (3,615) Still births:— Legitimate 933 (920) 1,034 (1,029) Illegitimate 101 (109) Live birth rate per 1,000 population:—15.1 (15.3) (adjusted rate 13.1 (13.3) ) Still birth rate per 1,000 total births:—20.3 (19.9) Deaths:— Males 19,381 (18,359) 1 • 37,877 (35,469) Females 18,496 (17,110) j Death rate per 1,000 population :—11*5 (10-7) (adjusted rate 11-4 (10-6) ) Deaths of infants :— Legitimate Illegitimate Total Under 1 month 716 (685) 118 (81) 834 (766) 1 month to 1 year 294 (251) 29 (30) 323 (281) Total under 1 year 1,010 (936) 147 (111) 1,157 (1,047) Infant mortality rate :— (per 1,000 live births) 21-96 (19-86) 38-41 (30-71) 23-22 (20-63) Neo-natal mortality rate :— (per 1,000 live births) 15-57 (14-53) 30-83 (22-41) 16-74 (15-10) Number of marriages :— 34,248 (32,896) Maternal mortality :— Postabortion Other pregnancy and childbirth Total Deaths from sepsis 5 (5) 3 (3) 8 (8) Deaths from other causes 3 (1) 28 (25) 31 (26) Total 8 (6) 31 (28) 39 (34) 3 INTRODUCTION Vital statistics The home population of the County in the middle of 1955 was estimated by the Registrar General to be 3,295,000—a decrease of 27,000 as compared with the previous year. The average age of the population was 37-5 years and the percentage above the age of 65 years was again 11.6. The live birth rate (15.1 per thousand population) was slightly lower than in the previous year. Of the total live births 7.7 per cent. were illegitimate, and this figure is the highest recorded since 1946. The still-birth rate which has remained relatively stable for some years was somewhat higher than in 1954 being 20.3 per 1,000 total births, the legitimate and illegitimate rates being 19.9 and 25.7 respectively. The death rate was 11.5 per 1,000 of the population, a higher figure than the rate for 1954 which was the lowest recorded so far. The increase in mortality was mainly among the aged and in the diseases affecting old age. Heart disease was still the major cause of death and accounted for nearly one-third of the mortality, cancer remained the second cause of death with an increased death rate of 2.39 per 1,000 as against 2.31 per 1,000 in 1954. The degenerative diseases, namely heart disease, other circulatory diseases, cerebral vascular lesions, nephritis and bronchitis were again responsible for over half all deaths. The sixth cause of death was again violence which had also increased slightly. The number of deaths from road accidents was the highest recorded since the war. The death rate of children under one year increased from 20.6 in 1954 to 23.2 per 1,000 live births in 1955, and the rate in the first four weeks of life was 16.7. The infant mortality rate among illegitimate infants was 30.8 per 1,000 illegitimate births. A review of mortality in this century appears at page 153. Weathei A table summarising the weather experienced during the year appears at page 189. Although the weather generally was good, temperatures were consistently low during the first quarter. Infectious diseases There were 16 confirmed notifications of diphtheria during 1955. In two cases, each of young children, it proved fatal. In neither case, although repeated offers had been made to the parents, had immunisation been carried out. There were 4,709 notifications of whooping cough with seven deaths. Each figure though somewhat high is of the same order as that for last year. The figure for scarlet fever notifications (2,070) was the lowest ever recorded. There were 49,110 notifications of measles with 15 resulting deaths, substantially higher than in the previous year and accounted for by the fact that it was the second and principal year of a biennial cycle. A low figure for deaths from enteritis and diarrhoea in children under two years of age (27) was again recorded. Deaths attributable to influenza (164) although nearly twice as numerous as in 1954 were below the average for recent years. The number of notifications of poliomyelitis was the highest to date, although mortality was lower than in previous large epidemics.Whilst about a third of the notifications were in respect of the 0-5 years age group, there was a proportionate increase in the 5-14 years age group with a corresponding drop in the group aged 15 years and more. Tuberculosis The incidence or bonne dysentery, although not so heavy as in 1954, was considerable (3,019 notifications as against 4,268). In 1955 there were 561 deaths (mainly in older men) from all forms of tuberculosis in the county as compared with 658 in the previous year. This reduction in mortality was accompanied by a reduction in morbidity, 4,122 new cases having been notified during this year compared with 4,691. Protective vaccination of thirteen year old school-children with B.C.G. has continued for those whose parents accepted. It is a great pity that 25 per cent. of this age group of London children are deprived of the protection afforded by this simple measure of proved value because parents remain indifferent or unconvinced. Scientific branch The work of this branch is summarised at page 54, whilst a fuller report is published separately.*However, the concern that was felt at the condition of the London atmos- *Annual Report of the Scientific Adviser, 1955, Staples Press, Ltd., London. 4 phere should be mentioned here. Careful observation was made by the Council's Scientific Adviser as part of a long-term investigation of the major pollutants and a special watch was kept upon the amount of sulphur compounds and smoke present. To this was added the estimation of some minor pollutants and also the examination of atmospheric dust for radio active constituents in order to obtain basic data for future comparison. Building programme The need for economy continued to limit building expenditure. A list of works completed appears at pages 65 and 66 and includes the Province of Natal Welfare Centre providing a wide range of maternity and child welfare and school health services which was opened in May 1955. The administration of this centre is the responsibility of a house committee of representatives of the Institute of Child Health, of the Council's Health Committee, of two of its Divisional Health Committees and of the Borough Councils of Holborn and St. Pancras, as well as of a voluntary association. It is an essay in co-operation. Co-operation with other parts of the service rrogress maae in co-operation witn tne general meaicai service or tne London Executive Council is described at page 102. There are many references in the report to the very wide range of services which depend upon the close co-operation existing between the Hospital and Specialist services and the local health authority's services for their full effectiveness. The possibility of further developments in this field is always in mind, an example is the conference (referred to on page 96) called to consider closer contact between mental welfare officers and psychiatric social workers on the one side and the physician superintendents of mental hospitals on the other. Care of mothers and young children The proportion of children who attended at welfare centres during the first year of life was again 86 per cent. Accommodation in day nurseries was slightly reduced (5,580 places in 99 day nurseries at the end of 1955 as against 5,850 at the end of 1954), whilst 1,500 were being cared for by child-minders under supervised arrangements. A scheme of restricted expansion of occasional creches began to operate. Attendance at ante-natal clinics dropped slightly and represented 43 per cent, of all women needing ante-natal care as against 45 per cent, in 1954. Attendances at educational activities at welfare centres were maintained. Effect has been given to the main recommendations of the study group, reported in 1954, on mental health education in the maternity and child welfare service. Intensive training of a limited number of medical officers and health visitors began in six of the nine divisions under the leadership of psychiatrists attached to local child guidance units, whilst a departmental advisory committee has been set up to advise on general developments in this field. A comprehensive inquiry was begun to ascertain the extent of the task presented by potential and hard-core problem families and the methods that should be used and the staff time required in preventive measures and assistance. The demand for recuperative holidays has again evidenced the diminishing trend apparent, except for a slight increase in 1954, since 1950. 1955 saw a reduction in recommendations for all classes consistent with the earlier figures. Domiciliary midwifery service The number of confinements attended declined as compared to the number for 1954 (9,898 as against 10,546). In addition to gas and air analgesia, 'trilene' was used in 3 per cent. of cases during a period of six months and as a result apparatus will be issued to all midwives. Home nursing The home nursing service has continued to be provided on an agency basis by voluntary district nursing associations, reduced in number in November, 1955, from 27 to 26, through the Central Council for District Nursing. The total number of visits paid and of treatments given during the year (1,953,182 ; 64,256) both show an increase over the figures for the previous year. Domestic help service 3,148 home helps (giving service equivalent to 2,029 whole-timers) were employed at the end of the year and no less than 80 per cent. of the persons for whom they 5 provided assistance were aged and chronic sick. Again efforts were made to provide service to prevent children having to be taken into care whilst preparation of a scheme began for the training and employment of selected home helps to work with health visitors in the homes of families in danger of breaking up. Prophylaxis The number 01 primary diphtheria immunisations and reinforcing doses, respectively 34,529 and 30,850, were considerably lower during 1955 than in the previous year because the service was interrupted owing to the incidence of poliomyelitis. The estimated percentage of children 0-4 years who had at any time been immunised was at the end of the year about 54 per cent. Whooping cough immunisation also suffered a reduction as the result of a withdrawal of facilities during the poliomyelitis epidemic. During 1955 the rate for children vaccinated during the first year of life was approximately 50 per cent, of the annual live births, the number of children vaccinated last year showed a decline for the first time for some years. The importance both of diphtheria immunisation and of vaccination cannot be too strongly emphasised. There can be no doubt that these protective measures have played their part in reducing the toll of both diseases and so have contributed to the present situation in which parents who have had no experience of either disease at first hand and in most cases who have heard little about them from their own parents are apt to scout the danger or to be indifferent to it. There remains much to be done in this field and this is particularly true with regard to diphtheria immunisation. The London Ambulance Service The London Ambulance Service with its ancillary services removed considerably more than a million patients in journeys approaching in total 6¼ million miles. During the rail strike in May/June up to 3,000 patients a day were dealt with by the general section whilst the normal accident service was maintained. Following discussion early in the year between the authorities concerned as to the responsibility for the payment of rail fares, the number of patients for whose fares the Council pays decreased notably. In 1954 free rail transport was provided for 5,867 patients, the corresponding number in 1955 was 3,466. The second new ambulance station since the war became available and slightly relieved pressure upon the accident section, but the total number of accident calls showed an increase on the previous year. Street accidents alone at which an ambulance was required increased by 2,056 to 17,338. On 10th October, 1956, the administrative and operation headquarters, hitherto separate, were housed under one roof; this should greatly facilitate the operation of the service, and was marked by the uninterrupted functioning of the central control room. Mental health services For the first time since 1948 the number of persons referred as allegedly of unsound mind showed a slight decline. The number of mentally defective persons awaiting institutional care continued to increase and at one point during the year it reached 250. By 31st December, 1955, it had been reduced to 230; this, however, was still substantially greater than the 205 awaiting admission a year earlier. A hostel for twelve mentally deficient girls from special schools for the educationally subnormal who have no suitable homes was opened in the autumn and by the end of the year six girls were accommodated there under guardianship. A scheme was introduced for placing mentally deficient boys for practical training under guardianship at Wallingford Farm training colony. As part of the provision made for the occupation and training of mental defectives an industrial training centre, the first in London, was opened in September for 20 male adult mental defectives. School health service The percentage of the school population found on inspection to be 'verminous' has again declined. For 1955 it was 2.2 per cent. as against 8 per cent. in 1948. 6 During the year pure tone sweep hearing testing began in two divisions as a pilot scheme, and a teacher of the deaf was employed and commenced work at two centres, north and south of the Thames, for the auditory training of very young deaf children. An increasing demand upon the services of the child guidance units was still apparent and. notwithstanding some increases of staff, waiting lists were lonorr than desirable Dental services The position remained similar to that in 1954. The ratio of one full-time dental officer for each 3,000 children on the school roll which is the Council's policy was no nearer achievement. The ratio for the county was only 1:6,400 (as against 1:5,600 in 1954). Systematic revisional treatment was impracticable but a further improvement was effected in the ratio of permanent teeth restored to permanent teeth extracted in school children. All applications for treatment from expectant and nursing mothers and children under five years were met and an increase in the number of sessions available for these patients was obtained, much of it by the working of voluntary additional sessions. As I said in my report for 1954 much remains still to be done before a fully comprehensive service as intended by the National Health Service Act, 1946, can be achieved. Training of student nurses from hospitals Hospital student nurses, as part of the revised syllabus of the General Nursing Council, again spent some time observing and being instructed in the Council's health services. Their number (3,627) increased considerably as compared with the number for whom facilities were provided in 1954 (about 3,000). Staff During the year the work and staffing of the department was reviewed by a team with experience in organisation and methods procedures. Their findings are reported at page 125. Throughout the year Dr. G. D. Pirrie, Principal Medical Officer engaged on school health, and Miss B. Thom, Divisional Nursing Officer for Division 8, were absent on secondment to the World Health Organisation, whilst Miss E. Beattie, Divisional Nursing Officer for Division 2, was absent on study leave. During the year Mr. L. Welsh and Mr. L. Wilkes, respectively Divisional Administrative Officers of Divisions 1 and 3, retired from the service. I regret to record the deaths of three valued officers of the public health department. Dr. E. B. Argles, m.r.c.S., l.r.c.p., an assistant principal medical officer whose wide experience and knowledge of housing conditions in London were of great value in the work of slum clearance under the Housing Acts upon which latterly he was principally engaged, died on 19th May, 1955, after a long illness. Dr. Evelyn C. M. McGregor, m.b., b.ch., d.p.h., the deputy divisional medical officer for Division 4, where her long experience in and enthusiasm for the maternity and child welfare and day nursery services were highly valued, died on 26th August, 1955, after a brief illness. On 15th December, 1955, Mr. F. E. Willson, the Divisional Administrative Officer of Division 9 who had given long and valuable service to London, much of it in the health field, died suddenly. 7 VITAL STATISTICS Population the total home population of the County in the middle of 1955 according to the Registrar-General was 3,295,000 compared with 3,322,000 in mid 1954—a decline of 27,000. Corresponding estimates for metropolitan boroughs are shown in Table 3 on page 181 and the rates given in this annual report are calculated on these figures. Table 1 (page 179) shows the age distribution of the population as at the date of the respective censuses for 1901, 1911 and 1921, and the mid-year population as estimated by the Registrar-General for 1931 and for each year from 1938 onwards. The net fall in the population from the middle of 1954 is made up of a loss of 30,000 in ages under 45 (19,000 between ages 25 to 44) slightly offset by a gain of 3,000 in the older age groups. As the birth rate has fallen from 15.8 in 1950 to 15.1 in 1955 the child population in the age range 0-4 years should decline because the numbers coming into the age group are fewer than the ones leaving it—the actual fall of4,000 is, however, greater than would have been expected on a purely arithmetical basis. Conversely, on a similar basis the child population in the age group 5-14 years should have risen with more school entrants than school leavers because of the birth rate of 15.8 in 1950 compared with 14.2 in 1940—in fact the population of this group also fell by 4,000. Although assumptions based on birth rates alone are not wholly valid because of changes in the total population over the years, the features set out above combined with the fall of 19,000 between ages 25 and 44 (the age of parenthood) can only be explained by net migration out of the county. Some 7,000 of the migrants were rehoused on the Council's own out-county estates and about another 3,000 are known to have gone to new and expanded towns—the greater part of the movement (17,000 approximately) was thus due to individual effort. To some extent this movement of young families results in an 'unbalanced' population. If each succeeding generation were reproducing itself a diagram of the age structure of a population would be pyramidal in shape, with the child population largest at the base and, because of successive losses by death, a gradation to the apex of old people: if the average family is large the base of the pyramid will be broad. This question of the reproduction rate, and hence population structure, is a complex of mortality, age and rate of marriage and fertility, of which the latter is perhaps the most important. Changes in the reproduction rate in Great Britain (and elsewhere) over the past two or three generations have affected the age structure of the population and have given rise to enquiry, e.g., the Royal Commission on Population. In the diagram of age structure on page 9. London's population is seen to be even more 'out of balance' than is the population of England and Wales, also shown in the same diagram. The age groups used for the diagram are determined by the figures available from the Registrar-General who gives the population estimates in this form. The London proportions aged 85 years and over, which are not quoted officially, are estimated on the assumption that age distribution at this extreme end of the age range is approximately the same in London as elsewhere in the country. For both London and England and Wales there will be noted a preponderance of women in the older age groups—much of that for the 55-64, and to a lesser extent, that of the 65-74 age groups is due to the higher mortality among men in the first world war—above these ages it is merely a reflection of the greater toughness of womankind. 1,755,000 of London's total population of 3,295,000 are women, an excess of 215,000 (6.5 per cent.) of which nearly half (101,000) comprises women aged 65 or more; corresponding figures for England and Wales are 23,052,000 women out of a total population of 44,441,000, an excess of 1,663,000 (3-7 per cent.) of which nearly two thirds (1,042,000) comprises women aged 65 or more. At the other end of 8 The size (area) of the block for each age group represents the proportion of the total population in that group. the pyramid the loss of shape below 25 years of age is most marked—a reflection of the low birth rates in the nineteen-thirties. Here London is even more deficient than the country as a whole, especially in children of compulsory school age. These deficiencies are even more noticeable in the face of the proportionate surplus in London of persons in the age group 25-34 years and to a lesser extent 35-44 years—the imbalance presumably arises from the attractions of London as a place of employment for the aspiring 9 provincial who, like the native Londoner (judging from the lower proportion of married persons in London at ages 25—44 years), devotes his early adult years to furthering his career and not until he becomes well-established does he turn to matrimony. The deficiency among young men aged 15-24 is not fully explainable but may be partly attributable to the fact that young Londoners do not follow those employments such as mining and agriculture which qualify for exemption from National Service. To sum up, the main characteristics of London's resident population are a deficiency of young people, even greater than in the country as a whole, proportionately more men and women between ages 25 to 44 years and after age 45 proportionately fewer men and more women than in the population of England and Wales. The County of London being the core of a conurbation receives a large daily influx of workers from residential areas outside its boundaries. The Registrar-General's recently published Report on Usual Residence and Workplace (one of the census volumes) shows that 972,000 persons come into the county every day to work, mainly to the central boroughs, and there is a movement in the opposite direction of 149,000, thus London's day-time population is 823,000 more, or 25 per cent. greater, than the number of residents. Fertility The total births allocated to London for 1955 were: Live 49,826 Still 1,034 Total 50,860 Live births The live birth-rate in 1955 was 15.1 per 1,000 total population as compared with 15-3 in 1954. (The figure actually published for 1954 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 hve births registered as occurring in London was 57,312, an excess of some 7,500 over those attributable to mothers residing within the County; the corresponding excess in 1954 was 7,700. The birth-rate in London tends to follow the same trend as for the country as a whole—indeed, since 1947 the crude rates have been practically identical. The two rates are not however strictly comparable because as was demonstrated in the population diagram, the proportion of women of child-bearing age in the population is greater in London than in England and Wales. Since 1949 the Registrar-General has provided a factor for the adjustment of local birth rates to permit of comparability between different areas and with the national rate. This areal comparability factor is based on the ratio of the proportion of the number of women aged 18-44 years in the local population to the national proportion and hence allows for the varying proportion of women of child bearing age but not for any other factor. For London this factor, which was 0.91 in 1949, has been 0.87 for the past three years and the crude birth rate multiplied thereby becomes 13.1 instead of 15.1 per 1,000 population as compared with the national figure of 15.0. This adjusted figure does not take into account, however, the differing proportions of married women in the two populations under consideration—the proportion of women married aged 15 to 44 in London was only 95 per cent. of the corresponding proportion for England and Wales at the census in 1951. Assuming no radical change in the pattern of marriage the 13 per cent, difference between the adjusted birth rate for London and the national figure can be accounted for as to 5 per cent, by the proportionately fewer married women in London and as to 8 per cent, by a real difference in the fertility of London marriages. The crude birth rate for the past 21 years is shown in the diagram (page 11) together with the national rate and, since 1949, the adjusted birth rate: the true comparative fertility of London lies somewhere between the lines for the crude rate and the adjusted rate. 10 The actual numbers and rates are given, together with those for still-births, in Table 2 (page 180). For the years 1940 to 1949, the rates will not agree with those published by the Registrar-General because the latter are based on the civil population whereas those quoted are based on an estimated total population—the justification for this divergence was given in 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 ear her years when total population was used. Rates based on total population 1935-1949, home population 1950— The number of marriages registered in London in 1955, was 34,248 or 20.8 persons Marriages married per 1,000 of the total population—the corresponding rates for 1954 and 1953 were 19.8 and 19.7 respectively. 11 Illegitimacy There were 3,827 illegitimate live births (7.7 per cent, of the total live births). The figures in recent years are: Year Illegitimate live births Illegitimate live births as a percentage of total live births London A.C. England and Wales 1938.42 14,910 6.6 4.7 1943 3,707 8.2 6.3 1944 4,237 9.4 7.2 1945 5,190 11.3 9.4 1946 5,218 7.9 6.7 1947 4,724 6.7 5.3 1948 4,207 6.9 5.4 1949 3,899 6.9 51 1950 3,752 7.0 5.1 1951 3,597 6.9 4.7 1952 3,607 7.0 4.8 1953 3,645 7.1 4.7 1954 3,615 7.1 4.7 1955 3,827 7.7 4.6 Illegitimate births in London reached a peak figure in 1946, but because or the high birth rate in that year this was not wholly reflected in the percentage figure. Since 1949 the number of illegitimate births has been fairly stable but with a fall in total births the percentage of illegitimate births has increased. 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. It is known from the records of voluntary organisations who care for unmarried mothers and their babies (see page 74) that 418 unmarried women came to London to have their babies in 1955; some 200 of these were Irish girls and about 60 were West Indians. Such births are however allocated to London and consequently increase both its illegitimate and total fertility rates. It is also known that at least 142 unmarried West Indian women already resident in London had illegitimate babies and were assisted by these voluntary organisations in 1955 (there may be others who did not seek assistance). Deaths under one year among illegitimate infants amounted to 38 per 1,000 illegitimate births compared with a rate of 22 for legitimate births. The corresponding rates for 1954 were 31 and 20 respectively. A detailed comparison of deaths in both groups is given in Table 6 (page 184). Still.births There were 1,034 still.births m 1955 or 20.3 per 1,000 total births—the legitimate and illegitimate rates being 19.9 and 25.7 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 180). After remaining stable for several years the still.birth rate fell sharply in 1943 and continued to fall until 1948 ; since then the rate in London has remained relatively stable and somewhat lower than that of England and Wales (23.2). Mortality'1' The total deaths in 1955 amounted to 37,877 or 11.5 per 1,000 of the population. Detailed figures are given in Tables 3 (population, etc. by boroughs f), 4 and 5 (pages 181, 182, 183). Mortality from infectious diseases is discussed under the heading of 'Infectious Diseases' on page 20, and tuberculosis is dealt with separately (see page 26). The trend of the death rate in London, together with the corresponding rate for England and Wales, is indicated by the diagram on page 14. The areal comparability *A review of mortality in this century appears as Appendix A (page 153). † A further commentary on the vital statistics of London by boroughs appears as Appendix B (page 164). 12 factor for the London death rate (which allows for the differing sex and age structure in the local population to enable comparison to be made with the national rate) was 0.99 for 1955 and has never been far from unity ever since its introduction in 1934. The two rates therefore, unlike the birth rates, are reasonably comparable without further adjustment. 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 to the exclusion of the young and healthy section of the population from the statistics but the heavy toll of air raids was also a 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 and until 1954, there was a steady decline to the lowest figure ever recorded, but in 1955 the rate has risen again to 11.5 per 1,000 population. The winter rise in mortality continued longer than is usual in the first three months of 1955; the temperature was consistently low in these months. The increase in mortality over 1954 was mainly among the aged and in the diseases affecting old age—pneumonia, bronchitis and diseases of the heart: the increase in the deaths of infants (110 over 1954) has only a slight effect on the general death rate but its effect is more pronounced in the infant mortality rate (discussed later). Leading causes of death The leading causes of death in London in 1955 were as follows: Deaths Rate per 1,000 population Diseases of the heart 11,118 3.37 Cancer 7,861 2.39 ^Pneumonia, bronchitis 4,980 1.51 Vascular lesions of the central nervous system 4,113 1.25 Other circulatory.. 2,024 0.61 Violent causes 1,499 0.45 Digestive diseases 1,430 0.43 Diseases of early infancy (immaturity, injury at birth, congenital malformation, etc.) 834 0.25 Tuberculosis (all forms) 561 0.17 Nephritis 259 0.08 Hyperplasia of prostate . 275 0.08 All other causes 2,923 0.89 Total 37,877 11.50 * Excluding pneumonia of the new bom (under 4 weeks) which is included in * Diseases of early infancy The only change in the order of magnitude compared with 1954 is that pneumonia and bronchitis, in which there was a considerable rise, has resumed third place in the order of ranking. Heart disease Heart disease, with a death-rate of 3.37 was still by far the major causc of death and accounted for nearly one-third of mortality. There was a rise from the figure of 3.22 in 1954, but this is a reflection of the overall increase in the death rate of which heart disease is the most important component: this component has remained consistently around 30 per cent, of total mortality for the past ten years. • Cancer The cancer death-rate for all ages in 1955 was 2.39 per 1,000, the highest ever recorded in peace time, see Table 4. 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. 13 Rates for specified age groups since 1948 are shown below : London A.C.: Cancer Mortality Rates per 1,000 living Age and Sex 1948 1949 1950 1951 1952 1953 1954 1955 Males: 0-14 0.03 0.06 0.11 0.10 0.11 0.12 0.11 0.10 15-44 0.30 0.29 0.38 0.35 0.37 0.39 0.34 0.33 45-64 4.05 4.09 4.45 4.28 4.19 4.28 4.31 4.50 65+ 12.54 12.75 13.25 15.64 15.50 15.69 15.29 15.73 All Males 2.21 2.27 2.45 2.60 2.61 2.68 2.64 2.73 Females: 0-14 0.03 0.05 0.07 0.09 0.08 0.07 0.06 0.08 15-44 0.36 0.33 0.37 0.35 0.35 0.38 0.32 0.33 45-64 2.96 2.68 2.84 2.80 2.85 2.85 2.85 2.93 65+ 9.08 9.08 8.95 8.79 8.77 8.73 8.39 8.43 All Females 1.95 1.93 1.98 1.99 2.02 2.04 2.02 2.08 All Persons 2.08 2.09 2.20 2.27 2.30 2.34 2.31 2.39 14 The improvement noted in the cancer death rate in 1954 has not been maintained; seen now in perspective it can only be regarded as a chance fluctuation in a continuing upward trend. The increase over 1954 has occurred mainly in cancer of the stomach and the lung for males and in cancer of the breast and uterus for females: over the eight years shown in the table above the cancer death-rate has increased by 24 per cent. in males and by 7 per cent. in females; the corresponding percentage increases for England and Wales are, males 13 per cent. and females 4 per cent. Most of the increase in males is due to cancer of the lung which now accounts for approximately one-third of all cancer in both London and England and Wales. The long term trend in London for both sexes combined can be seen from Table 4 (page 182). The increase there shown is due partly to the increasing age of the population and partly to improved diagnosis, but some part is undoubtedly attributable to increased incidence. The big differences in death-rates between the sexes at ages 45-64 and at 65 years and over, should be viewed in the light of the contribution cancer makes to total mortality at these ages. The total death-rate at ages 45-64 is for males, 14-7, and for females 7.4, and the contribution of cancer to these rates is 30 per cent. for males and 40 per cent, for females: at age 65 and over the corresponding contributions are, for males 19 per cent., and for females 15 per cent. (the total death-rates at this age are, males 83.2. and females 56.2). Cerebral haemorrhage, etc. The death-rate from vascular lesions of the central nervous system in 1955 was 1.25 per 1,000, slightly higher than the figure of 1.20 in 1954. It would appear that the rate, which had steadily increased from 1.01 in 1948 to 1.27 in 1952, has stabilised at around the latter figure. Bronchitis and Pneumonia The death-rate for the bronchitis and pneumonia group was 1.51 in 1955 compared with 1.14 in 1954. These are essentially diseases affecting the aged more than any other age group and hence the rise in mortality from these causes is a reflection of the rise in mortality of old people in 1955. Degenerative diseases 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 figures emerge: Mortality (per 1,000) from cardiovascular, renal disease and bronchitis 1946 6.11 1947 6-.27 1948 5.47 1949 6.11 1950 5.99 1951 6.82 1952 6.64 1953 6.21 1954 5.75 1955 6.19 The rates in post-war years still appear to be running higher than pre-war, but degenerative diseases appear to be a reflection of movements in the total death-rate and continue to be responsible for over half of it—doubtless a reflection of the increasing longevity of the population. Digestive diseases Mortality from digestive diseases (other than cancer) in 1955 was 0.43 per 1,000 (0.42 in 1954). Within this group the death-rate from ulcer of the stomach or duodenum was 0.16 per 1,000, the same as in 1953 and 1954. Diabetes Diabetes mortality fell steadily between 1939 and 1948 and as will be seen from Table 4 (page 182) the current figure of 0.07 is lower than that for any quinquennium 15 * in the present century. At ages under 55, where treatment is more effective, the number of deaths in 1955 was 21 which compares as follows with figures for previous years: 1939-41 (mean annual deaths) 71 1942-44 ,, ,, ,, 42 1945-47 ( „ „ „ ) 31 1948 27 1949 26 1950 39 1951 34 1952 34 1953 20 1954 22 1955 21 Violcncc At all age levels mortality from this cause in females is twice that in males. As the sixth most numerous cause of death, violence, under the sub-headings of suicide, road accidents and other forms, has been shown chronologically in Table 4 (page 182) (certain other items no longer of much importance have been omitted). The suicide rate fell slightly in 1955 but it has remained at about the same level since 1953, higher than during the war, and immediate post-war years: the suicide rate is lowest in times of war (both 1914-18 and 1939-45) and was highest in the nineteen-thirties. Sainsbury* has shown that poverty, per se, is not a cause of suicide but that sudden change from affluence to comparative poverty is a predisposing factor. Deaths from road accidents in 1955 were the highest since the war; comparison with pre-war years should take into account that from 1911 to 1940 the deaths are estimated and are least reliable for the period 1921-1930. It is noteworthy that the death-rate in the quinquennium 1906-10 from accidents involving vehicles and horses was almost as great as the current rate which, for the most part, arises from accidents involving motor vehicles. The accident rate in London may be much higher than is indicated by these figures because of the involvement of non-Londoners whose deaths are assigned to their place of residence. Other violence was lower in the last five years than at any time in this century; the high war-time figures are due to the inclusion therein of civilian casualties from enemy action. Infant mortality The infant mortality rate in 1955 was 23.2 per 1,000 live births which compares with rates of 20.6 in 1954 and 23.8 in 1953. The movements of the death-rates from the principal diseases at ages below one year since the years 1936-40 are shown in Table 7 (page 185), The diagram on page 17 illustrates the movements in the more important current causes of death. 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. The increase in 1955 over 1954 has occurred mainly in deaths from bronchitis and pneumonia and in deaths from immaturity: in the former case 1954 was an exceptional year and the rate of 3.57 per 1,000 live births for deaths from respiratory causes in 1955 is lower than in 1953. Deaths from immaturity, however, are higher than in any year since 1951 and the current rate for this cause is a reversal of the downward trend which has hitherto continued without any check since 1936; immaturity is almost wholly the concern of early infancy (the first four weeks of life) and is dealt with in more detail below. Neo-natal mortality Deaths in various periods of the first year of life during 1955 are shown in detail in Table 6 (page 184). Deaths under four weeks numbered 834 or 16.7 per 1,000 live births. Comparative rates for London and England and Wales in past years are: * Sainsbury P. (1955) ' Suicide in London ', Chapman and Hall, Ltd., London. 16 Year(s) 1931-35 1936-40 1941-45 1946-50 1951 1952 1953 1954 1955 London 25.1 22.9 23.4 18.4 17.3 15.8 16.1 15.1 16.7 England and Wales 31.4 29.0 25.9 20.9 18.9 18.3 17.7 17.8 17.3 1955 16-7 17-3 Thus, of the increase of 2.6 in the infant mortality rate for infants up to 1 year of age, 1.6, or 62 per cent. of it is attributable to deaths of infants within twenty-eight days of birth. The distribution of causes of death in the first four weeks of life in descending order of magnitude in 1954 and 1955 was as follows: Cause No. of deaths Per cent, of total 1954 1955 1954 1955 Immaturity 184 231 24.1 27.7 Post-natal asphyxia and atelectasis. 203 212 26.5 25.4 Injury at birth 118 128 15.4 15.3 Congenital malformations 121 104 15.8 12.5 Pneumonia of newborn 39 44 5.1 5.3 Gastro-enteritis and diarrhoea 1 1 0.1 0.1 All other causes 100 114 13.0 13.7 Total 766 834 100.0 100.0 17 B* There are two changes in order of ranking between 1954 and 1955 in the above table—immaturity moves up to first place, displacing post-natal asphyxia and atelectasis, and injury at birth moves up from fourth to third place displacing congenital malformations: this is a reversion to the 1953 order in the first four causes which together account for 81 per cent, of neo-natal deaths. Perinatal mortality Nearly all the neo-natal deaths in the first three causes listed above occur in the first seven days of life and of these about half occur in the first day. Thus the distinction between still-birth and live birth in such cases is very narrow and the term 'perinatal' mortality is being increasingly used to describe the total loss of life before, during and shortly after birth. There is no generally accepted definition of the term but in the report of the Chief Medical Officer to the Ministry of Health for 1954 the most useful definition is suggested as including still-births and deaths in the first week of life. A consideration of these two groups together allows for a better assessment of the problems of causation common to both. Comparative rates for perinatal mortality per 1,000 total births are given below for London and England and Wales. Year(s) London England and Wales 1931-35 49.9 62.5 1936-40 47.7 58.8 1941-45 43.9 48.3 1946-50 35.5 39.8 1951 34.6 38.2 1952 32.6 37.5 1953 34.7 36.9 1954 32.8 38.0 1955 34.8 37.6 The medical conditions causing still-birth cannot be determined since certification of the cause of still-birth is not required in this country (although it is in Scotland) but it is known that about half the number of still-births are premature.* Since prematurity contributes one-third of the neo-natal deaths in the first seven days this is the cause most commonly identifiable to perinatal mortality. In spite of the dramatic reduction in infant deaths from immaturity since 1936 (Table 7, page 185) the greatest scope for a further saving of infant life still lies in this field, especially as a predisposing factor in still-birth. Maternal mortality A summary of maternal mortality statistics is given below. Comparative figures for England and Wales in recent years are shown in Table 8 (page 185). Year Live births and stillbirths Deaths in pregnancy or child-birth excluding abortion Post-abortion deaths No. Rate No. Rate 1950 54,715 29 05.3 9 0.011 1951 53,460 24 0.45 18 0.023 1952 52,433 35 0.66 15 0.019 1953 52,080 21 0.40 16 0.021 1954 51,774 28 0.54 6 0.008 1955 50,860 31 0.61 8 0.011 Rates per 1,000 total births, except for deaths following abortion where the rates are expressed per 1,000females (15-44). The maternal mortality rate (excluding post-abortion deaths) in 1955 was 0.61, as compared with 0.54 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. * Annual Report of Chief Medical Officer, Ministry of Health, 1954. 18 Cause of death Post-abortion Other pregnancy and child birth Total 1952 1953 1954 1955 1952 1953 1954 1955 1952 1953 1954 1955 Sepsis 10 8 5 5 8 1 3 3 18 9 8 8 Other causes 5 8 1 3 27 20 25 28 32 28 26 31 Total maternal deaths 15 16 6 8 35 21 28 31 50 37 34 39 The trend of maternal mortality in London since 1906 is shown in Table 4 (page 182): 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 1935 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 and 1944-45 was not shared by the country as a whole, and this can be attributed to the effect of the air bombardment. The notification rate of puerperal pyrexia in 1955 was 39-01 per 1,000 total birth (1,984 cases) compared with 37-4 in 1954 and 32-9 in 1953. The weather A summary of the meteorological observations at Kew Observatory during 1955 is given in Table 13 (page 182). The months of January to March were cold but sunny ; April was warm, dry and sunny ; May was relatively cold and wet but sunshine was above average ; ' flaming ' June did not live up to its reputation but in early July a spell of fine weather set in which continued with minor breaks, until October, giving an exceptionally fine summer without the discomfort of extreme heat. October to November followed the usual pattern of autumn weather though drier than is customary for these months. There was no early cold spell at the beginning of winter. Rainfall for the year was light, 6 inches below the average of 24 inches. 19 INFECTIOUS DISEASES the notification rates and death-rates of the principal infectious diseases in London are shown in Tables 3, 4 and 9 (pages 181,182,186): Table 3 shows both rates for the constituent Metropolitan Boroughs in 1955 ; Table 4 shows death rates since 1906 for the County as a whole; and Table 9, notification 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 9). Table 10 (page 187) shows, in age groups, the distribution over 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 total 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 9. Anthrax Diarrhoea and Enteritis There were no notifications of anthrax during 1955. There were 27 deaths from diarrhoea and enteritis under the age of 2 years. The number of deaths from this cause had been 43 in 1952, 72 in 1953 and 24 in 1954. The figures in 1952 and 1953 had been comparatively high as a result of a number of cases of enteritis associated with the upper respiratory infections resulting from the severe fog in December, 1952. It will be seen from the diagram below that the death rate from enteritis now seems to have resumed the trend that was temporarily upset by the fog. The change that has occurred in this rate during the last few years is one of the most remarkable features of post-war vital statistics. Diphtheria After a period of two years without a death from diphtheria there were two deaths from this disease during 1955. One was a boy aged four years and the other an eight year old girl. The parents of both these children had repeatedly refused the offer of 20 21 immunisation. There was also a rise in the number of notifications from four in 1954 to 16 in 1955, the largest single focus being a family outbreak in Shoreditch involving one of the fatal cases. These events are a further reminder that the battle against diphtheria is not yet won, and that the danger to children who have not been immunised still remains. The present low incidence of this disease is the result of the immunisation campaign begun in 1940. It will be seen from the diagram on page 21, that when immunisation commenced in children aged 1 to 14 years there was an abrupt change in the rate of decline in notifications at these ages. The impossibility of guaranteeing freedom from imported infection in London means that efforts to attain the maximum degree of immunisation in the population must be maintained. The events of 1955 serve to drive home the facts that diphtheria has not been abolished from the County, and that when it occurs in children unprotected by immunisation it can be as severe as of old. Dysentery 1955 was another year of heavy incidence of Sonne dysentery in London although the number of notifications (3,019) was less than the record figure of 4,268 in the previous year. Only a very small proportion of the cases could be regarded as possible food-borne infections, the great majority having occurred as a result of personal contact. In the report for 1954 reference was made to an inquiry which took place in cooperation with the Borough Medical Officers in 1952 and 1953 and especially to the finding that exposure to symptomless excreters appeared to result in a much lower secondary attack rate in families than exposure to a clinical case with diarrhoea. This would appear to suggest that if the infection breaks out in a nursery or school it might be sufficient to exclude the clinical cases without embarking on a wide search for carriers. Whether or not this is true will no doubt emerge from trials currently in progress. During the year there was a slight drop in the percentage of cases in the 5-14 years age group. Nevertheless this disease continues to give far more trouble in the junior departments of the schools than it did a few years ago. Enteric fever There was a rise in the number of notifications of enteric fevers from 49 in 1954 to 111 in 1955. A large part of the excess over the previous year was due to a single epidemic of paratyphoid B in the boroughs of Hackney and Shoreditch. There was also a comparatively small outbreak of typhoid fever among residents in West London. Erysipelas There were 361 notifications of erysipelas, compared with 368 in 1954, and one death in each of these years. It has been recognised for some time that notification of this disease is grossly defective and the figures therefore give little idea of the true incidence of the disease. Food poisoning Notifications of food poisoning rose from 1,060 in 1954 to 1,530 in 1955. The great majority of the notifications were single sporadic cases or small family outbreaks. Larger outbreaks were comparatively rare. Influenza Although the number of deaths from influenza in 1955 (164) was nearly double the abnormally low figure of 83 registered in 1954, mortality from the disease was lighter than average, as will be seen from the following table giving the number of deaths from influenza in recent years. Influenza Influenza Year deaths Year deaths 1943 726 1950 256 1944 206 1951 809 1945 171 1952 162 1946 371 1953 514 1947 284 1954 83 1948 78 1955 164 1949 372 It is not possible to estimate accurately how much influenza was occurring in the population as the disease is not notifiable. Such indirect evidence as is available however suggests that the influenza epidemic of 1955 was of very modest proportions. 22 Leptospirosis The precautions taken against leptospirosis by the sewer workers in the Chief Engineer s department continued to work smoothly. One case occurred during the year. Measles The year 1955 was the second and principal year of a biennial cycle of measles. ] The epidemic had been gaining momentum during the last part of 1954 and rose to its maximum at the end of the first quarter of 1955. During the 13th week over 4,000 cases were notified, this being more than in any other week since notification of measles began. However the total of notifications during the year (49,110) was slightly lower than the record figure of 49,148 registered in 1951. There were 15 deaths frotn measles during the year, which is an improvement upon the figure of 25 deaths in the comparable year of 1951. The remarkable fall in mortality from this disease compared with conditions twenty years or more ago is partly due to the introduction of improved treatment of complications, particularly of pneumonia, and partly due to a reduction in the severity of measles itself during the period, which has resulted in comparatively low incidence of comnlications. Meningococcal infections 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 22 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. Fifty-nine of the corrected notifications were of children under the age of five years. Of the 14 deaths in children under five years of age, seven were less than a year old. The ratio ot notifications to deaths at various ages was as follows: Age Deaths Notifications Deaths as percentage of notifications 0-4 years 14 59 23.7 5-14 years 1 19 5.2 Over 14 years 7 20 35.0 Ophthalmia neonatorum The incidence ot 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 106 cases in 1955 (2-1 per 1,000 live births) in 94 of which the mother was a resident of the County of London ; full details of the latter are shown below : Number of cases Notified during the year Removed to hospital for special treatment Domiciliary confinements Institutional confinements Total 32 62 94 4 17 21 Of the 94 cases, vision was unimpaired in 84, two of the babies died, three were under treatment at the end of the year and the remaining five moved from the County. ^neumonia The 1,903 notifications of pneumonia in 1955 represent a rise over the very low figure of 1,502 in 1954, but the figure is not unduly high compared with the figures of recent years. It is difficult to know exactly what the significance of this figure is, as only acute primary pneumonia and acute influenzal pneumonia are notifiable and it is thought that even these conditions are substantially under-notified. One may hope however that the thoroughness with which these conditions are notified remains fairly constant from year to year and that variations in the annual figures may disclose the existence, if not the actual magnitude, of variations in the incidence of severe respiratory infections. 23 Poliomyelitis Following a year of unusually low incidence in 1954 the number of notifications in 1955 (960) was the highest to date. In other respects however the 1955 epidemic was less severe than those of 1947, 1949 and 1950. The first epidemic focus appeared early in the summer in Stepney and Poplar. Later the heaviest incidence was in SouthEast London. A study of the age distribution of the notifications shows that whereas the percentage in the 0-5 years age group remained roughly at the level of previous years there was an increase in the percentage at school ages at the expense of the over 15 years age group. During the year instances of multiple cases in schools were more frequently reported than in previous years, particularly in the areas of high incidence. Towards the end of the year a survey of all notified cases was made with a view to estimating the number of children who would require special educational facilities as a result of residual paralysis. This revealed that although the proportion of paralytic cases was less than in previous large epidemics the percentage of paralytic cases which were assessed as mild, moderate or severe were roughly similar to those in previous epidemics. The number of deaths from poliomyelitis was 26 compared with figures of 49, 50, and 36 in 1947, 1949 and 1950. The reasons for this apparent mildness are uncertain. As stated earlier the ratio of non-paralytic to paralytic notifications was higher than usual. It is not known whether this was due to the possible existence of an epidemic of a mild neurological infection of unknown origin running concurrently with the poliomyelitis epidemic, or to an increased thoroughness in the diagnosis of non-paralytic poliomyelitis. There is evidence that the latter suggestion at least was operative in 1955. The Medical Officer of Health of Lewisham has drawn attention to the fact that the notifications in his Borough are unfairly loaded by the large number of cases admitted from other Boroughs to an infectious diseases hospital in Lewisham and first notified from that hospital. That such notifications are not finally registered in the area of residence is an anomaly in the notification system which it is hoped can be rectified. Until that time it should be known that the use of notification figures in the different Boroughs may lead to erroneous conclusions. The number of notifications in the three main age groups was as follows Notifications by age Year 0-4 5-14 15+ Total 1947 196 257 249 702 1948 47 43 51 141 1949 356 173 139 668 1950 150 149 131 430 1951 27 45 40 112 1952 95 105 109 309 1953 116 104 112 332 1954 42 41 42 125 1955 334 391 235 960 The variations in the proportion of notifications falling in the 0-4 age group in recent years are seen in the following table: Percentage of notifications in age groups Year 0-4 5-14 15+ Total 1947 27.9 36.6 35.5 100.0 1948 33.3 30.5 36.2 100.0 1949 53.3 25.9 20.8 100.0 1950 34.9 34.6 30.5 100.0 1951 24.1 40.2 35.7 100.0 1952 30.7 34.0 35.3 100.0 1953 35.0 31.3 33.7 100.0 1954 33.6 32.8 33.6 100.0 1955 34.8 40.7 24.5 100.0 By the time that this report is published the British poliomyelitis vaccine will have been in use, but no vaccine was given during 1955. 24 Rheumatic fever Deaths in London from rheumatic fever in 1955 were 17, of which three 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 Rate per 1,000 living Year 0-4 5-14 15-44 Total (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 1955 2 2 272 276 0.133 Under the age of 15 the number of deaths is so small that considerable random fluctuations must be expected. Scabies Scabies became notifiable in London in August, 1943. Notifications in 1955 numbered 660, as compared with 699 in 1954. Scarlet fever Notifications of scarlet fever during the year numbered 2,070, the lowest figure ever recorded. Incidence of the disease has been low during the last year or two but it may also be that as a result of the prevailing mildness of the disease notification is less complete than formerly. The most striking feature of scarlet fever at present, compared with 30 or more years ago, is its mildness. Low mortality and lack of serious complications are due in part to improved modern treatment, but a change in the nature of the disease towards a milder form of illness has also contributed. It would be a mistake to assume that this change is permanent, for scarlet fever has fluctuated between great severity and mildness several times in the last 300 years. Smallpox There were no notifications of smallpox during the year. Tuberculosis Details relating to tuberculosis appear in the section which follows. Whooping cough There were 4,709 notifications of whooping cough during the year. There were only seven deaths, six of them of children under five years of age giving a fatality ratio of 0.149 per cent. Infectious diseases in schools The number of cases of certain infectious diseases involving exclusion or absence reported from schools in 1955 and previous years is shown on page 114, TUBERCULOSIS Introductory in my report for the year 1950 I included a review of the disease in London, and of the services provided to deal with it, during the preceding fifty years. Such periodic detailed studies serve the very useful purpose of focusing attention on the trends taken by this disease and on the measures employed for its control, and provide an opportunity for reassessing aspects which require special action. It may be possible in this way to focus attention on areas of persistently high incidence or mortality or of inadequate provision or acceptance of control facilities. Groups of the population still providing the main contributions to notification or to deaths are revealed, acting as a pointer to the inadequacy of treatment or of ascertainment in these cases. Changes in the rates of tuberculin reaction among children in different parts of London provide evidence of the distribution and persistence of infection risks in these areas. Measures taken to protect the public health against the inroads of tuberculosis must keep close pace with the deviations and changes in the pattern and character of the disease among the various groups comprising our community. 25 Changes in the social pattern of tuberculosis and in the type of disease in the individual patient have been observed in recent years. There has been a marked change in the place which tuberculosis occupies as a contributor to mortality in the population. Fifty years ago, tuberculosis accounted for 12 per cent. of all deaths in London, thirty years ago it provided 8 per cent. of the mortality, ten years ago 5 per cent. and in 1955 2 per cent. Nevertheless the deaths from tuberculosis in Londoners in 1955 were twice as many as road accident fatalities. When we come a little closer and examine the contribution which this disease has made to the deaths in different age groups we observe marked variation at different times of life. During the past five years tuberculosis has been responsible for 1 per cent. of all deaths in children under the age of 5 years, for 4 per cent. of deaths in schoolchildren, for 10 per cent. of the deaths among those aged 15–14 years and for 4 per cent. of persons from 45-65 years old. It is clear therefore that in the most productive and reproductive years of life, tuberculosis still takes serious toll. In 1955 there were 517 deaths in the County attributed to pulmonary tuberculosis and 392 of these occurred in men. Eighty-seven per cent. of these male deaths were in the age group 45 years and older. A marked predominance of male deaths among the older consumptives has been a feature of London tuberculosis mortality for many years. TUBERCULOSIS MORTALITY AND MORBIDITY 1934-1955 26 Pulmonary tuberculosis in the middle aged and elderly male is clearly still a disease to be reckoned with. Public health measures vigorously pursued have reduced the risks of infection for children and young adults but they have had less effect in present circumstances in preventing progressive disease in older men. Therapeutic measures too are far more successful in the first half of life than later. At the end of this report I have set out statistical tables as measures of the various aspects of infection, survival, etc., and these help to clarify the general picture as well as serving for a comparative secular record. But it must be remembered in studying these that they suffer certain shortcomings. Most tuberculosis statistics are calculated from information provided by others and this is not always complete or absolutely accurate. Enthusiasm for notification and even criteria for notification vary from district to district. The figures given for various groups of people or districts may represent a variable sample of the persons or areas. Too high a proportion (26 per cent. in 1955) of fatal cases were certified as having died of tuberculosis but had not been notified during life. Tuberculosis recorded as discovered among contacts and among persons submitting to mass X-ray does not include cases that must exist among the contacts not examined and the public not accepting X-ray examination. Not all known cases are notified or figure on chest clinic registers. Fatal cases are not representative of tuberculous persons as a whole—they are derived predominantly from those with less natural resistance and are likely to include more of those who do not co-operate with their physicians in treatment. All the tables and graphs provided should be carefully studied in the light of the appropriate paragraphs of the report to which they relate, when they will be found to serve as very valuable guides. Epidemiology of tuberculosis in London Epidemiology In the natural history of tuberculosis nowadays infection from a human source is by far the commonest cause. Even a recent outbreak of tuberculosis among monkeys at the London Zoo was attributed to such a source. Pasteurisation of milk has made bovine type tuberculosis uncommon. Nine out of ten newly notified cases are pulmonary. One of every three of these is found to be excreting tubercle bacilli and this represents a measure of the degree of infectivity of unrecognised cases existing in the population. Within a few months of treatment the majority of new cases become much less infective or even non-infective, so that the unrecognised case is individually a more serious public health menace than the case known and under treatment. Searching out undiscovered lung cases is therefore the keystone in tuberculosis control. There is evidence that once infected, many patients are unable completely to heal the diseased areas in the body and that these may persist as foci in which subsequent relapse can occur even many years after apparent healing of the disease has occurred. There is also some evidence that among adults, renewed exposure to intense infection may act as a stimulus to breakdown of an old arrested lung lesion. Other precipitant causes of relapse include inadequate nutrition, continued excessive physical exertion and prolonged or deep emotional disturbances. As infection and disease in children and young adults diminishes, so in due course of time, there should be fewer older persons with lesions in a state of liability to breakdown. Only a small proportion of the persons who are infected with tubercle bacilli show signs of ill health. Tuberculin skin tests reveal the persons who have been infected, while annual notifications and clinic registers provide a measure of those in whom infection has progressed to disease. The highest pulmonary notification rate (1.82 per 27 thousand) in men occurred in the age group over 45 while in women (at 1.48 per thousand) it was in the 15-44 years old group. The lowest incidence rates occurred in the males aged 5-14 years and in females after 45. Geographically the highest notification rates were in Deptford, Holborn, Camberwell and Stepney, the lowest in Stoke Newington, Hackney, Hampstead and Chelsea. Using a standard sensitivity test on groups of 13 year old children (not in contact with known cases) highest positive tuberculin rates were found in those attending schools in Shoreditch, Westminster, St. Marylebone and Hampstead, while schools with lowest rates were in Hackney, Holborn, Lewisham and Fulham. Tuberculosis death rates for all ages were highest in the City of London, Finsbury, Holborn and Shoreditch. Lowest mortality rates occurred in Stoke Newington, Greenwich, Hackney and Kensington. During 1955 no female under the age of 15 and only three of that age among males died of tuberculosis of the lungs. The highest rate of mortality in both sexes was in the over 45 years old, but the male rate in this age group at 0.66 per thousand was six times as high as the female rate. Among the various occupations pursued by London men newly notified, the highest rates occurred in those classified as unskilled workers of all kinds, those engaged in agriculture and horticulture and among retired persons (see Table T.9). The largest total number of new cases (418) came from unemployed men followed by 235 cases among transport workers. New cases among defined groups of employed women showed highest rates of notification in textile workers, wood and cane workers and unskilled workers. The largest total number of female cases occurred among housewives (692 cases) followed by clerks and typists (212 cases). Nearly half the newly notified adult male lung cases were infective and exhaling tubercle bacilli at the time of diagnosis. Some fifteen thousand contacts of the 3,624 newly diagnosed cases during the year were investigated and yielded a further 271 cases of tuberculosis. The rate of discovery (1.9 per cent.) of new cases among contacts of recently notified cases is more than 10 times that (0.11 per cent.) in the population as a whole. Young children are usually infected from within the family circle while young adults are infected mainly at work or among companions in recreation. Principles in the control of tuberculous infection Control It is clear from what has already been stated that certain principles can be expressed as the basis for applying measures designed to reduce the number of persons infected by tuberculosis from developing disease after infection, transmitting such disease to others or succumbing to the disease. (i) To reduce infection in the community Pasteurisation of all milk sold in London is now a compulsory practice but this does not prevent unpasteurised infected milk from being drunk in places where such a statutory regulation is not in force. Since most infection is acquired from infectious human beings it is manifestly necessary to keep uninfected persons who are the susceptible group of the population from contact with known and unknown infective cases. This however in a densely populated urban area is not really entirely practicable. Crowded housing conditions are still far commoner than is healthy. The children of known cases can be segregated from the infective household only for a limited period. In practice most children of an infective new case are already infected (though not yet necessarily diseased) by the time the index case is diagnosed. 28 Nevertheless it is sometimes practicable and helpful to segregate uninfected contacts so as to vaccinate them with B.C.G. or until the index case has been treated sufficiently to render his or her infectivity much less menacing. These measures can be of particular value in newborn contacts of cases under treatment. It is however necessary, particularly in the case of young infants, to balance the possible benefits of boarding at a nursery or temporary foster home against the physical dangers of intestinal infection and the psychological damage of estrangement from parents and home. Public ignorance of the mode of spread of tuberculosis is still too widespread and calls for continued health education. There are unsuccessfully treated patients who are still infectious and therefore of some danger to the community who are discharged from hospital simply because treatment has not been successful. Provision of hospital beds for active infectious lung cases solely for the purpose of segregation is not sufficiently made by hospital authorities. Although over a third of newly diagnosed cases are infectious, only 5 per cent. of all the known cases on London chest clinic registers are infectious. This reduction is attributable to successful modern drug and surgical treatment. Clearly therefore, early and intensive treatment of diagnosed cases makes the most important contribution to reducing infection. Contact of susceptible members of the population with unknown infective cases can only be prevented when these cases are diagnosed. To wait till such cases develop symptoms which lead them to doctor or hospital is to court late discovery. It is a better public health measure to make available—and for the adult public to accept—a periodic X-ray examination especially for those age-sex groups and occupations with the higher prevalence rates. At present less than one-tenth of the adult London population submits itself for X-ray investigation in any year. This is far too little to have any appreciable effect on the rate of discovery of unknown infectors, particularly those among middle aged and older men. School teachers and child minders of all kinds should because of their special contact with groups of children submit to regular chest X-ray examination. Vaccination of uninfected persons (that is negative tuberculin reactors) with B.C.G. vaccine has been shown to give substantial protection against human infection. Since most serious first infection occurs in infancy and in adolescence, these are the two groups who will most benefit by its application, and of these adolescents and young adults are the more urgent. Details are given later of the Council's activities in this field. (ii) To reduce the development of disease after infection The factors which decide whether or not an infected individual will develop tuberculous disease are compounded of hereditary disposition, nutritional state, special occupational or other exposure (e.g., in nurses and doctors), physical fatigue, emotional stress, predisposing disease, e.g., diabetes or stomach excision and other factors as yet unrecognised. To prevent the tuberculin reactor from becoming a patient with tuberculosis requires avoidance of the factors mentioned, together with periodic X-ray examination to reveal disease in its early manifestation. (iii) To reduce mortality from tuberculosis is a matter of early diagnosis and adequate treatment. Improvements in treatment in recent years have been remarkably successful and further improvements are likely. In some patients however treatment for a variety of reasons is unsuccessful and this is particularly so in the older male patient. Here the disease is not new but in almost all cases is the relapse of an old lesion, and in most of these cases the relapse is slow and 'silent' so that by the time diagnosis of breakdown has been made the disease process is well advanced. Here again repeated periodic X-ray examination would be likely to reveal active disease at an earlier stage than is usually seen. 29 All those already mentioned social, nutritional, occupational and psychogenic conditions which contribute to breakdown of health are the conditions which must be mitigated or avoided so that natural resistance to spread of disease in the individual is enhanced. Tuberculosis services in London Services 1. Provided by hospital authorities Diagnostic and treatment facilities for pulmonary and non-pulmonary cases of tuberculosis are provided at practically all the hospitals in London of the four Metropolitan Regional Hospital Boards, the University 'Teaching' Hospitals and the special hospitals and clinics for chest diseases, children, eye diseases, skin diseases, orthopaedics, gynaecology, genito-urinary diseases, etc. The pathology laboratories of these hospitals and of the Medical Research Council (which also operates a Tuberculosis Research Unit at Hampstead) make a special and valuable contribution to the services provided for dealing with tuberculosis. The X-ray departments of these hospitals and the static and mobile mass X-ray units of the Metropolitan Regional Hospital Boards provide the main diagnostic armament. A special report on the operations and findings of mass X-ray services available to Londoners follows on page 35. Hospital treatment made available by these authorities for tuberculous Londoners is now—apart from facilities simply for segregation of the infectious consumptive— ample. Long waiting periods for admission to hospital now affect only cases for surgical treatment of lung disease. An increasing tendency has been manifest in recent years for cases to be treated in bed at home under the supervision of specialist chest physicians and at their request nursing and other facilities—described in detail later—are provided by the London County Council for such cases. 2. Provided by the London Executive Council The general practitioners in the London area provide valuable and valued service in general medical supervision and supportive guidance to patients, as well as being the first usually to initiate diagnostic investigation in patients suspected of having chest or other forms of tuberculosis. Their contribution is widespread, influential and unostentatious. In the preventive field they are valued allies in encouraging families to accept the services offered by the London County Council. 3. Provided by the London County Council Services for the adult patient Home care The Council, as local health authority, has the duty of providing for the ' care and after-care ' of London tuberculous patients after hospital treatment and during treatment at home or chest clinic. The Council's specialist tuberculosis health visitors, in addition to working as chest clinic nurses, visit patients in their homes to advise on matters of hygiene, to ascertain home conditions and needs, and to persuade contacts to attend the clinic. Its domiciliary nursing service provides home nurses who give nursing attention under the direction of the family doctor or clinic chest physician. Nursing equipment, such as back rests, surgical mattresses, bedpans, sputum flasks, etc., is made available on loan to patients in need. Patients unable to make their own way to the local chest clinic for consultation, X-ray, pneumothorax treatment, etc., may be conveyed by ambulance or sitting-case car provided through the Council's ambulance service. Where garden space permits, the Council supplies on loan and erects wooden 'chalets' for infective patients at home so as to provide a separate 'room' and reduce close contact with young members of the household. The Council employs home helps to undertake domestic duties in the homes of bed-fast patients and to care in the home for the children of mothers undergoing treatment. 30 The Council provides extra nourishment (milk, butter, eggs), to necessitous patients, within a prescribed scale of maximum quantities, when recommended by the chest physician. The provisions made to occupy the patients' minds and talents during their enforced leisure are described under 'diversional therapy'. Diversional therapy During the year handicraft classes tor tuberculous patients able to attend the chest clinic have continued to be held at several clinics. A few classes have had to be closed because the small attendance did not justify the employment of the instructors provided by the Council's Education Department. The diversional therapy service for homebound patients, which started experimentally in 1953 in North West London, has proved useful and popular and was extended during the year to all parts of London where the need for such a service was apparent. This service is organised by the local voluntary tuberculosis care committees, some of which were already running schemes financed from their own funds. The Council appoints trained handicraft instructors for this work and gives financial assistance towards the cost of tools and materials. Instruction is given in a variety of arts and crafts, e.g., basketry, dressmaking, leatherwork, painting, rug and toy making, weaving, etc. Patients wishing to continue crafts they were taught while in sanatoria are able to do so through the visits of the handicraft instructors. Patients are allowed, on payment of the cost of materials used, to retain articles they make at classes or at home, or, at the discretion of the care committee, receive the profit from the disposal of the articles on their behalf at sales of work arranged by the committee. The articles are, of course, disinfected before display for sale. This is a service which helps patients to overcome their enforced idleness and provides cheerful and useful meetings with other patients in a club-like atmosphere while also giving the clinic social worker an opportunity of talking to patients in a more relaxed atmosphere. Industrial rehabilitation As the patient progresses towards recovery the question of returning to work becomes a matter of increasing importance. Many patients nowadays are able to return to their former occupations without danger to themselves or infective risk to others. In some cases, however, especially where the work was strenuous, an alternative mode of earning a living has to be envisaged. The Disablement Resettlement Officers of the Ministry of Labour have a special duty to try to place such patients in employment suited to their physical condition and capacity. In this they are on the whole very successful. Where necessary, training is arranged at a Government or other recognised training centre sometimes after preliminary assessment at a Ministry of Labour industrial rehabilitation unit. The Council also arranges for the maintenance of London patients during training at three private village settlements; the British Legion Village near Maidstone, Enham Alamein Village Centre near Andover and Papworth Village Settlement near Cambridge. Such patients must be fit to do at least five hours work a day. Occasionally these patients become 'settlers' at these establishments. Others after training and improvement in working capacity return to London. Mention should also be made of the correspondence courses in shorthand, bookkeeping, general educational subjects, light engineering, etc., arranged by the British Council for Rehabilitation for patients undergoing prolonged treatment at home. The cost of these courses is borne by the County Council, who also make a grant towards administration expenses. Apart from the Government-owned Remploy Ltd. special factory in Bermondsey, group working facilities are not yet available in London for tuberculous patients who, on account of infectivity or severe disablement, need part or whole-time employment under 'sheltered' conditions. Recuperative holidays Holidays for London tuberculous patients who have recently been ill or in whom breakdown threatens, are arranged through the Spero Holiday Scheme of the National Association for the Prevention of Tuberculosis or direct by the Council. During the year, 340 patients had holidays under these arrangements. 31 Care committees In connection with most of the chest clinics in London a voluntary tuberculosis care committee operates under a constitution prescribed by the Council and includes representatives of the Borough Councils and other bodies interested in the welfare of tuberculous persons and their families. The Council provides a local tuberculosis care organiser who is a social worker at each chest clinic and her duties include acting as secretary to the care committee. The care committees help patients with money or other benefits not available to them from official sources. Their funds are obtained from voluntary contributions, sales of work, sales of Christmas Seals of the National Association for the Prevention of Tuberculosis, Council grants from Sunday Cinema profits, etc. Hostels for homeless infective men There are a number of patients with advanced disease who have reached their maximum degree of improvement under hospital treatment but who cannot be discharged because they are homeless. Many homeless patients in this category find accommodation in London lodging houses where they may be an infective risk. In 1950 the Council decided to provide special residential accommodation for such patients and early in 1951 the first group were accommodated in a privately-run hostel near St. Albans, Herts, the Council paying an agreed charge for their maintenance. In September 1952 some of these residents were transferred to the hostel which the Council had maintained since October, 1951, in Highbury Quadrant, Islington, in a large house adapted for the purpose. The remaining men were transferred to special temporary accommodation made available at the British Legion Village, Preston Hall, Maidstone, Kent, on payment by the Council of the cost of their maintenance. A second hostel was opened by the Council in July, 1953, at Hurlingham Lodge, Fulham, and, after alteration and redecoration, came into full use for 28 men a year later. The hostel at Highbury Quadrant was replaced by better premises at Cromwell Lodge, Hornsey, on 30th September, 1954. This will eventually accommodate 31 men. Each hostel contains ample lounge and dining rooms and a series of bedrooms, W.C.s, bathrooms, ablution rooms and a sputum disposal sluice room. A suite of rooms is allocated to the warden and his family, and an equipped consulting room is provided for visiting doctors. Television, wireless, books, newspapers and games are provided and there are facilities for billiards and other recreations. Residents who are fit to work are helped to find employment through the Disablement Resettlement Officer of the local office of the Ministry of Labour. Most of the residents are unfit to work and are encouraged to undertake diversional handicrafts in the hostel or at classes at the nearest chest clinic. These hostels are run on pleasant, homely lines without 'institutional' atmosphere. Only the minimum disciplinary requirements are imposed, the residents being free to occupy their time as they wish. They are encouraged to lead sensible, careful lives and to keep under surveillance by the local chest clinic. Residents are also on the list of a local general practitioner, who visits the hostel regularly and is also available in emergency. He also maintains health surveillance of the staff. The charge for residence is at present £3 3s. a week, but this charge is subject to abatement on a scale of assessment of means, and in practice the full rate is rarely charged. Residents receive full board, lodging and laundry; clothing and footwear are provided by the Council for those in need. Responsibility for day to day administration of the hostels devolves on the divisional staff under the general supervision of the appropriate divisional health committee. Recommendations for admission are submitted by the chest physician having the patient under treatment or by a hospital physician if the man is about to leave hospital but has no home or suitable lodgings to which to return. No limit is imposed on the length of residence at the hostel, and a man stays until his health has improved sufficiently for him to live outside without infective risk to the community, or until he decides of his own volition to leave. Occasionally a man is asked to find other lodgings if his 32 conduct has become a source of serious annoyance to other hostel residents or to the staff, or if he persistently and unreasonably refuses to pay the charges assessed. These hostels provide the residents with the comfort and security of a home, with regular good meals, laundry and sympathetic companionship and constant medical care. The community derives advantage from segregating, as far as practicable, these infective tuberculous patients from the dangers of close and frequent contact with susceptible individuals. Photographs of the accommodation at the Hurlingham Lodge hostel, Fulham, are reproduced following page 34. Services for children Open-air schools For the convalescent tuberculous child of school age not yet fit enough to return to normal school life, the Council provides day and residential 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. Most children stay at the residential type of school for about a year. T uberculosis contact schcmc The occurrence of tuberculosis in a household where there are children brings the special problem of protecting them from the risk of infection and where the mother is the patient, of their care during her treatment at home or in hospital. When satisfactory private arrangements cannot be made to meet the conditions, use of the Council's day nursery, child minder or home help services is first considered. Where these alternatives do not cover the needs of the case the Council arranges, through the agency of the Invalid Children's Aid Association, for such children to be boarded-out in approved private nurseries or foster homes situated usually outside London. While boarded-out the children remain under the surveillance of the local chest clinic physician. Boarding-out is also arranged under this scheme when it is thought advisable to segregate children from known cases of tuberculosis during the process of B.C.G. vaccination. B.C.G. vaccination (i) B.C.G. vaccination has been provided under the Council's auspices since 1950 at chest clinics in London for the susceptible (tuberculin negative) contacts of known tuberculous patients when parental consent is given. Only about a third of the contacts seen at chest clinics at the time of diagnosis of the 'index' cases are still tuberculin negative. Some 4,000 contact children were vaccinated at the chest clinics in London under the Council's scheme during the year. During the five years in which this service has been available only very rarely has a vaccinated child remaining in contact with the tuberculous relative developed disease— far, far less often than in the unprotected tuberculin positive contacts. (ii) Since 1953 diabetic children residing at the Council's special residential school for such handicapped scholars have been tuberculin tested and, with parents' consent and if negative reactors, have been vaccinated with B.C.G. as special protection for this vulnerable group. (iii) In June, 1954, the Council instituted routine B.C.G. vaccination for all tuberculin negative 13-year-old children attending London schools whose parents had given written consent. By the autumn of 1955 this protective measure had been offered for children in all these schools. 76 per cent. of the parents took advantage of the offer and, out of 22,569 children tuberculin tested, 19,301 negative reactors had been vaccinated with B.C.G. This work is carried out in 415 schools by the full-time medical officers of the two B.C.G 'units', each school being visited twice in a week. On the first occasion the doctor gives the tuberculin test and at the second visit three days later notes and records the result and vaccinates the negative reactors, who are given a certificate of vaccination. The parents of children showing a 'positive' reaction are given a leaflet explaining its significance, and chest X-ray examination is subsequently arranged for these children when the parents consent. Children in out-County residential schools, approved schools and remand homes are also included in the scheme. 33 TUBERCULIN TESTING & B.C.G. VACCINATION 1955 13 YEAR OLD SCHOLARS 34 A session at a girls' Secondary School Laboratory at County Hall for preparation of equipment At a Secondary School for boys B.C.G. vaccination in London Hurlingham Lodge L.C.C. Hostel for homeless tuberculous men Annual X-ray of students at a London Technical College Almoner interviewing a patient at St. Thomas' Hospital Chest Clinic Health visitor with a patient and her family Patients working in a Remploy Ltd. factory Photographs are reproduced facing page 34 of the B.C.G. teams in operation at schools and of the specially designed laboratory at County Hall used for equipment preparation. Tuberculin solution and vaccine are provided by the Ministry of Health. Co-operation by head teachers and the Education Department has made this important preventive measure smoothly adaptable. No untoward incidents or reactions have occurred attributable to B.C.G. vaccination. Statistics of the year's B.C.G. work are set out on page 46. Preventive measures General X-ray examinations—Among the important preventive measures adopted by the Council are the arrangements made usually through the mass radiography services, for the chest X-ray of (i) newly-appointed groups of its staff who are likely to come into close or frequent contact with children during the course of their work; (ii) staff and senior pupils at the Council's occupation centres for mentally deficient persons; (iii) new residents over 15 years of age entering the Council's homeless families' units; (iv) positive reactors discovered among thirteen-year-old school-children tuberculin tested with a view to B.C.G. vaccination. In addition, upon the report of tuberculosis in any member of the Council's staff tuberculin testing and X-ray examination is undertaken of children and young adults thought to have been at risk in contact with the case. A summary of the findings of such incidents is given in Table T.8, page 40. Chest X-ray examination is arranged through the Council's maternity centres for all expectant mothers. The Health Department advises the Children's Officer of the suitability of prospective adopters of children when they (the prospective parents) give a history of past tuberculosis. The department advises the Housing Department on the justification or need for rehousing crowded tuberculous families. Mass radiography X-ray surveys In past reports I have recorded the findings of X-ray examinations at mass X-ray units situated or operating in London but examining persons living anywhere. Those figures did not relate to London populations and could not reliably be compared with county statistics. This year, for the first time, through the co-operation of the Registrar-General it has been possible to obtain statistics of the findings of London residents examined during the year at mass X-ray units throughout the country. Because some X-ray units had not sent in their year's figures to the Registrar-General for this report, the statistics tend to be slightly on the low side. However, from figures available it is manifest that over a quarter of a million Londoners of all ages submitted to examination at these units during 1955. Among these, 1,391 cases of active pulmonary tuberculosis were discovered and confirmed during subsequent observation and assessment. 27 cases of active lung tuberculosis were discovered in children under 15 years of age, 11 of the cases being in 13-year-old pupils referred after tuberculin testing. Among adults examined there were 22,660 male metal workers among whom 99 cases (4.4 per thousand) of active disease were discovered. In 22,660 housewives X-rayed by mass radiography units 144 (6.4 per thousand) were found to have active tuberculosis. 16 active cases of lung disease were found among 6,100 school teachers (2.6 per thousand) and 220 (3.9 per thousand) out of 56,940 clerks were similarly affected. Among the 14,770 transport workers X-rayed, 120 active cases (8 per thousand) 35 were found and the rate of infection was in male workers thrice as heavy as among women in the industry. Male hotel workers showed a remarkably high rate of 14.7 cases per thousand examined. For women engaged in this work the rate was 5.8. Nearly 32,000 men aged 45 years or more were X-rayed and produced 384 confirmed cases of lung tuberculosis, an incidence rate of 12 cases per thousand compared with a corresponding rate in women of 4.5 cases per thousand women in this age group. 22 per cent. of the male cases discovered in this age group were infective compared with 18 per cent. among the women. As I have indicated earlier, this is work of the first importance in controlling tuberculosis in the population. Detailed statistics of mass radiography will be found in Tables T.9, T.10 and T.12. Table T.l—Tuberculosis—Statutory notifications and deaths—Administrative County of London, 1921-55 (a) Year(s) Pulmonary tuberculosis Non-pulmonary tuberculosis Statutory notifications Deaths Statutory notifications Deaths No. Annual rate per 1,000 living No. Annual rate per 1,000 living No. Annual rate per 1,000 living No. Annual rate per 1,000 living 1921-25 38,807 1.71 22,980 1.01 10,881 0.48 4,383 0.19 1926-30 34,353 1.53 20,247 0.90 8,971 0.40 3,080 0.14 1931-35 29,569 1.38 17,075 0.79 6,322 0.29 2,354 0.11 1936-40 24,848 1.29 13,664 0.71 4,510 0.23 1,861 0.09 1941 4,577 1.83 2,552 1.02 675 0.27 343 0.14 1942 4,734 1.80 2,164 0.82 796 0.30 283 0.11 1943 5,066 1.82 2,204 0.79 782 0.28 256 0.09 1944 5,056 1.84 2,073 0.75 673 0.24 237 0.09 1945 4,893 1.68 2,033 0.70 614 0.21 224 0.08 1946 5,137 1.57 1,940 0.59 611 0.19 243 0.07 1947 5,421 1.59 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 1955 3,757 1.14 517 0.16 365 0.11 44 0.01 (a) Excluding posthumous notifications. Table T.2—Pulmonary Tuberculosis—Statutory notifications and deaths by age and sex— Administrative County of London, 1946-55 Rates per 1,000 living (i) Notifications Sex Age 1946 1947 1948 1949 1950 No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—4 105 0.80 108 0.81 149 1.08 153 1.08 162 1.15 5—14 175 0.92 187 1.01 158 0.87 153 0.82 141 0.75 15—44 1,787 2.78 1,809 2.56 1,873 2.66 1.886 2.70 1,711 2.46 45 + 849 1.71 973 1.61 957 1.60 1,093 1.84 945 1.59 All males 2,916 2.00 3,077 1.89 3,137 1.93 3,285 2.03 2,959 1.83 Females 0—4 81 0.70 96 0.76 124 0.94 126 0.94 116 0.86 5—14 177 1.07 174 0.96 171 0.96 188 104 140 0.77 15—44 1,682 217 1,811 2.41 1,797 2.40 1,821 2.45 1,740 2.34 45 + 281 0.47 263 0.36 244 0.34 279 0.39 234 0.33 All females 2,221 1.35 2,344 1.32 2,336 1.32 2,414 1.36 2,230 1.26 Total 5,137 1.65 5,421 1.59 5,473 1.61 5,699 1.68 5,189 1.53 Sex Age 1951 1952 1953 1954 1955 No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—4 137 0.98 85 0.65 105 0.84 77 0.64 66 0.56 5—14 143 0.74 109 0.53 144 0.69 104 0.48 83 0.39 15—44 1,574 2.18 1,549 2.16 1,417 2.01 1,246 1.79 1,132 1.65 45 + 969 1.91 970 1.88 1,083 2.09 1,049 2.02 948 1.82 All males 2,823 1.80 2,713 1.73 2,749 1.76 2,476 1.60 2,229 1.45 Females 0—4 123 0.92 88 0.70 101 0.85 63 0.55 47 0.42 5—14 127 0.68 119 0.61 131 0.65 115 0.55 100 0.48 15—44 1,582 1.98 1,501 1.90 1,399 1.80 1,291 1.71 1,099 1.48 45 + 242 0.36 292 0.43 288 0.42 286 0.41 282 0.41 All females 2,074 1.16 2,000 1.11 1,919 1.08 1,755 0.99 1,528 0.86 Total 4,897 1.46 4,713 1.40 4,668 1.40 4,231 1.27 3,757 1.14 (ii) Deaths Sex Age 1946 1947 1948 1949 1950 No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—4 16 0.12 12 0.09 8 0.06 3 0.02 7 0.05 5—14 7 0.04 9 0.05 2 0.01 1 0.01 1 0.01 15—44 484 0.75 495 0.70 463 0.66 323 0.46 236 0.34 45 + 731 1.47 748 1.24 762 1.27 719 1.21 585 0.99 All males 1,238 0.85 1,264 0.78 1,235 0.76 1,046 0.65 829 0.51 Females 0—4 9 0.08 13 0.10 7 0.05 4 0.03 5—14 5 0.03 8 0.04 6 0.03 4 0.02 2 0.01 15—44 498 0.64 527 0.70 487 0.65 342 0.46 238 0.32 45 + 190 0.32 232 0.32 165 0.23 189 0.26 156 0.22 All females 702 0.43 780 0.44 665 0.37 539 0.30 396 0.22 Total 1,940 0.62 2,044 0.60 1,900 0.56 1,585 0.47 1,225 0.36 Sex Age 1951 1952 1953 1954 1955 No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—4 3 002 – – 2 0.02 – – 2 002 5—14 — — – – 1 0.00 – – 1 000 15—44 196 0.27 127 0.18 86 012 46 0.07 48 007 45 + 627 1.23 557 1.08 421 0.81 383 0.74 341 0.66 All males 826 0.53 684 0.44 510 0.33 429 0.28 392 0.25 Females 0—4 3 0.02 – – 3 0.03 3 0.03 – – 5—14 3 0.02 – – 1 0.00 2 0.01 15—44 171 0.21 125 0.16 85 0.11 77 0.10 48 0.06 45 + 151 0.22 124 0.18 91 0.13 85 0.12 77 0.11 All females 328 0.18 249 0.14 180 0.10 167 0.09 125 0.07 Total 1,154 0.34 933 0.28 690 0.21 596 0.18 517 0.16 37 Table T.3—Non-pulmonary tuberculosis—Statutory notifications and deaths by age and sex— Administrative County of London, 1946-55 Rates per 1,000 living (i) Notifications Sex Age 1946 1947 1948 1949 1950 No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—4 43 0.328 69 0.520 55 0.398 39 0.275 34 0.241 5—14 89 0.468 87 0.472 87 0.479 75 0.404 50 0.265 15—44 143 0.222 118 0.167 116 0.165 109 0.156 114 0.164 45 + 24 0.048 36 0.060 29 0.048 32 0.054 29 0.049 All males 299 0.205 310 0.190 287 0.177 255 0.157 227 0.140 Females 0—4 44 0.383 56 0.444 38 0.289 42 0.312 40 0.296 5—14 96 0.582 71 0.394 69 0.388 68 0.375 49 0.271 190 0.253 171 0.229 159 0.214 183 0.247 45 + 28 0.047 35 0.048 35 0.049 29 0.041 30 0.042 All females 312 0.189 352 0.198 313 0.176 298 0.168 302 0.171 Total 611 0.197 662 0.194 600 0.177 553 0.163 529 0.156 Sex Age 1951 1952 1953 1954 1955 No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—4 29 0.207 26 0.198 18 0.144 17 0.142 13 0.110 5—14 57 0.294 56 0.275 32 0.152 30 0.139 30 0.140 15—44 103 0.143 103 0144 97 0.138 89 0.128 96 0.140 45 + 27 0.053 36 0.070 23 0.044 36 0.069 22 0.042 All males 216 0.138 221 0.141 170 0.109 172 0.111 161 0.105 Females 0—4 36 0.269 21 0.168 19 0.160 17 0.149 13 0.116 5—14 48 0.257 34 0.173 37 0.182 39 0.187 25 0.121 15—44 178 0.223 184 0.233 136 0.175 133 0.176 140 0.189 45 + 29 0.043 58 0.085 48 0.070 49 0.071 26 0.037 All females 291 0.162 297 0.165 240 0.135 238 0.134 204 0.116 Total 507 0.150 518 0.154 no 0.123 410 0.123 365 0.111 (ii) Deaths Sex Age 1946 1947 1948 1949 1950 No. Rate No. Rate No. Rate No. Rate No. Rate Males 0—4 31 0.237 30 0.226 26 0.188 13 0.092 6 0.043 5—14 25 0.132 20 0.109 10 0.055 12 0.065 6 0.032 15—44 38 0.059 44 0.062 38 0.054 36 0.052 25 0.036 45 + 22 0.044 38 0.063 29 0.048 34 0.057 25 0.042 All males 116 0.079 132 0.081 103 0.063 95 0.059 62 0.038 Females 0—4 33 0.287 19 0.151 23 0.175 16 0.119 10 0.074 5—14 20 0.121 16 0.089 11.35 0.062 7 0.039 7 0.039 15—44 44 0.057 48 0.064 20 0.027 16 0.022 45 + 30 0.051 37 0.051 30 0.042 18 0.025 27 0.038 All females 127 0.077 120 0.067 99 0.056 61 0.034 60 0.034 Total 243 0.078 252 0.074 202 0.059 156 0.046 122 0.036 Sex Age 1951 1952 1953 1954 1955 No. Rate No. Rate No. Rate No. Rate No. ###] Males 0—4 10 0.071 7 0.053 3 0.024 3 0.025 1 0.008 5—14 6 0.031 2 0.010 1 0.005 1 0.005 2 0.009 15—44 19 0.027 12 0.017 11 0.016 8 0.012 45 + 21 0.041 17 0.033 13 0.025 18 0.035 11 0.021 All males 66 0.042 45 0.029 29 0.019 33 0.021 22 0.014 Females 0—4 9 0.067 5 0.040 9 0.076 2 0.018 1 0.009 5—14 9 0.048 2 0.010 2 0.010 – – 1 0.005 15—44 15 0.019 14 0.018 13 0.017 7 – – 0.004 45 + 26 0.039 20 0.029 20 0.029 20 0.029 17 0.024 All females 59 0.033 41 0.023 44 0.025 29 0.016 22 0.013 Total 125 0.037 86 0.026 73 0.022 62 0.019 44 0.013 38 Table T.4—Tuberculosis—Statutory notifications by age groups— Administrative County of London, 1955 Form of tuberculosis notified Sex Number of notifications of new cases of tuberculosis by age all ages 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65+ Pulmonary tuberculosis M 8 18 47 36 153 199 457 323 391 326 231 2,229 F. 7 40 52 48 171 275 434 219 156 59 67 1,528 Other forms of tuberculosis M. — 13 14 16 18 19 38 21 11 4 7 161 F. — 13 15 10 21 26 66 27 14 6 6 204 All forms of tuberculosis M. 8 71 61 52 171 218 495 344 402 330 238 2,390 F. 7 53 67 58 192 301 500 246 170 65 73 1,732 Table T.5—Statutory notification of non-pulmonary tuberculosis— Distribution according to site and age, 1955 Site of tuberculous lesion Numbers of notifications of new cases of non-pulmonary tuberculosis by age all ages 0-4 5-14 15-24 25+ Bones and joints 8 22 29 69 128 Abdomen 1 3 9 20 33 Peripheral glands 5 13 25 43 86 Meninges 6 8 3 6 23 Skin and erythema nodosum 2 5 1 2 10 Genito-urinary — 1 15 60 76 Other sites 1 2 1 5 9 All sites 23 54 83 205 365 Table T.6—Patients on the registers*—Administrative County of London, 1946-55 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 Cases on the register at the end of the year: Pulmonary— Males 15,695 16,374 17,224 18,203 19,090 19,119 17,336 18,475 18,897 19,300 Females 12,262 12,862 13,549 14,223 15,031 15,556 14,672 14,930 15,576 15,846 Other forms: Males 2,821 2,699 2,889 2,752 2,591 2,520 1,530 1,508 1,442 1,371 Females 3,099 3,142 3,147 3,015 3,068 2,954 1,850 1,820 1,709 1,704 Total No. per 1,000 of population 33,877 35,077 36,809 38,193 39,780 40,149 35,388 36,733 37,624 38,221 10.9 10.6 11.0 11.3 11.7 12.0 10.5 10.9 11.3 11.6 *Since 1952 figures are taken from Chest Clinic registers; for earlier years they represent Borough M.O.H. register 39 d Table T.7—Condition of new cases and their contacts Men Women Children Total Number of new cases diagnosed as tuberculous at chest clinics during the year 2,094 1,474 337 3,905 Percentage of these new cases found to be 'T.B. plus' (i.e. Infective) 43.5 30.7 5.0 35.3 Number of those who attended as contacts and who were : (a) Diagnosed as tuberculous* 80 (2.7) 104 (2.4) 87 (1.1) 271 (1.8) (b) Not tuberculous 2,757 4,107 7,240 14,104 (c) Not determined (as at 31.12.55) 181 195 347 723 *Figures in brackets are percentages of the total contacts examined Table T.8—Summary of investigations into tuberculosis ' incidents ' at Council establishments in 1955 Establishment Notified case Children Adults Tuberculin tested Positive reaction X-rayed Abnormal X-rayed Abnormal Day schools Teacher – – 200 – 17 – Laboratory technician – – 521 2 21 – Teacher 25 2 2 – – – Pupil – 260 – 6 – Teacher 345 79 79 2 21 – Teacher 56 4 4 – 9 – Teacher 52 8 8 – 27 – Pupil – – 999 – 70 – Teacher – – 28 – 11 – Kitchen helper 252 25 20 – 20 – Teacher – – 28 – 4 – Pupil – – 407 2 22 – Teacher 273 6 6 – 9 – Teacher – – 31 – 7 – Pupils (3) 27 16 125 – 5 – Pupil – – 32 1 7 – Teacher 240 24 16 – 20 – Pupil – – 291 2 17 – Pupil 414 141 139 1 35 1 School secretary – – – – 3 – Teacher – – 349 – 39 – Pupil 161 31 31 – 13 – Pupil 19 2 2 – – – Technical college Student – – – – 325 – Totals (24) 1,864 338 3,578 10 708 1 Education officer's department students' hostel (1) Domestic assistant – – – – 92 – Children's department residential establishments (2) Domestic assistant 1 – – – 17 – Pupil 22 17 17 – – – Day nurseries (2) Nursery assistant 47 – – – 16 – Child 62 2 2 – 23 – Grand Totals (29) 1,996 357 3,597 10 856 1 40 Table T.9—Tuberculosis notifications and mass radiography details, 1955, by occupations Mass Radiography—1955 Registrar-Generals Short Classification of Employment Population mid 1951 Tuberculosis Notifications Number examined Cases of tuberculosis found 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 — — — — — — — — — — 1 — — — 2. Agriculture, horticulture, etc. 4,500 400 11 (3) 2.4 — — 300 67 20 50 6.7 — — 3. Mining, Quarrying occupations — — 1 .. — .. 30 — — — 3 100.0 — — 4. Non.metalliferous mining products 3,700 1,700 5 1.4 — — 580 157 330 194 6 10.3 — — 5. Coal, gas, coke, chemical workers 6,300 600 7 11 — — 680 108 150 250 3 4.4 — — 6. Metalwork, engineering 131,800 15,000 179(12) 1.4 8(1) 0.5 22,660 172 2,130 142 99 4.4 14 6.6 7. Textile workers 1,000 1,600 2 2.0 3 (1) 1.9 70 70 240 150 — — 2 8.3 8. Tanners, leatherworkers, etc. 6,700 5,000 11 1.6 4(1) 0.8 570 85 440 88 3 5.3 2 4.5 9. Textile goods and dressmakers 26,500 70,600 37 (2) 1.4 68 (9) 1.0 1,640 62 4,310 61 11 6.7 22 5.1 9. Textile goods and dressmakers 11,200 8,200 10 (1) 0.9 5 0.6 2,320 207 1,550 189 13 5.6 6 3.9 10. Food, drinks, tobacco makers 36,100 1,100 33 (3) 0.9 2 1.8 3,650 101 130 118 19 5.2 — — 11. Wood, cane, corkworkers 24,500 13,700 26 11 7(1) 0.5 3,540 144 1,350 99 26 7.3 4 3.0 12. Papermakers, bookbinders, printers 7.200 5,700 8 11 4 (2) 0.7 810 113 510 89 2 2.5 1 2.0 13. Other products (plastics, etc.) 66,700 — 48 (2) 0.7 1 — 3,170 48 — — 23 7.3 — — 14. Builders and contractors 35,500 1,300 37 (1) 10 — — 2,150 61 150 115 18 8.4 2 13.3 15. Painters and decorators 32,200 7,700 7 0.2 2 0.3 2,210 69 750 97 9 4.1 1 1.3 16. Administrators, directors, managers 162,400 16,500 235(9) 1.4 12(3) 0.7 11,320 70 3,450 209 109 9.6 11 3.2 17. Transport and communications 107,700 60,600 119(9) 11 76(5) 1.3 6,420 60 3,840 63 44 6.9 27 7.0 18. Finance, insurance, commerce 61,200 54,700 61 (1) 1.0 60 (9) 1.1 9,680 158 10,360 189 31 ‡ 3.2 26‡‡ 2.5 20. Defence services 40,300 1,200 57(2) 1.4 1 0.8 1,940 48 60 50 10 5.2 — — 21. Entertainment and sport 12,300 5,600 11 0.9 3 0.5 820 67 310 55 3 3.7 1 3.2 22. Personal services (hotels, etc.) 75,700 193,500 137(7) 1.8 141 (15) 0.7 3,810 50 12,000 62 56 14.7 70 5.8 23. Clerks, typists, etc. 94,900 167,300 174(3) 1.8 212 (15) 1.3 22,960 242 33,980 203 98 4.3 122 3.6 24. Packers, warehousemen, etc. 41,100 22,200 62 (4) 1.5 19(1) 0.9 5,360 130 2,590 117 39 7.3 16 6.2 25. Stationary engine drivers, stokers 10,700 — 19(1) 1.8 1 1,360 127 10 — 14 10.3 — — 26. Unskilled workers (not elsewhere specified) 74,500 28,800 228(18) 31 46(5) 1.6 11,630 156 6,470 225 116 10.0 37 5.7 27. Other and undefined workers 11,400 2,200 24 (2) 21 13(1) 5.9 1,450 127 320 145 14 9.7 3 9.4 Total (1.27) 1,086,100 685,200 1,549 (80) 1.4 688 (69) 1.0 121,130 112 85,450 125 771 6.4 367 4.3 28. Housewives .. .. .. .. 692 (77) .. .. .. 22,660 .. .. .. 144 6.4 Unemployed .. .. 418 (24) 103 (11) — — — — — Retired 83,000 32.300 201 (7) 2.4 40 (5) 1.2 — — — — — — — — Students .. .. 41 (5) 16 9,610 — 8,110 29 3.0 19 2.3 Children under 15 338,200 323,200 208(38) 0.6 212 (41) 0.7 6,240 18 5,340 17 10 1.6 17 3.2 Note.—Numbers in brackets are non-pulmonary cases included in the total. * Rates based on 1951 population census distribution. †Rates per 1,000 examined. Notifications are based on weekly (uncorrected) notifications and therefore differ by 46 from the Reg. Gen. Total (Table T.r). ‡ ncludes 8 cases of teachers out of 2,300 examined. ‡‡ udes 8 cases of teachers out of 3,800 examined. d* 41 Table T.10—Mass radiography findings in London residents Age Sex Number examined Active Tuberculosis confirmed in Case rate per 1,000 examined Positive sputum found in Infective case rate per cent 0-14 M 6,240 10 1.6 1 10.0 F 5,340 17 3.2 — — 15-24 M 40,200 92 2.3 20 21.7 F 40,940 146 3.6 38 26.0 25-44 M 60,820 352 5.8 68 19.3 F 51,800 271 5.2 52 19.2 45-64 M 28,570 320 11.2 68 21.3 F 23,060 102 4.4 16 15.7 65- M 3,320 64 19.3 17 26.6 F 2,770 16 5.8 5 31.3 Not stated M 30 1 33.3 — — F 30 — — — — All ages M 139,180 839 6.0 174 20.7 F 123,940 552 4.5 111 20.1 13 year olds M 1,560 4 2.6 1 25.0 F 1,100 7 6.4 — — 42 Table T.11—Summary of services provided for tuberculous patients, 1952-55 1952 1953 1954 1955 Clinic registers Total on registers at the end of the year 35,388 36,733 37,624 38,221 Work of local tuberculosis care organisers Patients assisted for the first time with:— Beds and bedding 541 431 435 291 Clothing or footwear 961 1,089 1,334 1,014 Patients at the end of the year receiving:— Extra nourishment 2,234 2,451 2,391 2,285 Home help service 673 618 729 660 Home care and treatment At the end of the year, patients:— Awaiting admission to hospital 738 494 209 71 Under treatment in their own homes 808 804 930 1,050 Receiving attention by home nurses 367 466 530 498 Rehabilitation At the end of the year the Council was financially responsible for rehabilitants at:— British Legion Village, Maidstone 25 25 33 36 Papworth Village Settlement, Cambridge 17 17 23 22 Enham-Alamein Village Centre, Andover 18 21 22 15 Barrowmore Hall, Chester 2 2 2 2 Correspondence courses arranged through the British Council for Rehabilitation for patients undergoing prolonged treatment at home 65 113 80 77 At boarding open-air schools Children convalescent from tuberculosis:— At the beginning of the year 33 29 34 22 Admitted during the year 47 27 23 2 At the end of the year 29 34 22 12 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 419 440 450 365 Placed during the year 490 562 411 398 Boarded-out at the end of the year 440 450 365 279 Average number boarded-out at any one time 442 486 417 310 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 11 Placed during the year 67 38 39 40 Boarded-out at the end of the year 24 6 11 7 Average number boarded-out at any one time 18 14 10 19 B.C.G. vaccination schemes Child contacts vaccinated by chest physicians in London 3,034 3,141 3,851 4,113 Boarded-out child contacts vaccinated by out-county chest physicians 139 161 48 43 Child contacts (mainly new-born babies) vaccinated in London hospitals prior to boarding-out 73 77 64 50 13-year-old school children – – 4,037 19,507 Diabetic children in the Council's care – – 26 12 Hostels for tuberculous men In residence at the beginning of the year 54 44 59 63 Recommendations approved during the year 61 84 57 49 In residence at the end of the year 44 59 63 58 43 Table T.12—Principal tuberculosis statistics—Metropolitan Boroughs and the Administrative County of London, 1955 Metropolitan Boroughs Estimated home population '955 New notifications New notifications per 1,ooo population Deaths ftom tuberculosis Tuberculosis deaths per l,ooo population Pulmonary tuberculosis deaths per 1,000 population aged 15 and over Number of tuberculosis cases on clinic registers at 31.12.55 Cases on register per 1,000 population Mass X-ray findings Pulmonary Tuberculosis of. Meninges and C.N.S. Other nonpulmonary tuberculosis Total Pulmonary Nonpulmonary tuberculosis Total deaths Number of pulmonary cases found per 1,000 adults examined Total Percentage sputum positive during 1955 Division 1 Chelsea 51,450 40 1 6 47 0.91 8 1 9 0.17 0.19 425 3.8 8.3 5.3 Fulham 118,600 101 1 11 113 0.95 27 – 27 0.23 0.28 1,357 3.5 11.4 4.3 Hammersmith 114,700 135 – 15 150 1.31 16 – 16 0.14 0.17 1,528 3.3 13.3 4.3 Kensington 169,400 193 – 25 218 1.29 12 5 17 0.10 0.08 1,649 4.7 9.7 4.2 Division 2 Hampstead 97,710 84 – 4 88 0.90 13 2 15 0.15 0.16 875 6.1 9.0 4.0 Paddington 121,500 177 2 16 195 1.60 15 2 17 0.14 0.15 1,347 8.8 1.11 4.0 St. Marylebone 73,440 75 – 2 77 1.05 9 – 9 0.12 0.14 819 3.2 11.2 3.0 St. Pancras 134,500 209 2 19 230 1.71 31 3 34 0.25 0.28 1,202 11.5 8.9 7.2 Westminster, City of 97,630 110 1 14 125 1.28 22 3 25 0.26 0.26 890 4.3 9.1 5.5 Division 3 Finsbury 35,100 41 1 5 47 1.34 15 – 15 0.43 0.54 242 5.8 6.9 3.3 Holborn 23,060 41 – 4 45 1.95 8 – 8 0.35 0.40 244 7.4 10.6 2.6 Islington 228,800 306 4 38 348 1.52 45 2 47 0.21 0.25 2,751 5.3 12.0 6.9 Division 4 Hackney 167,200 111 2 16 129 0.77 15 2 17 0.10 0.11 2,036 2.9 12.2 4.2 Shoreditch 45,480 36 1 5 42 0.92 15 – 15 0.33 0.43 477 6.7 10.5 5.3 Stoke Newington 50,470 32 – 4 36 0.71 4 – 4 0.08 0.10 757 2.5 15.0 5.9 Division 5 Bethnal Green 53,860 46 – 5 51 0.95 8 – 8 0.15 0.19 813 2.1 15.1 4.8 City of London 5,180 6 – 1 7 1.35 2 1 3 0.58 0.42 60 8.3 11.6 – Poplar 70,260 59 1 9 69 0.98 16 – 16 0.23 0.30 574 4.2 8.2 3.4 Stepney 98,180 149 1 22 172 1.75 17 3 20 0.20 0.22 1,240 7.3 12.6 6.0 Division 6 Deptford 72,890 164 – 4 168 2.30 14 – 14 0.19 0.25 1,134 2.5 15.6 7.6 Greenwich 89,490 89 – 7 96 1.07 7 1 8 0.09 0.10 1,003 3.2 11.2 6.0 Woolwich 148,500 141 1 9 151 1.02 22 1 23 0.15 0.19 1,973 1.6 13.3 4.9 Division 7 Camberwell 178,400 303 1 14 318 1.78 28 2 30 0.17 0.20 2,002 0.6 11.2 6.7 Lewisham 223,400 255 1 14 270 1.21 22 4 26 0.12 0.13 2,771 10.1 12.4 3.9 Division 8 Bermondsey 57,580 54 – 6 60 1.04 8 1 9 0.16 0.18 588 5.8 10.2 3.8 Lambeth 224,200 232 – 21 253 1.13 32 4 36 0.16 0.18 3,039 1.4 13.6 6.5 Southwark 93,820 146 2 7 155 1.65 23 3 26 0.28 0.31 1,394 3.7 14.9 2.8 Division 9 Battersea 113,700 115 1 13 129 1.13 14 – 14 0.12 0.16 1,165 2.0 10.2 5.0 Wandsworth 336,500 307 – 26 333 0.99 49 4 53 0.16 0.18 3,866 3.7 11.5 6.2 LONDON 3,295,000 3,757 23 342 4,122 1.25 517 44 561 0.17 0.20 38,221 4.5 11.6 5.4 44 Table T.13—Tuberculosis—Contact examinations at Chest Clinics Chest clinics Estimated population served Total new cases of tuberculosis (all forms) New contacts seen New contacts not determined New contacts diagnosed New contacts found tuberculous Per cent, new contacts found tuberculous among diagnosed contacts Calculated rate of new contacts seen per 100 new cases (1) (2) (3) (4) (5) (6) (7) Chelsea 51,450 51 220 – 220 1 0.5 431 Fulham 118,600 109 133 28 105 2 1.9 82 Hammersmith 114,700 137 734 – 734 4 0.5 536 Hampstead 97,710 89 372 – 372 – – 418 Paddington and Kensington 290,900 406 1,627 272 1,355 21 1.6 401 St. Marylebone 73,440 74 221 221 5 2.3 307 St. Pancras 134,500 154 388 20 368 2 0.5 252 City of Westminster 97,630 111 235 – 235 10 4.3 220 Finsbury 35,100 29 84 12 72 4 5.6 290 Holborn 23,060 46 443 4 439 8 1.8 963 Islington 228,800 356 620 48 572 26 4.5 174 Shoreditch 45,480 35 163 2 161 2 1.2 466 Stoke Newington and Hackney North 138,140 120 545 5 540 7 1.3 454 Hackney South and Bethnal Green 133,390 118 446 33 413 6 1.5 379 City of London 5,180 5 60 4 56 2 3.6 1,200 Poplar 70,260 64 311 87 224 1 0.4 486 Stepney 98,180 173 286 – 286 14 4.9 165 Deptford 72,890 170 358 12 346 14 4.0 210 Greenwich 89,490 91 470 24 446 16 3.6 516 Woolwich (both clinics) 148,500 153 378 83 295 6 2.0 247 Camberwell 178,400 334 1,093 1,093 19 1.7 327 Lewisham 223,400 259 2,015 – 2,015 19 0.9 778 Bermondsey 57,580 59 198 4 194 5 5.3 336 Lambeth North 103,800 126 509 – 509 5 1.0 404 Lambeth South 120,400 90 604 2 602 9 1.2 671 Southwark 93,820 164 526 526 5 1.0 321 Battersea 113,700 97 488 42 446 21 4.7 503 Wandsworth Town Hall clinic 181,660 185 257 2 255 18 13.6 139 Balham 154,840 100 493 39 454 10 2.2 493 TOTAL 3,295,000 3,905 14,277 723 13,554 262 1.9 366 Figures are taken from chest clinic returns T. 145 to Ministry of Health. * New contacts seen ' may include local work contacts not resident in the County of London. 45 Table T.14—Tuberculosis—Annual chest X-ray examination of mental defectives at senior occupation centres, 1955 Division Occupation centre E.B.—elder boys E.G.—elder girls Average roll at time of examination Date of examination No. X-rayed No. of cases of T.B. discovered Under 15 Over 15 1 Hammersmith (E.B.) 32 15.6.55 1 27 1 do. Aug., 1955 – 2 – North Kensington (E.G.) 25 16. 6.55 3 21 – 3 Archway (E.B.) 32 6. 9.55 – 26 – Islington (E.G.) 34 7. 9.55 4 21 – 4 Dalston (E.B.) 48 23. 9.55 9 25 – Hackney (E.G.) 32 29. 6.55 3 24 – 6 Greenwich (E.G.) 12 9.11.55 – 12 – Brockley (E.G.) 57 9.11.55 1 45 – 7 Peckham (E.B.) 60 15.11.55 3 50 – 9 Battersea (E.B.) 32 8. 7.55 1 22 – do. 1. 9.55 – 4 – Earlsfield (E.G.) 42 15. 7.55 – 25 – Totals 406 25 304 1 Annual X-ray examination of staff at occupation centres, 1955 No. of staff X-rayed on appointment 9 No. of existing staff X-rayed 76 Total 85 All satisfactory. Table T.15—B.C.G. vaccination under L.C.C. schemes in 1955 1. Day schools— 1955 No. of schools visited 415 No. of 13-year-old children at school 32,679 No. of consents 24,344 No. Mantoux tested 22,533 No. of positive reactors 3,149=13.9 per cent. No. given B.C.G. 19,375 No. vaccinated June, 1954, to December, 1955 23,645 Retests in 1955— No. of consents to retest 2,808 No. of retests 2,595 No. found negative 199=7.7 per cent. No. re-vaccinated 199 2. Residential establishments— No. of establishments visited in 1955 16 (includes 3 in-county establishments now covered by Divisional arrangements) No. of children tested 166 No. of positive reactors 36=21.7 per cent. No. given B.C.G. 132 (includes 2 without tests) 3. Notifications of Tuberculosis (all forms) in 14-and 15-year-old children in 1953 70 1954 82 1955 (first full year after B.C.G.) 45 4. Tuberculosis contacts— No. of contacts examined at chest clinics in 1955 14,975 No. of contacts given B.C.G. vaccination in London 4,113 No. of contacts given B.C.G. vaccination in London since inception of scheme in 1950 16,659 5. Diabetics— No. tuberculin tested No figures available. No. given B.C.G. in 1955 12 No. given B.C.G. since inception of scheme 25 46 Table T.16—B.C.G. vaccination of school children in 1955—Divisional figures Division No. of 13 years' old school children Total No. of consents Alleged contacts of known cases Consents included in (2) No. of children tested and read by B.C.G. units Children not dealt with because of refusal of consent or absence Positive reactors (among (4)) No. of negative reactors vaccinated by B.C.G. units No. Per cent. of (0 No. Per cent. (1) (2) (3) (4) (5) (6) (7) (8) (9) 1 4,208 2,917 18 2,720 1,470 35.0 369 13.6 2,350 (1 negative not vaccinated) 2 3,691 2,855 60 2,712 919 25.0 414 15.3 2,295 (3 negatives not vaccinated) 3 2,796 1,933 16 1,773 1,007 36.0 280 15.8 1,493 4 2,561 1,609 14 1,447 1,100 43.0 178 12.3 1,269 5 2,178 1,668 4 1,367 807 37.0 218 15.9 1,148 (1 negative not vaccinated) 6 3,942 3,188 60 2,903 979 24.8 381 13.1 2,519 (3 negatives not vaccinated) 7 4,483 3,486 73 3,332 1,078 24.0 436 13.1 2,896 8 . 3,906 2,978 84 2,782 1,040 26.6 417 15.0 2,365 9 4,914 3,710 49 3,497 1,368 28.0 456 13.1 3,040 (1 negative not vaccinated) Totals 32,679 24,344 378 22,533 9,768 29.9 3,149 13.9 19,375 47 GENERAL PUBLIC HEALTH Housing during the year, 12,773 houses and flats were erected by the Council and the Metropolitan Borough Councils. Of these, 10,727 were in London (4,225 erected by the Council and 6,502 by the Borough Councils) and the remainder (2,046) 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 171,262 (an increase in the year of 6,156) of which 84,181 were situated in London, and 87,081 outside the County. In addition, there were 7,563 temporary pre-fabricated 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 165,571, compared with 164,559 in 1954. New applications registered during the year totalled 24,553. 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, and (c) no basic housing need. Preferential housing During the year, 26,362 (6,370 fewer than in 1954) requests for preference in rehousing on health grounds were considered and suitable recommendations made to the Director of Housing. The number of applications on health grounds, although fewer than in the previous year, again exceeded the total number of applicants added to the Council's waiting list. This is mainly because applications which had been considered in previous years were reviewed in the light of changed medical or domestic conditions. Applicants living in unsatisfactory conditions are, of course, only too anxious to advance any possible claims in support of their applications for other accommodation and in very many instances they put forward ill-health as a reason. All such applications are considered carefully, and to enable a fair decision to be reached, many inquiries are made of the Medical Officers of Health of the Metropolitan Boroughs and out-County authorities, of family doctors, or of the staffs of hospitals. The assistance given by these authorities in providing reports is gratefully acknowledged. Of the applications considered, 3 per cent, were recommended for special preference because rehousing was urgently necessary to reduce the danger of infection arising from active pulmonary tuberculosis, 16 per cent, were classified as ' most urgent' on other health grounds, and 39 per cent, as less urgent but justifying preference for health reasons. In the remaining 42 per cent, it was decided that the degree of medical urgency disclosed by doctors' certificates did not warrant additional oreference. Slum clearance Work on the survey of areas included in the slum clearance programme adopted by the Council in 1951 continued throughout the year. Representations under section 25 of the Housing Act, 1936, were made in respect of 45 areas containing 2,356 unfit houses and preliminary surveys were completed in respect of a further 46 areas containing 2,292 unfit houses. In addition, seven areas containing 286 unfit houses were the subject of Declaration of Unfitness Orders made by the Council under the Town and Country Planning Act, 1947. The Minister of Housing and Local Government arranged 20 public local inquiries into Orders made by the Council and, by the end of the year, 12 of the Orders had been confirmed, two were confirmed in part and decisions in respect of six Orders were awaited. No objections were made in respect of four Orders, which the Minister confirmed, without holding a public local inquiry. The Housing Repairs and Rents Act, 1954, required all local authorities to submit to the Minister within twelve months, their proposals for dealing with those houses within their areas which were, on 31st August, 1955, so unfit for habitation as to justify action under Part III of the Housing Act, 1936. The Act also required the proposals in respect of the Administrative County of London to be submitted jointly by the Council and the Metropolitan Borough Councils. 48 As in the preparation of previous programmes of slum clearance the Metropolitan Borough Councils, following surveys of their areas, prepared their proposals and discussions on these took place with the borough medical officers of health. In spite of the size of the task and the short time available, the majority of the agreed proposals were in the hands of the Minister by the appointed day and all were submitted by the end of September, 1955. The estimated total number of houses in the County as revealed by the survey to be so unfit for habitation as to justify immediate demolition was 7,218 ; of this figure the Council has undertaken to secure the demolition of 4,094 unfit houses within the next five years. Improvement grants Surveys were made in respect of 71 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, 261 investigations were made in connection with applications for such grants made to Metropolitan Borough Councils. During the year 1,613 searches were made in connection with inquiries concerning premises scheduled as dangerous structures. Dangerou structures 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 arriving in London Milk sampling Since 1908 it has been the practice of the Council to take samples of liquid milk arriving by road or rail from the provinces and submit them to biological examination to ascertain the extent to which the milk on its arrival in London is infected with tuberculosis. In 1934 it was decided that no useful purpose would be served by sampling milk brought into the county in large tankers as it was impossible to trace the farm of origin ; since then sampling has been restricted to supplies arriving in churns. Any samples showing signs of infection by tuberculosis are reported to the medical officer of health of the district in which the farm of origin is situated so that, in conjunction with the district veterinary officer of the Ministry of Agriculture, Fisheries and Food, an inspection of the herd may be made with a view to the removal of infected cows. During 1955 samples of milk taken for this purpose numbered 201 and the results of the biological examinations were as follows: Designation Samples examined Results of examination T.B. bacillus isolated T.B. bacillus NOT isolated Test not completed* Percentage positive of completed tests Ordinary 158 5 138 15 3.5 T uberculin tested 43 — 41 2 — Total 201 5 179 17 3.5 * Guinea pigs died be/ore completion of test or the milk curdled. As a result of the investigations into the origin of the five positive samples, information has been received that one cow was slaughtered in each of three herds and that in another herd several cows were slaughtered. In the fifth herd investigated no tuberculous animals were detected. All the raw milk from which the positive samples were obtained was pasteurised before sale to the public. 49 At Council establishments The sampling of milk purchased for use in the Council's establishments is arranged in conjunction with borough and county medical officers of health. Details will be found on page 55. Dried milk Twenty-two samples of dried milk powder were taken from supplies purchased by the Council and were submitted to bacteriological examination. One sample only contained more than 100,000 organisms per gram and in two samples staphylococcus aureus was isolated. Disinfestation Sanitary inspection Reports of 133 instances of infestation involving 300 visits and re-inspections were received from establishments controlled by the Council, e.g., school meals centres, schools, welfare establishments and parks. Infestations by a variety of pests including rats, mice, pigeons, cockroaches, bugs, ants, silver fish, flour and clothes moths, furniture beetles, clover mites, plaster beetles, wasps, hornets, crickets and flies were investigated and the control measures carried out proved effective. School meals More than 600 visits of inspection were made to school meals centres and 34 reports of illness following consumption of school meals were investigated. Regular inspections relating to hygienic conditions were made at least once a quarter of 75 homes, hostels and other welfare establishments. Welfare establishments Complaints A large number of complaints of insanitary conditions were received from residents in London and referred to the health department of the appropriate metropolitan borough council. Exhumation of human remains Two disused burial grounds were cleared of human remains during the year. The first was a burial ground in Finsbury in respect of which the Council obtained the necessary powers in the London County Council (General Powers) Act, 1953. The operation took over 5 months to complete and during that time the remains of over 9,600 persons were exhumed, placed in 491 new coffins and re-interred at Brookwood Cemetery, Woking. The second burial ground was situated in Hammersmith and powers were obtained in the London and Middlesex (Improvements, etc.,) Act, 1936. Over a period of seven weeks the remains of 98 persons were placed in 43 new coffins and re-interred at Hammersmith Old Cemetery. In both schemes the work was done in accordance with conditions imposed by the Secretary of State and Regulations made by the medical officer of health ; the examinations and re-interments were carried out under the supervision of the Inspectorate of the department. Advisory and research work Advice was given to other departments of the Council on problems relating to sanitation, drainage, food hygiene and other public health matters in connection with the preparation of plans for new buildings and the adaptation of existing premises. The plumbing experiments referred to in the Report for 1952 were continued in association with the Architect's department and the Plumbing Research Committee of the Department of Scientific and Industrial Research. The installation of' single stack ' systems of plumbing was extended during the year and it is satisfactory to record that complete installations are functioning without complaint. The Chief Inspector continued to represent the Council on a number of Committees of the British Standards Institution appointed to consider standards in relation to sanitary appliances, traps, pitch-fibre drain pipes, refuse chutes and metal sinks and lavatory basins. Blind and partially-sighted persons During the year, 1,899 examinations were made in connection with certification under the National Assistance Act, 1948, of blind and partially-sighted persons. In addition, 276 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. On examination 76 persons were found to be neither blind nor partially-sighted. Re-examinations to confirm certificates given in previous years and certificates relating to persons already registered by other authorities who have moved into London are omitted from the tables. 50 New registrations Table (i) Number of new registrations during the year with percentage recommended to obtain treatment Age Principal cause of defective vision Total Cataract Glaucoma Retrolental fibroplasia Other conditions 0-4 years - - 3 19 22 5-15 years — — — 9* 9* 16-64 years 38 16 — 184 238 65-74 years 87 45 — 190 322 75 years and over 286 50 — 323 659 Age not known — — — 3 3 (a) Total No. of persons 411 1ll 3 728 1,253 (b) No. recommended to obtain treatment 243 69 1 241 554 (b) as percentage of (a) 59.1 62.2 33.3 33.1 44.2 * Includes six 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. The treatments recommended most frequently were surgical treatment for cataract (153 instances or 37 per cent, of those found with cataract as the principal cause of their defective vision) and medical treatment or hospital supervision for glaucoma (60 or 54 per cent.). That blindness is principally a problem associated with old age is demonstrated by the age distribution in table (i). Persons recommended to obtain treatment are re-examined at intervals after the initial registration. The number of persons re-examined for this reason in 1955 is shown in table (ii). Re-examinations 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 168 40 — 136 344 No. found to have had treatment 106 33 — 78 217 Percentage treated 63.0 82.5 — 57.4 63.1 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, a treatment rate of 63 per cent, can on the whole be regarded as satisfactory. As a consequence of successful treatment, 52 persons previously registered as blind were found, on re-examination, to be partially-sighted, and 41 persons previously certified as blind or partially-sighted were found to be improved to such an extent as no longer to be registerable. Figures for ophthalmia neonatorum are given on page 23. 51 Registration of nursing homes At the end of the year there were 41 nursing homes on the register, one fewer than in 1954. In the 41 homes there were 828 beds distributed as follows : Number of beds in home Number of homes Patients accommodated Maternity† Others* Total 25 or over 9 209 224 433 20 to 24 6 25 103 128 15 to 19 5 15 69 84 10 to 14 10 45 69 114 5 to 9 8 27 35 62 Under 5 3 2 5 7 Total 41 323 505 828 †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 supervision of the homes was maintained and visits of inspection were made at regular intervals by medical officers (53 inspections) and public health inspectors (93 inspections). The shortage of 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. Exemptions from the operation of part XI of the Public Health (London) Act, 1936, granted during the year numbered 39. Nursing homes and the National Health Service The following report was prepared before his death on 19th May, 1955, by Dr. E. B. Argles, who for many years had been responsible for the inspection of nursing homes in London :— Figures given in the annual reports of the county medical officer show that the second world war and the National Health Service Act caused great changes among the nursing homes of London. At the end of 1937 170 nursing homes were registered in the County. Evacuation, damage by enemy action, shortage of staff, and other difficulties reduced the number of active homes to 108 in 1945, and the homes which survived the war had great difficulty in maintaining their standards. The replacement of equipment (particularly linen), rationing, and the shortage of skilled staff had to be surmounted during the difficult war years, and most nursing homes were then faced with heavy expenditure on repairs and redecoration in the immediate post-war years. This alone was often enough to discourage the owners of the smaller type of home from continuing. In addition the pre-war nurse's salary of £60 to £90 a year, all found, had by 1953 become ,£350 plus a living-out allowance. It was not surprising, therefore, that between 1947 and 1953 there was a further drop in the number of nursing homes from 63 to 48. This drop of 24 per cent, in the number of homes in London since the National Health Service began, when measured in number of beds available, shows a decrease of 9.4 per cent. During this same period 19 new homes were registered, but 34 were closed. Rising costs have alarmed the users as well as the owners of nursing homes. Accommodation which before the war cost 5 to 8 guineas a week, with a maximum of about 12 guineas, to-day costs from 11 to 25 guineas a week—not a disproportionate increase when compared with rises in costs. Fees of this magnitude which may be borne for a short period by the acutely ill are an impossible burden on patients of advanced age with small fixed incomes ; in many cases the expense is met for a time out of capital or by relatives or friends. This is one of the main reasons why the number of empty beds has increased in nursing homes. There are still some small homes with from 6 to 10 beds charging about 6 guineas upwards, but at such a figure and with presentday prices no more than the bare minimum of nursing staff can be provided, and the 52 food could hardly be expected to be of the highest quality. Homes of this type appear to be on the border of solvency, and it may well be that few can survive. On the other side of the picture are a few homes charging fees as high as 30 to 35 guineas a week. These homes are in constant use by physicians and surgeons of high standing, and the professional skill and care are matched by a service similar to that of a luxury hotel. The introduction of the National Health Service came at a time when the falling birth-rate was reducing the admissions to maternity beds in nursing homes, and coincided with a period when maternity wards were being expanded in the hospitals. The number of confinements taking place in nursing homes in London was 3,167 in 1947 : in 1952 this had fallen to 1,091. This large drop cannot be wholly accounted for by the fall in the birth-rate from the exceptionally high figure of 20.9 per 1,000 of the population in 1947 to 15.3 in 1952. Recent annual reports of the medical officers of health of other large cities show the same trend. Most homes found that in the post-war years less use was being made of their operating theatres and more beds were being used for medical cases, particularly for the treatment of the chronic sick or senile patients : in 1948 30 per cent, of the beds in nursing homes were occupied by patients in those two categories. By 1953 this figure had risen to 44 per cent., and in the same period the proportion of beds occupied by maternity cases fell from 10 per cent, to 5 per cent., and of all beds occupied from 75 per cent, to 71 per cent. State-registered nurses are not as a rule keen to work in private nursing homes, and the comparatively uneventful nursing of the chronic sick does not greatly attract them. It is the State-enrolled assistant nurses, or the older women, trained but without State registration, who nurse such cases. The organization of comprehensive home nursing and home help services under the local health authority, and the establishment of old people's homes under welfare provisions, while in no sense a replacement of the private nursing home, have added to the facilities available and undoubtedly had some effect in reducing the numbers of those who might have gone into a private home. The borderline between what constitutes nursing of the sick and caring for the old and enfeebled is very ill-defined. Establishments which provide care for the aged by ordinary unskilled staff fill a real need, and there are good reasons why some of the smaller nursing homes should turn their attention to this type of elderly person who so often fails to find the accommodation for which he or she is seeking. 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 in work, reception centres for persons without a settled way of life and homes for the blind. Medical officers and inspectors on the central staff visit periodically to supervise the medical arrangements and hygiene. Homeless families units During the year two of the homeless famines units were closed and at the end of the year 158 mothers and 300 children (of whom approximately 66 per cent, were under five years of age and 21 per cent, under one year of age) were accommodated in the remaining three units. Particular attention was given to the control of infection which in 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 encouraged to attend sessions at neighbouring maternity and child welfare centres and a weekly child welfare session was held at one of the units. Nursery classes under the direction of the Education Officer for children aged between three and five years were conducted at two units. Hostels for mothers in work Medical officers on the central staff gave medical supervision to the two hostels for mothers in work. In one of the hostels the children were cared for during the day by the hostel staff and routine visits were made as to a day nursery by a medical officer on the divisional staff. Mothers in the other hostel took their children to day nurseries in the area. 53 Care of the chronic sick Despite the exchange of some chronic sick persons for infirm persons in hospital who could not be discharged to their own homes, the number of chronic sick remaining in the Council's homes at the end of the year was 533 (149 men, 384 women) a decrease of only 26 compared with the previous year. In some homes sick bays were provided for the care of the aged suffering from temporary acute illness for whom hospital beds were not available. Invalid Meals of London Invalid Meals of London provided (year ended 30th September, 1955) 182,399 meals for invalids and sick people compared with 166,165 in the previous year ; 152,884 of the meals were delivered to houses and 29,515 were served in the dining centres belonging to the organisation. The Council made a grant in aid of .£8,000 during the year. 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 eight cases during the year. SCIENTIFIC BRANCH the scientific branch undertakes analytical and consultative work in chemistry and allied sciences, and its services are available to all departments of the Council. 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. 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 domestic 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 30,335, which exceeds by 3,873 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, nor are details of the research projects numbered. 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, 54 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 frequently only by scientific appraisal can thev 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 3 Bacteriological, miscellaneous 75 Building materials 483 Chemicals, drugs and medical supplies 74 Clay, sub-soils and borehole waters 1,763 Detergents and soaps 127 Disinfectants 8 Fertilisers and Feeding Stuffs 99 Fire extinguishers 3 Floor oils 64 Fuel (coal and coke) 41 Foods 466 Gases:— Degreasing and rubber spreading works 8 Flue 48 Sludge digestion plant 416 Grit (from Power Stations) 4 Insecticides 7 Instrument sets (ambulance) for sterilisation 31 Insulating materials for hot water systems 18 Lamps, gas detector 376 Laundry tests 31 Liquor (effluent from Beckton Gas Works) 358 Meals 76 Metals (various) 47 Milk, liquid 53 Milk, condensed and powdered 13 Miscellaneous 100 Oils, lubricating and fuel, etc 75 Paints, varnishes and distempers 1,608 Petroleum and allied samples 69 Plastics 75 Rain-water (atmospheric pollution deposit gauges) 84 Rubber and rubber substitutes 11 Scale from boilers, etc. 1 Scouring powders and lavatory cleaners 13 Sewage and effluent 1,783 Sludge, primary and digested 2,595 Sludge, activated 1,927 Smoke in air, determinations 3,364 Sulphur gases in air, determinations :— Lead peroxide cylinder method 128 Volumetric method 3,378 Water, etc., from steam raising plants 1,320 Water, drinking, chemical 59 Water, drinking, free chlorine tests 516 Water, drinking, bacteriological 571 Water, swimming bath, chemical 324 Water, swimming bath, free chlorine tests 369 Water, swimming bath, bacteriological 473 Water, river, chemical 3,293 Water, river, bacteriological 311 Water, miscellaneous 40 Trade effluents 1,238 Research and investigation samples at Northern and Southern Outfall Works 1,658 30,335 55 E 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. River Thames The condition of the river flowing as it does through the County of London, is a matter of great importance to the Council. In addition to effluents from the Council's own sewage treatment plants, there are sources of pollution from other sewage works, impure tributaries, trade discharges, and contamination from shipping. To assess the condition of the water under varying conditions of fresh water and tidal flow, and to compare the state between seasons of the year and over periods of years, regular weekly examinations are made, involving chemical analysis of water taken from 26 points over a distance of 80 miles. The area examined extends from the upper limit of the tidal reaches of the Thames at Teddington to the outer estuary sludge dumping area at Black Deep. The condition of the river is worst in the summer because of higher air temperature and normally reduced fresh water flow, the most critical period being July to September. In 1955 the average daily fresh water flow over Teddington was only 301 million gallons as compared with 502 million gallons daily in the previous year. The warm weather coupled with the heated discharges from power stations resulted in the highest average water temperatures yet recorded from Kew to Gravesend. Sulphide was present extensively but, although higher concentrations were found than in the previous year, the number of occasions when daily samples contained sulphide was approximately the same. In view of the weather conditions, the low fresh flow and the water temperature, it would have been expected that the condition of the water would have been worse than found. New sedimentation tanks were put into service at the Northern Outfall Works during the year and there is evidence that the consequent reduced loading on the river prevented more serious deterioration. The Scientific Adviser continued to be a member of the Thames Survey Committee of the Department of Scientific and Industrial Research, and also of the Heated and Other Effluents Committee of the Ministry of Housing and Local Government. Both committees deal with aspects of the condition of the water of the river and are to report in due course their recommendations for its improvement. Sewage treatment The treatment of sewage at both Outfall Works is the joint responsibility of the Chief Engineer and the Medical Officer, and as a result of the happy collaboration which exists between their staffs, the Scientific work is carried out in the closest co-operation with the staff of the Chief Engineer. In addition to daily consultations on the works, the analytical results and research progress are discussed at a weekly meeting at the County Hall between the Divisional Engineer (Main Drainage) and the Scientific Adviser to suggest policy of operation, and to discuss methods of improving efficiency or overcoming difficulties. The analytical work includes examination of the following samples:—incoming sewages, effluents from different sections of the plant, sludges sent to sea, sludges entering and leaving digestion tanks, activated sludges, waters from the steam raising plant and effluent liquors from Beckton Gas Works (North Thames Gas Board). Routine observations of atmospheric pollution are also made daily. In July the new sedimentation plant designed by the Chief Engineer was officially opened and this necessitated an increase in the amount of laboratory work. With the advent of the new plant it is anticipated that the automatic sampling apparatus also designed by the Chief Engineer, and which is now in experimental use, will prove a great asset. 56 A considerable amount of research work and several special investigations were undertaken during the year, some items being:— The methane gas production of a temporary converted reservoir used for sludge digestion at the Northern Outfall had fallen below the expected amount and radioactive phosphorus (P.32) in the form of ammonium dihydrogen phosphate was used to trace the flow of sludge through the plant. It was found that the capacity of the plant had been reduced by spent sludge residues remaining on the floor of the tank but no channelling was occurring. The sludge leaving the plant was found to contain more sulphide than that entering the plant and examination of the dense bottom layer showed a concentration of calcium sulphate and sulphides. It was concluded that this sulphide production inhibited the growth of methane producing organisms. The numbers of sulphate reducing organisms in various types of sludge have been determined but the interpretation of the figures obtained has proved to be very complex. The incoming sewage was found to contain 8-10 parts per million of synthetic detergent and the effluent from the activated sludge plant about 7 p.p.m. A few tests made on the use of silicones to reduce foam formation in the effluent channel indicated that their use would be uneconomic on any scale which would give satisfactory results. During the year, assistance has been given on questions relating to the use of the sludge freezing process and to sewage treatment problems at the Atomic Energy Research Establishment at Harwell and officers from Harwell have advised the Scientific Branch on matters connected with tracer techniques. An exhibition was held at County Hall to mark the centenary of London's main drainage system and many aspects of scientific work relating to sewage treatment were on view to the public. A working model of an activated sludge plant capable of purifying 120 gallons of domestic sewage a day was constructed and displayed by officers of the Branch. Not only did this plant demonstrate the principles involved, but it has since proved most valuable in the laboratory as a means of assessing the amount of treatment required by certain gas liquors and trade wastes. Trade waste discharges This report covers the first full year's working under the provisions of the London County Council (General Powers) Act, 1953. 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, and the new Act enables the Council to exercise a close control over the discharge of trade wastes into the London sewerage system. The samples taken during the year, including those submitted for examination by four Borough Councils, numbered 950 ; of these 193 were considered to contravene the Act. Objectionable matter contained in quantity in various wastes included strong acids and caustic alkalis ; petroleum spirit, oils, tar ; tannery wastes containing excessive amounts of sulphide ; and solid matters such as fats, vegetable fibres and stone grindings. In some cases the wastes rendered the atmosphere of the sewer unbreathable. Waste heat contained in process and cooling waters was also a source of nuisance and possible danger ; 40 cases of discharges above the temperature limit of 110°F. laid down in the Act were investigated. It would indeed make for efficiency and economy if manufacturers considered more carefully the means of recovering such waste heat. The usual procedure, following the examination of samples which contravene the Act, is for officers of the Scientific Branch and of the Chief Engineer's Department to visit the premises to discuss with the occupiers the problems involved in treating the discharges. A similar procedure is followed when consideration is given to applications for permission to make new discharges where standards may have to be prescribed. 57 Safety in sewers Regular examination of inflammable gas detector lamps of the expanding metal spiral 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. Housing The work done by the branch for this service covers a wide field and is of considerable economic importance. Thus, in the particular case of paint and surface coatings for houses, flats, schools, bridges, etc., the annual expenditure of the Council on materials and the labour charge for their application amounts to approximately Jj\ million. By ensuring that materials of suitable quality are used, the savings in maintenance must greatly exceed the cost of an advisory service. The work in this section is reviewed regularly by an inter-departmental paint committee, on which all the departments using or concerned with paint are represented. Approved lists of manufacturers brands of paint are maintained, and during the year 88 new brands were approved after test while a further 88 were found not to be of the quality required. Some of the more frequent causes of rejection were :—low opacity, poor surface finish or hardness, and presence in exterior paints of lithopone or excessive amounts of chalk. In addition to the laboratory examination of materials, visits were made to sites to investigate defects arising from such causes as unsatisfactory preparation of surfaces or manner of application of paint. Advice on many aspects of decorating has been made available to all user departments. This has included assistance in questions of colour matching and the establishment of standards, and the recommendations for the painting of a wide variety of materials under various adverse conditions. Increased demands are being made on the facilities provided by the branch for the examination of building materials. The range of materials received for assessment of quality or investigation of possible faults included floorings, floor sealers and polishes, plasters, light alloys and plastic building materials, fire retardents, concrete, slates, asphalte and bitumen felts. In addition to laboratory tests, small scale practical trials under normal conditions of use are frequently made, and sometimes accelerated weathering tests are employed to assess the value of articles intended for external use. Wherever applicable reference is made to British Standard Specifications in assessing the quality of a product. Officers of the branch visited many sites to examine and advise on problems at first hand and have thus maintained close contact with the practical difficulties sometimes involved in the adoption of new methods and materials. Examination was made of clays and ground waters from building sites. The importance of tests on these samples has increased with the frequent use of high blocks of flats in housing schemes. The deep concrete foundations of these flats may be in contact with moist soil or ground water where sulphates normally present in London clay can weaken Portland cement concrete. Estimation of the sulphate content in the soil enables recommendations to be given as to the appropriate cement to use to resist aggressive attack by sulphate in excessive concentrations. Air pollution The Council has for many years co-operated with the Department of Scientific and Industrial Research in investigating the incidence of air pollution. Regular observations are made at 20 sites, which include seven of the parks, five sites near hospitals, both Council sewage outfall works, Kew Observatory, and the grounds of King George V Hospital at Godalming. Standard types of instrument are used and at a few of the sites comparative records are available for a period of 35 years. 58 The instruments in use throughout 1955 were: Seven deposit gauges for collection of matter settling from the atmosphere or washed down by rain ; these deposits are analysed monthly. Ten lead peroxide ' candles ' for the comparative measurement of the amount of sulphur dioxide in the air ; the amount of peroxide converted to sulphate is found by analysis each month. Three sets of volumetric apparatus for the dual measurement of smoke and sulphur dioxide ; this equipment normally requires daily attention. * Seven multiple-circuit sets of volumetric apparatus with which up to six consecutive samples can be taken before the filters and solutions need to be examined and renewed. This automatic sampler, recently devised in the laboratory, facilitates the study of peak concentrations of pollutants, and enables detailed observations to be made without manual attention during night and weekend periods. Air flow through the separate circuits is controlled by magnetic valves activated in sequence by a time switch, the duration of each test being varied according to weather conditions. The observations made during the year again showed a marked difference between rural and urban conditions, as did those in different localities within the County due to the varying amount of pollution from local sources. Seasonal fluctuations were clearly marked at all sites, the generally higher level of pollution in winter being due to the combined effect of increased coal consumption and the occurrence of meteorological conditions unfavourable to the dispersion of chimney gases. When the results are examined over a period of years the main change is a trend towards a slight reduction in the amounts of tarry matter and smoke ; this can be accounted for by the replacement of many domestic fires by the more efficient combustion units of blocks of flats. In the central area of London where the fuel consumption in office blocks and other centrally-heated buildings exceeds that of local fireplaces, the ratio of smoke (black suspended matter) to sulphur dioxide is less than that found in more residential areas. This is attributable to the better combustion conditions obtainable in large furnaces as compared with small grates burning coal. Use of the new time-controlled sampler enabled a more detailed analysis to be made of fluctuations of pollution during the daily cycle. Again a distinction could be drawn between the effects of domestic and industrial combustion. For example, on weekdays the smoke to sulphur ratio is at a minimum during the night, when most domestic fires die down whilst some industry keeps running. At weekends, when a greater proportion of industry is closed down, and domestic fires are burning for longer periods, this ratio is found to be higher than for comparable periods during the week. The long-term investigation of the common major pollutants of the atmosphere was supplemented by a special investigation directed towards the detection of various minor pollutants. In addition dust separated from large volumes of air was examined for radioactive constituents. The atmosphere has a small content of radioactive matter arising from natural causes, and the amount of this varies from day-to-day with changing meteorological conditions. There is also a very small proportion of such matter produced by nuclear explosions. The order of magnitude of both of these sources of radioactivity is being measured to provide a basis for future comparisons. On three occasions during the year apparatus and specimens were provided for public exhibitions. By a standing agreement with the Ministries concerned, the Scientific Adviser or his deputy accompanied the Chief Alkali Inspector of the Ministry of Housing and Local Government on visits of inspection to test the efficiency of the flue gas working plants at Battersea and Bankside Power Stations. Public health During the year, the water supplies to 24 establishments served by wells were regularly examined and visits were made to other premises to check the suitability of water from various sources and to give advice. The 571 bacteriological samples, 59 chemical and 516 free chlorine tests ensured that the water was efficiently chlorinated and at all times in satisfactory condition. 59 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 to remove carbon monoxide and, of 205 samples taken, only seven were above the specified limit of 250 parts per million. The highest individual figure being 460 parts per million. There was, some increase in the amount of black suspended matter, which is considered to be related to the increase in diesel-engined vehicles which produce less carbon monoxide than their petrol counterparts. Other work included the examination of disinfectants, and advice was given on the methods for sterilising such various articles as children's chambers, plastic tableware, soft toys and firemen's breathing apparatus, also on the steps needed to maintain children's sand pits in hygienic condition. Powder colours and modelling clay to be used by children were examined to ensure that toxic pigments were absent. Other matters in which advice was given to avoid possible dangers and safeguard health included the use of maleic hydrazide (known as MH) to stunt the growth of grass, and the use within the Council's educational services of lead glazing for pottery making. 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 99 samples examined, 57 varied, in some way, from the Statutory Statements or Voluntary Warranties given by the vendors, but only in three 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, 43 samples were found to come within the provisions of the Act. Visits of inspection were made to premises using inflammable solvent in licenced processes to ensure that the content of petroleum vapour did not exceed the limit prescribed for safety. 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 London County Council (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 to ensure efficient water treatment and pleasant bathing. A careful check is kept on the condition of the water by means of daily tests performed by bath attendants and periodic visits by officers of the branch. The favourable weather during much of 1955 led to increased attendances at the baths, and generally the new installations and methods adopted proved effective for the loading. School meals, education and children's departments The work done in co-operation with the School Meals and Catering Department was continued and 72 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. 60 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. All 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. 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 as the cause of fire and where particular materials had caused a fire to spread rapidly. In co-operation with Fire Brigade officers, detailed consideration has been given to special measures needed in combating fires involving dangerous chemicals, for example, alloys of sodium and potassium. The fire resistance of samples of fabrics and building materials were tested and also the fireproofing qualities of proprietory solutions applied to such materials. The use of certain phosphonium and also titanium derivatives is being examined with interest since the treated fabrics maintain their texture. A number of materials were tested for suitability in the fire service ; these included chemical extinguishers, foam producing compounds, and hoses made of woven nylon and terylene lined with polyvinyl chloride. 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 are to be included in the list. Six softener plants and 14 hot water systems are tested periodically and 10 others from time to time. One of the particular problems investigated during the year was the growth of sulphate-reducing bacteria in hot water installations. Experiment with bactericides showed that bacteristatic conditions could be achieved by dosing with acriflavine at a concentration of 15 parts per million. Experiments in this field are being continued. 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. 61 Miscellaneous Advice was given on a variety of other matters not falling under the preceding sections of this report, and some examples of these are given below :— (a) With a view to providing guidance on the construction of new athletic grounds, surfacing materials from several running tracks were examined, the grading of the different sized particles being of particular interest. (b) Fly ash, from the combustion of pulverised fuel at power stations, was examined and it was considered that it could be used for filling disused chalk workings without adversely affecting any local water supplies. (c) An investigation was begun on the effects of drying wool, cotton and synthetic fabrics in gas heated and electric drying cabinets. (d) A number of recommendations was made on such varied subjects as the use of insecticides and fungicides, the cleaning of glasshouses, imitation marble and fireman's gloves, the staining of wood for architectural purposes, court marking paint for a drill yard, the deterioration of electric cable, the sterilisation of sand in a play pit for children, thermal insulating material for boiler installations, anti-freeze solution, creosote, tar and glue. Both the Scientific Adviser and his deputy served on a wide variety of committees and welcomed many distinguished visitors to the laboratories. The staff numbered 59 which included 26 science graduates, 28 ancillary staff and five in the clerical section. 62 HEALTH SERVICE PREMISES Building programme Submission of annual building programmes in accordance with the revised procedure introduced in 1954 particulars of schemes costing more than £10,000 included in the capital building programme for the year 1956-57, and of similar schemes proposed for the year 1957-58, were submitted to the Minister of Health. The programme for 1956-57 included three new schemes and three other projects brought forward from earlier programmes. In addition, it was proposed to carry out during 1956-57 three schemes which no longer required individual approval by the Minister. Five schemes requiring his sanction were proposed for the year 1957-58, including one previously included among projects proposed for 1956-57. Particulars of outstanding schemes and of projects in the programmes for the years 1956-57 and 1957-58 are given below :— Grajton Hall, Lamberivell—Adaptations or existing building to provide a new Scheme occupation centre. It was decided not to proceed with this project owing to the high abandoned cost of acquisition and maintenance of the building. Division Premises Service Work involved 1 Walmer Road, Kensington Day nursery New building Schemes deferred until later in five year programme 3 Muriel Street, Islington Day nursery New building 5 Greenwood welfare centre, Peel Grove, Bethnal Green Maternity and child welfare centre New building Works completed 9 193, Mitcham Road, Wandsworth School treatment centre Adaptations - Cromwell Lodge, 55, Cholmeley Park, Hornsey Hostel for tuberculous men Adaptations to premises (Stage II) - ' Dover Lodge', Wood Vale, Camberwell Hostel for mentally defective girls Adaptations on acquisition - London ambulance service Headquarters, Waterloo Road, Lambeth Ambulance service Conversion of former fire station - Pear Place, Lambeth Headquarters ambulance station Additional accommodation - Brook ambulance station, Greenwich General ambulance station Reinstatement of war damage - Mottingham ambulance station, Woolwich Accident ambulance station New building - 52/54 Ashfield Street, Stepney Occupation centre Adaptation as boys' industrial training centre 2 86 Carlton Hill, St. Marylebone Day nursery Repairs on acquisition Works in hand at end of year 5 1a Wellington Way, Stepney Maternity and child welfare centre Reinstatement of war damaged block as offices and residential accommodation for staff - Upper Richmond Road ambulance station, Wandsworth Accident ambulance station New building 8 West Norwood welfare centre, Lambeth Maternity and child welfare and school treatment centre Adaptation to accommodate school treatment centre 5 Rochelle Street school, Bethnal Green Maternity and child welfare centre Adaptation of existing building Schemes approved but not commenced at end of year 7 Queen's Road centre, Camberwell Maternity and child welfare centre, day nursery and Peckham general institute (Education service) Completion of works of adaptation, including provision of hot water and heating systems 9 Stormont Road, Battersea Maternity and child welfare centre New building 9 67 Victoria Drive, Wandsworth Maternity and child welfare and school treatment centre Completion and adaptation of existing building 63 Schemes awaiting approval at end of year Division Premises Service Work involved - Cornwall Avenue, Bethnal Green Occupation centre.. Adaptation of premises - Shoreditch ambulance station Accident ambulance station Improvements - North-Western ambulance station General ambulance station Reinstatement of war damage - Margaret day nursery, St. Pancras District nursing Adaptation of vacant rooms for residential accommodation for nurses 2 Daleham Gardens, Hampstead Maternity and child welfare and school treatment centre New building 2 283a Harrow Road, Paddington Maternity and child welfare centre Extension of premises to provide additional maternity and child welfare facilities, school treatment centre, and office accommodation 5 Galbraith Street, Poplar Maternity and child welfare and school treatment centre Adaptation of existing building 2 Hampstead health institute, Maternity and child Adaptation of existing Dynham Road, Hampstead welfare centre ses Scheme plans in advanced stage at end of year Programme for 1956-57 The programme submitted to the Minister of Health for the year 1956-57 included the following projects: Division Premises Work involved 3 Basire Street (Coleman Fields), Islington Erection of day nursery 9 Roehampton Lane, Wandsworth Erection of maternity and child welfare and school treatment centre to serve new housing estates 9 'Southlands', Shuttleworth Road, Battersea Erection of maternity and child welfare and school treatment centre on site of premises at present accommodating maternity and child welfare centre and offices - 67 Perry Rise, Lewisham Erection of occupation centre to replace unsatisfactory temporary accommodation and provide additional places - South-Eastern ambulance station Extension of existing premises to provide additional accommodation for vehicles and other improvements - Foxley Road, Lambeth Conversion of former fire station to provide new accident ambulance station Arrangements were also made for the undermentioned schemes, which no longer require individual approval by the Minister, to be dealt with in the year 1956-57 : Premises Work involved Former Balham day nursery, Old Devonshire Road, Wandsworth Conversion to form new occupation centre to replace unsatisfactory temporary accommodation and provide additional places Knight's Hill day nursery, Lambeth Conversion after closure to form a hostel for tuberculous men Eastern ambulance station, Hackney Provision of additional covered space for vehicles Projects for I957-J8 The following projects requiring the approval of the Minister were proposed for inclusion in the building programme for the year 1957-58 : Division Premises Work involved 5 Old Church Road, Stepney Erection of day nursery 6 Abbey Wood, Woolwich Erection of maternity and child welfare and school treatment centre to serve new housing estates 6 William Barefoot Drive, Woolwich do. Highlever Road, Kensington Erection of occupation centre to replace unsatisfactory temporary accommodation and provide additional places - Iceni Sports Ground, Ickburgh Road, Hackney do. 64 Day nurseries Progress was made in securing the continued availability of requisitioned nurseries and other premises held on insecure tenure. Long-term leases were obtained in respect of five nurseries and negotiations for the lease or acquisition of eleven other nurseries were proceeding at the end of the year. Five nurseries were closed, two because of diminished demand and the remainder because the sites or the buildings were required for other purposes. Closure of day nurseries Division 1—St. Charles' day nursery, Kensington—This nursery was closed to enable the premises to be demolished to make way for the erection of school premises. No replacement was available but children were accommodated in neighbouring nurseries. Division 3—King Square day nursery, Finsbury—These requisitioned premises were closed without replacement as a first step towards the reorganisation of the day nursery service within the division. Division 4—Kingsmead day nursery, Hackney—This nursery was closed to enable the site to revert to use as open space. The children displaced were transferred to other nurseries in the locality. Division 5—Columbia Market day nursery, Bethnal Green—These premises were relinquished so that they might be brought into use as a nursery school. No replacement was available but accommodation for the children displaced was made available elsewhere in the area. Division 9—Battersea Park day nursery, Battersea—This nursery was closed because of diminished demand in the locality. The premises were subsequently brought into use for maternity and child welfare purposes. Works completed Maternity and child welfare centres Division 5—Greenwood welfare centre, Peel Grove, Bethnal Green—This purpose designed building was completed and the centre opened in April. The Bethnal Green welfare centre, Cornwall Avenue, was closed and the premises released for adaptation as an occupation centre. Division 8—Rose McAndrew welfare centre, Beale House, Lingham Street, Lambeth—New purpose designed accommodation was provided in flats on the Stockwell Gardens housing estate to replace the unsatisfactory centre at 146 Stockwell Road, which was closed. Replacements Division 3—John Street welfare centre, John Street, Holborn—The tenancy of these premises was terminated and the centre transferred on 13th June to new purpose designed accommodation at the Province of Natal centre, Guilford Place. Further reference to this centre is made on page 139. Division 5—Will Crooks welfare centre, Wigram House, Poplar High Street—This centre in flats was opened in May to replace premises at 154 Poplar High Street, the site of which was required for housing development. Division 8—West Norwood sub-centre, Baptist Hall, Gipsy Road, Lambeth—This centre was closed in September because of the inadequacy and poor condition of the premises. Arrangements were made for the clinic session to be transferred to the Gipsy Hill day nursery. Division 9—Ackroydon welfare centre, Tenants' Clubroom, Ackroydon Estate, Wandsworth— This temporary centre was opened in July when accommodation at ' Woodlands ', West Hill, ceased to be available for clinic purposes. The needs of new housing estates will be met from this centre pending the provision of a purpose designed maternity and child welfare and school treatment centre at 67 Victoria Drive. Division 9—Battersea Park welfare centre, Prince of Wales Drive, Battersea—These premises became available on the closure of the former Battersea Park day nursery and the accommodation was brought into use for clinic purposes to replace unsatisfactory premises at All Saints' Parish Hall, Prince of Wales Drive. 65 Provision of additional centre Division 9—Eastwood welfare centre, Eastwood estate, Wandsworth—This temporary centre was opened in April to meet the needs of new housing development pending the erection of a purpose designed maternity and child welfare and school treatment centre at Roehampton Lane. Centre closed Division 2—South Highgate welfare centre, 1 St. Albans Road, St. Pancras—This centre, which was held in unsatisfactory accommodation, was closed on 17th October. The clinic sessions were transferred to the Kentish Town welfare centre, Raglan Street, and to the Highgate New Town clinic, Chester Road. Accommodation for tuberculous men Works completed Cromwell Lodge, Cholmeley Park, Hornsey—Second stage works of adaptation were completed to bring the hostel into full occupation by 31 men. Further reference to this hostel is made on page 32. Occupation centres for the mentally defective Details regarding premises used as occupation centres for the mentally defective will be found on page 100. Additional centre 52-54 Ashfeld Street, Stepney—These premises, formerly used for maternity and child welfare purposes, were adapted and brought into use in September as an industrial training centre for elder boys. Centre enlarged Cecil Rooms, Woolwich Road—Additional accommodation was rented at these premises to provide an additional classroom for elder girls. Replacement centre Clifton Congregational church hall, Studholme Street, Camberwell—These premises were rented in June to replace the centre for elder girls at St. Chrysostom's Hall, Goldsmith Road. Later in the year this elder girl's centre and the junior centre at St. Peter's Hall, Cranfield Road, Brockley, exchanged accommodation to permit a better sub-division of the junior classes. Works completed Hostel for mentally defective girls under guardianship ' Dover Lodge '. Wood Vale, Camberwell—Adaptation of this building for use as hostel for girls placed under guardianship on leaving special schools for the educationally sub-normal was completed and the hostel opened in September. Works completed School health service Division 9—193 Mitcham Road, Wandsworth—Adaptation of these premises for use as a school treatment centre, speech therapy centre and health visitor's office was completed and the centre opened in January. The treatment centre replaced one formerly at 1071 Garratt Lane. Replacement centres Division 2—Soho school treatment centre, 9 Gerrard Street, Westminster—These premises were vacated in July and the centre transferred to purpose designed accommodation at the Province of Natal centre, Guilford Place. Division 3—North Islington school treatment centre, Rupert Road mission hall, Yerbury Road, Islington—As it was not possible to renew the lease of these premises the centre was transferred to rented accommodation at 6-9 Manor Road. Division 8—Norwood school treatment centre, Chestnut Road, Lambeth—These premises were relinquished on the expiry of the lease and the centre transferred to the West Norwood welfare centre, Hannen Road, where vacant accommodation was adapted for this purpose. Centre closed Division 5—Lefevre Road bathing centre, Poplar—Diminished demand permitted the closure of these premises in July, the work of the centre being transferred to other centres in the area. Division 8—Dockhead school treatment centre, St. Joseph's School, George Road, Bermondsey The work of this centre was transferred to the Bermondsey school treatment centre, Farncombe Street, and the accommodation, which was in school premises, was vacated. 66 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 tenancies and acquisition were completed during the year : Division Property Interest obtained Service 1 Latymer day nursery, Blechynden Street, Hammersmith Leasehold Day nursery 2 Regents Park day nursery, 4 Prince Albert Road, St. Pancras Leasehold Day nursery Dibdin House, Maida Vale, Paddington Leasehold Maternity and child welfare centre 3 37 Thornhill Road, Islington Leasehold School treatment centre 4 96 Dalston Lane, Hackney Leasehold Day nursery 29 Cadogan Terrace, Hackney Leasehold Maternity and child welfare and school treatment centre 9 37 Sister's Avenue, Battersea Leasehold Day nursery 67 Victoria Drive, Wandsworth Freehold Maternity and child welfare and school treatment centre 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 65. Expectant and nursing mothers First attendances at ante-natal clinics represented 43 per cent, of all women needing ante-natal care compared with 45 per cent, in 1954. There has been a fall in the number of attendances at post-natal clinics. The duty has now been laid on midwives to initiate post-natal examination of all mothers having a home confinement. Midwives are present at post-natal examinations at the centres and pay follow-up visits to those who do not attend. Educational activities at welfare centres (see page 68) were continued and increased attendances reported in the previous year were maintained. 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 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 1955 115 838 22,231 116,042 43 67 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 1955 3 8 415 3,635 520 4,373 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 1955 24 1,237 354 46,018 Tests All expectant mothers attending the ante-natal centres are given blood tests. Blood specimens are examined for Wasserman and Kalin reactions. Haemoglobin level is estimated at the first visit and follow-up tests are arranged for any mother with a low haemoglobin level. Rhesus factor testing and blood grouping are also done early in pregnancy and every mother is provided with a card showing the results of her blood tests. Tests for antibodies are made about 32nd-34th week for all mothers who are Rh negative. Arrangements are made in several divisions for cord blood tests to be taken by midwives. These tests are done either by the Blood Transfusion Service or by hospital laboratories in the area. Pregnancy diagnosis etc. These blood tests, carried out at Shrodells Hospital, Watford, are also arranged at ante-natal centres at the request of general practitioners for their patients who attend doctors' surgeries for ante-natal care. Chest X-rays X-ray examination of the chest is offered to all expectant mothers attending the ante-natal centres, and there has been a high acceptance rate. Mothercraft training 68 The residential unit at the Violet Melchett infant welfare centre, a voluntary organisation providing services on behalf of the Council under Section 22 of the National Health Service Act, 1946, continued to provide treatment for mothers and babies experiencing breast feeding difficulties and for babies with dietetic upsets. Comparative figures are : Mothers Accompanied infants Unaccompanied infants 1954 62 66 72 1955 56 59 75 Clinics 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 1,019 compared with 837 in 1954. The tables on pages 67 and 68 show attendances at sessions of various types held at maternity and child welfare centres. An average of 341 sessions a week were being conducted at the end of the year by sessional medical officers. Voluntary organisations Maternity and child welfare services were provided by 17 voluntary organisations under agreement 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 Seven family planning sessions were provided by the Council for expectant and nursing mothers for whom further pregnancy would be detrimental to health. In areas where such sessions were not held, mothers were referred to the Family Planning Association, a per capita payment being made by the Council to the association. 797 women were referred to the association during 1955 compared with 877 during 1954. At the end of the year thirty-three weekly sessions were being conducted 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. Attendances in the first year averaged about 14, but thereafter attendances tended to fall off rapidly. Cards were sent to parents on their children's birthday anniversaries to invite them to toddlers' sessions where they might discuss the care of their children and obtain a full medical examination. Year Clinics at end of year (including toddlers') Sessions per month Attendances Percentage of infants attending a centre at least once in the first year of life Under 1 year Over 1 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 1955 176 1,939 43,068 587,143 4,541 193,273 41,268 86 Walworth Road Health Centre, South wark— Solarium Since the solarium at the Walworth Road Health Centre was transferred to the Council in 1948 physiotherapy had been provided, as a continuance of the previous practice of the Southwark Metropolitan Borough Council, not only for children referred by the Council's school health and maternity and child welfare services but also for adult patients referred by local practitioners. The Council had no power itself as a local health authority to provide a physiotherapy service for adults but had done so as the agents of the hospital authorities. 69 In July, 1954, the Ministry of Health notified the Council that, in view of adequate resources of properly prescribed and supervised physiotherapy at local hospitals, there were no longer grounds for continuing the service but an extension was obtained while further negotiations took place. In the outcome, however, the Council had no alternative but to close the premises after 30th June, 1955, to patients over school age referred by general practitioners. Co-operation with hospitals —Discharge reports During the year efforts have been made to ensure that when a patient who was likely to need the Council's health or other services was discharged from hospital, all necessary information was given by the hospital authorities to the divisional medical officer, including a report on the patient's condition on discharge. Mental health education in the maternity and child welfare service During the year progress was made in giving effect to the main recommendations of the study group set up by the Council, whose report appeared in Appendix B of the report for 1954. With the co-operation of hospital authorities intensive training of a number of the Council's medical officers and health visitors was started in six of the nine health divisions through case conferences attended by the psychiatrist and psychiatric social worker from the local child guidance clinic. In addition, group discussions were started, led by the staff of the child guidance clinics, which aimed at the orientation of all available divisional professional staff towards the development of mental health education in the maternity and child welfare service. A departmental committee on mental health education was set up in April to advise on general developments in this field, including divisional training arrangements. Plans for the general scheme of intensive training depend considerably on the progress of the groups so far established and the work of the advisory committee during the year included a meeting with members of one of the divisional training groups, when the group's activities and experiences were discussed. Problem families and children neglected and ill-treated in their own homes Reference is made in the section dealing with the mental health services (page 100) to the provision of special child welfare services for backward children. A comprehensive enquiry was begun to ascertain the numbers of potential and hardcore problem families in London, the factors giving rise to problem families and the methods by which preventive work should be developed and the amount of time at present spent by health visitors on these families and an assessment of the time required to give effective assistance. The results of this enquiry will be available in 1956 and it is anticipated that the survey will point to ways in which additional effort can be concentrated on this difficult problem. Drugs, medicaments, welfare foods, etc. The Council, in company with other local health authorities, took over in the middle of 1954 the local distribution of welfare foods, i.e., national dried milk, orange juice, cod liver oil compound and vitamin A and D tablets, provided by the Ministry of Food. During 1955 the process in London of integrating this task with the maternity and child welfare service as a whole was materially advanced without inconvenience to the public. An average of 929 sessions a week were provided at 196 distributing points. Help continued to be given by the Women's Voluntary Services. At the request of the Ministry of Health, local health authorities conducted a special enquiry into the reasons for the falling off in the consumption, since 1st July, 1954, of all classes of welfare foods. The following table brings out the trend in consumption in London : Welfare food Average weekly consumption— Six months ended Average weekly consumption— Six months ended Percentage increase or decrease in consumption 1.1.55 2.7.55 (+or -) National dried milk (tins) 28,141 26,271 -6.6% Cod liver oil (bottles) 7,156 7,225 +0.96% Vitamin tablets (packets) 2,406 2,859 +18.8% Orange juice (bottles) 40,565 43,408 +7.01% 70 Figures for the health divisions individually showed a marked consistency with the trend for the County as a whole. In addition to the welfare foods 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 additional amenities for mothers and children attending welfare centres and day nurseries. These amenity funds were administered by small voluntary committees. Marriage guidance The report in 1947 of the Committee of Procedure in Matrimonial Causes (the Denning Committee) led to the setting up of the Departmental Committee on Grants for the Development of Marriage Guidance (the Harris Committee) whose recommendations in 1948 gave rise to the existing arrangements for grant aid from public funds to the three marriage guidance organisations. These arrangements provide for contributions by the Home Office towards the training and central administration expenses and by local authorities towards the case-work activities of the local marriage guidance councils. The final year of the present experimental term of financial aid by the Council to each of the three marriage guidance organisations operating in London, began on 1st April, 1955, and the total grants approved for that year to the London Marriage Guidance Council, the London Centre of the Catholic Marriage Advisory Council and the Family Discussion Bureau of the Family Welfare Association amounted to £5,200. The three organisations have developed on independent lines and a brief indication of the extent of their work may be of general interest. (a) London Marriage Guidance Council—Sessions totalling 875 in 1951 rose to nearly 1,500 in 1955. During the same period the number of voluntary counsellors increased from sixteen to twenty-nine and during 1955, 3,222 interviews were conducted. An average of twenty-nine counselling sessions were held each week during the year, fourteen at local centres (including twelve at L.C.C. clinics) and the remainder at the organisation's headquarters in Duke Street, W.l. Since 1951 the organisation have held a monthly series of talks for groups of engaged and newly-married couples on the practical, physical and emotional relationship in marriage and hundreds of couples have attended these talks. (b) Catholic Marriage Advisory Council (London centre)—During 1955, sixteen voluntary counsellors conducted 2,070 interviews. An average of twenty-nine counselling sessions was held each week during the year, the greater part of the work being carried out at the organisation's headquarters in Parliament Street, S.W.I. Three local centres were maintained. Training courses on pre-marriage work were arranged for doctors, social workers, priests etc. (c) Family Discussion Bureau—The number of persons interviewed during 1955 was 386, involving 4,251 appointment hours. References from doctors and hospital almoners, which were negligible in 1949, rose to almost 30 per cent, of all cases in 1954 and increased still further during 1955. Results of the research work into the value of the methods applied by the organisation were published in 1955 and the Bureau hope to investigate further many questions relating to marriage breakdown, family relationships etc. 71 Special investigations 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 was extended during the year to all nine health divisions. Follow-up continued of registered rubella cases for the Ministry of Health enquiry into virus infections during pregnancy. Maternity and child welfare and school health records When the National Health Service Act came into operation in July, 1948, a series of forms was introduced for use by clinic medical officers and health visitors and, subject to small amendments, they have continued in use. The forms were reviewed in the light of experience and certain changes were introduced in 1955. Three major departures were decided upon—firstly, to combine the child welfare and school medical records, so that the essential information of the pre-school period of a child's life may be transferred to the school and assimilated to the school medical record ; secondly, to combine the pre-school prophylaxis records with the child welfare record and to transfer this information to the school medical record ; thirdly, to institute new forms appropriate to the wider responsibilities of the health visitor towards the family as a whole. One of the main objects of the review in planning new forms and revising existing forms was to do away with overlapping between forms, which results in repetition of the same information on two or more forms, with a consequent increase of work for the health visitor. Medical supervision Residential establishments for young children The health of the children in the Council's residential nurseries is supervised by medical officers of the Public Health Department. Children admitted to these homes are medically examined by the visiting medical officer who also does routine medical examinations at intervals according to the age of the child. Where appropriate, children are immunised 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. A psychiatrist makes monthly visits to the larger nurseries and bi-monthly visits to the smaller ones, to advise the child care staff on the management and care of children who are emotionally disturbed. Primarily these visits are made for the education of the staff, and children who are sufficiently disturbed to require psychiatric treatment are referred to the local child guidance clinic. Minor outbreaks of gastro-enteritis and Sonne dysentery occurred, particularly in the two admission nurseries for children under three years of age where the high turnover and size of the nurseries increase the risk. A major epidemic of Sonne dysentery occurred in one of them. All contacts, children and staff, were swabbed and 5 staff and 34 children were found to be carriers and were treated in the nursery. There was an outbreak of ringworm of the scalp in a large nursery, introduced by a missed case among the admissions. Repeated investigations with Wood's Lamp were made, and all cases were transferred to Goldie Leigh Hospital, Abbey Wood, for treatment. Central medical staff visited a number of private residential nurseries offering vacancies to the Children's Committee for residential care of children under five years of age, to advise the Children's Officer on suitability of the nurseries. Plans of property likely to be adapted as residential nurseries were scrutinised and exploratory visits made together with officers of the Children's Department. Adoption and boarding-out The Medical Officer of Health advises the Children s Officer on the suitability on medical grounds of children for adoption and boarding-out in accordance with the duties placed upon the Council by the Children Act, 1948. 72 All children offered for adoption or boarding-out are medically examined either by the visiting medical officer of a residential establishment or by a family doctor, and blood reports are obtained. Their prospective adopters may be interviewed by a medical officer where the family background or the medical history may require special consideration before a child can be placed satisfactorily. Advice is also given, if requested, on the suitability on medical grounds of prospective adopters to adopt a child. 566 (642) children were referred by the Children's Officer for opinion as to their suitability on medical grounds for adoption and boarding-out. 2 (3) children were considered unfit and the remainder were grouped as follows : (1) Referred for adoption : 185 (203) (a) Fit for adoption 158 (178) (b) Fit for adoption subject to certain provisions 7 (7) (c) Unfit for adoption but fit for boarding-out 14 (17) (d) Case still under consideration 4 (1) (e) Withdrawn by Children's Officer 2 (2) Referred for boarding-out : 379 (436) (a) Fit for boarding-out 375 (434) (b) Withdrawn by Children's Officer 4 (2) The figures in brackets are those for 1954. Child life protection By arrangement with the Children's Officer responsibility has been continued tor duties under Part XIII of the Public Health (London) Act, 1936, as amended by Part V of the Children Act, 1948. The visiting of foster children and the inspection of premises in which the children are living is undertaken by health visitors designated as ' child protection visitors As at the end of 1954, 647 children were being supervised under these arrangements at the end of the year, 734 receptions and 734 removals being notified during 1955. Day nurseries and occasional creches Day nurseries Since 1951 it has been the Council's general policy to maintain day nursery provision substantially at the level then obtaining, subject to constant review of the actual need for places for children coming within the limits of the scheme of priorities laid down for admission. Where possible, in the course of this review, any redundancy of accommodation has been met by the amalgamation of nurseries. The number of maintained and grant-aided day nurseries and the total number ot places provided at 31st December, 1955, and a comparison with the previous year are given in the following tables : Number of day nurseries at 31st December. Maintained Grant-aided Total 1954 100 5 105 1955 94 5 99 Number of places provided at 31st December. Age-group Maintained Grant-aided Total 1954 1955 1954 1955 1954 1955 0-2 years 1,956 1,853 50 50 2,006 1,903 2-5 years 3,690 3,523 154 154 3,844 3,677 5,646 5,376 204 204 5,850 5,580 The loss of places due to the closure of six maintained day nurseries during 1955 was partly offset by the accommodation at two others being increased by 51 places. The net loss was 270 places. The number of training day nurseries at the end of the year was 56 (54 maintained and 2 grant-aided). 73 f* Occasional creches During the year it was possible to implement a scheme of restricted expansion of occasional creches. A programme was prepared to establish 27 additional creches providing 53 sessions a week making the total for the County 35 creches providing 77 sessions a week. As yet not all of the additional creches have been opened and at 31st December, 1955, the total number of creches was 18 providing 49 weekly sessions. The creches are held in health service premises and provide for the occasional care for two or three hours during the day of children under five years of age whilst their mothers visit hospitals or clinics, or attend to shopping, laundering and other domestic duties. The majority of the creches accommodate 20 children each and are open for two three-hourly sessions a week. A sessional charge of 1s. 3d. a child is made but this can be waived or reduced in necessitous cases and no charge is made when a child is left in a creche while the mother is attending a class or clinic held by the Council in the same premises. Childminders Nurseries and Child-Minders Regulation Act, 1948 In addition to the statutory registered child-minders, the Council has a scheme of voluntary registration whereby child-minders who are not required to register under the Act, e.g., those who mind only one or two children, receive a small weekly payment, in return for which they accept supervision by the Council and allow their homes to be inspected. The following table shows the numbers of minders and children cared for at 31.12.55 Child-minders statutorily registered 106 Children minded 649 Child-minders voluntarily registered 743 Children minded 851 Private day nurseries The number of private day nurseries registered under the Nurseries and ChildMinders Regulation Act, 1948, and the number of places provided at 31.12.55 were : Private day nurseries statutorily registered 56 Places provided 1,640 Care of the unmarried mother and her child General arrangements The care of unmarried mothers and their babies is discharged mainly through 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. Young unmarried expectant mothers who are unable to pay for their own maintenance are paid for by the Welfare Committee under the National Assistance Act, 1948. Voluntary mother and baby homes 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 1955, 20 homes were supported in this way, the total payments amounting to £11,048. Each of these homes was visited by medical officers of the Council at least twice during the year. The Medical Officer of Health is represented on the committees of these voluntary homes in London by the appropriate divisional medical officer who ensures that local health services are regularly available to the unmarried mother. Health visitors call regularly at mother and baby homes and follow-up the baby on discharge from the home. Mothers are encouraged to attend child welfare centres while they are resident in the homes. During 1955 the expectant or nursing mothers admitted to these 20 homes totalled 1,171, about 85 per cent, of whom were referred by moral welfare workers. Confinements take place in local hospitals except in two of the out-county homes grant aided by the Council. Management of the mother and baby homes is left to the voluntary committees who are, however, encouraged to provide educational facilities for young mothers resident there. Teachers are sent in by the Education Department on the request of the local committee if there are more than 10 mothers who require them. 74 Moral welfare associations In 1955 the Council, also under Section 22 of the National Health Service Act, 1946, paid grants totalling .£9,525 to the five large moral welfare associations working in London, that is, two Church of England, two Roman Catholic and one Jewish body. These five associations employ between them a total of approximately 35 paid full-time moral welfare workers, most of whom are engaged solely on outdoor visiting, and they also receive considerable assistance from voluntary workers. The headquarters of these associations are visited periodically by the Council's officers to review the service provided and to discuss matters of mutual interest. The Council's punched card system provides statistics of the work done by each association and during 1955 a total of 2,429 expectant or nursing mothers applied for assistance to the welfare workers of these associations. At the age of three months, 55 per cent, of the illegitimate babies were still with their mothers and only 18 per cent, had been placed for adoption. Annual moral welfare conference A conference is held at the County Hall annually or representatives or tne grantaided moral welfare associations and other voluntary bodies controlling mother and baby homes in London when the work of the previous year is reviewed. Problems discussed at the 1955 conference included : (a) The lack of accommodation for 'difficult' cases—associations controlling voluntary homes were urged to be less selective in the types they admitted. (b) The many unmarried immigrants arriving pregnant in London—the number of those coming from Jamaica and Eire had nearly doubled during 1955. (c) The need for hostel accommodation for unmarried working mothers—the accommodation at Welfare Department hostels was increased by about 85 per cent, during 1955. (d) The need for co-operation between the matron of the mother and baby home, the moral welfare worker and the health visitor to ensure that the unmarried mother knew of and benefited from the maternity and child welfare services available locally and that she had regular ante-natal care as early as possible in pregnancy. DOMICILIARY MIDWIFERY SERVICE General and staffing 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 (96), midwives employed by district nursing associations (34, including supervisory staff) and district midwives employed by hospitals. Thirteen hospitals, employing 44 midwives (including supervisory and parttime staff), have areas of practice. These areas are not in all cases adjacent to the hospital and hospitals carry out the work from their own district homes. North Woolwich Before 1st November, 1955, district midwifery and home nursing services in North Woolwich were provided on behalf of the Council by the Silvertown and North Woolwich District Nursing Association. The work of the Association was done mainly for the West Ham Corporation who decided during the year to provide its own direct service in Silvertown. The work in the remaining area was insufficient to justify continuation of the Association, which ceased to work on 1st November, 1955. The West Ham Corporation now provide midwifery staff to carry out domiciliary confinements (about 10 a year) in North Woolwich and payment is made to them for each case. Service organisation The service is centrally administered and supervised by four non-medical supervisors All the Council's midwives and the midwives of most of the district nursing association: give the ante-natal care of mothers at the local health authority centres, and work ir close association with health visitors who are responsible for mothercraft and health 75 education. Some of the midwives also share in this work and apparatus for inhalational analgesia is supplied to centres on request for demonstration to mothers. Classes for relaxation exercises are held by health visitors or midwives and in some centres by a physiotherapist. An increasing number of midwives now attend the surgeries of general practitioners and, through the interchange of records and by personal contact, the fullest co-operation is maintained with general practitioners giving maternity medical services. Midwives attend mothers for 14 days after confinement or longer when there are special reasons for doing so. In these instances the health visitor is notified to prevent duplication of visiting. Midwives' duties have been extended in the last year to include responsibility to see that mothers accept post-natal examinations either at the centres or at the general practitioner obstetricians' surgeries. Follow-up visits are paid when mothers fail to attend. In some parts of the county midwives undertake home visits to determine whether a hospital bed is necessary on social grounds. Accommodation for midwives During the year, the Nurses and Midwives Whitley Council reached an agreement (published in N.M.C. Circular No. 50), introducing, with effect from 1st April, 1955, revised charges for accommodation provided by the employing authorities for domiciliary midwives. The charge for unfurnished accommodation, inclusive of rates, was to be an amount not exceeding £52 a year provided that, in any case where the full economic rent, including rates, was less than £52, the charge should not exceed that rent. Subject to that proviso, the charge to be made up to the maximum should be at the discretion of the employing authority. London weighting (maximum £30 a year) should continue to be withheld from persons paying such a charge. It was further provided that a midwife occupying service accommodation who had dependent relatives or a housekeeper living with her should be treated as if she were living alone. Where the relatives living with the midwife were not dependent, a higher charge could be made up to the maximum of the full economic rent, including rates. Employing authorities could, at their discretion, treat as dependent relatives persons of other degrees of relationship. The Council accepted generally the recommendations of the Whitley Council but decided that the charge for unfurnished accommodation should not exceed £48 a year. A maximum charge of £25 a year was fixed for each person other than dependent relatives or persons treated as dependent relatives living with the midwife. Analgesia Apparatus tor the administration of 'Trilene' was supplied to 10 midwives who had cars. 'Minnitt' apparatus for the administration of gas and air was also available to all midwives and was delivered to patients' homes by the ambulance service. The use of 'Trilene' in 3 per cent, of cases during six months has proved satisfactory and apparatus will be issued to all midwives in the near future so that the selection of inhalational analgesia will be based on the suitability of the case rather than on availability of apparatus. Total number of domiciliary confinements attended by London County Council, Hospital and Nursing Association midwives—1953-1955 Number of confinements Number of confinements Doctor not booked Doctor booked Tear L.C.C. District Nursing Association Hospital L.C.C. District Nursing Association Hospital Grand Total 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 1955 245 3,729 54 1,745 22 1,776 759 1,042 138 157 98 133 9,898 76 Peri-natal deaths 9,898 mothers were confined at home ; of these 801 were primiparae and 9,097 multiparae. Of 10,057 babies born, there were 88 still-births and 52 neo-natal deaths in the first week of life, i.e., a still-birth rate of 8.8 and a peri-natal death rate of 13.9 per 1,000 live and still births. The figure for neo-natal deaths is not necessarily complete as the deaths of all babies transferred to hospital are not included. The still-birth and peri-natal rates for all London births are 20.3 and 34.8 respectively (see pages 12 and 18). In this respect the domiciliary service compares very favourably but it must be borne in mind that cases with forseeable complications and those developing complications during pregnancy or labour are more likely to be found in hospital confinements. Still-births Macerated 35 Fresh 53 88 Prematurity was a cause in 33 cases ; congenital defects were recorded in 17 cases ; intrapartum causes were present in 24 cases. Of the neo-natal deaths in the first week, 26 were of premature babies. It will be seen that prematurity was a cause in about one-third of the peri-natal deaths, which is the same as the national experience (see Page 12). Emergency obstetric unit The emergency obstetric unit was called out 141 times. Most or the calls were for maternal causes, mainly post-partum haemorrhage, but 14 calls were made on behalf of the baby. In 61 per cent, of cases the unit reached the home in under 30 minutes. 77 Premature babies During 1955, 479 babies weighing 5½ lb. or less were born to 447 mothers (46 sets of twins). 33 of these were still-born, 116 babies were transferred to hospital and the remaining 330 babies were nursed at home, making satisfactory progress when discharged by the midwife. Midwives Act, 1951 Inspections of midwives and maternity nurses are carried out by four non-medical 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 by district nursing associations. They carry out the routine inspections of all independent midwives and maternity nurses required by the rules of the Central Midwives Board ; investigate all cases of puerperal pyrexia, skin and eye infection, neo-natal death and still-birth occurring on the district; arrange, if necessary, for the suspension of midwives coming into contact with infection and scrutinise all medical aid notices issued bv midwives. Notification of intention to practise Notifications of intention to practise were received as follows : 1951 1952 1953 1954 1955 As midwives 1,337 1,331 1,171 1,142 1,193 As maternity nurses 205 232 175 168 150 Refresher courses Revised Rules of the Central Midwives Board, operative from 1st February, 1955, require that by the end of 1958 every practising midwife must have attended a course of instruction approved by the Board and, further, must attend similar courses thereafter at five-yearly intervals. By Section 17 (1) (g) of the Midwives Act, 1951, the duty is placed upon the Council as local supervising authority to provide or arrange for the provision of such courses, to enable midwives practising within its area to comply with the Rules of the Board. Lectures to midwives So tar as the Council's own domiciliary midwives are concerned, it has been the practice for the past ten years to send them every five years to the one-week residential summer schools organised by the Royal College of Midwives which are approved by the Board. The Council has, however, drawn the attention of all other midwives practising in London to their new liability to undergo refresher courses at least once every five years if they wish to be allowed to continue to practise in London after 1958. Two courses of six lectures each were given at the County Hall in January and February, 1955, to midwives working in London, Middlesex and Surrey. These courses were open to all who had notified their intention to practise in those areas and were attended bv 395 midwives. The lecture programme was : Lecturer Subject 1. Bernard E. Schlesinger, Esq., O.B.E., M.A., M.D., F.R.C.P. ' Care and Management of the Premature Baby ' 2. Dr. Hilda Roberts, M.R.C.S., L.R.C.P., D.C.H. ' Administration of Trilene during Labour ' 3. E. Robert Rees, Esq., M.D., M.R.C.S., M.R.C.O.G. ' Uterine Inertia, Causes and Management' 4. C. W. F. Burnett, Esq., M.D., F.R.C.S., F.R.C.O.G. ' Obstetric Emergencies in Post-Partum Period ' 5. Dr. Mary D. Sheridan, M.A., M.D., D.C.H. ' The Neglectful Mother and Problem Families' 6. Ian Taylor, Esq., M.D., M.R.C.P., D.P.H. ' Poliomyelitis ' FILM—following lecture ' The British Midwife ' 78 The annual lecture-demonstration course was attended by 45 midwives from London, Middlesex and Surrey who visited three maternity hospitals in London. The programme in October, 1955, was : Hospital Subject and lecturer British Hospital for Mothers and Babies, Samuel Street, Woolwich, S.E.18 ' Preparation for Breast Feeding ' Miss Cynthia Grose, S.R.N., S.C.M., H.V. Cert. ' Toxaemia of Pregnancy ' C. Keith Vartan, Esq., F.R.C.S., F.R.C.O.G. St. Thomas' Hospital, S.E.I ' Neo-natal Emergencies ' B. D. R. Wilson, Esq., M.B., B.S. General Lying-in Hospital, York Road, S.E.I ' Ante-natal and Post-natal Exercises ' Miss S. J. Thorlby, M.C.S.P. Fees to medical practitioners Fees paid under the Midwives Act to medical practitioners called in by midwives in emergency were as follows : 1951 1952 1953 1954 1955 Number of Claims 3,932 3,135 3,044 3,003 2,682 Amount £12,042 £9,491 £8,662 £8,935 £7,948 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 375 full-time units. In addition to their clinic and other duties these health visitors made 816,483 home visits. Home visits 1952 1953 1954 1955 Expectant mothers— First 25,226 24,608 24,739 22,999 Revisit 18,708 19,223 19,428 19,436 Per cent, of notified live-and still-births 47 47 47 45 Premature babies— First 1,834 1,894 1,624 1,315 Revisit 5,509 4,476 4,033 3,647 Still-births— First 930 921 887 744 Revisit 349 335 366 288 Per cent, of still-births 90 87 89 72 Children under 1— First 48,755 46,487 47,337 48,066 Revisit 183,816 168,833 178,262 173,413 Per cent, of live-births 91 90 94 96 Children 1 to 5— First 4,572 7,485 7,182 8,946 Revisit 377,986 368,668 369,948 353,818 Infectious diseases 13,396 13,774 5,320 14,841 Miscellaneous 51,278 51,676 58,864 58,821 Unsuccessful 131,748 124,124 118,155 110,149 TOTAL 864,107 832,504 836,045 816,483 79 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. Progress continued to be made towards integrating the health visiting service with the school nursing service and towards a closer association of health visitors with voluntary workers in the medical care of school children. Tuberculosis visitors Details of the duties and work of the Council's tuberculosis health visitors are described in the report on Tuberculosis on page 30. Training of student health visitors Details of the Council s scheme for the training of student health visitors are given on page 129. HOME NURSING the home nursing service was provided, as hitherto, by 27 voluntary district nursing associations (26 from 1.11.55) 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, 92 per cent, in 1953-54 and 93 per cent, in 1954-55 and 1955-56. The number of whole-time and part-time nurses employed at the end of 1955 was 572 (whole-time equivalent 512). This compares with 558 (508 whole-time equivalent) at the end of 1954. Of the staff other than superintendents, assistant superintendents and senior nurses, 321 were trained district nurses and 36 were State enrolled assistant nurses. Male nurses employed at the end of the year numbered 49. Twelve of the district nursing associations undertake district nurse training. The total number or visits paid was 1,953,182 compared with l,873,88l in 1954, giving an average of 13 visits daily for each nurse (13 in 1954). The average case load of a nurse at any one time was 24 (23 in 1954). Treatments completed totalled 64,256 (61,352 in 1954), and there were 12,535 patients being nursed at the end of the year (11,792 in 1954). The completed treatments related to the following conditions : Number Percentage of total Respiratory disease 17,086 26.59 Heart and arteries 7,941 12.36 Skin 6,226 9.69 Digestive diseases 4,975 7.74 Genito-urinary 3,703 5,76 Ear, eye and other sense organs 3,340 5.20 Cancer 2,417 3.76 Tuberculosis 2,040 3.17 Cerebral lesions of vascular origin 1,690 2.63 Diabetes 1,580 2.46 Injuries 1,503 2.34 Bones and joints 1,377 2.14 Veins and other circulatory diseases 1,252 1.95 Infections and parasitic diseases 993 1.55 Mental and other nervous diseases 804 1.25 Pregnancy 750 1.17 Other diseases or ill-defined 6,579 10.24 These patients were referred to the nursing associations by : Number Percentage of total General practitioners 51,269 79.8 Hospitals 10,588 16.5 Direct application 1,041 1.6 Chest clinics 964 1.5 Public health authorities 394 0.6 80 Taking both sexes together, 41 per cent, of all patients whose treatment was completed were 65 years of age and over. Children under the age of 5 years accounted for 6 per cent, of the total. The increased use of the service is shown in the graph on page 82. The number of visits paid and of treatments commenced rose to the customary peak in the March quarter. Although there was again no serious epidemic during that quarter, the number of completed treatments reached 20,042. This compares with 18,102 in the corresponding quarter of 1954, and 21,570 in 1953 when there was an influenza epidemic. The Council provided cars on loan to those district nursing associations who needed 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 associations and ranked for grant. At the end of the year 21 cars were in use by district nursing associations under this arrangement. The Council's direct concern in running a home nursing service in the county made it appropriate to appoint a supervisor with special duties in connection with the home nursing service, who took up her duties on 1st January, 1955, for an experimental period of one year. This experiment proved of mutual benefit to the Council, the Central Council for District Nursing in London, and the voluntary nursing associations. The appointment is being continued on a permanent basis. During the year the supervisor visited all the associations' homes at least once, and where necessary advised on day to day problems. Reports on the visits provided fruitful topics for discussion at the periodic meetings with the Central Council for District Nursing. Refresher courses Another experiment during the year was the holding by the Council of two nonresident refresher courses for district nurses, each of two days' duration. Hitherto such courses had been provided only by the Queen's Institute, the Royal College of Nursing and the Ranyard Nurses. This experiment also was successful, and similar courses, but of five days' duration, are being planned for the future. The longer period will allow for a wider range of subjects to be covered, and for more visits of observation to be made. Special efforts were made during the year, with noticeable success, to effect closer liaison between home nurses and their field colleagues in other parts of the personal health services. Informal meetings, discussions, talks and demonstrations were held in the divisions and have been welcomed by all who participated in them. The district nursing associations played their part in giving student nurses from hospitals an insight into the home nursing aspect of public health nursing. One voluntary association (Silvertown & North Woolwich District Nursing Association) ceased its activities on 1st November, 1955, home nursing for the Council's area concerned being carried out from that date by Woolwich and Plumstead District Nursing Association. Loan of home nursing equipment The supply of small articles of equipment on loan to patients being nursed at home was undertaken on the Council's behalf by the medical loan depots maintained by the British Red Cross Society who receive a block grant from the Council, and by the district nursing associations (for their own patients) whose expenditure on this account ranks for grant in the normal way. From January, 1953, the Council has undertaken responsibility for the supply of large and expensive items of equipment and all loan equipment needed for tuberculous patients, as the voluntary organisations experienced difficulty in purchasing and storing such items, and maintaining the extensive stocks required for long-term loans. The demand for expensive and unusual equipment has continued to increase, possibly due to the fact that many chronic sick and disabled persons formerly considered to be ' hospital' cases are now able to be nursed at home. For example, as a result of the work of the National Spinal Injuries Unit at Stoke Mandeville, many paraplegics are now able to care for themselves. 81 A deposit and a small charge, varying from 3d. to 1s. a week, is required from those who can afford to pay, except that a deposit only is required from tuberculous patients. 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 the Ministry of Health is maintained to ensure that the patient obtains the necessary equipment from the correct source with the least possible delay. 82 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 under school age) has continued to grow. The following figures illustrate the extent or the increase over the last three years : 1953 1954 1955 Cases assisted 30,335 32,503 34,785 Hours worked 4,269,408 4,601,168 4,660,600 Home helps employed at end of year 2,996 3,124 3,148 Equivalent of whole-time staff 1,866 1,992 2,029 The consistent pattern of cases assisted is shown by the percentage figures for the last three years : 1953 Per cent. 1954 Per cent. 1955 Per cent. Aged and chronic sick 75 77 80 Maternity 6 5 4 Tuberculous 4 4 3 Other reasons 15 14 13 The continuing high proportion of aged and chronic sick requiring service is in itself an outstanding commentary on the need for such a service for those old and sick persons and, with a growing proportion of aged people in the community, it seems inevitable that the demand will increase. The policy has continued that some service should be supplied to all in need and this year only 61 applications had to be deferred or refused owing to inability to supply, as compared with 161 in 1954. Night helps Night helps are provided to sit with chronic sick patients in their own homes to enable the relatives to get one or two nights' sleep a week. Night helps attend from 11 p.m. to 7 a.m. and carry out duties, other than nursing, which would normally be undertaken by the patient's family. The demand for this service was not heavy during the year, 48 new applications having been met. Child helps The health services continued to be used wherever possible during the year to prevent children from being received into care. The child help scheme, originally experimental, is now an integral part of the domestic help service, and has been extended so that help can be given where only one child is concerned (formerly there had to be at least two children needing care). Under the scheme resident help can be provided in the children's own homes to look after children temporarily deprived of the care of both parents (e.g. where the mother is in hospital and the father does night-work) and having no other adult staying in the home at night. In exceptional circumstances, and where paid employment has been given up for the purpose of undertaking the work, relatives of children to be cared for may be employed as child helps for those children. In other appropriate cases, neighbours or friends nominated by the parents may be employed for specific assignments. The employment of relatives and friends or neighbours is subject to the Council's normal conditions of service for child helps. During the first experimental year of the service ending November, 1954, 12 families (34 children) were helped. Contrary to expectations the demand in 1955 fell, and child helps were provided for only 5 families (16 children). Early morning and evening help Where children had to be cared for during the day-time only, specially suitable home helps were supplied and the hours of duty were arranged 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 205 new families in 1955, as compared with 85 families in 1954. 83 Prevention of break-up of families Arising from a suggestion in Ministry of Health Circular 27/54, a scheme was in preparation at the end of the year for the training and employment of selected home helps to work with health visitors in the homes of families in danger of break-up. The aim is that trained home helps should teach the rudiments of housecraft to mothers of such families in an endeavour to keep the home together and so prevent the children from having to be received into care. 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 1955 was 34,529. The figures for the last seven years are shown below : (All ages) 1949 1950 1951 1952 1953 1954 1955 Primary immunisations 57,929 47,605 40,339 42,958 36,004 47,621 34,529 Reinforcing doses 38,312 27,579 22,908 27,820 33,172 45,802 30,850 Estimated per cent, 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 54.1 The main reason for the reduced figures in 1955 was the poliomyelitis epidemic, which was unusually widespread and which continued for a considerable time. Immunisation was discontinued where and when the local incidence of poliomyelitis appeared to warrant it. This aspect of diphtheria immunisation is deserving of further study. Whilst the wisdom of postponing immunisation locally in the presence of a poliomyelitis epidemic cannot be questioned, it is not a simple matter to pick up at a later stage all those children who would have been immunised if the poliomyelitis epidemic had not occurred, but some effective method of doing this must be devised if a continued drop in immunisation is to be avoided. The warning given in my report for 1954 that the modern generation of mothers has not seen diphtheria and therefore has not learned to fear it was reinforced in that in 1955 there were two deaths from this disease, the first since 1952, when there were two. In neither instance had the children, one aged 4, and the other 8 years, been immunised against diphtheria. It cannot be repeated too often that the only effective method of preventing diphtheria, either in the individual or the community, is immunisation. 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. Although no publicity is given to whooping cough immunisation there is an established demand for it from 84 parents, undoubtedly due to their familiarity with whooping cough and to their appreciation of its potential danger. The number of children immunised against whooping cough fell as compared with 1954 but here, as with diphtheria immunisation, the effect of the withdrawal of facilities in the Council's immunisation clinics during the poliomyelitis epidemic is shown significantly in the table below as contrasted with the number of children immunised in both years by general practitioners where a slight increase is shown for 1955. The following figures show 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. 1952 1953 1954 1955 No. of children immunised against whooping cough : (a) under Council arrangements 19,447 19,292 31,985 22,367 (b) by general practitioners 2,786 3,427 5,449 5,574 Total 22,233 22,719 37,434 27,941 Vaccination Facilities provided for the vaccination of infants against smallpox are similar to those for diphtheria immunisation. The percentage of vaccinations of children under one year of age compared with the annual number of live births has increased steadily over the past seven 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 1955 24,649 50 (based on provisional birth figure) There were no cases 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 1953 1,501 1954 2,944 1955 2,923 7,346 vaccinations and 5,799 re-vaccinations were carried out by general practitioners during the year as compared with figures of 7,914 and 5,707 in the previous year. As a consequence of the Ministry of Health circular 6/55 on measures advocated to stimulate routine infant vaccination and the re-vaccination of school children and certain adults, the co-operation of general practitioners is being sought, through the London Executive Council, in displaying in their surgeries posters advising mothers to have their children vaccinated against smallpox. 85 LONDON AMBULANCE SERVICE since the inception of the National Health Service, the pressure of work has increased annually and resources are being taxed to the fullest extent to cope with the heavy demands. A full statistical analysisis shown on page 91 but the following comments underline the main trends. In 1955, the percentage increases in the number of patients carried and mileage covered by the general section of the Service, as compared with the previous year, were 6.5 per cent, and 1.4 per cent, respectively. Whilst efforts are continually being made to achieve the most efficient use of the Service, by the combination of orders and reduction of mileage per patient, there are limits to such possibilities. It was not found economical to extend much further the decentralization arrangements mentioned in the 1954 Report, although those in operation continued to relieve the strain on the control room at Headquarters and fostered close contact between certain hospitals and their appropriate ambulance stations. In some cases the periods during which vehicles were stationed at various hospitals were extended by agreement with the hospital transport officers. From 12th August, responsibility was undertaken for providing transport, outside normal office hours and on Saturdays and Sundays, for mentally deficient adults and children to be taken to various hospitals and homes. Rail rtansport The responsibility for the payment of rail fares formed the subject of correspondence and discussion at the beginning of the year between the Council, the County Councils' Association, and the Ministry of Health, as a result of which the number of patients for whom the Council now pays rail fares has decreased. Thus, whilst the number of patients eligible for free rail transport was 5,867 during 1954, it fell to 3,466 in 1955. The total number of persons for whom ambulance-train-ambulance arrangements were made (including those persons who were not eligible for free rail transport) was of course considerably higher and there is no doubt that hospital authorities are now more appreciative of the advantages of rail transport over long distances. Since London has many specialist hospitals a considerable number of orders are received from other local health authorities for patients to be met at railway termini, conveyed to hospital, and returned to the station later the same day. In view of the limitation of resources of men and vehicles, particularly at peak periods, these journeys, which involve precise timing, have to be given a disproportionate degree of preference as compared with others which would, otherwise, be considered to have a higher priority. During the year the continual efforts made to limit the number of 'lost' journeys resulted in a reduction in 'wasted' mileage from 1.56 per cent, of total mileage covered by the general section in 1954 to 1.33 per cent, in 1955. Emergency calls Pressure on the accident section has been slightly relieved by the addition of the second new ambulance station to be established since the war, but the total number of calls showed another increase over the previous year. On December 23rd a record number of 481 calls was received during the 24 hours. On that day the peak period occurred between 3 p.m. and 8 p.m. during which time 191 calls were received, and another 'peak' was experienced during the first hour of Christmas Day when 55 calls were recorded. During the year, 2,369 calls were received at the Headquarters control room describing emergencies in which it was clear that medical assistance rather than ambulance transport was required. In these cases, the caller was advised to summon the patient's general practitioner or was given particulars of other local medical practitioners who might be called upon. Ancillary services The ever-mcreasing demand tor ambulance transport was reflected not only m the statistics showing the work undertaken by the directly-provided Service but also in those relating to the ancillary services. During 1955, the measure of relief afforded by these latter services was particularly significant at a time when the London Ambulance Service was experiencing recruiting difficulties and was particularly hard pressed in 86 carrying out its obligations. Grateful thanks are, therefore, extended to the Director of the Ambulance Department of the Joint Committee of the Order of St. John of Jerusalem and British Red Cross Society and his staff, and to the County Organizer of the Hospital Car Service and her staff for their great assistance and willing co-operation throughout the year. Both services showed increases in the number of patients carried and miles covered as indicated in the table on page 91. There is a considerable difference in the mileage run per patient by the two services because the Ambulance Department of the Joint Committee undertakes the majority of the long-distance removals necessitated by the patient's medical or psychological condition, instead of ambulance-train-ambulance journeys, whilst the Hospital Car Service rarely undertakes a journey exceeding 40 miles. The arrangements whereby the West Ham County Borough Council undertakes, on behalf of the Council, the provision of ambulance services in the two parts of Woolwich lying north of the River Thames, continued throughout 1955. Visits of inspection by the Chairman of the Health Committee During the summer recess the Chairman of the Health Committee, inspected each of the general section ambulance stations, twelve of the accident section ambulance stations and the new ambulance Headquarters. She presented Safe Driving awards to many of the drivers and showed a very keen interest in the welfare of the staff upon whose smart bearing and alertness she expressed her satisfaction. She also commented upon the good care taken of the vehicles and equipment and the clean and tidy appearance of the premises. Railway Strike— 29th May/ 14th June The main problems with which the Service was faced during the railway strike were road traffic congestion and the conveyance over long distances of patients who normally would have travelled by train. On 31st May, the day after Whit Monday, when the excellent measures taken by the police for the control of road traffic were still in an experimental state, the number of calls on the accident section was 332, the highest for any day during the strike, yet the average time taken to reach the scene of an emergency was only eight minutes. Up to 3,000 patients a day were dealt with by the general section and the number of abnormal delays was very few ; no undue delay occurred in the removal of any urgent case. A very commendable spirit was shown by the operative staff in overcoming the difficulties of getting to and from their stations and very little special transport had to be provided for them. The conveyance of patients to distant destinations imposed a considerable strain on the resources of the Service, though this was partially offset by the cessation of requests from other authorities to meet patients at London railway termini. Many hospital authorities appreciated the difficulties and showed much consideration by exercising restraint in their demands. They were also very co-operative in deferring or varying the dates of patients' journeys to enable long-distance runs to be avoided or combined with those of other patients. Long distance removals entailed a great deal of additional work for the control room staff at Headquarters and several members of the staff voluntarily worked additional shifts. Much additional help in carrying out long-distance removals was given by the Ambulance Department of the Joint Committee of St. John of Jerusalem and British Red Cross Society and by the Hospital Car Service. An emergency system was established under which the control room maintained close liaison with ambulance services in the Home Counties so that any authority might use spare seats or stretchers in a vehicle of another, including vehicles of more distant authorities which had occasion to come into the London area. Under these arrangements, about 11,870 miles were run by vehicles of the London Ambulance Service and its auxiliary services and about 4,620 miles by those of other authorities. Major accidents The receipt of Ministry of Health Circulars 13/54 and HM(54)51 on the subject of major accidents led, during the year, to consultations with the Metropolitan Regional Hospital Boards and Hospital Management Committees as well as with the Police 87 o and Fire Services, to assist in formulating schemes for dealing with disasters. It was decided that in London it would be appropriate for the London Ambulance Service to initiate the calling out of the nearest available mobile medical team from designated hospitals in cases where large numbers of trapped or seriously injured casualties were involved. When necessary, it was also agreed that the Ambulance Service would provide transport for medical teams. On no occasion during 1955 were the special arrangements described above put into operation. There were, nevertheless, a number of accidents involving injury to several persons as the following list, which is not comprehensive, shows :— 2nd January Outbreak of fire in Wilkes Street, Stepney ; nine casualties removed, three of whom had been fatally injured. At this incident, use was made of an ambulance bus as a temporary rest centre for persons rendered homeless by the fire. 26th January A coach crashed into a shop at the junction of Old Kent Road and Trafalgar Avenue ; 11 casualties removed to hospital. 18th February Railway accident at Stepney East Station ; seven casualties removed to hospital. 14th April A train hit the buffers at Euston Station ; six casualties taken to hospital. 12th June Outbreak of fire at Shepherd's Bush Green ; seven casualties taken to hospital. 3rd August Railway collision at Aldwych Station ; five casualties taken to hospital. 20th August Collision of trolley buses at the junction of Parkhurst Road and Chambers Road, Holloway ; five casualties removed to hospital. 8th October Outbreak of fire at Dufferin Street, Finsbury ; five casualties, three of whom were found to be dead, taken to hospital. 2nd November Outbreak of fire in Brighton Terrace, Brixton ; seven casualties taken to hospital. 1st December Railway accident at Bromley-by-Bow Station ; 17 casualties taken to hospital and five casualties treated for minor injuries. In addition to attending the more serious accidents detailed above, assistance was rendered at the rail collision which occurred near Barnes Railway Station on 2nd December. At the request of Surrey Ambulance Service, two accident ambulances and an emergency vehicle were despatched to the scene and five patients were removed. In the meantime, ambulances from the general section conveyed seven casualties home from hospital, transferred casualties between hospitals, and carried out one ordinary urgent general removal on behalf of Surrey Ambulance Service. Visitors During 1955 more than 150 visitors, several of whom came from abroad, were shown over the Headquarters control room, and many took the opportunity of looking at a fully-equipped accident ambulance and of inspecting an ambulance station. Among the parties for whom special arrangements were made, including a short lecture on the organization and operation of the Service, were students from the Royal College of Nursing, St. John Ambulance Brigade cadets, and first-aiders attached to the London Electricity Board. Premises Mottingham Accident Ambulance Station—This was the second ambulance station to be opened since the war and came into operation on 10th October. It accommodates three ambulances, one of which is engaged continuously on emergency work, and covers the extreme south east of London leaving the ambulances stationed at Lee 88 more readily available to deal with emergencies occurring in the area to the west of this station. Upper Richmond Road Accident Ambulance Station—Work upon the new accident ambulance station in Wandsworth was proceeding at the end of the year and was expected to be completed by April, 1956. Administrative and Operational Headquarters—The outstanding event of the year under review was, undoubtedly, the merging of the administrative and operational headquarters under one roof at 150, Waterloo Road, London, S.E.I. The transfer of those hitherto separate branches from County Hall and from premises in Southwark, respectively, to premises adapted for the purpose was carried out on 10th October, without a break in the continuity of the service, an achievement for which a special tribute is due to the G.P.O. whose problem it was to maintain telephonic communication between the headquarters control room and the 25 outlying ambulance stations during the change-over. The new headquarters is equipped with up-to-date garage facilities and a control room which embodies many improvements. Vehicles Vehicle strength at the end of 1955 was as follows: Ambulances 230 Single-stretcher, sitting case ambulances 45 Sitting-case cars 47 Ambulance buses 10 Tenders 2 334 Staff numbers Staff The establishment was increased during the year by one station officer and 16 men in order to man the new accident ambulance station at Mottingham, bringing the total of uniformed supervisory staff and ambulance station officers to 40 and the permanent authorised establishment of ambulance drivers to 700, with 70 authorised relief positions. During the greater part of the year great difficulty was experienced in recruiting an adequate number of staff" to maintain the efficiency of the service, and in August, 1955, women drivers were once again recruited on a temporary basis. At the end of the year the number of ambulance drivers employed had increased to 743, including 53 women, of whom 15 were recruited during the latter part of the year. Following a comprehensive review of the work of the Ambulance Service which was undertaken by the Organisation and Methods Section of the Department of the Clerk of the Council, the authorised establishment of the control room at Headquarters was increased by one position (temporary) of ambulance control clerk in order to provide a relief for duty at any of the stations or at Headquarters in the event of sickness, holidav. etc. Safe driving and first-aid A very large percentage of the drivers continue to qualify for awards in the National 'Safe Driving' Competition held by the Royal Society for the Prevention of Accidents, which, in view of the increasing pressure of traffic, is a matter for some congratulation. The interest of the staff in securing further qualifications in first-aid to the injured has been maintained. General Civil Defence The advent of thermo-nuclear weapons has necessitated a complete review of the operational training of the Civil Defence Corps. Meanwhile the training of the volunteers has necessarily continued on the old basis. The interest and enthusiasm of volunteers has, however, been maintained in somewhat difficult circumstances. Publicity Efforts to recruit volunteers into the Ambulance and Casualty Collecting Section have continued throughout the year and a special effort was made in October to interest the voluntary aid societies in the formation of the Casualty Collecting Section. Representatives of the St. John Ambulance Brigade and of the British Red Cross Society 89 a* in London were invited to attend a conference on this subject and, the duties of the new section having been explained to them, they were urged to encourage their members to enrol, if possible as complete units. The results of this meeting have so far proved to be somewhat disappointing, although the Council has throughout had the co-operation and encouragement of the headquarters of both the great voluntary aid societies. Co-operation with other authorities and organisations The Ambulance and Casualty Collecting Section or the Civil Defence Corps has taken part in exercises, processions, recruiting displays, etc., organised by ten of the metropolitan boroughs on no fewer than thirty-four occasions. It has co-operated with units of the Industrial Civil Defence Section on six occasions, with the Casualties Union on one occasion and with the Welfare Section on four occasions. The Section also provided a detachment which took part in the ceremonial parade of Civil Defence Services held at the Horse Guards in July, and in the Guard of Honour which was provided on the occasion of the visit by the Home Secretary to the South Bank to inaugurate the first flight of the helicopter which has been allocated to the Civil Defence service. Instructors Five members of the instructional team have attended the Home Office Civil Defence School at Falfield. Two secured special certificates and three full certificates. Training During the year 16 Ambulance Section courses, Part I, were held, 21 Ambulance Section courses, Part II, 16 First-aid courses, and 12 driving and maintenance courses. Operative staff in the London Ambulance Service received training in the duties of the Civil Defence Ambulance Section in wartime. 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 91 for 1938 (the last full year before the war), 1947 (the last full year before the inception of the National Health Service) and 1950-55 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 1950-1955. The Accident Section statistics for 1954 and 1955 are analysed below to show the types of calls received. Analysis of Accident Section work (a) Numbers of patients : 1954 1955 Street accidents 15,282 17,338 Other accidents 19,450 20,345 Assaults 1,783 2,024 Attempted suicide 1,167 1,369 Mental 526 492 Epilepsy 1,348 1,329 Other sudden illness 17,278 18,458 Maternity 25,772 25,486 Special journeys with patients 244 323 82,850 87,164 (b) Non-patient carrying journeys : Delivery of analgesia apparatus 5,517 5,150 Special journeys without patients 289 270 Ambulance not required 6,004 6,747 11,810 12,167 The average time taken to reach a street accident in 1955 was 6.7 minutes. 90 16 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 1955 87,164 12,167 96,661 488,292 851,997 462,615 3,856,850 939,161 559,276 4,345,142 Work performed by the agency and supplementary services Year Ambulance Dept.— Joint Committee Order of St. John & British Red Cross Society 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 1955 21,539 429,980 127,938 1,425,624 416 4,621 149,893 1,860,225 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 1955 87,164 488,292 1,001,890 5,717,075 1,089,054 6,205,367 NOTES :—1. The figures are based on the Council's definitions of4 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 4 Total General Section Work * PREVENTION OF ILLNESS: CARE AND AFTER-CARE Foot clinics As reported in previous years, the chiropody service is generally inadequate to meet the demands upon it and is very unevenly distributed. In 1952 and 1954 the Council sought the approval of the Minister of Health to an expansion of the service but he was unable to agree to the Council's proposals. In December, 1955, however, the Council decided to make further representations and arrangements were made to send a deputation to the Minister early in 1956. 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 1955 9,089 184,628 43.8 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. Recuperative holidays With the exception of 1954, when there was an increase in recommendations for schoolchildren and a slight increase in respect of expectant and nursing mothers, the demand for recuperative holidays has declined since 1950. The admission figures for 1955 as compared with the previous three years were : 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 1955 403 2,803 405 153 2,784 6,548 Although there was a fall in recommendations for unaccompanied children, it was possible to maintain a high level of admissions throughout the year at the Council's recuperative holiday home at Littlehampton (accommodation for 36 children 3-8 years); at a seaside hotel used under the Council's Private Hotel Scheme (accommodation for 30 children 7-15 years) and at the Women's Voluntary Service's Home at Aldeburgh (accommodation for 24 children 3.11 years). In respect of the last named the Council contributed 90 per cent, of approved expenditure. The placing of mothers who are accompanied by their babies and sometimes also by toddlers, in small private homes rather than in the larger type of recuperative holiday 92 establishment, has proved satisfactory but there is a shortage of suitable accommodation and search continues to be made for homes offering facilities of the standard required. In most cases all the arrangements for recuperative holidays were made directly by the Council but the services of the Jewish Board of Guardians, the Wandsworth Peace Memorial and the St. Henry Convalescent Fund were also used and considerable assistance was received from the National Association for the Prevention of Tuberculosis (Spero Fund) in respect of tuberculous persons. Venereal disease Venereal disease A summary of the work done in 1955 at the London V.D. out-patient clinics will be found in Table 12, page 189. Approximately 77 per cent, of the patient swere resident in the County of London and a large number of persons who were found not to be suffering from venereal disease attended the clinics. The table below gives the number ot patients completing treatment and or detaulters as shown by analysis of the returns from the clinics : Syphilis Gonorrhoea Male Female Male Female Number of patients completing treatment 595 678 3,042 715 Number of patients not completing treatment 718 348 2,555 692 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 418 contacts was received but in 338 instances there was insufficient information for following-up. Of the remaining 80 cases 40 were traced of whom 30 were successfully brought to treatment. The welfare officers were also available to assist chnics 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 chnics at Holloway Prison and for following-up contacts and prisoners on discharge, were continued during the year. Health education Health education activities following the comprehensive review of this field, (Annual Report, 1952) continued to expand in 1955. Health visitors whether in the home or at the infant welfare centre were the principal contact with the public and lost no opportunity of furthering the cause of good health. In this they were helped very greatly by the medical staff whose opportunities of direct contact are, however, fewer. Evening public lectures by medical and nursing staff on health topics also continued to be given. The panel of senior medical, nursing and administrative officers formed to advise generally on health education activities considered a wide range of related problems and possibilities, and amongst the decisions implemented was the production of a series of slides relating to B.C.G. vaccination; the purchase of two tape recording machines for group instruction at welfare centres; the holding of a competition open to all of the Council's staff for the design and execution of visual aids for health education, and the approval of a range of demonstration material for use at infant welfare centres. Visual aids Greater use than ever was made of the department s library or films and film-strips, as well as of the films available on hire from other sources. Posters and leaflets on a wide range of health educational subjects were again displayed and distributed widely at the discretion of Divisional Medical Officers, who are 93 in a position to judge where their use is likely to be of maximum advantage and value. The topics on health subjects, loaned by the Central Council for Health Education, were displayed during the year at welfare centres and other premises of the department throughout the county and were frequently changed, so that during the year something approaching the full range of topics available could be seen at each centre making use of this method of publicity. Diphtheria immunisation campaign Diphtheria immunisation publicity ws carried out widely, and reached its peak in February when a two weeks' intensive campaign was held, supported by illustrated advertisements in about 40 local newspapers, special film and film-strip shows, and the distribution of about 50,000 leaflets on the subject, together with the display of about 600 posters. A special feature of this campaign was the display of cinema slides, urging the need for diphtheria immunisation, at nearly 100 cinemas throughout the county. Accidents in the home campaign The intensive campaign against accidents in the home held in November took as its subject for emphasis the dangers from burns and scalds. It was by far the most extensive undertaken so far. In addition to using the more usual channels for the distribution of literature and for the display of posters, special efforts were made to reach a wider section of the population by inviting the co-operation of the Metropolitan Borough Councils, London hospitals, general practitioners, schools, midwives, district nurses and moral welfare associations, as well as other departments of the Council. The extent of this co-operation can be judged from the fact that no fewer than 11,500 posters were displayed and almost half-a-million leaflets were distributed to the people of London by these agencies. Special mention should be made of the agencies outside the health department which distributed some 246,000 of these, no less than 209,000 being distributed to school children by the head teachers of over 500 schools. This form of distribution would, it was considered, ensure that a high proportion of the leaflets would find their way into homes where they would be seen and their message noted by parents and other adult members of the family. The four-minute film 'Dangerous Ages', produced by the Royal Society for the Prevention of Accidents, was shown at 15 cinemas in the county, 10 other films were hired for film shows arranged for mothers at welfare centres, and film-strips were used on 16 occasions at these centres to support talks given by staff of the department. Special advertisements drawing attention to the hazards encountered in the home were inserted in three London evening newspapers and in 54 local newspapers circulating in and around London. Press releases giving background notes about the home safety problem in general and the campaign in particular elicited a generous response and many newspapers gave valuable editorial and news space to the campaign and its implications. Articles were written for other periodicals and a special front page article was included in the Council's own Education Bulletin for the week previous to the campaign seeking the co-operation of all teachers. A small exhibition, stressing the dangers of accidents resulting from scalds and burns, was held during the week of the campaign in the main entrance of the County Hall and was well attended. It would be unwise to be too dogmatic about the results of the campaign as not enough is known about the various factors which influence the incidence of home accidents. It is a fact, however, as the figures set out below of weekly removals by the London Ambulance Service of home accident cases during October and November, 1955, show, that a noticeable drop occured during the week of the campaign and in the two weeks following. Compared with the average for the five weeks immediately preceding the campaign the number of home accident cases removed to hospital during the week of the campaign and the two weeks following showed reductions of 23 per cent., 23 per cent., and 17 per cent, respectively. The effects on minor accidents, not coming within the ambit of the London Ambulance Service, is unknown, but they could reasonably be assumed to follow the same pattern. 94 October, 1955 November, 1955 Week commencing 2.10.55—134 Week commencing 30.10.55—165 9.10.55—149 „ „ 7.11.55—150 16.10.55—146 „ „ 14.11.55—120* 23.10.55—166 „ „ 21.11.55—120 28.11.55—128 * Campaign week. Provision of care and treatment for the mentally ill MENTAL HEALTH SERVICES Lunacy and Mental Treatment Acts during the year, 8,346 cases of persons‡ alleged to be suffering from mental illnes: were referred to the mental welfare officers, compared with 8,690 in 1954. The following table shows how they were dealt with : 1955 1954 Male Female Total Admitted for observation to hospitals designated under section 20 of the Lunacy Act, 1890 2,003 2,204 4,207 4,622 Dealt with in their own homes, etc., under sections 14 and 16 of the Lunacy Act, 1890 433 1,161 1,594* 1,681 † Admitted direct to mental hospitals under section 11 of the Lunacy Act, 1890 16 26 42 34 No action under the Lunacy Acts found necessary 1,060 1,443 2,503 2,353 Total 3,512 4,834 8,346 8,690 ‡ It should be noted that a number of these patients were dealt with on more than one occasion although it is not possible to state from the records the extent to which this has occurred. An alteration has been made in the method of statistical recording and it is hoped to include this and other information in future annual reports. * Of these 197 male and 541 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 or the patients admitted to observation wards (including 129 patients in wards on 1st January, 1955) is shown below : 1955 1954 Male Female Total Certified and sent to mental hospitals 494 653 1,147 1,416 Admitted as voluntary patients to mental hospitals 719 865 1,584 1,501 Admitted as temporary patients to mental hospitals 20 37 57 36 Discharged to care of relatives (Section 22) 3 12 15 27 No order made by Justice and patient discharged 12 6 18 19 Transferred to general wards 59 42 101 90 Transferred to Tooting Bec Hospital without certification 39 40 79 162 Transferred to Abbots Langley Hospital without certification 2 2 4 1 Transferred to Mental After-Care Association homes 2 1 3 4 Died 50 25 75 83 Discharged by medical officer 599 495 1,094 1,285 Dealt with privately — 1 1 18 Dealt with under Mental Deficiency Acts 2 3 5 7 In ward at end of year 63 90 153 129 Total 2,064 2,272 4,336 4,778 Although, for the first time since 1948, the number of persons referred showed a slight decline, the number of persons dealt with in their own homes or otherwise than in an observation ward under sections 14 and 16 of the Lunacy Act, 1890, or under section 11 of the Act, was almost as great as in 1954, whilst the number admitted to observation wards showed a disproportionate decrease. Owing to the extra work caused by the large number of direct admissions to mental hospitals, an additional position of assistant mental welfare officer was authorised from 1st April, 1955. 95 Organisation of work of duly authorised officers The Council's approved proposals under section 51 of the National Health Service Act, 1946, provide that the work of securing that persons of unsound mind are placed under control and subsequently of obtaining reception orders for their detention, should be decentralised. Because of various problems, including the shortage of beds in observation units, however, the service was started on a centralised basis in 1948 and although the position has been reviewed year by year, on each occasion decentralisation has been considered impracticable and the centralised arrangements have been continued. During the year the matter was again fully investigated and it was decided that the Minister of Health should be asked to approve an amendment of the proposals to enable the service to be organised permanently on a centralised basis. Liaison with hospitals A meeting was held on 25th October, 1955, at the County Hall to which the physician-superintendents of all the mental hospitals receiving London patients were invited to discuss matters of common interest, including the establishing of closer contact between the mental welfare officers and the mental hospitals, and the integration of after-care services. It is hoped to hold further meetings of this kind in future. Domiciliary care and after-care Four psychiatric social workers were employed full-time to interview and advise persons suffering from psychiatric illness needing help with their personal problems. During the year 268 new cases were referred from the following sources : 1955 1954 General practitioners 26 15 Mental hospitals 50 58 Observation wards 2 11 General hospitals 4 9 Psychiatric clinics 25 34 Patients—Personal applications 13 23 Relatives or friends 15 13 Ministry of Labour 5 5 National Assistance Board 11 19 National Association for Mental Health 11 16 Mental After-Care Association Health visitors, housing welfare officers, etc. 57 45 Institute of Social Psychiatry 3 1 Citizens Advice Bureaux 16 12 Army (discharged personnel) 12 19 Other agencies 18 50 Total 268 330 The arrangements for patients to be interviewed either privately at the County Hall or at home were continued and it was possible from November to make arrangements for an additional session (making a total of two) to be held each week at Woodberry Down Health Centre by the psychiatric social worker responsible for interviewing patients living in North-East London. It is hoped to make similar arrangements at health lervice premises for the other psychiatric social workers in their respective areas. Social clubs and rehabilitation centre National Association for Mental Health Long-term care The Council continued to make a grant or 90 per cent, or the cost in respect of the attendance of London patients at the social clubs and the rehabilitation centre run by the Institute of Social Psychiatry for persons suffering from mental illness. It was decided, during the year, to renew for three years the annual grant of £200 made to the National Association for Mental Health in recognition of their general services to the community and to local health authorities in the field of mental health. The weekly maintenance rates at the homes at which chronic and senile patients are maintained by the Council remained unchanged during the year. Moor Place, Windlesham, Surrey, a home run by the National Association for Mental Health, at which three patients were maintained, was closed in November and the patients were transferred to a new home opened by the Association at Parnham House, Beaminster, Dorset. At 31st December, 1955, three patients were maintained at Parnham House, two at the Jewish Board of Guardians' hostel at 1 Daleham Gardens, N.W.3, and 96 109 in homes sponsored by the Mental After-Care Association, making a total of 114 compared with 107 at 31st December, 1954. Recuperative holidays Recuperative holidays were arranged for 196 persons recovering from psychiatric illness compared with 205 in 1954 and 210 in 1953. Of these 122 were recovering from mild psychiatric illnesses and were sent to general recuperative holiday homes for two or three weeks ; 49 were sent for short holidays to homes sponsored by the Mental After-Care Association and 25 were sent for periods up to twelve weeks, to assist in their rehabilitation, to the Mental After-Care Association's homes at Cheam, Surrey, and Dartford. Kent. Mental Deficiency Acts The following table shows the sources from which cases were brought to notice under Statistics the Mental Deficiency Acts and the action taken thereon : Sourccs of information 1952 1953 1954 1955 Totals from 1.4.14 to 31.12.55 Supervision section 14 9 16 11 1,611 Local education authority 570 533 502 501 17,089 Police authority (section 8) 32 24 18 15 2,030 Transfers from prison (section 9) — — — 1 230 Transfers from approved school (section 9) . — 2 4 1 572 From hospitals and institutions 124 97 91 99 801 Miscellaneous 222 222 229 261 11,234 Total 962 887 860 889 33,567 The position at 31st December, 1955, 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 : 1952 1953 1954 1955 Detained in institutions 7,862* 7,842* 7,799* 7,762* Discharged from institutional care 3,075 3,235 3,428 3,624 Removed to mental hospitals 555 572 592 596 Not subject for action 9,922 10,190 10,549 11,045 Died 4,678 4,853 5,006 5,158 Total removed from active list .. 26,092 26,692 27,374 28,185 * 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 : 1952, 259; 1953, 236 ; 1954, 247 ; 1955, 212. Under guardianship 222 223 217 224 In places of safety awaiting the presentation of a petition 11 11 11 6 Under supervision In hospitals, residential nurseries, etc., awaiting the 4,556† 4,815† 5,007† 5,059† presentation of a petition 41 59 61 79 Still under consideration 9 18 8 14 Total remaining on active list 4,839‡ 5,126‡ 5,304‡ 5,382‡ Grand Total 30,931 31,818 32,678 33,567 † 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:—1952, 1,040; 1953, 1,055; 1954, 986; 1955, 1,189. ‡ Of these the following were awaiting institutional care : 1952, 169 ; 1953, 199: 1954, 205 ; 1955, 229. 97 The following is a summary of the cases dealt with and comparable figures for the three preceding years: 1952 1953 1954 1955 Placed in institutions 369 306 284 286 Placed under guardianship 24 21 28 31 Placed in places of safety pending presentation of a petition 70 59 45 34 Placed under supervision 787 735 688 674 Discharged from institutional care or guardianship 203 193 216 228 Removed to mental hospitals under the Lunacy Acts 21 26 25 16 Ascertained not subject for action 69 76 111 112 Withdrawn from supervision 201 221 247 370 Removed to other areas 65 60 62 68 Died 165 174 153 151 Total 1,974 1,871 1,859 1,970 Ascertainment and supervision 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. The boundaries of the four areas served by the local offices were adjusted in 1948 to make them coterminous with those of the groups of health divisions with which their previous boundaries most nearly coincided. The case load at that time was fairly evenly distributed between the four districts but, largely as a result of post-war housing development, the number of persons under supervision in ' D ' district (Bermondsey, Lambeth, Camberwell, Lewisham, Deptford, Southwark Greenwich and Woolwich) has, since then, almost doubled. As there is no particular need for the district boundaries to coincide with those of the nine health divisions it was decided, in order to secure a more even distribution of work, that Lambeth should be transferred to 'A' district (Paddington, St. Marylebone, Westminster, St. Pancras, Holborn, Hampstead, Islington and Finsbury). During the year 20,698 visits were paid to persons under supervision or on licence from hospitals and 1,155 to persons under voluntary supervision, while 1,777 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. Petitions 9 During the year 171 petitions for institutional care and 31 for guardianship were presented to Judicial Authorities under section 6 of the Mental Deficiency Act, 1913, and 49 children were placed in institutions by their parents under section 3 of the Act. In no case was a petition dismissed. 30 applications for Varying Orders were made during the year as a result of which 14 patients who had become unsuitable for guardianship were admitted to institutions and 16 were transferred to other guardians. Five children, whose names were on the waiting list for institutional care, were found at special re-examinations to have improved to such an extent as to be considered educable and their names were removed from the list. Magistrates' courts The Council s medical officers continued to attend at Magistrates courts, as required, to give evidence as to the mental condition of defectives charged with criminal offences. 31 such defectives were ordered to be sent to institutions under section 8 of the Mental Deficiencv Act, 1913. Institutional accommodation The number of admissions during the year showed a slight increase over the 1954 figure—276 compared with 270—but the number on the waiting list at 31st December, 1955, was 230 compared with 205 at 31st December, 1954. 12 children, whose names were on the waiting list for admission to the Fountain Hospital, died before vacancies could be obtained. The need for more hospital accommodation for mentally defective persons became increasingly urgent and there seems little doubt that the waiting list will continue to rise. At one period in the year the total figure stood at over 250 but this was reduced by the end of the year mainly because of the opening of a new ward for male patients at Leavesden Hospital. 98 During 1955, 31 patients were placed under guardianship of whom 20 were school leavers with no satisfactory homes of their own who were considered suitable for life in the community. Guardianship At 31st December, 1955, there were 226 patients under guardianship as follows : 48 under the personal guardianship of the Council's inspectors. 65 under the guardianship of nominees of The Guardianship Society, Brighton. 72 under the guardianship of relatives and friends. 30 under the guardianship of superintendents of voluntary homes. Of the remainder, eight 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 one had absconded from his guardian and was untraced. The work of adaptation and redecoration of Dover Lodge, Camberwell, S.E.23, the premises acquired by the Council in 1954 for use as a hostel for twelve mentally deficient girls, was completed in July, 1955, and the warden and assistant warden were appointed and took up residence in August. The hostel is primarily for girls leaving special schools for the educationally sub-normal who have no suitable homes, the intention being to fit them for independent life in the community within a reasonable time Six girls had been admitted by 31st December 1955. Hostel for girls under guardianship The girls, who are under the guardianship under the Mental Deficiency Acts of women inspectors in the Public Health Department, were provided with initial outfits of clothing, and employment was secured for them in the locality of the hostel. They assist in some of the domestic duties in the hostel, and various amusements, including indoor games and television, are provided for them. In the short time since the hostel was opened, all the girls have progressed satisfactorily and retained the employment found for them. Pocket money of 10s. a week at age 16 and 12s. a week at age 17 or over and allowances for clothing at the same rates were authorised for the girls at Dover Lodge, and it was decided to apply the same allowances to other boys and girls who are accommodated in lodgings under the guardianship of the Council's inspectors. Both the girls in Dover Lodge and boys and girls in lodgings are required to contribute out of their earnings towards the cost of their maintenance to such extent as is possible up to a maximum of 42s. a week after the deduction of the allowances for pocket money and clothing and other necessary expenses. The position of boys and girls in lodgings will be reviewed individually when they reach the age of 18, and of girls in Dover Lodge, two years after admission. Following increases in National Assistance allowances, an increase from 35s. to 37s. 6d. a week was authorised in the maximum allowance payable for the maintenance of mentally deficient persons under the guardianship of relatives and friends. The Council authorised the Medical Officer to approve expenditure not exceeding 10s. a head, when this is considered desirable, for the provision of extra fare, etc., at Christmas for patients under guardianship. Christinas extras A scheme whereby a maximum number of 10 boys will be placed under the guardianship of the Warden of Wallingford Farm training school was approved and at 31st December, 1955, five boys had been so placed. The boys, on leaving special schools for the educationally sub-normal, had no homes, or unsuitable homes and wished to undertake training in farm work, market gardening, boot repairing, bricklaying, carpentry or painting. The period of training is usually about 18 months and at the end of this period it is hoped that the boys will be placed by the school in employment at normal rates of pay. The cost of maintaining each boy is 19s. Od. a week, plus the cost of clothing. Wallingford Farm training school Temporary care in accordance with the provisions of Ministry of Health Circular 5/52 has been provided in an increasing number of cases. The Council arranged such care for 41 patients (7 adults and 34 children) during the year at various approved and private homes, because of family difficulties and emergencies. The cost of providing this care, which was borne by the Council, varied from approximately £3 to £6 16s. 6d. a head Short-term care 99 a week. Patients or their relatives were assessed to contribute towards the cost in accordance with the Council's approved scale of assessment. The provision of a short-stay home at Hillingdon, Middlesex, by the Middlesex County Council (referred to in the Report for 1954) where it was proposed that a number of beds would be allocated solely for the use of London patients was delayed and it has since been learnt that the Middlesex County Council have had to abandon the scheme as the Minister of Health refused his consent because of the need for economy. In addition to the 41 patients mentioned above, who were accommodated at the expense of the Council, 100 patients (24 adults and 76 children) were admitted to various mental deficiency hospitals for temporary care. The total number of patients provided with temporary care during the year was thus 141 compared with 119 during 1954. This form of care gives much needed relief to harassed parents and relatives. Home tuition A qualified teacher continued to provide tuition for three sessions a week in her own home to a mentally defective child who is deaf and dumb and could not, therefore, attend an occupation centre. Welfare clinics for backward children under five The work of the seven special welfare clinics for backward children under five, which were set up during 1954, was reviewed during the year. It was found that parents who were reluctant to take their children to ordinary welfare clinics welcomed the opportunity of attending the special clinics where they could discuss their special difficulties with a doctor experienced in mental deficiency as well as maternity and child welfare. A social worker and a health visitor also attend the clinics to advise parents as to their child's capabilities and the facilities available. In particular, advice and help have been given to parents on the care of children awaiting admission to hospitals for the mentally deficient; and in some cases admission to a hospital has been expedited, or a period of short-term care for the child arranged to give the parents a rest. Another feature of the clinics is that the parents meet others who share the same difficulties. The existing arrangements are at present adequate for the needs of the whole county. Students Facilities were again given for students taking university courses of training in social science and the University of London's Institute of Education course in the care of educationally sub-normal children, to spend short periods in the district offices of the supervision section and with the psychiatric social workers in the psychiatric care and after-care service. The students also witnessed the proceedings when petitions were presented by authorised officers of the Council to Judicial Authorities for orders under the Mental Deficiency Acts. Accommodation Occupation centres In June, 1955, the former Peckham elder girls' centre was transferred from unsatisfactory premises to a rebuilt church hall and rooms attached to the Clifton Congregational Church, Studholme Street, Peckham. In September, however, this centre exchanged premises with the junior centre at Brockley, as the Clifton premises were considered more suitable for juniors. To meet the increasing need, additional accommodation was taken in June at the Greenwich centre for juniors and elder girls. Industrial training centre The Industrial Training Centre at 52 Ashfield Street, Stepney (mentioned in the Report for 1954) ,was opened in September. Simple wooden articles for use in nursery schools are made for the Council's Supplies Department and a large order was almost completed by the end of the Christmas term, the total value of the goods made being about £l00. As this experimental centre has been open for only a short time it is early to assess the results, but there is every indication that it will be a success and justify the opening of similar centres in other parts of London. 100 The accommodation available in all centres at 31st December, 1955, was as follows: Centres Accommodation Centres Accommodation Centres for children Centres for elder girls Bethnal Green 35 Brockley 60 Brixton 40 Earlsfield 60 Clapton 60 Hackney 40 Clifton 60 Islington 35 Finsbury 60 Centres for elder boys Fulham 75 Archway 40 Greenwich Including a class of elder girls 60 Battersea 30 North Kensington 70 Dalston 50 Peckham 45 Hammersmith 35 Wandsworth 90 Peckham 60 Industrial training centre (elder boys) Stepney 20 Total 1,025 Schemes to replace unsatisfactory premises reached various stages during the year. Plans were prepared for the adaptation of Cornwall House, Bethnal Green, during 1956, and for the erection of a new permanent centre for 120 children on a site in Perry Rise, Lewisham, in 1957, each to replace two centres in east and south London respectively. A scheme was also in preparation for the adaptation of the former Balham day nursery premises as a permanent centre to replace the Battersea elder boys' centre. Arrangements were also approved to transfer the Brixton junior centre to better premises at Herne Hill at Easter, 1956, and arrangements to open an additional elder girls' centre at Greenwich in 1956 were under consideration. To cope with increased attendances, additional coaches were hired. Nineteen coaches now serve the junior and elder girls' centres. Transport Various functions were held during the year to show to parents and friends the work and activities carried out at the centres. Receipts for articles made and sold at the centres amounted to approximately £41 at junior centres, £121 at elder girls' centres, and £576 (including £132 for shoe repairs) at elder boys' centres, where some small apparatus and equipment for other centres were also made. Open days and sales of work Ail staff, and all detectives over 15 years or age attending centres, had chest X-ray examinations. One case of active tuberculosis was discovered and the boy concerned was excluded and is now under treatment. Chest X-ray examinations 199 children and adults, of whom 81 necessitous persons received free or assisted holidays, participated in the annual holiday at a seaside camp. Some centres organised day outings to the sea or country, or visits to a circus or pantomime. Facilities were provided for periodic visits during the summer months to local parks for recreation or sports. Elder boys' centres organised inter-centre cricket and football matches. Christmas parties were held at all centres. Holidays, outings and parties Gifts of money to provide extra amenities at several centres were given by parents' groups and other persons. Gifts Parties of students from various organised courses of training, and interested persons from other authorities and countries, visited the centres during the year. The usual annual reports on the centres by Inspectors of the Board of Control were received and centres were also visited by members of the Mental Health Sub-Committee. Members of divisional health committees also attended some centre functions. Visits to centres Eleven staff who attended the two-year part-time course of training organised by the National Association for Mental Health, which commenced in September, 1953, completed the course and were awarded the Association's Diploma. A further course on similar lines commenced in September, 1955, in which thirteen occupation centre Staff— courses of training 101 staff are participating, their fees being paid by the Council. Students from other authorities taking the part-time course and the Association's full-time day course undertook periods of practical training of up to two months in London centres. Attendance at occupation centres of patients under guardianship chargeable to other authorities The arrangement whereby a charge of £12 12s. a head a year (plus cost of meals and conveyance to and from the centre) was made in respect of the attendance at the Council's occupation centres of defectives under guardianship chargeable to out-county authorities, was reviewed. It was decided that, unless reciprocal arrangements could be made with the authority concerned, the full ascertained cost of attendance should be charged in respect of future out-county cases attending the centres. Attendance of London patient at a Middlesex occupation centre The Council authorised payment of the full cost of attendance, viz., 12s. 4d. a day to enable a London patient under guardianship living in Middlesex to attend one of the Middlesex County Council's occupation centres. Dental inspection and treatment Because children at occupation centres are not attending school the dental services provided by the Council's school health service have not been available to them, thus increasing the difficulties in obtaining proper dental treatment for them. Although the position in the priority dental service was far from satisfactory, the Council decided to seek the approval of the Minister of Health to the use of the service by children attending the occupation centres. It was felt that the number of such children was so small in relation to the number of schoolchildren that their inclusion in the school dental inspection and treatment arrangements would cause little additional difficulty. The Minister was sympathetic to the proposal and suggested that the Council should seek an amendment of its proposals under section 28 of the National Health Service Act, 1946, to enable children attending the Council's occupation centres to receive dental inspection and treatment at its school treatment centres or dental clinics if they were unable to obtain such treatment by other means. Steps have been taken to secure the necessary amendment to the Council's proposals. CO-OPERATION WITH GENERAL PRACTITIONERS co-operation with other health services has continued on the lines indicated in the comprehensive statement in my report for 1954 and has been further developed. The initiative in establishing liaison with general practitioners still rests with the Council but in some districts there are encouraging signs of increasing readiness, especially on the part of the younger practitioners, to co-operate more actively with health visitors and in some cases quite valuable results have been achieved. The extent of the assistance which can be offered to general practitioners is somewhat limited by the current shortage of health visitors but the future holds promise of successful developments in this field, particularly in encouraging general practitioners to take a leading part in the work being undertaken in respect of potential and existing problem families. General practitioners co-operated extensively with the Council in its campaigns to forward diphtheria immunisation and to combat accidents in the home. At the end of the year, 359 medical officers were employed on a sessional basis and conducted an average of 720 sessions a week in the school health and maternity and child welfare clinics. The majority were also engaged in general practice and others held appointments in hospitals and industry. The practical experience of the personal health services gained in this way by doctors having professional interests outside the Council's service is an important factor in the development of co-operation. SCHOOL HEALTH SERVICE Organisation the school health service, like the maternity and child welfare service, is organised on a divisional basis (see pages 132-153 for reports of divisional medical officers). 102 The Voluntary School Care Committees, appointed by the Education Committee, have now been in existence for nearly 50 years and their contribution to the well-being of London school children continues to be an essential part of the School Health Service. In 1948 at the inception of the National Health Service Act, their voluntary workers numbered 1,430. The figure now stands at 2,436. This number is the more noteworthy when it is compared with the 600 workers in the whole county who in 1945, as the schools settled down after wartime disturbance, were doing this work. Care committee workers attended 95 per cent. of the medical inspections and their responsibility for the following-up, in spite of the greatly improved response on the part of parents, is still a valuable link with the home and family through which other and deeper problems may be revealed. It is impossible to assess exactly the contribution they make to the prevention of ill-health, but its value is indeed considerable. Since the amendment to the Care Committee Constitution, referred to in the 1954 report, the co-operation between the care committee workers and the School nursing sisters health visitors has steadily increased, greatly to the benefit of the work for, in this as in all fields of social work, the paramount need in the now highly developed social services in London is closer co-operation between workers in the field. Medical inspection rooms in schools In a large number of schools, particularly voluntary schools, there is no separate accommodation for the medical inspection of school children. School halls, spare classrooms and in some cases the head teacher's room, have to be used for this purpose. Opportunity is taken when minor improvements are contemplated to press for a separate room for this work. Owing to financial restrictions necessarily imposed by the Ministry of Education only a small fraction of the money necessary has been allocated for this purpose so that the rate of improvement has been slow. Nevertheless, during 1955 improvements in the accommodation for medical inspections were made in 60 schools at a cost of £5,240. The position in new schools, however, is very much better. The planning included a medical inspection room and in the larger secondary schools a medical suite of rooms. During the year new buildings have been brought into use and in each case suitable accommodation has been provided for the medical inspection and treatment of pupils, viz. : Name of school Nominal roll Catford 1,190 girls Dick Sheppard 900 „ Holloway 840 boys Mayfield 1,620 girls Woodberry Down 1,200 mixed Pupils on school rolls At the end of 1955 there were 442,917 pupils on the day school roll. 314,014 children of primary and secondary school age were in attendance at county schools, 104,764 at voluntary or assisted schools, 15,790 children under five years of age in nursery schools and classes or in primary schools and 8,349 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 103 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 1955, with comparable figures for the two previous years, are as follows : 1953 1954 1955 General medical inspections Routine age groups Entrants 51,814 44,415 41,162 7 years old 40,870 44,604 38,161 11 years old 33,940 34,312 37,290 Leavers 27,768 27,892 25,308 Total 154,392 151,223 141,921 Nursery 8,507 7,958 8,164 Other ages 23,481 27,593 26,552 Special schools 2,708 2,470 2,518 Training colleges 308 178 177 Secondary schools annual surveys 21,530 16,667 13,978 Total general inspections 210,926 206,089 193,310 1953 1954 1955 'Urgents' and ' Specials' (a) 23,618 27,262 24,380 Other inspections Special inspections Employment certificates 3,984 4,604 4,521 School journeys 19,375 19,503 22,400 Miscellaneous (b) 13,364 8,223 6,210 Total 60,341 59,592 57,511 Re¬. J inspections Nutrition cases (c) 62,708 64,909 68,051 Other 115,622 107,131 101,278 Total other inspections 238,671 231,632 226,840 Total all inspections 449,597 437,721 420,150 NOTES:— (a) Pupils brought urgently to the attention of the school doctor by parents, heads, school nurse, care committee, etc. (b) Handicapped pupils for their special defect, candidates for higher awards, nautical school, etc., children engaged in theatrical employment, T.B. contacts, etc. (c) Pupils receiving school meals, extra milk or vitamin capsules on the recommendation of the school doctor (set page 105). Apart from annual surveys in secondary schools children seen at routine inspections in 1955 formed 40.5 per cent. of the total of 442,917 on school rolls, compared with 42.8 per cent. in 1954. The percentages of these children who were referred for treatment (other than for infestation or teeth) compared with the preceding years were : Pupils referred for treatment Age group and sex 1953 1954 1955 Nursery Boys 12-2 12-7 11-1 Girls 12-2 10-3 8-4 Entrants Boys 15-1 13-8 12-4 Girls 13.4 11.9 10.5 7 years old Boys 17.9 16.8 15.3 Girls 17.2 15.4 14.1 11 years old Boys 15.8 14.5 14.0 Girls 17.6 15.9 14.6 Leavers Boys 12.7 11.7 11.6 Girls 16.0 15.6 14.9 Other ages Boys 16.0 16.3 15.4 Girls 20.4 18.2 17.7 All pupils* 15.8 14.8 13.7 *Exclusive of special schools, training colleges and annual surveys in secondary schools. 104 The following table shows the percentages of the principal defects (other than infestation, teeth or errors of refraction) found in pupils of all age groups inspected at general medical inspections and referred for treatment or observation, with comparable figures for 1953 and 1954. 1953 1954 1955 *Numbers examined 186,380 186,774 176,637 Percentages Skin diseases 1.29 1.39 1.35 External eye diseases 0.75 0.72 0.58 Defective hearing 0.64 0.59 0.59 Otitis media 0.97 0.74 0.66 Enlarged tonsils and adenoids 7.61 6.92 5.97 Defective speech 0.75 0.72 0.75 Enlarged cervical glands 1.62 1.45 1.30 Heart and circulation 0.84 0.87 0.79 Lung disease (not T.B.) 1.77 1.55 1.41 Orthopaedic defects 5.25 5.10 4.82 Defects of nervous system 0.37 0.37 0.39 Psychological defects 0.86 0.97 0.97 Anaemia 0.26 0.19 0.14 Enuresis 1.76 1.56 1.57 *Excluding special schools, training colleges and annual surveys in secondary schools. Compared with 1954 a reduction in the number of enlarged tonsils and adenoids was shown in all groups except boys in the nursery and eleven years old groups, whilst all age groups showed lower rates for orthopaedic defects. 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 clear that such a change in the system of classification meant that it would be some years before the statistics of assessment on the new scale could be regarded as stable enough to enable significant conclusions to be drawn from year to year comparisons : Year Excellent Normal SubNormal and Bad Percentages referred: Treatment Observation Total 1946 18.0 76.4 5.6 1.3 0.7 2.0 Good Fair Poor 1948 40.8 56.0 3.2 1.0 0.5 1.5 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 1955 60.4 38.0 1.6 0.8 0.8 1.6 Pupils receiving school meals, extra milk or vitamin capsules on the recommendation of the school doctor are re-inspected each term. During 1955 the number of such re-inspections was 68,051. 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 1955 14.5 70.3 15.2 School meals, milk and vitamin supplements A return to the Ministry of Education for a typical day in September, 1955, showed that 223,413 pupils, 55.3 per cent. of the number present, were provided with school dinners; of these, 18,687 received dinners free of charge. On the same day, 361,527 children had school milk. This cannot be expressed as a percentage of the number present, as it included milk collected for children absent from school through sickness. 105 H* Vitamin capsules are supplied daily free of charge to pupils recommended for them by the school medical officer. Other children may have them at the request of their parents, on payment of 1s. a term. In October, 1955, meals were being produced at 600 kitchens (including seven central kitchens) and served to children at 957 separate premises. During the course of the year some 4l½ million meals were served to children and teachers and the output of mid-day dinners to children reached a record daily figure of 224,000. 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: Age group Minimum 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, 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 60). 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 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 types. The following table gives the results of such vision tests carried out during 1955: Visal 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 year old Boys 79.4 13.7 6.9 3.0 6.4 0.6 5.8 Girls 78.5 14.4 7.1 3.3 6.8 0.7 6.1 11 year old Boys 83.5 8.5 8.0 8.2 7.5 2.5 5.0 Girls 80.1 10.7 9.2 8.9 8.9 2.6 6.3 Leavers Boys 81.9 8.5 9.6 11.4 8.2 3.4 4.8 Girls 78.4 10.6 11.0 13.1 10.5 4.2 6.3 Other ages Boys 80.6 10.3 9.1 7.4 8.8 2.3 6.5 Girls 78.8 11.2 10.0 9.2 9.7 2.8 6.9 Of those referred tor treatment of detective vision the proportion who were already wearing spectacles rose from about one.tenth at age seven to two.fifths at age 15. The higher total percentages of children referred for treatment at older ages was thus almost wholly due to cases needing natural adjustment of refraction correction with the passage of time. In 1955, the incidence of defective vision and the precentage of pupils referred for treatment defective vision remained fairly stable compared with the preceding years. As experienced over many years, the recorded incidence of defective vision was greater among girls than boys. 106 Squint was most prevalent in the entrant group, falling to insignificant residual level in the leaver group. The overall figure of pupils referred for treatment of squint was 0.8 per cent. compared with 0.8 per cent. in 1954, 0.9 per cent. in 1953 and 1.1 per cent. in 1952. 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 112 and 113. 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, which she also visits in accordance with a rota, to carry out hygiene inspections. 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 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 following table gives the results of the personal hygiene inspections carried out during 1955: Total Number of Inspections Pupils found to be verminous* Number Percentage Boys 405,946 2,704 0.6 Girls 440,214 9,373 2.1 Infants 406,215 4,888 1.2 Total 1,252,375 16,965 1.4 *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 seven 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 1955: 1. Number of occasions on which pupils were found to be 'verminous' (as defined) 16,965 2. Number of individual pupils comprising item 1 9,613 3. Number of advice cards issued 10,483 4. Number of families involved in item 3 4,581 5. Number of pupils found to be clean after issue of advice card 1,176 6. Number of pupils voluntarily attending bathing centre after advice card 7,001 7. Number of statutory notices issued 1,532 8. Number cleansed voluntarily after statutory notice 459 9. Number compulsorily cleansed after statutory notice 977 The total number of individual verminous pupils treated at bathing centres fell by 2,263 to 9,867, while treatments needed decreased by 3,624 to 15,756. The steady decline in the numbers of verminous pupils in recent years is shown in 107 the following table, and may be attributed to improved social standards, greater concern on the part of parents, and the effectiveness of the cleansing scheme. Year No. of pupils on school rolls No. of nurses' hygiene inspections No. of 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 1954 442,129 1,299,358 21,872 1.7 11,801 2.7 1955 442,917 1,252,375 16,965 1.4 9,613 2.2 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, 169,329 medical re-inspections were carried out, 68,051 in respect of pupils noted as 'nutrition' cases (see page 104) and 101,278 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 15.4 per cent. of both sexes examined. Work requiring normal vision and that involving eye strain again headed the list of contra-indications for both sexes. Next came heavy manual work, normal colour vision (for boys only), exposure to bad weather, and prolonged standing or quick movement. The following table gives the main contra-indications disclosed at the medical inspections of the 21,722 school leavers during 1955: Contra-indications Boys Girls Occupations involving: Heavy manual work 293 212 Sedentary work 17 37 Indoor work 4 2 Exposure to bad weather 109 180 Wide changes of temperature 56 52 Work in damp atmosphere 95 104 Work in dusty atmosphere 113 79 Much stooping 24 30 Climbing 65 49 Work near moving machinery or moving vehicles 69 34 Prolonged standing, much walking or quick movement from place to place 107 149 Eye strain 512 558 Normal vision 730 540 Normal colour vision 288 2 Normal use of hands 13 5 Exposure of hands to moisture, chemicals, etc. 24 29 Handling or preparationof food 69 77 Normal hearing 70 44 108 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, 4,521 medical examinations were carried out locally in respect of the issue of employment certificates. In addition, medical examinations were carried out at the County Hall of children concerning their employment under licence in public entertainments, comprising 232 boys and 318 girls. Children under five years of age At the end of 1955 there were 168 nursery classes with accommodation for approximately 5,040 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 22 maintained day nursery schools with accommodation for 1,310 children from 2 to 5 years, three nursery centres each providing part-time education for 80 to 100 children half of whom attend in the mornings and half 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 15,790 children under five years of age on the day school rolls, 13,161 being in the Council's schools and 2,629 in voluntary schools. Gramophone audiometer testing Routine hearing testing is carried out by school nursing sisters using gramophone audiometers in schools. Since the gramophone test takes the form of a series of numbers which are ' read ' to the class pupils must be old enough to write from dictation, the tests therefore are carried out on entrance to junior school at the age of 7+ years. 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. This is an individual test carried out under quiet conditions and takes the form of a note of variable pitch and volume which may be intermitted or continuous to which the child listens through earphones which exclude as far as possible external noise. Any pupils failing their pure tone test are referred to an otologist at the audiology centre. The sisters who act as 'audiometricians' are engaged exclusively on this work and are responsible for the clerical work, home visits, transport of equipment, arrangements with schools, cure tone sessions and attendance at audiology sessions. Audiometry Whilst in the hospital services the duties of hearing aid technicians and audiometricians include the fitting, testing and maintenance of individual hearing appliances and the emphasis is on the technical side, both in their training and duties, the work done by these school nursing sisters is an extension of their normal nursing duties. They are not concerned with the technical aspect, e.g., the repair and maintenance of the apparatus they use is the responsibility of the Council's Chief Engineer. Testing the hearing of children is as much or more a mattec of establishing a personal relationship based on a knowledge of their management, as of methods of testing hearing. Hearing tests of this type are useless if carried out by an unsuitable person and this is particularly Audiometricians 109 the case when dealing with younger children. The nurse is also able to use her professional judgment, as hearing may be affected by the child's general health, e.g., wax in the ears, and to assist the otologists professionally at the audiology centres. All work in connection with the children's hearing is thus centred on the same school nursing sister. Technicians would not be qualified to perform the functions of a ' clinic sister ' in this way. Audiology centres Towards the end of 1953 it was considered desirable to carry out field trials in London of the rapid pure tone sweep method of testing school entrants aged 5+ years. As it was essential to arrive at an estimate of the number of staff required if this method were to be adopted, it was decided to conduct an experiment in two divisions, and pilot schemes began in 1955 after the purchase of two Amplivox Model 70 portable audiometers. Before the field trials commenced, a medical officer and school nursing sister from each of the two divisions received training at the Royal National Throat, Nose and Ear Hospital. The pilot schemes were visualised as a modification of the existing London procedure only in the substitution of a rapid sweep test in school for the gramophone test in school. The reference of school test failures' to a full pure tone test, and of full pure tone test failures to the otologist, remained as before. Similarly, in these pilot schemes, the school nursing sister remains responsible for making all ancillary arrangements as before. The records of the audiometric tests in 1955 were as follows: Age 7+ (7 Divs.) + (2 Divs./) Estimated school population 41,097 12,794 First gramophone test 40,509 — Second gramophone test 11,883 — Sweep test — 7,947 Referred to otologist at audiology centre 1,165 Training of very young deaf children There are nine audiology clinics equipped with a pure tone audiometer and other special equipment and staffed by part-time otologists serving the nine health divisions of the county. Whenever there is any question of suspected hearing defect, children are referred to these clinics by school doctors from routine or special medical inspections, by school nursing sisters after group gramophone tests in school, by teachers, speech therapists, etc. The eventual disposal of these children depends upon the medical and educational recommendations made by the otologist at the audiology centre. The majority of the children are found by this specialist either not to be deaf, or to be only temporarily ' hard of hearing ' due to a ' cold ', wax in the ears, or to some condition, such as septic tonsils, which requires treatment. Minor treatments are carried out at the audiology centre. Children whose condition is more serious are referred to an ear, nose and throat clinic at a hospital, where any necessary treatment (including the supply of hearing aids, and operations, such as tonsillectomy or mastoidectomy) is carried out. During 1955, 292 audiology sessions were held, at which there were 3,299 attendances, including 1,164 new cases. A small residual number of children, who may require special educational treatment after ascertainment as handicapped pupils, are referred to the County Hall for examination by the Council's consultant otologist. In general, it is seldom that a pupil requiring special educational treatment is found by routine audiometer, or other tests in school. The needs of the majority of these children are noticed before they reach the age of five years. Pure tone sweep testing Training in speech and understanding should begin at the age when a child normally beings to speak, i.e., at about 10 months, and should be given continuously at home by the parent. The parent therefore needs to receive instruction from the teacher so that 110 the training of the child is not direct but through the mother. This training is what is called the auditory training of the deaf, as opposed to the traditional manual and oral methods. The child also receives training from the teacher in lip reading, speech correction and the correct attitude to deafness. In 1951, the Royal National Throat, Nose and Ear Hospital adapted a house in Gray's Inn Road, near the hospital, for the examination and education of the very young deaf child and its parent. Three teachers were employed by the hospital (Ministry of Health) and education began as early as 10 months. At that time, the problem of deafness in very young children was the subject of intensive investigation. This pioneer work carried out in London by the Royal National Throat, Nose and Ear Hospital was, however, limited in scope and mainly exploratory. As the local education authority, the Council had a close interest and duty in the matter, and it was hoped that the Council's audiology units would develop along the same lines. The kind of staff envisaged was three teachers, employed by the Education Officer's department, and nine nurses employed on audiometer testing. The work in the auditory training centres would be with the parents and children under the age of three : it was hoped that the children would be found later to be suitable for admission to ordinary schools. In August, 1952, the appropriate Committees of the Council authorised the employment of teachers of the deaf to work with young deaf children at the Council's audiology centres. It was pointed out that, although the Education Act, 1944, made provision for the teaching of deaf children from the age of two years, it was unusual to admit children to the Council's nursery classes for the deaf before the age of three years, as below that age a child was too young for full-time attendance at school. By the time a deaf or partially deaf child was admitted to school, however, much valuable time had been lost unless, from an early age, he had been receiving special training to enable him to overcome his handicap. The untrained child, on admission to school, had to spend educational time in basic training to enable him to benefit from education and might never wholly make up the time lost. To ensure that any medical treatment which might ameliorate their hearing conditions would be carried out, the Council undertook that its consulting ear, nose and throat surgeons would examine all children, whether of school age or under the age of five, and whether deaf or partially deaf, who came under the scheme for the training of very young deaf children. When the Council's proposal was approved by the Ministries of Health and Education a letter was sent to all those in London who were entitled to refer deaf children to the special clinics. A suitable peripatetic teacher to start the scheme commenced work on 25th April, 1955, and is now working at the Province of Natal Centre, Holborn and St. George's Dispensary, Elephant and Castle. The teacher is under the direction of the Education Officer through his inspectorate, and is responsible singlehanded for the teaching of deaf children carried out at the two audiology centres named above. She is also responsible for the follow-up of the progress of pupils now attending ordinary schools who formerly attended partially deaf units, to ensure that they are successfully coping with a normal hearing environment. Each child attends with a frequency determined in the light of its need and the case load. The length of a session for each child varies. 52 children were attending her sessions by the end of November, 1955. It is intended to appoint a second teacher and to open two additional centres in 1956. 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 22,400 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. 1ll 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, 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 Kingsdown, Kent; Barrow, Lancashire (diabetic children), and Brockley, Northants (epileptic children). Scabies, impetigo and ringworm Individuals treated for scabies totalled 961, compared with 898 in 1954. Cases of impetigo treated at minor ailment and bathing centres numbered 3,749, compared with 3,196 in 1954. The incidence of scalp ringworm (9 cases) was the lowest ever recorded in the County. Medical treatment Under Section 3 of the National Health Service Act, 1946, it became a duty of the Minister of Health to provide through Regional Hospital Boards and Boards of Governors of Teaching Hospitals, the services of specialists at hospitals, health centres, clinics, etc. The Council, as Local Education Authority, also has a duty under Section 48 (3) of the Education Act, 1944, ' to make such arrangements .... as are necessary for securing that comprehensive facilities for free medical treatment are available to its pupils either under this Act or otherwise'. 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 schoolpupils 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 he with the Regional Hospital Boards. In the 1953 and 1954 reports attention was drawn to the difficulty in obtaining the necessary vision sessions in one of the four metropolitan hospital regions, the Regional Hospital Board being unable to accept any additional financial commitments. As a special case the Ministry of Health authorised the Council to employ ophthalmologists to deal with the mounting waiting lists. Up to the end of December, 1955, 1,414 sight tests were carried out at 241 vision sessions in the three divisions concerned. The Regional Hospital Board agreed to make provision for additional vision sessions in 1956. School treatment centres At the end of the year there were 112 school treatment centres, 91 run directly by the Council and 21 by voluntary committees. The following table shows the number of clinics available in school treatment centres for the treatment of each defect (comparable figures for 1954 are shown in brackets) : Type of clinic Minor Ailments 88 (83) *Dental 65 (63) †Vision 44 (41) †Orthoptic 13 ( 8) †Ear, Nose and Throat 8 (12) Audiology 11 ( 9) ‡Speech Therapy 37 (35) †Enuresis 1 (1) Special Investigation 21 (15) Nutrition 31 (29) †Rheumatism (Supervisory) 14 (14) *Several of these are twin surgeries. †Specialists provided in most cases by regional hospital boards. ‡In addition to 27 in day E.S.N., 17 in P.H., and five in residential schools. 112 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. Today 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. 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 296 996 104 Ear, Nose and Throat 307 530 135 Vision 180 1,623 865* Orthoptic 73 755 † Orthopaedic 87 211 82 * Spectacles either obtained or not needed. t Not available. The total number of attendances of school-pupils seen in departments of the hospital attended by the organisers was 5,055. Ministry of Education returns call tor inrormation 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 : Treatment statistics Type of clinic 1953 1954 1955 *Vision *Orthoptic *Ear, Nose and Throat Audiology Minor Ailments Dental *Rheumatism Nutrition Special Investigation *Enuresis New cases 35,222 34,420 34,425 Attendances 92,511 94,176 93,082 New cases 1,517 1,410 1,276 Attendances 11,564 11,643 11,200 New cases 6,301 6,439 4,642 Attendances 15,291 15,056 11,826 New cases 1,330 1,153 1,164 Attendances 2,676 2,954 3,299 New cases 169,443 166,173 165,558 Attendances 794,263 757,220 739,923 New cases 116,499 129,712 121,362 Attendances 269,061 300,912 315,750 New cases 959 786 613 Attendances 6,936 5,681 5,003 New cases 1,144 1,090 933 Attendances 10,593 10,594 9,565 New cases 957 904 867 Attendances 4,588 5,626 5,587 New cases 808 592 535 Attendances 4,026 3,466 3,275 *Hospital and specialist services provided by boards of governors or regional hospital boards. 113 114 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 1955 and the preceding years are given below : Cases of infectious illness involving exclusion or absence reported from schools in 1955 and preceding years Year Chickenpox Diphtheria German measles Impetigo Measles Mumps Ophthalmia and Conjunctivitis Poliomyelitis Ringworm Scabies Scarlet fever Whooping cough 1938 11,018 3,576 2,383 1,018 31,852 4,805 342 — 278 2,718 3,988 4,067 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 1955 8,366 7 639 522 16,724 1,982 271 206 80 72 984 1,614 These figures are uncorrected for diagnosis, but they form the best available index of the trend of those infectious diseases in the child community, 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. Handicapped pupils At the end of the year special educational treatment was being provided for more than 10,500 pupils, and the following table shows the main categories of handicap and numbers of pupils receiving full-time special educational treatment: Day special schools Boarding special schools Hospitals Non-Council boarding schools, hostels, foster-homes Blind — 48 — 66 Partially sighted 311 — — 7 Deaf and partially deaf 312* 53 — 63 Physically handicapped 1,152 74 409 42 Delicate 1,418 299 — 89 Educationally sub-normal 3,332 510 — 66 Epileptic — — — 38 Maladjusted 43 211 45 285 *Includes 69 pupils in partially deaf units. In addition part-time special educational treatment at day special classes was provided for 319 maladjusted pupils and 1,507 pupils with speech defects. During the year the numbers of new formal ascertainments were as follows: Day Boarding Blind — 24 Partially sighted 35 — Deaf and partially deaf 35 6 Delicate 548 612* E.S.N 813 124 Epileptic — 9 Maladjusted 121 169 Physically handicapped 216 16 Speech defect 1,027 25† Dual defect — 39 *Including diabetic and E.S.N./Delicate. †Including 12 pupils already E.S.N, and seven already P.H. The following table gives details of the numbers of children found to be no longer in need of special educational treatment during 1955: Day Boarding E.S.N 106 10 Physically handicapped 85 6 Partially sighted 26 — Maladjusted 141 21 Deaf and partially deaf 12 2 Epileptic — 4 Blind — 3 Speech defect 405 — The above figures include children enabled to leave school at the age of 15 years on the grounds that education in a special school is no longer necessary. Particulars of children discharged from schools for the delicate are not shown as the need for this type of special educational treatment is, as a rule, for comparatively short periods. Section 57 of the Education Act, 1944, deals with the examination and reporting to the local health authority of children considered incapable of receiving education at school, of children whom it is considered inexpedient to educate with other children and of children needing supervision under the enactments relating to mental health Educationally subnormal children 115 after leaving school. Details of the numbers reported under this section are given below: Section 57 (3)—Incapable of receiving education: Children not in any school 94 Children in normal schools 9 Children in special schools 90 Children receiving home tuition under Section 56 of the Education Act 1 194 Section 57 (3) and (4)—Inexpedient to educate with other children 6 Section 57 (5)—School leavers 348 In 1955 another 87 school leavers were in need of voluntary supervision only. Section 8 of the Education (Miscellaneous Provisions) Act, 1948, enables a review to be made in the case of any child who has been reported to the local health authority under Section 57 (3) of the Education Act, 1944, and gives authority for the cancellation of the report where the child, on re-examination, is found to be educable. Reports on five such children were cancelled. Of these children, two were ascertained as educationally sub-normal, two were ascertained as educationally sub-normal and partially deaf. The fifth child was considered suitable for admission to a school for educationally sub-normal children but as he and his family moved out of London immediately after the withdrawal of the report to the local health authority his ascertainment is a matter for the local education authority of the area where he is now living. In addition to the examinations of pupils who were eventually ascertained as handicapped, in some 1,500 other instances it was recommended, after examination, that the pupils should remain in ordinary school with, if necessary, special treatment such as restrictions on games, special coaching, favourable position in class, etc. Physiotherapy for physically handicapped pupils Reference has been made in previous annual reports to the very successful arrangements, started in 1950, at the Venetian special school for physically handicapped pupils whereby physiotherapy has been given to the pupils at the school by physiotherapists working under the supervision of the Director of Physical Medicine from King's College Hospital. Negotiations with other hospitals have now resulted in similar arrangements at a number of other schools. In addition to King's College Hospital, mentioned above, the Middlesex, Royal Free, London and St. Mary's (Princess Louise) Hospitals are linked with local schools for the physically handicapped, and provide physiotherapy in the schools. Negotiations are still proceeding in respect of certain schools, in the south of London, where there are no nearby teaching hospitals. Diabetic pupils The Council maintains a residential hostel for diabetic pupils at Palingswick House, Hammersmith. Children suffering from diabetes melhtus, which cannot be adequately controlled at home, and who are of such intelligence as to profit by their stay are admitted. The principles of control of the disease and the importance of diet 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 day to day care and a consultant visits regularly. The children attend local schools, the infants returning to the hostel for lunch, the others have part school meal and part food taken with them from the hostel. Speech therapy As indicated in the 1954 report, there has been an extension or the speech therapy service in both day and residential schools. Sessions at school treatment centres have increased from 28 to 38, those at day schools for the educationally sub-normal from 25 to 26, at day schools for the physically handicapped from 15 to 17 and at residential schools from 4 to 5. At the end of the year 1,483 pupils were under treatment at these 116 various speech therapy classes. New admissions during the year amounted to 628 and 473 pupils were discharged as either improved or cured. 259 pupils, most of whom have shown some improvement, ceased to attend the classes for various reasons. The increased activity indicated was made possible by additional staff engaged during the year, the total of which on 31st December stood at 13 full-time speech therapists (including one senior therapist), 3 part-time and 7 sessional therapists. 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. Two sessions a week for school pupils were held and the number of new cases seen throughout the year was 255 (289). The waiting period has averaged three weeks and has not risen above six weeks. There was a total attendance of 1,555 (1,759) and 91 (137) children were discharged as cured. A number of former pupils who failed to re-attend were, necessarily, removed from the current fde, but a home visit from a care committee worker often resulted in a resumption of attendance. Enuresis is also 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 Following a slight but steady decline during the past three years, there has this year been an abrupt fall in the number of cases of juvenile rheumatism referred for admission to Queen Mary's Hospital for Children, Carshalton. Nominations received 63 Outstanding from previous year 2 65 Admitted to rheumatism unit 63 Nominations withdrawn 1 Not suitable for unit 1 65 The indication that acute rheumatism is become progressively less prevalent is not alone sufficient to account for this fall and further factors therefore must be looked for to account for admissions being less than half those for the previous year whereas the new cases at the rheumatism advisory centres still seem to follow the previous trend. It may be that some patients have been admitted direct to Queen Mary's Hospital without going through the Rheumatism Scheme Register and that more patients are being diverted to the Special Rheumatism Unit of the Canadian Red Cross Hospital, Taplow. Although the total numbers have fallen, the percentage of children with cardiac involvement has risen and this is seen mainly amongst the boys (an increase from 28.1 per cent. to 44.8 per cent.) whereas the percentage of girls has fallen slightly (31.5 per cent. to 27.8 per cent.). Aortic disease was again more evident amongst the boys. 117 Percentage of children with cardiac involvement on admission during recent years has been: 1948 1949 1950 1951 1952 1953 1954 1955 70.2 51.7 60.8 49.1 43.7 41.2 34.5 41.3 As heretofore the figures for chorea show a feminine predominance, but the proportion is higher than last year and also the complication of carditis is more evident. The condition on admission of the children admitted during 1955 was as follows: Boys Girls Articular rheumatism Number admitted 29 18 Percentage with: Carditis 44.8 27.8 Valvular damage: Mitral 6.9 5.5 Mitral and aortic 3.5 — No cardiac involvement 44.8 66.7 Chorea Number admitted 2 8 Percentage with: Carditis — 12.5 No cardiac involvement 100.0 87.5 Articular rheumatism and chorea Number admitted — 4 Percentage with: Carditis — 50.0 Valvular damage: Mitral — 25.0 No cardiac involvement — 25.0 N.B.—Two children were diagnosed ' not rheumatism Remedial exercises classes Special classes to correct foot defects, before they develop into permanent disabilities are held, mainly in primary schools. The classes 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. The general medical supervision of the classes is undertaken by the consultant in postural defects who visits each class at least once a year. A school medical officer in each division is responsible for selecting the children and for their discharge on improvement. Psychiatry Child guidance The year was again a busy one at the Council's four child guidance units and the increasing demand for their services has continued. Some increases of staff have helped the units to undertake more treatment but waiting lists remain longer than is considered desirable. The length of the waiting list, resulting in delays before children can be seen or treatment undertaken, has constituted the major problem facing the medical directors. Staff from the units have co-operated with maternity and child welfare centres in the scheme for mental health education in the Maternity and Child Welfare service (see page 70). In addition psychiatric guidance for parents of children under five continued to be provided at two clinics run in conjunction with the local infant welfare centres. 118 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 163 72 90 180 505 No. awaiting first interview at 31st December 38 11 21 32 102 No. interviewed and awaiting treatment 6 23 18 9 56 Number of patients In treatment at 1st January 35 136 56 40 267 New cases treated 136 58 73 156 423 Total 171 194 129 196 690 In treatment at 31st December 133 45 50 82 310 Discharged 139 48 79 114 380 No. of follow-ups 7 — 20 — 27 No. of home visits by psychiatric social worker 15 14 7 47 83 No. of school visits by staff 38 78 114 105 335 Disposal of patients Treatment completed 52 20 33 47 152 Transferred to other treatment 12 1 5 5 23 Further attendance impossible 10 10 18 6 44 Unco-operative 59 16 19 46 140 Placed or placement recommended 4 — 3 5 12 Taken into care 1 1 1 4 7 Total 138 48 79 113 378 Closing status of completed treatments Improved 46 16 30 40 132 No change 5 4 3 7 19 Worse 1 — — — 1 Total 52 20 33 47 152 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 create 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. Psychiatric services at boarding special schools and residential establishments The Lilian Baylis School, the first day school for maladjusted children in the County, was opened in 1954, and much interest has been aroused in this experiment in the 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. Day school for maladjusted children It was round necessary in 1955 to appoint a part-time psychiatric social worker to work at this school as many of the children were not under treatment at a child guidance clinic and there was insufficient contact with parents. She has made a valuable contribution towards the work of the school. 119 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 management of the Children's Committee. There were six residential establishments at the end of the year with accommodation for 2,378, four approved schools with a total accommodation of 428, 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 at least once very week. His duties include the medical examination of children on admission and on discharge or transfer and in addition he gives each child a complete physical examination once a year. During 1955 4,690 medical examinations were held. The visiting medical officer is also the children's ' family doctor' under the National Health Service Act. Periodic visits were made by senior medical and nursing officers from County Hall. Arrangements were made for the dental treatment of the children, and visits were made by the Council's psychiatrists. Bed-time for schoolchildren The importance of adequate sleep to the growing child has been emphasised over many years and the problem of how to persuade parents of that importance and of their duty to see that their children get adequate sleep has always been well in the minds of education authorities. In 1918 a pamphlet was printed and issued by the Council urging on parents the importance of early bed-times for children. In 1937 following consideration of the problem by the Central Consultative Committee of Head Mistresses of Girls' Schools, this pamphlet was completely redesigned. Heads of all schools were asked in 1938 to distribute copies to the eldest child of each family in the school so that every family received a copy; and a supply of the pamphlet (slightly amended from time to time) has been available since then to all schools on requisition. The 1938 pamphlet received wide publicity in the press and several other authorities asked for copies with a view to their distributing similar pamphlets. The Central Council for Health Education has also published a pamphlet on the importance of sleep and this has been placed on the schools requisition list. The requisition rate in 1955 was about 19,000. The pamphlet is revised from time to time. The report of the Education district inspector's enquiry suggested that these troubles cannot, however, be put down entirely to the watching of television programmes. This view is confirmed by information supplied by the British Broadcasting Corporation from the findings of an audience research survey of nearly 3,000 homes : 5-7-year old—' There is, however, little or no evidence to suggest that children of this age group go to bed later in T.V. than in non-T.V. homes.' 8-11-year old—' It seems that on weekdays 8-11's in T.V. homes stayed up, on the average, about a quarter of an hour later than did those in non-T.V. homes.' 12-15-year old—' There was no great difference between the bed-times of 12-15's in T.V. and non-T.V. homes, but boys seemed to stay up a little later than girls.' Through the years, various attractions and habits have been blamed as being the cause of children going later to bed than they should. For example, in the early part of the century, children awaited parents who were in public houses, then it was ' summertime' and the cinema; 'double summer-time'; the radio; exhibitions such as the speedway, and now television. In some homes shortage of accommodation is no doubt one reason for children going late to bed. In the past, the problem has been thought to be mainly, though by no means wholly, one of the summer months when children are reluctai.: to return home to go to bed whilst it is still daylight. However the responsibility must be with the parents for seeing that their children get adequate sleep. If an 120 attraction, such as television, is a special cause of lateness to bed, it is the parents who must be persuaded to exercise the necessary control. It seems likely, however, that if a parent allows a child to be late to bed for one reason, be it television or the cinema, that same parent would probably permit late hours, in the absence of that particular attraction, for other reasons such as late play in the street or the park. The attention of the Heads of schools was again drawn to the matter and they were requested to lose no opportunity of bringing parents to a realisation of the importance of sleep. Research and investigation Mr. K. P. Murphy, of the University of Manchester Department of Education of the Deaf was granted permission to carry out intelligence tests on deaf children in the Council's schools, as part of the survey of abilities and achievement of pupils in schools for the deaf and partially deaf being carried out by the Medical Research Council's Committee on the Educational Treatment of Deafness. Mr. P. Venning, of the Department of Anatomy, University College, London, was granted permission to carry out X-ray examinations of the feet of a group of children as part of his study of skeletal growth. Dr. M. Morley, of the Royal National Orthopaedic Hospital, was granted permission to examine a group of children as part of her enquiry into postural defects. DENTAL SERVICES the council's Chief Dental Officer and Principal School Dental Officer reports as follows : Since 1951 there has been an increase in the number of operative and inspection sessions in the Council's dental services but, as may be seen from the graphs on page 123 there was little change in 1954 and 1955. Recruitment of new staff in 1955 almost balanced resignations. The number of full-time dental officers fell and in part-time staff there has been about 50 per cent, turn-over in 12 months. Dentistry is a personal service and such frequent staff changes naturally disturb many patients and parents and give rise to many problems in supervision and co-ordination of effort. Table I shows the staff numbers at the end of the year but does not reveal the position referred to above, with its resultant adverse effect upon the standards and efficiency, of this multi-surgery dental service. 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 (Dec.) 1953-93 113 52 61 659/11 57/11 547 177$ 40 22¾ 724½ 62¾ (Dec.) 1954-93 114 54 60 68 62/11 569 179 41 27 748 68 (Dec.) 1955-93 116 49 67 6710½/11 52½/11 527½ 220 33½ 24 747½ 57½ 121 School dental service For the third successive year since the Council approved the policy of attempting to obtain a ratio of one full-time dental officer for each 3,000 children on the school roll (i.e. about 150 dental officers), lack of recruits prevented attainment of even the interim establishment of 93. The year under review produced further evidence of the need for national consideration of dental man-power problems if there is to be any hope of producing an efficient and sufficient dental service for children in Britain. In 1955 the County ratio attained was 1 : 6,400, (1954, 1: 5,600) the rise being due to increased school population. This ratio ranged from 1 : 4,400 in Health Division 4 to 1 : 8,000 in Health Divison 7. Against such odds the service struggled to spread treatment evenly for the good of the greatest number. Systematic revisional treatment was impracticable. As would be expected with almost the same number of staff the years 1953, 1954 and 1955 produced very similar statistical results and the accompanying tables for the respective sections of the dental service show only moderate fluctuations. I would however, draw attention to certain indications. In Table II the percentage of schoolchildren found to require treatment has, for the second successive year risen quite sharply and is shown as 11 per cent, higher than two years ago. Table II 1952 1953 1954 1955 Number of inspection sessions held at schools 584 1,448 2,056 2,008 Number of children inspected at schools by dental officers 59,677 153,293 199,041 202,242 Number found to require treatment 38,069 97,736 139,955 151,326 Percentage requiring treatment 63.8% 63.8% 70.3% 74.8% Additional number inspected at centres 71,452 76,291 67,604 50,887 Total number found to require treatment 109,521 174,027 207,559 202,213 Total cases treated 93,823 116,499 129,712 121,362 Attendances 202,571 269,061 300,912 317,684 Ordinary treatment sessions 19,563 27,366 29,022 29,698 General anaesthetic sessions 1,494 1,725 1,939 1,578 Temporary teeth extracted 96,561 103,922 108,825 83,539 Permanent teeth extracted 17,283 19,727 21,095 16,527 Temporary teeth restored by fillings 26,353 37,787 46,256 45,256 Permanent teeth restored by fillings 66,680 92,576 112,226 122,097 Fillings in temporary teeth 27,556 40,120 49,148 48,075 Fillings in permanent teeth 72,369 102,178 124,974 135,384 Other operations—temporary teeth 45,985 59,863 65,280 62,496 Other operations—permanent teeth 30,291 44,250 57,086 65,811 Local anaesthetics for extraction 24,667 27,020 21,216 17,341 Local anaesthetics for conservative treatment 3,753 7,072 8,352 7,130 General anaesthetics 33,448 37,887 43,899 36,099 Cases for whom immediate treatment was completed 13,135 15,196 17,474 13,744 Cases discharged as dentally fit 63,638 81,488 86,957 80,964 Total extractions, however, have fallen while fillings have increased and a gratifying figure is shown in Table III; the continued improvement in the ratio of permanent teeth restored to those extracted. Table III Ratio of permanent teeth restored to permanent teeth extracted in schoolchildren 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 1955 7.39 to 1 122 123 Orthodontics Table IV shows, for the fifth successive year, improvement in the number of orthodontic treatments undertaken but it is unfortunate that in 1955 the Hospital Service (Part II, N.H.S.) was unable to accept a greater number of patients for this special form of dental care. The loss of treatment in the hospitals was to some extent off-set at the new Province of Natal Centre by four additional sessions a week specifically for orthodontic treatment introduced by the Council in October. Table IV 1951 1952 1953 1954 1955 Number of special orthodontic sessions 245 134 138 134 185 Number accepted at special orthodontic sessions 117 85 80 98 195 Number accepted at routine sessions — 209 290 389 432 Number referred to hospitals — — 100 127 59 Total number of patients accepted 117 294 470 614 686 The steady increase in the number of orthodontic patients accepted at the Council s routine dental sessions is indicative of the more thorough treatment for individual patients made possible by the evenly balanced sessional case loading system now in operation. There is no doubt that with smaller numbers of patients attending each session more constructive and conservative treatment is being given than could be possible if waiting rooms were more heavily loaded. Maternity and child welfare dental service The very slow growth in the maternity and child welfare dental service commented upon in 1954 continued throughout 1955 and an increase of 212 sessions on the previous year was obtained—to some extent by continuing to utilise voluntary evening sessions. All applications for treatment from expectant and nursing mothers and children under five were met but, for another year, it was impracticable to organise systematic dental inspection of all potential patients, nor was it possible to follow-up reluctant patients. Table V shows comparative figures. Table V Attendances and treatments of maternity and child welfare patients 1952 1953 1954 1955 Number of ordinary sessions 2,031 2,505 2,780 2,992 Number of general anaesthetic sessions 306 299 253 228 Number of appointments offered 24,609 30,441 33,797 35,854 Attendances—by appointment 18,995 22,675 24,692 26,430 —other 2,162 2,122 1,873 1,526 Silver nitrate treatment 2,907 4,256 4,433 5,058 Fillings 8,852 11,074 12,312 13,212 Extractions 8,463 9,565 10,157 9,177 Dentures supplied—new full 310 373 461 572 —new partial 400 520 646 686 Number made dentally fit 5,479 6,818 6,802 7,117 Dental service in boarding schools and residental establishments At most of the Council's boarding schools and residential establishments dental services to meet local requirements were in operation throughout the year. These services were obtained by use of visiting dental officers wherever possible or by engagement of local practitioners in their own premises. A variety of contracts had to be made to meet recruitment difficulties and, in consequence, accurate records of work done are not available for comparison with previous years. I would record my thanks to and appreciation of the efforts of all dental staff who have assisted throughout another difficult year. 124 STAFF the staff employed in the public health department is set out in Appendix D on page 190. Review of the public health department In 1953, the Council decided to institute a continuous programme of comprehensive reviews of the work, organisation and staffing of each of its departments, the aim being to complete each cycle of reviews in five years or thereabouts. A review of the public health department was completed towards the end of 1955. A steering committee including senior officers from the public health department and other departments, under the chairmanship of an assistant clerk of the Council, was appointed to conduct the review whilst the detailed examination of the various branches and divisions was carried out by a small team of trained organisation and methods officers allocated by the Council's director of establishments. Proposals were approved by the Council during the year to transfer to the Metropolitan Borough Councils (subject to any necessary legislation being forthcoming and to certain other conditions) some of the Council's health functions, and for this reason certain major aspects of the department's work were left for future consideration. Despite these limitations, the review was a formidable undertaking, as the public health department is the third largest in the service, with a staff of over 7,000 and an annual salaries and wages bill of approximately £3,384,000 a year. The full report which the steering committee submitted contained a number of recommendations. One of these was concerned with the determination of staffing ratios for professional and auxiliary staff, several with the organisation and staffing of services run centrally, with divisional organisation and staffing and with matters for future reconsideration. These recommendations were accepted by the Council. In addition many matters of lesser importance were discussed with departmental officers during the course of the review and action was taken or active consideration given to them without the need for specific recommendation. The acceptance of the proposals will result in the immediate or near future in a net reduction of 32 staff positions, representing with the regrading of certain other positions, a financial saving of £23,300 a year. A brief resume of the principal aspects of the report, and of action taken on it, follows. Functions and general organisation of the department The present structure of the department was designed to enable the Council to undertake the duties for which as local health authority it found itself responsible from 5th July, 1948, when the National Health Service Act, 1946, came into operation. The principal factor governing the present departmental organisation was the decision of the Council that, in order to permit the largest practicable measure of decentralisation of its personal health services, London should be divided into nine divisions, each consisting of the area of two or more metropolitan boroughs, and each with a divisional health committee as a sub-committee of the main Health Committee. About 60 per cent. of health service expenditure is incurred locally, and about 80 per cent. of the staff of the department work in services locally controlled. Work at head office falls naturally into three main spheres, to which the three branches of the department correspond : Head office organisation Branch 1—Maternity and child welfare; school health; domestic help; home nursing. This branch is the responsibility of the senior principal medical officer, and is served not only by medical staff but by the chief dental officer, the chief nursing officer and the principal organiser of children's care work. 125 Branch 2—Co-ordination of planning within the department and with other bodies; social and preventive work relating to tuberculosis and other diseases; after-care; mental health; health education; epidemiology; housing; statistics; research. This branch is under the supervision of the deputy medical officer of health; besides medical staff it includes the chief inspector and the scientific adviser with the staff of the laboratories at the County Hall and at the main drainage outfall works. Branch 3—Lay administration, including co-ordination of the work of all divisions and the London ambulance service. This branch is in the charge of the administrative officer, and is organised in four divisions as follows: A—Work broadly corresponding to that of branch 1. B—Co-ordination of planning; acquisition of sites and provision of new buildings; ascertainment and after-care of mental defectives and the mentally ill; social and preventive work relating to tuberculosis and other diseases; after-care generally; epidemiology; and various other related functions, including slum clearance and the registration of nursing homes. C—Health education and propaganda; estimates and finance, including the preparation, on a mechanised system, of wages sheets for head office and divisional staff; recovery of expenses; statistics, supervision of committee work, annual reports, examination of new legislation, and other administrative matters not dealt with elsewhere. Divisional organisation D—Staff and establishment matters. The administration of the London ambulance service is at present largely selfcontained and forms, in effect, a fifth division of branch 3. The divisions, of which there are nine, vary in size approximately from 6½ to 22½ square miles, and in population from under a quarter of a million to over half a million. There is liaison with the Metropolitan Borough Councils, who are responsible for the'environmental health services, both at member and at officer level. The membership of each divisional health committee consists of approximately twice as many representatives from the Metropolitan Borough Councils within the division as there are members of the Council and/or Health Committee, together with local representatives of professional and other bodies. Under an agreed scheme, some borough medical officers of health or their deputies act for part of their time as divisional medical staff of the Council and vice versa. The divisional medical officer is responsible for general supervision of the Council's health services and staff in the division, and is the principal local adviser to the divisional health committee. Lay administration is the responsibility of the divisional administrative officer. Nursing staff, who are allocated to divisions centrally, are under the supervision of the divisional nursing officer, who, like the divisional treatment organiser in her sphere, is responsible to the divisional medical officer for local arrangements. This complex organisation, in which professional and lay officers work side by side, and where some services come under central, some under divisional control, and some are divided between the two, led the steering committee to consider the following three questions before reaching conclusions on the organisation and staffing of individual services or divisions : (a) The numbers and status of professional and administrative top-level staff at the department's central office. On this, the conclusion was reached that existing numbers and gradings were appropriate. (b) The divisional system, which has two aspects, namely whether more (or fewer) services should come within its scope and whether the degree of divisional autonomy in regard to services under local control should be extended or limited in any way. (c) How to secure even loads and levels of professional work and service, and the determination where practicable of standards of output to help in determining staff numbers. 126 This was found to be a question difficult of solution, albeit an important problem, as the salaries of the staff concerned account for about half the total pay bill of the department. Professional and auxiliary staff must be free to work according to the highest standards of their professions and cannot be tied to any hard and fast rules governing output a session. Yet to look for some evaluation of work performance measured in terms of cases dealt with is the only rational way of approaching the problem. From the little research so far done, either nationally or otherwise, it is apparent that conceptions of the standards on which calculations might be based vary remarkably. The problem is complicated in London, too, by the divergence, sometimes wide, in demand or level of service provided, between one division and another. Nevertheless, certain useful criteria for establishing staffing ratios were suggested ; their application to each grade of staff concerned will necessarily take time. The deputy medical officer of health and the establishment officer have been given the joint responsibility for the continued scrutiny and the giving of advice on it. The view was that, subject to general conformity with centrally directed policy, it was reasonable to leave divisional medical officers to run their divisions in their own way, provided that local variations were not carried too far; on the whole the proper balance had been struck, though in certain respects there was a need for greater uniformity as regards procedures and forms. It was felt that the decentralisation of the services handled in divisions should be continued but there appeared to be little scope at present for its extension to the mental health, ambulance and midwifery services. For the ambulance service central control is essential. In the mental health service, it was agreed that the centralisation of work under the Lunacy and Mental Treatment Acts should be continued permanently, but it is proposed to decentralise the mental deficiency inspectorate and combine its work with the supervision work now undertaken from four district offices. There is no practical alternative at present to central control of midwifery, but some future decentralisation is not precluded. A considerable volume of work, mainly case work, is handled centrally either as a service to other departments, e.g., medical examination of staff, or as part of a mainly decentralised service, e.g., the scrutiny of divisional recommendations for the ascertainment of educationally sub-normal children. In view of the need to maintain uniform professional standards, to ensure fair judgment in applying priorities dictated by restricted facilities, to deploy specialist services quickly and economically, and to secure liaison between staff handling complex cases and for administrative convenience, no change is proposed in those arrangements. London ambulance service—Two types of work are dealt with, accident or emergency removals and general removals (usually to and from hospitals). The service operates from a headquarters station with a central control room, from six large general ambulance stations and from 19 accident ambulance stations. Organisation and staffing of centrally administered services As organisation and methods staff in 1952 investigated traffic control and the procedures and staffing at ambulance stations, the present review was restricted to the headquarters organisation. Greater decentralisation since 1952 has enabled a 28 per cent. increase of work to be absorbed without increasing the control room staff, but a slight strengthening of headquarters staff has now been agreed for this and other purposes. Mental health services. (a) Mental deficiency—Six social workers (inspectors), based on the County Hall, make reports as part of the ascertainment procedure and are responsible for defectives living under their guardianship in lodgings or hostels and for the supervision of defectives under the guardianship of other persons (including relatives and friends). This work is to be decentralised and merged with the work, based on four district offices, of the local organisers and their assistants responsible for supervision of mental defectives living at home. Inspectors will gradually be replaced by assistant local organisers. 127 (b) Lunacy and mental treatment—Central administration of the work of securing that persons of unsound mind are placed under control, now undertaken by a mental welfare staff of 24, based on the County Hall, has been made permanent. No case was found for combining this work with mental deficiency work. A slight reduction in the current strength of the headquarters administrative staff has been agreed upon. Scientific branch—This branch undertakes chemical analysis and scientific investigation for all departments through a central laboratory at the County Hall and laboratories at the main drainage outfalls. When the review began, it was known as the chemical branch, and its head as the chemist-in-chief. To indicate its wider range and to accord with civil service practice, these titles have since been altered to scientific branch and scientific adviser, and more appropriate titles given to other grades of staff. The analysis of samples of food, building materials, fuels, etc., and the research undertaken is either necessary in the interests of the public or of direct financial benefit to the Council, and could not be done so efficiently or economically by other means. To avoid unnecessary or unprofitable work, the department is giving requests for service stringent examination before acting on them and is keeping under review the need for frequent and extensive analysis of food from stock, and of sewage. Inspectorate—The chief inspector and his deputy, who are available for advice or consultation in relation to the Council's services generally, had under them 13 inspectors organised rather flexibly in two groups; one concerned with housing and town planning, and the other with the other functions of the inspectorate which include health questions at Council establishments and at nursing homes and other general public health matters. To reduce pressure on housing and slum clearance work, two temporary inspectors have been added. Action is being taken to simplify procedure at the hearing of objections to clearance orders and compulsory purchase orders, and to regulate the frequency of inspection. Tuberculosis—Diagnostic and curative work is the hospitals' function ; the Council is responsible for prevention, care and after-care. The focal points of both are the 32 chest clinics; the chest physicians in charge are appointed and paid by the hospital authorities, but undertake certain of the Council's duties for which the Council reimburses 3/11ths of their salary. Both the hospital authorities and the Council employ other staff at the clinics. For most clinic areas there is a voluntary tuberculosis care committee, which raises and uses voluntary funds for patients' benefit. The Council's clinic staff is 24 local tuberculosis care organisers, the equivalent of about 19 clerical staff, one shorthand-typist, a few part-time senior occupational therapists and the equivalent of 90 health and tuberculosis visitors; the cost of a further 7½ clerical staff provided by the hospital authorities is reimbursed. Day to day administration of the Council's tuberculosis work is, with certain exceptions, through the divisions. The difficulties arising from the division of responsibility for tuberculosis work were the subject of part of the evidence submitted by the Council to the Guillebaud Committee. Pending that committee's report and the conclusions of national working parties on social workers and health visitors, consideration of the questions of rationalisation of the chest clinic service, the use by the Council of local tuberculosis care organisers and the specialisation of health visitors in tuberculosis visiting work were deferred. It was concluded that so long as the present allocation of functions between the hospitals and the Council obtains, the existing arrangements appear to be the best that can be expected. A position of organiser of tuberculosis care work will eventually be withdrawn and a slight reduction in strength of other staff in the headquarters section has been made. Minor procedural changes and staff adjustments have also been made in the staff medical examinations, school health and miscellaneous public health sections and some saving effected. 128 Each divisional health committee is responsible for current administration of the work carried out in the divisions, i.e., maternity and child welfare, school health, health visiting, local liaison with district nursing associations on home nursing, domestic help, prevention of illness, care and after-care and certain other matters. Organisation and staffing of local health divisions Of the medical staff, in general only the divisional medical officer and the deputy divisional medical officer in each division undertake administrative work, and some of them hold a joint appointment from the Council and a metropolitan borough council or councils, devoting up to 40 per cent. of their time to borough work. Other medical staff in divisions are engaged almost exclusively on clinic duties. The nursing staff has recently been strengthened by increasing the establishment of centre superintendents (health visitors with supervisory duties). Lay administration is generally organised in three sections, a maternity and child welfare and general section, a committee and staff section and a finance section. The review has disclosed that there is room for more uniformity between divisions and further delegation of work to less senior staff. In future the second administrative officer will act also as head of the committee and staff section, thereby enabling an administrative position in the next lower grade in each division to be given up, the remaining staff being strengthened in some divisions. The duties of clinic clerks were considered to require definition and consideration is being given to the possibility of attracting more voluntary workers for general clinic duties, and to the employment of sessional clerical assistance instead of using full-time officers. Methods and procedures in the divisions have been examined and there are to be improvements in regard to recording of information about births, the form of vaccination and immunisation statistics, the handling of recommendations for preferential housing on medical grounds, accounting for unaccompanied children sent on recuperative holidays, debt collection, the design of forms and other matters. Domestic help service—A special section of the reviewing committee's report was devoted to this service. Each division is divided into between two and five home-help districts. A home-help organiser, assisted by one or more assistant organisers and clerical staff is responsible for the service in each district. When the review began the total staff comprised 29 organisers, 33 assistant organisers, 46 clerical staff and 3,004 (equivalent to 1,919 full-time) home helps. Over 80 per cent. of the service given is for the chronic sick, aged and infirm, and the service is expanding; the number of hours worked by home helps has increased by 30 per cent. and the cost has nearly doubled in four years since 1950. The organisation was examined thoroughly and comparison made with the service of six other authorities. There is considerable variation in standards of service from district to district and from division to division and there is scope for greater uniformity. Suggestions for increasing supervision and adjustments in staffing have been remitted for examination to a departmental working party, who will also consider suggestions concerning district organisation and boundaries. Training of students health visitors The University or London Institute or 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 235 of the Council's student health visitors trained since 1948, 228 have been successful in the examinatior of the Royal Sanitary Institute for the health visitors certificate and, of these, 121 are still in the Council's service while a further 40 students are in training. Staff medical examinations 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 14,657, compared with 14,040 in 1954. Members of the staff found to be permanently unfit for further duty with the Council numbered 298 and 289 candidates were found to be unfit for appointment. Reciprocal arrangements with provincial authorities for 129 the local examination of new entrants were continued. Provincial medical officers of health arranged for the examination of 79 entrants to the Council's service and the Council's medical officers examined 59 persons for provincial appointments. The Council's staff medical examiners made 81 home visits to examine members of the staff who were unable to travel, compared with 84 during 1954. Food-handlers in contact with infectious diseases Arrangements were made for the bacteriological examination of specimens from members of the food-handling staff in Council estabhshments who had been absent from work suffering from illnesses which might have given rise to food-borne infection or who had been in contact with such illness in their own homes. During the year 252 persons (including 58 contacts) were examined, all but 13 of whom were allowed to return to work after examination. The 13 who were regarded as infectious were referred to their private doctors for treatment before being allowed back on duty. FINANCE Capital the total capital expenditure on the health services of the Council in the year ended 31st March, 1955, was £84,931, details of which are as follows: Ambulance service:— £ Acquisition and erection 19,541 Adaptation and equipment 12,007 Reinstatement after war damage 13,805 Day nurseries—acquisition, erection, extension, repair 8,568 District nursing—purchase of cars 860 Hostels:— Cromwell Lodge—acquisition, adaptation and ment 2,964 Dover Lodge—acquisition, adaptation and equipment 4,388 Maternity and child welfare centres—acquisition, erection, equipment 16,498 Occupation Centres—adaptation 2,349 Other Health Centres and estabhshments 3,951 £84,931 Maintenance The gross cost of the various services in 1954-55—including central administrative charges but excluding debt charges—and the contributions recovered from recipients of the services were : Service Cost Amount recovered in charges £, £ Ambulance service 870,461 — Day nurseries 982,980 203,251 Domiciliary midwifery service 171,283 — General health services (including £163,152 contribution to Metropolitan Borough Councils for salaries of sanitary officers) 191,275 — Health centres 18,581 — Health visiting 307,060 — Maternity and child welfare 597,698 41,229 Mental health 188,146 — Prevention of illness— Home nursing 369,956 — Domestic help 766,404 39,616 Other preventive services 485,224 26,595 School health 802,844 9,112 £5,751,912 £319,803 130 The net cost of the services after allowing for Government grant, expressed in terms of rate in the £ was 11-22d., divided as follows: Ambulance service 1.76 Day nurseries 1.52 Domestic help service 1.53 Domiciliary midwifery service .35 General health services .78 Health visiting .65 Home nursing .78 Maternity and child welfare 1.17 Mental Health .39 Prevention of illness (care and after care; chest clinics, foot clinics, etc.) .83 Vaccination and Immunisation .14 School health 1.32 11.22 VISITORS TO THE DEPARTMENT the majority of visitors to the department visited the Woodberry Down health centre, either solely or as part of a wider programme, partly because under its roof may be seen so many examples of the services provided by the department and partly because of the unique nature of the Centre. Visitors In 1955, 526 visitors from home and abroad went there. Further details of visitors to the health centre are given on page 143. Facilities for visits to other premises and services or for talks with senior, medical, nursing or administrative staff, were extended to 266 visitors (some of whom also went to Woodberry Down health centre and are therefore included in the larger figure above) 163 being from 52 overseas countries. Hospital student nurses, of whom 3,627 visited during the year, were again the Students largest single class of student for whom the department provided opportunities for observation and instruction, and their number increased considerably compared with that for the previous year. 470 students engaged in various types of training connected with the education of the educationally sub-normal, the training of the mentally defective and social science field visited occupation centres for the mentally defective. Health visitor students from Battersea Polytechnic and from the Royal College of Nursing continued to gain practical experience in the divisions while arrangements were also made for them to pay visits of observation in parties to services and premises administered by the Public Health and other departments of the Council. Post-graduate medical students studying for the Diploma in Child Health and the Certificate in Public Health continued to be given facilities under the supervision of the medical staff for visiting premises relating to the maternity and child welfare services and to the school health services. During the year about 1,125 visits were arranged for 75 students preparing for the Diploma and about 180 visits were arranged for some 36 students preparing for the Certificate. Training centres continued to send groups of medical, nursing or social science students to undertake visits of observation and to be given talks relating to the department's activities and during the year students came from the following organisations : London School of Economics Royal College of Nursing Battersea Polytechnic Women Public Health Officers' Association Battersea Training College of Domestic Science King Edward's Hospital Fund Staff Training College Queen Elizabeth College Bedford College The National Training College of Domestic Subjects. 131 REPORTS BY THE DIVISIONAL MEDICAL OFFICERS Division 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington. Dr. Violet Russell reports : Welfare of mothers and children There was again a fall in the estimated number of children and people of all ages in the division and this resulted in some reduction in the services provided by the Council for mothers and young children. The number of births, both in hospital and at home, was lower than last year and consequently there were fewer attendances at ante-natal and child welfare clinics and some reduction was made in the number of sessions at the welfare centres. The welfare session for mentally defective children at Campden Hill welfare centre continued to provide advice, information and help to the mothers who attended with their children. Vaccination and immunisation Visits by health visitors were also fewer, to some extent owing to sickness among the staff and difficulty in filling vacancies. With the continued fall in the number of young children in the division there was a decrease in the number who were vaccinated against smallpox and also in the number immunised against diphtheria. This was partly due to the suspension of immunisation sessions during the early summer following an outbreak of poliomyelitis in North Hammersmith, but it is hoped that all children whose immunisation was deferred will be dealt with during the winter and early spring. Notwithstanding this reduction there was a slight improvement in the proportion of children under five years of age who had been immunised, and of the children of this age in the division about 54 per cent. have now been protected. In addition to the national campaign held in February constant efforts were made to bring to the notice of parents the importance of immunisation, and the ever-present risk of a serious outbreak of diphtheria among unprotected children. Spastics A pilot scheme of research into infantile cerebral palsy, conducted by Dr. Dunham, a specialist from Charing Cross Hospital, under the auspices of the Medical Research Council, was extended to this division. The object is to ascertain the earliest possible signs and symptoms of spasticity in young infants in order to facilitate an early diagnosis. Arrangements were made for Dr. Dunham to speak to members of the local divisions of the British Medical Association and also to the health visitors and midwives. A centre for spastic children was opened by the South West Metropolitan Regional Hospital Board at Cheyne Hospital, Chelsea. Children attend for the day for education and treatment. Arrangements have been made for meals to be provided for the children and staff by the Cheyne Hospital day nursery. Neglect and ill-treatment of children Health visitors have again taken a leading part in the close partnership which has been established among all field workers concerned with the prevention of ill-treatment and neglect of children and of juvenile delinquency. Cases were kept under constant review and much effort was directed to helping problem families. In order to avoid the break-up of families, all available services provided by the Council and voluntary agencies were fully utilised. Every opportunity has been taken to foster the close co-operation of all social workers in the field. The health visitors have been encouraged to develop a close relationship with the local general practitioners and a series of informal social meetings was arranged so that care committee workers and head teachers could have an opportunity of becoming more closely acquainted with health visitors and school nursing sisters and the work which they undertake. Welfare foods The arrangements for the distribution of welfare foods continued to operate satisfactorily with only minor changes in selling times. There has been a slight fall in the quantities issued during the year. Health education continued to play an important part in the activities of the welfare centres and improvements were made in the facilities for display of posters and other exhibits. Mothercraft classes at some of the larger centres continue to be well attended. 132 Health education A Home Advice Group was formed in North Kensington to institute a series of elementary classes in housewifery for mothers of children attending a local school. Facilities were given at a welfare centre for meetings to be held on one evening each week and the group is now open to other mothers living in the district. Home advice group St. Charles Day Nursery, Kensington, was closed early in the year and the children were accommodated in other nurseries. As a result of this loss of accommodation there was a considerable waiting list for admission to Kensington nurseries until the opening of the annexe at Kensal House day nursery. This provided additional accommodation for six babies and ten children between the age of one and two years. Adaptations to provide additional accommodation at Grove House day nursery, Fulham, were completed. During the year there was a decrease in the demand for admission to day nurseries and there were generally some places for children between the ages of two and five which could not be filled. The number of children in the third priority group whose parents' income exceeded £9 a week rose slightly to about 27 per cent. Improvements were carried out at a number of the day nurseries and electric washing machines and drying cabinets were installed at several of them. There was a slight reduction in the numbers in the care of daily minders and of children attending private day nurseries. Day nurseries and childminders Occasional crèches Two creches were opened, one in Kensington and the other in Hammersmith, where children under five years of age could be left for periods of two or three hours in order to give their mothers free time for shopping, laundering, visits to dentists or hospitals or other duties. Each creche is open twice weekly and can accommodate up to ten children. At the outset attendances were disappointingly low, but they have improved somewhat and may continue to do so as the facilities become more widely known. Arrangements were made for occasional special sessions to be held at Hammersmith school treatment centre for the treatment of children suffering from plantar warts with carbon dioxide snow. School health In order to deal with the large number of children awaiting re-examination by eye specialists, arrangements were made for 124 additional sessions to supplement the regular vision sessions. By the end of the year this had removed the time lag in re-examinations, and it is hoped that it will be possible to arrange additional sessions in the new year to meet the increasing demand. Tuberculosis B.C.G. vaccination The scheme introduced in 1954 for inoculating with B.C.G. children in secondary schools in the division in the year preceding their 14th birthday was repeated. The arrangements again worked smoothly, but there was a slight falling off in the number of consents given for inoculation. Consents were received for about 69 per cent. of the children; of these approximately 86 per cent. gave a negative reaction to the Mantoux test and were given B.C.G. vaccine. The children vaccinated in 1954 were followed up and consents were given for testing about 70 per cent. of them. Of those retested 11 per cent. were found to give a negative reaction to the test and these were re-vaccinated. Children who were found to give a positive reaction to the first test were followed up by X-ray examinations at the chest clinics. Home help service The demands for the service of home helps continue to increase. There was considerable difficulty in recruiting sufficient helps, particularly in Chelsea and to a less extent in Hammersmith, but help was provided to the fullest extent possible wherever it was essential. Home helps in North Kensington formed a club, and facilities were provided for them to hold evening meetings about once a month during the winter. Morning and evening home help was provided in many instances for homes from which the mother was temporarily absent. The children were given breakfast, dressed and taken to school or to the day nursery in the mornings, the father having already gone to work, and in the evening the help fetched the children from school or day nursery, prepared tea and looked after them generally until the father's return. 133 Child help A resident child help was provided for one family to look after the children whose mother had died and whose father had to be admitted to hospital. Night attendance— chronic sick The requests for service were fewer than was expected but ten homes were supplied with night help for varying periods to give some relief to relatives. District nursing The calls upon the home nursing service continue to increase and the invaluable work of the district nurses has undoubtedly lessened the demand for hospital beds and has been of great assistance to family doctors. Loan equipment more requests are being received from general practitioners ana district nursing associations for the loan of home nursing equipment and stocks were increased. Wheelchairs and commodes are among the articles in greatest demand. Foot clinics Attendances at root clinics continue to increase and many old people have gained benefit from the treatment given. Waiting lists are still heavy and six to eight weeks usually elapse between appointments. The service is supplemented by voluntary organisations in each borough, two of which arrange domiciliary visits. Domiciliary care of the tuberculous Recent advances in the early diagnosis and methods of treatment of the tuberculous have led to the earlier admission of patients to sanatoria. In consequence fewer patients have been cared for at home and there has been a reduced demand for extra nourishment. Occupational therapists have now been appointed to visit those patients who are homebound and give them instruction and advice on handicrafts which can suitably be undertaken at home. Hurlingham Lodge The 28 beds at Hurlingham Lodge hostel were fully occupied. A few of the residents go to work, but most of them are too old or unfit for regular employment. Arrangements were made for the re-conditioning of an old greenhouse in the hostel grounds which will be adapted as a small work-shop where residents will be able to undertake handicrafts or other work in which they are interested. Recuperative holidays There was again some reduction in the demand for recuperative holidays : this is probably due in part to some improvement in general health standards and in part to the fact that many more families can now afford to go away for an annual holiday. There is still difficulty in finding accommodation for mothers with babies, but otherwise all demands were met. Prevention of accidents in the home A survey was commenced ot the cause ot accidents in the home, and local publicity was arranged during the London 'Safety in the Home' campaign held in November. Special emphasis was given to this subject by health visitors in their talks to schoolchildren and parents during the campaign week. I should like to express my deep appreciation of the help I have received from all my colleagues on the divisional staff. I should also like to acknowledge the invariable co-operation and assistance of the borough medical officers of health, the staff of other departments of the Council and the members and staff of the numerous voluntary committees and associations in this division. In conclusion I must thank the Chairman and members of the Divisional Health Committee for their constant help and support. Their unfading interest is a great stimulus to all working in the division. Division 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and Westminster. Day nurseries and childminders Dr. H. L. Oldershaw reports : The occupation during the last quarter of the year was 85 per cent. compared with 88 per cent. in 1954. There were 56 per cent. in the first and second priority groups, and 44 per cent. in the third. The number of statutorily and voluntarily registered childminders at the end of the vear was 109. compared with 171 at the end of 1954. Immunisation and vaccination Owing to the incidence of poliomyelitis in the division and in surrounding areas, it became necessary to suspend diphtheria immunisation in schools for a major part of the autumn term. During the year, 5,077 children were immunised against diphtheria, 134 of whom 3,779 received the combined protection against diphtheria and whooping cough. In addition 5,662 were given diphtheria reinforcing injections, while 158 children were immunised separately against whooping cough. Of the 4,390 children who were primarily vaccinated against smallpox, 4,346 were under the age of five years. Parents of children who, according to our records, have not been vaccinated when the child is about four months old, are sent a leaflet stressing the importance of vaccination, while a birthday card-immunisation reminder for all children for whom no record of immunisation has been received, is posted to arrive on the first birthday. As in previous years, the chronic sick, including the aged and infirm, made the greatest call upon the service. Home help service Increased use was made of the special services whereby 580 hours of early morning and evening help were given to 28 families which included 75 children. Night help was sent in to nine cases to relieve relatives of chronic sick persons, for a total of 153 hours (20 nights). The home help service was responsible for preventing 75 children from being taken into care. B.C.G. vaccmation of 13-year-old school children in this division was inaugurated during the spring and summer terms of this year. The number of eligible children was 3,691 and parental consents were received for 2,855 (77.4 per cent.). Of the 2,743 who were skin-tested, 2,295 children were given an injection of B.C.G. vaccine. A positive reaction to the Mantoux test was shown in 414 children, and 298 of these were examined by chest X-ray. Only four were found to have abnormal chest conditions. B.C.G. vaccination against tuberculosis mere was a steady demand from hospitals, general practitioners and others for various articles of home nursing equipment, most of which were supplied within a few davs of reauest. Home nursing equipment The total number of recommendations sanctioned for inclusion in the Council's scheme was 1,175 compared with 1,269 during 1954. Recuperative holidays As a general rule medical treatment is arranged at the school treatment centres with little delay. There is, however, a waiting list at University College Hospital for the enuresis cases and at Western Ophthalmic Hospital for vision cases. (At both these hospitals special clinics are held for L.C.C. children.) School medical treatment A new orthoptic clinic has been started at Somers Town school treatment centre where the orthoptist attends for two sessions a week. This clinic is fulfilling a great need. The position with regard to dental treatment in the division is satisfactory, and most children are dentally inspected once a year. Dental treatment The dental clinic at Barnes House welfare centre has been re-opened, and ten sessions a week are held for school children and maternity and child welfare cases. Nine evening dental sessions are held in the division, and are well attended by older children who prefer not to miss school. It is proposed to arrange evening sessions for expectant and nursing mothers if there is a demand. Continued attention is being given to problem families. By the end of the year, the index register contained information of 308 families who were receiving careful supervision and help. Co-ordinating committees are held throughout the Division, as necessary, to which all welfare workers and representative organisations concerned are invited, to consider the particular family or families involved. Problem families Of the total number mentioned above, 246 are classed as potential problem families, i.e., where it is felt that given practical advice, help (and in many cases better housing conditions) there is every possibility that in time they will be rehabilitated. Health education continues to develop on similar lines to those set out in my report for 1954. Health education It is gratifying that the number of schools in the division requesting health and mothercraft talks to school leavers is increasing each year. In 1955, 14 head teachers asked for a health visitor/school nurse to give this service. 135 The schoolgirls are taken during the course to maternity and child welfare centres, where they learn at first hand of the services many will wish to use a few years after leaving school. Poster competition In order to stimulate interest in visual aids to health education, a poster competition was held in 1955. Entries received from health visitors, school nurses, divisional clerical, and day nursery staff were judged by Dr. W. Emrys Davies, the Education Officer of the Central Council for Health Education, who was much impressed by the variety and standard of the work submitted. In all 60 posters were entered. Hospital nurse trainees and the social aspects of disease Since 1951 Divisional Health Visiting staff have lectured to hospital nurses on the social aspects of disease. The number of requests from hospitals in the division has increased since this subject was included in the General Nursing Council Syllabus in 1952. During 1955, 46 lectures were given to a total of 426 nurses. Individual visits were arranged to health establishments and schools in the division for this number. Selected nurses were taken into the homes of families. The nurses are now aware not only of the close link between hospital and local authority where the after-care of hospital patients is concerned, but also of the positive health-teaching carried out in the homes of the community. They now see their patients as personalities with a definite home background and those anxieties about family and job, which are so often a contributory cause to disease. Home safety Throughout the year, health visitors and school nurses paid particular attention to this subject. Talks were given in welfare centres and schools, film strips were shown and the elderly were advised on the hazards to be met in the home. Careful attention has been given to the provision of fireguards essential both for the safety of the very young and the very old. During the home safety weeks, in addition to the usual advice, school children were given leaflets and it is interesting to note that one boy of 14 years, when visiting a school treatment centre later, remarked to a school nurse in charge, ' I see you practice what you preach and have proper fireguards and no inflammable materials near the fire'. He was able to relate from memory all he had read in his pamphlet, and a party of senior school girls taken to the children's ward of a local hospital have told of a young child who had just been admitted with extensive burns as a result of playing with matches—they enquired later about this 3-year old and were told that she had died. This incident will no doubt be remembered later in life when they themselves will be bringing up children. Care of the aged Hope for the future lies in the education of the mothers and fathers of tomorrow. An increasing amount of the time of health visitors is now being taken in the domiciliary care of old people who live alone. 249 old people were referred by hospitals for follow up. Many of the lone elderly men and women are found by health visitors as they visit on their districts. They are able to advise on the services available and to contact the various voluntary and statutory bodies on behalf of those in need. They get in touch with relatives and friends who are asked to give assistance in the care of the aged who live alone. Conclusion I would again like to express my sincere appreciation of the loyal co-operation 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 Five whole-time medieal officers continued to be employed throughout 1955, the sixth position on the establishment being filled by the employment of equivalent parttime staff so as to maintain liaison with the general medical services. Two of the wholetime staff are acting as deputy Medical Officers of Health to the Islington and Finsbury Borough Councils. Four whole-time and three part-time medical officers approved for this purpose continue to be available for the ascertainment of educationally subnormal children. 136 Co-operation with hospitals and general practitioners The scheme of interchange between the Council's medical officers and the medical staff of the Hospital for Sick Children has proceeded with mutual benefit and the usual two sessions weekly have been resumed after a short interruption caused by a temporary shortage of hospital medical staff. Regular reports on the discharge of children have been received from this hospital and have been followed up, but it has still not been possible to persuade other hospitals in the division to send such reports as a routine. Four meetings with hospital almoners were held in 1955 and at two of these I was able to arrange for officers of the Welfare Department to give talks on the Council's services for the physically handicapped and the blind. These talks were most stimulating and helpful and are to be repeated for the benefit of divisional staff. I continued to be a member of the National Health Service Liaison Committee for the North Central Area of London and was able, with the willing co-operation of the Welfare Department, to give the committee details of the technique used in adapting the homes of handicapped persons to their special needs. Relations between health visitors and general practitioners have continued to be good. I referred last year to the closer co-ordination with hospitals resulting from the new syllabus of general nursing training, which requires that student nurses shall be introduced to the work of the local health authority. During 1955, 966 student nurses from nine hospitals (408 more than in 1954—an increase of 73 per cent.) were given insight into the Council's services in this division, as were 31 nursery nursing students and 36 medical students. In addition, 31 lectures were given and discussions were attended by the senior divisional nursing staff. Student district nurses from the North London and the Metropolitan District Nursing Associations were also introduced to the work of the division. Problem families My report for 1954 dealt in some detail with problem families, their characteristics and the methods adopted to help them to play their part as satisfactory members of the community. It may suffice to refer to them here very briefly. Monthly conferences, attended by voluntary and statutory workers, consider the families under review, decide which of the field workers can best co-ordinate the services for each family, and from time to time consider reports from those workers. This enables a personal, friendly relationship to be built up and all necessary services to be provided, whilst avoiding multiplicity of visiting. These broad methods were continued in 1955 and as a result of the careful and systematic work done it is possible to say that some families showed distinct signs of improvement. A special survey was also made with the object of assessing the extent and the degree of the problem, and it was found that, out of 15,573 families known to the health visitors in this division, 233 families were known to need special attention but only 79 could properly be classified as 'hard-core problem families'. Most of the others were 'potential problem families', a category less menacing to the community, and capable of reasonably speedy return to normality, though none the less in need of help and advice. It is noteworthy that the families needing special care amounted to 1.5 per cent. of all families known. It has been argued that it would be more practical to concentrate the ameliorative social services on those families which show some hope of redemption rather than spread the effort to include the ' hard-core ' families which, even with continual support, are never likely to be better than a drag on the community. This is clearly a matter of opinion, and in this division we offer help to all in need. Child neglect and ill-treatment Allied to the question of problem families is the neglect and ill-treatment of children in their own homes. Every effort has been made to ensure that such cases are brought to notice so that remedial action can be taken, and to this end a meeting has been held between representatives of the various field workers (health visitors, domiciliary midwives and home nurses) to discuss co-operation in this and other common problems. In some cases it is found necessary to take the children into care under Section 1 of the Children Act, 1948, but this can often be prevented by the timely provision of help 137 from the home help service, day nurseries, etc., or by arranging for nursing attention or a recuperative holiday for an ailing parent. The need for reception into care can often be similarly averted in times of crisis in households where child neglect does not ordinarily occur. In the last nine months of 1955 it is estimated that reception into care of 135 children was avoided by prompt action of this sort. Care of the aged The needs of old people have made a continuing and growing demand on the service throughout the year. Perhaps the heaviest burden has fallen on the home helps, who attended the homes of 2,162 chronic sick, aged and infirm people during 1955 (312, or 17 per cent., more than in 1954). Households in all categories attended numbered 2,915 (2,599 in 1954) and 231 home helps (equivalent to just over 164 whole-time staff) were employed at the end of the year. Many old people were visited by district nurses and we were able to help them and other sick persons by lending home nursing equipment in 51 cases. Full use has been made by home-bound old people of the domiciliary chiropody service provided out of voluntary funds by the North London District Nursing Association (for which health visitors can nominate suitable cases) and attendances at the Council's own foot clinic, over 80 per cent. of which are estimated to be by old people, again rose from 25,264 in 1954 to 25,551 in 1955. No applications were received from any organisations wishing to provide a chiropody service for old people in the Council's premises. We provided recuperative holidays for 84 people over 70 years of age out of a total of 457 adults, and the total number of holidays provided for all classes of persons was 1,017 (956 in 1954). At the request of the organisation, we helped Invalid Meals for London to review the needs of their clients in the division and gave advice on certain aspects of procedure, so as to ensure that meals were provided to as many needy persons as possible (principally the aged and chronic sick) but that at the same time service was not continued indefinitely without review. Other services for old people operating in the division include the laundry services provided by the borough councils. Care of mothers and young children Throughout 1955 fifteen welfare centres and branch centres were open, but the centre in John Street, Holborn, was closed on 28th May and replaced by the Province of Natal centre, to which special reference is made in a succeeding paragraph. The special feature of 1955 has been the development of toddlers' clinics. It is a matter of experience that the toddler, especially the only child, tends not to be taken to the welfare centre, and defects are not infrequently found on school entry which could and should have been treated and corrected years before. The toddlers' clinic is an attempt to overcome this difficulty. The children are seen by appointment as near their birthday as possible, and it is found that about one-half of the children invited do, in fact, attend. They are all seen by the clinic doctor. Sessions are now held in all main centres and at the end of the year six sessions were being conducted weekly and one fortnightly, as against two each week only at the end of 1954. First attendances of children under one year at infant welfare sessions numbered 4,236 representing 84 per cent. of the live births for the year (1954 figure 90 per cent.). Other activities at welfare centres continued but, except those dealt with in special paragraphs below, presented no features worthy of special comment. Special arrangements were instituted for expectant and nursing mothers and children under five, and it is hoped that in consequence all those needing treatment will be persuaded to have it. Voluntary workers in welfare centres We have always encouraged voluntary workers in the welfare centres, where they are particularly helpful in relieving the busy nursing staff of their non-nursing duties. During 1955 we have made special efforts to encourage more voluntary help, with special emphasis on relieving the clinic nurse at prophylaxis sessions. One British Red Cross auxiliary is now undertaking regular work of this nature, and other voluntary workers sell welfare foods (2 centres), weigh babies (3 centres), staff occasional creche sessions (1 centre—see below as to occasional creches generally), or undertake clerical and receptionist duties at immunisation sessions (1 centre). 138 Province of Natal centre On 26th May, 1955, the Province of Natal centre (formally known as the Model Welfare centre) was officially opened by His Excellency the High Commissioner for the Union of South Africa. It was taken into use on 30th May for the provision of a wide range of maternity and child welfare and school health services, including infant welfare, ante- and post-natal, child guidance for children under five, family planning, dental services, orthodontics, teaching of young deaf children, audiology and audiometry, nutrition, special investigation and minor ailment clinics. Attendances have been reasonably satisfactory, but the many new services are still being built up. The centre serves primarily residents in Holborn and South St. Pancras, but at some special clinics patients from anywhere within the County are treated. This centre represents a unique partnership between the Institute of Child Health of the University of London and the Council in its capacities as local health and local education authority. The cost of the site, the building and its initial equipment has been met out of money given during the war by the people of Natal to the South African Gift to Britain scheme, supplemented (for the purposes of building the Institute's reference library and laboratory on the upper floors) by the University Grants Committee. Repairs and replacements so far as the Council's services are concerned will be primarily the Council's responsibility. The administration of the centre is undertaken by a House Committee which includes representatives of the Institute of Child Health, the Council's Health Committee, the Divisional Health Committees for divisions 2 and 3 and Borough Councils. The superintendent is a member of the Council's staff and day-to-day problems are dealt with effectively by close liaison between the secretary of the Institute, the superintendent of the centre, and the divisional health office. Financial responsibility is shared on the broad basis that the Council contributes 90 per cent. of the cost incurred in providing the maternity and child welfare and school health services. The two-fold object of the centre, as Professor Alan Moncrieff pointed out in his address on the occasion of the opening ceremony, is to give a model service to the children of this part of London whilst bearing in mind the University functions of teaching and research. Its physical proximity to and professional ties with the Hospital for Sick Children should guarantee the fulfilment of the hopes placed in it. Special curveys Two new special surveys were instituted in 1955, both concerning cerebral palsy. One was essentially statistical in nature, designed to ascertain the number of such children in the division, the extent and type of disability and the treatment (if any) received. It has involved close co-operation with the Part II and Part IV services. The other survey was sponsored by the Medical Research Council and was concerned with the early detection of infantile cerebral palsy and the development of new methods of examination from a study of infantile reflexes. Both surveys, whilst undertaken cheerfully and willingly, have of necessity placed yet a further burden on the field workers and divisional office staff. Welfare foods The distribution of national welfare foods from the welfare centres is now an established divisional activity and is functioning very smoothly. The number of distribution points remains at 15, but sessions at some have been slightly reduced. In the light of the publicity given in the summer of 1955 to the national trend towards declining sales of these commodities, the following distribution figures for division 3 are of interest : 6 months ended National Dried Milk Cod Liver Oil Vitamin A&D tablets Orange Juice 1 Jan. 1955 2 July, 1955 31 Dec., 1955 77,392 71,600 71,565 16,749 16,870 17,345 5,589 6,278 6,735 98,242 103,760 117,178 The fall in sales of National Dried Milk is almost certainly caused by the preference of many mothers for branded goods. The nine day nurseries and one grant-aided voluntary day nursery were in operation Day until the end of the year, when two in requisitioned premises (King Square and Plimsoll nursenes 139 Road day nurseries) were closed and the children admitted to other nurseries. Plimsoll Road nursery had to be re-opened temporarily as an annexe to Canonbury nursery, where extensive repair work necessitated a reduction in accommodation. Nurseries showed an average occupation of 81 per cent. throughout the year and it is of interest that of the 464 ' nursery weeks' in 1955, quarantine was in force in the Council's nurseries during 128 weeks—i.e., 27.6 per cent. of the time. There were 78 children on the waiting list for admission at 31st December, nearly all in the third priority. At the same date, 12 children were in the care of the five child-minders registered under the Nurseries and Child Minders Registration Act, 1948, and 123 children in the care of the 102 minders voluntarily registered under the Council's scheme. One new registration under the Act was made in 1955. Occasional crèches This new service, which started in this division in 1955, aims to provide care for children under five for one or two half-days a week to enable their mothers to attend sessions at the welfare centres or to undertake shopping and other tasks which can be more effectively done unhampered by a small child. Authority was given for two sessions a week to be held, each for 20 children, at four of the main welfare centres, but so far it has been possible to staff sessions at only three centres, and that to one-half the authorised extent, so that capacity is in fact limited to 10 children at each of the six operating sessions. Attendances have averaged about half capacity. Both sessions at the Province of Natal centre are staffed by voluntary workers ; paid staff are employed elsewhere. Vaccination and immunisation Primary courses of immunisation against diphtheria were completed in 1955 for 3,505 children, representing 71 per cent. of the live births, and boosting doses were given to 3,596 schoolchildren. The latter figure compares with 3,843 in 1954 and 1,939 in 1953, and is particularly gratifying when it is remembered that immunisations had to be severely restricted for some weeks owing to the incidence of poliomyelitis, a condition which did not obtain in 1954. The scheme for Saturday morning immunisation sessions for schoolchildren has again proved its worth, and attendances have been very satisfactory. 2,775 children had complete courses of immunisation against whooping cough. 3,200 primary vaccinations against smallpox and 2,734 re-vaccinations were given, compared with 2,894 primary vaccinations and 2,742 re-vaccinations in 1954. As the policy on re-vaccination of schoolchildren is now to leave this work mainly to general practitioners, no further sessions will be arranged in this division once the current applications have been dealt with. There was one case of diphtheria in the division during 1955, a schoolchild not immunised since infancy. There were 60 cases of poliomyelitis, of which 38 were paralytic. School health service Three schools opened in the division during 1955, and the infants' department at another closed. One boys' school became a comprehensive school with an increased roll and extra medical services were arranged. The physiotherapy work at Cloudesley School for the physically handicapped has proceeded very smoothly under the aegis of the Royal Free Hospital. Of the 40 whole-time and part-time health visitors employed in the division (other than on tuberculosis work) at 31st December, 34 were undertaking combined school and maternity and child welfare work. The central B.C.G. team visited the division for the first time in May—June to carry out B.C.G. vaccination of the 13-year-old children in 37 schools. Of the 1,857 children given skin tests, 1,493 were subsequently vaccinated. Follow-up of 280 of these resulted in 170 being sent for X-ray, 169 of whom were found to be normal. During the year tuberculosis was found in three members of the teaching staff, one pupil and one school kitchen helper and, with the co-operation of the head teachers, investigations were made among the children in the five schools concerned. Arrangements for X-ray examinations were in hand at the end of the year. Toward the end of the year there was an outbreak of infection believed to be of virus origin in the infants' department of an Islington school. The illness was characterised by malaise, sore throat, some glandular enlargement, abdominal pain, with moderate 140 pyrexia and, in a few cases, diarrhoea, or nausea, or vomiting, or conjunctivitis. It spread to the junior department of the school and subsequently to the infants' and junior departments of another school. The Council's medical and nursing staff paid regular visits to the affected schools and excluded children thought to be suffering from the infection. The Medical Officer of Health for Islington and I sent out a joint letter to the general practitioners in the area warning them that cases were likely to be referred to them and that the Central Public Health Laboratory at Colindale was co-operating in a bacteriological and virological enquiry. Special arrangements were made for segregation of children taking school meals during the holidays. In all, 903 children were affected, of whom 462 were excluded from school on one occasion only, 291 on two occasions, and 150 on three or more. All cases were followed up at home by the borough Medical Officer of Health, his and the Council's staff. The outstanding feature of school treatment centre work in 1955 was the continued and rapid decline in the number of children attending with rheumatism. The figures were 23 children and 123 attendances in 1955; 33 children and 218 attendances in 1954 ; 48 children and 289 attendances in 1953. Very few cases of impetigo now come to notice. The number of children found to be verminous again fell, from 3,561 in 1954 to 1,192 in 1955, continuing a trend evident over a number of years. Partly owing to the declining numbers and partly owing to the continued co-operation of the Finsbury, Stoke Newington and St. Pancras Borough Councils in making their bathing centres available for Islington children, the inability of the Islington Borough Council to re-open their bathing centre during the year caused no great inconvenience. Nutrition and special investigation clinics have continued to meet a real need. Dental services in the south of the division suffered considerable dislocation with the temporary closure of the priority clinic at Finsbury Health centre. Patients have had to be referred either to the Province of Natal centre or to the Thornhill Road school treatment centre, to the latter of which the Finsbury dentist was transferred. Three of the voluntary school treatment centres were taken over by the Council during the year at the request of the committees concerned. A fourth committee received notice to quit their premises in North Islington and we were able to help them secure the use of rooms in the North Islington (Voluntary) Infant Welfare Centre with the willing co-operation of the voluntary committee of the latter centre. The sole remaining trustee of a fifth voluntary school treatment centre asked the Council to assume responsibility for their premises, but the technical officers advised against this and negotiations for a lease were being considered at the end of the year. The Province of Natal centre is one of two centres in the County selected for an experiment in the withdrawal of treatment organisers from certain types of session in school treatment centres, their work being covered in its professional aspects by a health visitor and in its clerical and administrative aspects by a clerk. These new arrangements, which involved consultation with the District Organisers of Children's Care of divisions 2 and 3, and much detailed procedural planning, came into operation on 28th November and seemed to be working satisfactorily at the end of the year, though it is yet too soon for any firm conclusions to be drawn. Tuberculosis Following the discovery of a high incidence of tuberculosis in the borough a special tuberculin survey of Islington schoolchildren was undertaken in 1954, with the enthusiastic support of the Divisional Education Officer and Head Teachers, the Chest Physician and the Director of the Mass X-ray Unit of the North West Metropolitan Regional Hospital Board at Drayton Park. The results, published early in 1955, showed that 5,075 children were given jelly patch tests, and of these 326 boys and 289 girls showed a positive reaction and 2,178 boys and 2,282 girls a negative reaction. Only 4,138 of the children presented themselves subsequently for X-ray, and abnormalities were found in the X-ray films of two boys and two girls who had shown positive reactions to the skin test and three boys and two girls who had shown negative reactions. Four of these nine children were found not to be tuberculous, and were given appropriate treatment. 141 The remaining five were active cases of tuberculosis at the time of the survey and in one other case an adult suffering from tuberculosis was discovered from the fact that the result of a child's skin test was positive. The Islington Mass X-ray Unit continued to be used throughout the year for routine examination of teaching and other staff. The hostel for tuberculous men is now well established at Cromwell Lodge, Highgate. Most of the major works of improvement have been completed, and toward the end of the year it was found possible, by re-allocating and adapting rooms, to provide a dining room in the basement and thereby to increase the accommodation from 27 to 31 places. Recuperative holidays were provided for 60 tuberculous persons (61 in 1954). At the end of the year extra nourishment was being supplied, on the advice of the Chest Physician, to 139 persons. Health education Arrangements for the publication in the Islington Public Libraries Bulletin of articles on health topics contributed by members of the staff have continued during 1955 to be a valuable means of health education, as have the presence in the tliree borough libraries of books recommended by me as being of value to expectant mothers and mothers of young children. Borrowing has been facilitated by the posting in the welfare centres of a list of the recommended books with the library reference number of each. Welfare centre activities included individual talks and discussion groups conducted by health visitors, cookery demonstrations, sewing classes, film shows, etc., and 788 special educational sessions with 7,621 attendances were held (figures for the previous record year of 1954 were 757 sessions with 6,640 attendances). Some centres have parents' clubs which organise kindred and supplementary activities, and these receive every encouragement. Divisional establishments and town halls (by permission of the borough councils) have displayed posters and leaflets on seasonal topics, changed monthly, and general practitioners have also co-operated by displaying propaganda material, e.g. on prophylaxis. Conclusion Mr. N. B. Chapman has replaced Mr. Wilkes as Divisional Administrative Officer. Miss E. M. Smith, Assistant Divisional Nursing Officer, retired at the end of January after nearly 36 years' service with the Council, and was replaced by Miss M. V. Naunton. Relations with voluntary and statutory organisations and their officers are, as ever, most cordial, and I should like to express my thanks to them, to the Divisional Health Committee and to the divisional staff for a further twelve months of courtesy, consideration and loyal co-operation. Division 4, comprising the boroughs of, Hackney, Shoreditch and Stoke Newington. Dr. S. King reports : Woodberry Down Health Centre Further expansion of the service provided at Woodberry Down Health Centre occurred during the year, the most important addition being the commencement of physiotherapy for the patients of general practitioners in practice at or within a mile radius of the centre. This service, restricted to two sessions weekly at the outset, is under the supervision of a consultant in physical medicine. It was agreed during the year to provide a pathological laboratory service at the centre for these general practitioners. The number of local health authority sessions held each week had increased to 153 by the end of the year, and these sessions attracted a weekly attendance of 1,463 persons. Health education continues to take an important place in the work of the centre. The occasional creche at the centre is open for nine sessions each week and, apart from its primary purpose of relieving mothers temporarily of the care of their children, is much used by mothers attending the centre, particularly the various health education activities. The original six general medical practitioners continue to practise at the centre and one of them is chairman of the centre's medical staff committee which meets monthly. 142 Clinical meetings have been held from time-to-time and general practitioners in Stoke Newington and the Council's medical officers employed in the division have been invited to these meetings. The general dental service continues at 11 sessions each week, but, notwithstanding representations which have been made, the second surgery provided for this service still awaits the appointment of a dental surgeon. Three successful blood donor sessions were held during the year and the local club for diabetic patients has continued to meet at the centre. Visitors to the centre numbered 1,930 of whom 386 came from overseas. Once again a large proportion of the visitors (1,475) were either post-graduate or student doctors, nurses, health visitors, midwives, social workers or others concerned with the health services. There were 8,165 ante-natal and 372 post-natal attendances and 3,444 first attendances of infants under one year of age (equal to 85 per cent, of children born during 1955) at the Council's clinics. Maternity and childwelfare A start has been made in the introduction of preventive mental health work into the maternity and child welfare service by holding a weekly meeting of the medical director and staff of the child guidance unit and a medical officer and a health visitor. At these meetings cases are discussed and guidance given to the health visitor in her further work for the families. Preventive nental health Kingsmead day nursery was closed at the end of the year, thus reducing the number of day nursery places from 603 to 553. Day nurseries and childminders Five private day nurseries provide accommodation for 175 children and 3 statutorily registered child-minders care for 14 children. In addition, there were at the end of the year 65 daily minders approved under the arrangements for voluntary registration. Health education Health education has been extended in accordance with a planned programme and a committee of officers in the various grades concerned with these activities has been established to plan and co-ordinate the work and to suggest ways and means for further development. Educational work in the welfare centres has been still further fostered as the following figures show : Sessions Attendances 1952 210 2,172 1953 288 5,421 1954 414 6,494 1955 564 6,775 Hobdays were provided for 915 patients, comprising 83 children under school age, 393 schoolchildren, 13 nursing mothers and 426 other adults. Recuperative holidays Help was given by this service up to the limit of the available workers. Efforts to obtain more home helps continued throughout the year and the organisers are continuously faced with the problem of selecting the applicants in most urgent need of help and spreading the help as widely as possible. There is a constant need for more workers suitable and willing to attend tuberculous households. Home help service The service has grown as follows : 1952 1953 1954 1955 Total cases given help 2,928 3,293 3,645 3,979 No. of home helps employed at end of year (whole-time equivalent) 191 220 249 269 The divisional committee of statutory and voluntary workers concerned with the Problem special needs of problem families has continued to meet, usually monthly, and con- and sidered 23 cases during 1955. The number of such families known as the result of a children special canvass is 219 and all are visited and reported upon by the health visitors or other appropriate workers as frequently as circumstances indicate. 143 There has been continued close contact between the Area Children s Office and the Divisional Health Office to avoid children being taken into care when with some assistance their needs could satisfactorily be met in their own homes. Full use has again been made of day nurseries, home helps and child-minders. Handicapped children Physiotherapists from the London Hospital now attend daily to treat the physically handicapped children attending the Geffrye Primary School. Chiropody Seventy-seven chiropody sessions are held in the division each week and a high level of attendances for treatment is maintained. The demand for foot treatment continues to exceed the available resources. Priority is given to children and elderly people. Prophylaxis During the year 2,265 children were vaccinated against smallpox, 3,042 completed a primary course of immunisation against diphtheria and 4,826 received reinforcing injections and 2,525 were immunised against whooping cough. For the first time all 13-year-old schoolchildren in the division were offered B.C.G. vaccination. 59.4 per cent. of the children were tested and of these 87.7 per cent. were negative re-actors and were given an injection of B.C.G. vaccine. The positive re-actors to the skin test (178) were given appointments for chest X-ray and all but seven attended. Occupational therapy for the tuberculous One schoolgirl was found to be suffering from active pulmonary tuberculosis. Occupational therapy for home-bound tuberculous persons became available in October, 1955 when two whole-time therapists took up their appointments. They devote 14 half-day sessions each week to patients in division 4 and spend the balance of their time in an adjoining division. Early indications are that this is a welcome and useful addition to the tuberculosis service. Home nursing and loan equipment The three District Nursing Associations continue to give a high standard of service to sick persons being nursed at home. The steady demand for the loan of items of home nursing equipment continues to be met. Division 5, comprising the boroughs of Bethnal Green, Poplar, Stepney and the City of London. Dr. G. O. Mitchell reports : Poliomyelitis In London the epidemic of poliomyelitis struck first in this division, and in the late spring cases began to occur in Stepney and Bethnal Green. On 10th June, after consultation with the Borough Medical Officers of Health concerned, routine diphtheria and whooping cough immunisation was stopped in the Council's clinics and schools in Stepney and Bethnal Green; and at the request of the Stepney Borough Public Health Committee leaflets were distributed by the teachers to schoolchildren in Stepney for the information and reassurance of parents. As the disease gradually spread through the division (with the exception of the City of London) the ban on routine immunisation was extended, after consultation with the appropriate Borough Medical Officer of Health, to the Isle of Dogs, Poplar, on 27th June, and eventually to the whole of Poplar on 5th July. With the waning of the outbreak in the late autumn routine immunisation was recommenced on 14th November. The general practitioners in the divisions were kept informed of these decisions about immunisation. In all 90 cases were notified during the year, 67 non-paralytic and 23 paralytic, and 76 of these notifications were of children below the age of 16 years. There were four deaths, three being of children under four years of age. Premises Two new welfare centres were completed and brought into use in the division during 1955, the Greenwood welfare centre, Peel Grove, Bethnal Green, and the Will Crooks welfare centre, Wigram House, Poplar. The proposal to build a centre on the Peel Grove site, adjacent to Bethnal Green Town Hall, was initiated by the Bethnal Green Borough Council before 1948, but its implementation was long delayed by difficulty in securing the necessary approval for the commencement of the work because of restrictions then placed on expenditure 144 and the use of labour and materials in health service projects, and because a part of the site had been earmarked for Civil Defence purposes. The building was finally completed in the early part of the year and was opened for clinics on 14th April. The accommodation, in addition to ante-and post-natal clinics, comprises a combined weighing and lecture room with a kitchen annexe which can be used for cookery demonstrations, a room for health visitors, and a separate office for the centre superintendent. This excellent modern centre replaces the former Bethnal Green welfare centre at Cornwall Avenue. The centre was named after Dr. W. P. Greenwood, Superintendent of Bethnal Green Hospital, who attended a house-warming ceremony at the centre shortly before his untimely death. The Will Crooks centre in Wigram House was provided to replace the former centre at 154 Poplar High Street, the site of which was urgently required by the Housing Committee as part of the Poplar High Street Housing Scheme. Efforts to find other suitable accommodation having failed, the Housing Committee agreed to make available three flats on the ground floor of Wigram House and these were adapted to provide a small but pleasant welfare centre which was opened on 26th May. Accommodation consists of doctor's room, health visitors' office, a weighing room, two waiting rooms, a room which is used for interviews and for artificial sunlight treatment, patients' and staff cloakrooms, a small kitchen and a food store and food sales room. The centre, like the housing estate in which it is situated, was named after the late Will Crooks, the well known Poplar pioneer in social reform. Day nurseries For some time the future of the Columbia Market day nursery, Bethnal Green, had been in doubt, and the Education Committee who own these premises finally decided that they were urgently needed for their original purpose, i.e. as a nursery school. The day nursery, therefore, had to close and alternative accommodation was found for most of the 60 children. The majority of these were transferred to the Brunswick day nursery in Shoreditch, which is quite near to the Columbia Market day nursery, and all other children who required it were found accommodation elsewhere. With regard to day nursery accommodation in the division, there had for some time been an increasing difficulty in finding places in the Stepney nurseries for children in the higher priority groups and the overall position was worsened by the loss of Columbia Market day nursery. The most acute shortage of places had been in the 2-5 age group, and to help meet this difficulty steps were taken to extend the accommodation at the Mary Hughes day nursery to provide 10 more places in this category. It is hoped that this additional accommodation will be available early in 1956. Welfare foods The selection of distribution points for welfare foods in the division, made when responsibility for this service passed to the Council in 1954, appears to have been satisfactory and to have met the public demand which shows no sign of diminution at present. Sessions 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, the minor ailment sessions at the Rochelle Street and Bethnal Green school treatment centres and the ante-natal sessions at the East India Dock Road centre being reduced to 'short-sessions', while a fortnightly toddlers' session was substituted for an infant welfare session at the Mary Hughes welfare centre. Dental service The position with regard to the priority dental services showed little change during the year, and the difficulty in recruiting dental surgeons continued to prevent any real expansion of these services. Childminders At the end of the year there were 92 voluntary registered minders caring for 88 children. This showed a reduction of 36 minders but a reduction of only one child being cared for, and was due to an intensive review of the list of minders. The minders are under constant supervision by the health visitors and attend clinics regularly with the children in their care. 145 Home helps The demand for the services of home helps was still heavy, and during the year the households attended per 1,000 of the population again exceeded the London average. Little difficulty is experienced in recruiting home helps in Bethnal Green and Poplar, but there is considerable difficulty in Stepney. Here again the demand for the services of the district nurses remained heavy and throughout the year the number of visits per nurse was generally higher than that in any other division. District nursing In the field of health education, the preparatory work of previous years is beginning to show results which are seen chiefly in the increased interest of the mothers and the increasing attendances at health talks and demonstrations. Health visitors An ante-natal relaxation class was instituted at the Bromley welfare centre at Newmill House. There was encouraging evidence of improving co-operation between health visitors and general practitioners, and arrangements have been made for a series of informal meetings at welfare centres where local general practitioners are invited to meet the health visitors. School health service The provision of physiotherapy was introduced during the year for pupils attending schools for physically handicapped children. Bromley Hall school, after being adapted and equipped for the purpose, became the centre for this work, the physiotherapy being carried out by staff from the London Hospital. During the year the scheme for vaccinating 13-year-old schoolchildren with B.C.G. was introduced. After a preliminary meeting with the head teachers of the secondary schools to explain the scheme and to invite their help, 1,511 children were vaccinated in the schools, parental consent having been obtained for 81 per cent. of the children eligible. The success of the scheme has been largely due to the co-operation of the head teachers and I am most grateful to them for their continued support of this new and important venture. Division 6, comprising the boroughs of Deptford, Greenwich and Woolwich. Dr. F. R. Waldron reports : Special investigation clinics 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. These clinics have proved well worth while, and have enabled children with minor behaviour problems, etc. to have more individual attention, with noticeably good results. Bathing and cleansing 2,221 children were treated during the year at cleansing stations, compared with 2,519 in 1954. Childminders The number of statutorily and voluntarily registered child-minders at 31st December, 1955, was 77, compared with 83 at 31st December, 1954. Foot clinics 73,025 chiropody treatments were given at eight centres, and the average number of weekly sessions was 173. Specimen percentage attendance figures were—women over 60 years of age, 31 per cent.; men over 65 years of age, 8 per cent; schoolchildren, 6 per cent. Health visitors at hospital clinics Continuing the policy of fostering co-operation with local hospitals, health visitors attended on a rota system at out-patient, paediatric, asthma and diabetic clinics at three local hospitals. Council officers, members of the hospital staffs, general practitioners and other interested parties worked well together, and the good relationship continued to develop with mutually beneficial results. B.C.G. vaccination The Council's central team of medical staff successfully concluded at the end of February the initial scheme for the B.C.G. vaccination of 13-year-old schoolchildren. There were 3,453 children in the age group and approximately 84 per cent. of the parents agreed to their children taking part in the scheme. 146 Ante-natal clinics Ante-natal clinics were held at 19 centres, with an average of 28 sessions a week. Relaxation and mothercraft classes were held at varying intervals at nine centres. Chest X-ray examinations were arranged for no less than 1,060 expectant mothers during the year. 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 Nursing Association rendered most valuable and co-operative service during the year. The Silvertown and North Woolwich District Nursing Association ceased to function on 1st November, 1955, but the district nursing was taken over by the Woolwich and Plumstead Nursing Association, and midwifery cases on an agency basis by the County Borough of West Ham. There was no break in either of these services. Prophylaxis Additional sessions for prophylaxis were made available during the year; apart from the immunisation sessions held weekly at schools in the division, full or part-time sessions were held weekly at 14 centres. 3,252 children (0-15 years) received a primary course of diphtheria immunisation and 1,525 reinforcing injections during 1955. These figures are less than those for 1954, but the falling off was due without doubt to the outbreak of poliomyelitis, which covered a more prolonged period than in previous years. Vaccination was carried out in 2,308 cases and re-vaccination in 561, whilst 2,893 primary and 129 secondary whooping cough inoculations were carried out. Dr. Dunham, of the Department of Physical Medicine, Charing Cross Hospital, continued 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. Cerebral palsy Parallel with this research, an inquiry was made with the co-operation of hospitals, general practitioners, health visitors, school nursing sisters, and others, in order to obtain up-to-date records of London children suffering from any form of cerebral palsy. The research was made so that the extent of the problem could be assessed and all possible medical, educational and social help afforded. Mentally backward children In co-operation with the local mental welfare organiser, clinics for mentally backward children under five years were held at two centres. It is hoped as a result of the experience already gained, to develop specially co-operation in the welfare problems which beset parents. Welfare foods National welfare foods were distributed during 110 sessions held weekly at 29 centres throughout the division. Domiciliary diversional therapy Persons suffering from tuberculosis and confined to their homes, were given instruction in a number of crafts by the occupational therapist from the beginning of October. By the end of the year there was no doubt that the patients had been most co-operative, had shown marked enthusiasm, and had derived considerable benefit from the training and the interest it created. Poliomyelitis There were 185 confirmed cases of poliomyelitis in the Division during the year, The outbreak was most marked in the Plumstead area of the Borough of Woolwich, where it did not decline until the end of November. I acknowledge most sincerely the good work of everyone associated with the health services in the division. Division 7, comprising the boroughs of Camberwell and Lewisham. Dr. H. D. Chalke reports : Premises Some of the rented premises used for maternity and child welfare centres have given cause for concern. They are mainly old premises at which there is very limited scope for improvement. In one instance, it has been possible to arrange for the service to be transferred to a newly-built church hall; in another instance, new terms have 147 been negotiated with the owners under which the Council will be able to improve thh heating and decoration of the rooms which it uses. Other premises which presen problems still remain in use. One major piece of work has been undertaken in reconstructing the walls at a day nursery which had suffered from bomb damage during the war and, more recently from sub-soil settlement. Local meetings with district nurses To roster co-operation with district nursing services a series or open meetings have been arranged to discuss problems of mutual interest to district nurses, midwives, health visitors, home helps, etc. The Council is providing speakers on such subjects as health education in the home, problem families, care of old people. As a further measure of co-operation, the health visitors at the various centres met informally and entertained the district nurses working in the area. Health education The health education programme was extended, and greater use was made of visual aids, particularly the flannelgraph. In addition to films and film strips, a tape recorder was brought into use. Societies and clubs in the division were written to, and the services of speakers at their meetings offered. The programme was carried out in close collaboration with the public health departments of the two metropolitan boroughs. Particular attention was paid to the prevention of home accidents, and an enquiry was made into one important aspect of this—the increasing occurrence of accidental coal-gas poisoning among older people. The enquiry was undertaken in collaboration with local officers of the South Eastern Gas Board, who examined the gas appliances in the homes of old persons in receipt of home help. This liaison has proved valuable, and it has resulted in the replacement of a number of defective and dangerous fittings. The results of this enauirv will be published in due course. Health visitors The field of work of the health visitors is progressively widening. Co-operation with the general medical services improved slowly but steadily, and the arrangement whereby a health visitor was attached for part-time work to a group of doctors continued to prove successful. Links with hospitals were tightened also : particularly valuable was the domiciliary work carried out by health visitors in connection with the diabetic unit at King's College Hospital. This work is to be extended in the near future. Observations on the widening sphere of work of the health visitor have been published elsewhere (1). The health visitor at one centre has organised a club for mothers, which is combined with an ante-natal relaxation exercise class. Subjects of interest are discussed (e.g. home nursing and first aid, prevention of infection, knitting, washing, etc.), films are shown and free discussion is encouraged. The response has been encouraging. The average attendance is 10. Home-making course for inexperienced mothers Approval ror this, ror an experimental period or one year, was given by me health Committee in September, 1954. The experiment has proved very successful, but there are many difficulties. It was found essential to carry out follow-up work in the homes, after a period of about a week of intensive instruction. The additional cost of this work has been almost negligible, and the experiment is to continue for a further year. The aged The care and welfare of older members of the community, especially those who live alone (a large proportion), is producing problems of increasing complexity; fortunately they are being dealt with more effectively as co-ordination of effort improves. Suitable long-stay accommodation remains the greatest need. As in previous years, maximum effort has been concentrated on enabling the old persons to remain at home provided their medical condition permits it. The use of an assistant medical officer as a co-ordinating officer between the various agencies concerned has proved to be well worth-while. A discussion on the medical care of those living alone has been published (2). Mental health education As a result of the Medical Officer of Health s Working Party on Mental Health Education in the Maternity and Child Welfare Service, weekly case conferences have been held at one of the Council's centres between the centre doctor and health visitor (1) The Practice of Health Visiting (Journal of the Royal Society of Health, No. 8 August, 1955.) (2) The Medical Care of Those Living Alone. (Medical Press 14.12.55.) 148 on the one hand, and on the other a psychiatrist and psychiatric social worker fror King's College Hospital. Cases presenting mental health problems are submitted b the Council's workers, and discussed with the psychiatrist. B.C.G. vaccination of schoolchildren During the summer term, the Council s B.C.G. team visited 66 schools in the division and tested 3,370 children aged 13+ years. They found 419 positive reactors of whom 24 were referred to chest clinics for further investigation. ; School „ treatment The increase in work is evidenced by a growing demand tor orthodontic treatment at King's College Hospital and additional nutrition and speech therapy sessions at the Council's centres. Changing patterns in child welfare centres Among the activities to which increasing attention has been paid are discussion groups, cookery and sewing demonstrations, play corners and health educational displays. Routine weighing of infants has been steadily reduced. The findings of an investigation into the reasons why mothers attend or do not attend municipal centres have provided some useful information which has been used to advantage in moulding the pattern of many of the centres. The guiding principle has been the maintenance of a friendly atmosphere in which mothers readily seek help and reassurance and learn the basic requirements for the promotion of mental and physical health. Treatment has been almost entirely eliminated and any tendency for a centre to simulate the hospital ante-natal department has been counteracted. The response of mothers to the new outlook is most encouraging. My thanks are due to my medical and lay colleagues and to the members of the divisional staff for their loyal co-operation and support. Division 8, comprising the boroughs of Bermondsey, Lambeth and Southwark. Dr. W. H. S. Wallace reports : Welfare centres The new Rose McAndrew welfare centre, comprising the ground floor of Bcale House, Lingham Street, Stockwell, was opened by the Mayor of Lambeth in March, 1955. The new clinic replaces the former Rose McAndrew Centre in Lansdowne Way which was administered by a voluntary committee, and the Council's former centre at Stockwell. Although the centre is administered by the Council, the name of Rose McAndrew has been retained in recognition of the valuable service she rendered in the maternity and child welfare movement. The new clinic is centrally situated near Stockwell tube station and is conveniently reached in regard to both the areas served The usual services—infant welfare, ante-natal, toddlers' clinics and sale of welfare foodsare provided at the centre. Arrangements have been made, in conjunction with the South London Hospital, for ante-natal services, the Registrar from the Hospital is responsible for the work, and mothers booked with the Council's midwives, or the Hospital': midwives, attend the clinic. Dr. Warren, of the Brixton Child Guidance Unit, is kindl) giving assistance to the medical and nursing staff in dealing with psychological problem: in the management of children. The premises, which are spacious and convenient, have a good entrance hall, which is most valuable for health education, mothercrafi and other clinic activities. Day nurseries The day nurseries in the division have remained well-filled except in the Norwood area, where there has been a considerable fall in the demand for vacancies. The offering of vacancies in priority III, in which parents pay higher fees, was expected to result in these vacancies being filled. This, however, has not been the case and few parents having to pay a surcharge make use of the day nursery. In other parts of the division the nurseries have been well-filled, and the daily average attendance in nurseries throughout the division has been over 80 per cent. There has been a heavy demand for day nursery accommodation in the Brixton area, where the children of the coloured population constitute a serious problem. Immunisation Special efforts have been made to encourage mothers to have their children immunised, as the almost entire absence of diphtheria has resulted in many parents failing to recognise the continued need to maintain immunisation. As an experiment in this 149 division special letters urging them to have their children immunised are being sent to all parents when their children reach the age of four months. A further letter is sent six months later if no record of the child having been immunised has been received. The effect of these letters began to show in an increase in the number of children immunised but unfortunately they had to be discontinued on account of the epidemic of poliomyelitis that occurred during the summer. It was, unfortunately, not possible to commence immunisation again until November and consequently the total number of immunisations during the year has shown a substantial fall. School health services The health or the school children has continued to show an improvement and there has been a considerable decrease in the number of children found to require treatment at medical and hygiene inspections. The attendance at minor ailment clinics has continued to diminish and it has been possible to reduce the hours of opening of these clinics. The minor ailment clinic at Dockhead School was closed and amalgamated with the clinic at Farncombe Street. The number of cases of discharging ears has also greatly decreased and the cases that do occur are cleared up very rapidly with modern treatment. There has also been a fall in the number of children attending rheumatism and nutrition clinics and the number of sessions has been reduced. The improvement in the health of the school children is also reflected in the diminution in the number of admissions to schools for physically handicapped children. There has been an increase in the number of children attending the audiology clinic. This has been due not to an increase in the amount of deafness but to the fact that the cases are being brought to light, as a result of the routine hearing tests being carried out on all schoolchildren. Children under school age are also attending the clinics, as the importance of early diagnosis and treatment is now fully recognised. An auditory training session has been established at St. George's centre for the assessment and training of deaf children. There has been an increase in the number of children recommended for admission to schools for the educationally subnormal. This is not due to an increase in the number of mentally backward children but to the fact that the value of these schools is being more fully recognised and more borderline cases are being admitted to them. Norwood treatment centre The school treatment centre in Norwood Road had to be vacated early in the year, as the Council's lease expired. Arrangements were made to transfer the dental, minor ailment and refraction sessions to the maternity and child welfare centre at Hannen Road. Certain alterations and improvements are being made to the building. The installation of the new dental chair and equipment was not completed during the year. The centre has proved particularly valuable in combining the school and maternity and child welfare services and it has therefore been chosen as an experimental area for the proposals of the working party on treatment organisers and health visitors. The scheme was started towards the end of the vear and commenced without anv difficulty. Home help and district nurses Other services in the division have continued satisfactorily. The home help service continues to increase, largely on account of the needs of the aged. The District Nursing Association are taking on more staff to meet the needs of the area. The home help and district nursing services, which provide for patients, particularly the aged, in their own homes, are most valuable at the present time, when the large number of old people in the community is constituting an increasing problem. The nursing of the aged sick in their own homes is of benefit to the old people themselves as well as in the interest of national economy. Conclusion I would like to thank the staff and voluntary organisations in the division for their loyal help and co-operation in working together to give an efficient service to the public. Division 9, comprising the boroughs of Battersea and Wandsworth. Dr. J. T. R. Lewis reports: For the fourth year it gives me very great pleasure to report on the work in health division 9. The year was again a busy one and many matters which will affect the health 150 and well being of future residents in Battersea and Wandsworth have been dealt with. 1955 was the fourth year during which the tripartite arrangement between the Metropolitan Boroughs of Battersea and Wandsworth and the London County Council has been operating, and throughout the year it worked entirely satisfactorily. I made some brief reference last year to the health needs of the large housing estates which are being built in this area. The broad lines along which the health services in the new estates should be planned were further considered during 1955. In addition, detailed consideration was given to the services for the Ranelagh estate, since the boundary between the County of London and the County of Surrey runs right through this L.C.C. estate ; provisional arrangements had been arrived at at the end of the year. Premises Consequent upon the closure of the Battersea Park day nursery, to which reference is made below, it was possible to transfer the All Saints' infant welfare centre to the day nursery premises. This has been much appreciated, I believe, no less by the mothers and their babies than by the staff working at the centre. The temporary welfare centre which was opened in 1954 at ' Woodlands', West Hill, was closed in July and the centre's activities were transferred to the tenants' clubroom at the Ackroydon estate. A maternity and child welfare centre was opened at the community centre on the Eastwood estate for one session a week. The new Tooting school treatment centre at 193 Mitcham Road was formally opened in January. Day nurseries The Battersea Park day nursery closed in May, which left 549 places in 11 nurseries of which eight are recognised for training students. Maternity and child welfare Spccial arrangements have been made for the ante-natal care of expectant mothers on the Ashburton estate, where one of the Council's midwives holds an ante-natal clinic in a surgery very kindly placed at our disposal by one of the doctors on the estate. Toddlers' sessions were commenced at the five following infant welfare centres ; Balham (weekly); St. Margaret's, Cricklade Avenue (fortnightly) ; Earlsfield, Fairfield and Riggindale (monthly). An additional monthly session was inaugurated at the Putney infant welfare centre. An occasional creche was opened for one session a week at the Fairfield infant welfare centre in October. Nurseries and ChildMinders Regulation Act, 1948 At the end of the year there were 11 registered child-minders and nine registered private day nurseries authorised to care, respectively, for a total of 78 and 226 children, representing a small net decrease. Research I mentioned last year the home-making scheme which had been inaugurated in the area for mothers of problem families. This experimental scheme ceased in September, and although its success was limited, it did produce valuable ideas. It has enabled us in certain ways to reorientate our approach to these difficult problem families. The research in conjunction with the Medical Research Council into the efficacy of a combined diphtheria-pertussis prophylactic in the prevention of diphtheria and whooping cough has continued and during the year the total number of children in the investigation topped the 5,000 mark. The investigation is now concentrating on the following-up of these children. The investigation into the early diagnosis of cerebral palsy under Dr. Dunham continues. Special Investigation clinics A total of 1,133 attendances were made at 188 special investigation clinics, a slight decrease in the attendances compared with the previous year. There were 196 new cases compared with 235 in 1954. Recuperative holidays Applications for recuperative holidays placed by the division number 837 compared with 886 in 1954. Health education Again during the year a good deal of attention was given to health education. One of my senior medical colleagues has interested himself particularly in this important aspect of our work and talks and lectures on problems of health education have been given to a number of organisations. 151 L Tuberculosis A diversional therapy service for home-bound tuberculous patients was commenced in December and by the end of the year 26 patients were receiving service. At the time of writing it looks as though this service is going to prove to be highly successful and much welcomed by the patients. Home helps The home helps attended 3,507 households during the year, an increase of 8.5 per cent. over the previous year. As mentioned in last year's report, the general recognition of the value of the home help service is making increasing demands on this service, which covers all cases of sickness but is particularly valuable in helping old people. The main problem we are facing in this division, which apparently is not experienced to the same extent by some other divisions, is the difficulty in recruiting a sufficient number of staff. Attempts made by means of special forms of advertisement to increase the recruitment to this service were only partially successful and it is unfortunate that recruitment difficulties limit the amount of service we are able to give. In some individual cases the recipients of the service or their relations enquire why it is not always possible to meet the demands which they feel the patient needs. The answer is, of course, that where the needs are so many, and the staff limited, some discretionary allotment of the service is unavoidable. In other words, the existing service must be spread to give the greatest possible benefit to the greatest number and this is what we trv to do. Welfare of old persons The welfare of old people is a problem which has caused considerable anxiety throughout the year, in spite of the increasing amount of time which the department is now giving to the care of old people. This applies to the work of the health visitors and the home helps. Among many aspects of this problem which still need to be considered, are the following : The difficulty of obtaining admission to hospital of old people when they need it. The provision of some form of nursing supervision at night-time to old people who are being nursed at home pending their admission to hospital. The problem of the old person who refuses to consider going into a hospital or welfare home, in spite of the fact that such admission would be desirable. One of our senior nursing officers is devoting an increasing amount of her time to the administrative problems concerned with old people and their admission to hospital; and in spite of the difficulties, I think that the old people benefit from what help we can give. Organisation It is again a great privilege to thank all my colleagues for the great help and support which they have given me during the year. While this applies to all divisional staff, I would like particularly to mention my senior colleagues—Dr. W. G. Harding, Dr. A. Garland, Miss W. M. Winch, and Miss G. U. Cox. I cannot conclude this year's report without making a short reference to the untimely and tragic loss which we in this division and, indeed, the whole health services of the Council, experienced by the death of Mr. F. E. Willson, our late Divisional Administrative Officer. It is appropriate that I should say something about his sterling qualities, for he had long been closely identified with the Council's health services generally, and, more particularly, with the health services in this'area. Mr. Willson had a long period of service (upwards of 40 years) with the Council, and had been Divisional Administrative Officer in division 7 before he was transferred to this area a month or two before I took up office in 1952. I found that I had as my divisional administrative colleague a man of outstanding knowledge, ability and integrity. He entered so wholeheartedly into the work of the division and he assumed all duties and responsibilities with such enthusiasm that no one could fail but to admire, and often to marvel at, his energy. He had in full measure the gifts which make the able administrator, whether lay, legal or medical. He was able to approach his problems (and they were many) with an absorbing attention to detail, where this was necessary, without in any way losing sight of the general principle involved. Add to this a tolerance, generosity and, indeed, great humanity, and one has the reasons why Mr. Willson was so successful in his job. He was intensely jealous of the great reputation of the Council and even more 152 so of the welfare of the population which the Council served. In his personal contacts he was always friendly, always helpful, always ready to give of his wide experience and knowledge whether to members of the Committee or to his colleagues, senior or junior. His loss has been greatly felt in this area, both by members of the Divisional Health Committee to whom he had endeared himself and by all of us who had the great privilege of working with him. Our deepest sympathies go out to his family. APPENDIX A REVIEW OF MORTALITY IN THIS CENTURY On pages 156 to 159 will be found a series of diagrams showing the trend of mortality for different sex and age groups since 1900. The graphs are logarithmic in the vertical scale to permit of easy comparison of rates of change in the different age groups ; the relative change depicted in one part of the graph is directly comparable with other parts by the slope of the lines. It will be seen that the most striking reductions in the death rates have been in ages under 45, especially in children aged 1-4 years. The percentage reductions in the age groups are detailed below : Percentage reductions in death-rates (1900-04 to 1951-55) Age group Males Females 0-1 83 85 1-4 96 96 5-14 84 90 15-24 77 83 25-44 79 78 45-64 45 61 65 and over 7 28 At all ages throughout the period under review death rates for males are higher than for females, which accounts for the higher expectation of life in women, and the differential reduction in the death rate at ages 45-64 years now results in the death rate for men at these ages being twice that for women. Except for ages 65 and over men aged 45-64 have shown the least improvement during the period under review. Reduction of the death rate over 65 years is, of course, not a matter of prevention (since all must ultimately die) but of delay, thereby giving added years over the biblical span of three score and ten and in this respect women aged 65 now have an expectation of life of 15 years compared with 12 years for men : at the turn of the century the corresponding expectations were for women 11 years and for men 10 years. The rate of decline in the death rate has been comparatively steady throughout the period in older age groups, but for those under 45 the rate of decline has quickened in the last ten years. There are certain abnormal fluctuations requiring explanation. In both war periods there were violent fluctuations, more so in the second world war than the first, and in both these periods rates for men aged 15 to 44 have been discontinued because of the large scale withdrawal of men from the civilian population for military service ; the female rates for these ages in the second world war are probably slightly overstated for similar reasons. The death rates cannot be regarded as exact in certain years because of estimations which had to be made of the populations at risk in the several sex and age groups. For the decade 1900 to 1910 the census figures for 1901 and 1911 have been used and interpolations made for intermediate years. Rates for 1915-30 and 1939-49 are based on civilian deaths and civilian populations with considerable estimations of the populations at risk in the war years. For the remaining years populations used are those supplied by the Registrar-General known as 'total' populations until 1938 and as ' home ' populations from 1950 onwards. The rates are least reliable in the middle of the period 1901-1911 and in the war and post-war periods 1915-1920 and 1939-1949. 153 L* The peaks in the year 1918 were due to the pandemics of influenza which raged at the close of the first world war and which affected young people to a greater extent than the aged ; the peaks in 1929 were for a similar reason though in this epidemic the age distribution was different—the old being affected more than the young. The peaks in 1922 in the rates for boys and girls aged 1-4 were due to the prevalence of epidemics of measles and whooping cough. The total death rates for the various age/sex groups, whilst informative, do not give the whole picture. Accordingly, in the diagrams shown on pages 160 to 163 an indication is given of changes in the causes of death over the half-century by showing, for each sex and each age group separately, the major causes of death for the years 1901,1926 and 1951 : 1901 and 1951 have been chosen as years at each end of the period with most reliable population figures (census years) and the year 1926 as midway between these two. Because of the wide variation in death rates, both between age groups and between years, and the desire to give the maximum pictorial effect to changes in the causes of death, scales of death rates have been chosen which best accommodate the particulars displayed : for this reason neither the horizontal nor the vertical scales are the same for each age group and in addition they may vary from year to year within an age group. Hence, except as an indication of the order of ranking of a specific disease they require careful study and reference to the scale employed. Finally, no allowance has been made for the sharp change in the classification of deaths which took place in 1940 when the Registrar-General abandoned the rules of selection which had hitherto operated in multiple causes of death.* In the earlier years deaths from certain infective and respiratory diseases were of such proportions as to merit individual mention with the residual deaths from these major groups described as 'other infective' or 'other respiratory', whereas in some instances in 1951 deaths from these causes are so few as no longer to justify their separate mention and they are accordingly included in ' all infective 'or' all respiratory '. Looking at the diagrams for each of the age groups in turn the most striking change is in infant mortality (0-1 year): some terms used for causes of death in 1901 are no longer current medical terminology in death certification, e.g. ' feeding difficulties and teething ' rickets'. In 1901 the most frequent cause of death in infancy was gastritis, enteritis and diarrhoea which by 1926 had fallen to second place and by 1951 to last but one of the specified causes. Prematurity, which in 1901 held second place rates highest in 1926 and in 1951; this is the cause of death in infancy which, despite its reduction from 1907 per 100,000 infant deaths in 1901 to 1,411 in 1926 and to 472 in 1951 still offers the greatest resistance to further reduction of the infant mortality rate, see page 16. The lesser causes in 1901 of congenital malformations (see also footnote below*), post-natal asphyxia and birth injury have become more important by 1951 because of the very great reduction in deaths from the infective and respiratory causes. In young children (1-4 years) the specific infective causes of death—diphtheria, measles and scarlet fever—seen at the turn of the century have largely disappeared as causes of mortality. Violence (accidental death) despite its decline from 99 deaths per 100,000 population in 1901 to 38 in 1926 and 20 in 1951 now ranks as second in importance instead of more than half-wav down the list in earlier vears. * The general movements resulting from this change and also to a lesser extent the changes in the same year resulting from the revision of the International List of Causes of Death, 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 per cent. Bronchitis + 100 per cent. Cancer - 3 tt t, Pneumonia + 5 „ „ Diabetes - 30 „ „ Other respiratory diseases.. + 50 „ „ Heart diseases - 10 ,, ,, Nephritis + 12 „ „ Other circulatory diseases - 6 „ „ Diseases of pregnancy, etc. + 10 ,, ,, Congenital malformations + 13 „ „ † Based on the dual classification of deaths for England and Wales. 1939. 154 The improvement in the death rate of schoolchildren is largely a history of the overcoming of mortality from the infective diseases: the death rate in this group is now only 44 deaths per 100,000 population or one death for every 2,300 children, and violence accounts for one-third of them for boys in this age group. With young adults (15-24 years) the reduction in the death rate is again largely due to the almost complete disappearance of infective disease; tuberculosis, which is treated outside the description of 'infective disease' in this context, now occupies second instead of first place in this age group though the death rate from this cause is only 13 per cent. of what it was in 1901 (tuberculosis is dealt with in detail in pages 25 to 49). Cancer appears currently in this age group as a major cause of death for the first time although it has increased only slightly (from 5 to 6 per 100,000 population over the fifty years) ; it appears now because of the great reduction in mortality from other causes. Deaths from pregnancy and childbirth in young women are now only a tiny fraction of what they were and are too insignificant to warrant separate mention. Violence now accounts for nearly one-half of male deaths in this age group. At adult ages of 25-44 years tuberculosis has disappeared as a major cause of death and cancer now occupies first place in this age group, though its contribution to mortality remains the same as in 1901 (46 per 100,000 population compared with 45 in 1951). Deaths from pregnancy and childbirth in women at these ages, despite their decline from 48 to 6 per 100,000 population still occupy eighth place in the list because of the very great decline in deaths from other causes. Alcoholism, which figures in the list for 1901, has virtually disappeared as a cause of death. Violence still occupies a prominent place in deaths of males in this age group. The mention of violence in current mortality in each of the three foregoing age groups is noteworthy, especially as a cause of death in males. At 'middle age' (45-64 years) the sex differential in the death rate has been commented on earlier and this difference between the sexes, which has increased, is readily seen from the difference in length of the black (male) and hatched (female) lines; thus in cancer, which shows an absolute increase over the period, the male death-rate is now one and a half times that of the female rate whereas in 1901 the female rate was one seventh higher than that for males. Pneumonia and bronchitis, which took a heavy toll in lives at these ages at the beginning of the century are still major causes of death though the statistical change in 1940 referred to in the footnote on page 154 applies in this context; the death-rate for males from these causes is three times that of females. Deaths from tuberculosis at these ages show a marked decline but again the sex differential has increased over the fifty years to the disadvantage of men. As with the previous age group, alcoholism, which was of some importance as a cause of death in 1901 (53 per 100,000 population) has disappeared. This is the first age group in which syphilis and its sequelae receives mention in each of the three years—no doubt this is a reflection of the increase in facilities for treatment which received such an impetus in the first world war, younger age groups have received effective treatment whereas for persons of this generation adequate treatment probably came too late to save them from the late effects of syphilis and babies are now protected by ante-natal care. Throughout this age group the important feature is the higher male death-rate, a sex differentiation which has increased over this century and which, with two exceptions (vascular lesions of nervous system and diabetes), persists in every one of the causes of death Listed. At the extreme end of life, 65 years and over, the pattern of death remains similar over the fifty years with, perhaps, more specificity in the certification of death, e.g., 'old age' in 1901. The main causes of death in each of the years is from degenerative causes—heart disease, other circulatory disease, vascular lesions, nephritis and bronchitis. The big difference in scale for each of the three years should be borne in mind when making comparisons at these ages. The outstanding feature of this review is the great reduction in mortality from the infective and respiratory diseases and from tuberculosis. Diseases in which he the greatest scope for further prevention of death are certain causes of neo-natal mortality (prematurity, post-natal asphyxia, etc.), violence in young people and cancer in the middle-aged. 155 156 157 158 159 160 161 162 163 APPENDIX B VITAL STATISTICS OF THE COUNTY OF LONDON IN THE YEARS 1901 TO 1951 by W. J. MARTIN Medical Research Council's Statistical Research Unit, London School of Hygiene and Tropical Medicine The following paper is reproduced from the British Journal of Preventive and Social Medicine, 1955, vol. 9, page 126 by courtesy of Dr. Martin and the editors of that journal. It brings together in small compass data that are scattered in a number of publications and also discusses the changes that have taken place in the correlation between mortality and various social indices. The growth and development of London during the past 50 years has been influenced by three major factors. The first factor to operate, and one which still functions, is the continuous growth of London as a commercial centre and the consequent pressure exerted on living conditions by the creation of new offices, shops, warehouses, and factories, especially in the central areas. Secondly, the first world war brought about a social revolution, and perhaps one of its most important consequences was the large increase in opportunities for female labour in office and factory. Thirdly, during the second world war, thousands of houses in London were destroyed, and a very severe housing shortage ensued. With the publication of the 1951 Census for London it is possible to see how these factors have influenced the vital statistical trends of the different London boroughs during the last half century. Population At the beginning of the 20th century London had already overflowed its boundaries in the east and the north-east where other towns had become contiguous with London. Some boroughs were not completely built up and in the north-west and south some land was still used for agriculture and wild life still persisted. Since horse vehicles and steam trains were the only methods of transport, most members of the population were compelled to live fairly close to their places of employment. The development of electricity for traction in the first decade of the 20th century led to the electrification of some surburban train services, the District and Metropolitan railways, and the construction of the underground system of 'tubes'. Further electrification and the introduction of the motor bus greatly facihtated travelling; the centre of London became more commercialized and surrounding country was engulfed for dormitories. Table I shows the population enumerated at the last five censuses and the changes that have occurred in the distribution of the population during the past 50 years. The central cluster of boroughs (including the City, Finsbury, Holborn, St. Marylebone, Southwark, and Westminster) showed a continuous decline in population during the first 30 years and much house property was converted to commercial uses. On the other hand the outer boroughs, and those incompletely built-up boroughs in 1901 (Fulham, Hammersmith, Hampstead, Lewisham, Wandsworth, and Woolwich) showed consistent rises. The changes in the distribution of population between 1931 and 1951, particularly the large falls in population in the adjacent boroughs of Bermondsey, Bethnal Green, Finsbury, Poplar, Shoreditch, Southwark, and Stepney, reflect the damage done during the war. In all these districts the 1951 population was approximately only half the 1931 level. Only in Hampstead, Lewisham and Woolwich did the population of 1951 exceed that of 1931, and the gains here were very slight. The best residential districts in 1901 were situated in Hampstead and Kensington, and the large number of female domestic staff employed accounts for the very low proportion (39 per cent.) of males in the population of these boroughs. Despite the disappearance of large domestic staffs, the great preponderance of women in these 164 areas persisted until 1951. The occupational section of the 1951 Census is not yet published, but it is probable that the excess female population is due to women in personal service in the hotels and boarding houses to which the large private houses were converted in many instances. Similarly the excess of females in some other boroughs —Chelsea, Holborn, Paddington, and St. Marylebone—is probably due to the many hotels which are here situated. The City, Bermondsey, Bethnal Green, Greenwich, Poplar, Shoreditch, Southwark, Stepney, and Woolwich had high male ratios in each census year. 165 166 Table I—Populations of Boroughs Borough Populations (thousands) Intercensus Variations (per cent.) Percentage of Males in Population 1901 1911 1921 1931 1951 1901-11 1911-21 1921-31 1931-51 1901 1911 1921 1931 1951 City 27 20 14 11 5 -27.0 - 30.3 - 19.8 - 51.6 51.4 51.3 49.0 50.7 49.7 Battersea 169 168 168 160 117 - 0.7 - 0.0 - 4.9 - 26.6 48.4 48.2 46.9 47.3 46.8 Bermondsey 131 126 119 112 61 - 3.7 - 5.1 - 6.6 - 45.6 49.8 50.0 48.8 49.2 49.2 Bethnal Green 130 128 117 108 58 - 1.2 - 8.5 - 7.7 - 46.1 48.9 48.9 48.4 48.3 47.3 Camberwell 259 261 267 251 179 0.8 2.2 - 5.9 - 28.5 47.4 47.5 47.0 47.2 47.1 Chelsea 74 66 64 59 51 -10.1 - 4.0 - 7.3 - 13.7 44.4 42.9 40.5 40.6 41.6 Deptford 110 109 113 107 75 - 0.8 2.8 - 5.0 - 29.4 48.6 48.4 48.1 48.3 47.1 Finsbury 101 88 76 70 35 -13.3 - 13.6 - 8.0 - 49.4 49.2 48.5 47.6 48.1 47.8 Fulham 137 153 158 151 122 11.7 3.0 - 4.4 - 19.1 47.1 47.4 46.4 46.7 46.4 Greenwich 96 96 100 101 90 0.2 4.7 0.5 - 11.0 49.7 49.2 48.6 49.1 48.7 Hackney 219 223 222 215 171 1.6 - 0.2 - 3.1 - 20.4 46.1 46.3 45.9 46.3 47.2 Hammersmith 112 122 130 136 119 8.3 7.2 4.0 - 11.9 47.0 47.8 48.0 48.0 47.9 Hampstead 82 85 86 89 95 4.3 0.8 3.2 7.0 38.7 38.4 38.6 39.3 41.8 Holborn 59 49 43 39 25 - 16.9 -12.5 - 10.0 - 36.2 49.6 48.8 48.0 46.8 45.4 Islington 335 327 331 322 236 – 2.3 1.0 - 2.7 - 26.8 47.6 47.6 46.8 47.2 47.2 Kensington 177 172 176 181 168 – 2.4 2.1 2.7 - 6.9 39.1 38.6 38.6 39.3 42.9 Lambeth 302 298 303 296 230 – 1.3 1.6 - 2.2 - 22.3 47.3 47.7 46.7 47.2 47.6 Lewisham 127 161 174 220 228 26.1 8.3 26.3 3.5 44.5 45.3 45.4 46.3 46.9 Paddington 144 143 144 145 125 - 1.0 1.2 0.5 - 13.4 42.8 42.4 41.9 42.4 45.7 Poplar 169 162 163 155 74 - 3.8 0.1 - 4.6 - 52.6 50.2 49.8 49.5 49.4 49.2 St. Marylebone 133 118 104 98 76 -11.4 - 11.8 - 6.3 - 22.3 43.4 42.0 39.4 39.7 41.7 St. Pancras 235 218 211 198 138 - 7.2 - 3.2 - 6.3 - 30.2 48.6 48.9 47.1 47.6 47.8 Shoreditch 119 111 104 97 45 - 6.1 - 6.4 - 6.9 - 53.8 49.0 49.2 48.3 48.7 48.2 Southwark 206 192 184 172 97 - 6.9 - 3.9 - 6.9 - 43.4 50.1 49.8 48.6 49.3 48.7 Stepney 299 280 250 225 99 - 6.3 -10.8 - 9.8 - 56.1 50.4 50.1 49.1 48.9 49.4 Stoke Newington 51 51 52 51 49 - 1.1 3.0 - 1.9 - 4.0 44.1 44.7 45.0 45.0 47.6 Wandsworth 232 311 328 353 330 34.3 5.4 7.5 - 6.4 44.7 45.2 44.8 45.2 45.8 Westminster 183 160 142 130 99 - 12.4 - 11.7 - 8.5 - 23.6 46.4 45.8 43.4 43.6 46.4 Woolwich 117 121 140 147 148 3.6 15.7 4.6 0.7 52.3 50.5 49.6 49.8 48.9 London 4,536 4,522 4,485 4,397 3,348 - 0.3 - 0.8 - 2.0 - 23.9 47.2 47.0 46.2 46.5 46.8 Table II–Density indices of Boroughs Borough Percentage of the population living more than 2 to a room Persons per room 1910* 1911 1921 1931 1951 1911** 1921 1931 1951 City 10.9 12.3 6.6 5.6 0.8 1.06 0.98 0.91 0.77 Battersea 10.9 13.3 12.4 11.9 2.1 1.09 1.04 0.98 0.81 Bermondsey 19.7 23.4 23.2 21.8 2.7 1.37 1.34 1.25 0.93 Bethnal Green 29.6 33.2 27.8 23.6 2.8 1.56 1.46 1.35 0.92 Camberwell 9.6 13.5 12.8 10.4 1.6 1.08 1.04 0.96 0.80 Chelsea 14.4 14.9 13.7 10.2 1.9 1.04 0.85 0.79 0.75 Deptford 9.1 12.2 12.8 11.0 1.7 1.06 1.05 0.98 0.81 Finsbury 35.2 39.8 34.0 29.4 3.4 1.61 1.50 1.42 0.96 Fulham 10.9 14.6 13.1 10.5 2.7 1.09 1.05 0.97 0.84 Greenwich 8.3 12.1 13.8 11.1 1.9 1.05 1.01 0.94 0.83 Hackney 10.2 12.4 11.5 9.6 1.5 1.08 1.06 1.00 0.85 Hammersmith 11.8 14.2 13.8 10.2 3.9 1.05 1.04 1.01 0.90 Hampstead 6.4 7.1 6.5 4.1 2.7 0.86 0.71 0.70 0.80 Holborn 25.0 25.6 19.8 17.1 2.3 1.30 1.12 1.07 0.92 Islington 17.0 20.0 19.4 16.0 3.8 1.22 1.18 1.12 0.92 Kensington 14.8 17.1 16.7 12.6 4.6 1.04 0.81 0.80 0.82 Lambeth 12.2 13.6 12.7 10.6 2.1 1.05 1.02 0.97 0.83 Lewisham 2.7 3.9 4.7 4.1 1.4 0.83 0.80 0.81 0.77 Paddington 13.6 16.2 15.4 12.3 5.2 1.10 0.93 0.90 0.88 Poplar 16.4 20.6 21.2 20.1 3.5 1.33 1.31 1.25 0.93 St. Marylebone 21.1 20.7 17.9 13.1 2.2 1.14 0.88 0.81 0.76 St. Pancras 24.0 25.5 22.4 17.6 4.4 1.32 1.22 1.13 0.93 Shoreditch 30.0 36.6 32.0 29.1 3.5 1.61 1.54 1.45 0.98 Southwark 22.4 25.8 23.5 21.6 2.9 1.43 1.36 1.28 0.93 Stepney 33.2 34.9 29.0 23.6 3.4 1.56 1.45 1.33 0.94 Stoke Newington 5.5 8.8 8.1 6.6 1.7 0.95 0.92 0.90 0.86 Wandsworth 4.5 6.3 6.8 5.2 1.3 0.89 0.84 0.79 0.75 Westminster 13.0 12.9 10.1 7.1 2.3 1.06 0.81 0.76 0.76 Woolwich 6.6 6.3 7.8 5.7 1.3 0.98 0.97 0.88 0.73 London 16.0 17.8 16.1 13.1 2.5 1.14 1.05 0.98 0.83 * In this year the index is of persons living more than two to a room in tenements of less than five rooms as a percentage of the total population, and consequently the value is slightly lower than it would have been on the basis of subsequent years. ** For 1911 the rate was based on families living in 1.9 rooms and is therefore slightly more than a rate based on all private families as in the other years. Density Two measures of density are given in Table II. The most striking feature is the very great decrease in overcrowding that was accomplished by 1951. Between 1911 and 1931 a small improvement had taken place in the overcrowding indices but no large changes occurred in the relative positions of the boroughs ; the boroughs with the most overcrowding in 1911 still had the most in 1931. In 1951, in most boroughs, the proportion living more than two to a room had become only a fraction of the corresponding proportion in 1931. The lowest indices of overcrowding were recorded at each Census for the boroughs of Hampstead, Lewisham, Stoke Newington, Wandsworth, and Woolwich. Foreign.born population For the first 30 years of the 20th century the foreign.born population of London remained almost constant in proportion (some 3 per cent.). In 1951 the proportion rose to 5 per cent. and became more widely dispersed through London (Table III, next page). 167 M Thus, early in the century, there were two distinct colonies. One was in the Soho district, partly in Holborn and partly in Westminster, and was mainly Italian, French and German. The other was in Stepney and consisted mainly of persons born in Russia, or Russian Poland, who formed about 80 per cent. of the foreign.born population in Stepney. By 1951 the Russians and Poles had overflowed into the neighbouring boroughs and formed two.thirds of the large foreign-born population in Hackney. Political refugees from Poland and Germany formed a large proportion of the increase in the foreign-born population recorded at the 1951 Census. Thus, Germans and Poles form the largest groups of foreign-born persons in the adjacent boroughs of Hampstead, Kensington, Paddington, and St. Marylebone. In 1951 the absolute number of foreignborn persons in these areas taken together was four times the figure of 1901, and formed 34-5 per cent. of the total foreign-born population of London compared with 11-3 per cent. in 1901. In Hampstead in 1951 one person in six was of non-British birth. Table III—–Number offoreign-born persons enumerated at each census and their percentage of total population in each area Borough 1901 1911 1921 1931 1951 No. Per cent. No. Per cent. No. Per cent. No. Per cent. No. Per cent. City 1,243 4.6 1,049 5.3 738 5.4 567 5.2 197 3.7 Battersea 952 0.6 1,129 0.7 1,291 0.8 1,214 0.8 2,689 2.3 Bermondsey 1,133 0.9 983 0.8 897 0.8 804 0.7 818 1.3 Bethnal Green 4,634 3.6 7,791 6.1 6,864 5.9 5,356 5.0 1,951 3.3 Camberwell 1,494 0.6 1,723 0.7 1,920 0.7 1,828 0.7 3,509 2.0 Chelsea 1,263 1.7 1,553 2.3 1,760 2.8 1,551 2.6 4,033 7.9 Deptford 742 0.7 577 0.5 588 0.5 620 0.6 1,083 1.4 Finsbury 2,467 2.4 2,442 2.8 1,966 2.6 1,564 2.2 1,124 3.2 Fulham 1,778 1.3 2,273 1.5 2,343 1.5 2,195 1.5 4,916 4.0 Greenwich 790 0.8 765 0.8 783 0.8 839 0.8 1,387 1.5 Hackney 3,201 1.5 4,788 2.2 8,273 3.7 10,291 4.8 12,639 7.4 Hammersmith 1,568 1.4 3,152 2.6 2,870 2.2 2,430 1.8 4,817 4.0 Hampstead 2,269 2.8 3,219 3.8 4,619 5.4 5,691 6.4 15,650 16.5 Holborn 5,706 9.6 5,223 10.6 4,652 10.4 3,521 9.1 2,094 8.4 Islington 4,300 1.3 5,076 1.6 5,120 1.5 5,050 1.6 7,502 3.2 Kensington 4,669 2.6 6,534 3.8 8,469 4.8 8,214 4.5 19,871 11.8 Lambeth 3,506 1.2 5,192 1.7 5,506 1.8 4,738 1.6 7,517 3.3 Lewisham 1,082 0.8 1,264 0.8 1,536 0.9 1,704 0.8 3,393 1.5 Paddington 2,822 2.0 4,523 3.2 5,344 3.7 5,298 3.7 12,741 10.2 Poplar 2,104 1.2 1,966 1.2 2,517 1.5 1,666 1.1 1,320 1.8 St. Marylebone 5,560 4.2 6,274 5.3 5,998 5.8 5,179 5.3 8,872 11.7 St. Pancras 8,156 3.5 10,476 4.8 9,066 4.3 7,267 3.7 7,899 5.7 Shoreditch 2,625 2.2 2,018 1.8 1,745 1.7 1,556 1.6 847 1.9 Southwark 1,593 0.8 1,766 0.9 1,744 0.9 1,352 0.8 1,751 1.8 Stepney 54,310 18.2 53,060 19.0 41,017 16.4 30,083 13.4 8,503 8.6 Stoke Newington 1,073 2.1 1,563 3.1 2,061 4.0 2,712 5.3 3,883 7.9 Wandsworth 2,065 0.9 3,090 1.0 4,261 1.3 9,455 2.7 13,567 4.1 Westminster 11,831 6.5 13,047 8.1 12,318 8.7 9,229 7.1 9,401 9.5 Woolwich 441 0.4 612 0.5 816 0.6 902 0.6 1,811 1.2 London 135,377 3.0 153,128 3.4 147,082 3.3 132,876 3.0 165,785 5.0 168 Table IIIA—Foreign.born residents by nationality Country of origin Percentage of all Foreign.born in London 1901 1911 1921 1931 1951 Russia 39.5 41.2 23.8 15.4 11.7 Poland 21.1 22.5 23.9 Germany 20.3 17.8 6.2 7.4 13.2 France 8.3 9.0 9.7 7.9 5.9 Italy 8.0 7.6 8.0 8.1 7.0 Austria 4.6 5.3 1.1 1.5 7.0 Others 19.3 19.1 30.1 37.2 31.3 Total 100 100 100 100 100 Death.rates Before the adoption in 1911 of the method of transference of deaths to place of usual residence, the death.rates in the London boroughs were affected by the number of hospitals and institutions within their boundaries, deaths occurring in such institutions being credited to the borough in which the institution was situated. The study of mortality has therefore been limited to the years 1911 onwards. Some method of standardization is necessary for comparing the London boroughs owing to the varying sex and age constitutions of the populations. For this purpose the direct method of standardization has been used, with the census population of London in 1931 as the standard population. The standardized death.rates calculated on this basis are shown in Table IV which shows that considerable variation in the death rate between London Table IV—Standardized Death-rates Borough 1911-13 1920-22 1930-32 1950-52 City 19.45 15.42 13.10 8.05 Battersea 15.29 13.56 11.53 8.65 Bermondsey 20.31 16.84 14.04 9.68 Bethnal Green 18.86 16.39 13.18 9.69 Camberwell 15.11 13.57 11.45 8.97 Chelsea 14.25 12.09 11.35 8.63 Deptford 16.89 14.21 12.04 9.11 Finsbury 21.90 17.61 14.51 9.77 Fulham 16.20 13.09 11.80 8.69 Greenwich 14.92 13.46 11.17 8.60 Hackney 14.85 13.47 11.70 8.90 Hammersmith 15.78 13.65 12.32 9.05 Hampstead 12.35 11.32 10.68 7.80 Holborn 17.71 15.55 13.50 8.86 Islington 16.03 14.27 12.37 9.07 Kensington 14.97 13.58 12.50 8.49 Lambeth 15.51 13.72 11.99 9.05 Lewisham 12.09 11.14 9.93 8.08 Paddington 14.47 12.92 12.61 8.92 Poplar 18.26 15.21 12.74 9.78 St. Marylebone 16.29 14.27 12.36 8.67 St. Pancras 16.82 14.77 12.78 9.12 Shoreditch 19.51 16.33 13.22 9.69 Southwark 19.68 16.41 13.99 10.10 Stepney 18.87 16.53 14.35 10.65 Stoke Newington 13.98 13.42 11.92 9.16 Wandsworth 12.57 11.49 10.27 8.08 Westminster.. 15.72 13.47 12.12 8.34 Woolwich 14.78 12.42 11.53 8.44 London 15.98 13.91 12.05 8.77 169 M* boroughs was present in each period. The range between the boroughs decreased slightly, however ; the ratio of the highest to the lowest was 1.8 in 1911-13 and 1.4 in 1950-52. The boroughs of Hampstead, Lewisham, and Wandsworth had the lowest death-rates throughout the 40 years, and the boroughs of Bermondsey, Bethnal Green, Finsbury, Shoreditch, Southwark, and Stepney the highest. As is well known, the fall in the death-rate has been largely due to the fall in infant and child mortality. This can be illustrated by considering the death-rates for the first and last period for London as a whole (Table V) : Table V—Administrative County of London death-rates per 1,000 Age (yrs) 1911-13 1950-52 Males Females Males Females 0- 43.0 36.3 6.4 4.9 5- 2.7 2.6 0.6 0.4 15- 3.2 2.5 0.9 0.6 25- 7.3 5.1 2.2 1.7 45- 24.6 17.2 16.4 8.5 65- 68.2 51.5 61.5 32.5 75+ 158.6 135.8 152.7 115.3 It will be noted that between the ages of 45 and 74 the female death-rate has decreased faster than the male rate. The death-rate for most causes of death in these two age groups shows a female advantage. For three large and important groups of causes the rates in 1951 were as shown in Table VI. Table VI—Death-rates for certain causes for ages 45 and over Cause of death Cancer Heart Diseases Bronchitis Age 45-64 Males 4.3 4.4 1.9 Females 2.7 1.8 0.4 Age 65-74 Males 13.5 20.4 8.4 Females 6.6 11.1 2.5 Since the overcrowding indices had been so drastically reduced by 1951 it seems of interest to see whether, as in the past, the indices of living conditions are correlated with the death rate. Excluding the City of London from the calculations, the correlation coefficients between the socio-economic conditions of the boroughs and their standardized deaths rates are as follows : Correlations 1911-13 r 1920-22 r 1930-32 r 1950-52 r Standardized Death Rate and Percentage living more than two to a room 0.889 0.922 0.874 0.364 Persons per Room 0.930 0.906 0.799 0.800 Proportion of population in Social Classes IV and V - 0.694 0.625 0.900 5 per cent. level of significance r = 0.36, 1 per cent. level r = 0.46. 170 The death rate was highly correlated with the percentage of persons living more than two to a room in the first three periods, but the coefficient had only just reached the 5 per cent. level of significance in 1950-52. On the other hand the death rate and persons per room was the same for the last two triennia and only slightly below the earlier figures. The correlation between the death rate and the proportion of the male population in Social Classes IV and V was significant for each of the three triennia for which this index was available and significantly larger in 1950-52 than in the earlier periods. Birth rate Heron (1906), from a study of the data relating to the London Boroughs, found a negative correlation between fertility and social status. Some of the indices used were approximate, but Mitra (1937) extended the analysis to include data for the 1931 census, with its more accurate index of social conditions, and substantially confirmed Heron's conclusions. The crude birth rate is influenced by the sex and age constitution of the population, and for this reason the legitimate births per 1,000 married women aged 15-44 have been used in the present study (Table VII). Table VII—Legitimate births per 1,000 married women aged 15-44 Borough 1911-13 1920-22 1930-32 1950-52 City 103 107 66 68 Battersea 193 183 121 99 Bermondsey 250 242 149 116 Bethnal Green 250 228 142 108 Camberwell 201 190 118 101 Chelsea 172 168 117 113 Deptford 209 190 123 105 Finsbury 236 232 145 124 Fulham 193 168 110 90 Greenwich 209 188 122 100 Hackney 198 185 117 94 Hammersmith 185 168 111 101 Hampstead 142 138 93 102 Holborn 146 134 79 95 Islington 195 189 125 104 Kensington 180 169 117 114 Lambeth 184 174 114 101 Lewisham 166 157 101 96 Paddington 176 157 107 106 Poplar 255 238 151 111 St. Marylebone 164 146 99 92 St. Pancras 193 179 115 105 Shoreditch 257 250 156 120 Southwark 229 215 135 112 Stepney 245 221 156 126 Stoke Newington 178 163 111 102 Wandsworth 168 151 98 92 Westminster 134 122 85 98 Woolwich 176 170 108 100 London 198 183 119 102 The highest birth rates were in the East End boroughs throughout the period, while the lowest were those of Hampstead, Holborn, and Westminster in the first three triennia, and of Fulham, St. Marylebone, and Wandsworth in 1950-52. A comparison 171 M** of Table VII with Tables II and III suggests that the birth rate, like the death rate, is correlated with the density indices. The correlations are : Correlations 1911-13 r 1920-22 r 1930-32 r 1950-52 r Legitimate Birth Rate and Standardized Death Rate 0.748 0.741 0.588 0.718 Percentage living more than two to a room 0.666 0.750 0.777 0.491 Persons per room 0.768 0.876 0.825 0.601 Proportion of population in Social Classes IV and V — 0.811 0.776 0.670 All the correlations are significant. The indices of density in 1950-52 were not so highly correlated with the birth rate as in former years, and the correlation between birth rate and the proportion in the lowest social classes of the population has also decreased since 1920-22, though the difference between 0.811 and 0.670 is not significant. Infant mortality Hersch (1943) chose infant mortality as the best single numerical index of the degree of civilization of a population. He considered that a decrease in this rate reflected the advances made in hygiene, medicine, chemistry, and public instruction, and that it was the best sign of improved living conditions. When Hersch was writing, infant mortality in Europe ranged from 37 in the Netherlands to 180 in Rumania, and even higher rates occurred in Eastern countries. In England and Wales infant mortality has been used in the past as an index of the socio-economic level of the community, since the highest rates were found to occur where living conditions were worst, and infant mortality varied directly with social class. McKinlay (1928) attempted to standardize for varying social conditions in the London boroughs, but found that such standardization for economic status did not reduce the variability between the boroughs by as much as seemed a priori probable. Stocks (1928), using the occupations of the males from the census returns, attempted to find a correction factor which would reflect the social make-up of the London boroughs. This correction, however, only reduced the variability between the infant mortality rates of the London boroughs from 17 to 14 per cent. in 1911-13, and from 15 to 13 per cent. in 1921-25. The findings of McKinlay and Stocks are in agreement, and clearly the economic factor, as measured by their indices, was not very important in determining the level of infant mortality in the various boroughs. During the past 25 years the effect of many variables has been studied : e.g. indices of density, proportion of mothers employed, fertility rate, and proportion of males in the professional classes and in the lowest type of labour, etc. These investigations have shown that infant mortality was affected by socio-economic conditions, but since the variables used were themselves inter-related it has not been possible to assess the relative importance of their contributions. In recent years infant mortality has fallen rapidly. In England and Wales the rate was 154 deaths per 1,000 live births in 1900, by 1922 this had been halved, and in 1930 the rate was down to 60. Between 1930 and 1941 the rate fluctuated between 51 and 66, but since 1941 when it was 60 it has fallen steadily to 25.5 in 1954. In 1950-52 the infant mortality rate for London (24) was below the rate for the whole country (29), and much below the rates for the county boroughs of Durham (40), Lancashire (36), Staffordshire (34), and Yorkshire West Riding (31). Not only was the infant mortality lower in London than in the large industrial towns of the north but 172 the range was smaller ; thus the rates in 1950-52 ranged from 19 to 31 in the 28 London boroughs, from 29 to 47 in the seventeen county boroughs of Lancashire, and from 23 to 38 in the eleven county boroughs of Yorkshire West Riding. The low level and relatively small range of infant mortality make the London boroughs unrepresentative of urban areas in general. Use of the 1931 census data showed that, although the infant mortality by social class in London showed the same progression as in the whole of the country, the usual indices of social structure in urban areas were less highly correlated with infant mortality than formerly. It was reasonable to suppose that these correlations would have declined still further during recent years, although the social class differential would still exist. No data, however, existed to test this hypothesis until the publication of the 1951 census for London. The occupational supplement is not yet published and it is not possible to display the infant mortality by social class, but there is no reason to suppose that the relative differences between the social classes has undergone much change. A triennial period centred in the census year was used for the appropriate rates shown in Table VIII, overleaf. For the County of London as a whole, infant mortality in 1950-52 (24 per 1,000) was less than one-quarter of the rate in 1911-13 (109 per 1,000). The largest falls occurred Table VIII—Infant mortality Borough 1911-13 1920-22 1930-32 1950-52 City 95 80 58 52 Battersea 107 75 57 24 Bermondsey 134 93 59 21 Bethnal Green 122 95 72 27 Camberwell 100 74 58 25 Chelsea 91 67 45 23 Deptford 117 80 60 28 Finsbury 137 83 73 19 Fulham 105 76 61 26 Greenwich 102 68 65 21 Hackney 100 73 55 24 Hammersmith 114 75 66 20 Hampstead 72 57 58 23 Holborn 101 73 78 31 Islington 107 77 67 27 Kensington 112 91 81 27 Lambeth 104 74 57 26 Lewisham 84 59 49 24 Paddington 109 80 91 28 Poplar 126 81 65 27 St. Marylebone 97 69 72 22 St. Pancras 98 75 66 27 Shoreditch 150 102 73 25 Southwark 122 85 63 22 Stepney 121 86 71 22 Stoke Newington 85 67 54 23 Wandsworth 96 64 60 22 Westminster 95 70 67 28 Woolwich 84 62 54 24 London 109 75 64 24 in boroughs where the rate was previously very high, the ratio of the lowest to the highest infant mortality being 2.1 in 1911-13 and 1.6 in 1950-52. The correlations 173 with social indices exhibited by the standardized death rates and the legitimate birth rates are not apparent in these infant mortality rates. The correlations are : Correlations 1911-13 r 1920-22 r 1930-32 r 1950-52 r Infant Mortality and Percentage Occupied Males in Social Classes IV and V — 0.649 0.132 - 0.072 Persons per Room 0.823 0.767 0.300 0.020 Percentage living more than two to a room 0.782 0.812 0.478 0.184 Infant mortality showed a large positive correlation with each of the three indices of social status up to 1920-22. In 1930-32 it has almost ceased to be affected by the measures of social conditions, and only the percentage living more than two to a room was significantly correlated with the rate. In 1950-52 no significant correlation was present. The general death rate, crude or standardized, has been frequently used as a broad measure of the health of the people, and recently the birth rate has given an indirect measure of the conditions of living since it has shown a steep gradation with social class. The correlations of infant mortality with these rates for the last four census periods are: Correlations 1911-13 t 1920-22 r 1930-32 r 1950-52 r Infant Mortality and Crude Death Rate 0.879 0.785 0.523 - 0.275 Crude Birth Rate 0.812 0.702 0.043 - 0.275 Standardized Death Rate 0.853 0.794 0.553 - 0.126 Legitimate Birth Rate for Women aged 15-44 yrs. 0.836 0.754 0.089 - 0.225 In 1911-13, the correlations were all of the same order, being large and positive. In 1920-22, they were slightly smaller, but still large and significant and approximately equal. In 1930-32, the infant mortality was no longer correlated with the measures of the birth rate ; the correlation with the measures of mortality had fallen considerably but was still significant. In 1950-52, no significant correlation existed at all. From the preceding correlations it might be inferred that infant mortality has now fallen to such a low level that it is no longer any criterion of the social or economic differences between the London boroughs. While this is so for the death rate for the whole of the first year of life, it must be realized that the neonatal mortality is now affecting the correlation more than in former years, since the deaths in the first month of life form a much larger proportion of the infant deaths than formerly. The percentage of deaths at various ages in the first year of life in London, for the period reviewed, are shown in Table IX : 174 Table IX—Deaths in the first year of life Age (mths) 1911-13 1920-22 1930-32 1950-52 Under 1 31.7 37.6 39.2 67.4 1-3 19.1 18.8 17.1 13.3 3-6 19.4 18.1 18.4 10.4 6-12 29.8 25.5 25.3 8.9 Total 100 100 100 100 The very different structure of infant mortality in 1950-52 suggested that it would be of interest to examine the relation of infant mortality and socio-economic indices by ages: Age (months) Years Proportion of Population in Social Classes IV and V r Persons per room r Percentage living more than two to a room r Under 1 1920-22 0.177 0.226 0.350 1930-32 -0.295 -0.184 -0.187 1950-52 -0.430 -0.389 -0.118 1-3 1920-22 0.499 0.618 0.632 1930-32 -0.155 0.027 0.116 1950-52 0.273 0.319 0.322 3-6 1920-22 0.541 0.698 0.691 1930-32 0.113 0.242 0.476 1950-52 0.387 0.430 0.328 6-12 1920-22 0.714 0.786 0.802 1930-32 0.521 0.622 0.749 1950-52 0.428 0.288 0.248 1-12 1920-22 0.667 0.778 0.788 1930-32 0.273 0.428 0.620 1950-52 0.496 0.484 0.414 In the first two triennia the correlations between neonatal mortality and the indices of socio-economic conditions were not significant, but in 1950-52 the percentage of the population in Social Classes IV and V and the number of persons per room showed a significant negative correlation. During the period the fall in the birth rate, from 198 legitimate births per 1,000 married women aged 15-44 in 1911-13 to 102 in 1950-52 for the whole of London, may account for this negative correlation by increasing the relative importance of the first births. Heady, Daly, and Morris (1955) showed that, for mothers aged 25 years and over, neonatal mortality is highest among first-born children and increases with age of mother. It has been shown that the birth rate is correlated with the three indices of general living conditions, i.e., the lower the social index the higher the birth rate, and it is known that the age of marriage decreases with social class. In 1920-22, the infant mortality at all later ages, 1-3 months, 3-6 months, 6-12 months, and 1-12 months, was significantly correlated with the three indices of environmental conditions. In 1930-32, the correlations at 1-3 months were all insignificant, at 3-6 months one was significant (the percentage of the population living more than two to a room) and at 6-12 months all three were significant. For the post-neonatal period as a whole (1-12 months) the correlation between infant mortality and the percentage in Social Classes IV and V was insignificant, but the other two correlations 175 were significant. In 1950-52, the infant mortality at 1-3 months was not correlated with any of the indices, at 3-6 months it was significantly correlated with the percentage in Social Classes IV and V and the number of persons per room but not with the other index of overcrowding, while at 6-12 months only the percentage in Social Classes IV and V gave a significant figure. For the post-neonatal period, all three indices were significantly correlated with infant mortality. This sub-division of infant mortality by ages shows, as expected, that the trend of the neonatal mortality is at least partially responsible for the lack of correlation in 1950-52 between infant mortality and socio-economic conditions. The post-neonatal rate remains significantly correlated with the three indices, though probably at a lower level than in 1920-22 (the differences between the two periods are not significant, except the percentage living more than two to a room). The relationship between the social indices and infant mortality may rest partly on the population of the boroughs. Most boroughs conform to the official description of a large town having a population of over 50,000; they were divided arbitrarily into three groups* and the correlations found between the percentage living more than two to a room and infant mortality and neonatal mortality: Population No. of Boroughs Percentage living more than two to a room (1951) correlated with Neonatal Mortality Infant Mortality r P r P 120,000 and Over 11 0.47 >0.1 0.89 <0.01 Over 60,000 and Under 120,000 11 -0.12 >0.1 -0.32 >0.1 Under 60,000 6 -0.72 >0.1 -0.19 >0.1 In all three groups the neonatal mortality is insignificantly correlated with the overcrowding index. Infant mortality is significantly correlated with this index in the very large boroughs but not in the other two groups of smaller boroughs. No explanation suggests itself to account for this difference. The infant deaths were rather few in the third group of boroughs (27 and 37 in 1950-52 in the two smallest), but in the second group the smallest borough had 69 deaths. Paucity of deaths cannot be an explanation. It is of some interest to see whether the relationship between the various indices of socio-economic status have changed during the period : Correlations 1920-22 r 1930-32 r 1950-52 r Percentage Occupied Males in Social Classes IV and V and Persons per room 0.744 0.739 0.757 Percentage living more than two to a room 0.658 0.722 0.314 Percentage living more than two to a room and persons per room 0.899 0.934 0.617 The large significant correlation between the proportion of occupied males in Social Classes IV and V and the number of persons per room has remained constant over the 30 years. The relationship between the proportion of occupied males in Social Classes IV and V and the percentage living more than two to a room had fallen below the level of significance in 1950-52 although a large significant correlation was found * The City of London has been omitted from all the correlations in this paper since it has a very small and unusually constituted population. 176 in the other two periods. The correlation between the two indices of density, which was very large in the two earlier triennia, fell significantly in 1950-52 but was itself still significant. The decline in the size of the correlation coefficients with the percentage living more than two to a room is directly attributable to conditions arising from the second world war. The destruction of so many houses led to an acute shortage and the opportunity was taken in the rebuilding programme to re-house Londoners outside the county boundaries. The result or this policy is that the population or London was one million less in 1951 than in 1931 (Table I), a dechne of 23-9 per cent, at all ages, and of 30-9 per cent, at ages 0-15 years. The magnitude of the change is shown by the densities for the whole : Overcrowding Index 1911 1921 1931 1951 Percentage living more than two to a room 17.8 16.1 13.1 2.5 Average persons per room 1.14 1.05 0.98 0.83 Summary Between 1901 and 1931 the population of the County of London was approximately stationary. Between 1931 and 1951 it fell by over a million, and in seven of the 28 boroughs the population in 1951 was only about half that in 1931. The result of these changes was a great reduction in the proportion of persons living in overcrowded conditions. From 1901 to 1931 the proportion of the population living more than two persons to a room was between 1 in 6 and 1 in 8; by 1951 it had fallen to 1 in 40. From 1901 to 1931 about 3 per cent, of the population of London was foreign-born; in 1951 the figure was 5 per cent, for the County, and over 10 per cent, in four boroughs: Hampstead (16 per cent.), Kensington (12 per cent.), Paddington (10 per cent.), and St. Marylebone (12 per cent.). The downward trend of the death rate during the 20th century has been remarkably similar in the London boroughs, so that the boroughs with the highest and lowest rates in 1911-13 were in the same relative position in 1950-52. The fall has, however, been larger in the boroughs where the rate previously was highest so that the actual and relative range of the death rates between London boroughs in 1950-52 was somewhat smaller than in 1911-13. The general death rate (standardized) is still significantly correlated with the indices of socio-economic status (persons per room, and percentage in Social Classes IV and V). The birth rate followed a trend similar to that of the death rate, and, generally, the relative level of the birth rate of a borough, high or low, has remained the same throughout the period. With the exception of the percentage of the population living more than two to a room, the correlations between the birth rate and the socio-economic indices have changed very little. The very large fall in infant mortality in the London boroughs has been relatively greater in those boroughs where the initial level was highest. In 1911-13 and 1920-22, infant mortality was significantly correlated with the percentage of occupied males in Social Classes IV and V and with the two measures of overcrowding. In 1930-32 the correlations between infant mortality and overcrowding were reduced but still significant, while the percentage of occupied males in Social Classes IV and V was not significantly correlated with infant mortality. In 1950-52 the correlations between infant mortality and the three indices were not significant. The lack of correlation in 1950-52 was partly due to the increasing contribution made by neonatal mortality, and partly to the fact that the relationship is no longer demonstrable in the smaller boroughs although it still exists in the largest boroughs. If the neonatal component is excluded, the correlation of infant mortality for the first year of life is significant in 177 1950-52 for each of the three socio-economic indices. The successful efforts to reduce overcrowding have lessened the sensitivity of this index of socio-economic conditions. In 1911 the percentage of persons living more than two to a room ranged from 3.9 to 39.8 in the London boroughs, while in 1951 the range was only from 1.3 to 4.6: thus this index of overcrowding was no longer a measure of either the vital-statistical or socio-economic differences between the London boroughs in 1950-52. References Heady, J. A., Daly, C., and Morris, J. N. (1955). Lancet, 1, 395. Heron, D. (1906). Drapers' Company Research Memoirs.' Studies in National Deterioration. I. On the Relation of Fertility in Man to Social Status.'Dulau, London. Hersch, L. (1943). Mid. et Hyg. (Gineve), 0, 10. McKinlay, P. L. (1928). Lancet, 2, 938. Mitra, K. (1937). J. Hyg., 37, 108. Stocks, P. (1928). Ann. Eugen. (Camb.), 3, 194. 178 APPENDIX C STATISTICS (a) Table 1—Population (b)—Administrative County of London, 1901-55 Year Mid-year (c) estimate of population by the Registrar-General by age groups Average age (years) Total 0-4 5-14 15-24 25-44 45-64 65+ 1901 4,536,500 495,600 862,300 919,700 1,400,200 673,200 185,500 27.7 1911 4,521,700 467,400 835,600 834,500 1,423,100 740,100 221,000 28.9 1921 4,484,500 376,100 809,200 796,600 1,365,500 877,100 260,000 30.8 1931 4,374,300 297,700 646,700 827,940 1,330,200 951,000 320,760 33.4 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 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 3,322,000 234,000 425,000 394,000 1,056,000 827,000 386,000 37.4 1955 M. 1,540,000 118,000 214,000 175,000 512,000 378,000 143,000 36.0 F. 1,755,000 112,000 207,000 216,000 525,000 451,000 244,000 38.8 3,295,000 230,000 421,000 391,000 1,037,000 829,000 387,000 37.5 (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 Jrom that published in the Annual Report for that year, b) 1901-39—Total population. 1940—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) Population at census date 1901, 1911 and 1921. 179 Table 2—Live births and still-births—Administrative County of London, 1931-55 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 50,745 15.3 1,029 19.9 1955 49,826 15.1 1,034 20.3 *1931.49—Total population. 1950— Home population. 180 181 Table 3— Vital statistics—Metropolitan Boroughs ana the Administrative County of Lonaon,1995 (a) Metropolitan Boroughs Estimated home population mid 1955 Live birth rate. Death-rates Notifications of infectious disease Deaths {all causes) Infant mentality (pet l,ooo live births) Heart disease Other circulatory Cerebral vascular lesions Peptic ulcer Pulmonary tuberculosis Pneumonia Other respiratory diseases (inc. Bronchitis) Cancer VioItnce Scarlet fever Dysentery Poliomyelitis Food Poisoning Acute pneumonia Measles Whooping cough Tuberculosis Paralytic Son Paralytic Pulmonary Nonpul monary Division 1 Chelsea 51,450 14.8 160 33 4.22 1.63 1.90 0.25 0.16 1.03 0.80 3.03 0.76 0.84 4.20 0.04 0.08 0.52 0.47 14.3 1.65 0.78 0.14 Fulham 118,600 14.3 11.1 27 2.88 0.45 1.30 0.22 0.23 0.46 0.98 2.32 0.49 0.62 0.73 0.09 0.10 0.29 0.39 14.6 1.59 0.85 0.10 Hammersmith 114,700 14.9 10.9 30 2.80 0.54 1.22 0.15 0.14 0.57 1.07 2.40 0.40 0.77 0.69 0.17 0.16 0.22 1.00 14.3 1.71 1.18 0.13 Kensington 169,400 15.9 10.3 31 3.05 0.47 1.28 0.16 0.07 0.60 0.75 1.88 0.61 0.30 0.58 0.06 0.12 0.31 0.62 8.4 0.68 1.14 0.15 Division 2 Hampstead 97,710 14.1 10.0 17 2.81 0.71 1.19 0.13 0.13 0.41 0.62 2.25 0.59 0.24 0.33 0.09 0.29 0.57 0.54 10.5 1.17 0.86 0.04 Paddington 121,500 17.4 10.7 25 2.75 0.53 1.23 0.18 0.12 0.53 0.84 2.37 0.64 0.32 0.24 0.10 0.12 0.57 0.42 13.1 0.98 1.46 0.15 St. Marylebone 73,440 11.1 15.5 15 6.09 0.75 2.19 0.10 0.12 0.41 1.21 2.51 0.49 0.26 0.16 0.11 0.08 1.59 0.16 8.0 0.50 1.02 0.03 St. Pancras 134,500 16.5 10.7 23 2.77 0.62 0.89 0.13 0.23 0.45 1.14 2.48 0.43 0.38 1.26 0.12 0.18 0.74 0.43 120 0.79 1.55 0.16 Westminster, City of 97,630 11.0 10.1 27 2.67 0.52 112 0.10 0.23 0.60 0.57 2.31 0.60 0.31 0.70 0.10 0.05 0.09 0.16 9.4 1.30 1.13 0.15 Division 3 Finsbury 35,100 19.8 10.2 30 2.76 0.17 0.68 0.14 0.43 0.57 1.34 211 0.66 0.83 3.30 0.09 0.03 0.54 0.97 15.6 2.91 1.17 0.17 Holborn 23,060 110 10.4 28 2.60 0.26 1 04 009 0.35 0.56 0.69 2.47 0.74 0.17 0.17 0.35 0.17 0.52 — 7.5 0.04 1.78 0.17 Islington 228,800 17.5 11.3 25 3.26 0.62 105 0.17 0.20 0.86 1.11 2.18 0.50 0.93 1.78 0.16 0.07 1.32 0.52 12.6 1.57 1.34 0.18 Division 4 Hackney 167,200 140 10.4 23 318 0.47 1.06 0.25 0.09 0.44 1.08 2.26 0.32 0.48 2.67 0.11 0.10 0.26 0.39 12.8 1.77 0.66 0.11 Shoreditch 45,480 16.8 12.9 20 3.43 0.62 1.54 018 0.33 0.73 1.41 2.51 0.35 0.77 5.54 0.15 0.09 0.13 0.29 10.3 3.32 0.79 0.13 Stoke Newington 50,470 15.7 10.7 18 311 0.53 115 0.14 008 0.67 0.95 2.66 0.40 0.55 0.75 0.12 0.12 0.73 0.71 14.9 1.60 0.63 0.08 Division 5 Bethnal Green 53,860 160 10.3 20 2.58 0.46 0.87 0.24 015 0.87 1.21 2.30 0.35 0.52 1.21 0.20 0.02 0.41 0.09 15.3 1.75 0.85 0.09 City of London (b) 5,180 6.4 10.6 30 212 0.39 0.39 0.39 0.39 0.77 0.39 3.28 1.16 0.39 — 0.39 0.19 — 0.77 3.9 — 1.16 0.19 Poplar 70,260 16.8 10.9 29 2.48 0.81 1.02 0.20 0.23 0.73 1.22 2.33 0.44 0.58 0.51 0.28 0.13 0.56 0.80 22.2 2.73 0.84 0.14 Stepney 98,180 18.6 120 23 3.04 0.66 105 0.18 0.17 0.86 1.48 2.52 0.48 0.26 1.50 0.25 0.21 0.18 0.55 18.7 1.50 1.52 0.23 Division 6 Deptford 72,890 14.4 11.8 11 3.55 0.71 1.34 019 019 0.71 1.10 2.54 0.33 0.54 0.12 0.07 0.01 0.07 0.56 14.2 1.56 2.25 0.05 Greenwich 89,490 14.5 9.3 16 2.82 0.55 0.94 009 008 0.49 0.74 1.93 0.28 0.64 01.9 0.26 0.36 0.16 0.16 18.8 1.84 0.99 0.08 Woolwich 148,500 13.3 10.4 20 3.04 0.50 1.08 0.17 0.15 0.66 0.78 2.20 0.41 0.30 0.22 0.40 0.40 0.16 0.92 20.1 1.19 0.95 0.07 Division 7 Camberwell 178,400 14.9 10.5 20 2.80 0.82 0.95 0.14 016 0.62 1.07 2.31 0.41 0.54 0.54 0.07 0.02 0.29 0.36 15.0 0.77 1.70 0.08 Lewisham 223,400 14.0 10.8 17 3.55 0.51 1.33 0.13 0.10 0.47 0.92 2.37 0.32 0.71 0.49 0.40 0.31 0.24 0.54 17.5 1.84 1.14 0.07 Division 8 Bermondsey 57,580 15.9 10.0 23 2.78 0.54 1.15 0.24 0.14 0.43 1.04 2.15 0.42 1.95 0.50 0.17 0.07 0.21 0.40 22.1 0.87 0.94 0.10 Lambeth 224,200 1.60 10.6 21 2.98 0.58 1.24 0.18 0.14 0.65 0.98 2.07 0.37 0.62 0.36 0.08 0.05 0.37 0.60 16.9 1.28 1.03 0.09 Southwark 93,820 17.4 13.9 28 3.41 0.80 1.82 0.20 0.25 1.13 1.16 2.34 0.37 1.97 2.39 0.30 0.18 0.29 1.33 22.9 1.50 1.56 0.10 Division 9 London,1955 3,295,000 15.1 11.5 23 3.37 0.61 1.25 0.17 0.16 0.63 0.99 2.39 0.45 0.63 0.92 0.16 0.14 0.46 0.58 14.9 1.43 1.14 0.11 London,1954 3,322,000 15.3 10.7 21 3.22 0.57 1.20 0.16 0.18 0.48 0.76 2.31 0.44 0.74 1.28 0.02 0.01 0.32 0.45 2.24 1.41 1.27 0.12 (a) Rates are per 1,000 home population. (b) Including Inner and Middle Temple. 182 Table 4—Principal vital statistics—Administrative County oj London, 1906.1955 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) Tuberculosis Diphtheria Influenza Measles Meningococcal infection Whooping cough Bronchitis Pneumonia (all forms) Other resp. diseases Heart disease Cancer Diabetes Violence Infants 0—1 Diarrhoea and enteritis 0—2 Puerperal sepsis Other child-birth Pulmonary Non-pulmonary Suicide Road accidents Other violence 1906-10 .. 26-5 17-4 14-9 1-39 0-48 0-14 0-22 0-42 (0 0-29 1-22 1-49 0-22 1-26 1-11 0-10 0-12 (<0 0-09 0-40 114 23-8 1-46 1-47 1911-15 .. 24-0 20-0 14-8 1-39 0-39 0-13 0-16 0-43 0-02 0-22 1-29 1-33 0-21 1-54 1-16 0-11 0-10 0-12 0-38 108 28-0 1-40 1-57 1916-20 .. 20-0 20-1 151 1-43 0-34 0-17 1-01 0-28 0-04 0-20 1-30 1-38 0-19 1-71 1-28 0-09 0-08 0-13 0-34 92 15-4 1-64 1-72 1921-25 .. 19-9 17-9 12-3 1-01 0-19 0-17 0-32 0-17 0-01 0-15 0-97 1-14 0-16 1-66 1-38 0-10 0-12 0-12 0-23 71 11-7 1-36 1-63 1926-30 .. 16-2 18-6 12-3 0-90 0-14 0-10 0-30 0-16 0-02 0-11 0-72 1-00 0-16 2-29 1-52 0-12 0-14 0-18 0-25 64 10-2 1-60 1-63 1931-35 .. 13-8 19-5 12-1 0-79 0-11 0-08 0-26 0-09 0-03 0-07 0-47 0-85 014 2-99 1-66 0-14 0-16 0-17 0-25 63 11-6 0-99 1-38 1936-40 .. 13-6 25-4 13-4 0-72 0-09 0-04 0-19 0-04 0-02 0-04 0-67 0-83 0-13 3-67 1-87 0-16 0-15 0-15 0-70 56 10-9 0-48 0-96 1941—45 .. 15-4 23-3 16-0 0-90 0-11 0-02 0-14 0-01 0-02 0-04 1-14 0-91 0-16 3-99 2-38 0-11 0-12 0-12 1-27 48 8-0 0-27 104 1946-50 .. 18-2 22-4 11-8 0-53 0-06 0-00 0-08 0-01 0-01 0-02 0-87 0-62 0-13 3-31 2-10 0-07 0-12 0-09 0-29 32 3-0 0-07 0-53 1951 15-6 20-6 12-6 0-34 0-04 0-00 0-24 0-01 0-01 0-01 1-14 0-64 0-12 3-87 2-27 0-09 0-13 0-09 0-24 25 0-8 0-06 0-39 1952 15-3 19-9 12-0 0-28 0-03 0-00 0-05 0-00 0-01 0-00 1-09 0-61 0-12 3-55 2-30 0-08 0-11 0-07 0-22 23 0-8 015 0-51 1953 15-3 19-7 11-6 0-21 0-02 — 0-15 0-00 0-01 0-01 107 0-64 0-12 3-25 2-34 0-07 0-14 0-08 0-21 24 1-4 0-02 0-38 1954 15-2 19-8 10-7 0-18 0-02 — 0-02 0-00 0-01 0-00 0-66 0-48 0-10 3-22 2-31 0-06 0-15 0-08 0-21 21 0-5 0-06 0-48 1955 15-1 20-8 11-5 0-16 0-01 0-00 0-05 0-00 0-01 0-00 0-88 0-63 0-11 3-37 2-39 0-07 0-14 0-10 0-22 23 0-5 0-06 0-55 (a) Death-rates from 1939 to 1949 relate to the civilian population only (4) 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. r- ■ " ■«< ™ - <•-— ..-/K, Table 5—Deaths by cause—Administrative County of London, 1955 Cause Sex 0— 1 — 5— 15— 25— 45— 65— 75+ Total 1955 1954 1. Tuberculosis—respiratory M — 2 1 4 44 191 108 42 392 429 F — — — 7 47 40 21 76 125 167 2. Tuberculosis—other M — 1 2 — 8 5 3 3 22 33 F — 1 1 — 3 10 3 4 22 29 3. Syphilitic disease M — — — — 4 23 52 25 104 112 F — — — — 3 17 18 76 54 77 4. Diphtheria M — 1 — — — — — — 1 — F — — 1 — — — — — 1 — 5. Whooping cough M 2 2 1 — — — — — 5 2 F 7 1 — — — — — — 2 2 6. Meningococcal infection M 2 4 1 — 1 2 — 1 11 20 F 5 3 — — 1 2 — — 11 8 7. Acute poliomyelitis M — 3 4 3 4 — — — 14 2 F 1 3 1 4 3 — — — 12 4 8. Measles M 4 3 1 — — — — — 8 2 F 7 5 1 — — — — — 7 — 9. Other infective, &c., diseases M 2 — 1 1 4 15 10 7 40 46 F 4 2 2 2 2 14 9 8 43 38 10. Malignant neoplasm: Stomach M — — — — 18 243 194 124 579 564 F — — — 1 15 104 119 772 411 445 11. Malignant neoplasm: Lung, bronchus M — — — 2 62 810 492 159 1,525 1,464 F — — — — 13 151 101 73 338 321 12. Malignant neoplasm: Breast M — — — — — 4 1 3 8 5 F — — — — 63 304 181 766 714 675 13. Malignant neoplasm: Uterus F — — — — 26 163 76 48 313 286 14. Other malignant and lymphatic neoplasms M 1 9 11 16 108 612 633 604 1,994 1,957 F 7 5 8 8 107 576 500 579 1,784 7,772 15. Leukemia, aleukemia M 1 4 8 6 15 32 28 11 105 107 F 1 5 6 2 13 22 23 18 90 81 16. Diabetes M — — 1 —- 4 14 26 25 70 51 F — — 2 2 5 29 63 59 160 132 17. Vascular lesions of nervous system M — — — 4 32 344 493 717 1,590 1,635 F — — 1 6 38 398 680 7,400 2,523 2,367 18. Coronary disease, angina M — — — — 105 1,169 1,033 842 3,149 3,087 F — — — — 12 338 652 7,074 2,016 7,909 19. Hypertension with heart disease M — — — — 2 70 144 198 414 420 F — — — — 4 39 154 363 560 528 20. Other heart disease M 1 — 1 10 52 255 429 1,165 1,913 1,870 F — 1 1 5 82 233 518 2,226 3,066 2,884 21. Other circulatory disease M — — 1 2 20 149 255 404 831 811 F — — 1 2 13 130 301 746 1,193 7,077 22. Influenza M — — — 1 2 16 19 20 58 47 F — 1 1 — 8 9 16 77 106 36 23. Pneumonia M 75 13 2 5 21 177 258 481 1,032 804 F 46 15 9 6 11 93 209 667 1,050 802 24. Bronchitis M 41 9 1 1 23 550 672 670 1,967 1,469 F 76 2 3 — 5 106 255 544 931 734 25. Other diseases of respiratory system M 3 3 — — 15 84 75 69 249 194 F 7 3 2 1 5 33 28 50 123 775 26. Ulcer of stomach and duodenum M — — — 1 16 126 136 111 390 365 F — — — — 4 23 51 88 166 767 27. Gastritis, enteritis and diarrhoea M 14 1 — 3 2 20 15 19 74 73 F 70 3 — — 8 23 32 41 117 90 28. Nephritis and nephrosis M — 2 1 11 30 44 33 21 142 162 F 1 1 — 7 19 23 33 33 117 158 29. Hyperplasia, prostate M — — — — 1 23 66 185 275 285 30. Pregnancy, childb. : abortn. F — — — 6 33 — — — 39 34 31. Congenital malformations M 99 9 5 9 13 19 9 3 166 155 F 72 12 7 5 12 17 4 6 135 126 32. Other defined and ill defined diseases M 430 11 19 13 87 283 241 310 1.394 1,329 F 295 17 17 19 87 287 299 606 1,627 1,441 183 Table 5 (contd.)—Deaths by cause—Administrative County of London, 1955 Cause Sex 0— 1 — 5— 15— 25— 45— 65— 75+ Total 1955 1954 33. Motor vehicle accidents M _ 5 13 36 53 42 30 34 213 175 F 7 5 2 7 77 72 20 38 96 94 34. All other accidents M 14 3 18 17 86 99 39 80 356 351 F 77 4 3 8 23 48 64 189 350 326 35. Suicide M _ _ _ 6 78 119 53 20 276 315 F _ _ 7 6 53 76 36 73 185 179 36. Homicide, operations of war M _ 1 1 2 6 3 1 _ 14 18 F 7 _ 7 2 2 3 _ _ 9 72 ALL CAUSES M 689 86 93 153 916 5,543 5,548 6,353 19,381 18,359 F 468 89 77 100 731 3,323 4,466 9,248 18,496 17,110 Table 6—Infant mortality—Administrative County of London, 1955 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 7 yr. No. Male Female Total Male Female Whooping Cough Leg. — — — 3 3 2 1 0.06 0.08 0.04 Illeg. — — — Tuberculosis Leg. — — — — — — — — — — Illeg. — — — Measles Leg. — — — 5 5 4 1 0 10 0-16 0-04 Illeg. — — — Convulsions Leg. — — — — — — — — — — Illeg. — — — Bronchitis and Pneumonia Leg. 3 23 19 128 178 116 62 3.57 4.52 2.56 Illeg. — 1 4 Gastro Enteritis and Diarrhoea Leg. — — 1 23 24 14 10 0.48 0.55 0.41 Illeg. — — — Congenital Malformation Leg. 26 31 40 67 171 99 72 3.43 3.86 2.98 Illeg. 1 5 1 Immaturity Leg. 119 68 8 2 233 122 111 4.67 4.76 4.59 Illeg. 21 14 Injury at Birth Leg. 62 44 4 1 129 83 46 2.59 3.24 1.90 Illeg. 13 5 — Post.natal Asphyxi, and Atelectasis Leg. 113 70 1 3 215 135 80 4.32 5.26 3.31 Illeg. 17 9 2 Haemolytic disease Leg. 13 11 1 1 29 17 12 0.58 0.66 0.50 Illeg. 1 — 2 Accidental Leg. Til — — — 3 3 1 2 0.06 0.04 0.08 Mechanical Suffocation Illeg. — — — Other causes Leg. 17 29 13 87 167 96 71 3.35 3.74 2.94 Illeg. 15 5 1 All causes .. Leg. M. 210 165 46 186 1,010 607 403 21.96 25.61 18.08 F. 143 777 41 108 Illeg. M. 36 23 6 17 147 82 65 38.41 42.18 34.52 F. 32 16 5 72 Total, 1955 421 315 98 323 1,157 689 468 23.22 26.86 19.36 Total, 1954 373 297 96 281 1,047 627 420 20.63 24.22 16.90 Leg. M. 192 168 50 143 936 553 383 19.86 23.02 16.58 F. 139 101 35 108 Illeg. M. 26 19 6 23 111 74 37 30.71 39.72 21.12 F. 16 9 5 7 184 Table 7—Infant mortality by cause—Administrative County of London, 1936-1955 (Rates per 1,000 live births) Cause of death 1936 to 1940 1941 to 1945 1946 to 1950 1951 1952 1953 1954 1955 Whooping cough 1.69 1.49 0.55 0.17 0.08 0.27 0.06 0.06 Tuberculosis 0.54 0.49 0.26 0.08 0.04 0.14 0.08 — Measles 0.82 0.30 0.08 0.13 0.06 0.02 0.10 Bronchitis and Pneumonia 11.07 8.94 5.48 4.47 3.89 4.04 2.70 3.57 Gastro.enteritis 10.33 7.64 2.83 0.73 0.80 1.27 0.43 0.48 Immaturity 12.40 11.48 6.93 4.71 4.20 3.98 3.70 4.67 Congenital malformations 4.79 4.94 4.32 3.82 3.93 3.41 3.51 3.43 Injury at birth 2.22 2.40 2.33 2.98 2.82 2.71 2.34 2.59 Post.natal asphyxia and atelectasis 2.07 2.38 3.48 3.82 3.50 3.90 4.06 4.32 Haemolytic disease (a) (a) (a) 0.86 0.72 0.53 0.55 0.58 Convulsions 0.20 0.14 0.03 — — 0.02 _ Accidental mechanical suffocation 0.54 1.08 1.10 0.25 0.17 0.14 0.12 0.06 Other causes 8.56 6.96 4.24 3.42 2.96 3.40 3.04 3.35 All causes 55 48 32 25 23 24 21 23 (a) Included in other causes. Table 8—Maternal mortality (excluding abortion)—Administrative County of London and England and Wales, 1945.55 (Rates per 1,000 total births) 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 Puerperal sepsis : London 0.26 0.12 0.12 0.13 — — 0.06 0.15 0.02 0.06 0.06 England and Wales 0.24 0.18 0.16 0.13 0.12 0.12 0.10 0.09 0.10 0.09 0.11 Other causes : London 1.09 0.80 0.55 0.37 0.40 0.53 0.39 0.51 0.38 0.48 0.55 England and Wales 1.23 1.06 0.86 0.74 0.70 0.60 0.56 0.50 0.54 0.49 0.43 185 Table 9—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—Administrative County of London, 1934.1955 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 ###] 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 (b) 137 0.032 467 (f) 8.24 5,569 1.320 74 0.018 758 (a) 12.91 (b) 18,238 4.32 144 0.034 — — ' (b) 1935 2 0.0005 3 0.0007 9,294 2.23 199 0.048 15 0.004 187 0.045 1,868 0.448 37 0.009 105 0.025 382 6.87 3,707 0.888 85 0.020 652 11.31 10,954 2.63 — — — — 1936 — — 4 0.001 7,030 1.68 304 0.072 12 0.003 255 0.061 1,815 0.432 35 0.008 113 0.027 462 8.10 4,141 0.986 38 0.009 635 10.92 10,705 2.55 — — — — (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 — — — — 1938 4 0.001 1 0.0002 7,611 1.88 1,049 0.259 5 0.001 191 0.047 1,829 0.451 16 0.004 (c) 282 0.28 182 0.045 489 9.00 3,962 0.978 134 0.033 853 15.18 8,093 2.00 — — — — W 1,891 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 6.56 2,688 0.876 20 0.007 472 9.91 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 5.54 2,518 1.064 41 0.017 340 9.88 2,372 1.00 — — — — 7,944 3.36 1942 1 0.0004 1 0.0004 1,813 0.756 749 0.312 3 0.001 67 0.028 1,034 0.431 16 0.007 19,987 8.33 341 0.142 210 5.15 2,246 0.936 25 0.010 505 12.01 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 5.17 3,159 1.267 43 0.017 471 10.20 (d) 9,689 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 4.70 2,292 0.931 17 0.006 399 8.68 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 4.84 1,930 0.742 63 0.024 515 10.97 14,753 5.69 4,079 1.57 3 0.001 3 0.001 3,264 1.25 1946 — — — — 747 0.240 845 0.272 6 0.002 44 0.014 844 0.271 168 0.054 22,846 7.35 184 0.059 268 4.06 2,125 0.683 29 0.009 553 8.18 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 3.27 2,110 0.638 702 0.212 441 6.11 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 7.42 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. Cases Rate Cases Rate 1950 2 0.0006 — — 81 0.024 960 0.283 18 0.005 63 0.019 566 0.167 20 0.006 22,282 6.57 90 0.027 145 2.70 1,691 0.499 267 0.079 163 0.048 371 6.78 (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 3.93 1,908 0.567 204 0.061 105 0.031 1,860 35.47 535 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 32.87 527 0.16 3,425 1.02 — — — — 11,027 3.30 1,269 0.38 1954 1 0.0003 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 37.43 669 0.20 2,444 0.74 — — 1 0.0003 4,691 1.41 1,060 0.32 1955 — — 1 0.0003 16 0.005 3,019 0.916 20 0.006 111 0.034 361 0.110 40 0.012 49,110 14.90 98 0.030 106 2.13 1,903 0.578 512 0.155 448 0.136 1,984 39.01 660 0.20 2,070 0.63 — — — — 4,709 1.43 1,530 0.46 (a) Rate per 1,000 total births. (b) Comparable figures not available for this period, (c) Cases relate to last quarter only—Rates are adjusted on an annual basis, (d) Cases relate to last 22 weeks only—Rates are adjusted on an annual basis, (e) In order to preserve uniformity with published national figures the practice of the Registrar.General has been followed in producing this table, namely in taking full account of any known changes in diagnosis after the receipt of the original notification. These corrections were not available prior to 1944. Comparable figures can be obtained by the method given in the footnote to this table in previous annual reports. (f) Rate per 1,000 live births, (g) For cause of increase since 1950 see page 16 of Annual Report for 1951. 186 Table 10—Notification of ccrtain infectious diseases—distribution by age and date of notification—Administrative County of London, 52 weeks commenting week ended 8th January, 1955 Four. weekly periods 1955 Dysentery Measles Meningococcal infection Pneumonia Poliomyelitis Scarlet fever Whooping cough Paralytic Non.paralytic or not stared Ages Ages Ages Ages Ages Ages Ages Ages 0—4 5—14 15+ Total 0—4 5—14 15+ Total 0—4 5—74 15+ Total 0—4 5—14 75+ Total 0—4 5—14 75+ Total 0—4 5—74 75+ Total 0—4 5—74 15+ Total 0—4 5—14 15+ Total 1— 4 M 52 23 10 85 956 857 13 1,830 3 1 — 4 21 19 95 136 2 1 3 1 1 27 57 5 89 135 121 3 259 F 49 18 28 96 931 784 30 1,749 5 1 — 6 18 72 133 764 — 7 2 3 — 7 7 2 24 54 8 86 184 132 6 323 5— 8 M 42 24 18 85 1,888 2,367 15 4,281 5 2 2 9 29 26 101 157 — 1 1 1 — — 1 20 65 6 91 164 115 1 281 F 44 31 46 121 1,782 2,214 27 4,031 3 7 7 5 27 23 114 160 2 — — 2 — — — — 25 49 3 77 178 774 5 298 9—12 M 83 155 38 279 3,271 3,426 52 6,762 4 1 1 6 18 13 91 122 — 1 1 2 — 1 1 2 17 57 2 76 160 113 4 278 F 58 141 77 279 3,027 3,290 73 6,402 1 — 7 2 72 19 99 131 7 — 7 2 — 7 — / 9 36 4 49 753 132 9 294 13—16 M 64 65 38 168 3,819 2,698 69 6,609 1 2 1 4 14 16 96 126 1 1 2 1 — 3 38 35 4 77 107 77 2 187 F 55 58 54 168 3,640 2,732 83 6,475 5 — — 5 74 7 80 104 — — — — — — 7 / 21 40 4 65 756 55 4 245 17—20 M 53 39 36 128 1,852 677 47 2,580 3 2 5 5 3 38 46 1 1 — 2 — — 3 3 23 38 5 66 97 68 2 169 F 61 29 24 115 1,727 645 87 2,465 — 7 7 2 3 2 42 47 3 7 2 6 — — 7 / 29 32 7 68 727 77 6 210 21—24 M 39 25 31 95 966 590 25 1,584 1 1 3 4 27 34 3 1 1 5 — 3 3 6 25 40 2 67 68 52 2 122 F 42 13 28 83 924 605 25 1,556 2 — — 2 5 6 28 37 2 7 7 — — 7 1 75 50 6 72 50 54 3 137 25—28 M 50 27 21 98 475 247 6 730 4 1 3 8 4 7 21 32 9 3 3 15 4 13 1 18 24 38 3 65 77 61 1 139 F 49 30 24 104 477 268 20 769 3 7 2 6 7 19 29 5 2 4 77 4 6 5 15 19 43 2 64 87 85 3 175 29—32 M 51 14 26 91 214 91 6 312 3 2 2 7 1 5 18 24 27 19 4 50 14 39 7 61 13 24 3 40 91 57 2 150 F 44 18 25 88 185 95 6 287 3 7 7 5 4 2 13 79 9 77 9 29 8 29 18 55 27 22 2 45 707 67 7 175 33—36 M 68 24 13 106 99 21 3 123 1 — 1 2 5 2 13 20 26 17 9 52 20 25 18 63 14 11 2 27 89 64 — 153 F 58 18 32 108 97 23 5 125 7 — — / 2 3 77 16 24 7 77 42 9 19 74 42 20 79 3 42 94 57 3 148 37—40 M 60 25 11 97 31 17 48 4 — — 4 2 2 21 25 24 10 9 43 29 37 17 84 23 47 — 70 65 39 — 104 F 60 16 39 117 37 20 1 58 — — — — 4 6 77 23 74 77 8 33 9 23 76 49 14 34 — 48 56 41 2 99 41—44 M 33 36 15 84 50 23 73 2 2 10 3 41 54 17 19 13 49 21 41 9 72 31 87 — 118 60 44 — 104 F 32 33 41 107 45 18 2 65 2 — 2 5 2 32 59 75 74 77 40 77 25 6 45 35 81 4 118 59 36 — 95 45—48 M 35 20 18 73 39 15 1 55 5 3 8 7 7 47 62 9 4 6 19 3 10 3 16 45 95 — 141 69 58 — 127 F 29 33 33 95 44 13 3 60 — — 5 9 6 57 66 3 77 10 24 6 5 4 75 34 101 3 138 77 66 3 14U 49—52 M 50 21 10 82 22 6 _ 28 3 3 24 18 57 99 3 3 4 11 1 6 — 7 39 84 — 123 72 60 — 132 F 48 15 25 90 30 4 3 38 3 7 — 4 19 18 67 704 — j 2 5 2 7 2 11 35 95 130 79 45 7 125 Total (52 weeks M 680 498 285 1,471 13,682 11,035 237 25,015 36 9 18 63 124 125 666 937 121 79 52 253 95 177 62 337 339 678 32 1,050 1,254 929 17 2,205 F 629 453 476 1,571 12,946 10,711 365 24,080 29 8 6 43 117 113 700 939 78 62 6/ 207 49 779 69 238 299 636 46 7,002 1,431 985 46 2,464 Notes: 7. 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 figutes will not necessarily agree with the total notifications given in Table 10 which relates to the calendar year 1955. 187 Table 11—Statistics of the administrative work carried out by the Metropolitan Borough Councils in 1955. Borough DWELLINGS CLEARANCE AREAS DWELLING HOUSES SMOKE NUISANCES CLEANSU} 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 (1) Water supply provided to tenement houses Complaints Observations Intimation notices served Nuisance notices served Adults cleansed Children cleansed Premises disinfected Premises disinfested Establishment Employed at end of year Assistants employed at end of vear Unfit Houses Other Houses On complaint On notification of illness House-to-house Other reasons Section 11 Section 12 Licensed slaughterhouses Other offensive trades Dairies and milk shops Ice cream premises Common Lodging Houses Public Health (London) Act Housing Act Demolished Closed by undertaking Rooms closed Undertakings accepted At home At a cleansing station Demolished Persons displaced Demolished Persons displaced Underground rooms Other rooms Underground rooms Other rooms Closing Orders made By owners By local authority By owners By local authority Number Persons displaced Number Persons displaced 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 Chelsea 49 52 16,523 — — — — 888 336 102 — 216 84 — 58 — 8 38 — — 10 — — — — — — — — — 25 12 30 — — — 380 411 130 303 — — 46 198 — 193 7 2 9 6 2 8 — — — Fulham 47 20 31,337 — 16 — — 2,506 165 467 — 268 2,096 10 — 1 4 8 — — 5 20 2 5 — — — 1 1 2 22 502 — — — 68 9 69 442 — — 132 229 — 146 15 1 16 13 1 14 1 — 1 Hammersmith 138 135 26,442 — — — —__ 3,751 367 — 955 576 1,509 45 2 — 3 23 — — 12 22 — — — — — — 2 10 6 36 136 1 — 1 467 790 48 249 2 — 98 309 — 270 14 1 15 9 1 10 — — — Kensington 148 19 38,804 59 114 1 — 3,237 3,608 644 2,208 773 479 2 — —• — — — — 78 23 2 — 6 3 — — —- — 1 15 77 — — — 281 1,155 369 566 — — 181 343 — 223 19 — 19 15 — 15 — — — Division 2 Hampstead 89 194 21,751 — — — — 2,506 688 120 — 958 176 — — — — — — — 12 — — — — — — — 1 2 6 11 334 4 — — 27 48 203 162 — — 50 243 — 134 12 1 13 11 1 12 3 — 3 Paddington 385 44 24,685 _ — 4,130 † 412 725 1,309 333 1 13 3 19 32 3 1 — 18 5 — — — — 165 34 330 1,283 — — 124 198 1 137 17 1 18 14 1 15 — — — St. Marylcbone 170 199 24,222 — _ 1,278 500 371 134 216 142 — — — — — — — 72 11 — — — — — — — — 8 55 667 17 — — 688 316 197 441 1 — 172 219 2 787 10 3 13 10 3 13 — — — St. Pancras 366 17 29,046 4,008 404 148 1,671 1,621 1,498 3 67 — — — — — — — — — 68 32 57 — — — 817 649 573 480 2 — 225 498 — ‡850 21 1 22 21 1 22 — — — Westminster, City of 232 144 26,403 5 39 — — 1,105 313 1,191 3,488 253 2 — — — 2 — 2 — 67 77 3 3 3 121 2,413 7 7 — 363 130 342 1,178 — — 122 233 2 3,031 20 1 21 19 1 20 — — — Division 3 Finsbury 48 3 9,497 — — 1,781 — — 411 864 86 — — — — — — — 26 2 — — — — — 13 39 1 16 150 1 — — 114 888 315 292 — 2 126 131 1 405 8 — 8 8 — 8 3 — 3 Holborn 44 4 6,180 — — — — 122 88 240 109 6 — — — — — — — 6 — — — — — — — 1 — — 29 358 2 — — — — 53 80 — 5 69 106 2 469 5 — 5 b — 5 — — — Islington 144 421 46,006 4 22 — — 7,623 † — — * 3,984 — 1 — 5 20 6 26 105 97 25 10 4 — 3 — 9 56 46 54 477 12 — 38 111! 37 401 453 1 13 330 552 — 637 31 3 34 20 3 23 4 — 4 Hacknev 485 126 40.625 6 14 — — 4.562 0098 — 918 556 2,504 48 3 — 4 3 — — 34 18 2 2 — — — — 8 36 28 1,837 14 3 8 24 420 230 — 6 227 388 1 221 28 — 28 17 — 17 2 — 2 Shoreditch 358 20 12,454 — — — 2,244 979 582 2,781 1,677 264 — — — — — — — 40 23 86 107 6 2 18 21 4 32 — 10 669 17 — — 20 2 137 514 — 1 88 162 — 272 9 — 9 6 — 6 3 — 3 Stoke Newington 159 — 11,450 — — — 1,240 156 — — 150 173 29 13 9 12 20 124 97 117 — — 47 104 — 43 7 — 7 6 — 6 — — — Bethnal Green 98 26 16.615 5 23 — — 2.502 757 276 1,355 1,192 586 4 1 — — — — — 2 3 10 17 — — — — 10 34 — 16 — 3 1 7 40 7 20 695 1 1 121 156 — 154 9 — 9 7 — 7 — — — City of London 18 — 1,118 — — — — — — — — 2 — — — — — — — — — — — — — — — — — — — 20 74 1 — — 481 148 3 30 — — 26 69 1 971 20 — 20 20 — 20 1 — 1 Poplar 227 72 18,047 32 110 28 76 2,157 62 270 48 1,217 663 — 1 — 9 29 — — 8 11 — — — — — — 8 35 1 9 23 — — 3 47 17 381 825 2 1 145 182 1 288 9 — 9 9 — 9 — — — Stepney 27 519 29,900 — — — 2,951 315 46 1,788 2,242 617 11 2 — 3 5 — — 85 2 4 6 — — — — 2 — 43 94 — — 59 432 55 245 591 — 21 257 306 t> 900 18 — 18 15 — lb — — — Division 6 Deptford 37 3 16,871 — — — — 1,869 174 1,281 781 423 272 990 103 375 2 1 91 189 1 90 8 — 8 8 — 8 — — — Greenwich 114 87 23,408 17 47 — — 1.923 149 2 784 879 168 2 7 18 95 — — 38 220 542 241 361 — — 110 252 — 230 9 1 10 I 1 8 1 — 1 Woolwich 213 219 41,956 25 261 — 1,996 949 2,274 11,541 1,461 575 — 2 1 7 23 — — 31 30 3 2 — — — — 16 67 — 21 133 4 4 12 106 721 321 381 2 2 181 322 1 296 18 1 19 17 1 18 — — — Division 7 Camberwell 292 391 43.456 8 12 — — 5.379 446 — 1,981 355 2,779 9 7 — 2 10 — — 6 18 24 32 — — — .— 2 5 1 37 232 3 — — 75 648 461 628 2 5 226 484 1 345 19 — 19 19 — 19 — — — Lewisham 464 137 61,878 2 2 1,585 115 439 1,987 624 382 1 19 4 — — 2 5 — — 38 25 — — — — 5 20 — 8 — — — — 34 243 460 105 1 — 112 395 — ‡250 20 — 20 16 — 16 1 — 1 Division 8 Bermondsey 102 54 15,200 40 20S 1 — 2,743 1,541 38 2,576 1,088 646 6 — — — — — — 4 5 30 — 2 3 — — 15 73 — 6 287 3 — — 103 504 15 221 — 8 118 188 2 285 12 — 12 10 — 10 — — — Lambeth 172 436 55.013 11 14 — — 3.267 574 168 2,575 1,404 956 123 1 — 7 5 2 10 48 86 3 9 5 11 1 4 12 29 3 54 16 5 1 — 193| 59 959 664 — 2 265 509 — 223 17 2 19 15 2 1/ — — — Southwark 214 25,009 22 79 — — 3,777 573 3,433 2,338 5 1,185 71 8 — 19 34 — — 82 15 39 — — — — — 2 — — 16 163 9 — — 1,493 1,032 280 1,264 — 4 147 254 6 433 19 1 20 16 1 1/ 5 — 5 Division 9 Battersea 36 258 28,080 — — — — 3,853 895 — 1,569 873 800 57 — — 1 5 — — 10 — — — — — — — 5 19 28 20 207 2 — — 266 2,318 795 183 1 2 151 270 — 164 14 2 16 13 2 15 — — — Wandsworth 408 1,613 103,814 23 57 — — 7,235 1,306 — 7,337 1,875 784 3 — — — — — — 23 28 41 253 3 2 — 54 6 585 209 — — 282 745 — 492 23 23 19 19 — — — LONDON 5,284 5,213 845,790 259 1,015 30 76 82,218 15,558 10,983 50,691 23,544 23,900 423 118 9 95 210 12 41 878 500 271 218 37 19 22 25 117 458 217 767 9,284 108 18 166 7,361 11,883 8,553 13,322 17 74 4,219 8,144 27 12,941 438 21 459 371 21 392 24 — 24 †included in previous column. * included in next column. J estimated. Notes :—(1) Local Government (Miscellaneous Provisions) Act, 1953 : Two Closing Orders were determined in Kensington, in Hackney and in 'oolwich ; one was revoked and a Demolition Order made in Hackney and in Lewisham. (2) Licensed Cowsheds : Camberwell— 1. (3) Seamen's Lodging Houses : Poplar—2, Stepney—5. (4) Prosecutions : Inadequate Water Supply to Tenement Houses : St. Pancras—6 (5 convictions). Dairies and Milkshops : St. Pancn 1 (1 conviction), Shoreditch—1 (1 conviction). Ice-Cream Establishments : Stepney—5 (5 convictions). Restaurants, Eating Housbs and Canteens : Kensington—7 (7 convictions), Hampstead—1 (1 conviction), St. Pancras— 1 (1 conviction), Westminster—2 (2 convictions), Hackney—5 (5 convictions), Shoreditch—1 (1 conviction). City of London—1 (1 conviction), Stepney—5 (5 convici 0- 188 Table 12—Treatment of venereal disease at London clinics Year New cases Total attendances Syphilis s. Chancre Gonorrhoea Total venereal cases Total non-venereal cases 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 1955 625 400 77 6 5,916 1,457 6,618 1,863 18,735 7,056 221,381 103,815 Table 13—Weather during 1955 (as recorded at Kew Observatory) Temperature Rainfall Sunshine Month Mean (a) °F Difference from Average (b) °F Total ins. Difference from Average (b) ins. Total hrs. Difference from Average (c) hrs. January 38.5 —1.2 1.92 —.0.04 35 —.7 February 36.8 —.3.5 1.15 —.0.40 78 +19 March 39.2 —.3.6 0.89 —.0.65 157 +51 April 49.8 +2.3 0.31 —.1.40 182 +32 May 51.1 —.2.5 3.73 +1.98 229 +31 June 59.2 —.0.2 2.17 +0.19 172 —29 July 65.0 +2.3 0.39 —.1.99 244 +48 August 65.5 +3.7 0.71 —.1.53 197 +12 September 58.4 +1.0 1.77 —.0.22 166 +25 October 49.5 —0.8 2.36 —.015 111 +17 November 46.6 +2.4 0.89 —.1.45 43 —.9 December 44.6 +3.9 1.76 —.0.40 46 +8 Year 50.4 +0.4 18.05 —.606 1,660 +198 (a) Average of the daily means of 24 hourly readings. (b) Average over the 80 years ended 1950. (c) Average over the 70 years ended 1950. O 189 APPENDIX D 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 Administrative Officer C. R. Geere Principal Medical Officers Maternity and child welfare Dorothy F. Egan School health G. D. Pirrie (seconded to the World Health Organisation) Evelyn A. Mower. White (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 Scientific Adviser S. G. Burgess 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 Statistician C. W. Shaddick Chief Inspector J. C. Clancey Principal Organiser of Child Care Frances C. K. Gregson Senior Officers of the Divisions Divisional Medical Divisional Administrative Divisional Nursing Division Officer Officer Officer 1. Violet I. Russell G. J. Newton Mary Sidebotham 2. H. L. Oldershaw H. J. Norton Eveline Beattie (absent on study leave) Kathleen E. Harvey 3. Bertha E. A. Sharpe N. B. Chapman Catherine Walsh 4. S. King J. C. Minter Ellen M. Hazell 5. G. O. Mitchell A. J. Cridland Katherine M. Roe 6. F. R. Waldron L. R. T. Coward Lilian Berry 7. H. D. Chalke F. L. Clark Kathleen L. Sewell 190 Senior Officers of the Divisions—continued Divisional Medical Divisional Administrative Divisional Nursing Division Officer Officer Officer 8. W. H. S. Wallace W. H. C. Bishop Bessie Thom (Seconded to World Health Organization) Margery D. Butler (from 29/6/54) 9. J. T. R. Lewis F. E. Willson* Winifred M. Winch *Died 15.12.55—no appointment made during 1955. The following statement shows the number of staff employed in the Public Health Department in December, 1955 (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) 216 606 75 897 Medical staff 26 155 — 181 Dental staff 2 74 — 76 Chemists 22 9 — 31 Inspectors 16 — — 16 Nursing staff 10 2,125 103 2,238 Medical auxiliaries (c) 14 139 22 175 Social worker grades (including mental health) 36 168 118 322 Supervisory staff (ambulance service) 6 — 12 18 Manual workers, operative staff (ambulance service), domestic grades, etc. 14 2,699 842 3,555 Totals 362 5,975 1,172 7,509 (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 84 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. 191 INDEX Page Accidents in the home 94 Adoption of children 72 Air pollution 58 Ambulance service 86 Analgesia 75 Ante-natal sessions 67 Anthrax 20 Analysis of samples 54, 61 Appendix. 153 Audiometry 109 Bathing centres107 Births 10, 180 Blind persons 50 Bronchitis15 Building materials examinations 58 Building programme 63 Cancer 13,181 Care of mothers and young children .. 67 Cerebral hemorrhage 15 Child guidance 118 Child helps 83 Child life protection 73 Child-minders 74 Child welfare 72 Chronic sick 54 Dangerous structures 49 Day nurseries 73 Deaths12, 182, 183 Degenerative diseases 15 Dental services 102, 121 Detergents 57 Diabetes 15,116 Diarrhoea and enteritis 20 Digestive diseases 15 Diphtheria 20, 84, 114 Disinfestation 50 Domestic help service 83 Domiciliary midwifery service 75 Dysentery 22 Emergency obstetric service 76 Employment of children 108, 109 Enteric fevers 22 Enuresis 117 Epileptic children 115 Erysipelas 22 Expectant and nursing mothers 67 Family planning 69 Fertilisers and feeding stuffs 60 Fertility 10 Finance 130 Food poisoning 22 Foot defects 61 Foot clinics 92 General Practitioners 78,102 Page Handicapped children 115 Handicapped persons 54 Health centre 142 Health education 93 Health visiting 79 Heart disease 13 Home nursing 80 Homeless families units 53 Hospital services .. .. 5, 30, 70, 112 Hostel for mentally defective girls 99 Housing 48 Hygiene inspection of school pupils .. 107 Illegitimacy 12 Immunisation 84 Improvement grants 49 Infant mortality 16, 184, 185 Infectious diseases 20,114 Infectious diseases in schools 114 Insecticides 62 Influenza 22 Introduction 4 Leptospirosis 23 Marriages 11 Marriage guidance 71 Maladjusted children 118 Mass miniature radiography 35, 68 Maternal mortality 18, 182, 185 Maternity and child welfare records 72 Meals for children 105 Meals for invalids 54 Measles 23 Medical inspection of school children 103 Medical treatment of school children 112 Meningococcal infections 23 Mental health services 95 Mental health education 70 Midwifery service 75 Milk sampling 49, 50 Mortality 12,153 Neo-natal mortality 16 Nephritis 13, 15 Night helps 83 Nurseries, day 73 Nurseries, residential 72 Nursing home registration 52 Occasional creches 74 Occupation centres 100 Ophthalmia neonatorum 23 Orthodontics 124 192 IN D E X—continued Page Peri-natal mortality18, 76 Pneumonia15 Poliomyelitis 24 Population .. .. 8, 166, 179, 181 Premature babies18, 77 Premises 63 Prevention of illness 92 Problem families 70, 84 Public Health laboratory 49 Psychiatry 118 Puerperal pyrexia 19 Recuperative holidays 31, 92, 97 Remedial exercises 118 Reports of Divisional Medical Officers 132 Residential establishments 72 Review of Staff 125 Rheumatic fever 25 Rheumatism scheme 117 River pollution 56 Road accidents 16 Sanitary inspection 50 Scabies 25, 112 Scarlet fever 25 School dental service121 School health service 103 School children under five years 109 School meals 50, 60, 105 Scientific branch 54 Sewage treatment 56 Sewers 58 Page Sleep for schoolchildren 120 Slum clearance 48 Smallpox 25 Special investigations 72 Speech therapy 116 Staff 7, 125,190 Statistical tables 3, 90, 91, 179 to 189 Stillbirths 12, 77, 180 Sunday cinema grants 71 Swimming baths 60 Trade waste discharges 57 Training student health visitors 129 Tuberculosis 25 Tuberculous milk 49 Unmarried mothers 12, 74 Vaccination 85 Venereal diseases..93,189 Very young deaf children .. Ill Vision tests 106 Visitors 131 Vital statistics 3, 8 Voluntary organisations. 69,71,74 Water sampling 55, 59 Weather during 1955 19, 189 Welfare Committee establishments 50, 53 Welfare foods 70 Whooping cough 25, 84 193