LCC 62 Library LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1956 Published by the London County Council Sold at the County Hall, Westminster Bridge, S.E.1 and, directly or through any bookseller, from Staples Press Limited (Bookshop: 14 Great Smith Street, Westminster, S.W. 1) 1957 No. 3973 2s. 6d. Postage extra Corrections Page 5, line 44, for "country" read county. "117, line 10, parenthetical reference should be to page 1 168, line 45, for "231" read 165. 243 (Index) - Air pollution 48, 186 Ambulance service 78, 215. General Practitioners 5, 38, 65, 66, 69, 73, 90, 155 Home Safety 86, 212 Hospital Car Service 78 " 244 Problem families 108, 150. LONDON COUNTY COUNCIL Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1956 By J. A. SCOTT, O.B.E., M.D., F.R.C.P., Q.H.P. county medical officer of health and principal school medical officer THE COUNTY HALL WESTMINSTER BRIDGE, S.E.i a* CONTENTS London Administrative County—Vital Statistics page 3 Introduction 4 Vital Statistics 8 Infectious Diseases 21 Tuberculosis 26 General Public Health 38 Scientific Branch 44 Health Service Premises 52 Care of Mothers and Young Children 57 Domiciliary Midwifery Service 65 Health Visiting and Nursing Services 68 Home Nursing Service 69 Domestic Help Service 72 Immunisation and Vaccination 75 London Ambulance Service 78 Prevention of Illness: Care and After-Care 85 Mental Health Services 88 School Health Service 98 Dental Services 123 Staff 127 Finance 129 Visitors to the Department 130 Reports by the Divisional Medical Officers 131 Appendices: (a) Problem Families in London 150 (b) Atmospheric Pollution and Health 186 (c) Accidents in the Home 212 (d) Statistics 229 (e) Staff of the Public Health Department 241 Index 243 800 (W. &S. Ltd. 63412) 10.57 158988 LONDON ADMINISTRATIVE COUNTY VITAL STATISTICS, 1956 Figures in brackets are for 1955 Population:— Males 1,531,000 Females1,742,000 3,273,000 (3,295,000) Areal comparability factors:— Births 0.88 (0.88) Deaths 1.00 (0.98) Live births:— Legitimate 47,737 (45,999) Illegitimate 4,434 (3,827) 52,171 (49,826) Still births:— Legitimate 940 (933) Illegitimate 130 (101) 1,070 (1,034) Live birth rate per 1,000 population:—15.9 (15.1) (adjusted rate 14.0 (13.3) ) Still birth rate per 1,000 total births:—20.1 (20.3) Deaths:— Males 19,557 (19,381) Females 18,760 (18,496) 38,317 (37,877) Death rate per 1,000 population:—11.7 (11.5) (adjusted rate 11.7 (11.3) ) Deaths of infants :— Legitimate Illegitimate Total Under 1 month 737 (716) 93 (118) 830 (834) 1 month to 1 year 260 (294) 16 (29) 276 (323) Total under 1 year 997(1,010) 109 (147) 1,106 (1,157) Infant mortality rate:— (per 1,000 live births) 20.89 (21.96) 24.58 (38.41) 21.20 (23.22) Neo-natal mortality rate:— (per 1,000 live births) 15.44 (15.57) 20.97 (30.83) 15.91 (16.74) Number of marriages registered:— 33,884 (34,248) Maternal mortality:— Postabortion Other pregnancy and childbirth Total Deaths from sepsis 6 (5) – (3) 6 (8) Deaths from other causes 5 (3) 16 (28) 21 (31) Total 11 (8) 16 (31) 27 (39) 3 INTRODUCTION Vital statistics The home population of the County in the middle of 1956 was estimated by the Registrar-General to be 3,273,000—a decrease of 22,000 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 11.8. A rise in the number of births gave a live birth rate of 15.9 per thousand population, higher than in any year since 1949. Of the total live births 8.4 per cent were illegitimate, the highest figure recorded since 1946. The still-birth rate, 20.2 per thousand total births, was somewhat lower than in 1955 but remained of the same order as has been experienced over some years; the legitimate and illegitimate rates were respectively 19.8 and 29.6. The death rate, 11.7 per thousand of the population, was higher than in 1955. The increase in mortality was mainly among the aged and the diseases affecting old age. Heart disease was the major cause of death and again accounted for nearly one-third of the total deaths whilst cancer, the second cause of death, showed a further increased rate of 2.42 as compared with 2.39 per thousand in 1955. The degenerative diseases, heart disease, other circulatory diseases, cerebral vascular lesions, nephritis and bronchitis following the pattern of previous years were responsible for over half all deaths. The sixth cause of death, violence, again showed a slight increase and the number of deaths from road accidents was the highest recorded since the war. The rate for suicides which has remained at about the same level for the past four years showed a slight increase, 480 were recorded as compared with 461 in 1955. The death rate of children under one year decreased from 23.2 per 1,000 live births in 1955 to 21.3 per 1,000 live births in 1956, the rate in the first four weeks of life was 16.0. The infant mortality rate for illegitimate infants was 25 per 1,000 illegitimate births. Weather The weather experienced during the year is summarised in a table at page 240. The summer was notably deficient in sunshine and heavy rain was experienced. Infectious diseases There were 11 confirmed notifications of diphtheria during 1956. Two deaths were registered, but only one resulted from illness contracted during the year. The child concerned, aged four years, had never been immunised, although immunisation had been offered. There were 5,450 notifications of whooping cough with five deaths. Notifications were considerably higher than in the previous year but the number of deaths was rather lower. Scarlet fever notifications (2,198) although higher than in 1955 was the second lowest figure recorded for this disease. 1956 was not an epidemic year for measles, 9,651 notifications with two deaths (one a woman over 70 years of age) were recorded. The number of deaths (20) from enteritis and diarrhoea in children under two years was again less and lower than in 1955. Deaths from influenza (120) were lower than the previous year (164). Notifications of poliomyelitis were fewer than in 1955, about one-third of the cases notified being paralytic as against nearly one-half in the previous year. The pattern of incidence in the age groups 0-5 years, 5-14 years and 15 years and over, whilst broadly similar to that of the previous year, showed a reduction in the 0-4 years age group with an increase in the 15 years and over age group. The highest incidence of dysentery was recorded since the disease became notifiable in 1919 (6,392 notifications as against 3,019) with a marked increase in the proportion of notifications falling in the 5-14 year age group. Tuberculosis In 1956 there were 455 deaths from all forms of tuberculosis as compared with 561 in the previous year and 3,929 new cases were notified as compared with 4,122. Scientific branch The work of this branch is summarised at page 44, whilst a fuller report is published separately.* The long term investigation of the major pollutants of the air has continued. Air pollution An account of a survey of the effect of atmospheric pollution upon health appears as Appendix B at page 186. Building programme Building has continued to be limited by the need for economy but a number of works has been completed and put in hand during the year. * Annual Report of the Scientific Adviser, 1956, Staples Press, Ltd., London. 4 Co-operation with other parts of the service Readers of the report will find reference in many places to the close co-operation which exists between the Council's health service and the general medical services of the London Executive Council; at many other places, although no specific reference is made they will assume its existence. In fact general practitioners are in contact with the department in every aspect of its work and their experience and co-operation are invaluable to it. A considerable number of medical officers are employed on a sessional basis in school health and maternity and child welfare clinics, many of them being in general practice, and others hold appointments in hospitals and industry. Co-operation with the hospital and specialist services continues and becomes more effective; whilst this is highly appreciated by the Council's officers its effect is greatly to increase the value of the service to the public. Care of mothers and young children The proportion of children who attended welfare centres during the first year of life was for the third successive year 86 per cent. The case conference groups have continued to meet in six divisions and for medical officers who have gained experience in this way a course of advanced training in the study of parent-child relationship has been given at the Tavistock clinic. Problem families in London are fully discussed in Appendix A (page 150). Accommodation in day nurseries has been reduced from 5,580 places in 99 day nurseries in 1955, to 5,143 places in 91 day nurseries at the end of 1956, whilst childminders were caring for 1,497 children under supervised arrangements. The scheme for the extended provision of occasional creches continued and it was considered that they had proved of real value to mothers. It was decided, however, pending a further review that no more occasional creches should be provided although the service should continue. As a result of the continuing diminishing demand the number of recuperative holidays provided was lower than in the previous year. Domiciliary midwifery service Confinements attended increased in number from 9,898 in 1955 to 10,242. Inhalers for the administration of 'trilene' were provided for all midwives and it was decided following a successful trial, to equip all of the Council's midwives with intra-gastric oxygen resuscitation apparatus after the completion of training courses. At a conference of representatives of moral welfare associations the need for the associations' workers to urge unmarried expectant mothers to seek early ante-natal care was emphasised. Home nursing Through the Central Council for District Nursing twenty-six voluntary district nursing associations have continued to provide a home nursing servicc on an agency basis. The total number of visits paid (1,962,733 as compared with 1,953,182) again increased as compared with the previous year, although the number of treatments completed showed a reduction (60,772 as compared with 64,256). Domestic help service The equivalent of 2,089 whole-time staff (actual number of home helps 3,326) was employed at the end of the year, and approximately 80 per cent of the persons assisted were aged and chronic sick. During the year the service was reviewed by a departmental working party and a number of recommendations made, for the improvement of the service and, notably, to ensure greater uniformity in standards of service throughout the country and establish desirable standards of home visiting by organising staff. Prophylaxis No interruption of the diphtheria immunisation programme during the year was occasioned by poliomyelitis, as occurred in 1955, and probably this was the principal reason for a marked increase in the numbers of primary diphtheria immunisations and reinforcing doses, 44,237 and 43,866 respectively, as compared with the numbers for that year. The estimated percentage of children 1-4 years who had at any time been immunised against diphtheria was at the end of the year 68 per cent. Whooping cough immunisation which also suffered a reduction in 1955, probably for the same reason, increased from 27,941 completed vaccinations in that year to 36,556. 5 During 1956 the rate for children vaccinated against smallpox during the first year of life was approximately 49 per cent of the annual live births although the actual number of vaccinations was somewhat larger than in the previous year. Arrangements were made to take part in the Ministry of Health scheme for inoculation against poliomyelitis and 120,644 children were registered for inoculation of whom at the end of the year 14,025 had received two injections and 2,100 one injection. The London Ambulance Service The London Ambulance Service and its ancillary services again removed more patients than in the previous year, and considerably more than a million patients altogether, a total distance of over 6 million miles, 136,000 fewer than in 1955. The number of cases which were eligible for free rail transport again fell, from 3,466 in 1955 to 2,928. During the year radio control was introduced and by the end of the year seven vehicles had been equipped with radio and seven adapted as reserves. Emergency calls showed an increase from 96,661 in 1955 to 97,823. Mental health services A re-arrangement of the statistics covering the work of the mental welfare officers has been introduced to give a more accurate picture of its scope. The number of separate referrals to mental welfare officers again showed a reduction as compared with those for the previous year. The work of domiciliary care and after-care after some restriction because of shortage of staff showed a marked rise towards the end of the year when the full establishment of four psychiatric social workers was employed. The number of mentally defective persons admitted to institutional care during the year was somewhat higher than in 1955 and the number on the waiting list at the end of the year was 186 as compared with 230. During the year the remainder of the twelve places in the hostel for mentally deficient girls opened in the previous year were filled. A proposal that boys and girls leaving schools for the educationally sub-normal should be maintained by the Council without certification under the Mental Deficiency Acts in two hostels to be established by the National Association for Mental Health was submitted to the Minister of Health for approval. During the year there was an increase in the number of places available in occupation centres from 1,025 to 1,115. Health education During the year it was decided to provide for all school-leavers from the Council's schools a leaflet, in the form of a guide to health, giving prominence to the causal connection between cigarette smoking and lung cancer. An investigation into the causes of fatal and non-fatal home accidents and other related matters was carried out and has been included as an appendix (page 212). School health service The percentage of school children found to be verminous showed a further decline. In 1956 it was 1.9 per cent as against 8 per cent in 1948. The scheme for the auditory training of very young deaf children was expanded. 95 per cent of school children were found at medical inspections to be satisfactory under the system of classification with only two categories 'Satisfactory' and 'Unsatisfactory' introduced by the Minister of Education on 1 January, 1956. The facilities for speech therapy were expanded and satisfactory progress was made. Pressure of work at the child guidance units continued to be heavy and because of the long waiting lists consideration began to be given to the expansion of these facilities. Dental services The position was not markedly different to that in 1955. A staff/pupil ratio of 1: 6,100 was the average throughout the County and notwithstanding this slight improvement and an additional number of overtime sessions compared with the previous year the position could only be regarded as thoroughly unsatisfactory. So far as expectant and nursing mothers and children under five years were concerned all demands were met but systematic inspection or advice could not be attempted. 6 Hospital student nurses Hospital student nurses were again received into Council establishments as part of their training under the revised syllabus of the General Nursing Council, their number (3,736) being somewhat larger than in the previous year (3,627). Staff Dr. G. D. Pirrie, principal medical officer in charge of school health, returned to the service as did Miss B. Thom, divisional nursing officer for Division 8, after secondment to the World Health Organisation and Miss E. Beattie, divisional nursing officer for Division 2, returned following study leave. Miss C. Walsh, divisional nursing officer of Division 3, was seconded to the World Health Organisation. Early in the year Mr. R. E. Haymes was appointed divisional administrative officer of Division 9. In October 1956 Dr. Violet I. Russell, M.D., B.S., M.R.C.S., L.R.C.P., M.R.C.O.G., F.R.S.H., the divisional medical officer for Division 1 since December 1949, retired. Dr. Russell became assistant divisional medical officer of Division 1 in 1948 after many years' service with the Royal Borough of Kensington. Her long experience and personal qualities enabled her to make an outstanding contribution to the development of the Council's health services, and particularly the maternity and child welfare services. Dr. Russell was succeeded by Dr. Bertha E. A. Sharpe, previously divisional medical officer of Division 3. The deputy divisional medical officer of Division 1, Dr. R. H. Simpson, M.D., F.R.C.P., D.P.H., retired earlier in the year. By his retirement the Council lost the services of an able and experienced officer whose long service had been marked by his keen interest in the health of school children. I regret to record the death of Dr. L. G. Bach, M.R.C.S., L.R.C.P., D.P.H., an assistant principal medical officer on the central medical administrative staff engaged upon duties connected with the maternity and child welfare services whose work was of great value to the department. 7 VITAL STATISTICS Population The total home population of the County in the middle of 1956 according to the Registrar-General's estimate was 3,273,000 compared with 3,295,000 in mid-1955—a decline of 22,000. Corresponding estimates for metropolitan boroughs are shown in Table 3 on page 231 and the rates given in this report are calculated on those figures. Table 1 (page 229) 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 of 22,000 in the population from the previous year's figure is accounted for almost entirely by changes in the age groups under forty-five years; the population at middle-age (45-64 years) remains the same and the group aged 65 years and over shows a fall of 1,000. Under age 45 the population changes are a fall of 1,000 in children aged 0-4 years, a rise of 6,000 in children of school age, a fall of 7,000 in young adults (15-24 years) and a fall of 19,000 in the age group 25-44 years. So far as the children are concerned, assuming wastage from death and migration to be of the same order as in previous years, the alterations are of the magnitude to be expected and are a reflection of changes in the birth rate in appropriate years: the birth rate in 1951 was higher than it is now (and than it was fifteen years earlier)—hence the rise in the population aged 5-14 as a larger quota moves in and the fall in the 0-4 population as it moves out. As regards the adults, although the contrast between the high birth rates preceding the first world war and the low ones of the nineteen-thirties doubtless plays some part in net alterations of the population, the migration factor plays a more important part. The fact that the changing numbers in the different age groups are net changes and conceal a large amount of inward and outward migration cannot be too strongly stressed. In my last annual report reference was made to the differences in the age structure of London's population compared with that for England and Wales—the population changes above, which are slight in relation to the total numbers involved, make no appreciable change in the picture then presented. Fertility The total births allocated to London for 1956 were : Live 52,171 Still 1,070 Total 53,241 Live births The live birth-rate in 1956 was 15.9 per 1,000 population as compared with 15.1 in 1955. The number of live births registered as occurring in London was 59,560, an excess of some 7,400 over those attributable to mothers residing within the County; the corresponding excess in 1955 was 7,500. The birth-rate in London tends to follow the same trend as for the country as a whole—indeed, since 1947 the crude rates have been practically identical. The two rates are not however strictly comparable because the proportion of women of child-bearing age in the population is greater in London than in England and Wales; adjusting for this difference by multiplying the crude rate by the Registrar-General's areal comparability factor for London births (0.88) the rate becomes 14.0. This factor makes no allowance however for the differing numerical proportions of married women in London compared with England and Wales—at the 1951 census the proportion of London women married at these ages was 95 per cent. 8 of the corresponding proportion for England and Wales. The crude birth rate for the past 21 years is shown in the diagram (page 10) 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. The actual numbers and rates are given, together with those for still-births, in Table 2 (page 230). For the years 1941 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 earlier years when total population was used. The rise in the number of births (2,345) occurred mainly in the first nine months of the year with the peak of the rise in the second quarter (corresponding to conceptions in the third quarter of 1955) and the birth rate has risen to the highest level since 1949. The actual number of births was higher in that year and also in 1950 and 1951—it has to be remembered that with a falling population (as in London) the course of the birth rates and the numbers of births can diverge. A less pronounced rise in the birth rate occurred in the country as a whole—a birth rate of 15.6 in 1956 compared with 15.0 in 1955, the highest since 1950. It is difficult to say whether this is the beginning of a new trend or a random fluctuation, the fall to a post 1951 level in the fourth quarter of the year suggests the latter but births have again risen in the first quarter of 1957, both locally and nationallv, suggestine the former. Marriages The number of marriages registered in London in 1956, was 33,884 or 20.7 persons married per 1,000 of the total population—the corresponding rates for 1955 and 1954 were 20.8 and 19.8 respectivelv. Illegitimacy There were 4,434 illegitimate live births (8.5 per cent. of the total live births). The figures in recent years are: Illegitimate live births as a percentage of total live births Year Illegitimate live births London A.C. England and Wales 1938 3,419 6.3 4.2 1940-1945 21,520 8.4 6.5 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 5.1 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 1956 4,434 8.5 4.8 The proportion of illegitimate births in London levelled off at about 7 per cent. after the war but in the past two years has risen to 7.7 and 8.5 per cent. respectively. This is doubtless an overstatement of the true illegitimate fertility rate of Londoners because the numbers are inflated by the influx of unmarried mothers making their way to London to bear their children in the shelter of the anonymity of a large city and to take advantage of the facilities available therein. Deaths under one year among illegitimate infants amounted to 25 per 1,000 illegitimate births compared with a rate of 21 for legitimate births. The corresponding rates for 1955 were 38 and 22 respectively. A detailed comparison of deaths in both groups is given in Table 6 (page 234). 9 Still-births There were 1,070 still-births in 1956 or 20.1 per 1,000 total births—the legitimate and illegitimate rates being 19.3 and 28.5 respectively. The number of still-births and rate per 1,000 total births in each year since 1946 and for the preceding quinquennium is shown in Table 2 (page 230). 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 (22.9). Mortality The total deaths in 1956 amounted to 38,317 or 11.7 per 1,000 of the population. Detailed figures are given in Tables 3 (by boroughs), 4 (by years) and 5 (by age and sex) (pages 231-4). Mortality from infectious diseases is discussed under the heading of 'Infectious Diseases' on page 21, and tuberculosis is dealt with separately (see page 26). LIVE BIRTH RATELONDON (A.C.) AND ENGLAND & WALES 1936-1956 * Rates based on total population 1936-1949, home population 1950— 10 The trend of the death rate in London, together with that for England and Wales, is indicated by the diagram on page 13. The areal comparability 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 1.00 for 1956 and has never been far from unity ever since its introduction in 1934. The two sets of rates therefore, unlike the birth rates, are reasonably comparable without further adjustment. The course of the death rate in London and the high rate during the war years has been commented upon in reports for earlier years. Mortality in 1956 followed the pattern of 1955—a characteristic of both years was the cold weather in the early part of the year (February 1956 was exceptionally cold) accompanied by a rise in deaths following low temperatures; there was also a thick fog in London from 4th-6th January which it has been estimated caused some 400 excess deaths in the County** though precise estimation of the excess mortality is difficult because of the normal seasonal rise in mortality which occurs at this time of year. ‡ Leading causes of death The leading causes of death in London in 1956 were as follows: Deaths Rate per 1,000 population Diseases of the heart 11,318 3.46 Cancer 7,920 2.42 Bronchitis pneumonia,* 5,334 1.63 Vascular lesions of the central nervous system 4,158 1.27 Other circulatory 1,929 0.59 Violent causes 1,553 0.47 Digestive diseases 1,415 0.43 Diseases of early infancy (immaturity, injury at birth, congenital malformation, etc.) 830 0.25 Tuberculosis (all forms) 455 0.14 All other causes† 3,405 1.05 Total 38,317 11.71 There was no change in the order of ranking of the causes of death compared with 1955. The pattern of mortality over the past eleven years is shown in the diagram on page 12, which, by expressing deaths from the causes shown as a percentage of all deaths in each year, shows the trend of the contribution of the four principal causes and of mortality from tuberculosis. Over the period heart disease and vascular lesions showed a tendency to rise; these are the causes of death particularly associated with old age and the extent of the rise has been matched by a corresponding increase in the proportion of old people in the population. The continuing upward trend in cancer deaths is clearly demonstrated; the variation in deaths from bronchitis and pneumonia reflected the severity or otherwise of the weather, 1948, 1950 and 1954 were generally years of mild weather, this was especially so in 1948 and 1950 during the first quarter of the year in which, as a general rule, one-third of the annual deaths occur. Heart disease Since the war and its aftermath the death rate from heart disease seems to have settled down at around 3.5 per 1,000 and, as stated earlier, now accounts for about one-third of total mortality. The table below shows the figures for the last seven years, from which it will be noted that the male death rate consistently exceeded that of females, on average by about 11 per cent. * Excluding pneumonia of the new born (under 4 weeks) which is included in ' Diseases of early infancy'. † Including 571 deaths (rate of 0.17) from nephritis and hyperplasia of prostate formerly separately listed. ‡ This is discussed more fully in Appendix B. ** Logan, W. P. D. 4Mortality from fog in London, Jan. 1956', Brit. Med. Jul. 31.3.56. 11 PATTERN OF MORTALITY—LONDON A.C. 1946-1956 Death rates from heart disease per 1,000 living 1950 1951 1952 1953 1954 1955 1956 Average Males 3.63 4.06 3.76 3.41 3.47 3.56 3.70 3.66 Females 3.46 3.70 3.37 3.10 3.00 3.21 3.24 3.30 Total 3.54 3.87 3.55 3.25 3.22 3.37 3.46 3.47 M/F Ratio 1.05 1.10 1.12 1.10 1.16 1.11 1.14 1.11 As regards mortality at different ages the table below, based on an average of the seven years under review, and ignoring the child population among which deaths are negligible we find first, as might be expected, that the incidence rises sharply with age and secondly that the sex ratio varies with age also. Average annual deaths and death rates 1950.56 per 1,000 population Ace in years 15-44 45-64 65-74 75+ All ages over 14 Males No. 186 1,498 1,769 2,241 5,694 Rate 0.26 4.04 17.44 50.92 4.65 Females No. 118 703 1,462 3,579 5,862 Rate 0.15 1.56 9.60 43.43 4.04 M/F Ratio of rates 1.73 2.59 1.82 1.17 1.15 12 DEATH RATE—LONDON (A.C.) AND ENGLAND & WALES 1936-1956 The fact that the overall sex ratio of the death rates is less than that for any of the age groups shown is because at age 75 years and over there are about twice as many women as men in the population and as the death rates are nearly comparable at this age there is, as can be seen from the table, a much larger number of women dying from heart disease. It is difficult to believe that the marked female advantage in rates below 75 years, particularly in the 45-64 age group, is due wholly to the greater toughness of women and one is drawn to the hypothesis that in addition to the nature of the work undertaken, the strain of being the main income earner with all its attendant problems of travel, promotion, unemployment and so on is a factor in accounting for the sex differential, particularly when the balance is largely reduced in later (non-earning) years. The whole question may also be examined from the aspect of the contribution of the various components that go to make up the heart group. These are, in order of ascending magnitude, chronic rheumatic heart disease (International List Nos. 410-416), heart disease due to hypertension (440-443), other heart disease (421-434) and coronary disease, angina (420). The order has changed over the period; until 1952 other heart disease ranked highest, from 1953 top place has been taken by coronary disease, angina. The all age death rates for the years under review for the different components are set out in the following table: 13 Death rates from component parts of heart disease 1950 1951 1952 1953 M. F. T. M. F. T. M. F. T. M. F. T. Chronic rheumatic 0.21 0.34 0.28 0.22 0.32 0.27 0.20 0.31 0.26 0.20 0.29 0.25 Hypertensive 0.45 0.43 0.44 0.50 0.47 0.48 0.26 0.31 0.29 0.27 0.29 0.28 Other 1.32 1.78 1.57 1.52 1.93 1.74 1.32 1.70 1.52 1.07 1.48 1.29 Coronary, angina 1.65 0.90 1.25 1.83 0.98 1.37 1.98 1.05 1.48 1.88 1.05 1.43 Total 3.63 3.46 3.54 4.06 3.70 3.86 3.76 3.37 3.55 3.41 3.10 3.25 1954 1955 1956 M. F. T. M. F. T. M. F. T. Chronic rheumatic 0.17 0.29 0.23 0.17 0.27 0.22 0.16 0.27 0.22 Hypertensive 0.27 0.30 0.29 0.27 0.32 0.30 0.28 0.35 0.31 Other 1.04 1.34 1.20 1.07 1.48 1.29 1.05 1.38 1.23 Coronary, angina 1.99 1.08 1.50 2.04 1.15 1.56 2.21 1.24 1.70 Total 3.47 3.00 3.22 3.56 3.21 3.37 3.70 3.24 3.46 From 1950 to 1956 coronary disease has increased both as a rate, by 36 per cent. (34 per cent. for males, 38 per cent. for females), and in importance, in that whereas in 1950 it formed 35 per cent. of total mortality from heart disease, by 1956 this figure had risen to 49 per cent.; the other three components have all declined both absolutely and relatively. A brief glance at these three reveals one or two interesting features. As regards sex incidence generally both chronic rheumatic heart disease and other heart disease show a female excess over the years whereas heart disease due to hypertension starts with a slight male excess and ends with a more marked female excess. These facts, however, ignore the great increase in mortality with increasing age. It is only in the comparatively minor component of chronic rheumatic heart disease that there is a true female excess age group by age group whereas for both heart disease due to hypertension and other heart disease the much higher rates at the older ages at which women are in the majority are what produce the overall female excess. The 1956 age specific deaths and death rates set out below illustrate the point. Age specific deaths and death rates, 1956, for chronic rheumatic, hypertensive and other heart disease 15.44 45.64 65.74 75+ All ages Chronic rheumatic Males No. 50 98 54 48 251 Rate .07 .26 .55 1.09 .16 Females No. 65 196 108 100 470 Rate .09 .43 .70 1.12 .27 Hypertensive Males No. 2 76 145 203 426 Rate .00 .20 1.48 4.61 .28 Females No. 1 61 183 356 601 Rate .00 .14 1.18 4.00 •35 Other Males No. 18 157 347 1,081 1,604 Rate .03 .41 3.54 24.57 1.05 Females No. 11 94 374 1,931 2,412 Rate .01 .21 2.41 21.69 1.38 As regards coronary disease, angina, the pattern both by years and age groups is set out below. It will be seen that although the maximum death rate (at age 75+) is less for either sex than that for other heart disease, the rate is much higher at middle age (45.64) than the other components and it is for this reason that its importance is manifest. Here too lies the main reason for the general male excess of the ' heart death rate over the female and, whereas at these ages the female rate has remained relatively constant, the male rate has steadily increased to about five times the female. At later ages the rates for both males and females have risen and again the larger rise, both proportionately and absolutely, occurs in males. 14 Age specific death rates from coronary disease, angina, 1950-56 Age Group 1950 1951 1952 1953 1954 1955 1956 15–44 M. 0.12 0.14 0.14 0.12 0.14 0.15 0.16 F. 0.02 0.02 0.01 0.01 0.02 0.02 0.03 45–64 M. 2.76 2.80 2.92 2.81 3.03 3.09 3.13 F. 0.67 0.67 0.64 0.64 0.69 0.75 0.64 65.74 M. 8.17 10.26 11.00 10.55 10.42 10.43 11.56 F. 3.97 4.23 4.59 4.42 4.44 4.21 5.01 75+ M. 13.72 16.79 18.63 16.64 18.34 19.14 21.77 F. 10.32 10.33 10.85 10.87 10.25 11.39 12.15 All ages M. 1.65 1.83 1.98 1.88 1.99 2.04 2.21 F. 0.90 0.98 1.05 1.05 1.08 1.15 1.24 To summarise, mortality from heart disease has remained at around 3.5 per 1000 living for the last seven years with a slight excess of male deaths; the rate rises steeply with age from about 0.21 at ages 15.44 to 46.04 at 75+ years and the male/female ratio rises to a maximum of 2.59 at ages 45.64 years. Within the heart group coronary disease, angina is increasing in importance, both absolutely and relatively, and the main reason for this is a greater increase in respect of males and a higher rate for both sexes among the middle-aged than for the other components : only in chronic rheumatic heart disease is there a true female excess of deaths and in the other two—heart disease due to hypertension and other heart disease—the overall female excess is due to the high number of female deaths at 75+ years which swamps the overall mortality figures. Cancer The cancer death-rate for all ages in 1956 was 2.42 per 1,000, the highest ever recorded in peace time. 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. 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 1956 Males: 0–14 0.03 0.06 0.11 0.10 0.11 0.12 0.11 0.10 0.13 15–44 0.30 0.29 0.38 0.35 0.37 0.39 0.34 0.33 0.36 45.64 4.05 4.09 4.45 4.28 4.19 4.28 4.31 4.50 4.51 65+ 12.54 12.75 13.25 15.64 15.50 15.69 15.29 15.73 15.77 All Males 2.21 2.27 2.45 2.60 2.61 2.68 2.64 2.73 2.76 Females: 0–14 0.03 0.05 0.07 0.09 0.08 0.07 0.06 0.08 0.10 15–44 0.36 0.33 0.37 0.35 0.35 0.38 0.32 0.33 0.38 45.64 2.96 2.68 2.84 2.80 2.85 2.85 2.85 2.93 2.77 65+ 9.08 9.08 8.95 8.79 8.77 8.73 8.39 8.43 8.75 All Females 1.95 1.93 1.98 1.99 2.02 2.04 2.02 2.08 2.12 All Persons 2.08 2.09 2.20 2.27 2.30 2.34 2.31 2.39 2.42 Over the nine years shown in the table above the cancer death-rate has increased by 25 per cent. in males and by 9 per cent. in females; the corresponding percentage increases for England and Wales are, males 14 per cent. and females 6 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. 15 The long term trend in London for both sexes combined can be seen from Table 4 (page 232). The increase there shown is due partly to the increasing age of the population and partly to improved diagnosis, but some part is doubtless attributable to increased incidence. 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 7.2, 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 18 per cent. and for females 15 per cent. (the total death-rates in this age group are, males 85.3 and females 57.9). Cerebral haemorrhage, etc. The death-rate from vascular lesions of the central nervous system in 1956 was 1.27 per 1,000, slightly higher than the figure of 1.25 in 1955. 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 1.63 m 1956 compared with 1.51 in 1955. Degenerative diseases If deaths from heart disease, other circulatory diseases, cerebral vascular lesions, nephritis and bronchitis are combined as indicative of mortality from degenerative diseases, the total mortality rate in recent years, is as follows : Mortality (per 1,000) from cardiovascular, renal disease and bronchitis 194 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 1956 6.37 Degenerative diseases continue to be responsible for over half the total death-rate. Digestive diseases Mortality from digestive diseases (other than cancer) in 1956 was 0.43 per 1,000, the same as in 1955. Within this group the death-rate from ulcer of the stomach or duodenum remained at 0.16 per 1,000 as in 1954 and 1955. Diabetes Diabetes mortality at 0.07 also remained at the same level as in 1955. At ages under 55, where treatment of diabetes is more effective, the number of deaths in 1956 was 26 which compares as follows with figures for previous years : 1938 83 1946 41 1947 19 1948 27 1949 26 1950 39 1951 34 1952 34 1953 20 1954 22 1955 21 1956 26 Violence 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, is shown chronologically in Table 4 (page 232). 16 There were 480 suicides in 1956 compared with 461 in 1955 and although the suicide rate shows a slight increase, it has remained at about the same level for the past four years. Deaths from road accidents in 1956 were 325, six more than in 1955, and 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 death rate attributable to other violence at 0.22 remained the same as in 1955. Infant mortality The infant mortality rate in 1956 was 21.3 per 1,000 live births which compares with rates of 23.2 in 1955 and 20.6 in 1954. The movements since the years 1936-40 of the death-rates from the principal diseases at ages below one year are shown in Table 7 (page 235). The diagram on page 18 illustrates the changes 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. There were no infant deaths from tuberculosis or measles in 1956; compared with 1955 there were proportionately fewer deaths from bronchitis and pneumonia, gastroenteritis, immaturity and post-natal asphyxia. The reduction in the last two is particularly encouraging—immaturity is the highest single cause of infant mortality and the decline in post-natal asphyxia is an interruption of the upward trend of the past twenty vears. Congenital malformations and iniurv at birth show slight increases over 1955. Neo-natal mortality Deaths in various periods of the first year of life during 1956 are shown in detail in Table 6 (page 234). Deaths under four weeks numbered 830 or 15.9 per 1,000 live births. Comparative rates for London and England and Wales in past years are: Year(s) London England and Wales 1938 23.0 28.3 1940-1945 22.9 26.5 1946-1950 18.4 20.9 1951 17.3 18.9 1952 15.8 18.3 1953 16.1 17.7 1954 15.1 17.8 1955 16.7 17.3 1956 15.9 16.9 B* 17 INFANT MORTALITY Mortality per 1,000 live births The distribution of causes of death in the first four weeks of life in descending order of magnitude in 1955 and 1956 was as follows: No. of deaths Per cent of total Cause 1955 1956 1955 1956 Immaturity 231 213 27.7 25.7 Post-natal asphyxia and atelectasis 212 188 25.4 22.7 Injury at birth 128 137 15.3 16.5 Congenital malformations 104 122 12.5 14.7 Pneumonia of newborn 44 50 5.3 6.0 Gastro-enteritis and diarrhoea 1 1 0.1 0.1 All other causes 114 119 13.7 14.3 Total 834 830 100.0 100.0 In the same way that there has been no perceptible trend in neo-natal mortality there has been nothing remarkable in the pattern of causes. The order of ranking is the same in 1956 as it was in 1955; immaturity and post-natal asphyxia and atelectasis accounted for nearly half the deaths, nearly all of which occurred in the first seven days and just over half of them in the first day. Birth injuries accounted for 16.5 per cent., slightly higher than in the previous two years but below the level of 1951 and 18 1952. Deaths from congenital malformations are not so restricted to the first seven days of life as are the three causes already commented upon; the figure of 14.7 per cent. is higher than in 1955 but is around the level of 14-15 per cent. of the past five years. There was only one neo-natal death from gastro-enteritis, the same as in 1955. Perinatal mortality The great majority (85 per cent.) of all the neo-natal deaths occur in the first seven days of life and of these about half occur in the first day. Thus the distinction between still-births and live births 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. 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 Year London England and Wales 1938 47.4 58.6 1953 34.7 36.9 1940-1945 44.2 49.5 1954 32.8 38.0 1946-1950 35.5 39.8 1955 34.8 37.6 1951 34.6 38.2 1956 33.3 36.8 1952 32.6 37.5 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 with perinatal mortality. In spite of the dramatic reduction in infant deaths from immaturity since 1936 (Table 7, page 235) the greatest scope for a further saving of infant life still lies in this field, especially as a predisposing factor in still-birth. The Health Committee of the Council, following a request from Divisional Health Committee for Division 4, authorised me to raise with the Ministry of Health the matter of the registration of the cause of still-birth which would involve legislation to amend the Births and Deaths (Registration) Act 1953. It is understood that the Ministry, in conjunction with the General Register Office, has in mind a national enquiry into the cause of perinatal mortality and it would await the outcome before giving consideration to any proposals on the subject. Maternal mortality A summary of maternal mortality for England and Wales in recent years statistics is given below. Comparative figures are shown in Table 8 (page 228). Year Live births and stillbirths Deaths in pregnancy or child-birth excluding abortion Post-abortion deaths No. Rate per 1,000 total births No. Rate † 1950 54,715 29 0.53 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 1956 53,241 16 0.30 11 0.015 * Annual Report of Chief Medical Officer, Ministry of Health, 1954. † Rate for deaths following abortion is expressed per 1,000 females aged 15-44 years. 19 The maternal mortality rate (excluding post-abortion deaths) in 1956 was 0-30 as compared with 0.61 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. Of the 16 deaths in pregnancy or childbirth not one was due to sepsis ; six of the eleven post-abortion deaths came under the category of 'abortion with sepsis'. The trend of maternal mortality in London since 1906 is shown in Table 4 (page 232): 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 ' ther causes' was interrupted by the second world war. The course of maternal mortality since 1946 for both London and England and Wales is shown by the following diagram. MATERNAL MORTALITY (excluding abortion) Mortality per 1,000 births The rates for England and Wales have been adjusted to bring them into line with the latest International Classification of Causes of Death. Puerperal pyrexia Notifications of puerperal pyrexia numbered 1,792 compared with 1,984 in 1955. Since notifications are in respect of all women having their babies in London the denominator to be used in the calculation of a rate should be total births registered in London without correction for place of residence. On this basis the notification rate becomes 29.5 per 1,000 total registered births compared with 33.9 in 1955 and 32.5 in 1954. The weather A summary of the meteorological observations at Kew Observatory during 1956 is given in Table 13 on page 240. January was a wet month with temperature about average; there were three days of thick fog early in the month. February was dry and very cold. March was relatively dry with sunshine about average for the time of year. April, May and June were dry and cold months and sunshine for the month of June was particularly low. In July a deluge set in, with rainfall for the month more than twice the average; this type of weather continued until mid-September resulting in a notoriously 'bad' summer characterised by excessive rain and a deficiency of sunshine. October and November were relatively dry with sunshine above average. December was mild, wet and sunless—only nine hours of sunshine were registered for the whole month. 20 INFECTIOUS DISEASES The notification rates and death-rates of the principal infectious diseases in London are shown in Tables 3, 4 and 9 (pages 231/2, 6): Table 3 shows both rates for the constituent Metropolitan Boroughs in 1956; Table 4 shows death rates sincc 1906 for the County as a whole; and Table 9, notification rates for the County sincc 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 (p. 237) 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 There was one notification of anthrax in 1956. It related to a man of 46 who worked in a tannery. He developed a malignant pustule on the side of his neck. The diagnosis of anthrax was confirmed bacteriologically. Treatment in hospital with pencillin was followed by recovery in four weeks. Diarrhoea and enteritis There were 20 deaths from diarrhoea and enteritis under the age of two years, compared with 27 in the previous year. This represents a rate of 0.38 per 1,000 live births, which shows a continuation of the low figures of recent years. The change that has occurred in this disease in the last 29 years can be shown by the comparison of the rate of 0.38 per 1,000 births in 1956 with the corresponding rate of 4.1 in 1946 and 14.5 in 1936, see diagram below. Improved social and economic conditions have combined with better treatment to produce the marked reduction in mortality from this cause. DEATHS FROM DIARRHOEA AND ENTERITIS (UNDER TWO YEARS) 21 Diphtheria A fall occurred in the number of notifications of diphtheria from 16 in 1955 to 11 in 1956. No considerable outbreaks took place. Of the two deaths registered only one resulted from an attack of diphtheria during the year, this being in an unimmunised child of four years of age. The other was a woman of 59 who died from heart disease which it was thought resulted from diphtheria some years ago. The continued occurrence of cases of this disease underlines the necessity for keeping up the highest level of immunity in the population by immunisation of young children and the giving of booster doses at school entry. This is particularly important in a large centre of population such as London which is always open to the danger of imported infection. An interesting change that has occurred in recent years is the reduction in the number of notifications of diphtheria in very young children. Only two of the eleven notifications in 1956 were of children under the age of 5 years. Dysentery In common with the rest of the country London experienced in 1956 the highest incidence of dysentery since the disease became notifiable in 1919—half as high again as the previous highest total in 1954. Since 1919 there have been three periods of increased incidence, the first in 1937-38, the second from 1943 to 1945 and the most recent from 1951 to 1956, both of the last two epidemics being substantially larger than the preceding one. (See diagram below.) NOTIFICATIONS OF DYSENTERY—LONDON A.C. 1930-1956 Practically all the notifications represented infection with the mild Sonne type of dysentery and they showed the usual seasonal incidence with the peak of the epidemic occurring at the end of March. The secondary autumn peak that formerly characterised this disease was again absent in 1956; the disappearance of this peak has been accompanied by a notable decrease in food-borne epidemics of dysentery. The year saw a marked increase in the proportion of notifications falling in the 5-14 year age group. There were more cases at this age than in younger children. A disease that was formerly largely a problem in nurseries now presents problems in the schools and attention has been given to possible methods of preventing spread of the disease in schools. The disease spreads quickly to other members of the family in the home, the younger children being most frequently affected. The increased risk to mothers of children is shown by the fact that whereas at ages under 15 years the sexes are affected about equally, at older ages women arc affected about twice as frequently as men. Enteric fever There was a fall in the number of notifications of enteric fevers from 111 in 1955 to 73 in 1956. There were no considerable outbreaks, the notifications representing for 22 the most part single sporadic cases. Many of these would have arisen from contact with unrecognised carriers in the population and the problem presented by these infections is largely that of discovering the symptomless carriers and bringing them under effective treatment. Erysipelas There were 297 notifications of erysipelas, compared with 361 in 1955 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 fell from 1,530 in 1955 to 1,327 in 1956. The great majority of the notifications were single sporadic cases or small family outbreaks. Larger outbreaks were comparatively rare. Influenza There were 120 deaths from influenza in 1956, compared with 164 in the preceding year. Reference to the figures given below will show that the last three years have all shown an influenza death rate that was lower than average. No severe epidemic of influenza has occurred during these years, but as the visitations of the influenza virus have been irregular in the past no inference can be drawn as to future epidemics. Year Influenza deaths 1943 726 1944 206 1945 171 1946 371 1947 284 1948 78 1949 372 Year Influenza deaths 1950 256 1951 809 1952 162 1953 514 1954 83 1955 164 1956 120 Leptospirosis During the year arrangements were made with certain hospitals in London for the administration of a prophylactic course of penicillin V to sewer workers who sustained minor injuries while at work. Apart from this addition to the first-aid facilities the precautions taken by sewer workers against leptospirosis remained unchanged. One case occurred during the year among the sewer workers in the Council's employment. Measles The year 1956 was not an epidemic year and incidence followed the expected course. Notifications increased steadily during the second quarter of the year, after which they declined during the autumn to rise in November and during the latter part of the year towards the peak of the biennial epidemic which did not occur until the early months of 1957. The mildness shown by this disease in recent years was once again exhibited in 1956. There were only two deaths in 9,651 notifications and one of these was in a woman in the 70-74 years age group. 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. Cases were spread fairly evenly through the year and there was no sign of local epidemicity in any one district. There was a reduction in the number of deaths from this infection, a reduction which was most marked in the 0-5 years age group and not accompanied by a corresponding decrease in notifications at this age. Details are shown in the following table: Notifications by age Deaths by age Year 0-4 5-14 15+ 0-4 5-14 15+ 1952 51 17 14 24 2 3 1953 65 19 14 21 — 3 1954 62 15 9 19 3 6 1955 59 19 20 14 1 7 1956 61 13 20 7 2 6 Between 1954 and 1956 reports were obtained from Coroners and hospitals in respect of deaths from meningococcal infection. The majority had resulted from an illness of an acute fulminating type with purpura and suprarenal haemorrhage. The duration of the illness from onset to death was frequently less than 24 hours, a finding that underlines the necessity for instituting early and vigorous treatment. In a number 23 of cases death occurred before admission to hospital could be arranged, but this was due to the rapidity of the disease more than to delay in seeking hospital admission. A finding of some interest was that in the fatal cases investigated only 15 per cent. were proved to be meningococcal in origin, although there had been a report of intracellular organisms in a further 12 per cent. Ophthalmia neonatorum The incidence of ophthalmia neonatorum, which since 1921 had remained fairly constant between 8 and 10 new cases per 1,000 live births, commenced to fall slightly towards the end of the period 1931-40 and, in recent years, has fallen to between 2 and 4 per 1,000 live births. There were 83 cases in 1956 (1.59 per 1,000 hve births) in 75 of which the mother was a resident of the County of London; full details of the latter are shown below: Domiciliary Institutional Number of cases confinements confinements Total Notified during the year 26 49 75 Removed to hospital for special treatment 1 3 4 Of the 75 cases, vision was unimpaired in 61, one died, three were under treatment at the end of the year and the remaining 10 moved from the district: of the three under treatment at the end of the preceding year vision was unimpaired. Pneumonia There was a fall in the number of notifications of pneumonia from 1,903 in 1955 to 1,633 in 1956. Only acute primary pneumonia and acute influenzal pneumonia are notifiable, so this figure represents only a part of the total incidence of pneumonia. The notification of pneumonia is of somewhat doubtful value, but it is found that the level of notification varies with the incidence of influenza in the population and a rise in the notification of pneumonia is sometimes an early sign of the beginning of an epidemic of influenza. Poliomyelitis There was a considerable fall in the number of notifications of poliomyelitis from the record figures of 1955. This year the smaller epidemic followed roughly the usual seasonal pattern although the peak week (25 cases) was slightly later than usual. The customary slight excess of cases in males was observed. Roughly one third of the notifications were non-paralytic compared with nearly a half in 1955, this being a return in 1956 to the customary ratio. The fatality rate (6 deaths in 279 notifications) suggests a less severe infection than was experienced in previous epidemics. The number of notifications in the three main age groups in recent years 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 1956 88 115 76 279 The variations in the proportion of notifications falling in the 0-4 group 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 1956 31.5 41.2 27.3 100.0 24 Last year it was noted that whereas the proportion of notifications falling in the age groups 0-4 years had remained at about one third, the proportion in the 5-14 years age group had risen from a third to about 40 per cent., with a corresponding fall in the proportion occurring at ages over 15 years. This change was repeated in 1956. The reason for it is not yet clear; it is not entirely due to changes in population in the different age groups. The use of the British poliomyelitis vaccine began during 1956. Details are given on page 76. The number of children inoculated during 1956, about 14,000, was insufficient to affect substantially the incidence of the disease. Rheumatic fever Deaths in London from rheumatic fever in 1956 were 14, of which one was a child 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 1956 2 3 275 280 0.136 Scabies Scabies became notifiable in London in August, 1943. Notifications in 1956 numbered 703 as compared with 660 in 1955. Scarlet fever Notifications of scarlct fever during the year numbered 2,198 the second lowest figure ever recorded; 1955 was the lowest with 2,070 notifications. 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 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 5,450 notifications of whooping cough during the year. There were only five deaths all of them of children under five years of age giving a fatality ratio of 0.09 per cent. Infectious diseases in schools The number of cases of certain infectious diseases involving exclusion or absence reported from schools in 1956 and previous years is shown on page 111. 25 TUBERCULOSIS Services provided the services provided by the Council as local health authority and described in detail in my report for 1955 for the care and after-care of tuberculous patients and the prevention of tuberculosis continued to be available during the year. They are summarised for the years 1952-1956 in Table T.10 (page 33). Introduction There were 455 deaths from all forms of tuberculosis in the County and of these 423 were attributable to pulmonary tuberculosis but of the 321 male deaths from this form of the disease, 272 or 85 per cent. occurred in men over 45 years of age. No death was recorded for a male person under 25 years of age for the first time on record. The steady reduction in tuberculosis mortality in recent years has been one of the outstanding features of health advance. During the year there were 3,929 fresh notifications, 3,602 of pulmonary tuberculosis, nearly a third of these being men of 45 years or over. The corresponding figures for 1955 were respectively 4,122 and 3,757 of which 25 per cent. were in respect of men of 45 years or over. The hard core of the tuberculosis problem at the present time persists in this section of the population. Newly notified disease in middle aged and older men is not due to fresh infection but to breakdown of existing lung lesions which have been quiescent and apparently inactive for years. The causes of this type of relapse, so much more frequent in men than in women, are not clearly recognisable. It is not a feature of the present generation alone of middle aged men but has been high lighted by the greater success of modern drug treatment of tuberculosis in young adults. Persistent infective lung tuberculosis among older men is now the main source of new infections in the younger members of the population. Unrecognised cases among men over 40 must be assiduously sought by regular X-ray examination especially among those who have close contact with children at home. Home care Specialist tuberculosis health visitors, who also act as chest clinic nurses, visited patients in their homes to advise on matters of hygiene, to assess home conditions and needs, and to persuade contacts to attend the chest clinic. The domiciliary nursing service provided home nurses to give injections and nursing attention and undertake any other nursing activities which the family doctor or chest physician requested. Nursing equipment, such as back rests, air beds, bedpans, sputum flasks, etc., was made available on loan to patients in need. Patients too ill to make their own way to the local chest clinic for consultation, X-ray, pneumothorax treatment, etc. were conveyed by ambulance or sitting-case car provided through the Council's ambulance service. Home helps employed by the Council performed domestic duties for bed-ridden patients and assisted in the home care of children whose mothers were undergoing treatment. The Council provided extra nourishment (milk, butter, eggs) for necessitous patients within a prescribed scale of maximum quantities, when recommended by the chest physician. Diversional therapy During the year handicraft classes continued to be held for tuberculous patients at several chest clinics. The Council employs trained handicraft instructors for this work and gives fmancial assistance towards the cost of tools and materials. Instruction is given in a variety of arts and crafts, e.g. basketry, dressmaking, leather-work, weaving, rug and toy making. Provision is also made for the instruction by occupational therapists or home handicraft instructors of home-bound tuberculous patients in some form of diversional therapy. A patient who wishes to continue a craft learnt while in a sanatorium is encouraged and enabled to do so. Patients may either retain the articles they make by paying the cost of materials or, at the discretion of the care committee, offer the article for sale at a sale of work arranged by the care committee and receive the profit. The articles are, of course, disinfected before sale. 26 Industrial rehabilitation In addition to the arrangements made by the local disablement resettlement officers of the Ministry of Labour for the training and employment of tuberculous patients, the Council sent selected patients during the year to three village settlements, viz. the British Legion Village, Preston Hall, near Maidstone, Enham—Alamcin Village Centre, near Andover, Hants., and Papworth Village Settlement, near Cambridge. 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 Council, who also make a grant towards administration expenses. Apart from the special factory in Bermondsey run under Government aegis by Remploy Ltd., there are no group employment facilities under sheltered conditions available for tuberculous patients in London and the need for additional facilities of this kind continues. Recuperative holidays London tuberculous patients who have recently been ill or are threatened with relapse are able to have holidays arranged for them through the Spero Holiday Scheme of the National Association for the Prevention of Tuberculosis. Holidays under this scheme were provided during the year for 322 patients. Care committees The voluntary tuberculosis care committees associated with most of the 29 chest clinics in London continued their valuable work of assisting patients and their families financially or in other ways where help was not available from official sources. The Council's local tuberculosis care organisers act as secretaries to these committees. Hostels for homeless infective men The Council continued to provide special residential accommodation for men with advanced disease who have received the maximum benefit from hospital treatment but cannot be discharged because they are homeless. The accommodation and facilities provided at the Council's two hostels for tuberculous men, Cromwell Lodge, Hornsey and Hurlingham Lodge, Fulham, were fully described in my report for 1955. In addition arrangements have continued for up to 16 infective ex-servicemen to be accommodated temporarily in hostel accommodation at the British Legion Village, Preston Hall, Maidstone, where they are provided with board, lodging and diversional therapy. Accommodation in the hostels has always been fully occupied and there has been an average waiting list of 18 men. Plans are in hand for the establishment of a third hostel. Services for children Open-air schools The Council provides day and residential open-air schools for school children who are convalescing from tuberculosis and not sufficiently fit to resume normal school life. Under medical supervision educational activities are pursued at a gentle pace in favourable surroundings and special attention is paid to adequate rest and nutrition. Tuberculosis contact scheme Through the agency of the Invalid Children's Aid Association the Council continued to arrange for the boarding out of children exposed to infection at home, or needing care because a parent or parents were receiving treatment for tuberculosis, where private arrangements could not be made or their needs could not be met by other services, e.g. day nursery or child-minder. Boarding out was also arranged under the scheme where this was thought desirable during the process of B.C.G. vaccination. As will be seen in Table T.10 (page 33) the number of children placed annually under the scheme continues to fall. B.C.G. vaccination The Council s schemes for the B.C.G. vaccination of susceptible (tuberculin negative) child contacts of known tuberculous patients, diabetic children and thirteen-year-old school children continued successfully during 1956. The numbers of children in these three groups vaccinated in the year are shown in (Table T.14 page 36). In November, 1956, the Rank Organisation Ltd. made for the Council a three minute colour film on B.C.G. vaccination which will be shown at its cinemas throughout London for a year. It will appear at cinemas in each of the nine health divisions 27 shortly before the visits to schools in the division by the Council's B.C.G. vaccination unit and will explain to adult audiences why B.C.G. vaccination is advisable and howit is done in London. Preventive measures X-ray examinations—Preventive measures arranged by the Council include the chest X-ray of (i) all newly appointed teaching and other staff who are likely, through their work, to be in close and frequent contact with children; (ii) staff and senior pupils at the Council's occupation centres for mentally deficient persons (Table T.13 page 36); (iii) new residents over 15 years of age entering the Council's homeless families' units; (iv) positive reactors discovered among thirteen-year-old children tuberculin tested with a view to B.C.G. vaccination. Epidemiological investigations are made of the school or other workplace contacts of cases of tuberculosis notified among the children, staff or residents in the Council's establishments. A summary of the findings of such investigations is given in Table T.9 (page 32). TUBERCULOSIS MORTALITY AND MORBIDITY 1935-1956 DEATHS NOTIFICATIONS 28 Table T1—Tuberculosis—Statutory notifications and deaths—Administrative County of London, 1921-56 (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 5,473 161 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 1956 3,602 110 423 0.13 327 0.10 32 0.01 (a) Excluding posthumous notifications. Table T2—Pulmonary tuberculosis—Notification and death rates per 1,000 living by age and sex, 1947-1956 Year Age 0-4 5-14 15-44 45 and over All ages M F M F M F M F M F Notification rates 1947 0.81 0.76 1.01 0.96 2.56 2.41 1.61 0.36 1.89 1.32 1948 1.08 0.94 0.87 0.96 2.66 2.40 1.60 0.34 1.93 1.32 1949 1.08 0.94 0.82 1.04 2.70 2.45 1.84 0.39 2.03 1.36 1950 1.15 0.86 0.75 0.77 2.46 2.34 1.59 0.33 1.83 1.26 1951 0.98 0.92 0.74 0.68 2.18 1.98 1.91 0.36 1.80 1.16 1952 0.65 0.70 0.53 0.61 2.16 1.90 1.88 0.43 1.73 1.11 1953 0.84 0.85 0.69 0.65 2.01 1.80 2.09 0.42 1.76 1.08 1954 0.64 0.55 0.48 0.55 1.79 1.71 2.02 0.41 1.60 0.99 1955 0.56 0.42 0.39 0.48 1.65 1.48 1.82 0.41 1.45 0.86 1956 0.33 0.37 0.31 0.34 1.62 1.31 2.01 0.41 1.47 0.78 Death rates 1947 0.09 0.10 0.05 0.04 0.70 0.70 1.24 0.32 0.78 0.44 1948 0.06 0.05 0.01 0.03 0.66 0.65 1.27 0.23 0.76 0.37 1949 0.02 0.03 0.01 0.02 0.46 0.46 1.21 0.26 0.65 0.30 1950 0.05 — 0.01 0.01 0.34 0.32 0.99 0.22 0.51 0.22 1951 0.02 0.02 — 0.02 0.27 0.21 1.23 0.22 0.53 0.18 1952 — — — — 0.18 0.16 1.08 0.18 0.44 0.14 1953 0.02 0.03 0.00 0.00 0.12 0.11 0.81 0.13 0.33 0.10 1954 — 0.03 — 0.01 0.07 0.10 0.74 0.12 0.28 0.09 1955 0.02 — 0.00 — 0.07 0.06 0.66 0.11 0.25 0.07 1956 — 0.02 — — 0.07 0.05 0.52 0.09 0.21 0.06 29 Table T3—Non-pulmonary tuberculosis—Notification and death rates per 1,000 living by age and sex, Administrative County of London, 1947-1956 Year Age 0-4 5-14 15-44 45 and over All ages M F M F M F M F M F Notification rates 1947 0.520 0.444 0.472 0.394 0.167 0.253 0.060 0.048 0.190 0.198 1948 0.398 0.289 0.479 0.388 0.165 0.229 0.048 0.049 0.177 0.176 1949 0.275 0.312 0.404 0.375 0.156 0.214 0.054 0.041 0.157 0.168 1950 0.241 0.296 0.265 0.271 0.164 0.247 0.049 0.042 0.140 0.171 1951 0.207 0.269 0.294 0.257 0.143 0.223 0.053 0.043 0.138 0.162 1952 0.198 0.168 0.275 0.173 0.144 0.233 0.070 0.085 0.141 0.165 1953 0.144 0.160 0.152 0.182 0.138 0.175 0.044 0.070 0.109 0.135 1954 0.142 0.149 0.139 0.187 0.128 0.176 0.069 0.071 0.111 0.134 1955 0.110 0.116 0.140 0.121 0.140 0.189 0.042 0.037 0.105 0.116 1956 0.111 0.089 0.078 0.095 0.109 0.176 0.048 0.058 0.084 0.114 Death rates 1947 0.226 0.151 0.109 0.089 0.062 0.064 0.063 0.051 0.081 0.067 1948 0.188 0.175 0.055 0.062 0.054 0.047 0.048 0.042 0.063 0.056 1949 0.092 0.119 0.065 0.039 0.052 0.027 0.057 0.025 0.059 0.034 1950 0.043 0.074 0.032 0.039 0.036 0.022 0.042 0.038 0.038 0.034 1951 0.071 0.067 0.031 0.048 0.040 0.019 0.041 0.039 0.042 0.033 1952 0.053 0.040 0.010 0.010 0.027 0.018 0.033 0.029 0.029 0.023 1953 0.024 0.076 0.005 0.010 0.017 0.017 0.025 0.029 0.019 0.025 1954 0.025 0.018 0.005 — 0.016 0.009 0.035 0.029 0.021 0.016 1955 0.008 0.009 0.009 0.005 0.012 0.004 0.021 0.024 0.014 0.013 1956 0.009 — — — 0.009 0.004 0.023 0.014 0.012 0.007 Table T4—Tuberculosis—Statutory notifications by age groups, 1956 Form of tuberculosis notified Sex Number of notifications of new cases of tuberculosis by age Total all ages 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65+ Pulmonary tuberculosis M. 2 37 37 30 117 190 410 380 392 364 289 2,248 F. 5 36 33 38 132 227 370 225 140 70 78 1,354 Other forms of tuberculosis M. — 13 9 8 9 8 34 23 16 6 3 129 F. 3 7 14 6 18 25 54 31 16 8 16 198 All forms of tuberculosis M. 2 50 46 38 126 198 444 403 408 370 292 2,377 F. 8 43 47 44 150 252 424 256 156 78 94 1,552 Table T5—Tuberculosis—Deaths in Administrative County of London, 1956 Form of tuberculosis Sex Age at death Total all ages 0- 1- 5- 15- 25- 45- 65- 75+ Pulmonary tuberculosis M. — — — — 49 132 91 49 321 F. — 2 — 2 35 25 25 13 102 Other forms of tuberculosis M. — 1 — — 6 8 2 2 19 F. — — — — 3 6 1 3 13 All forms of Tuberculosis M. — 1 — — 55 140 93 51 340 F. — 2 — 2 38 31 26 16 115 30 Table T6—Statutory notification of non-pulmonary tuberculosis—Distribution according to site and age, Administrative County of London, 1956 Site of tuberculous lesion Numbers of notifications of new cases of non-pulmonary tuberculosis by age Total all ages 0-4 5-14 15-24 25+ Bones and joints 10 11 21 71 113 Abdomen — 3 9 13 25 Peripheral glands 7 7 14 38 66 Meninges and C.N.S. 2 14 5 5 26 Skin and erythema nodosum 2 2 — 3 7 Genito-urinary 1 — 9 68 78 Other sites 1 — 2 9 12 All sites 23 37 60 207 327 Table T7—Patients on the registers*—1947-1956 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 Cases on the register at the end of the year Pulmonary— Males 16,374 17,224 18,203 19,090 19,119 17,336 18,475 18,897 19,300 19,715 Females 12,862 13,549 14,223 15,031 15,556 14,672 14,930 15,576 15,846 15,928 Other forms: Males 2,699 2,889 2,752 2,591 2,520 1,530 1,508 1,442 1,371 1,339 Females 3,142 3,147 3,015 3,068 2,954 1,850 1,820 1,709 1,704 1,710 Total 35,077 36,809 38,193 39,780 40,149 35,388 36,733 37,624 38,221 38,692 No. per 1,000 of population 10.6 1.10 11.3 11.7 12.0 10.5 10.9 11.3 11.6 11.8 * Since 1952 figures are taken from chest clinic registers; for earlier years they represent Borough M.O.H. register. Table T8—Condition of new cases and their contacts, 1956 Men Women Children Total Number of new cases diagnosed as tuberculous at chest clinics during the year 2,141 1,360 274 3,775 Percentage of these new cases found to be 'T.B. plus' (i.e. Infective) 40.6 27.6 6.9 33.5 Number of those who attended as contacts and who were: (a) Diagnosed as tuberculous* 67 (2.9) 94 (2.6) 72 (0.9) 233 (1.7) (b) Not tuberculous 2,030 3,188 7,335 12,553 (c) Not determined (as at 31.12.56) 184 275 442 901 *Figures in brackets are percentages of the total contacts examined. 31 c Table T9—Summary of investigations into tuberculosis 'incidents' at Council establishments —Administrative County of London, 1956 Establishment Notified case Children Adults Tuberculin tested Positive reaction X-rayed Abnormal X-rayed Abnormal Day schools Teacher 191 16 16 Nil 8 Nil School Secretary — — 587 2 53 Nil Teacher 244 15 15 Nil 2 Nil Teacher — — — — 43 Nil Pupils (3) 210 38 38 2 12 Nil Teacher — — 495 Nil 29 Nil Pupil — — 562 Nil 42 Nil Teacher — — — — 12 Nil Pupil 254 59 59 Nil 11 Nil Pupil 165 26 18 1 21 Nil Pupil 42 4 12 Nil 2 Nil Pupil 279 48 46 1 38 Nil Teacher 15 1 1 Nil 6 Nil Teacher 96 18 22 Nil — — Kitchen Helper 29 3 2 Nil 13 Nil Teacher 321 78 89 1 34 Nil Teacher 27 7 6 Nil 2 Nil Teacher 84 9 9 2 — — Pupil — — 30 Nil 1 Nil Teacher 25 Nil — — 13 Nil Teacher 345 21 21 9 17 Nil Pupil 318 58 * — — — Pupil 10 3 3 Nil 1 Nil Pupil — — — — 24 Nil Pupil 19 4 2 Nil — — Totals (25) 2,674 408 2,033 18 384 Nil Residential School Pupil 28 4 4 Nil 12 1 Day Nursery Nursery Assistant 89 1 — — 14 Nil Occupation Centre — — — — 35 Nil Welfare homes (2) Resident Resident — — — — 34 98 Nil 6 Hostel Cleaner — — — — 12 Nil Grand Total (31) 2,791 413 2,037 18 589 7 * Not reported. Tuberculosis notifications and mass radiography details by occupation and mass radiography findings in London residents. Figures are only available in respect of the year 1955 and may be found in the Annual Report for this year at pages 41 and 42 (Tables T9, T10). 32 Table T10—Summary of services provided for tuberculous patients—Administrative County of London 1952-56 1952 1953 1954 1955 1956 Clinic registers Total on registers at the end of the year 35,388 36,733 37,624 38,221 38,695 Work of local tuberculosis care organisers Patients assisted for the first time with:— Beds and bedding 541 431 435 291 240 Clothing or footwear 961 1,089 1,334 1,014 847 Patients at the end of the year receiving:— Extra nourishment 2,234 2,451 2,391 2,285 2,183 Home help service 673 618 729 660 624 Home care and treatment At the end of the year, patients:— Awaiting admission to hospital 738 494 209 71 22 Under treatment in their own homes 808 804 930 1,050 334 Receiving attention by home nurses 367 466 530 498 405 Rehabilitation At the end of the year the Council was financially responsible for rehabilitants at:— British Legion Village, Maidstone 25 25 33 36 33 Papworth Village Settlement, Cambridge 17 17 23 22 26 Enham-Alamein Village Centre, Andover 18 21 22 15 10 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 33 At boarding open-air schools Children convalescent from tuberculosis:— At the beginning of the year 33 29 34 22 12 Admitted during the year 47 27 23 2 3 At the end of the year 29 34 22 12 8 Awaiting admission at end of year 11 7 1 — 2 Boarding-out of child contacts Children in nurseries and foster homes at the beginning of the year 419 440 450 365 279 Placed during the year 490 562 411 398 272 Boarded-out at the end of the year 440 450 365 279 172 Average number boarded-out at any one time 442 486 417 310 215 Hoarding-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 7 Placed during the year 67 38 39 40 28 Boarded-out at the end of the year 24 6 11 7 4 Average number boarded-out at any one time 18 14 10 19 13 B.C.G. vaccination schemes Child contacts vaccinated by chest physicians in London 3,034 3,141 3,851 4,113 4,245 Boarded-out child contacts vaccinated by out-county chest physicians 139 161 48 43 58 Child contacts (mainly new-born babies) vaccinated in London hospitals prior to boarding-out 73 77 64 50 41 13-year-old school children — — 4,037 19,507 22,203 Diabetic children in the Council's care — — 13 12 9 Hostels for tuberculous men In residence at the beginning of the year 54 44 59 63 58 Recommendations approved during the year 61 84 57 49 82 In residence at the end of the year 44 59 63 58 69 33 C* Table T11—Principal tuberculosis statistics—Metropolitan Boroughs and the Administrative County of London, 1956 Metropolitan Boroughs New notifications Deaths from tuberculosis Tuberculosis deaths per 1,000 population Pulmonary tuberculosis deaths per 1,000 population aged 15 and over Number of tuberculosis cases on clinic registers at 31.12.56 Cases on register per 1,000 population Mass X-ray findings Estimated home population mid 1956 Pulmonary Tuberculosis of Meninges and C.N.S. Other nonpulmonary tuberculosis Total New notifications per 1,000 population Pulmonary Nonpulmonary tuberculosis Total deaths Number of pulmonary cases found per 1,000 adults examined * Total Percentage sputum positive during 1956 Division 7 Chelsea 51,070 35 1 3 39 0.76 1 — 1 0.02 0.02 468 2.1 9.2 5.3 Fulham 117,100 130 1 10 141 1.20 12 2 14 0.12 0.13 1,403 4.3 12.0 4.3 Hammersmith 113,300 156 — 9 165 1.46 17 17 0.15 0.19 1,536 2.7 13.6 4.3 Kensington 168,800 233 — 23 256 1.52 19 1 20 0.12 0.13 1,619 6.1 9.6 4.2 Division 2 Hampstead 97,580 88 — 12 100 1.02 4 — 4 0.04 0.05 965 1.8 9..9 4.0 Paddington 121,200 220 2 20 242 2.00 15 — 15 0.12 0.15 1,444 6.9 11.9 4.0 St. Marylebone 73,040 66 — 5 71 0.97 8 1 9 0.12 0.12 854 1.8 11.7 3.0 St. Pancras 133,100 176 2 13 191 1.44 24 4 28 0.21 0.22 1,233 11.6 9.3 7.2 Westminster, City of 96,100 103 — 7 110 1.14 16 3 19 0.20 0.19 839 3.9 8.7 5.5 Division 3 Finsbury 34,870 36 — 5 41 1.18 5 2 7 0.20 0.18 257 7.4 7.4 3.3 Holborn 22,640 33 — 3 36 1.59 2 1 3 0.13 0.10 249 5.2 11.0 2.6 Islington 228,300 299 1 34 334 1.46 34 1 35 0.15 0.19 2,772 4.2 12.1 6.9 Division 4 Hackney 165,800 114 1 8 123 0.74 18 — 18 0.11 0.14 2,059 1.6 12.4 4.2 Shoreditch 44,520 40 1 3 44 0.99 4 1 5 0.11 0.12 452 3.3 10.2 5.3 Stoke Newington 50,420 51 — 4 55 1.09 3 — 3 0.06 0.08 767 1.0 15.2 5.9 Division 5 Bethnal Green 52,280 60 — 4 64 1.22 5 3 8 0.15 0.12 837 4.1 16.0 4.8 City of London 5,180 4 — 2 6 1.16 2 — 2 0.39 0.43 56 5.4 10.8 Poplar 68,620 58 — 6 64 0.93 9 — 9 0.13 0.17 581 3.3 8.5 3.4 Stepney 98,160 116 4 7 127 1.29 17 — 17 0.17 0.22 1,199 3.6 12.2 6.0 Division 6 Deptford 71,840 103 — 9 112 1.56 15 1 16 0.22 0.27 1,160 2.4 16.1 7.6 Greenwich 88,780 72 1 8 81 0.91 12 1 13 0.15 0.18 1,011 3.4 11.4 6.0 Woolwich 147,500 145 — 10 155 1.05 17 5 22 0.15 0.15 2,042 2.0 13.8 4.9 Division 7 Camberwell 177,800 307 2 21 330 1.86 24 1 25 0.14 0.17 1,886 0.5 10.6 6.7 Lewisham 222,100 195 4 13 212 0.95 29 — 29 0.13 0.17 2,785 8.8 12.5 3.9 Division 8 Bermondsey 56,200 60 — 6 66 1.17 10 — 10 0.18 0.23 594 5.2 10.6 3.8 Lambeth 223,900 180 — 18 198 0.88 22 — 22 0.10 0.13 3,135 1.4 14.0 6.5 Southwark 92,300 140 1 15 156 1.69 21 1 22 0.24 0.29 1,448 3.9 15.7 2.8 Division 9 Battersea 112,900 102 2 4 108 0.96 14 1 15 0.13 0.16 1,118 2.9 9.9 5.0 Wandsworth 337,600 280 3 19 302 0.89 44 3 47 0.14 0.16 3,923 3.5 11.6 6.2 London 3,273,000 3,602 26 301 3,929 1.20 423 32 455 0.14 0.16 38,692 3.8 11.8 5.4 *These are the latest available figures and relate to 1955. Table T12—Tuberculosis—Contact examinations at Chest Clinics—Administrative County of London 1956 34 Table T12— Tuberculosis—Contact examinations at Chest Clinics—Administrative County of London, 1956 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 Chelsea 51,070 43 106 — 106 — — 247 Fulham 117,100 142 168 124 44 1 2.3 118 Hammersmith 113,300 152 530 — 530 8 1.5 349 Hampstead 97,580 98 426 — 426 5 1.2 435 Paddington and Kensington 290,000 483 1,562 305 1,257 28 2.2 323 St. Marylebone 73,040 76 213 — 213 7 3.3 280 St. Pancras 133,100 156 310 17 293 3 1.0 199 Westminster, City of 96,100 100 204 — 204 4 2.0 204 Finsbury 34,870 36 95 14 81 1 1.2 264 Holborn 22,640 38 122 4 118 — — 321 Islington 228,300 371 752 50 702 28 4.0 203 Shoreditch 44,520 36 184 3 181 — — 511 Stoke Newington and Hackney North 137,320 122 516 6 510 13 2.5 423 Hackney South and Bethnal Green 131,180 123 451 33 418 3 0.7 367 City of London 5,180 4 79 6 73 3 4.1 1,975 Poplar 68,620 63 298 151 147 4 2.7 473 Stepney 98,160 122 598 — 598 9 1—5 490 Deptford 71,840 118 279 5 274 5 1.8 236 Greenwich 88,780 78 498 12 486 8 1.6 638 Woolwich (both clinics) 147,500 157 431 61 370 13 3.5 293 Camberwell 177,800 317 968 — 968 12 1.2 305 Lewisham 222,100 196 877 — 877 14 1.6 447 Bermondsey 56,200 64 202 — 202 10 5.0 316 Lambeth North 103,700 99 653 — 653 4 0.6 660 Lambeth South 120,200 80 317 — 317 6 1.9 396 Southwark 92,300 157 672 — 672 3 0.4 428 Battersea 112,900 83 355 27 328 11 3.4 428 Wandsworth Town Hall clinic 182,300 164 362 31 331 6 1.8 221 Balham ,, 155,300 97 459 52 407 21 5.2 473 TOTAL 3,273,000 3,775 12,687 901 11,786 230 2.0 336 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. 35 *These are the latest available figures and relate to 1955. Table. T13—Tuberculosis—Annual chest X-ray examination of mental defectives at senior occupation centres—Administrative County of London—1956 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.) 34 20.9.56 4 24 — North Kensington (E.G.) 19 7.5.56 — 12 — do. 10 12.9.56 — 9 — 3 Islington (E.G.) 36 3.0.56 3 30 — Archway (E.B.) 33 4.0.56 2 28 — 4 Hackney (E.G.) 37 30.4.56 5 29 — do 8 19.9.56 4 2 — Dalston (E.B.) 50 28.9.56 7 28 — 5 Stepney (E.B.) 20 12.10.56 — 20 — 6 Greenwich (E.G.) 31 19.11.56 — 28 — Brockley (E.G.) 55 19.11.56 1 38 — 9 Battersea (E.B.) 31 22.10.56 1 22 — Earlsfield (E.G.) 63 23.10.56 2 41 — Totals 427 29 311 — Annual X-ray examination of staff at occupation centres, 1956. No. of existing staff X-rayed 78 All satisfactory. Table T14—B.C.G. vaccination under L.C.C. schemes in 1956 1. Day schools— 1956 No. of schools visited 413 No. of 13-year-old children at school 36,102 No. of consents 26,748 No. Mantoux tested 25,077 No. of positive reactors 3,687=14.7 per cent. No. given B.C.G. 21,364 No. vaccinated June, 1954, to December, 1956 45,009 Retests in 1956— No. of consents to retest 9,571 No. of retests 8,524 No. found negative 373=4-4 per cent. No. re-vaccinated 373 2. Residential establishments— No. of establishments visited in 1956 6 (includes 1 in-county establishment now covered by Divisional arrangements) No. of children tested 128 No. of positive reactors 29=22.7 per cent. No. given B.C.G. 99 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 1956 38 4. Tuberculosis contacts— No. of contacts examined at chest clinics in 1956 12,687 No. of contacts given B.C.G. vaccination in London 4,245 No. of contacts given B.C.G. vaccination in London since inception of scheme in 1950 20,904 5. Diabetics— No. tuberculin tested No figures available. No. given B.C.G. in 1956 9 No. given B.C.G. since inception of scheme 34 36 Table T15—B.C.G. vaccination of school children in Administrative County of London, 1956—Divisional figures Division No. of 13-yearsold school children Total No. of consents Alleged contacts of known cases 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 Consents included in (2) No. Per cent. of (1) No. Per cent. (1) (2) (3) (4) (5) (6) (7) (8) (9) 1 4,026 2,892 2 2,739 1,285 31.9 409 14.9 2,330 (4 negatives not vaccinated) (1 negative not vaccinated) 2 4,143 3,061 18 2,934 1,191 28.7 484 16.5 2,446 3 2,767 1,925 5 1,849 913 32.9 311 16.8 1,537 4 3,219 2,243 3 2,136 1,080 33.6 328 15.4 1,808 5 2,773 2,131 5 1,960 808 29.1 335 16.6 1,624 (1 negative not vaccinated) (7 negatives not vaccinated) (8 negatives not vaccinated) 6 4,194 3,291 28 3,075 1,091 26.0 387 12.6 2,681 7 5,608 4,293 37 3,981 1,590 28.4 538 13.5 3,435 8 4,279 3,244 46 2,878 1,355 31.7 4.33 15.0 2,445 9 5,093 3,668 34 3,525 1,534 30.1 462 13.1 3,058 (5 negatives not vaccinated) Totals 36,102 26,748 178 25,077 10,847 30.0 3,687 14.7 21,364 37 GENERAL PUBLIC HEALTH Housing during the year 9,234 houses and flats were erected by the Council and the Metropolitan Borough Councils. Of these 7,906 were in London (3,427 erected by the Council and 4,479 by the Borough Councils) and the remainder (1,328) 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 175,807 (an increase in the year of 4,545) of which 87,431 were situated in London and 88,376 outside the County. In addition there were 7,260 temporary pre-fabricated bungalows erected by the Ministry of Works but managed by the Council. During the year the Housing Committee undertook a comprehensive survey of the housing situation. This was done to assess the extent to which future housing commitments could be met, having regard to the scarcity of land available for building houses and the demand for rehousing accommodation arising from slum clearance operations and other redevelopments. Preferential housing As a result of this review, revised arrangements were introduced for allocating the accommodation likely to become available over the next three years for applicants on the waiting list and for dealing preferentially with families recommended for rehousing on health grounds. So far as preferential rehousing was concerned, provision was made for the setting aside of a limited number of houses each year for families containing tuberculous persons recommended by chest physicians for urgent rehousing and for applicants suffering from very serious medical conditions aggravated by housing circumstances. The very restricted number of houses available each year for preferential allocation made it necessary to discontinue the acceptance of medical certificates in support of housing applications submitted by applicants themselves. Only those applicants personally recommended by family or hospital doctors as being in urgent need of improved housing conditions can be considered. At the end of the year a letter was sent to all general practitioners and hospitals explaining the reason for the changed procedure and seeking co-operation in ensuring that recommendations should be made only in respect of those families whose need for rehousing was exceptionally and vitally urgent so that unnecessary disappointment might be avoided. Divisional medical officers are responsible for reviewing recommendations received under the revised arrangements and for selecting those which they feel merit special consideration, the final choice being undertaken by a senior member of the central medical staff. Before the introduction of the new scheme in November, 1956, divisional medical officers continued as in previous years to assess the merits of medical certificates submitted by applicants seeking preference on health grounds and to enable fair decisions to be reached many enquiries were made to medical officers of health of metropolitan boroughs and out-county authorities, of family doctors, and of the staffs of hospitals. The assistance thus afforded is again gratefully acknowledged. Of the 19,088 applications considered, 4 per cent. were recommended for special preference to reduce the danger of infection arising from active pulmonary tuberculosis, 20 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 37 per cent. it was decided that the degree of urgency disclosed by doctors' certificates did not warrant additional preference. Slum clearance Work on the survey of areas included in the slum clearance programme for the five years 1956 -60 proceeded throughout the year. Representations under section 25 of the Housing Act, 1936, were made in respect of 68 areas containing 3,345 houses and preliminary surveys were completed in respect of a further 111 areas containing 3,255 unfit houses. 38 In addition, two areas containing 91 unfit houses were the subject of Declaration of Unfitness Orders made by the Council under the Town and Country Planning Act, 1947 and an area of 264 unfit houses was surveyed for the purpose of giving corroborative evidence in support of a metropolitan borough council. The Minister of Housing and Local Government arranged 37 public local inquiries into and four informal hearings in connection with Orders made by the Council and, by the end of the year, 28 of the Orders had been confirmed. No objections were made in respect of nine Orders which the Minister confirmed without holding public local inquiries. Improvement grants Surveys were made in respect of 92 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 193 investigations were made in connection with applications for such grants made to metropolitan borough councils. Dangerous structures Searches were made in connection with 1,439 inquiries concerning premises scheduled as dangerous structures. Public health laboratory Full use was made of the facilities available at the Medical Research Council's 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 During the year 190 samples were taken of liquid milk arriving in London in churns 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 169 5 158 6 2.96 Tuberculin tested 17 2 15 — 11.76 do. (Farm bottled) 4 — 2 2 — Total 190 7 175 8 3.68 *Guinea pigs died before completion of test or milk curdled. As a result of the investigations into the origin of the seven positive samples, information was received that four cows from four herds producing ordinary milk had been slaughtered and in one herd no tuberculous animals were found. With regard to the two samples from tuberculin tested herds, no tuberculous animals were detected. All the raw milk from which the positive samples were obtained was pasteurised before sale to the public. 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. Reports were received on 1,420 samples taken for examination, all of which were found to be satisfactory. Dried milk Five samples of dried milk powder were taken from supplies purchased by the Council and were submitted to bacteriological examination. No sample contained more than 100,000 organisms per gram, nor was staphylococcus aureus isolated. 39 Sanitary inspection Disinfestation Reports of 200 instances of infestation, involving 350 visits and re-inspections, were received from establishments controlled by the Council, e.g. school meals centres, schools, welfare establishments, housing estates and parks. Infestations by a variety of pests including rats, mice, pigeons, cockroaches, bugs, ants, silverfish, clothes moths, furniture beetles, clover mites, wharf borers and flies were investigated and control measures proved effective. The extended use of insecticidal resins was found to be most effective, particularly in the eradication of infestations of cockroaches. A number of establishments were treated and two long standing infestations were eradicated. School meals More than 500 visits of inspection were made to school meals centres and 22 reports of illness following consumption of school meals were investigated. In no case was the meal found to be the cause of the outbreak. Welfare establishments Regular inspections, relating to hygienic conditions, of 71 homes, hostels and other welfare establishments were made at least once a quarter. 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. 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 and in connection with the preparation of plans for new buildings and the adaptation of existing premises. The plumbing experiments referred to in the Reports for 1952 and 1953 were continued and extended in association with the Architect's department and the Department of Scientific and Industrial Research. The installation of 'single stack' plumbing continued during the year and it is satisfactory to record that completed 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 fittings, drain pipes, traps, refuse chutes and refuse containers. Blind and partially-sighted persons During the year 1,820 examinations were made in connection with certification under the National Assistance Act, 1948, of blind and partially-sighted persons. In addition, 247 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 65 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. New registrations 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 (110 instances or 36 per cent. of those found with cataract as the principal cause of their defective vision) and medical treatment or hospital supervision for glaucoma (82 instances or 68 per cent.). That blindness is principally a problem associated with old age is demonstrated by the age distribution in table (i). 40 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 2 — 1 12 15 5-15 years — — — 1 1 16-64 years. 28 21 — 187 236 65-74 years 63 37 — 168 268 75 years and over 214 62 — 348 624 Age not known 2 1 — 7 10 (a) Total No. of persons 309 121 1 723 1,154 (b) No. recommended to obtain treatment 190 90 — 314 594 (b) as percentage of (a) 61.5 74.4 — 43.4 51.5 Re-examinations Persons recommended to obtain treatment are re-examined at intervals after the initial registration. The number of persons re-examined for this reason in 1956 is shown in table (ii). Table (ii) Re-examination of persons recommended to obtain treatment Principal cause of defective vision Cataract Glaucoma Retrolental fibroplasia Other conditions Total No. of persons re-examined 165 38 2 143 348 No. found to have had treatment 109 33 1 98 241 Percentage treated 661 86.8 50.0 68.5 69.3 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 69 per cent. can, on the whole, be regarded as satisfactory. As a consequence of successful treatment, 40 persons previously registered as blind were found, on re-examination, to be partially-sighted and 39 persons previously certified as blind or partially-sighted were found to be improved to such an extent as no longer to justify registration. Figures for ophthalmia neonatorum are given on page 24. During the year the Ministry of Health published, under the title 'Blindness in England 1951-1954,' a review by Professor Arnold Sorsby, M.D., F.R.C.S., of the data contained in the blind registration certificates obtained from certain local authorities including the Council. 41 Registration of nursing homes During the year one new nursing home was registered and three registrations were cancelled at the request of the keepers. At the end of the year there were 39 homes on the register with 837 beds distributed as follows: Number of beds in home Number of homes Patients accommodated Maternity† Others* Total 25 or over 9 209 225 434 20 to 24 6 25 106 131 15 to 19 6 15 85 100 10 to 14 9 35 75 110 5 to 9 7 27 30 57 Under 5 2 — 5 5 Total 39 311 526 837 †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 (60 inspections) and public health inspectors (102 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 37. Welfare Committee establishments Arrangements were continued during the year for the close medical supervision of establishments of all types under the control of the Welfare Committee. These include large and small homes for the aged and infirm, mother and baby homes, homeless families units, reception centres for persons without a settled way of living, lodging houses, homes for the blind, hostels for mothers in work, and for other persons in employment. Homeless families units At the end of the year 104 mothers and 191 children were accommodated in the four homeless families units. These units frequently presented difficult problems in the control of infection. Factors responsible included the large number of residents who had to be admitted and the fact that at all times a proportion of those admitted were careless about cleanliness and hygiene. Intestinal infections were the most difficult to control; when an epidemic of dysentery was present in London it invariably gave rise to increased incidents in the homeless families units. Whenever a case occurred, bacteriological examination of all room contacts was carried out; all who gave a positive result and all who suffered from symptoms were removed to hospital. When there were signs that infection had spread outside the ring of close contacts arrangements were made for the bacteriological examination of all residents in the unit. Special accommodation was provided for mothers with young infants. 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 children's 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. 42 Hostels for mothers in work Medical supervision was given to two hostels for unmarried mothers who go out to work during the day. Mothers were admitted to the hostels direct from maternity hospitals or from mother and baby homes and allowed to remain until the baby reached the age of eighteen months. In one hostel babies were taken by their mothers to a day nursery during the day, while in the other the babies were cared for, in the absence of the mothers, by the hostel staff. Care of the chronic sick Despite the exchange of some chronic sick for infirm persons in hospital who could not be discharged to their homes, the number of chronic sick remaining in the Council's homes at the end of the year was 688 (190 men and 498 women) an increase of 155 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 for London Invalid Meals for London provided during the year ended 30th September, 1956, 187,578 meals for 1,635 invalids and sick persons compared with 182,399 for 1,677 persons in the previous year; 162,002 of the meals were delivered to homes and 25,576 served in the dining centres belonging to the organisation. The Council made a grant in aid of ₤11,500 during the year. Welfare of handicapped persons Medical advice was given regarding the eligibility of three applicants for registration under the Council's scheme for the welfare of handicapped persons other than the blind and partially-sighted. 43 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 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. Not only have the 26 science graduates a wide collective experience but there is regular contact between the Council laboratories and the Department of Scientific and Industrial Research's research establishments and liaison with other research organisations and with scientists in the nationalised industries. With this broad basis materials are examined and claims and proved facts disentangled. 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 33,491, which exceeds by 3,156 that of the previous year. This 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 extensively in recent years and, serving as it does to give an opinion, frequently informally, on materials to be used, must tend to reduce maintenance costs appreciably. It is important that this liaison with user departments should be encouraged, for the use of unsuitable materials can be the cause of considerable replacement costs and frequently only by scientific appraisal can they be known to be unsuitable. The following sections of this report deal in greater detail with many aspects of the work done and the following table summarises the number of samples examined. Air—tunnels 260 Bacteriological, miscellaneous 83 Building materials 590 Chemicals, drugs and medical supplies 107 Clay, sub-soil and borehole waters 2,477 Detergents and soaps 126 Disinfectants 12 Fertilisers and Feeding Stuffs 87 Floor oils 87 Fuel (coal and coke) 18 Foods 366 44 Gases:— Degreasing and rubber spreading works 18 Flue 4 Sludge digestion plant 228 Insecticides 9 Instrument sets (ambulance) for sterilisation 32 Insulating materials for hot water systems 41 Lamps, gas detector 415 Laundry tests 63 Liquor (effluent from Beckton Gas Works) 357 Meals (school and nursery) 76 Metals (various) 42 Milk, liquid 39 Milk, condensed and powdered 8 Miscellaneous 96 Oils, lubricating and fuel, etc. 97 Paints, varnishes and distempers 2,041 Petroleum and allied samples 56 Plastics 17 Rain-water (atmospheric pollution deposit gauges) 84 Rubber and rubber substitutes 16 Scouring powders and lavatory cleaners 30 Sewage and effluent 2,468 Sludge, primary and digested 2,101 Sludge, activated 1,614 Smoke in air, determinations 4,359 Sulphur gases in air, determinations:— Lead peroxide cylinder method 123 Volumetric method 4,356 Water, etc., from stream raising plants 1,360 Water, drinking, chemical 49 Water, drinking, free chlorine tests 515 Water, drinking, bacteriological 562 Water, swimming bath, chemical 240 Water, swimming bath, free chlorine tests 391 Water, swimming bath, bacteriological 495 Water, river, chemical 3,101 Water, river, bacteriological 258 Water, miscellaneous 20 Trade effluents 1,890 Research and investigation samples at Northern and Southern Outfall Works 1,607 33,491 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 examination 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. 45 The flow was consistently less than 500 million gallons per day from early May until early September, and at the beginning of July it fell to 170 million gallons per day. From a survey of the analytical results obtained during the year the present position appears as follows: (a) The length of the river which was devoid of dissolved oxygen in the summer quarter was less than in the previous year. (b) At high tide the length of the river which contained sulphide on any one occasion decreased appreciably but at low tide there was little change. (c) The number of occasions when some dissolved oxygen was found off the northern outfall works showed an increase and the incidence of sulphide decreased. The suspended solids of this outfall considered as an average from daily samples showed a decrease in the summer quarter, which may well be attributed to the fact that the combined effluent now discharged contains less suspended matter than previously found in the river during periods of low fresh water flow. (d) Some general slight improvement is reported and although the increased flow during the last month of the worst period to some extent contributes to this, the substantially decreased loading from the northern outfall works due to the first stage of the work, must be having a beneficial effect. The new sedimentation plant with the present method of works operation has decreased the load on the river by approximately 70 tons of oxygen demand (B.O.D.) and 70 tons of suspended matter per day. (e) The urgent necessity for further substantial reduction of the load on the river is apparent. As the loading is decreased the zone devoid of oxygen will gradually decrease but considerable further decrease of loading is yet required before oxygen is likely to be present at all times. 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. Considerable analytical work was done on the new sedimentation tanks and as a result of the operation of this section of the new plant the suspended solids content of the primary effluent was reduced by one half and the B.O.D. (5 days) by one-third. The research work undertaken at the works included the following : (a) Investigation of flow patterns using radioactive chromium as sodium chromate and radioactive bromine as ammonium bromide. This work may have far reaching effects on the design of sedimentation tanks when the causes of the flow characteristics are ascertained. (b) In collaboration with the Chemical Research Laboratory of the Department of Industrial and Scientific Research, a process of producing sulphur from calcium sulphate 46 and sewage sludge is being investigated in a pilot plant of 50 gallon capacity and consideration is being given to extending the scale of operation. (c) Various means of treating digested sludge liquor have been examined which include: (i) Coagulation with surplus activated sludge. (ii) By diffused air activated sludge treatment. (iii) By treatment on a conditioned percolating filter. Method (i) was most successful and the details were worked out. (d) The rate of aeration of water was investigated using various spacings of 7-in. dome diffusers to obtain the most economical use of the air at selected air flows. It was found that there was a certain spacing below which the efficiency of air usage decreased considerably. (e) Miscellaneous problems examined included those connected with synthetic detergents, automatic samplers, deposits of chalk from sludge liquor, etc. A member of the scientific staff attended a month's course at the Isotope School, Atomic Energy Research Establishment, Harwell, because it is. considered that by the application of this new technique valuable information on plant performance and design can be obtained. Indeed the first stage of this development has been mentioned briefly in (a) above. Trade waste discharges 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 London County Council (General Powers) Act, 1953 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 1,890; of these 279 were considered to contravene the Act. Objectionable matter contained in quantity in various wastes included strong acids and caustic alkalis; petroleum spirit, oils, tar; cyanide from plating shops; 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; 61 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 have to be prescribed. 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 47 D and the labour charge for their application amounts to approximately ₤4 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 83 new brands were approved after test, while a further 84 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, low flexibility 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, 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 retardants, concrete, slates, asphalts 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 GeorgeV 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. The instruments in use throughout 1956 were: Seven deposit gauges for collection of matter settling from the atmosphere or washed down by rain; these deposits are anlaysed monthly. Ten lead peroxide cylinders 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, devised in the laboratory, facilitates the study of peak concentrations of pollutants, and enables detailed observations to be made covering night and weekend periods. 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 48 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 automatic sampler enabled a more detailed analysis to be made of fluctuations of pollution during the daily cycle. 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, of which the amount varies from day-to-day with changing meteorological conditions. There is also a very small proportion of such matter produced by nuclear explosions. The incidence of both of these sources of radioactivity is being measured to provide a basis for future comparisons. 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 of 19 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. Of the samples taken 562 were examined bacteriologically, 56 chemically, and 515 for free chlorine content. At three wells some degree of contamination was found in the untreated water, but chlorination ensured that all storage water delivered to the services was entirely free of contamination. A series of 15 whole day meals supplied by day nurseries were examined to ascertain that adequate standards were being maintained. 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 limits. Carbon monoxide was kept within the specified limit on most occasions at both Blackwall and Rotherhithe tunnels, but the amount of black suspended matter showed an increase in comparison with previous years. This change is attributable to the larger proportion of diesel-engined heavy vehicles now in use, which can be a prolific source of smoke unless carefully maintained and properly driven. The amount of carbon monoxide produced by the diesel engine is, however, relatively low. Other work included the examination of disinfectants, and advice was given on the methods for sterilising such various articles as recorders, plastic tableware, 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. Recommendations were made for the use of types of synthetic glues which would avoid the risk of dermatitis. 49 D* 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 83 samples examined, 20 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, 32 samples were found to come within the provisions of the Act. Visits of inspection were made to premises using inflammable solvent in licensed 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 (revoked in September 1956), 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 21 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. School meals, education and children's departments The work done in co-operation with the School Meals and Catering Department was continued and 58 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. In addition to these examinations various ingredients used for the meals were analysed. 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 The field of work for this department includes paints, fuels, lubricating oils, foods, soaps, plastics, solders, chemicals, drugs and general medical supplies and more than 3,000 samples were examined during the year. Particularly close liaison was maintained with officers of all branches of the Supplies Department and this 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. 50 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. 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. 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 plants, laundries In collaboration with the Chief Engineer's Department many plants under this heading were examined and 20 steam raising plants were regularly visited. Six softener plants and 14 hot water systems were tested periodically and 10 others from time to time. One of the particular problems on which investigation continued during the year was the growth of sulphate-reducing bacteria in hot water installations. Experiment with bactericides has showed that bacteriostatic conditions could be achieved by dosing with acriflavine at a concentration of 15 parts per million. Experiments are being continued with cheaper material. The Council maintains 19 large laundries with commercial type equipment and numerous small ones with domestic appliances. With the scientific staff available every effort is made to visit these establishments, determine the efficiency of the processes and advise on difficulties arising. Economically, this is a very important branch of the work, in view of the value of the goods involved and the damage that can be done by incorrect washing procedures. Special methods are often recommended, taking into account the circumstances, equipment available, financial considerations and staff. Miscellaneous Advice was given on a variety of other matters not included in the previous sections of the report, and the following are mentioned as examples : (a) A study was made, in collaboration with the Parks Department, of the use of tree wound dressings. Tests with trees of different genera showed that the composition recommended was effective in sealing wounds and preventing the growth of harmful organisms without having any adverse effect on the trees. (b) An investigation was continued on the protection from corrosion of underground storage tanks through their electrical connexion with blocks of magnesium metal buried in the surrounding clay. (c) Recommendations were made as to the choice and properties of materials for various purposes such as peat and soil for horticulture, chemicals for cleaning leather cloth and typewriters, heat insulating materials for boiler systems and anti-freeze solutions. The Scientific Adviser and his deputy served on a wide variety of committees and welcomed a number of distinguished visitors and organised parties to the laboratories. The staff numbered 59, and comprised 26 graduates, 28 ancillary staff, and 5 in the clerical section. 51 HEALTH SERVICE PREMISES Building programme Restriction of capital expenditure the minister of health in Circular 3/56 gave guidance on the types of health service buildings which in existing financial circumstances he was likely to be able to sanction. Although projects in the Council's health service building programme are not subject to individual loan sanctions, the Council decided, in the light of the Minister's advice, to review its programme with a view to determining which projects could be postponed. Major schemes of an estimated value of .£100,375 were deferred by the Health Committee ; in addition the divisional health committees decided not to proceed for the time being with a considerable number of works of minor improvement. Submission of annual building programmes In accordance with the procedure introduced in 1954, particulars of schemes costing more than £10,000, included in the Council's capital building programme for 1957-58 were submitted to the Minister of Health. These included two new schemes and two projects carried forward from the previous year. Six other schemes, which do not require individual approval by the Minister, were included in the programme. Particulars of outstanding schemes and of projects in the programme for the year 1957-58 are given below. Scheme abandoned A new lease was offered of the Cheyne Hospital day nursery and it was decided not to proceed with the proposal to adapt St. George's Home, Chelsea to replace this nursery. Works completed Division Premises Service Work involved 2 86 Carlton Hill, St. Marylebone Day nursery Repairs on acquisition 3 42 Richmond Avenue, Islington Maternity and child Repairs and removal of hot welfare centre and cold water system 4 96 Dalston Lane, Hackney Day nursery Repairs to structure ; ment of space heating and hot and cold water supplies 5 Rochelle Street school, Bethnal Maternity and child Adaptation of existing build- Green welfare centre ing 6 1a Wellington Way, Stepney Maternity and child Reinstatement of war dama- welfare centre ged block as offices and residential accommodation for staff 7 Queen's Road Centre, Camberwell Maternity and child Provision of new hot water welfare centre, day and heating systems nursery and Peckham general institute (Education service) 8 West Norwood welfare centre, Maternity and child Adaptation to accommodate Lambeth welfare and school school treatment centre treatment centre 8 China Walk, Lambeth Day nursery Replacement day nursery built in ground floor of block of flats - Cornwall Avenue, Bethnal Green Occupation centre Adaptation of premises Margaret day "nursery, St. Pancras District nursing Adaptation of vacant rooms for residential accommodation for nurses Upper Richmond Road ambulance Accident ambulance New building station, Wandsworth station - South Western ambulance station, Ambulance station Rebuilding of badly cracked Lambeth wall (dangerous structure) and repair of war damage Works in hand at end of year 2 Daleham Gardens, Hampstead . . Maternity and child New building welfare and school treatment centre 52 Division Premises Service Work involved 9 67 Victoria Drive, Wandsworth .. Maternity and child Completion and adaptation of welfare and school existing building treatment centre 9 37 Sister's Avenue, Battersea Day nursery .. Improvements to sanitary accommodation, heating and hot and cold water services Former Balham day nursery, Old Occupation centre Conversion to form new Devonshire Road, Wandsworth occupation centre to place unsatisfactory temporary accommodation and provide additional places Dalston ambulance station, Hack- Ambulance station Improvement of staff accomney modation Schemes approved but not commenced at end of year 2 66 Lancefield Street, Paddington Maternity and child Conversion of former day welfare centre nursery to welfare centre 8 Keeton's Road, Bermondsey Maternity and child New centre in ground floor of welfare and school block of flats treatment centre 8 Ethelm Street, Lambeth Day nursery Replacement day nursery to be built in conjunction with block of flats 9 Ashburton Estate Maternity and child New centre in ground floor of welfare and school block of flats treatment centre Schemes deferred due to financial restrictions 2 Hampstead Health Institute, Maternity and child Adaptation of existing premi- Dynham Road, Hampstead welfare centre ses 3 Basire Street (Coleman Fields), Day nursery Erection of day nursery Islington 9 Stormont Road, Battersea Maternity and child New building welfare centre South Eastern ambulance station Ambulance station Extension of existing premises to provide additional accommodation for vehicles and other improvements - Foxley Road, Lambeth Ambulance station Conversion of former fire station to provide new accident ambulance station Eastern ambulance station, Ambulance station Provision of additional Hackney covered space for vehicles North Western ambulance station Ambulance station Reinstatement of war damage Programme for 1957-58 The programme approved for submission to the Minister of Health for the year 1957-58 included the following projects: Division Premises Work involved 5 Burdett Road, Stepney Group practitioner building, later to be extended to maternity and child welfare and school treatment centre 9 Roehampton Lane, Wandsworth New maternity and child welfare and school treatment centre to be built concurrently with housing estate Shaftesbury School, Lewisham (Perry New occupation centre to replace unsatisRise) factory temporary accommodation and provide additional places - Highlever Road, Kensington New occupation centre to replace unsatisfactory temporary accommodation and provide additional places Arrangements were also made to proceed with the undermentioned schemes, which did not require individual approval by the Minister: 53 Division Premises Work involved 4 Cranston Estate tenants' clubroom, Shore- Adaptation to form maternity and child ditch welfare centre (sessional use) 6 Lionel Road, Woolwich Adaptations to provide additional dation Fulham ambulance station War damage repairs - Kingsland Road, ambulance station, Widening entrance Shoreditch - Streatham ambulance station Provision of covered accommodation - Former Knight's Hill day nursery Conversion to form hostel for tuberculous men and redecoration Day nurseries Progress was made in securing the continued availability of requisitioned nurseries and other premises held on insecure tenure. Long-term leases were negotiated in respect of three nurseries and negotiations for the lease or acquisition of ten other nurseries were proceeding at the end of the year. Seven nurseries were closed, because of reduced demand and it was found unnecessary to continue one other nursery when the lease expired. One nursery was transferred to new accommodation provided in a block of flats. Work completed Division 8—China Walk, Lambeth—This new nursery, built in the ground floor of a block of flats was opened on 25th June and replaced the St. George's Hall day nursery, Westminster Bridge Road, which was derequisitioned and returned to the owners. Closure of day nurseries Division 2—Ampthill Square, St. Pancras—This nursery was closed because of reduced demand in the locality. The upper and part of the ground floors of the building were continued in use as a maternity and child welfare centre. Division 2—Regency Street, Westminster—The lease of the nursery expired and it was found possible to admit the children to other nurseries in the locality. Division 2—Westbourne day nursery, Paddington—This nursery was closed because of reduced demand in the locality. Division 2—Queen's Parle day nursery, Paddington—This nursery was closed because of reduced demand. The building is to be converted for use as a maternity and child welfare centre. Division 1—Downham day nursery, Lewisham—These requisitioned premises were closed owing to reduced demand. Division 8—Knight's Hill day nursery, Lambeth—Peduced demand enabled this nursery to be closed and plans to be made for the building to be converted into a hostel for tuberculous men. Division 9—Clapham Common day nursery, Battersea—Owing to reduced demand for places for priority cases, it was found possible to close this nursery and to enable the site to revert to use as an open space. Division 9—Larkhall Rise day nursery, Wandsworth—This nursery was closed owing to reduced demand in the locality. Works completed Maternity and child welfare centres Division 5—Rochelle Welfare centre—This centre was established in Rochelle Street school, Bethnal Green. Adaptation was completed and the centre opened in December, 1956. It will meet the needs of the Council's Boundary Street Estate and the densely populated districts on both sides of the Bethnal Green Road. Replacements Division 3—East Islington Branch welfare centre—In September this branch centre was transferred from unsatisfactory accommodation to more suitable premises at Elizabeth House Junior Club, 6 Hurlock Street, Islington. 54 Division 3—West Islington welfare centre—This centre was transferred on 31st May from unsuitable premises at St. Luke's Mission Hall, Goodinge Road to better accommodation in the Hilldrop Estate Tenants' Clubroom where minor adaptations had been carried out to make the premises suitable for the purpose. Division 4— West Hackney welfare centre—This centre was transferred on 31st January from the Methodist Church Hall, Stoke Newington High Street which was to be demolished. A new centre was established in the West Hackney Church Hall, Evering Road. Division 7—Lee and Blackheath welfare centre—The Lee and Blackheath School for Mothers, a voluntary committee, gave up the administration of the centre at St. Margaret's Hall, Old Road, Lee, and, as from 2nd March, a new centre, administered by the Council, was established for two sessions a week at the Methodist Church Hall, Lee High Road. Division 7—Forest Hill infant welfare centre—The centre was transferred on 1st October from unsuitable premises at St. James' Church Hall, Stanstead Road to better accommodation at St. Saviour's Church Hall, Brocklev Rise. Additional centres Divisions 6 and 7—Tranquil Vale (All Saints') welfare centre—Accommodation in All Saints' Parish Hall, Tranquil Vale, Lewisham was rented for use by Division 6 for two sessions weekly and by Division 7 for one session each week. Division 7—Denmark Hill welfare centre—This centre was opened for one session a week on 1st March to meet the needs of the extensive housing development in the Denmark Hill area. A further session was introduced from 18th Tune. Centre closed Division 8—North Lambeth Babies' Care welfare centre—The voluntary committee resigned and administration of this centre at 121 Kennington Road was taken over by the Council on 1st April. The services were eventually transferred to the Moffat welfare centre, Alford House, Aveline Street as the Kennington Road premises were in such a condition that the Council could not consider taking a lease. Accommodation for district nursing association Division 4—Kingsland Road welfare centre—Adaptations were carried out to provide suitable accommodation to be leased to the Shoreditch and Bethnal Green district nursing association. Occupation centres for the mentally defective Information about premises used as occupation centres for the mentally defective will be found on page 96. Additional centre Greenwich (Elder girls) occupation centre—This centre was opened in Rothbury Hall, Azof Street, Greenwich to accommodate elder girls from Greenwich Junior and Brockley centres and to help to meet the demand for additional places. Replacement centres Bethnal Green occupation centre—The Council's freehold premises in Cornwall Avenue, Bethnal Green, formerly used as a maternity and child welfare centre, were adapted for use as an occupation centre for junior pupils and elder girls. The work had been completed at the end of the year. The centre will replace unsatisfactory accommodation at Oxford House, Mape Street, Bethnal Green (junior centre) and Old Gravel Pit Hall, Hackney (elder girls) which were closed at the end of the autumn term. Heme Hill occupation centre—The Methodist Church Hall, Half Moon Lane, Camberwell was brought into use as a junior mixed centre to replace unsatisfactory accommodation. Hostel for mentally defective girls under guardianship. Dover Lodge, Wood Vale, Camberwell—A number of minor improvements were made at the hostel, including the provision of a laundry and a cloakroom in the basement. At the end of the year work was in progress to extend the heating system to serve these rooms. 55 Work completed Clinic reopened School health service Division 8—West Norwood welfare centre, Lambeth—Adaptations were completed to accommodate a school treatment centre in the building. Division 1—Westbourne Grove Clinic, Kensington—This centre, which had been adapted as a dental clinic but had not been used pending the appointment of a dentist, was opened in July. 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 acquisitions were completed during the year. Division Property Interest obtained Service 1 112-124 (even) Palling Road, Freehold Day nursery Hammersmith 2 41 Brunswick Square, St. Maryle- Leasehold Day nursery bone 20 New End Square, Hampstead Freehold Maternity and child welfare centre 69 Flask Walk, Hampstead Freehold Maternity and child welfare centre 6 Mottingham Ambulance station Leasehold Ambulance station (site) 8 Cowley day nursery Hutted buildings ac- Day nursery quired 21-29 (inclusive) Stevens Street, Freehold Day nursery Bermondsey 3-10 (inclusive) Whitstable Street, Freehold Day nursery Bermondsey 65 Sancroft Street, Lambeth Leasehold Home nursing 9 21 and 27 Summerley Street, Freehold Day nursery Wandsworth ' Southlands ', Shuttleworth Road, Ministry of Health Maternity and child welfare Battersea apportionable in- centre terest 56 CARE OF MOTHERS AND YOuNG CHILDREN Administration day to day administration of the services is the responsibility of the nine divisional health committees and during the year members of the committees regularly visited health establishments in their areas. The reports of the individual divisional medical officers are given in the section which commences on page 131. Maternity and child welfare centres Details of changes in centres during the year will be found in the section on health service premises, page 54. Expectant and nursing mothers Forty-four per cent of all women needing ante-natal care attended at an ante-natal clinic and made an average of five visits. This percentage has remained comparatively constant for several years. Statistics relating to ante- and post-natal and educational sessions are given in the following tables : Year Ante-natal Post-natal Clinics at end of year (including ante-natal, post-natal, and combined) Sessions per month Attendances Percentage of pregnant women attending at an ante-natal clinic No. of women attending during year First Total 1952 118 906 21,959 145,088 41 4,501 1953 119 986 22,713 129,451 44 4,062 1954 120 920 23,204 126,270 45 4,489 1955 118 846 22,231 116,042 43 4,258 1956 116 805 23,379 122,662 44 4,543 Of those who received ante-natal care 18 per cent. attended the centres for post-natal examinations in 1956. Most mothers who have intermediate ante-natal care at the Council's centres, but who have booked a hospital bed for the confinement, return to the hospital for post-natal examination. Many general practitioners called in to give medical aid to mothers confined at home, complete their attendance by giving the postnatal examination. These factors account in part for the low attendance rate at post-natal clinics, which has remained at the same level since 1953. It is recognised that some multiparae are apathetic or find it difficult to attend and in an attempt to raise the level attendances, many post-natal and ante-natal sessions are combined. Domiciliary midwives in the Council's service are now responsible for seeing that the mothers attend for post-natal examination either by their doctor or at the centre. Follow-up visits are paid by domiciliary midwives to mothers who fail to attend. Tests Expectant mothers are offered a full range of blood tests at the clinics, and chest X-ray through the mass X-ray service. Facilities for all clinical tests are available for doctors giving maternity medical services whether the mother is given ante-natal care at the centre by the midwife or not. Blood is taken for Wasserman and Kahn reactions, and Rhesus state. Tests are made for antibodies at about the 32nd week of pregnancy, specimens being sent to the hospital laboratories or to the Blood Transfusion Service. Every mother is given a card showing her blood test results, Rhesus state and blood grouping. Haemoglobin levels are estimated 57 Mother-craft training at the first visit and repeated about the 30th to 32nd week of pregnancy, and further readings are made when the level is low and iron therapy has been given. Residential facilities for the treatment of infant feeding difficulties are provided at the Violet Melchett welfare centre, a voluntary organisation providing services on behalf of the Council under section 22 of the National Health Service Act, 1946. Comparative figures are : Mothers Accompanied children Unaccompanied children 1955 56 59 75 1956 51 57 63 Clinics The North Islington infant welfare centre, maintained by a voluntary organisation also providing services under section 22, continues to afford similar but non-resident facilities. The tables on pages 57 and below show attendances of the various types held at maternity and child welfare centres. An average of 342 sessions a week were being conducted at the end of the year by medical officers employed on a sessional basis. Voluntary organisations Maternity and child welfare services were provided by 17 voluntary organisations by agreement with the Council under 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 grantaided by the Council. Family planning Family planning advice was provided for women for whom further pregnancy would be detrimental to health. Seven weekly sessions were held by the Council but in areas where those facilities were not provided the services of the Family Planning Association were obtained and per capita payments made to the association. 797 women were referred to the Association's clinics in 1955 and 729 during 1956. At the end of the year 35 weekly sessions were being held by the association, some in the council's centres where accommodation was made available without charge. Toxaemia of pregnancy The Council has been represented by divisional medical officers and non-medical supervisors of midwives at the series of meetings convened by Boards of Governors and Hospital Management Committees of professional representatives from the three parts of the National Health Service to discuss professional issues raised in the memorandum of advice from the Standing Maternity and Midwifery Advisory Committee in regard to ante-natal care related to toxaemia. The meetings had not been completed by the end of the year. Discharge of mothers and babies from hospital The form provided by the Council to hospitals with maternity units for notifying the discharge of mothers and infants was revised. Upon receipt of the notification, which includes information about feeding, the divisional medical officers arrange for health visiting and other personal health services to come into play and the chief amendment of the form was to facilitate wherever desired the passing of the information to the family doctor by the hospital in the same clerical process. Child welfare Year Clinics at end of year (includspecial clinics for 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 Toddlers First Total First Total 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 1956 178 1,953 44,910 595,690 4,492 189,388 41,055 86 58 The preceding table gives details of the child welfare clinics provided and of attendances recorded during the year and comparable figures for the previous four years. The percentage of infants who are brought to a centre at least once in the first year of life has remained constant at 86 for the past three years. Cards are sent to parents on children's birthday anniversaries inviting them to sessions especially for toddlers. Mental health education in the maternity and child welfare service A departmental committee was set up in 1955 to advise on general development or mental health education in the field of maternity and child welfare. The committee has received reports from the divisional medical officers on the work of case conference groups which have now been established in Divisions 1, 2, 4, 7, 8 and 9. Doctors and health visitors from two groups met the committee for discussion on the progress of their training. Through the co-operation of hospital authorities each case conference group is led by a child psychiatrist, and has developed in its own way under his guidance, within the framework of the general scheme. Medical officers have been for the most part permanent members of their groups but there have been frequent changes in health visitors—but the groups have continued to work as coherent units. Training groups have had to be integrated into the general pattern of the work of the divisions. This has been facilitated in at least two divisions by the inclusion in the group of a senior member of the divisional medical staff who has taken an active part in assisting in the administrative problems which inevitably arise. After two years' experience none of the groups is yet ready to work without the constant support of the psychiatrist and further expansion can come only through the establishment of additional groups. A course of advanced training in the study of parent-child relationships has been given at the Tavistock clinic for medical officers who have had experience of work in case conference groups. Three divisions have held broad educational courses to which a wide range of staff from the Public Health and Children's Departments was invited. These courses consisted of 2-4 sessions, and took the form of discussion groups. Maternity services A summary is given below of the written evidence, which was submitted to the Departmental Committee of Enquiry into the Maternity Services (Cranbrook). Supplementary oral evidence was given on particular points : (i) Although any fixed proportion of hospital to domiciliary confinements is not advocated, a reduction of the time that the mother stays in hospital is not favoured, the need is emphasised for the hospitals to consult the local health authority whenever admission to hospital on social grounds is under consideration. (ii) The domiciliary midwifery service should remain the responsibility of the local health authorities. (iii) Ante-natal clinics, including mothercraft and health education, should remain the responsibility of the local health authorities and ante-natal care, including interim ante-natal care of women booked for hospital confinements, should be undertaken at the local health authority clinic. (iv) Consideration should be given to the possibility of every woman who is to have a domiciliary confinement booking a general practitioner obstetrician to provide her with maternity medical services and the general practitioner obstetrician so booked should be encouraged to use the local health authority clinic. (v) There should be a stricter standard for admission to the general practitioner obstetrician list and every general practitioner obstetrician should have as a deputy another general practitioner obstetrician. (vi) More use should be made of the local health authority clinics for clinical teaching purposes. 59 Drugs, medicaments, welfare foods, etc. Drugs and medicaments (provided free), and nutrients (at fixed charges, abated where necessary) continued to be supplied on medical recommendation at the welfare centres in accordance with approved lists. During 1956 the local distribution of national welfare foods taken over from the Ministry of Food in June, 1954 was further combined with the work of the maternity and child welfare centres. A number of sales points continued to be provided by the Women's Voluntary Services, and this and other voluntary help was much appreciated. The following table gives comparative figures of issues during 1955 and 1956 : Welfare food Average weekly issues 1955 1956 National dried milk (tins) 26,515 25,413 Cod liver oil (bottles) 7,100 6,156 Vitamin tablets (packets) 2,877 2,952 Orange juice (bottles) 45,838 48,163 Amenities funds Small voluntary committees administered funds for the purposes of additional amenities for mothers and children attending welfare centres and day nurseries. The voluntary committees received contributions from Sunday cinematograph entertainments as in previous years. Marriage guidance Financial aid by the Council towards the case work of three marriage guidance organisations continued in 1956. With the consent of the Minister of Housing and Local Government under section 136 of the Local Government Act, 1948, grants were approved totalling .£5,500 for the year ending 31st March, 1957, to the London Marriage Guidance Council, the Catholic Marriage Advisory Council and the Family Discussion Bureau. In November, 1956, the Council urged the early adoption of the recommendation of the Royal Commission on Marriage and Divorce that local authorities should be enabled to make contributions, without ministerial consent, to agencies engaged in matrimonial conciliation and that expenditure should rank for Exchequer grant at a rate not less than 50 per cent. The Council suggested that such contributions should be made under Section 28 of the National Health Service Act, 1946. A resume of the extent of the work of the three organisations referred to in the preceding paragraph was given in my report for 1955. In October, 1956, the Family Discussion Bureau changed from the sponsorship of the Family Welfare Association (which established the Bureau in 1948) to that of the Tavistock Institute of Human Relations, and a closer link with the mental health services as a whole was thereby formed. Day nurseries The number of maintained and grant-aided day nurseries and the number of places provided at 31st December, 1956, and a comparison with the previous year are shown in the following tables: Number of day nurseries at 31st December. Total MAINTAINED GRANT-AIDED 1955 94 5 99 1956 86 5 91 Number of places provided at 31st December. Age-group Maintained Grant-aided Total 1955 1956 1955 1956 1955 1956 0-2 years 1,853 1,725 50 50 1,903 1,775 2-5 years 3,523 3,214 154 154 3,677 3,368 5,376 4,939 204 204 5,580 5,143 60 The Council's day nurseries provide for children whose families fall into either the first or second categories of a scheme of priorities. When the needs of these two categories have been met any places which remain unfilled are available for those in a third category but the Council does not take into consideration the third category when determining the need for day nursery accommodation. The first priority covers children who have no mother or whose mothers are ill or are the sole providers in the home, and children whose health might suffer through environmental factors (including poor housing) if not admitted to a day nursery. The second priority provides for children whose mothers are obliged to work because the father is unemployed or earns insufficient to maintain a home. The third priority provides for children whose mothers go to work but the father's income is higher than the amount which qualifies for the second priority. Excessive provision is avoided by closing or amalgamating nurseries when the level of attendances justifies such action and during 1956 nine maintained day nurseries were -closed in pursuance of this policy or because the premises were no longer available. A replacement nursery of 40 places was opened and the accommodation at another maintained nursery was increased by ten places. The net reduction of places was 437. Two training nurseries were among the nurseries closed and another was reduced to non-training status. The number of training nurseries at the end of the year was 53 (51 maintained and two grant-aided). The provisions allowances for children and staff were increased as a result of a review of dietary scales and laboratory analysis of sample meals. Occasional creches In agreeing to a programme prepared in 1955 to establish 27 additional creches providing 53 sessions a week (which would make a total for the County of 34 creches providing 75 sessions a week) the Minister of Health did so on the understanding that the whole cost—or practically the whole cost—would be recoverable in charges to parents. After twelve months working of the programme 12 of the 27 additional creches had been provided but due to low occupancy coupled with the number of free attendances they were not self-supporting, little more than half the running costs being recovered in charges. The Council considered, however, that the creches had proved to be of real value to mothers having to visit hospitals or needing occasional relief of the care of their children whilst they attended to shopping and other domestic duties as well as to others living in poor home conditions. The creches had also helped some children with mild behaviour problems. It was thought that if active steps were taken to make the service better known to mothers attendances might improve and it was decided that although no more occasional creches should be opened the service should be continued pending a further review. The majority of the creches have accommodation for 20 children at each session. Except in special circumstances attendances for a child at a creche are limited to two sessions a week. No charge is made when a child is left in a creche whilst the mother is attending a clinic or class held by the Council in the same premises. Otherwise a charge of 1s. 3d. a session (raised to 1s. 9d. in 1957) for each child is made. The charge is waived or abated in cases of need. An indication of the extent of the scheme during the twelve months to 31st July, 1956, may be seen from the following figures : Total number of creches 19 Total number of places 350 Total number of sessions held 2,330 Total number of attendances : Free attendances 6,325 Full fee paid 18,825 Abated fee 207 25,357 61 Gross cost of service : Staff, equipment, heating, lighting, etc. £2,242 Less fees received 1,177 Net cost of service £1,065 Nurseries and Child-Minders Regulation Act, 1948 The number of private day nurseries registered under the Act and the number of places provided, as compared with 1955, were: At 31st December 1955 1956 Private day nurseries statutorily registered 56 58 Places provided 1,640 1,646 The number of child-minders, both statutorily and voluntarily registered, as compared with 1955 was: At 31st December 1955 1956 Child-minders statutorily registered 106 102 Children minded 649 611 Child-minders voluntarily registered 743 777 Children minded 851 886 Child-minders who, for reward, look after more than two children—other than relatives—under the age of five years from different households are required to register under the Act. Those who are not required to register under the Act are encouraged to register voluntarily and they receive a small weekly payment in return for which they accept supervision by the Council and allow their homes to be inspected. Medical supervision Residential establishments for young children The Medical Officer of Health advises the Children's Officer on the health and hygiene of children in London County Council residential establishments. A visiting medical officer is appointed to each nursery to carry out routine medical examinations and immunisation. Children and staff are taken on his list for general medical services. On appointment all staff in the nurseries have an X-ray of the chest which is repeated annually in most instances. A consultant psychiatrist visits the residential nurseries to give guidance to the staff on the mental health of the children. She advises on individual children showing signs of emotional disturbance. Those children who require psychiatric treatment are referred to the local child guidance clinic. No serious outbreaks of infectious disease occurred in the nurseries although small numbers of children developed measles, Sonne dysentery and winter vomiting during the periods in which these infections were prevalent in the general population. There was a mild outbreak of food poisoning at one nursery, which affected 38 children and 12 members of the staff. The cause was Cl.Welchii which was found in minced meat which had been reheated for dinner. Central medical staff visit private residential nurseries where children are placed by the Children's Officer. Arrangements are being completed for routine medical examinations of children by a visiting medical officer and staff are encouraged to accept annual X-ray examination. Adoption and boarding-out Children who are to be boarded out, with or without a view to adoption are medically examined by the visiting medical officer or family doctor. Prospective adopters may be interviewed by a medical officer where the family background or 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. 62 503 (566) children were referred by the Children's Officer for opinion as to their suitability on medical grounds for adoption or boarding out. Four (2) children were considered unfit and the remainder were grouped as follows : (?) Referred for adoption : 173 (185) (a) Fit for adoption 147 (158) (b) Fit for adoption subject to certain provisions 7 (7) (c) Unfit for adoption but fit for board- ing-out 15 (14) (d) Cases still under consideration 3 (4) (e) Withdrawn by Children's Officer 1 (2) (2) Referred for boarding-out: 326 (379) (a) Fit for boarding-out 324 (375) (b) Withdrawn by Children's Officer 2 (4) The figures in brackets are those for 1955. Child life protection By arrangement with the Children's Officer responsibility has been continued for duties under Part XIII of the Public Health (London) Act, 1936, as amended by Part V of the Children Act, 1948. The visiting of foster children and the inspection of premises in which the children are living is undertaken by health visitors designated as ' child protection visitors'. At the end of the year, 661 children were being supervised under these arrangements as compared with 647 at the end of 1955, 663 receptions and 613 removals being notified during 1956. General arrangements Voluntary mother and baby homes Care of the unmarried mother and her child Accommodation for unmarried mothers in mother and baby homes is provided mainly by voluntary organisations. The Welfare Committee has one mother and baby home and pays under the National Assistance Act, 1948, for individual girls accommodated in homes maintained by the voluntary organisations. Grants-in-aid for the maintenance and upkeep of voluntary mother and baby homes are paid by the Council under Section 22 of the National Health Service Act, 1946. In 1956, 19 homes received these grants, the total payments amounting to .£10,755 compared with £11,048 for 20 homes in the previous year. Each of these homes was visited by medical officers of the Council at least twice during the year to ensure that satisfactory standards of diet, staffing and accommodation were maintained. The Medical Officer of Health is represented on the committees of these voluntary homes in London by divisional medical officers. Mothers are encouraged to attend child welfare centres while they are resident in the homes and regular calls are made by health visitors who follow-up the baby on discharge. During 1956, the expectant or nursing mothers admitted to these 19 homes totalled 1,308, about 85 per cent. of whom were referred by moral welfare workers. Moral welfare associations Under Section 22 of the National Health Service Act, 1946, the Council paid grants totalling £9,625 (£9,525 in 1955) to the five large moral welfare associations of the major religious denominations. These five associations employ between them 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. During 1956, a total of 2,908 expectant or nursing mothers applied for assistance to the welfare workers of these associations ; the comparable figure for 1955 was 2,429. Annual moral welfare conference For some years a conference has been held at the County Hall of representatives of the grant-aided moral welfare associations and other voluntary bodies controlling mother and baby homes in London, when the work of the previous year has been reviewed. Problems discussed at the 1956 conference included : (a) the need for the associations' workers to urge unmarried expectant mothers to seek early ante-natal care. There has been considerable evidence that a very large 63 e number of them had little or no ante-natal care, other than blood tests, before admission to a mother and baby home ; (b) the difficulties experienced in providing sufficient help for the increasing number of Jamaican girls with illegitimate children. Many were in debt for their fares from Jamaica or contributed towards the keep of children which they had left in that country and in consequence were unable to pay foster-parents to care for the children they had in this country. They were reluctant to take court proceedings for affiliation orders because of their fear that such action jeopardised their chance of later marriage. Few of the girls would agree to repatriation as most of them considered that their children had a much better chance of education and employment in this country. 64 General and staffing DOMICILIARY MIDWIFERY SERVICE 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 (92), midwives employed by district nursing associations (46, including supervisory staff) and district midwives employed by hospitals. At the end of 1956, 13 hospitals had 44 district midwives. The rate of payment to hospitals providing midwifery services on behalf of the Council was increased on 1st April, 1956 from £10 10s. Od. to £13 4s. Od. for each confinement. Payments to the district nursing associations were made in the form of block grant (93 per cent.) for both midwifery and home nursing. Service organisation The service which is centrally administered is supervised by tour non-medical supervisors. The Council's and the district nursing associations' midwives work in close association with health visitors who, in the main, are responsible for the teaching of hygiene in pregnancy and mothercraft. All the Council's midwives and those of the district nursing associations carry out ante-natal examinations of mothers at the clinics and, in addition, at least three home visits are made. A number of midwives attend the surgeries of general practitioners and, where this arrangement has not been made, co-operation between general practitioner and midwife is secured by personal contact supplemented by the interchange of written information. Many meetings have been held in the County to consider the proposals of the Minister of Health in his circular (9/56) on ante-natal care in relation to toxaemia, at which the divisional medical officers represented the Medical Officer of Health. Opportunity was thus given for discussion of problems relating to toxaemia and, as a result, co-ordination between hospital, general practitioners and local health authority services has been improved. All mothers having a home confinement are weighed regularly ; each is seen by the clinic doctor at 30 weeks, in addition to initial and 36th week examinations, and routine blood tests are carried out by the blood transfusion service or at hospital laboratories, including initial and 30th week haemoglobin estimates. Rhesus negative mothers without anti-bodies at the 34th week may be confined at home and in these cases routine cord blood tests are carried out in most parts of the County. The midwives' record card has been redesigned so as to avoid the necessity of duplicate records being made by the midwife and her relief. The card is now printed in two sections, one of which can be left at the patient's house during the puerperium. Midwives are responsible for securing the mother's attendance for post-natal examination and follow-up visits are made to the mother who fails to keep her appointment. Attendances for post-natal examination are, however, still too low. Analgesia All midwives now carry inhalers for the administration of ' Trilene The service for providing ' Minnitt' apparatus by ambulance is also maintained so that the form of inhalation analgesia given to the mother can be based on clinical judgment of the case. During 1956, inhalation analgesia was administered to 84 per cent. of mothers delivered at home, an increase of 3 per cent. as compared with 1955. Premature babies 509 babies weighing 5½ lb. or less were born to 475 mothers during 1956. There were 65 sets of twins which included 78 premature babies. 389 babies weighed over 4½ lb. and 120 weighed between 2 lb. and 4½ lb. 354 premature babies were nursed at home. There were 11 neo-natal deaths in this group and 343 were discharged well. Still-births Of 10,247 babies born there were 90 still-births (52 fresh and 38 macerated) during the year, a rate of 8.8 per thousand births. Among the ascertained causes were : Prematurity 36 Congenital defects 16 Post Maturity 1 Breech presentation 3 Prolapse cord 3 Impacted shoulders 3 Bilateral adrenal haemorrhage 1 65 E* Ten were emergency deliveries where the patient had had no ante-natal care and at 5 of these a doctor was present at the delivery. A doctor was present at the delivery of 49 still-births, 33 of which were fresh. Neo-natal deaths 38 neo-natal deaths were recorded in the first week of life and of these 18 died at home and the remainder in hospital. 33 of the babies were premature and 12 had congenital defects. Peri-natal mortality rate The record of neo-natal deaths is incomplete because of transfers to hospital. The total number of still-births and deaths in the first week of life was 132, a perinatal mortality rate of 12.9 per thousand births. 70 of the babies were premature and 28 had congenital defects. Intra-gastric oxygen The Central Midwives Board has agreed that the administration of intra-gastric oxygen is a proper function of the midwife, provided that she has been trained in its use. During the year twelve sets of intra-gastric oxygen resuscitation apparatus were purchased as an experiment for use by the Council's midwives in the treatment of asphyxia of the new born. A demonstration of the use of the apparatus was given at the British Hospital for Mothers and Babies to a group of the Council's midwives and in October the sets were distributed. The apparatus issued is light and readily portable in a pocket in the side of the delivery bag. Experience in the use of the apparatus has proved encouraging and sets will be issued to all the Council's midwives as soon as training courses have been completed. District training for pupil midwives Approximately 70 per cent. of the Council's midwives are approved by the Central Midwives Board as teachers under the Board's second period training scheme. Many of the pupils are resident with the midwife teacher, others remain in hospital and go out with the midwife on call. The district midwifery home of the General Lying-in Hospital in South London has been rebuilt and four pupils in training there have their district experience with the Council's midwives. Total number of domiciliary confinements attended by London County Council, Hospital and Nursing Association midwives—1954-1956 Number of confinements Number of confinements Doctor not booked Doctor booked Year 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 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 1956 193 3,500 68 1,790 25 1,944 847 1,293 134 197 103 148 10,242 It will be seen from these statistical tables that there was a slight increase in the number of domiciliary confinements during 1956. Of the total of 10,242, a doctor was booked to give maternity medical services in 2,722 cases but in only 1,084 (less than 50 per cent.) of these was the doctor present at the confinement. In the remaining 7,520 in which no doctor was booked, a doctor was called to attend the confinement in 286 cases. 66 Notification of intention to practise. Midwives Act, 1951 Notifications of intention to practise were received as follows : 1952 1953 1954 1955 1956 As midwives 1,331 1,171 1,142 1,193 1,164 As maternity nurses 232 175 168 150 144 Refresher courses In addition to the statutory requirement to attend every 5 years a refresher course approved by the Central Midwives Board, all midwives were offered a lecturedemonstration course of six lectures at County Hall. These courses which were open to all midwives who had notified their intention to practise in London and Surrey were attended by 321 midwives. Fifty-six midwives also attended a course in natural childbirth by Dr. and Mrs. Grantlv Dick Read, arranged by the Central Council for Health Education. Fees to medical practitioners Fees paid under the Midwives Act to medical practitioners called in by midwives in emergency were as follows : 1952 1953 1954 1955 1956 Number of claims 3,135 3,044 3,003 2,682 2,554 Amount £9,491 £8,662 £8,935 £7,948 £7,503 67 The use of the service is shown in the graph on page 71. 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 19,435. This compares with 20,042 in the corresponding quarter of 1955, and 21,570 in 1953 when there was an influenza epidemic. The Council provided cars on loan to some district nursing associations who needed them but were unable to purchase them from their own resources. The Council licensed, insured and periodically overhauled the cars, but running costs were borne by the associations and ranked for grant. At the end of the year 23 cars were in use by district nursing associations under this arrangement. In addition, the payment of mileage allowance to nurses who used their own motorised vehicles on official duties was recognised for grant purposes in approved cases. During the year two meetings were held between officers of the Public Health Department and representatives of the Central Council for District Nursing, at which matters of mutual interest were discussed. Refresher courses The Council has agreed to give a five-day refresher course every five years to all district nurses employed in London. Places are taken for courses run by the Queen's Institute of District Nursing, the Ranyard Nurses, and the Royal College of Nursing. In October, 1956, the Council held a course for 30 nurses at the County Hall. The course included lectures on poliomyelitis, the home treatment of and social services for tuberculous and diabetic patients and demonstrations of the lifting and handling of patients. Visits were paid to a hospital geriatric unit and to a children's hospital. Superintendents and assistant superintendents of district nursing associations also attended approved residential courses. Close liaison was maintained between district nurses and their colleagues in the field in other parts of the personal health services and district nurses attended informal meetings, discussions and talks which were arranged by the divisional medical officers. The district nursing associations play their part in giving student nurses from hospitals an insight into the home nursing aspect of public health nursing. 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. Since January, 1953, the Council undertakes responsibility for the supply of large and expensive items of equipment and all loan equipment needed for tuberculous patients, as the voluntary organisations experience difficulty in purchasing and storing such items, and maintaining the extensive stocks required for long-term loans. Requests for lifting apparatus to assist the district nurses in the treatment of handicapped patients continued to be made in increasing numbers. Close liaison is maintained with the Council's Welfare Department on the question of the supply of home nursing equipment for the handicapped. A deposit and small charge, varying from 3d. to 1s. per 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. 70 HEALTH VISITING AND NURSING SERVICES the average strength of the health visitor service available during the year tor health visiting duties, apart from the tuberculosis and school health services, was equivalent to 367 full-time units. In addition to clinic and other duties these health visitors made 811,952 home visits. Home visits 1953 1954 1955 1956 Expectant mothers— First 24,608 24,739 22,999 23,143 Revisit 19,223 19,428 19,436 21,422 Per cent. of notified live- and still-births 47 47 45 44 Still-births 1,256 1,253 1,032 1,173 Children under 1— First 48,381 49,381 48,225 51,960 Revisit 173,309 182,295 174,864 173,774 Per cent. of live-births 95 97 97 100* Children 1 to 5 376,153 377,130 362,764 357,215 Care of old people 65,450 63,764 77,014 12,842 Miscellaneous 66,823 Unsuccessful 124,124 118,155 110,149 103,600 TOTAL 832,504 836,145 816,483 811,952 * The true percentage is somewhat less, but it is not practicable to exclude from the year's figures a small number of immigrants and of children visited in 1956 but born in 1955. Included in the figures given in the above table for 1956 there were 3,426 visits to premature babies, and 18,777 visits to problem families. The continuing national shortage of health visitors has led to redeployment of staff to ensure that the health visitor is able to use her special skills to the greatest advantage. Selective visiting has enabled the health visitor to allocate more time to the families most in need of the help and support which she can give them. Group working by health visitors enables problems to be shared and makes it easier to meet language or religious difficulties and ensures continuity when staff are absent through sickness or annual leave. Home visiting and medical follow-up of children attending the Council's schools has for the last forty-nine years been undertaken by voluntary children's care committee workers, trained and organised by social workers employed in the Education Officer's and public health departments. To an appreciable degree the health visiting service has been integrated with the school nursing service. In December 1954, 275 members of the staff were engaged on combined health visiting and school nursing duties. In 1955 and 1956 the figures rose to 283 and 327 respectively. This is a continuing aim as is the closer association of health visitors with voluntary workers in the care of school children. Tuberculosis visitors Training of student health visitors Details of the duties and work of the Council s tuberculosis health visitors are described in the report on tuberculosis on page 26. Details of the Council's scheme for training student health visitors are given on page 127. 68 HOME NURSING IN THE ADMINISTRATIVE COUNTY OF LONDON 71 HOME NURSING SERVICE the home nursing service was provided, as hitherto, by 26 voluntary district nursing associations 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. since 1954-55. The number of staff employed at the end of 1956 was as follows : Total number of nurses employed, whole-time and part- time 584 Full-time equivalent of nurses employed 538 Number of trained district nurses 327 Number of state enrolled assistant nurses 35 Number of male nurses 38 Twelve district nursing associations undertake district nurse training. The total number of visits paid was 1,962,733 (1,953,182 in 1955) giving a daily average of thirteen visits for each nurse. Of the total visits 871,973 were paid by nurses for the sole purpose of giving injections, and 131,302 for injection and other treatment at the same visit. There were in addition, as a result of encouragement given to ambulatory patients to attend at centres, 32,694 such attendances for injections only, 32 for injection and other treatment at the same attendance, and 189 for purposes other than injection, e.g., dressings. The average case load of a nurse at any one time was 24 (24 in 1955). Treatments completed totalled 60,772 (64,256 in 1955), and there were 12,806 patients being nursed at the end of the year (12,535 in 1955). The completed treatments related to the following conditions : Number Percentage of total Respiratory disease 14,952 24.60 Heart and arteries 8,427 13.87 Skin 5,560 9.15 Digestive diseases 4,574 7.53 Genito-urinary 3,126 5.14 Ear, eye and other sense organs 2,933 4.83 Cancer 2,450 4.03 Diabetes 1,681 2.77 Cerebral lesions of vascular origin 1,616 2.66 Tuberculosis 1,602 2.64 Bones and joints 1,494 2.46 Injuries 1,259 2.07 Veins and other circulatory diseases 1,184 1.95 Pregnancy 858 1.41 Mental and other nervous diseases 816 1.34 Infections and parasitic diseases 732 1.20 Other diseases or ill-defined 7,508 12.35 These patients were referred to the nursing associations by : Number Percentage of total General practitioners 48,293 79.46 Hospitals 10,506 17.29 Direct application 934 1.54 Chest clinics 730 1.20 Public health authorities 309 0.51 Taking both sexes together, 43 per cent. of all patients whose treatment was completed were 65 years of age and over (41 per cent. in 1955). Children under the age of five years accounted for 5 per cent. of the total (6 per cent. in 1955). 69 DOMESTIC HELP SERVICE under section 29 of the National Health Service Act, 1946, a domestic help service is provided to households requiring help because of the presence of any person who is ill, lying-in, an expectant mother, mentally defective, aged, or a child not over compulsory school age. The number of cases assisted fell slightly during the year, but the growth of the service in terms of hours worked and home helps employed is illustrated by the following figures : 1954 1955 1956 Cases assisted 32,503 34,785 34,557 Hours worked 4,601,168 4,660,600 4,779,600 Home helps employed at end of year 3,124 3,148 3,326 Equivalent of wholetime staff 1,992 2,029 2,089 The consistent pattern of cases assisted is shown by the percentage figures for the last three years : 1954 Per cent. 1955 Per cent. 1956 Per cent. Aged and chronic sick 77 80 79 Maternity 5 4 5 Tuberculous 4 3 3 Others 14 13 13 The proportion of aged and chronic sick requiring help remains high and if old people are to continue to be cared for in their own homes its provision must be regarded as an essential service. Service is supplied as far as possible to all those in need but this year 76 applications had to be deferred or refused because home helps were not available, as compared with 61 in 1955. In addition to the ordinary service to households during normal working hours special services are provided as described below. Night helps Night helps who sit in with chronic sick patients in their own homes are provided for a maximum of two nights a week to enable relatives to have some relief. They attend normally from 11 p.m. to 7 a.m. and carry out such duties, except nursing, as would be undertaken by the patient's family. The demand for this service was not high, 37 new applications having been met (48 in 1955). Child helps The supply of a home help may often help to avoid the need arising for receiving children into care, but this did not always go far enough. The scheme was extended and under it a resident home help may look after a child or children temporarily deprived of the care of both parents (e.g. where the mother is in hospital and the father does night work) and where no other adult is available at night. In exceptional circumstances, and where paid employment has been given up for the purpose of undertaking the work, relatives of children may be employed as child helps and neighbours or friends nominated by the parents may be employed for these specific assignments. The employment of relatives and friends or neighbours is subject to the Council's normal conditions of service. The use of the resident help service was low, only 5 families (20 children) were helped during the year under this scheme. The figures for 1955 were 5 families (16 children). Early morning and evening help Where children had to be cared for during the day-time only, 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 180 new families, as compared with 205 families in 1955. 72 Special home helps A short training course has been given to selected home helps to enable them to work with health visitors in the homes of families in danger of break-up. The aim is to 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. The training of selected home helps was undertaken in two periods. During the first period 49 were trained and were ready to undertake their special duties by 1st May. During the first 6 months of the scheme (from 1st May), 49 families (involving 212 children) received the special help, the service given ranging from 1 hour to 8 hours a day. When a measure of improvement becomes apparent, the amount of service given is gradually reduced, so that the mother may progressively accept more responsibility for the running of the home. Not all of the home helps were given assignments during the first 6 months and some attended more than one family. In all but 7 cases no difficulty was experienced in obtaining the entry of the home help for her special duties. Some improvement was noted in 44 families helped. The scheme has been in operation too short a time to assess its value, but experience of the first 6 months' working is encouraging. Throughout, the closest liaison has been maintained between health visitors, home help organisers, special home helps and, where appropriate, school care committees. Review of service In June a working party, composed of officers of the public health department, began enquiries into the home help service under the following terms of reference : ' To review the domestic help service and to make recommendations as would appear to be both practicable and desirable, having particular regard to : (i) comments on the service made in the report of the Reviewing Committee of the work, organisation and staffing of the Public Health Department, and (ii) the report on the subject by the field workers of the Director of Establishments' Branch of the Clerk of the Council's Department.' By the end of the year the working party had completed their investigations, which included visiting the 31 home help offices in the county, and their report published in February, 1957, was subsequently approved by the Council. The recommendations of the working party were mainly directed to ensuring greater uniformity in standards of service throughout the county by way of strengthening divisional supervisory arrangements and holding more frequent meetings of home help organisers and other officers such as tuberculosis care organisers, hospital almoners, superintendents of district nursing associations and representatives of other services as might be appropriate to discuss problems in which the responsibilities of these officers were interrelated. Furthermore certain desirable standards of home visiting by organising staff were postulated. The working party came to the conclusion that it was undesirable from the point of view of effective supervision and proper employment of organisers that districts should be disproportionately large or small, despite the fact that the number of assistant organisers and clerks who supported them might accord with an overall case load. For this reason recommendations were put forward for a limited adjustment in district boundaries ; the general observation being made that wherever possible the size of home help districts should be such that they were not called upon to deal with more than 1,000 cases or less than 500 cases on the books. A considerable number of improvements in procedure was proposed for introduction, including a revised basic records system in home help offices which would be implemented initially in two divisions preliminary to its general adoption. The co-operation existing with general practitioners was welcomed and it was recommended that home help organisers should be encouraged to develop to the fullest possible extent the practice of consulting general practitioners regarding their patients' needs of home help, especially if there were any doubt as to the need on medical grounds. It was recommended that the assessment of charges for services be undertaken by the organising staff, with check and guidance where necessary, who should give provisional 73 assessments to applicants on request, that the organising staff as far as possible should verify expenses claimed by applicants by scrutiny of rent books, insurance policies, etc., and that home helps be encouraged to collect charges, a contribution card to be made available to the applicant, in whose custody it should remain, for immediate temporary acknowledgment by the home help. Consideration was proposed of the provision of post-entry training for assistant home help organisers and the suggestion was made that consultation with the Institute of Home Help Organisers should be effected in this connection. It was considered that all home helps working in tuberculous households should be chest X-rayed and Mantoux tested as a routine before employment in such households and be X-rayed periodically afterwards. The desirability of all home helps being X-rayed on engagement and periodically thereafter should also be considered. Other matters dealt with by the working party included standards of accommodation for home help offices, liaison with Old Peoples' Welfare Committees and the recommendation was made that except where required for statutory or legal purposes the domestic help service in London should be referred to as the ' home help service'. The concluding section of the report of the working part was as follows : ' We have found the enquiry one of absorbing interest. The information and data included in our report present a picture of the Council's home help service which has not hitherto been available in such comprehensive form. We submit our recommendations in the confidence that their implementation will increase the efficiency of the home help service. It is of the first importance that it should be closely integrated with other branches of the personal health services. ' The scope and growth of the home help service are clearly shown. In spite of a reduction since 1953 by half an hour in the average weekly amount of service to each patient the total cost has continued to rise and is estimated to reach the considerable figure of -£846,000 for the current financial year. There is no evidence that the demand for assistance will lessen ; rather is the number of cases, particularly of the chronic sick, aged and infirm (92.9 per cent. of the total number at 30th September, 1956) likely to increase. We do not regard the amount of service given as over generous. A home help service is now securely established as an essential feature of the functions falling to be discharged by a local health authority. It will be apparent from our report that we have been unable to make any proposals for large-scale economies. Matters of that kind would appear to involve questions of policy, for determination by the Council.' 74 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 or children immumsed against diphtheria for the first time in 1956 was 44,237. The figures for the last seven years are shown below: (All ages) 1950 1951 1952 1953 1954 1955 1956 Primary immunisations 47,605 40,339 42,958 36,004 47,621 34,529 44,237 Reinforcing doses 27,579 22,908 27,820 33,172 45,802 30,850 43,866 Estimated per cent. at end of year of children 1-4 years who had at any time been immunised against diphtheria 67 65 63 63 66 67 68 The figures for immunisation against diphtheria show an increase compared with the figures for 1955. This is probably due to the fact that immunisation was generally carried out throughout the year and was not interrupted to the extent made necessary by the poliomyelitis epidemic of the previous year. The 'estimated' percentage figure of children aged 1 to 4 years immunised is the highest ever recorded. There were, in 1956, two deaths from diphtheria, one a child aged 4 years who had not been immunised against diphtheria, the other, a woman, aged 59, who died from heart disease said to have resulted from diphtheria contracted abroad 12 years before. The mother of the child later stated that immunisation had been suggested by the health visitor who had also advised her of the clinic times at which immunisation could be given, but that she had been persuaded by friends and relatives not to have the immunisation carried out. It cannot be repeated too often that the only effective method of preventing diphtheria, either in the individual or the community, is immunisation. Vaccination against whooping cough There is no scheme in London for vaccination 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 parents, undoubtedly due to their familiarity with the disease and to their appreciation of its potential dangers. The number of children immunised shows a marked increase as compared with 1955 and this, as with diphtheria immunisation, is probably due to the fact that immunisation continued throughout the year. 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. 75 1953 1954 1955 1956 No. of children vaccinated against whooping cough: (a) under Council arrangements (b) by general practitioners Total 19,292 3,427 22,719 31,985 5,449 37,434 22,367 5,574 27,941 29,423 7,133 36,556 Vaccination against smallpox Facilities provided for the vaccination of infants against smallpox are similar to those provided for diphtheria immunisation. The figures below show the number of children under one year of age vaccinated against smallpox, together with the percentage of annual live births for the past seven years : Vaccination of children under 1 Number vaccinated Percentage of annual live births 1950 16,836 32 1951 19,700 38 1952 23,106 45 1953 24,434 48 1954 24,995 49 1955 24,649 50 1956 25,734 49 (based on provisional figures) Four cases of generalised vaccinia were reported during the year. In three of these cases the eruption was sparse, consisting of only a few aberrant vesicules ; the other child who had suffered from infantile eczema had a more serious attack, but made a satisfactory recovery. A child aged 6 years developed headache, drowsiness and pyrexia four days after primary vaccination. On admission to hospital a diagnosis of encephalomyelitis was made. Within a few days his condition had improved and he was later reported to have made a complete recovery. 7,483 vaccinations and 2,622 re-vaccinations were carried out by general medical practitioners during the year. Inoculation against poliomyelitis As a consequence of the Ministry of Health circular 2/56, arrangements were made to participate in the Ministry of Health scheme for inoculation against poliomyelitis of children born from 1947 to 1954 inclusive. Parents of children in the eligible age group were informed of the scheme by letter, either through the schools or by post for pre-school children, and were invited to register their children for inoculation against poliomyelitis. The vaccine was given during May and June to a random sample of the registered children. The sample consisted of those born in certain months which were chosen by the Ministry of Health. The following figures show the position at the end of June, 1956, when inoculation was suspended for the duration of the poliomyelitis season: 76 Number of children offered inoculation Number of children registered for inoculation Percentage registration Number of children inoculated Percentage inoculation of registered children No. of injections Total (4) and (5) in (2) No. of injections Total (7) and (8) Two One Two One (1) (2) (3) (4) (5) (6) (7) (8) (9) 358,145 120,644 33.7% 12,057 3,249 15,306 10% 2.7% 12.7% Inoculation against poliomyelitis was resumed in December, 1956, when children who had received only one injection during May and June were given priority for a second injection. Any vaccine remaining from this issue was used to give first injections to further children who were registered earlier in the year. The number of children inoculated during December is given below: Number of children Number of children Total who received a who received a second injection first injection 1,968 819 2,787 The total number of children who received inoculation during the year was therefore : Two injections One injection 14,025 2,100 During May and June, 1956, arrangements were made for 1,494 children to be visited by a health visitor 24 hours after receiving a dose of vaccine. Reports of these visits showed that the poliomyelitis vaccine was singularly free from after effects. LONDON AMBULANCE SERVICE as will be seen from the statistical tables (page 84), there was a still further increase in demand for ambulance transport during 1956, though the increase was less than in any year since the inception of the National Health Service and it seems probable that some 'levelling out' or at least a slower rate of increase may continue to be expected. The fact that the total mileage covered by the directly provided and ancillary services was 136,000 less than the 1955 figure, although 25,000 more patients were conveyed, reflects the increasing efficiency which is being achieved as a result of the close liaison with the hospitals served, improvements in the co-ordination of journeys and the economical use of available transport. Rail transport Extensive use continued to be made of ambulance-train-ambulance arrangements for the conveyance over long distances of patients able to travel in this way. The number of such patients eligible to have their rail fares paid by the Council, however, fell from 3,466 in 1955 to 2,928 in 1956. Radio controlled ambulances Operational trials in the use of radio controlled ambulances and the training of staff in radio telephony began in May and by the end of the year seven vehicles had been equipped with radio and seven adapted as reserves. A transmitter at Hampstead is operated from the headquarters control room and gives complete radio cover over the county. Improved mobility and availability of vehicles resulted from the use of radio control but the effects in terms of financial economy and operational efficiency were still being examined at the end of the year. Emergency calls There was a further increase in the number of emergency calls received from 96,661 in 1955 to 97,823 in 1956. The figures are analysed in the table on page 84. Nearly 3,000 calls were received at the headquarters control room in which it was clear that medical assistance rather than ambulance transport was required. In such cases the caller is advised to summon the patient's own general practitioner or is given particulars of other medical practitioners in the locality. Ancillary services There was an appreciable increase in the amount of work undertaken during the year under agency arrangements by the ambulance department of the Joint Committee of the Order of St. John of Jerusalem and the British Red Cross Society. 24,358 patients were conveyed over a total distance of 436,927 miles as compared with 21,539 patients and 429,980 miles in 1955. The Joint Committee continues to undertake on behalf of the Council the majority of long distance removals by road where the medical or psychological condition of the patient precludes the making of ambulance-trainambulance arrangements. This affords considerable relief to the directly provided service and grateful thanks are again due to the Director and his staff for their willing help and co-operation. Hospital car service During 1956 the Hospital Car Service, on behalf of the Council, transported 120,122 patients over a distance of 1,399,355 miles, compared with 127,938 patients and 1,425,624 miles in 1955. The greater part of the work undertaken is the conveyance of ambulant out-patients to and from hospitals within the Administrative County, a most valuable contribution to the work of the Service as a whole. Warmest thanks are extended to the County Organizer and her staff for their continued help and co-operation. Reference is made later to certain suggestions affecting the Hospital Car Service made by the Minister of Health following a survey of the London Ambulance Service. Arrangements in North Woolwich The arrangement, whereby the West Ham County Borough Council undertakes, on behalf of the Council, to provide ambulance services in those parts of the Metropolitan Borough of Woolwich which he north of the Thames, continued during 1956 and details of the work done appear in the statistical tables on page 84. 78 Visits of inspection by the Chairman of the Health Committee During the summer recess Mrs. F. E. Cayford, J.P., the Chairman of the Health Committee paid a series of visits to establishments of the Ambulance Service, including each of the six general stations, twelve of the nineteen accident stations and the headquarters station. During her visits the Chairman took the opportunity of speaking to many of the supervisory officers and members of the operative staff about some of the operational problems which have arisen from the continued increase in demand on the Service. She presented 185 'Safe Driving' Competition awards to men drivers and 10 to women drivers. In her subsequent report to the Health Committee the Chairman again drew attention to the high standard of efficiency of the Service and recorded how impressed she had been by the smart bearing and alertness of supervisory officers and crews and by the clean and orderly appearance of the ambulance stations. Major accidents No occasion arose during the year to operate the 'major disaster' procedure, involving the calling out of a mobile medical team from the appropriate 'designated' hospital, but there were, nevertheless, a number of incidents, of which the following are examples, in which several casualties were removed : 13th January Collision between a lorry and a hearse at junction of Burbage Road and Turney Road, Camberwell; six casualties taken to hospital. 23rd April Explosion in garage, Buckingham Palace Road, Westminster; nine casualties taken to hospital. Two firemen treated for minor injuries. 21st/22nd May Fire in deep shelter in Goodge Street, Bloomsbury; 21 firemen overcome by smoke fumes and removed to hospital, numerous cases treated on the spot. 27th May Collision between a car and a troop lorry at junction of Portobello Road and Westbourne Park Road, Notting Hill ; four casualties taken to hospital. 1st June Explosion in Strand, near Somerest House; manhole covers blown up ; nine casualties removed to hospital. 20th June Fire in railway arch stores, Goding Street, Vauxhall; four firemen removed to hospital suffering from effects of smoke and shock. 21st August Collision between a trolley bus and a private car at junction of Southgate Road and Northchurch Road, N.l; five casualties removed to hospital. 25th August Collision between a motor coach and a lorry at junction of St. George's Drive and Charlwood Street, S.W.1; five casualties removed to hospital. 22nd October Collision between two trains outside London Bridge Station ; seven casualties removed to hospital. 31st October Collision between two buses at junction of Brixton Road and Atlantic Road, S.W.9; 14 casualties removed to hospital. 5th November Multiple car collision at junction of Bromley Road and Bargery Road, Catford; eight casualties removed to hospital. Visitors More than 170 visitors, many from overseas, were received at Headquarters during 1956. Special talks and demonstrations on the general organization and operation of the Service were given to students from the Royal College of Nursing, members of the Association of Public Health Lay Administrators, members of the British Red Cross Society and students from the London School of Hygiene and Tropical Medicine. 79 Premises Several building improvement schemes scheduled to commence during 1956 were postponed because of financial restrictions imposed by the Government early in the year. Administrative and Operational Headquarters—The merging of the administrative and operational headquarters under one roof at 150 Waterloo Road, S.E.I, referred to in the 1955 report, was completed and the building was formally opened by Mr. I. J. Hayward, ll.d., j.p., the Leader of the London County Council, on 20th January, 1956. Upper Richmond Road Accident Ambulance Station—This new accident station, the third to be built since the war, came into operation at 9 p.m. on 5th May and, within six minutes, an ambulance from it had answered the first emergency call. The station was formally opened by the Chairman of the Health Committee on 26th June. It is well sited to serve the large area it must cover and provides accommodation for three ambulances, one of which is in commission for 24 hours every day while each of the other two operates for 16 hours each week-day. Battersea Accident Ambulance Station—This station was destroyed by enemy action in September, 1940, and had since been housed in a temporary structure erected on the site. It was closed down simultaneously with the opening of the Upper Richmond Road Station but will be re-built as soon as circumstances permit. Dalston Accident Ambulance Station—Work on the scheme for the enlargement and improvement of this station was commenced on 27th December. Vehicles The vehicle strength at the end of 1956 was as follows :— Large ambulances 228 Single-stretcher, sitting-case ambulances .. 53 Sitting-case cars 41 Ambulance buses 10 Tenders 3 335 Replacement programme In formulating the current vehicle replacement programme, the growing demand from hospital out-patient departments, with the consequent need for a higher proportion of sitting-case vehicles, was taken into account. To meet this need and to secure more economical running and maintenance, the number of large ambulances at present in use will be reduced as they wear out and will be replaced by the new and more economical type of ambulance referred to below or by smaller dual-purpose vehicles. Most of the motor cars, also, which are less economical from the point of view of accommodation, will be replaced by more suitable vehicles. During the year, a prototype ambulance was designed and produced in the Mechanical Works Division of the Supplies Department to the special requirements of the service and this prototype, whilst preserving the same low loading level and accommodation for patients comparable with that of the existing large ambulance, is smaller in over-all dimensions, lighter in weight and more economical in operation. The basic chassis used will be available with either petrol or diesel engine and the body is made of glass-reinforced polyester resin. Trials were proceeding at the end of the year. Ministry of Health Survey The Ministry of Health survey of the Service demonstrated that the Council's ambulance service was well organised and efficiently operated and that the total annual cost was not unreasonable having regard to the exceptionally large volume of work undertaken. The Minister noted the good relations which existed with hospital authorities and with neighbouring ambulance authorities to ensure the most economical use of available ambulance capacity. The very full use made of the Hospital Car Service was acknowledged but the suggestion was made that further economy in vehicles and staff could be achieved by channelling Hospital Car Service calls through the Council's system of control. Plans for bringing such a scheme into effect were under consideration at the end of the year. Reference was also made to the desirability of increasing the proportion of small one-stretcher dual-purpose vehicles and of reducing the number of 80 large ambulances and other less suitable vehicles to provide for the more economical conveyance of sitting patients. As mentioned above, these considerations were taken into account in formulating the current vehicle replacement programme. The Minister referred to the possible economies to be derived from the use of diesel driven vehicles, a matter which is at present being studied following the installation of diesel engines in a number of vehicles. Staff numbcri Staff The recruitment of operative staff improved during the last quarter of the year and the number of ambulance driver/attendants at 31st December. 1956. was 760. Leading drivers The decision to introduce the rank of Leading Driver into the service was implemented towards the end of 1955 when two leading drivers were appointed at each of the ' six general ambulance stations. The decision has proved its worth in that the rank provides an additional link between the supervisory officers and the operative staff and gives some relief to Superintendents, particularly in the early morning and late evening. Award of resuscitation Certificates Two drivers in the accident section or the Service were awarded the Royal Humane a Society's Resuscitation Certificates during the year for rendering artificial respiration J and administering oxygen to a woman who had attempted suicide by coal-gas poisoning. The woman was removed to hospital and subsequently recovered. Medical staff at the hospital stated that the treatment the patient received prior to arrival at the hospital played a major part in her recovery. Safe driving and first-aid A 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. Of 716 drivers entered for the Competition in 1956 no less than 82 per cent, gained awards. Only 4-6 per cent, were disqualified, the remaining 13-4 per cent, being accounted for by resignations and exemptions owing to prolonged sickness. It is gratifying to record that two ambulance drivers hold awards for over 30 years' safe driving and 13 for 25 years and over. The interest of the staff in securing further qualification in first-aid to the injured has been maintained. Training school In April, 1956, the scope of the Civil Defence Training School was extended to cover the training of new entrants to the service in peace-time duties as well as in civil defence. Between April and December, 1956, seven courses were conducted for new entrants, comprising one week's civil defence training and two weeks' training in peace-time duties including first-aid to the injured. At the end of each course an examination for the Council's Elementary First-aid Certificate was held and all new entrants who attended these courses (79) qualified for that certificate. In addition to the training of new entrants, a number of courses in civil defence were held for existing members of the regular service and the opportunity was taken to include some refresher instruction in the use of peace-time equipment. Civil Defence In the Birthday Honours List H.M. the Queen conferred the M.B.E. upon Mr. R. E. Ridgwell, the Superintendent of the ambulance and casualty collecting section of the Council's Division of the Civil Defence Corps. Mr. Ridgwell has been responsible for training regular staff and volunteers since 1951 and the honour he has now received is an acknowledgment of the fine work he has done for the Civil Defence Corps in London. Honours A major difficulty in the organisation of civil defence training is that a large number of those who enrol in the corps fail to attend for training and give no explanation of their absence. It is very difficult to know whether these volunteers are temporarily prevented from attending or whether they have lost interest in the Corps and a great 81 Non-effective members of the Section deal of time has been spent in following them up. In 1956, a Home Office circular advised local authorities to make a final effort to interest these volunteers in the training programme and to withdraw all those who did not indicate that they wished to continue training. As a result of the circular, the numbers of the ambulance and casualty collecting section are being reduced to a more realistic figure. Recruiting campaign Despite the withdrawal of inactive volunteers, the membership of the section did not fall very sharply in 1956. This was principally because of the success of the autumn recruiting campaign. A number of displays were staged in various parts of London during September and October by the Council and the metropolitan boroughs to show the civil defence services in action. These displays took place at night in the light of arc lamps and were designed to show the co-operation between the different sections and the role each would play in an emergency. The ambulance and casualty collecting section played an important part in the production and presentation of these displays. Exercises Ihroughout the year careful thought was given to the problems which would be created by the use of thermo-nuclear weapons and volunteers from the ambulance and casualty collecting section took part in two large-scale exercises in which a hydrogen bomb was assumed to have burst over London. One,' Exercise Trafalgar ', was designed to test the control and movement of the mobile services from the depot areas into the capital, while the other ' Exercise Barbigate was concerned with the problems confronting civil defence forces which had arrived in the affected area. Exercises of this kind are essential if civil defence planning is to be capable of immediate application in an emergency. During 1956, volunteers from this section took part in 23 exercises organised by metropolitan boroughs and in eight exercises organised by industrial civil defence units. Selection of officers At the end or the year, the first selection course for officers was held and after examination eight shift leaders and eight deputy shift leaders were appointed. Volunteers are being invited to attend officer selection courses in order of enrolment and all fully trained members of the section will have an opportunity to attend. Visit by Home Secretary On the 27th February, 1956, Major the Rt. Hon. Gwilym Lloyd George, the Secretary of State for Home Affairs, visited the Fourth Arms Training Centre and saw an Courses of training ambulance section class in progress. During 1956, the following evening courses were held for civil defence volunteers : Ambulance Section, Part I .. 12 First Aid Practical Revision .. 6 Ambulance Section, Part II 12 Ambulance Section Practical Revision 5 First Aid .. .. .. .. 8 New Entrants Course .. .. 1 Driving and Maintenance .. 9 Officers Selection Course .. .. 1 Casualty Simulation .. .. 1 Training of the regular staff The training of the operative staff of the London Ambulance Service in civil defence duties continued throughout the year and 13 lectures were given to various outside organisations on the work of the ambulance and casualty collecting section. On 12 occasions, Civil Defence ambulance and staff helped with industrial civil defence training. In 1956, five members of the staff attended the Home Office Civil Defence School at Falfield and one was awarded a special civil defence instructor's certificate and four received full certificates. Instructors 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 84 for 1938 (the last full year before the war), 1947 (the last full year before the inception of the National Health Service) and 1951-56, 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 1951-56. 82 The accident section statistics for 1955 and 1956 are analysed below to show the types of call received. Analysis of accident section work (a) Numbers of patients: 1955 1956 Street accidents 17,338 17,502 Other accidents 20,345 19,567 Assaults 2,024 2,392 Attempted suicide 1,369 1,361 Mental 492 567 Epilepsy 1,329 1,219 Other sudden illness 18,458 19,433 Maternity 25,486 26,227 Special journeys with patients (including urgent transfers between hospitals and journeys involving the transport of mobile obstetric units) 323 340 87,164 88,608* (b) Non-patient carrying journeys : Delivery of analgesia apparatus 5,150 4,433 Special journeys without patients (including journeys to assist other ambulance crews and transport of obstetric units) 270 320 Ambulance not required 6,747 7,106 12,167 11,859* The average time taken to reach a street accident in 1956 was six minutes. * These figures total to more than the number of calls because a call may involve more than one patient. 84 Work performed by the directly provided service Tear Accident Section General Section Total Patients Non-patient carrying journeys Total journeys (calls) Mileage Patients Journeys Mileage Patients Journeys Mileage 1938 54,070 4,126 56,318 293,166 217,908 171,000* 1,930,172 271,978 227,000* 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 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 1956 88,608 11,859 97,823 491,929 881,006 463,158 3,736,550 969,614 560,981 4,228,479 •Estimated. Work performed by the agency and supplementary services Tear Ambulance Dept.— Joint Committee Order of St. John British Red Cross Society Hospital Car Service West Ham County Borough Council Total Patients Mileage Patients Mileage Patients Mileage Patients Mileage 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 1956 24,358 436,927 120,122 1,399,355 378 4,152 144,858 1,840.434 Work performed by both sections of the directly provided service and by the agency and supplementary services Tear Total Emergency Work Total General Section Work Grand Total Patients Mileage Patients Mileage Patients Mileage 1938 54,070 293,166 217,908 1,930,172 271,978 2,223,338 1947 61,136 362,880 182,206 1,768,550 243,342 2,131,430 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 1956 88,608 491,929 1,025,864 5,576,984 1,114,472 6,068,913 NOTES:—1. The figures are based on the Council's definitions of 'patient ' and journey which differ from those adopted by the Ministry of Health. 2. The agreements with the agency and supplementary services have been in operation only since 5th July, 1948, the ' appointed day' under the National Health Service Act, 1946. 3. The work carried out by the agency and supplementary services is almost entirely analogous to the 'General Section' work of the directly provided service and has been included in the table for ' Total General Section Work' PREVENTION OF ILLNESS: CARE AND AFTER-CARE Foot clinics reference has been made in previous years to the general inadequacy of the chiropody service to meet the demands made upon it and to its uneven distribution. Further representations to the Minister of Health seeking approval to the expansion of the service were made during the year. Whilst the Minister was unable to agree to the Council's proposals, he gave his approval to arrangements for a more even geographical distribution of existing chiropody sessions throughout the County. Facilities in new areas were provided for the exclusive benefit of expectant and nursing mothers and of old people. 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 1956 7,362 170,855 41.8 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 The demand for recuperative holidays continued to decline in 1956 particularly in respect of unaccompanied children under five years of age. Apart from the possible general improvement in the health of the children it is thought that the trend reflects the general acceptance of the view that the emotional disturbance caused by the separation of young children from their parents may wholly outweigh the advantages of good food and fresh air. Admissions to recuperative holiday homes Years Unaccompanied children Accompanied children Expectant and nursing mothers Other adults Total Under 5 years School children 1954 486 3,404 424 197 2,954 7,465 1955 403 2,803 405 153 2,784 6,548 1956 278 2,793 373 141 2,590 6,175 A satisfactory level of attendances was maintained throughout the year at the Council's recuperative holiday homes at Littlehampton (accommodation for 36 children of 3.8 years); at Deal under the Council's Private Hotel Scheme (accommodation for 30 children of 7.15 years) and at the Womens Voluntary Service's Home at Aldeburgh (accommodation for 24 children of 3-11 years). The Council contributed 90 per cent. of approved maintenance expenditure at this last home. 85 The services or voluntary organisations, such as the Jewish Board or Guardians, the Wandsworth Peace Memorial and the St. Henry Convalescent Fund were also used and assistance was rendered by the National Association for the Prevention of Tuberculosis in respect of tuberculous persons. Venereal disease Venereal disease A summary of the work done in 1956 at the London V.D. out-patient clinics will be found in Table 12, page 240. Approximately 79 per cent. of the patients were 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 of patients completing treatment and of defaulters as shown by analysis of the returns from the clinics: Syphilis Gonorrhoea Male Female Male Female Number of patients completing treatment 818 645 3,663 780 Number of patients not completing treatment 639 326 3,172 801 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 370 contacts was received but in 277 instances there was insufficient information for following-up. Of the remaining 93 cases 50 were traced of whom 44 were successfully brought to treatment. The welfare officers were also available to assist clinics in case of difficulty in following-up patients who defaulted. The arrangements whereby the services of a full-time welfare officer are made available for attendance at clinics at Holloway Prison and for following-up contacts and prisoners on discharge, were continued during the year. Health education It has long been appreciated that generally there can be no more favourable opportunity for health education than afforded by the direct approach of the medical and health visiting staff in the normal course of their duties, but to supplement the continuous efforts of these officers a comprehensive campaign on health education was conducted throughout the year and many varied aspects of the work of the department were covered. Special campaigns Special attention was paid to diphtheria immunisation and the prevention of accidents in the home and, as in previous years, each was made the subject of an intensive campaign. The diphtheria immunisation campaign held in February was sustained for two weeks, and took the form of advertisements in thirty-eight local newspapers, special film and film strip shows, the distribution of approximately 50,000 leaflets and the exhibition of some 600 posters. With the generous co-operation of the managements concerned, two-minute films or slides were shown at over 100 cinemas throughout the County area and much assistance was received from Press notices and comments other than the official advertisements. The effect of the campaign proved difficult to assess but there was some evidence that its immediate impact was impaired by adverse weather. The campaign against accidents in the home was conducted on similar lines and was held during the week commencing 5th November. It is not generally appreciated that more deaths are caused by accidents in the home than on the roads. Many victims of non-fatal accidents, particularly burns and scalds, have to spend long periods in hospital 86 in pain and discomfort, often with permanent impairment to follow. For the children, permanent physical or psychological handicap may result with difficulties of education and conduct. It has been estimated that over the country as a whole each year the aftermath of home accidents causes some 1,400,000 days of hospital care, costing over four million pounds. The co-operation of London school teachers was sought and generously given. In all some 521,000 leaflets were distributed and over 19,000 posters displayed. Further information about these campaigns with an account of an investigation into the causes of home accidents and other related matters are to be found in Appendix C. Safety handbook Arrangements were made to distribute to the public, free of charge, through the Council's divisional health organisation, an illustrated home safety handbook, produced by a commercial firm. Altogether it was estimated that some 72,000 copies of this handbook would become available and a considerable number were distributed before the end of the year. To facilitate the publisher's advertising campaign and at the same time make the book more convenient in size for its readers a separate edition for each metropolitan borough and the City of London was prepared. The book covered all aspects of home safety and reference was also made to industrial and road safety. Other editorial material supplied by the Council gave information about the personal health services provided by the Council within the area of distribution. Health education against cancer A conference of representatives of all the medical authorities concerned was held in May 1956 to consider the problem of health education against cancer, with particular reference to smoking and lung cancer. It considered that the population fell naturally into three classes : schoolchildren whose care would best be left to parents and teachers ; adolescents and the young adult ; the middle-aged, in whose case education would best be directed towards securing early diagnosis. It was further considered that health education on this subject would best be carried out in the general context of health education rather than being made the subject of a special campaign. As a result the preparation of a leaflet for leavers from the Council's schools which, in the form of a guide to health, gave prominence to the causal connection between cigarette smoking and lung cancer was put in hand. Visual aids The library of films and film strips was again extensively used, approximately 330 films being hired and a little under 200 requests for the loan of one or more film strips being made. The majority of these films and film strips were for use at educational classes at maternity and child welfare centres. Two new film strips were made, one, ' Three Years and Five Senses', is described more fully in Appendix C, the second, ' Vaccination against Smallpox' was produced commercially on the Council's behalf and stresses the dangers of infection and the procedure of vaccination. The decision to have a film made for use in cinemas to publicise the B.C.G. vaccination of schoolchildren is referred to more fully in the section dealing with tuberculosis. Leaflets and posters on a wide range of topics in addition to those used during the two specialised campaigns were distributed and displayed through the divisional health offices. Generally, the method followed was to publicise one subject or aspect of health education for a period of a month, at the end of which the subject was changed, this ensured a wide coverage and maintained interest. Talks, etc. Talks and demonstrations were given regularly at many of the Council s welfare centres during the day and 56 evening lectures outside the normal hours of duty were arranged for audiences of parents, parent-teacher associations and schools. Among the subjects covered were first-aid and home nursing, sex education, preparation for motherhood, feeding and child welfare. For a number of lectures and demonstrations at welfare centres, designed to be of interest to expectant and young mothers, special invitations were extended to fathers and those attending showed a lively interest and appreciation of the part they could play in the upbringing of a healthy family. 87 MENTAL HEALTH SERVICES Lunacy and Mental Treatment Acts Provision of care and treatment for the mentally ill persons alleged to be suffering from mental illness with such degree of disturbed behaviour that urgent action appears to be required either for their own protection or for the protection of others are referred for investigation to the Council's mental welfare officers (duly authorised officers). Persons needing help in their domestic, occupational, social or personal problems associated with potential psychiatric breakdown or following psychiatric treatment are referred to the Council's psychiatric social workers. Particulars of the cases needing such help are given later in this report. The information given in previous annual reports regarding the large number of cases referred to the mental welfare officers may have tended to suggest that these officers are concerned only with the removal of patients to observation wards or their direct admission to mental hospitals after certification or under urgency orders and that otherwise they take no action. This is by no means the case, but the extent to which other action has been taken has not been known because the necessary records have not been kept. In 1955, however, Dr.J. Alan Herd, the Council's medical adviser in mental health, in consultation with the department's statistician and the senior mental welfare officer, planned a new system of statistical recording, which was introduced on 1st January, 1956, from which a large amount of additional information can be obtained. Much of this information in respect of the year 1956 has yet to be analysed, but for the purposes of this report Dr. Herd has devised the tables which follow. The following table shows the number of persons referred to the mental welfare officers during the year and the number of separate investigations : Male Female Total No. of persons referred once in the year 2,256 3,091 5,347 No. of persons referred twice in the year 306 447 753 No. of persons referred three times in the year 59 79 138 No. of persons referred four times in the year 20 29 49 No. of persons referred five times in the year 9 16 25 No. of persons referred six times or more in the year 2 4 6 Total 2,652 3,666 6,318 No. of separate investigations 3,183 4,447 7,630* *This figure compares with 8,346 in 1955 and 8,690 in 1954. 15 per cent. of the persons seen were referred more than once. The total of 6,318 persons is equivalent to 2.4 per 1,000 of the population over the age of 15 years. Sources of referral The following table gives the sources of referral of cases to the mental welfare officers during the year: Source No. of cases General practitioners 3,257 Psychiatrists 861† Hospital wards (with no psychiatric assessment) 874 Hospital casualty departments 737 Non-medical 1,901 7,630 † Mental welfare officers also sought the opinion of a psychiatrist, with the consent of the general practitioner, on 123 other occasions after seeing the patient and before taking action. 88 The following table shows the initial action taken by mental welfare officers in age groups under 65 and over 65 : Action taken Under No. 65 Percentage Over No. 65 Percentage Tote No. Percentage Removed to observation wards 3,564 82.1 531 32.5 4,095 68.6 Brought before a Justice 515 11.9 944 57.8 1,459 24.4 Other action 262 6 157 9.7 419 7 Initial action No action was possible or necessary at the time of the visit in 1,133 cases under 65 and 518 over 65 years of age. This represents approximately 20 per cent, of the total cases seen. The figures in this table indicate the practice to avoid admitting persons over 65 to observation wards. This prevents the limited accommodation in the wards becoming congested as these patients tend to remain in the wards longer than the younger patients before final disposal. The mental welfare officers do, however, exercise discretion in each case as to the most suitable procedure having regard to the patient's mental and physical condition. Disposal of patients from observation wards The ultimate disposal of the patients admitted to observation wards (including 17 out-county cases) is shown below : Male 1956 Total 1955 Female Total Certified and sent to mental hospitals 460 615 1,075 1,147 Admitted as voluntary patients to mental hospitals 629 754 1,383 1,584 Admitted as temporary patients to mental hospitals 12 30 42 57 Non-statutory admissions (to Tooting Bee Hospital) 33 42 75 79 Non-statutory admissions (to Abbots Langley Hospital) .. — 1 1 4 Other non-statutory admissions 9 27 36 — Transferred to general wards.. 40 38 78 101 Transferred to Mental After-Care Association Homes — — — 3 Discharged to care of relatives (Section 22) 4 5 9 15 Dealt with privately 1 — 1 1 Discharged by medical officer 709 625 1,334 1,112 Dealt with under Mental Deficiency Acts 1 1 2 5 Died 51 19 70 75 Escaped from mental hospital and returned 6 — 6 — Total 1,955 2,157 4,112 4,183 More detailed analysis of these cases reveals that the discharge rate is highest in respect of patients admitted from the casualty departments of hospitals (particularly teaching hospitals), followed closely by the rate for patients admitted from the wards of general hospitals. The discharge rate in respect of all patients admitted from hospitals is 42-2 per cent, compared with 29-8 per cent, for other cases. It seems probable that some of the patients referred from hospitals could be adequately observed and treated in the hospital itself if facilities were available, even temporarily, for further medical assessment. The lack of such facilities necessitates the admission of these patients to observation wards and this in turn swells the discharge rate from these wards. Also revealed are the facts that in the five major observation wards there are wide differences in (a) the percentage of cases transferred to mental hospitals as voluntary patients and (b) the percentage of discharges by the medical staff. These are as follows : Observation ward Admitted as voluntary patients to mental hospitals . Discharged by medical officer A B C D E percentage 19-3 45-3 22-6 32-8 43-2 44-3 25-3 45-4 20-1 22-6 It would be interesting to know what factors explain these differences as there is no special selection of cases for individual observation wards by the mental welfare officers. 89 Disposal of all cases A summary is given below of the final disposal of all cases investigated by the mental welfare officers, including those admitted to observation wards, divided into age groups under 65 and over 65. Under 65 Over 65 Total No. Percentage No. Perc.ntage No. Percentage Certified 1.239 22.6 516 2 1,755 23 Voluntary patients 1,513 27.6 284 13.2 1,797 23-5 Temporary patients 40 .7 5 .2 45 .6 Urgency Orders 26 .5 10 .5 36 .5 Non-statutory 36 .7 248 11.5 284 3.7 Other disposals 1,352 24.7 356 16.6 1,708 22.4 Miscellaneous 135 2.5 213 9.9 348 4.6 No action possible or necessary 1,133 20.7 518 24.1 1,651 21.7 Total 5,474 2,150 7,624* *Plus 6 patients whose ages are not known (5 in ' no action ' group). Approximately 50 per cent. of all patients in each age group were eventually admitted to a mental hospital but the proportion of those admitted who were certified was higher for those over 65 (48 per cent.) than for those under that age (43 per cent.). These percentages do not, of course, represent the proportion of certified patients in relation to all admissions to the mental hospitals, since many voluntary patients are admitted through other agencies without reference to the mental welfare officers. It is felt that the number of aged patients who are certified would be reduced if more of these patients were referred for assessment to out-patient clinics or for domiciliary visits by psychiatrists when no doubt other methods of disposal would be suggested in some cases. Endeavour will be made to arrange for such assessments to be obtained through the general practitioners. 86.9 per cent. of the patients under 65 who were considered by the mental welfare officers to need action during 1956 received a psychiatric assessment, the majority in observation wards, whereas the comparable proportion in respect of those over 65 was only 41.7 per cent. It has not been possible hitherto to record what action, if any, was taken by the mental welfare officers in respect of the cases in which no action under the Lunacy Acts was taken. There were 2,353 and 2,503 such cases in 1954 and 1955 respectively. In 1956, there were only 1,656 occasions when no action of any kind was possible or necessary. Among the other actions and disposals arranged or recommended by the mental welfare officers, which in previous years were included in the 'no action' group, were: Referred to out-patient clinics with the consent of the general practitioner 41 Arranged for admission as voluntary patient 415 Arranged for non-statutory admission 172 Recommended admission welfare home 63 Recommended other disposal 93* * These include patients referred to a psychiatric social worker, to the sanitary authority and back to the general practitioner, either because the patient was physically too ill to be moved on mental grounds or because the patient appeared to be in need of continued medical care either at home or in hospital for physical rather than mental reasons. Marital status of persons referred The following table shows the rate of referral of cases to the mental welfare officers per 10,000 population in each age-status group. In general the figures reveal a much lower rate of referral of married persons than single, widowed or divorced persons. This difference is more striking because approximately one-sixth of the married persons seen by the mental welfare officers were in fact separated but they had to be included in the 'married' group because there is no record of the number of 'married but separated' persons in the population. 90  Single Married Widowed Divorced Age group Male Female Male Female Male Female Male Female All ages 37.2 33.7 16.5 21.9 58.9 54.3 54.1 51.2 15-29 25.1 15.6 7.5 12.3 (39.4) (19.5) (14.0) (21.0) 30-39 49.8 53.9 11.8 18.9 (65.1) (24.9) 76.7 72.2 40-49 56.1 39.5 11.8 23.9 (30.2) 35.7 56.4 49.5 50-59 59.6 41.8 20.2 26.0 45.1 35.9 (42.7) (47.2) 60-64 46.3 38.8 22.4 20.4 (28.8) 33.5 (36.1) (108.2) 65-69 47.0 34.3 25.3 31.7 39.8 41.6 (29.7) (60.2) 70-74 68.3 68.5 30.9 36.1 43.7 55.6 75-79 (53.6) 103.8 68.0 68.4 63.8 71.1 80+ (104.9) 169.1 94.7 104.3 145.1 124.0 Where there are less than 20 cases in a group, the figures are shown in brackets. Dr. Herd is indebted to the mental welfare officers for their co-operation and ready acceptance of increased clerical work and fact finding, and to the statistical section for their great help and interest in the analysis of the recorded data. Domiciliary care and after-care This work was considerably restricted at times during the year owing to shortage of staff, but during the last two months, when the full establishment of four psychiatric social workers was employed, there was a marked rise in the number of patients referred and the total for the year was slightly higher than in 1955. This service is now being used as an expert advisory bureau by other agencies already involved with patients whose problems are found to have a psychiatric cause. The extent to which the advice of the Council's psychiatric social workers is being sought in this way has not been recorded in the figures below, which include only those cases interviewed personally by the psychiatric social workers, but a substantial number of cases has been dealt with by discussions which have enabled the agency concerned with the case to continue to deal with the patient's problems. The discussions are frequently time-consuming but there is evidence of the value of the advice given in the increasing number of cases in which it is being sought. It does, moreover, avoid the need for a second social worker to visit the patients. of the cost of attendance of London patients at the centre and at the social clubs run by this Institute. National Association for Mental Health A grant of £,200 was again 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. Long term care 114 chronic and senile psychiatric patients were maintained by the Council during the year, 111 at homes owned or sponsored by the Mental After-Care Association, two at Parnham House, run by the National Association for Mental Health, and one at a hostel run by the Jewish Board of Guardians. Recuperative holidays 128 persons recovering from mild psychiatric illness were granted recuperative holidays for periods of two or three weeks in general recuperative hohday homes ; 63 who had more serious breakdowns were sent for similar periods to homes sponsored by the Mental After-Care Association and 21 were accommodated for periods up to 12 weeks at the Mental After-Care Association homes at Dartford, Kent, and Cheam, Surrey, which provide specially for the rehabilitation of younger patients capable of work. The total of 212 compares with 196 in 1955. Statistics Mental Deficiency Acts The following table shows the sources from which cases were brought to notice under the Mental Deficiency Acts and the action taken thereon : Sources of information 1953 1954 1955 1956 Totals from 1.4.14 to 31.12.56 Supervision section 9 16 11 6 1,617 Local education authority 533 502 501 490 17,579 Police authority (section 8) 24 18 15 14 2,044 Transfers from prison (section 9) — — 1 2 232 Transfers from approved school (section 9) 2 4 1 2 574 From hospitals and institutions 97 91 99 71 872 Miscellaneous 222 229 261 225 11,459 Total 887 860 889 810 34,377 The position at 31st December, 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: 1953 1954 1955 1956 Detained in institutions 7,842* 7,799* 7,762* 7,549* Discharged from institutional care 3,235 3,428 3,624 4,006 Removed to mental hospitals 572 592 596 610 Not subject for action 10,190 10,549 11,045 11,585 Died 4,853 5,006 5,158 5,306 Total removed from active list 26,692 27,374 28,185 29,056 * This figure includes patients on licence who were visited at regular intervals by officers of the Council on behalf of the regional hospital boards as follows: 1953, 236; 1954, 247; 1955, 212; 1956, 122. Under guardianship 223 217 224 217 In places of safety awaiting the presentation of a petition 11 11 6 1 Under supervision 4,815† 5,007 † 5,059t 5,0321† In hospitals, residential nurseries, etc., awaiting the presentation of a petition 59 61 79 46 Still under consideration 18 8 14 25 Total remaining on active list 5,126‡ 5,304‡ 5,382‡ 5,321‡ Grand Total 31,818 32,678 33,567 34,377 † In addition to those 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:—1953, 1,055; 1954, 986; 1955, 1,189; 1956, 1,329. ‡ Of these the following were awaiting institutional care: 1953, 199; 1954, 205; 1955, 229; 1956, 186. 92 The following is a summary of the cases dealt with and comparable figures for the three preceding years : 1953 1954 1955 1956 Placed in institutions 306 284 286 295 Placed under guardianship 21 28 31 25 Placed in places of safety pending presentation of a petition 59 45 34 14 Placed under supervision 735 688 674 633 Discharged from institutional care or guardianship 193 216 228 407 Removed to mental hospitals under the Lunacy Acts 26 25 16 20 Ascertained not subject for action 76 111 112 117 Withdrawn from supervision 221 247 370 408 Removed to other areas 60 62 68 75 Died 174 153 151 153 Total 1,871 1,859 1,970 2,147 During the year 20,155 visits were paid to persons under supervision or on licence from hospitals and 1,244 to persons under voluntary supervision, while 1,508 enquiries were made to ascertain the home circumstances of patients in connection with the statutory review of orders and the consideration of applications for leave of absence or discharge. Ascertainment and supervision The ascertainment of the majority of defectives and the oversight of defectives under guardianship has in the past been carried out by medical officers and social workers on the central staff and the supervision of defectives in their own homes by social workers employed in four local offices. Following an investigation in 1955 into the organisation and methods in use in the department it was decided that the social workers employed centrally should be allocated to the four local offices. The retirement of the senior inspector in 1956 provided an opportunity to make this decision effective and in December the change was made. As a result in future, with the exception mentioned below, all mental deficiency social work will be undertaken by the four local offices. A senior organiser charged with the duty of co-ordinating and supervising the work of the social workers in the local offices was appointed to the central staff and this officer will, in addition, undertake personal guardianship in certain special cases, in particular of the girls at Dover Lodge, visit residential (E.S.N.) schools having children about to be dealt with under the Mental Deficiency Acts and act as a link with the medical staff who will remain at the central office. Definition of ' neglected ' In February, 1956, a case affecting the working of the Mental Deficiency Acts (Regina v. The Board of Control ex parte Rutty) was heard by the Lord Chief Justice, Mr. Justice Hilbery and Mr. Justice Devlin in the Divisional Court. The Court expressed the opinion that the word 'neglected' in Section 2(1) (b) of the Mental Deficiency Act, 1913, which sets out the circumstances which render defectives subject to be dealt with, must at least be construed as meaning 'physically suffering from a lack of essentials through want of reasonable care' and that the words 'found neglected' can only intend a condition in existence at the time and cannot refer to a future condition which it is apprehended will or may come about. This interpretation of the meaning of 'neglected' is much narrower than has commonly been observed by local authorities in the past. It has, for example, been the practice of the Council, where a person in a home for normal persons or a home for persons with a handicap other than mental deficiency, has been ascertained to be mentally deficient and the authorities of the home have expressed the intention to discharge him, to regard him as 'neglected' if he has no home of his own to go to and to deal with him under the Mental Deficiency Acts. The only alternatives to this course of action are either to leave him in the home, which is not provided for his type of case, or to discharge him into the street and wait until he is ' physically suffering from a lack of essentials The effect of the decision is to bring into question the validity of many orders made in the past under the Mental Deficiency Acts and to make it virtually impossible to deal with defectives on the ground of 'neglect' either on petition or by removal to a 93 'place of safety' under section 15 of the Mental Deficiency Act, 1913. This means that many defectives, receiving care in public or charitable institutions not properly staffed or equipped to deal with them, cannot be brought within the scope of the Mental Deficiency Acts and given the care and training they need. Petitions During 1956, 185 petitions for orders for institutional care and 26 for guardianship were presented to judicial authorities under section 6 of the Mental Deficiency Act, 1913. 2 petitions were dismissed. In addition 55 children were placed in institutions by their parents under Section 3 of the Mental Deficiency Act, 1913. 32 applications for varying orders were made and, as a result, 17 patients were transferred to other guardians and 15, who had become unsuitable for guardianship, were admitted to hospitals and institutions. Magistrates' courts The Council s medical officers continued to attend magistrates courts as required to give evidence as to the mental condition of defectives charged with criminal offences. During the year 29 such cases were ordered to be sent to mental deficiency institutions under section 8 of the Mental Deficiency Act, 1913. Institutional accommodation The shortage of accommodation for mentally defective persons, especially for children under 16, continued to cause grave concern to the Council. Difficulties arose especially in respect of children in the Council's boarding (E.S.N.) schools, who had been ' reported ' under section 57 of the Education Act, 1944, as ineducable, for whom vacancies in mental deficiency institutions or hospitals were not available. As a result, a number of these children had to be taken into care by the Council's Children's Committee and placed in private establishments until vacancies became available. In June 1956 the Council decided to send a deputation to the Minister of Health urging the need for the provision of more hospital accommodation for the mentally deficient. The deputation was received by the Minister on 17th October, 1956. At the same time, representations were made to the Minister regarding the shortage of observation ward accommodation for urgent cases of acute mental illness. Towards the end of the year the position as regards mental deficiency hospital accommodation for patients from the North West, North East and South West Metropolitan regions showed some improvement, but the position in respect of the South East region remained extremely difficult. The total number of admissions rose slightly, 292 patients being admitted in 1956 compared with 276 in 1955. At the end of the year the number on the waiting list for admission was 186 (including 161 under 16 years of age) compared with 230 (including 184 under 16) at the end of 1955. Six children on the waiting list were found on re-examination to have improved to such an extent as to be considered educable and their names were removed from the waiting list and twelve patients on the waiting list died. Guardianship During the year 25 patients were placed under guardianship. Of these 13 were school leavers who had no satisfactory homes but were considered suitable for life in the community. At 31st December, there were 217 patients under guardianship as follows : 52 under the personal guardianship of the Council's social workers. 64 under the guardianship of nominees of the Guardianship Society, Brighton. 65 under the guardianship of relatives and friends. 31 under the guardianship of superintendents of voluntary homes. Of the remainder, three were temporarily in institutions awaiting decisions as to their future care, one was receiving treatment in a mental hospital and one had absconded from her guardian and was untraced. During the year 14 patients were discharged from the orders placing them under guardianship, 19 were transferred from guardianship to institutional care and one died. Monetary grants Following increases in the National Assistance allowances, an increase from 37s. 6d. to 40s. a week was authorised in the maximum allowance payable for the maintenance of mentally deficient persons under the guardianship of relatives and friends. Christmas extras Authority was given for expenditure not exceeding 10s. a head in approved cases for the provision of extra fare etc. at Christmas for patients under guardianship. 94 An allowance of 10s. a head a year was authorised for the provision of summer outings and Christmas extras for certain London patients under the guardianship of nominees of the Guardianship Society, Brighton, who attend the Society's occupation centres. In the past the cost of these amenities had been met by a private benefactor who died. The Guardianship Society, Brighton At the beginning of 1956 there were six girls in residence at Dover Lodge, 41 Wood Vale, S.E.23, the hostel for twelve mentally deficient girls, which was opened in September, 1955, and six were admitted during the year. All the girls were soon found employment and contributed out of their wages amounts varying from 35s. a week to the maximum charge of 42s. a week towards the cost of their maintenance. These contributions were made after the authorised allowances for pocket money and clothing (in each case 10s. a week at age 16 and 12s. at week at age 17 and over) and necessary incidental expenses had been paid to the girls out of their wages. Two girls made such good progress that they were placed in private lodgings from which they continued in the same employment and were completely self-supporting. One girl was transferred to another form of care under guardianship owing to behaviour difficulties and one was transferred to a hospital because her mental condition deteriorated. At the end of the year eight girls were in residence. All those admitted were placed under the guardianship of officers in the public health department. The girls wash their own clothes and assist in some of the domestic work in the hostel. Various amenities, including indoor games, radio and television, are provided. Close co-operation has been maintained between the warden and the medical and administrative staff and social workers of the department and the results so far obtained at the hostel are considered to be satisfactory. Visits to the hostel have been made by members and officers of various authorities, including the Ministry of Health, the Board of Control, the National Association for Mental Health, the Visiting Justices, and other interested persons. Hostel for girls under guardianship Provision of hostels by the National Association for Mental Health During the year the National Association for Mental Health, with the support of the Trustees of the London Parochial Charities, decided to establish two hostels in the greater London area to accommodate E.S.N, school leavers—one for boys and one for girls. The proposed hostels will be on similar lines to the Council's hostel, Dover Lodge, but it is the intention of the Association that boys and girls admitted to the hostels shall not be certified under the Mental Deficiency Acts but maintained under section 28 of the National Health Service Act, 1946. To enable it to maintain cases in the Association's hostels, when provided, the Council decided to seek an amendment of its scheme under section 28 of the National Health Service Act, 1946, empowering it in appropriate cases to maintain mentally deficient persons in suitable hostels without securing their judicial certification under the Mental Deficiency Acts and a proposal on these lines was submitted to the Minister of Health whose approval was awaited at the end of the year. Approval would enable the Council to maintain cases without certification not only in the Association's hostels, but also in Dover Lodge or in any other suitable hostel. Wallingford Farm training school Suitable boys leaving special schools for the educationally sub-normal with no homes or unsuitable homes, wishing to undertake farm work, market gardening, boot repairing, brick laying, carpentry or painting, continued to be placed under the guardianship of the warden of Wallingford Farm training school. The cost of maintaining each boy at the school is £5 15s. 6d. a week, plus the cost of clothing. On 1st January, five boys were undergoing training at the school, five more were admitted during the year and one left, leaving nine at the school on 31st December. Reports on the progress of the boys have been satisfactory. Some of the boys have nearly completed their period of training and it is hoped in the near future to place them in suitable employment in the community where they will be partially or fully self-supporting. The Board of Control has been asked to consent to the number of boys placed under the guardianship of the warden being increased to 15. Short-term care During the year temporary care in accordance with the provisions of Ministry of Health Circular 5/52 was arranged for 37 patients (7 adults and 30 children) at various 95 G approved and other private homes. In addition, 128 persons (91 children and 37 adults were admitted to mental deficiency hospitals for temporary care. The total number o defectives provided with short-term care during the year was thus 165, compared with 141 in 1955. The seven special welfare clinics for mentally retarded children under 5 years of age continued to function throughout the year. Parents in the London area may bring their children to these clinics to receive specialist advice on the special needs of retarded children as well as the problems of maternity and child welfare. There is evidence that the clinics are much appreciated. Welfare clinics for backward children under five Students Facilities were again given for students taking university courses of training in social science and similar studies to spend short periods in the local offices of the mental deficiency service. Students also witnessed the presentation of petitions to judicial authorities for orders under the Mental Deficiency Acts. Visitors Visitors trom other parts of the country and abroad were given information on the Council's work under the Mental Deficiency Acts. Accommodation Occupation Centres The accommodation available in all centres at the end of December, was as follows : Accommodation Centres Accommodation Centres for children Centres for elder girls Bethnal Green 90 Brockley 60 Clifton 60 Clapton 60 Finsbury 75 Earlsfield 60 Fulham 75 Greenwich 35 Greenwich 60 Islington 40 Herne Hill 60 Centres for elder boys North Kensington (including a class of elder girls) 70 Archway 40 Battersea 30 Peckham 45 Dalston 50 Wandsworth 90 Hammersmith . 35 Peckham 60 Industrial training centre (elder boys) Stepney 20 Total 1,115 In April a new occupation centre for elder girls was opened at Rothbury Hall, Azof Street, S.E.10, and named the Greenwich (Elder Girls) Occupation Centre. The new centre, which has accommodation for about 35 girls, by providing additional places for elder girls previously attending the Greenwich and Brockley junior centres, released places in those centres for children in south east London. At the same time the Brixton junior occupation centre (for 40 children) was transferred from premises at Christ Church Hall, Mowll Street, S.W.9, to new, larger and improved accommodation (for 60 children) at the Methodist Church Hall, Half Moon Lane, S.E.24, and renamed the Heme Hill centre. Additional accommodation was also taken in April at the Finsbury junior centre and in September at the Earlsfield elder girls' centre to provide extra places and reduce overcrowding. In December, arrangements were completed for the closure of the Bethnal Green junior centre at Oxford House, Mape Street, E.2, and the transfer of the children from this centre and the Clapton junior centre at St. Michael's Hall, Northwold Road, E.5, to adapted premises at Cornwall House, Cornwall Avenue, E.2, which had been previously used as a maternity and child welfare centre. At the same time the Hackney elder girls' centre at Old Gravel Pit Hall, Valette Street, E.9 was closed and the centre transferred to the premises formerly occupied by the Clapton junior centre. 96 At the end of the year progress was being made with the adaptation of the former Balham day nursery premises to provide a permanent centre, which it was expected would be ready for occupation in the summer term, 1957, to replace the Battersea elder boys' centre. Ministry of Health approval was received for a scheme to erect a new occupation centre on a site at Perry Rise, Lewisham, to be built during the financial year, 1957-58, and plans were in preparation for a second new centre to be built on a site in North Kensington. These centres will be the first purpose built centres provided by the Council. They will replace existing unsatisfactory centres and provide additional places. Open days and sales of work Various functions were held during the year to show to parents and friends the work and activities carried out at the centres. Articles made and sold at the centres realised approximately £73 at junior centres, £131 at elder girls' centres and £764 (including £140 for shoe repairing) at elder boys' centres (excluding the industrial training centre). Some small apparatus and equipment for other centres was also made at the boys' centres. Stepney industrial training centre A review of the working of the industrial training centre carried out in June, 1956, revealed that the value of goods produced up to May had covered the cost of materials used and the pocket money (1s. a day) paid to the boys, leaving a small surplus. The position will be further reviewed from time to time to ascertain whether an increase in pocket money can be justified by the output. The total value of orders completed for the Council's Supplies Department during 1956 was approximately £564 and a few items were also made for other occupation centres. The experiment at Stepney is proving well worthwhile and it is hoped to start a second industrial training centre in south London when suitable premises can be obtained. Admissions to special schools and to employment During the year, ten children were sent or returned to special schools and twelve boys from the elder boys' centres and the industrial training centre left to take up employment. Home teaching A home teacher was appointed for an experimental period of one year, to commence duty in January, 1957, for the instruction of approximately thirty physically and mentally handicapped children and adults who cannot attend the occupation centres. Speech therapy Arrangements were also made for speech therapy sessions to start at two occupation centres early in 1957 for an experimental period of one year. Chest X-ray examinations Chest X-ray examinations were arranged for all staff and for defectives over fifteen years of age attending the centres. No case of tuberculosis was discovered. Holidays, outings and parties 200 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. Facilities were provided for periodic visits during the summer months to local parks for recreation and sports. Elder boys' centres organised inter-centre cricket and football matches. Christmas parties were held at all centres. Gifts, including sums of money to provide extra amenities, were given to most centres, by parents' groups and other persons. Gifts Parties of students undergoing 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 attended some centre functions. Visits to centres Thirteen staff who are participating in the current two-year part-time course of training organised by the National Association for Mental Health, which commenced in September, 1955, completed periods of practical training in centres of other local authorities and students from other authorities taking the same course and the Association's full-time day course, received periods of practical training in London centres. Staff courses of training O* 97 SCHOOL HEALTH SERVICE Organisation the school health service, like the maternity and child welfare service, is organised on a divisional basis (see pages 131-149 for reports by divisional medical officers). In 1956, the voluntary workers of the school care committees, who numbered 2,000 at the end of the year, attended 95 per cent. of the medical inspections. This figure shows very clearly the importance the care committees attach to carrying out this duty on behalf of the Council. The attendance of parents at inspections in primary schools on the average remains high, and the care committee workers still regard the inspections as the chief way of establishing an easy contact with the children and their parents. The need for home visits after inspections is decreasing owing to the growing co-operation of parents ; but it exists in connection with such problems as recuperative holidays and attendance at specialist clinics of all kinds, both in school treatment centres and hospitals. These visits provide opportunity for the preparation of the parent and child and the collection of background information which is made available through the public health children's care organisers to the doctors. Medical inspection rooms in schools There is no legal requirement for the provision of a separate medical inspection room in a school and consequently in a large number of schools, particularly denominational schools, there is no special accommodation for this purpose. School halls, spare classrooms, staff rooms and sometimes the headteacher's room, are used for medical inspection and mothers have to undress their children in accommodation unsuitable for the purpose. Whenever substantial improvements to a school are contemplated, the question of providing a separate medical room is considered. Only a small amount of money is available for improvements, so that progress is unfortunately slow. Nevertheless, during 1956, improvements in medical accommodation were made in 27 schools, at a cost of £3,275. The larger secondary schools now coming into use were planned some years ago with separate rooms for doctor, nurse and dentist, and provision for waiting space for parents and children. Building costs continued to rise during the year, but the permitted cost per place remained unchanged and, consequently, economies had to be made in planning and in finishing. To help meet this increasingly serious problem, the planning of medical suites for future construction was revised to provide a smaller area. No reduction in service is envisaged, but part of the accommodation will be designed in such a manner as will allow of it being used for other purposes. Under the school building programme, the following new large secondary schools were opened during the year, and each was provided with separate rooms for the school health service : Name of School Nominal roll Eltham Green 2,210 mixed Elliott 2,080 „ Parliament Hill Extension 924 (girls) Forest Hill 1,350 (boys) Kynaston 891 „ Quintin 621 (boys) Hurlingham 1,024 (girls) Sydenham County Extension 1,178 „ Tulse Hill 2,080 (boys) Wandsworth County Extension 1,620 „ Pupils on school rolls At the end of 1956 there were 445,870 pupils on the day school rolls, 316,649 children of primary and secondary school age were in attendance at county schools, 105,704 at voluntary or assisted schools, 15,374 children under five years of age in nursery schools and classes or in primary schools and 8,143 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 the child's school life. However, the Ministry of Education circular No. 269, of 25th August, 1953, indicated that the Minister would be prepared to approve schemes not based on periodical inspections if local education authorities wished to experiment in this direction. In London the practice for many years has been to carry out four general medical inspections at specified ages during school life. During 1956, a small departmental working party was set up to consider the whole field of the Council's schools medical inspection arrangement, and in particular whether any alteration to four periodic inspections was desirable. The working party had not completed their deliberations at the end of the year under review. Details of the medical inspections carried out m 1956, with comparable figures tor the two previous years, are as follows : 1954 1955 1956 General medical inspections 'Routine age groups Entrants 44,415 41,162 37,423 7 years old 44,604 38,161 34,259 11 years old 34,312 37,290 34,033 Leavers 27,892 25,308 25,650 Total 151,223 141,921 131,365 Nursery 7,958 8,164 8,632 Other ages 27,593 26,552 23,492 Special schools 2,470 2,518 2,450 Training colleges 178 177 156 Secondary schools annual surveys 16,667 13,978 11,811 Total general inspections 206,089 193,310 177,906 Other inspections Special inspections 1954 1955 1956 'Urgents' and 'Specials' (a) 27,262 24,380 23,256 Employment certificates 4,604 4,521 5,377 School journeys 19,503 22,400 25,220 Miscellaneous (b) 8,223 6,210 6,549 Total 59,592 57,511 60,402 Reinspections "Nutrition cases (c) 64,909 68,051 64,565 Other 107,131 101,278 96,186 Total other inspections 231,632 226,840 221,153 Total all inspections 437,721 420,150 399,059 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. (r) Pupils receiving school meals, extra milk or vitamin capsules on the recommendation of the school doctor (see page 101). Apart from annual surveys in secondary schools children seen at routine inspections in 1956 formed 37.3 per cent. of the total of 445,870 on school rolls, compared with 40.5 per cent. in 1955. The percentages of these children who were referred for treatment (other than for infestation or teeth) compared with the preceding years were : 99 Pupils referred for treatment Age group and sex 1954 1955 1956 Nursery Boys 12.7 11.1 10.9 Girls 10.3 8.4 8.2 Entrants Boys 13.8 12.4 11.5 Girls 11.9 10.5 9.7 7 years old Boys 16.8 15.3 15.3 Girls 15.4 14.1 14.0 11 years old Boys 14.5 14.0 13.7 Girls 15.9 14.6 14.2 Leavers Boys 11.7 11.6 10.4 Girls 15.6 14.9 13.4 Other ages Boys 16.3 15.4 14.4 Girls 18.2 17.7 15.7 All pupils* 14.8 13.7 12.9 * Exclusive of special schools, training colleges and annual surveys in secondary schools. 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 1954 and 1955. 1954 1955 1956 Numbers examined 186,774 176,637 163,489 Percentages Skin diseases 1.39 1.35 1.10 External eye diseases 0.72 0.58 0.57 Defective hearing 0.59 0.59 0.60 Otitis media 0.74 0.66 0.66 Enlarged tonsils and adenoids 6.92 5.97 5.88 Defective speech 0.72 0.75 0.77 Enlarged cervical glands 1.45 1.30 1.22 Heart and circulation 0.87 0.79 0.74 Lung disease (not T.B.) 1.55 1.41 1.35 Orthopaedic defects 5.10 4.82 4.41 Defects of nervous system 0.37 0.39 0.34 Psychological defects 0.97 0.97 0.94 Anaemia 0.19 0.14 0.13 Enuresis 1.56 1.57 1.62 * Excluding special schools, training colleges and annual surveys in secondary schools. Compared with 1955 a reduction in the number of skin diseases was shown in all groups except girls in the nursery and entrant groups, whilst all age groups showed lower rates for orthopaedic defects. In the case of the all other defects there was insufficient variation in the figures to justify comment. Tonsillectomy In September, 1955, with a view to initiating a study of tonsillectomy in children, the Ministry of Education asked if it could be arranged for examining medical officers to record whether or not each child examined at routine medical inspections at day and nursery schools and classes from 1st January, 1956, onwards (i.e., in subsequent years also) had undergone tonsillectomy at any time previously. The tabulated results of this inquiry show that of nearly 140,000 children inspected in five age groups, 19.8 per cent. had previously undergone tonsillectomy, the rate rising from 4.7 per cent. in the nursery group to 30.8 per cent. in the leavers' group, with sightly more boys than girls having had the operation in all age groups except leavers. Currently the greatest number of tonsillectomy operations are performed on children aged between 5 and 11 years, with rather more between 5 and 7 than between 7 and 11. 100 Routine medical inspections, 1956 Pupils known to have had tonsillectomy Numbers inspected Pupils who had tonsillectomy Percentage Age groups (1) (2) (3) Boys Girls Total Boys Girls Total Boys Girls Total Nursery (under five's) 4,424 4,208 8,632 225 183 408 5.1 4.3 4.7 Entrants 19,213 18,210 37,423 1,708 1,206 2,914 8.9 6.6 7.8 Seven-year.olds 17,685 16,574 34,259 3,664 3,012 6,676 20.7 18.2 19.5 Eleven-year.olds 16,996 17,037 34,033 5,025 4,746 9,771 29.6 27.9 28.7 Leavers 13,007 12,643 25,650 3,917 3,982 7,899 30.1 31.5 30.8 Total 71,325 68,672 139,997 14,539 13,129 27,668 20.4 19.1 19.8 School meals, milk and vitamin supplements A return to the Ministry of Education for a typical day in September, 1956, showed that 227,417 pupils, 56.2 per cent, of the number present, were provided with school dinners; of these 17,670 received dinners free of charge. On the same day, 361,942 children had school milk, including some children absent through sickness whose milk was collected for them. Vitamin capsules are supplied daily without charge to children recommended for them by the school medical officer ; other children whose parents so desire may have them on payment of 1s. a term. In October, 1956, meals were being produced at 613 kitchens (including nine central kitchens) and served to children at 967 separate premises. During the course of the year over 48½ million meals were served to children, teachers and staff and the output of middav dinners to children reached a record daily figure of 227.700. 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 Under 7 years 500 7 to 11 years 650 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. 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 spectacles wearing them for the test. This 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. 101 The following table gives the results of such vision tests carried out during 1956 : Visual acuity (with glasses, if worn) Percentage referred for treatment 6/6 0/ /o 6/9 0/ /o 6/12 or worse 0/ /o 0/ /o wearing glasses Already wearing glasses Not wearing glasses Total 7.year-old Boys 79.5 13.4 7.1 3.3 0.7 6.0 6.7 Girls 78.4 14.6 7.0 3.5 0.7 6.5 7.2 11-year-old Boys 82.8 8.5 8.7 7.9 2.4 5.7 8.1 Girls 80.1 10.8 9.1 9.4 2.8 6.0 8.8 Leavers Boys 83.0 8.0 9.0 10.7 3.2 4.4 7.6 Girls 79.8 10.1 10.1 12.9 4.3 6.1 10.4 Other ages Boys 82.0 9.9 8.1 8.1 2.6 6.0 8.6 Girls 79.1 11.3 9.6 9.8 3.0 7.2 10.2 As can be seen, a proportion of those referred for treatment of defective vision were wearing spectacles already. This proportion 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 those needing natural adjustment of refraction correction with the passage of time. In 1956, the incidence of defective vision and the percentage of pupils referred for treatment of defective vision remained fairly stable compared with the preceding years. As experienced over many years, the recorded incidence of defective vision was greater among girls than boys. Squint was most prevalent in the entrant group, falling to insignificant residual level in the leaver group. The overall figure of pupils referred for treatment of squint was 0.7 per cent., compared with 0.8 per cent, in 1955, 0.8 per cent, in 1954 and 0.9 per cent, in 1953. Much interest has been shown in recent years in the question of routine vision tests of young children. The problem is a difficult one and, in London, attention was drawn to it during the course of a special study of the growth of the eye by Prof. A. Sorsby mentioned in the Annual Report for 1954. The question has been referred to the working party to which reference has already been made. Nutrition Classification of General/Physical Condition and referrals for treatment or observation From 1947 to 1955 inclusive, school doctors carrying out general medical inspections were required by the Ministry of Education to classify the ' general condition ' of the pupils on a three-point scale—'good'fair' or 'poor'. This classification replaced a four.point scale of 'nutrition' assessment (' excellent','normal', 'sub.normal' or ' bad'), and it has been stressed that because these are descriptions of purely subjective assessments, such a change in the system of classification meant that it would be some years before the statistics produced on the new scale could be regarded as sufficiently stable for valid conclusions to be drawn from them. Bearing this in mind, it has nevertheless been apparent over the past few years that the general condition of the pupils has been steadily improving—the figures showing a consistent increase in the number classified as ' good ' and corresponding decreases in the ' fair ' and ' poor' categories. As from 1st January, 1956, a further change in the system of classification was made by the Ministry of Education, the former description ' Classification of General Condition ' being replaced by ' Classification of Physical Condition with only two categories provided for, i.e., ' Satisfactory ' and ' Unsatisfactory '. The figures for 1956 show an overall allocation between these two groups of 95.0 per cent, satisfactory and 5.0 per cent, unsatisfactory, but it is manifestly impossible to make any comparison between these figures and the three.point classification which operated for the previous nine vears. 102 The table below shows the classifications under the two separate scales for 1953.1955 and 1956 respectively, together with the percentages referred for treatment or observation of nutrition defects : Classification Referred for Observation Total A—Good B—Fair C—Poor Treatment Percentages A 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 Satisfactory Unsatisfactory 1956 95.0 5.0 0.9 0.9 1.8 Pupils receiving school meals, extra milk or vitamin capsules on the recommendation of the school doctor are re-inspected each term. During 1956 the number of such re-inspections was 64,565. 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 1956 17.5 70.3 12.2 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 1956 : Total Number of Inspections Pupils found to be verminous* Number Percentage Boys 375,144 2,282 0.6 Girls 440,320 7,881 1.8 Infants 383,636 5,002 1.3 Total 1,199,100 15,165 1.3 *'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. During the year two of these borough cleanings stations were closed and arrangements were made for the pupils to attend stations in adjoining boroughs. The following table shows the results of the operation of this 'cleansing scheme' during 1956 : 103 1. Number of occasions on which pupils were found to be ' verminous ' (as defined) 15,165 2. Number of individual pupils comprising item 1 8,238 3. Number of advice cards issued 9,614 4. Number of families involved in item 3 3,836 5. Number of pupils found to be clean after issue of advice card 1,690 6. Number of pupils voluntarily attending bathing centre after advice card 6,452 7. Number of statutory notices issued 1,223 8. Number cleansed voluntarily after statutory notice 325 9. Number compulsorily cleansed after statutory notice 853 The total number of individual verminous pupils treated at bathing centres fell by 198 to 9,669, while treatments needed decreased bv 986 to 14,770. The steady decline in the numbers of verminous pupils in recent years is shown in 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 1956 445,870 1,199,100 15,165 1.3 8,238 1.8 Scabies, impetigo and ringworm Individuals treated for scabies totalled 762 compared with 961 in 1955. Cases of impetigo treated at minor ailment and bathing centres numbered 2,766 compared with 3,749 in 1955. For the first time on record, no cases of scalp ringworm were found in the County during the year. Re-inspection and 'follow-up ' The 'follow-up' of children referred by the school doctors for observation or treatment, which is an essential part of the school health service, is carried out by the children's care organisation. Each child referred is re-inspected by the school doctor a few months after medical inspection, to allow time for treatment to be carried out, and further re-inspections are made, if necessary, to ensure that as far as possible every child gets adequate treatment. During the year, 160,751 medical re-inspections were carried out, 64,565 in respect of pupils noted as ' nutrition ' cases (see page 102) and 96,186 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. 104 Pupils advised against particular forms of employment again formed 15.4 per cent, of both sexes examined and work requiring normal vision and that involving eye strain again headed the list of contra-indications for both sexes. Next came normal colour vision (for boys only), heavy manual work, exposure to bad weather, work in dusty atmosphere, and prolonged standing or quick movement. The following table gives the mam contra-indications disclosed at the medical inspections of 22,500 school leavers during 1956 : Contra-indications Boys Girls Occupations involving : Heavy manual work 245 193 Sedentary work 37 20 Indoor work 10 7 Exposure to bad weather 137 141 Wide changes of temperature 73 41 Work in damp atmosphere 122 91 Work in dusty atmosphere 146 86 Much stooping 30 29 Climbing 48 55 Work near moving machinery or moving vehicles 57 49 Prolonged standing, much walking or quick movement from place to place 87 141 Eye strain 617 795 Normal vision 765 616 Normal colour vision 330 1 Normal use of hands 12 10 Exposure of hands to moisture, chemicals, etc 21 39 Handling or preparation of food 83 86 Normal hearing 76 47 Other 19 13 Employment of children The bye-laws governing the employment of children require, inter alia, that the school medical officer shall certify that the employment of the child will not be prejudicial to his health and physical development and will not render him unfit to obtain the proper benefit of the education provided for him. Such a certificate is valid only (i) during a period of six months from the date of its issue, and (ii) for the class of employment referred to in the certificate. During the year, 5,377 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 182 boys and 267 girls. Children under five years of age At the end of 1956 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. Children in nursery schools and classes attend during the ordinary school hours of primary schools. 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. School health visitors attend nursery classes and schools frequently and each child is examined every term by a school medical officer. 105 Nursery schools and classes were originally planned to provide among other objects a community in which the isolated or mildly handicapped child could receive the social training he needs. The modern auditory training of deaf children recognised sufficiently early had led to a growing tendency for the admission of some of these children to nursery schools and classes in a normal hearing environment rather than to nursery classes in deaf schools. Audiometry Routine hearing testing of school children aged 7 + years, fully described in the Annual Report for 1955, has continued to be carried out by school health visitors using gramophone audiometers in schools. Pupils failing in two consecutive gramophone tests are referred to the local school treatment centre for pure tone testing and subsequently, if necessary, to an otologist at an audiology centre. Pure tone sweep testing It became clear during 1956 as a result of the pilot schemes initiated in two divisions for the pure tone sweep testing of school entrants aged 5+ years that this form of testing could be extended to the remaining divisions without any considerable staff repercussions. The necessary preliminary steps were accordingly taken to enable pure tone sweep testing to be substituted for gramophone testing in all divisions in 1957. The records of the audiometric test in 1956 were as follows: Aged 5+ (2 Divs.) Age 7+ (7 Divs.) First gramophone test — 35,467 Second gramophone test — 9,600 Sweep test 11,591 — Referred to otologist at audiology centre 1,306 Audiology centres 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. Children are referred to these clinics by school doctors from routine or special medical inspections, by school health visitors after gramophone or pure tone sweep tests in school, by teachers, speech therapists, etc., whenever there is suspected hearing defect. 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 1956, 282 audiology sessions were held, at which there were 3,318 attendances, including 1,234 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. 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. Training of very young deaf children The training of very young deaf children which was referred to in the Report for 1955 (pages 110-111) was extended by the appointment of a second teacher with centres at Woodberry Down health centre and the Shooter's Hill welfare centre. The appointment of a third teacher is contemplated. 106 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 23,703 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 pone on a school journey. Holidays for diabetic and epileptic children During the summer the Diabetic Association again organised holidays tor 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 Brackley, Northants (epileptic children). Medical treatment Section 3 of the National Health Service Act, 1946, places upon the Minister of Health the duty of providing, 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 school-pupils in consultation and agreement with local education authorities, but, in fact, the final word on any growth of the specialist side of the school health service would appear to lie with the Regional Hospital Boards. The evolution of the school health service in recent years, particularly its relationship with the national health service since 1948, reached a point where it appeared desirable to review the classification of certain types of clinic held at school treatment centres to remove anomalies which had developed during this period of evolution. During discussions with the four Metropolitan Regional Hospital Boards on the question of responsibility for school health service clinics, it became apparent that certain of the work of investigation and supervision carried out by the Council at these clinics, which had been regarded in principle as specialist, was not acceptable as such by the Boards since it did not necessarily require the services of a medical officer of consultant or specialist status. This work was thenceforward regarded as the duty of the Council under Section 48 (3) of the Education Act, 1944, and the clinics at which it had been performed are for convenience classified below. Consultative clinics There was room tor experiment in the methods of dealing with enuresis, and certain clinics previously called 'enuresis' were renamed 'consultative' to avoid confusion with the specialist enuresis clinics held at a number of hospitals, but not only enuresis is dealt with at these consultative clinics. In some health divisions children are also treated for minor behaviour problems, whilst in other divisions they also advise on nutrition and investigate children referred from school medical inspections for further examination. Children with enuresis seen at the Council's consultative clinics requiring specialist treatment are referred to hospital enuresis clinics. The work of the consultative clinics has now been absorbed, however, into that of the special investigation clinics. 107 Existing special investigation clinics A school medical officer at an inspection session in a school often has neither sufficient time nor suitable accommodation or facilities to examine some pupils as thoroughly as may seem desirable at the time. In the new schools which are being equipped with medical suites the work can be done, as it should be, in the school, but in the older schools the problem has been approached in various ways. One way has been a development of the minor ailment session at a school treatment centre, so that the school medical officer who carries out the medical inspections in the school also holds sessions in the local minor ailment centre where he can investigate more thoroughly the difficulties disclosed at the inspection done in the school.There has also been increasing use of nutrition and other clinics for the same purpose. In most divisions, however, special investigation sessions are being held. Nutrition clinics Nutrition clinics were started by the Council in 1935. From the outset, children other than those suffering from malnutrition were examined, and the function of the clinics developed rapidly, so that further inspection and advice for a wide range of conditions were given. This is well illustrated in the report for 1935 (pages 20-26). The problem of malnutrition has changed enormously since the war and there really is no purpose in holding special clinics under this heading. The nutrition work can conveniently form part of the special investigation clinics. Rheumatisrr advisory clinics The South East Metropolitan Regional Hospital Board in 1954 discontinued rheumatism supervisory clinics as such, as far as that Board was concerned, on the ground that the facilities for those children requiring specialist advice were available at normal cardiological, orthopaedic or paediatric clinics staffed by hospital specialists. Discontinuing clinics on the part of the Board did not necessarily mean the closing of the clinics as far as the Council was concerned. Patients were divided into those needing speciahst advice, who were referred to hospital, and those children who would benefit by supervision and follow-up, but a speciahst would not be necessary for this purpose. The treatment of these latter children is supervised by a school medical officer. This work of inspection and advice is thus closely allied to the work carried out at special investigation clinics. Other Regional Hospital Boards will follow a similar line when vacancies for rheumatism advisory clinic specialists arise. Special investigation clinics (new classification) In view of the development of the consultative, existing special investigation and nutrition clinics already described, and of the future use of rheumatism supervisory clinics, there is no longer any need to distinguish between these various types of clinic and it is more satisfactory to have only one type called ' special investigation ' to deal with pupils requiring further inspection, investigation, supervision or advice. Divisional medical officers have surveyed the facilities available in their divisions and have made any necessary adjustments, such as combining existing sessions or arranging new sessions where the need arises. The treatment statistics given later should be read in the light of what has been written above. The reclassified special investigation clinics, which include the nutrition clinics, commenced operation on 1st July, 1956, and consequently the figures for nutrition clinics are applicable to only half the year. Those for the rheumatism supervisory clinics are lower than those for 1955 because of the transfer of some of the work to special investigation clinics. Accordingly, the returns for the special investigation clinics are considerably higher than for 1955. Special investigation clinics— problem and potential problem families Miss T. E. Watts, an assistant organiser of children care work in the public health department writes : Constructive preventive case work for families referred to these clinics by school doctors, minor ailments clinics and, occasionally, infant welfare clinics is now possible. These families often present psychological, physical or moral problems. ' Hard core ' families, where one or both parents are mentally backward are often dealt with. The referral of a child because of some symptom of disturbed behaviour such as nail biting, nervous tics or anti-social behaviour by a school medical officer, often points to disharmony in the home and the possible uncovering of a family problem. 108 The fact that the mother has brought her child for some specific difficulty and not because there is a reflection on her management of him encourages her to pour out her troubles; she will often accept advice readily from a clinic doctor and the mere talking about her difficulties is a tonic to her. The doctor by recommending a child for boarding open air school or recuperative holiday, thereby relieving tension in a family, may save a complete breakdown. The nurse at the clinic often knows the family well and so has a valuable contribution to make. The social worker, a children's care organiser in the public health department, is in constant touch with the school care organisation and thus has reports of the home and the child's progress at school. Her training and knowledge of the social services enable her to co-ordinate to the family's advantage the help that can be given by other agencies and all concerned endeavour as a team to prevent family breakdown. An example of what is being done is a 'hard core' family, the despair of everyone concerned, and in whose case the only solution appeared to be to take into care the children. The problem was discussed in the light of all the information available and as a result it was decided to ask for a special home help, for two children to be sent to boarding open air school and two children to a nursery school. This family so improved that the National Society for the Prevention of Cruelty to Children was able to discontinue supervision. Clinics are often held in health or welfare centres where other services such as the home help service, the health visiting service, the dental service, are available and as co-ordination with other social workers is as important as a good relationship with the family, it is an enormous help to have a good everyday relationship with them. A child from a problem family was in urgent need of dental treatment and was seen by the dentist and dental attendant after an appointment made at special investigation clinic where the mother—who until then had always been 'anti-dentist' as her husband believed all fillings fell out !—was persuaded to attend the clinic. The child subsequently received treatment. As indicated earlier special investigation clinics with their appointment system and nursing and medico-social help, provide better conditions for the handling of difficult problems by the medical officer than would be possible at school medical inspections. It may be that these clinics will prove most useful in the field of mental health, with advances corresponding to those made in this field in the care of the pre-school child. 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 1955 are shown in brackets) : Type of clinic Minor Ailments (doctors' sessions) 86 (88) *Dental 66 (65) †Vision 44 (44) † Orthoptic 13 (13) †Ear, Nose and Throat 8 (8) Audiology 11 (11) ‡Speech Therapy 41 (37) †Enuresis 1 (1) **Special Investigation 39 (21) †Rheumatism (Supervisory) 12 (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., 16 in PH., and 7 in residential schools. ** Includes nutrition (see page 102). Treatment of school pupils at hospitals The co-operation between the London school health service and the hospitals dates back to the earliest days of the school health service, a Children's Care Organiser being appointed as long ago as 1911 to the London Hospital to direct the flow of patients and 109 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. 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 Discharged— attendances treatment complete Children's 272 978 121 Ear, Nose and Throat 264 590 149 Vision 123 1,417 594* Orthoptic 19 553 † Orthopaedic 100 183 76 * Spectacles either obtained or not needed. † Not available. The total number of attendances of school-pupils seen in departments of the hospital attended by the organisers was 4,427. Treatment statistics Ministry or education returns call tor information on all treatment known to have been provided whether by the Council or otherwise. Such statistics are necessarily incomplete, since no figures are available from general medical and dental practitioners, opticians or from the many hospitals that have no direct link with the Council's organisers. Even at some of the co-operating hospitals, the medical records and documentation adopted by the hospitals, for the purposes of their own returns to the Ministry of Health, do not enable separate figures for the L.C.C. school-pupils to be extracted. Care should, therefore, be exercised before attempting to draw conclusions about the incidence of defects or the extent to which treatment has been obtained, from the figures that follow : Type of clinic 1954 1955 1956 *Vision New cases 34,420 34,425 35,637 Attendances 94,176 93,082 92,904 *Orthoptic New cases 1,410 1,276 1,275 Attendances 11,643 11,200 10,455 *Ear, Nose and Throat New cases 6,439 4,642 4,194 Attendances 15,056 11,826 10,880 Audiology New cases 1,153 1,164 1,234 Attendances 2,954 3,299 3,318 Minor Ailments New cases 166,173 165,558 157,957 Attendances 757,220 739,923 684,507 Dental New cases 129,712 121,362 115,587 Attendances 300,912 317,684 332,785 *Rheumatism New cases 786 613 503 Attendances 5,681 5,003 3,997 Nutrition New cases 1,090 933 526 Attendances 10,594 9,565 5,136 *Enuresis New cases 592 535 409 Attendances 3,466 3,275 3,016 Special Investigation New cases 904 867 1,202 Attendances 5,626 5,587 9,290 * Hospital and specialist services provided by boards of governors or regional hospital boards. 110 Ill H 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 1956 and the preceding years are given below : Cases of infectious illness involving exclusion or absence reported from schools in 1956 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 1956 8,424 4 1,775 354 2,903 6,059 280 66 49 53 1,020 1,857 These figures are uncorrected for diagnosis, but they form the best available index of the trend of infectious disease in the child community and are the only figures available in respect of diseases which are not statutorily notifiable. When the number of cases of infectious disease reported from a particular school indicates the possibility of an outbreak, special visits are made by a school health visitor 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 nearly 11,000 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 46 63 Partially sighted 304 — — 8 Deaf and partially deaf 297* 34 — 86 Physically handicapped 1,088 72 359 61 Delicate 1,385 205 — 133 Educationally sub-normal 3,379 568 — 58 Epileptic — — — 42 Maladjusted 38 233 56 289 * Includes 62 pupils in partially deaf units. In addition, part-time special educational treatment at day special classes was provided for 302 maladjusted pupils and 1,821 pupils with speech defects. year the numbers or new formal ascertainments were as follows : Day Boarding Blind — 13 Partially sighted 41 — Deaf and partially deaf 50 7 Delicate 391 575* E.S.N 808 106 Epileptic — 11 Maladjusted 107 205 Physically handicapped 235 9 Speech defect 1,037 511 Dual defect — 53 * Including diabetic and E.S.N./Delicate. † Including 30 pupils already E.S.N, and 17 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 126 12 Physically handicapped 116 6 Partially sighted 20 — Maladjusted 124 16 Deaf and partially deaf 19 1 Epileptic — 2 Blind — 3 Speech defect 396 — 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. Educationally sub-normal children 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 after leaving school. 112 Details of the numbers reported under this section are given below : Section 57 (3)—Incapable of receiving education : Children not in any school 97 Children in normal schools 1 Children in special schools 102 200 Sections 57 (3) and (4)—Inexpedient to educate with other children 4 Section 57 (5)—School leavers 351 In 1956 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. During 1956 six reports were cancelled and all the children concerned were ascertained as educationally sub-normal Cerebral palsy During the year there was in progress a comprehensive statistical survey of all children in the administrative county known to the Council to be sufferers from cerebral palsy. Over 700 completed questionnaires were received from hospitals, institutions, schools, maternity and child welfare centres, etc., but the necessary statistical tabulations and analyses had not been completed by the end of the year. Dr. W. Dunham, who in 1955 was appointed the Council's consultant in cerebral palsy, writes as follows : The subject of infantile cerebral palsy is still a controversial one, but it is agreed that, whatever the kind of palsy, the defect in these conditions is one of brain. It is agreed, too, that palsy interferes with the acquisition of achievements, making the learning of activities called for in everyday life difficult. It follows that children with palsy need help in this learning to achieve competence. If a child fails to learn competence, medical science cannot provide this for him, though it can devise ways in which he can be helped to learn. The Pre-school Child—The child's range of activities expands most rapidly in the early months of life, and the efficiency he achieves in the simplest of these activities forms the foundation on which the more complex are later built. For a child for whom efficiency is difficult of attainment, help must be provided early. To make this possible, early recognition that the child has such a difficulty is essential, though it may well be that the evidence of abnormality is slight. It is with the aim of improving the reliability of the criteria upon which early diagnosis of cerebral palsy can be based that research, initiated under the auspices of the Medical Research Council and continued with the support of Queen Mary's Hospital, Carshalton and the Charing Cross Hospital, has continued during the year in the divisions. The number of babies and young children examined now exceeds 150. A report is being prepared in association with Mrs. Eirene Collis on the findings in the course of this research. As a valuable though incidental outcome of the research, in which medical officers, midwives and health visitors in the divisions have collaborated, 23 babies with cerebral palsy were discovered and referred for special care : it was possible to reassure the mothers of 24 children who had previously been suspected of having cerebral palsy that their children were normal. Children of School Age—The first consideration in arranging schooling for a child with cerebral palsy is, of course, to obtain education appropriate to his intellectual capacity : whether or not he must be given special consideration as a physically handicapped child will depend on his ability to compete without harm with physically normal children. In many instances such children are unable to compete in this way and must be accommodated in day or residential schools for the physically handicapped. The number attending the Council's schools for physically handicapped children during the year was 341, of whom 38, mainly for social reasons, were admitted to residential schools. H* 113 Quite apart from the question of expense, residential provision is avoided wherever possible because of the difficulty of ensuring that the emotional, as well as the educational and physical, requirements of the child are fully met. The responsibility for the child's physical welfare is itself a heavy one. This applies equally to the day schools and the function of the consultant is to give guidance in deciding upon the course to be taken in the best interests of the child. The aim of any special provision for the child with cerebral palsy is to enable him to attain in his everyday life, so far as possible, the same competence as any other child. For him, as for any other child, the attainment of competence in everyday activities demands practice in performing those activities in a normal way, and since it is in the home and at school that practice of everyday activities is of necessity largely carried out, it is vitally necessary that activities practiced there should be performed in a normal way until this is habitual. Activities currently too difficult to be performed in a normal way should be postponed until the necessary competence has been acquired. Thus special provision for these children, if it is to be realistically orientated, must be so planned that those in a position to influence what the child does and the way in which he does it, especially, parents and teachers, use this influence intelligently and consistently. To do so, they must have an understanding of the difficulties of the individual child. Through lectures and through the consultations between the consultant, teachers, school nurses, Care Committee representatives, the parents and the child himself, this understanding is being developed. The Council, in 1943, was responsible for setting up the first special unit in this country for children with cerebral palsy, at Queen Mary's Hospital for children, Carshalton. As an extension of the work of that unit, the first Parents Advice Clinic for the parents of children with cerebral palsy was started at the Lambeth Hospital. The scheme which has been described will, it is hoped, mark a further step forward in the provision of those special facilities necessary for children with cerebral palsy. Physiotherapy for the physically handicapped The arrangements for physiotherapy at day schools for the physically handicapped, described in previous reports, were continued during 1956 and negotiations with various lospital authorities were continued with a view to extending them to other schools. Diabetic pupils The Council maintains a residential hostel for diabetic pupils at Palingswick House, Hammersmith. Children suffering from diabetes mellitus, which cannot be adequately controlled at home and who are of such intelligence as to profit by their stay, are admitted. The principles of 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 105 sessions were held at 41 speech therapy clinics in addition to 42 sessions in 25 day schools for the educationally sub-normal, 28 sessions in 17 day schools for the physically handicapped and 16 sessions in residential schools. During the year 1,088 pupils (including 194 in special schools) were 'ascertained ' under the Handicapped Pupils and School Health Service Regulations, 917 were admitted for treatment and 219 remained on the waiting list. 475 pupils were discharged as either improved or cured and 204 pupils, most of whom showed some improvement, ceased to attend the clinics for various reasons. The number of children under treatment at the end of the year was 1,198. The increased activity during the year was made possible by engaging additional staff, the total on 31st December stood at 15 full-time speech therapists (including one senior therapist), three part-time and eight sessional therapists. Dr. R. E. C. Copithorne, an assistant principal medical officer, writes : Many children with defective speech improve and achieve normal speech after a period of a few months' attendance at a speech clinic. While this is the point to be aimed 114 at and which, it is hoped, every child will reach, it is well known that there is a proportion which will get only so far and for whom continued therapy seems useless. This is true only if the criterion of success is perfection. If a lower standard is accepted the picture becomes brighter, and the stimulus to aim higher in any particular case continuosuly grows as each stepping stone is negotiated. That it is right to accept this lower standard is open to question only if the situation in the field is unknown to the questioner. Though speech is an accepted method of communication in human affairs, it is not an inborn power, and the acquisition of speech is much harder for some children than others. Too often it is forgotten that speech must be learned and the child needs teaching. Teaching may be by organised lessons or, as occurs in most families, by giving an example to be followed. The speech used by the parents, and incidentally the language, is that which will be used by the infant in first starting to speak. Even before words are used the intonation and tune of the words will be copied. The normal infant with all normal faculties will be the best copyist, if there be any reduction in these faculties, almost any one of them, it is likely that speech will be affected. Developmental defects of the mouth such as a cleft palate, or defects, congenital or acquired, of hearing are easily seen to be likely to affect the process of learning speech. Sometimes the importance of vision as an aid to the acquisition of speech is forgotten ; blind children are often slow in developing good speech. When the adult of normal intelligence utters a word it is seen mentally in all its aspects, spelling, meaning, sound and pictured if it be possible to do so ; when this complex is disrupted the state is one of aphasia. This may arise as a result of brain damage, for example after cerebral thrombosis, or cerebral tumour. In the child a similar picture is seen where there is no real aphasia but one of the links is missing. A child with undetected high tone deafness presents a frequent example and it is only when the real handicap is revealed that progress is made in treatment. Mental retardation is another misleading cause of speech difficulty, and it is with this group that this note is specially concerned. It is worth while to give speech therapy to the educationally sub-normal child with defective speech. Though some make rapid progress, most of these children go very slowly. What is learned today is lost tomorrow. Repetition over many months may succeed in effecting great improvement, and speech becomes more developed and comprehensible. Even if, as may well be the case, perfect speech is beyond the capabilities of the child, he will have achieved a very much better standard than had the situation been left as it was. The child is more easily understood in conversation, and is therefore better able to hold its own in the world, he becomes more acceptable to his fellows and altogether more socially competent. Slow progress is the rule and the measure of success can be only an individual one, but there is a measure in nearly every case ; such progress is not evenly, regularly made but proceeds at differing speeds and, as already said, seems sometimes for a time almost to cease. Perseverance, patience and refusal to be discouraged are qualities necessary to the therapist. When children treated in primary schools for the educationally sub-normal move into secondary schools, their relative improvement in speech may regress, so that it is necessary to keep them under observation and, if their old habit of slovenly speech returns, to institute a short course of training. It is in these ways that the weekly attendance of a speech therapist in each of the Council's schools for educationally sub-normal children has been justified. The development of speech therapy for these handicapped children has been a most satisfactory advance. Home and hospital tuition Some handicapped pupils receive tuition at home or hospital in accordance with the provisions of Section 56 of the Education Act, 1944. The numbers vary from day to day, as children are admitted to, or discharged from, hospital, but during 1956 approximately 250 children received such tuition, about 60 to 70 at home, 40 to 50 individually in hospital and about 140 in permanent teaching groups in ten hospitals. 115 Poliomyelitis in 1955 During 1956 an attempt was made to estimate the number of children who would be likely eventually to require special educational treatment as a result of poliomyelitis contracted in 1955. The figures were as follows : Sex Notifications Number with residual paralysis Number estimated to require special educational treatment All Paralytic Boys 415 215 150 48 percentage 51.8 36.1 11.6 Girls 284 151 113 34 percentage 53.2 39.8 12.0 Total 699 366 263 82 percentage 52.4 37.6 11.7 While the usual male excess is present in the incidence of paralytic cases, the percentage figures suggest no sex difference in the severity of paralysis. An analysis of the degree of severity in the 263 cases with residual paralysis was as follows : Slight 117 44.5% Moderate 96 36.5% Severe 50 19.0% 263 These figures may be compared with those quoted in the Monthly Bulletin of the Ministry of Health, 1950.9. p.218, in respect of the 1947 and 1949 epidemics : England and Wales London 1947 % 1949 % 1955 % Slight 41.1 40.5 44.5 Moderate 38.5 38.5 36.5 Severe 20.4 21.0 19.0 The figure of 82 children likely to require special educational treatment is only an estimate, but it must be regarded as realistic, indeed it may be an underestimate, since 146 children were recorded with either moderate or severe paralysis. The 82 cases may be analysed as to age group and sex as follows : Age group Boys Girls Total 0-4 33 12 45 5-11 14 18 32 12-16 1 4 5 48 34 82 This shews that the majority of the 82 will eventually need to be placed in special schools, which should not involve any difficulty. Juvenile rheumatism The diminishing volume of work in the rheumatism advisory clinics is demonstrated below : 116  1954 1955 1956 Number of children under supervision of school doctors (31st December) 147 98 87 Number of children under supervision at rheumatism advisory centres 1,840 1,563 1,118 Number of children attending for first time 786 613 503 Total attendances 5,681 5,003 3,997 Number of rheumatism advisory centres (See also page ) 23 23 20 Dr. R. Cove-Smith, the Council's consultant on rheumatism, writes : It was just thirty years ago that the Council's Rheumatism Scheme was inaugurated at the suggestion of Dr. C. J. Thomas, Principal Medical Officer for School Health at that time, so perhaps a brief review of some of the findings at each decade might not be inappropriate. In 1936 the percentage of children with cardiac involvement admitted to the rheumatism units was 37.7, but by 1946 the figure had risen to 62.4, only to fall again to 40.8 this year. It was in 1941 that the percentage began to rise steeply but as this rise occurred during the war, when there was a reduction in the number of beds available for treatment, it is doubtful whether it represented a real increase in severity or merely the selection of the more severe cases for the beds available. The percentage of cases regarded as permanently unfit on discharge from rheumatism units in 1936 was 2.9 and in 1946 2.4, but in 1956 the figure worked out at 14. Although the percentage of incidence of permanent and severe cardiac damage can be looked upon as a fair indication of the severity of the rheumatic infection these figures are hardly comparable, for whereas in 1936* 2,039 cases were accepted for treatment in rheumatism units and in 1946 591, there were only 49 recorded from Queen Mary's Hospital for Children, Carshalton, in 1956. It would appear that the milder cases are being dealt with adequately elsewhere, and only the more severe cases are seeking hospital admission. Here it should also be mentioned that the rheumatism unit at Queen Mary's Hospital as such has ceased to exist and that rheumatic cases are being nursed in the general wards, so that instead of being sent to Queen Mary's Hospital for long term treatment, the tendency is for the cases to be retained in the general hospitals and then sent to their own convalescent homes or to the Canadian Red Cross Hospital, Taplow, where there is a special rheumatism unit and research work with follow-up investigations is still being carried out. Twelve London children (7 girls, 5 boys) were admitted to and discharged from Taplow during the year. Of these, four had rheumatism with no residual carditis, one chorea with no carditis, one rheumatism and chorea ; three had mitral and aortic disease and three Stills disease. On discharge, eight were fit for ordinary school and four for schools for the physically handicapped. Since the inception of the scheme thirty years ago the streptococcal aetiology of juvenile rheumatism has been established and the pioneer work of Poynton and Paine brought to fruition, but the exact nature of the sensitivity reaction, which causes carditis in a certain proportion of those infected by the haemolytic streptococcus still remains to be elucidated ; nor can we yet say in which cases this is most likely to occur. The association with scarlet fever still persists. Although both are diminishing in severity the seasonal incidence of the two diseases shows little correlation. In 1936 the percentage of the school population accepted for treatment in the rheumatism units was 0.42, but in 1946 this figure had fallen to 0.19, while in 1956 it was 0.01. Nearly twice as many girls as boys were admitted to Queen Mary's Hospital this year and among them the percentage of carditis was much higher, 40.60 per cent, as against 18.25 per cent. * This was the first year in which cases were accepted from the Council s own hospitals as well as outside sources. 117 In 1946 a research into the effects of sulphanilamide prophylaxis on cases with a rheumatic history was carried out by several of the physicians in charge of the rheumatism supervisory centres but the results at that stage were disappointing and unconvincing. Further experience, however, over the last ten years has led to a partial acceptance of this principle of prophylaxis, using oral sulphatriad or penicillin tablets in daily dosage for a period of several years. Some authorities state that this should be kept up till the age of 18 years—an expensive item on the drug bill. Others, however, still feel that the immediate treatment of intercurrent respiratory infections with large doses is better than prolonged prophylaxis in small dosage. The follow-up of cases by the rheumatism supervisory centres and the school doctors still continues to be an important integral part of the scheme. At the 20 supervisory centres 1,118 children, including 503 new cases, gave a total of 3,997 attendances, while school medical officers had 87 cases under regular review. Prevention and remedying of postural defects in school children A number of surveys carried out in the Army during the last war revealed serious faults in foot and body posture in a high percentage of recruits, both young men and women. Dr. Doris Baker, who was at that time attached to the Royal Army Medical Corps, as a specialist in physical medicine, found in a survey of young women in the Auxiliary Territorial Service that breakdowns, due to postural defects, occurred in the young women after they had been carrying out for varying periods the wide range of occupations open to them in that service. The chief weakness was faulty foot posture. By introducing remedial treatment, consisting of specialised daily exercises for short periods, it was found possible to overcome many of these faults, thereby saving the loss of many hours of working time and also inculcating in those concerned a general sense of fitness and well-being. The correction of faults in posture which have become a habit over a number of years, however, presents many difficulties as age advances, and the introduction of suitable exercises during a child's early years to cultivate correct body carriage and correct ways of walking and sitting is, therefore, of paramount importance. Such services may save much personal discomfort in later life. Furthermore, the social and aesthetic value of a good carriage and an appearance of well-being is a valuable asset in all walks of life. In 1946 Dr. Baker was invited to undertake the supervision of special remedial classes for postural foot defects in a number of the Council s primary schools. A selection of suitable children likely to benefit from attendance at these classes was made and teachers who volunteered for this work were given a short preliminary training course at the Council's College of Physical Education. In the first year, classes comprising 10 to 14 children were held at thirty schools, selected in all districts of London, the choice being governed by the amount of time and accommodation that heads and their staffs were able to offer, and some 1,200 children were given special exercises. The results were so successful that it was decided to continue and extend the classes to other schools where teachers could undertake this work. Further courses of training for teachers at the Council's College of Physical Education have been arranged from time to time. In 1950, owing to staffing difficulties caused largely by the growing school population, not only were extensions of the scheme not possible to the large number of schools at which there might be children who could benefit, but some existing classes had to cease. Although consideration was given to other methods of staffing these classes, no alternative proved possible. A tribute is due to the many teachers who, at one time or another, have volunteered for this specialised form of instruction and treatment and to the heads of schools who have encouraged members of their staffs to undertake this work, involving, as it has, the withdrawal of teachers from some of their ordinary class-work and sometimes 118 alterations in the normal school time-table; such success as has been obtained has been, in no small measure, due to their understanding and skill. Children who are considered to be in need of these special exercises are selected by school doctors and are fitted in as and when classes can be arranged. Decisions on the length of time for which treatment should be continued are made periodically by the divisional medical staff, in the light of progress made. Incidentally, it is the opinion of the consultant that an essential feature of treatment by means of these exercises is that they must be given regularly, preferably daily, but certainly not less than four days a week ; little benefit is likely to be derived from exercises given at less frequent intervals. All classes are visited periodically by Dr. Doris Baker who, in 1951, was appointed the Council's Consultant for postural defect work. Inspectors from the College of Physical Education have also given such help and encouragement from time to time as their other duties have permitted. With a view to developing and helping these classes still further, the Council agreed to the appointment of two specially qualified and experienced instructors in remedial exercises, working in the public health department. They took up their appointments in January, 1956, and their duties comprised visiting the schools where remedial classes were being held, and attempting to organise new classes in primary schools wherever there is a need. By the end of 1956 classes were being held in 105 schools, an increase of 50 per cent, over the previous year. Divisional case conferences Psychiatry In each of the nine divisions, a case conference is held regularly to consider problem children. Each conference consists of the education district inspector, the divisional medical officer, the education divisional officer and the district organiser of children's care work (education) and, whenever possible, an educational psychologist attends and headteachers are invited for discussion of children from their schools. During the year, the conferences dealt with a total of 3,802 cases, of which 1,808 were new cases. Of these new cases, 1,377 were referred to child guidance clinics. Child guidance Pressure of work at the Council s four child guidance units continued to be heavy and, on occasion, it was even necessary for a short time to close the waiting list at one of them. Long waiting lists arc most undesirable since they involve a real risk of deterioration in the condition of the child before treatment can begin. Towards the end of the year, therefore, plans began to be formulated for the expansion of the child guidance facilities in the County and it is hoped that it will be possible to report the results in 1957. There were several changes of staff at the units but the filling of vacancies generally proved comparatively easy and work was not seriously hampered thereby. Close liaison was maintained between three of the units and tne local maternity and child welfare services. Regular meetings of both staffs were held, the purpose of which was the education of doctors, nurses and health visitors in the early detection and prevention of maladjustment in families with children under school age. Thefollowing table gives details of the work carried out during the year at the four units : Baltersea Brixton Earls Court Woodberry Down Total No. of applications received 74 217 71 154 516 No. awaiting first interview at 31st December 13 57 25 35 130 No. interviewed and awaiting treatment 15 8 25 15 63 119  Battersea Brixton Earls Court Woodberry Down Total Number of patients In treatment at 1st January 45 133 50 82 310 New cases treated 54 141 59 117 371 Total 99 274 109 199 681 In treatment at 31st December 32 133 46 63 274 Discharged 67 140 63 136 406 No. of follow ups 9 40 49 No. of home visits by psychiatric social worker 7 11 4 50 72 No. of school visits by staff 48 24 291 106 469 Disposal of patients Treatment completed 27 60 24 62 173 Transferred to other treatment 4 12 2 6 24 Further attendance impossible 10 12 10 9 41 Unco-operative 21 40 21 55 137 Placed or placement recommended 3 14 6 3 26 Taken into care 2 2 — 1 5 Total 67 140 63 136 406 Closing status of completed treatments Improved 33 70 26 80 209 No change 34 70 37 56 197 Worse — — — — — Total 67 140 63 136 406 Psychiatric services at boarding special school and residential establishments In accordance with the Council's policy to make available psychiatric advice at all residential establishments for children, efforts continued to be made throughout the year to ensure regular visits of a psychiatrist, assisted by a psychiatric social worker wherever necessary. The demand for these services has been growing, as the value to the staff of the psychiatrist's assistance in handling the children in their care has been more widely appreciated. During 1956, therefore, two new part-time psychiatrists took up duty with the Council. The recruitment of psychiatric social workers for work in the boarding special schools, however, proved very difficult and one of the schools unfortunately had to be left without full coverage for several months. It also proved impossible to fill vacancies for part-time psychiatric social workers at any of the approved schools. Day schools for maladjusted children A second day school for maladjusted children, Moatbridge School in Eltham, was opened during the year and organised in the same way as the Lilian Baylis School, on which I reported in 1955 (page 119). Regular visits were paid by one of the psychiatrists to see individual children and to take part in case conferences and a psychiatric social worker established contact with the children's homes to ensure the co-operation of the parents during out-of-school hours. Miss G. Clarkson and Miss P. Winterbottom, two of the psychiatric social workers allocated to schools for maladjusted children, write : The psychiatric social worker (P.S.W.) in a school for maladjusted children is part of a team who is trying to help emotionally disturbed children to develop to the utmost of their own potentialities, and to help their parents and families to make this possible. While the teaching staff and, in the boarding school, the resident child-care staff too, work directly with the children, the P.S.W. is mainly concerned with the parents, who themselves are frequently very disturbed people with the burden of a disturbed child. 120 The work of the P.S.W. in the day schools for maladjusted children is, like that of the schools themselves, still growing and developing, but a certain pattern is emerging. The fact that the child returns daily to the environment in which his troubles developed, may mean that the period of overt disturbance lasts longer than if he were to go away from home, but the very fact that his problems are, as it were, ' kept on the boil', means that there is something for the P.S.W. and parents to tackle together. In practically every case, the parents are anxious to be co-operative and, as a rule, the child would not have been recommended for day school rather than a boarding school unless it was felt that there was much that was positive about the home. Nevertheless, deep problems do exist in many homes. The difficulties of parents and children are usually intertwined in the most complicated way, and one cannot be tackled without the other. Most, though not all, children come to the school through child guidance clinics, and it is the P.S.W's job to see that co-operation between school clinic and other social agencies is as close as possible. Only about one-third of the children attending day schools for the maladjusted are actually receiving child guidance treatment. In addition to this type of work, there are the more mundane, but equally necessary, practical matters of clothes, holidays, free dinners, etc., to be dealt with. This side of the work is undertaken by arrangement with the district care organiser (Education Department), to avoid having too many visitors to the same family. Dental appointments, incidentally, often provide plenty of scope for the P.S.W., owing to the anxieties they arouse. There was the boy who felt it necessary to go to the dental clinic armed with a large hammer hidden under his jacket—'just, in case . . . One of the joys of the P.S.W's work at Gideon primary school is the fact that she has her office as part of the school, and has constant informal contacts with both staff and children. This kind of give and take is both fascinating and clearly valuable to her in her work. At Bredinghurst, the only boarding school for maladjusted children within the county boundary, the P.S.W. has been working since the beginning of 1950. She is looked upon by the rest of the staff as a member of the team whose main concern is with the parents and families. She spends a certain amount of time actually in the school, where she has her own office, partly attending to correspondence, telephone calls and record keeping but, more especially, in discussion with other members of the staff in a two-way exchange of information and ideas. The P.S.W. attends the weekly staff conference and is in day-to-day consultation with the resident staff, the headteacher and the psycho-therapist who treats the children in the school. In the autumn and winter terms, she leads a weekly evening discussion group of houseparents. Unlike the children at the day schools, no children at Bredinghurst attend child guidance clinics for regular treatment, though they sometimes visit their former clinic in the holidays. This means that the P.S.W. carries the whole of the work normally done by the P.S.W. at the clinic, and works in with other social agencies concerned with the families. Children at such boarding schools are separated temporarily from their families, though they go home for weekends and holidays. This arouses special difficulties for many parents. At first, there is the feeling of relief when the child who is a symptom of the family disturbance is away from home. Sometimes, this feeling turns to one of anger and resentment when other people are, apparently, dealing more successfully with the child. The P.S.W. has to be willing to accept these changing attitudes and to help the parents to bear them. Frequently, the removal of one child from a family uncovers other problems. The P.S.W. is invited into family discussions with other children, whose difficulties were ignored, or unseen, while the maladjusted child remained at home. The results of a P.S.W's work are not often spectacular. Parents with years of practice at being not very successful with their children are not going to change over night, particularly when their own emotional problems are often so deepseated. The wonder is, that so many of them can modify their own attitudes sufficiently so as to be a positive help to their maladjusted children. 121 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 2,376, three approved schools with a total accommodation of 298, two remand homes with accommodation for 142 children, and a number of other smaller establishments—reception centres, small homes, family homes and after-care hostels. At the large establishments a visiting medical officer, appointed by the Council, attended at least once every 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 1956, 4,065 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 the County Hall. Arrangements were made for the dental treatment of the children, and visits were made by the Council's psychiatrists. Research and investigation Mr. Michael Reed, of the audiology unit of the Royal National Throat, Nose and Ear, Hospital, was granted permission to carry out tests in connection with an investigation as to the defect of slight deafness on school children under adverse conditions. Dr. L. Fisch, of the audiology unit at the Royal National Throat, Nose and Ear Hospital, was granted permission to use the school organisation in research projects, to establish the incidence of deafness (a) in children suffering from cerebral palsy, and (b) in educationally sub-normal children. 122 DENTAL SERVICES the council's Chief Dental Officer and Principal School Dental Officer reports as follows : Some progress can be recorded in most aspects of the dental service for the year 1956 (graphs on page 126). While total numbers employed remained far below the desired establishment of 142 full-time dental officers, staff turn-over was not so alarming as in immediately preceding years. A slight increase in staff, plus an additional number of voluntary overtime sessions, resulted in an increase of 1,500 sessions compared with the number in 1955. School dental service Two disturbing figures emerge however from statistical computations : (i) the continued rise in percentage of school-children found on inspection to require dental attention (Table II) and (ii) the retrogression in the filling : extraction ratio (Table III). The former is beyond the control of dental officers but the latter can be influenced by the nature of the attention given to patients who attend for treatment. It is difficult, however, if not impossible, to give in every instance the desired standard of treatment in a dental surgery which is affected by the demands of far too many patients. The average staff: pupil ratio throughout the county remained at a very unsatisfactory and gravely overloaded figure with one full-time dental officer to each 6,100 schoolchildren. Health division 7 proved worst at 1 : 8,000 and health division 2 was best with a ratio of 1 : 4,500 which is, nevertheless, still excessive. With such ratios, regular and systematic dental inspection followed by thorough attention is impossible, and it is perhaps fortunate for all concerned that a considerable number of parents undertook to have their children treated privately. Not all parents, however, who state they will adopt this course do in fact do so, their failure being due either to procrastination or to inability to find a private practitioner able and willing to accept child patients. Neglected mouths with extensive caries or other faults remained all too prevalent throughout the year. Table I Year Establishment approved temporarily (fulltime positions) Staff Equivalent in Full-time staff Sessions Total Sessions per week Total Number employed Fulltime Parttime School Service MCW Service School Service MCW Service School service MCW service Fulltime Parttime Fulltime Parttime (Dec.) 1954 93 114 54 60 68 6 2/11 569 179 41 27 748 68 (Dec.) 1955 93 116 49 67 67 -10½/11 5 2½/11 527½ 220 33½ 24 747½ 57½ (Dec.) 1956 95 122 52 70 73 4½/11 6 4/11 561 ½ 246 42 ½ 27 ½ 807 ½ 70 123 An increased number of surgeries were renovated and re-equipped with more modern apparatus—an improvement aimed at better service resulting from better working conditions and retention of staff. Throughout the year recruitment of sufficient dental attendants proved almost as difficult as engagement of dental officers and in consequence a number of untrained girls were accepted and, following a brief period of instruction, were posted to duty. I would like to record my appreciation of the excellent and valuable assistance given by the dental attendants ; in particular in surgeries staffed by part-time dental officers. Table I shows the numbers of dental officers at the end of the year with comparative figures for the preceding two years. The comparative figures given in Table II relate to the school dental service and show increases under most headings. In spite of the increase in number of sessions, the total cases treated fell slightly ; but total attendances rose—an indication that treatment was, possibly, more thorough and that at least some children attended a greater number of times to be rendered dentally fit. In attempting an accurate comparison of attendances in 1956 with previous years' figures, there is some confusion as, for the first time, attendances for orthodontic treatment are also included in total attendances. The rise in the number of permanent teeth requiring extraction is to be deplored. Table II 1954 1955 1956 Number of inspection sessions held at schools 2,056 2,008 2,111 Number of children inspected at schools by dental officers 199,041 202,242 213,957 Number found to require treatment 139,955 151,326 163,414 Percentage requiring treatment 70.3% 74.8% 76.4% Additional number inspected at centres 67,604 50,887 44,078 Total number found to require treatment 207,559 202,213 207,492 Total cases treated 129,712 121,362 115,587 Attendances 300,912 317,684 332,785 Ordinary treatment sessions 29,022 29,698 31,257 General anaesthetic sessions 1,939 1,578 1,708 Temporary teeth extracted 108,825 83,539 83,341 Permanent teeth extracted 21,095 16,527 19,992 Temporary teeth restored by fillings 46,256 45,256 43,474 Permanent teeth restored by fillings 112,226 122,097 129,931 Fillings in temporary teeth 49,148 48,075 46,088 Fillings in permanent teeth 124,974 135,384 144,746 Other operations— temporary teeth 65,280 62,496 58,808 permanent teeth 57,086 65,811 68,972 Local anaesthetics for extraction 21,216 17,341 16,195 Local anaesthetics for conservative treatment 8,352 7,130 9,494 General anaesthetics 43,899 36,099 38,740 Cases for whom immediate treatment was completed 17,474 13,744 11,614 Cases discharged as dentally fit 86,957 80,964 79,994 Table III Ratio of permanent teeth restored to permanent teeth extracted in schoolchildren 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 1956 6.50 to 1 124 Orthodontics In the specialised field of orthodontic treatment during 1956 there was little change in the surgeries but much effort was expended in pursuing possibilities of closer liaison with hospital and dental teaching authorities with a view to their increasing their contribution to this work. While no very effective results were apparent in the report for the year, hopes were raised that some progress would be made in the near future. The main problem everywhere was the shortage of manpower and this had a particularly serious effect upon the orthodontic service with its demand for more advanced techniques. Table IV shows improvement in total numbers accepted for orthodontic treatment. Table IV 1954 1955 1956 Number of special orthodontic sessions 134 185 290 Number accepted at special orthodontic sessions 98 195 252 Number accepted at routine sessions 389 432 427 Number referred to hospitals 127 59 182 Total number of patients accepted 614 686 861 Maternity and child welfare dental service Statistical figures in Table V for this service show only relatively slight fluctuations for 1956. Any drive to increase the service results, in present circumstances, in a corresponding reduction in the school service and policy for a further year was to maintain the service already given : approximately 10 per cent, of the total dental effort. All patients recommended and responding were dealt with but no systematic dental inspection and advice were attempted. Table V Attendances and treatments of maternity and child welfare patients 1954 1955 1956 Number of sessions 3,033 3,220 3,169 Number of appointments offered 33,797 35,854 36,711 Attendances—by appointment 24,692 26,430 27,640 —other 1,873 1,526 1,799 Silver nitrate treatment 4,433 5,058 4,716 Fillings 12,312 13,212 13,465 Extractions 10,157 9,177 9,561 Dentures supplied—new full 461 572 538 —new partial 646 686 778 Number made dentally fit 6,802 7,117 7,492 Dental service in hoarding schools and residential establishments Visiting dental officers or local practitioners, under a variety of contracts, continued to deal with the dental needs of children in the Council's care or at boarding schools, but at some establishments the problems of escort and transport remained very troublesome. 126 STAFF the staff employed in the public health department is set out in Appendix E on page 241. Staff training Refresher courses As in previous years arrangements were made for many of the medical, nursing and other professional staff to attend refresher courses to keep them abreast of developments in their respective fields. For medical staff, where the general aim is that each officer shall receive the equivalent of one week's refresher training every five years, courses in paediatrics and school health organised by the British Post-graduate Medical Federation and the Society of Medical Officers of Health were well supported, these being attended by over sixty officers. During the year rather more than a hundred members of the nursing and midwifery staff attended post-certificate refresher courses organised by their professional associations. In-service training included short courses of lectures given at the County Hall, by lecturers eminent in their particular fields, for ward sisters in welfare homes and for nurses in boarding special schools with the object of keeping them in touch with new developments and techniques ; in addition lectures were arranged on a divisional basis. In collaboration with the Central Council for Health Education a series of in-service training courses and lectures were arranged for members of the staff of the Department. These proved very popular and instructive and dealt with the education and care of women in childbirth, the avenues of approach to foot health, the construction of visual aids and presentation of displays in welfare centres. When the Report of the Working Party on the Recruitment and Training of Health Visitors was published a lecture on the report was given to health visitors and other nursing staff by Dr. A. Beauchamp, a member of the Working Party. Reference is made elsewhere in this report (page 67) to refresher training provided for domiciliary midwives during the year. Post-entry Training it is opportune to mention the extent to which post-entry training ot administrative and clerical staff had developed by 1956. New entrants attend compulsorily a series of lectures, given by senior officers of the department, both on local government and the health services generally and on particular aspects of the Council's administration of the health services and also attend meetings of the Council and of the Health Committee and visit various establishments to see the health services in action. In addition, under service-wide arrangements most new entrants go to a 3-day residential induction course at which they are given an insight into the organisation and administration of the Council's services generally. For intermediate grades of administrative staff series of meetings are arranged consisting of talks and discussion groups covering a variety of subjects associated with local government in general and the Council's own administration. These meetings, which are well supported though attendance is quite voluntary, are proving valuable both in the imparting of knowledge and in giving staff an opportunity of voicing their opinions in open discussion. Health visitors The increasing demand on the services of health visitors to give guidance in homes faced with difficult situations particularly where advice on the availability of the various social services is needed, led to an experimental course in social case-work being introduced late in 1955. The course, which comprised eight fortnightly half-day sessions in the form of seminars attended by eighteen health visitors and led by a lecturer in social studies from the London School of Economics, was completed early in 1956 and proved most successful. It is intended that as many health visitors as possible shall receive this special form of training and a second course for a further eighteen visitors started in the autumn. Training of student health visitors The University of London Institute of Education continued to provide the theoretical instruction for the majority of the Council's student health visitors. Of the remainder, some received it at the Battersea College of Technology and others at the Royal College of Nursing. 127 J Nearly 50 per cent. (i.e., 134) of the students successfully trained since 1948 and appointed to the Council's staff as health visitors are still in the service. At 31.12.56, 50 students were undergoing training. Training student hospital nurses Associated with an increase in the number of students has been the appointment of an additional health visitor tutor and the up-grading of the former health visitor tutor to principal health visitor tutor. Members of the medical and nursing staff continued to give instruction to student nurses at hospitals and to other students throughout the year. Staff medical examinations The number or references to the department tor medical examination, tor advice concerning the health of staff and for the fitness of candidates for appointment totalled 15,598 compared with 14,657 in 1955. Members of the staff found to be permanently unfit for further duty with the Council numbered 302 and 297 candidates were found to be unfit for appointment. Under reciprocal arrangements, provincial medical officers of health arranged for the examination of 69 entrants to the Council's service and the Council's medical officers examined 76 candidates for provincial appointments. The staff medical examiners made 108 home visits to examine members of the staff who were unable to travel, compared with 81 in 1955. Food-handlers in contact with infectious disease Arrangements were continued tor the bacteriological examination of specimens from members of the food-handling staft in Council establishments 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. In order to comply with the requirements of the Food Hygiene Regulations, 1955, the public health department became responsible for the duty of notifying the appropriate metropolitan borough medical officers of health whenever a member of the Council's food-handling staff was found to be suffering from, or a carrier of, any of certain specified diseases. Details of the procedure being followed to deal with each case were also included to prevent the possibility of duplication of action. During the year, 446 persons (including 139 contacts) were referred for bacteriological examination, all but 16 of whom were allowed to resume work after examination. These figures compared with 252 persons referred (58 contacts) in the previous year. The 16 who were regarded as infectious were referred to their private doctors for treatment before being allowed to return to duty. 128 FINANCE the total capital expenditure on the health services of the Council in the year ended Capital 31st March, 1956, was .£56,813, details of which are as follows: Ambulance service:— £ Acquisition, erection and adaptation 12,306 Waterloo Road—adaptation and equipment 14,332 Reinstatement after war damage 4,552 Day nurseries—erection, adaptation, repair 1,384 Hostels:— Cromwell Lodge—acquisition, adaptation and equipment 7,940 Dover Lodge—adaptation and equipment 5,180 Maternity and child welfare centres-—acquisition, erection, equipment 10,500 Occupation Centres—adaptation 238 Other establishments 381 £56,813 The gross cost of the various services in 1955-56—including central administrative Maintenance and debt charges—and the contributions recovered from recipients of the services were: Service Cost Amount recovered in charges £ £ Ambulance service 965,773 — Day nurseries 1,021,543 203,734 Domiciliary midwifery service 197,416 — General health services (including £183,205 contribution to Metropolitan Borough Councils for salaries of sanitary officers) 213,522 — Health centres 27,043 — Health visiting 331,059 — Maternity and child welfare 635,592 45,784 Mental health 210,728 — Prevention of illness— Home nursing 422,087 — Domestic help 846,956 44,740 Other preventive services 484,569 29,661 School health 847,885 6,671 £6,204,173 £330,590 The net cost of the services after allowing for Government grant, expressed in terms of rate in the £ was 11.87d., divided as follows: d. Ambulance service 1.92 Day nurseries 1.57 Domestic help service 1.67 Domiciliary midwifery service .38 General health services .83 Health visiting .68 Home nursing .88 Maternity and child welfare 1.2 Mental health .42 Prevention of illness (care and after-care; chest clinics, foot clinics, etc.) .8 Vaccination and immunisation .14 School health 1.38 11.87 129 j* VISITORS TO THE DEPARTMENT Visitors during the year visitors were received in the department from many parts ot the world, facilities being given for visits to various clinics and premises of the Council including maternity and child welfare centres, day nurseries, school treatment centres and speech therapy clinics. A large number of talks with senior medical, nursing and administrative members of the staff were also arranged. Programmes were provided for 343 visitors from 57 overseas countries and colonies and many of these included a visit to Woodberry Down Health Centre where a total of 876 visitors excluding students were received. (See report of Divisional Medical Officer, Division 4, page 138). Arrangements were also made for 465 visitors to occupation centres for the mentally defective. Students The department was pleased to assist medical, nursing and social science students by affording facilities for visits in groups and arranging talks on various aspects of the work. Apart from hospital student nurses, of whom 3,736 were received in the department during the year, students were received from the following training centres: Royal College of Nursing Battersea College of Technology Queen Elizabeth College Battersea College of Domestic Science Bedford College South-East Essex Technical Training College University of London Surrey County Council King Edward's Hospital Fund National Training College of Domestic Subjects. As in previous years health visitor students from the Royal College of Nursing and Battersea College of Technology received practical training with the nursing staff in the divisions and arrangements were made for them to have insight into the work of the various other departments of the Council. Requests were received from 72 post-graduate students studying for the Diploma in Child Health for facilities to visit premises relating to the maternity and child welfare and school health services under the supervision of the medical staff, as required by the regulations governing entry to the examination. During the year some 830 visits were arranged for these students. In addition 60 visits were arranged for 50 post-graduate students preparing for the Certificate in Public Health. 130 REPORTS BY THE DIVISIONAL MEDICAL OFFICERS Division 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington. Dr. B. E. A. Sharpe reports: Divisional Medical Officer Although this report appears under my name, the division was under the direction of Dr. Violet I. Russell until her retirement on 20th October, 1956, so that for the most part I am reporting on her behalf. Dr. Russell had been associated with the local health services in the division, to the success of which she had made a great contribution, since its inception in 1948 and with the maternity and child-welfare services in the Royal Borough of Kensington previously. The Divisional Health Committee placed on record their high appreciation of her magnificent work. Vital statistics The downward trend in the birth-rate which had been noticeable for some years halted in 1956, the total births being 10 per cent. more than last year with a 7 per cent. increase in the number of home confinements. Welfare of mothers and children As might be expected the higher birth-rate was rehected in an increase m attendances at the Council's ante-natal sessions, the total being 774 greater than in the previous year, but surprisingly attendances at the infant-welfare sessions fell by 1,711. The number of visits paid by the health visitors increased slightly and the service has maintained its great popularity. Attendances at special sessions arranged at the welfare centres for health education fell slightly but the lectures, demonstrations and filmshows were enthusiastically received by the mothers. Health education receives constant attention and new means of maintaining the interest of mothers are constantly being tried. As an experiment a monthly discussion group for mothers of toddlers was introduced at one welfare centre at which the mothers discussed their problems. The group has proved a great success and it is hoped to establish others. Day nurseries ihe average daily attendances at the day nurseries rose very slightly by just over 3 per cent. in 1956 but there was a further reduction of 19 approved places during the year. The demand for places for children between two and five years of age has fallen steadily but the demand for places for babies will exceed the number of places available, particularly in Hammersmith and Kensington. Necessary redecorations and improvements were carried out at all the buildings and an electric ironing machine and a potatopeeling machine were installed as an experiment at the largest nursery. Childminders The child-minder service continues to grow. Ihere was a 12 per cent. increase in the number of child-minders and an 11 per cent, increase in the number of children minded. The number of voluntary nurseries also rose, from 11 to 14, the number of children in them increasing from 388 to 410. Occasional creches Two creches opened in 1955, in Kensington and Hammersmith respectively, continued to give service to mothers wishing to visit hospitals, go shopping, or engage in other duties. Attendances improved slowly but the demand for these facilities has been less than was expected. Welfare foods The arrangements for the distribution of welfare foods from welfare centres continued satisfactorily. It was found possible to close the distribution centre at 176 Goldhawk Road, W.12, towards the end of the year. Vaccination and immunisation There was a further decrease in the number of children vaccinated against smallpox. Primary vaccinations fell by 3 per cent., and re-vaccinations were 70 per cent. less than last year. It is gratifying to be able to report that the number immunised against diphtheria rose considerably, there being an increase of 10 per cent. in primary immunisations and 86 per cent. in reinforcing injections. Poliomyelitis inoculation At the beginning of the year the proposal of the Ministry of Health to commence inoculation against poliomyelitis was made public and the parents of some 41,000 children born between 1947 and 1954 were informed of the scheme. The parents of just over one-third of the children gave their consent to the inoculation but the supplies of vaccine received were sufficient only for 1,356 to receive two injections and 368 one injection. Two-thirds of the children invited attended for the first inoculation and of 131 these 90 per cent. also received the second inoculation. Altogether fifty-three special sessions were held at infant-welfare and school treatment centres in May and June and another five sessions in December. Mental health education Dr. Felix Brown, the consultant psychiatrist, who is the director of the Earls Court child guidance unit, assisted by one of the Council's psychiatric social workers, commenced the training during the year at one of the welfare centres of a medical officer and health visitors who have a special interest in and aptitude for dealing with problems of mental health in children under five years of age. Later a medical officer and the health visitors from another welfare centre joined the training scheme and for convenience meetings were then held at the child guidance unit. The problems of mental health arising in the course of maternity and child-welfare work are discussed on an individual case basis and guidance is given on their management. The training has proved of great benefit alike to medical officers and health visitors. Behaviour problems A special clinic was held monthly at St. Quintin welfare centre. The number of children seen has been necessarily small, but the work has proved very valuable and the results are encouraging. Neglect and ill-treatment of children The close partnership which has grown up over the years between the health visitors and all other field workers concerned with the prevention of ill-treatment and neglect of children and of juvenile delinquency has been strengthened by the introduction of regular monthly meetings of a divisional standing committee which are attended by all field workers concerned with the cases discussed. Home advice groups The Home Advice guroup formed 111 Kensington last year continued to meet one evening a week at a welfare centre and good progress has been made. A similar group for mothers living in Hammersmith was started during the year and facilities have been given for them to hold their weekly meetings at a welfare centre. Vision sessions During the year the Regional Hospital Boards agreed to an increase in the number of vision sessions in the division, so that at the end of the year three were being held each fortnight and approval had been given for an additional session to start in January, 1957. Special investigation clinics It was decided to hold two special investigations each month, one in the south and one in the north of the division, for children showing mild behaviour-problems and for those children needing a more thorough medical examination than is possible at a routine inspection. The southern clinic started in December and the northern clinic was arranged to start in January, 1957. Tuberculosis B.C.G. vaccination The scheme first introduced in 1954 for inoculating with B.C.G. children in secondary schools in the year preceding their fourteenth birthday was again repeated. Consents were received for about 71 per cent. of the children and of these approximately 85 per cent. gave a negative reaction to the Mantoux test and were given B.C.G. vaccine. Arrangements were made for children who were found to give a positive reaction to be followed-up by X-ray examination. Domiciliary care of the tuberculous The earlier admission of patients to sanatoria and recent advances in treatment have again resulted in fewer patients being cared for at home and requests for extra nourishment have further declined. The twenty-eight beds at Hurlingham Lodge hostel remained fully occupied. There has been a slight increase in the number of men taking up outside employment. An old greenhouse in the hostel grounds was adapted as a workshop where residents can undertake handicrafts or other work in which they are interested. So far activities have been restricted to rug-making and basket work. Home help service As in previous years tne demand for home helps increased. The difficulity in recruiting home helps in Chelsea improved to some extent and help was provided wherever it was most needed. The demand continued for the provision of morning and evening home help in homes from which the mother was temporarily absent, the home helps carrying out all the duties which would normally be undertaken for the children by their mothers. 132 Child help In addition to a resident child help who was provided for a few days at the beginning of the year to look after two children whose mother had died and whose father was under treatment in hospital, another child help was employed to look after eight children between one and thirteen years while the mother was in hospital for two periods amounting to twenty-one weeks in all, the father being employed entirely on night work. Night attendance— chronic sick Few requests tor this service were received during tne year. Prevention of break-up of families Some expansion or the domestic help service was approved by the Health Committee to permit of the employment of selected home helps to teach housecraft to mothers in their own homes when the health visitor considered there was imminent or potential risk of a family break-up. Two home helps from each of the four areas in the division received a short course of training and each of them has since carried out useful work among some of the families in the division. Home nursing As in previous years the number ot home nursing visits increased and the district nurses continued to maintain an excellent standard. Their work is of exceptional value because it eases the strain on hospitals and similar institutions and enables old people to remain in the comfort and security of their own homes. Loan equipment Requests trom general practitioners and the district nursing associations tor the loan of home nursing equipment continued to increase. The provision of this equipment undoubtedly helps the work of the district nurses and relatives nursing patients in their own homes. Chiropody There has been no diminution in attendances at the root clinics and the waiting lists are still heavy with a six to eight-week period between appointments. With the cooperation of the London Ambulance service, it has been possible to convey some homebound patients to the clinics for treatment. Office hours Towards the end ot the year was introduced a change in the office hours of the administrative and clerical staff, giving them more free Saturdays in return for longer hours of duty. The new hours have proved satisfactory in operation and the service to the public has not been affected. Staff changes During the year Dr. R. H. Simpson, deputy divisional medical officer, and Miss M. B. Edwards, divisional treatment organiser, retired after many years of loyal and distinguished service in the School Health Service. We were pleased to welcome Dr. E. M. Cran as deputy divisional medical officer on transfer from a similar position in Division 7 and Miss K. Blagdon on promotion to the position of divisional treatment organiser. I should like to express on behalf of Dr. Russell and myself sincere thanks to the Chairman and members of the Divisional Health Committee for their constant support and interest and to our colleagues on the divisional staff for their unfailing and willing help, and also to acknowledge with gratitude the co-operation of the borough medical officers of health, of the staff of all departments of the Council and of the members and staff of the many voluntary committees and associations in the division. Division 2, comprising the boroughs of Hampstead, Paddington, St. Marylebone, St. Pancras and Westminster. Dr. H. L. Oldershaw reports: Day nurseries and child- minders During the year, four Council day nurseries with a total of 186 places were closed, all but a few of the children involved being transferred to other nurseries, without hardship. Occupation of the remaining 19 Council nurseries remained at the same level85 per cent.—as at the end of 1955. The number of private day nurseries registered under the Nurseries and ChildMinders Regulation Act, 1948, dropped during the year, from 21 to 19, representing a reduction of 51 places, and the number of statutorily registered child-minders under the Act decreased from 15 to 12, with a consequent reduction of 15 children minded. 133 There were, however, six more voluntarily registered child-minders at the end of the year than at the beginning, making a total of 100 taking 119 children, an increase of 25 children. Home help service As in past years the number of families calling on the services of the home helps continued to increase, 4,459 were served in 1956, against 4,092 in 1955. Once more 76 per cent. were aged, infirm or suffering from chronic illness. Four patients were supplied with night help for a total of 7 nights. This service continued to make a valuable contribution towards the prevention of break-up of families, under which heading details are given. Prevention of break-up of families The unfortunate effects on children of separation from their famines is well known, and every effort is made to prevent the break-up of families, even for short periods. During the year, the use of the various health services has enabled 486 children to remain at home during periods of temporary family difficulty, such as illness of the mother, who would otherwise have had to go into residential homes. For 140 children this was achieved by providing home help, either during the day or in the early morning and evening. There were 89 children admitted to day nurseries, and in the remaining 257 cases the health visitors were able to suggest or make other arrangements, such as the use of child-minders or neighbours. In April four home helps were trained to give intensive help in home making to families in danger of breaking up because of more serious difficulties. Six families, with 29 children, subsequently received help and although progress was necessarily slow, a definite improvement was apparent in most families by the end of the year. The efforts of all persons interested in such problem families, both in this department and in the Children's, Education and Welfare departments, together with probation officers, housing officers, Family Service Units and many others, are co-ordinated by a Committee which all attend as necessary, under the chairmanship of the Deputy Divisional Medical Officer. Eleven such meetings were held during 1956 at which 15 families were discussed. School medical treatment As a general rule medical treatment is arranged at the school treatment centres with little delay and the facilities available appear to be quite adequate. In the five Hospitals (Paddington General Hospital, St. Mary's Hospital, W.2, University College Hospital, Hampstead General Hospital, and Whittington Hospital (Highgate Wing)) where special clinics are held for L.C.C. children, arrangements run smoothly and there is very good co-operation between the Hospitals and ourselves. Dental treatment During the year dental inspections have been held regularly in all parts of the division. There are only very short waiting lists for treatment at the various centres. Evening dental sessions are held where necessary for the older children and also for expectant and nursing mothers. Special investigation clinics There has been an interesting development with regard to spccial investigation clinics. An increasing number of cases are being referred to these clinics by the Education Officer's Problem Cases Conference as it is realised that the doctor there is able to discuss fully with the parents the problems connected with the child. In some cases referral to a child guidance clinic may eventually be necessary but in other cases the need does not arise. Diphtheria and whooping cough There was an increase in the number of children immunised against diphtheria during the year. No less than 5,355 children were given primary immunisation, including 4,635 who received combined diphtheria/whooping cough immunisation, compared with 5,077 and 3,779 last year; and 7,400 were given reinforcing doses, a noticeable improvement on the figure of 5,662 for the previous year. Only 75 children received immunisation against whooping cough alone, an indication of the popularity of combined injections. Smallpox 4,645 children (only 58 of whom were over 5 years of age) were vaccinated against smallpox, a slight increase on the 4,390 vaccinated in the previous year. 134 Poliomyelitis In March the parents of all children born on or between 1st January, 1947 and 31st December, 1954 were invited to register their children for inoculation against poliomyelitis. Of the 46,291 eligible children in this division, 14,318 (30.9 per cent.) were registered, and the amount of vaccine subsequently received during the year enabled 1,799 children to receive a full course of injections (12.6 per cent. of those registered), and 348 to receive one injection (2.4 per cent. of those registered). It is interesting to note that in spite of their parents having applied for them to be inoculated, as many as 696 children who were given appointments failed to arrive, without any explanations being offered or further appointments sought. B.C.G. vaccination B.C.G. Vaccination of 13-year-old children took place during the spring and summer terms this year. The number of children eligible was 4,143, and parental consent was received for 3,061 (73.9 per cent.); 2,978 of these children were skintested, and 2,446 given an injection of B.C.G. vaccine. A positive reaction to the Mantoux test was shown in 504 children and 365 of these were examined by chest X-ray. Only two were found to have abnormal chest conditions. Children given an injection of B.C.G. vaccine in 1955 were re-tested. Of 2,296 concerned, parental consent was received for 1,746, of whom 1,615 were re-tested. Only 48 were found to require re-vaccination. Home nursing equipmem There continued to be a steady demand for various articles of home nursing equipment. A total of 159 requests were dealt with during the year, 93 patients being supplied ; 111 articles were involved, consisting of commodes, hospital beds, dunlopillo mattresses, hoists, wheelchairs and similar articles. Health education Dr. Emrys Davies or the Central Council tor Health Education who judged a poster competition in 1955 took coloured photographs of a number of exhibits which he used to illustrate lectures at the Central Council's Summer school last August. Subsequent to the divisional competition the L.C.C. had a county wide Visual Aids Competition and Miss Akeroyd, tuberculosis visitor, obtained first prize, while Miss Madden, school nursing sister, took the second. A stock of health education equipment is being built up at each centre and staff are given every encouragement to develop health teaching. Conclusion I would again like to express my sincere appreciation of the loyal co-operation and successful work of all my colleagues in the divisional health services. Division 3, comprising the boroughs of Finsbury, Holborn and Islington. Dr. M. C. Polhill, Acting Divisional Medical Officer, reports: Medical Officers Dr. B. E. A. Sharpe, Divisional Medical Officer, was transferred to Division I on 21st October, and her successor (Dr. Wilfrid G. Harding) had not taken up duty at the end of the year. Accordingly, as Acting Divisional Medical Officer, it became my duty to report on the year's work in the division. Dr. J. E. Marshall was transferred to the central office in February and replaced in November bv Dr. M. T. McOuaid. Other senior staff Miss C. Walsh, Divisional Nursing Officer was seconded to the World Health Organisation for two years and left the division in March, being replaced by Miss M. D. Butler. Co-operation with hospitals, general practitioners and other authorities The Hospital for Sick Children continues to be the only hospital from which regular discharge reports on children, which are so valuable for follow-up work, are received as a routine. The scheme for the interchange of medical officers with the staff of that hospital for two sessions a week has continued to be of mutual benefit. Liaison with the hospital services was strengthened by the holding of meetings with hospital almoners and three meetings were held during the year. The Divisional Medical Officer continued to be a member of the National Health Service Liaison Committee for the North Central area of London and was appointed to three sub-committees set up to consider liaison problems at chest clinics, the handicapped child, and the maternity services. Relations between health visitors and general practitioners have continued to be good. 135 During the year, 1,136 student nurses (against 966 in 1955) as well as 54 medical students, 24 nursery nurses and 19 student district nurses were shown the Council's health services in the division, and the senior nursing staff of the division gave lectures and attended discussions in a number of hospitals. These duties, although a substantial burden on the staff, are recognised as important since they give our colleagues some knowledge of the working of branches of the health services with which they might otherwise be unfamiliar. Problem families Monthly divisional case conferences have continued and the division has, with two other divisions, pioneered a scheme whereby the Divisional Treatment Organiser has acted as Secretary to the conference and has done necessary following-up in association with the Divisional Nursing Officer. With the co-operation of various housing authorities it proved possible to rehouse three families for whom bad housing conditions were considered to be a major cause of difficulty. Five families in this division were assisted during the year by home helps specially trained to teach homecraft to problem families, and at the end of the year seven home helps had been trained under the County scheme for this purpose. At the end of the year, 149 families were known who presented special problems of one kind or another. Home help service The three home help service areas were re-organised in June in order to even out, as far as possible, the number of cases in each area and to improve ease of access by the public to the area offices. A total of 226 home helps (the equivalent of 158 whole-time staff) were employed at the end of the year. During the year home help service was provided in 2,025 households because of the needs of aged and chronic sick persons, out of a total of 2,734 households attended, so that the aged and chronic sick accounted for 74.1 per cent. of the total number. Maternity cases represented 4.3 per cent., tuberculosis cases 2.9 per cent. and other cases 18.7 per cent. of the total. At the end of the year the number of persons receiving home-help was 1,215 compared with 1,163 a year earlier. Chiropody Foot clinics for old age pensioners who are not home-bound have been started by the Islington Old People's Welfare Council and six sessions a week are now provided in this way. Foot treatment at home has been provided under the auspices of the North London District Nursing Association (who maintain a voluntary fund for this purpose) for a number of home-bound elderly people nominated by the health visitors. The Council's own foot clinic arrangements were altered at the beginning of December so that Islington residents could have the benefit of eight sessions a week at the East Islington Welfare Centre in Drayton Park, thus saving the journey to the Finsbury health centre, where chiropody was previously concentrated. The total number of sessions provided weekly in the Division remained unchanged however. Attendances at the Council's foot clinics during the year numbered 25,035 against 25,551 in 1955. Care of mothers and young children Fifteen welfare centres and branch centres (including those run by voluntary organisations) were in operation throughout the year, but two branch centres in unsatisfactory premises in church halls were rehoused in better premises near their former sites. Health educational sessions have once more been an important feature of the work of the welfare centres, and the 793 sessions were attended by 7,248 mothers during 1956. Group education does not, however, replace the need for teaching individuals and much of this must be done as well. 55.4 per cent. of expectant mothers attended the Council's ante-natal clinics, and post-natal attendances were also higher than in the past. First attendances of children under one year of age at infant welfare sessions represented 89.2 per cent. of the five births for the year (1955 figure 84 per cent.) and attendances at special toddlers' clinics were well maintained. Attendances at the occasional creches attached to certain welfare centres have been disappointingly low. A welcome increase in the dental work for expectant and nursing mothers and young children was due to special efforts made to follow-up unkept appointments. Day nurseries Seven Council day nurseries and one grant-aided voluntary nursery functioned in 1956. The average percentage occupation through the year was 73.7 but comparison 136 with attendances for previous years would be misleading as Canonbury Place day nursery was out of commission to a varying extent throughout the year owing to extensive structural works, and the number of places actually available fluctuated. The nursery was still not fully available at the end of the year. Of the 364 'nursery weeks' in 1956, some quarantine was in force during 157 weeks, i.e., 43.1 per cent. of the time. There were 63 children on the waiting list for admission to day nurseries at 31st December of whom 55 were in the third priority group. Childminders At the end of the year there were four statutorily registered child-minders in the division caring for 13 children, and 116 voluntarily registered child-minders caring for 117 children. Registration under the Nurseries and Child-Minders Regulation Act, 1948, was also granted to the West London Mission, which runs a grant-aided day nursery in Holborn, in respect of a scheme for day-time care of school children during the holidays when their parents are at work. Vaccination and immunisation Primary courses of immunisation against diphtheria were completed for 4,104 children, representing 77.6 per cent. of the live births, and boosting doses were given to 2,286 school children. Saturday morning sessions for school children had to be discontinued in September and sessions in schools, with the consent and co-operation of the heads, have been arranged in their stead. 3,715 children had completed primary courses of immunisation against whooping cough, and 526 had boosting doses. 3,059 primary vaccinations against smallpox were given. There were two cases of diphtheria in the division in 1956—both adults (aged 20 and 25 years respectively) and neither fatal—and one death from whooping cough—a pre-school child whose parents had refused immunisation. There were 13 cases of poliomyelitis, of which nine were paralytic. Three of the cases (one paralytic) were adults and the rest children (eight paralytic). There were no fatalities, and none of the victims had been immunised against poliomyelitis. Immunisation against poliomyelitis started in this division in May in common with the rest of the country, and in the period to the end of July, 862 children in the division had had a complete course of two injections and 332 had had a first injection only. About 32,000 invitations and consent cards had been sent out to parents and nearly 9,000 were returned. Inoculations were resumed in December, and by the end of the year a further 195 second injections and 162 first injections had been given. School health service Two of the grant-aided voluntary committees providing school treatment centres decided, because of difficulties in replacing members of their committee, to terminate their work during the year and at their request the Council took over the administration of their centres. In the case of the North Islington school treatment centre the change of administration was preceded by a transfer of the centre to premises in Manor Gardens, Islington, already housing the Council's Holloway (Dental) school treatment centre, and the opportunity was taken to merge the two centres under the title of Manor Gardens school treatment centre. Attendances for minor ailments dropped somewhat because the change of location made it necessary for children in some schools to cross the busy Holloway Road to secure treatment. The number of children attending rheumatism supervisory clinics showed a marked upward trend in the last quarter of the year, but it is too soon to say whether this marks the end of the steady decline evident since 1953. Attendances at special investigation clinics (which include the former nutrition clinics) were well maintained. Dental work increased in volume with the return of a dentist to Finsbury health centre at the end of April and fairly regular dental inspections of school children have been held. The Islington bathing centre, which had been closed throughout 1955, was reopened in April. The amount of trained nurses' time allocated to the school health service was equivalent to nearly 22 whole-time staff. 35 of the staff are engaged on combined health visiting and school nursing work. 137 Tuberculosis The B.C.G. unit operating north of the Thames visited the division in the early summer and carried out B.C.G. vaccination of the 13-year-old children in 36 schools. Of parents asked to consent to B.C.G. vaccination of their children 69.6 per cent. did so. The Islington Mass X-ray unit, which has been stationed at the rear of the maternity and child welfare centre at Drayton Park, Islington, continued to be used throughout the year for routine examination of teaching and other staff. One case of tuberculosis occurred among the teaching staff of an evening college for adults. An epidemiological investigation was made in the course of which the remainder of the staff were X-rayed but no abnormalities were found. It was not practicable to follow up all the students concerned. The diversional therapy scheme for home-bound tuberculous patients, which started in the latter part of 1955, became well established during 1956. In Islington, two wholetime occupational therapists are now employed, and a further two sessions weekly have been found sufficient for patients' needs in the rest of the division. Grants amounting to £187 were paid during 1956 for the purchase of materials and equipment for the scheme, and at the end of the year 38 persons were benefiting from the service. Recuperative holidays were provided for 64 tuberculous persons in 1956—four more than in the preceding year—and at the end of December extra nourishment was being supplied, on the advice of the chest physician, to 144 persons. The accommodation at the hostel for tuberculous men at Cromwell Lodge was temporarily reduced to 24 during a part of the year to permit interior redecorations to be carried out. During the year 26 men were admitted and 27 left, 26 remaining in residence at the end of the year. Islington Centenary Exhibition The Islington Borough Council invited the Council to participate in an exhibition organised to commemorate the centenary of the appointment of the first Medical Officer of Health of that Borough. Exhibits illustrating the history of the services for maternal and child care, care of the elderly and control of infectious diseases were shown jointly by the Borough Council and this Council with other agencies, whilst this Council was solely responsible for the provision of exhibits on the history of the midwifery, school health and ambulance services. Very generous assistance was given by the Royal College of Midwives in presenting the display dealing with midwifery. Conclusion Our relations with the statutory and voluntary bodies in the division have continued to be marked by the greatest cordiality. To their officers, to the members of the Divisional Health Committee, and to the divisional staff I wish to express my thanks for their assistance, guidance and co-operation which have resulted in a fruitful year's work. Division 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports: Woodberry Down health centre The services provided at the Health Centre continue to develop, notable additions during the year being the provision of a pathological laboratory service (two sessions weekly) and an increase from two to four in the weekly physiotherapy sessions for general practitioners' patients. These services are available to general practitioners working in the centre and to those practising within a mile radius of it. Towards the end of the year a class for auditory training of young deaf children (four sessions a week) also commenced. The total number of sessions held each week had increased to 222 by the end of the year, with a weekly attendance of 2,297 persons. Of these, 47 were general medical sessions (average attendance 437) and 11 were general dental sessions (average attendance 94). The occasional creche was open for nine sessions a week and, apart from its primary purpose of relieving mothers temporarily of the care of their children, was much used by mothers attending the centre; there was an appreciable increase in average weekly attendances this year. 138 The original six general medical practitioners continue to practise at the centre, one of them being chairman of the centre's medical staff committee, which met at regular intervals. Clinical meetings were held from time to time and were attended by general practitioners in the area and medical officers employed in the Division. The general dental service remained at the same level (11 sessions weekly), the appointment of a second dental surgeon still being awaited. Three successful blood donor sessions were held during the year and the branch clinic of the Family Planning Association continued its weekly sessions. Visitors to the centre numbered 1,686, of whom 402 came from overseas, some forty countries being represented. Post-graduate or student doctors, nurses, health visitors, midwives, social workers and others concerned with the health services accounted for 1,090 of the total. One of the Study Groups attending the H.R.H. the Duke of Edinburgh's Commonwealth Conference on Human Industrial Problems visited the centre in july, 1956. Preventive mental health Weekly meetings of the medical director and staff of the child guidance unit, two medical officers and four health visitors were held throughout the year to discuss not only individual cases but also the broader aspects of positive mental health. Two mental health seminars were held during the year and provided a further opportunity for co-operation between the divisional nursing staff and the staff of the child guidance unit at the centre. Maternity and child welfare There were 7,100 ante-natal and 362 post-natal attendances and 3,477 first attendances of infants under one year of age (equal to 84 per cent. of children born during 1956) at the Council's clinics. Day nurseries and childminders The number of day nursery places in the Division remained at during the year. Five private day nurseries provided accommodation for 175 children and four statutorily registered child-minders cared for 17 children. In addition there were, at the end of the year, 43 daily child-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 met in alternate months to plan and co-ordinate the work and to suggest ways and means for further development. Educational work in the welfare centres is continuing steadily as the following figures show: Sessions Attendances 1952 210 2,172 1953 288 5,421 1954 414 6,494 1955 564 5,775 1956 698 6,402 Recuperative holidays Holidays were provided for 815 patients comprising 70 children under school age, 379 school children, 14 nursing mothers and 352 other adults. Home help services Help was given by this service up to the limit of available workers. Enorts to obtam 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. The service has grown as follows: 1952 1953 1954 1955 1956 Total cases given help 2,928 3,293 3,645 3,937 4,520 No. of home helps employed at the end of year time equivalent) 191 220 249 269 293 Problem families and help for children The divisional committee of statutory and voluntary workers concerned with the special needs of problem families has continued to meet at intervals as necessary. They considered 28 new cases and reviewed 44 cases. There were 220 cases on the special register of existing and potential problem families in the division at the end of the year. 139 A total of six home helps employed in the division received special training at the two courses, each of a week's duration, held at Woodberry Down health centre during March and October. The courses were designed to train selected home helps to assist in the rehabilitation of problem families. These home helps have since been employed in this work, receiving an enhanced rate of pay, and early indications are that they will make a valuable contribution to the work of holding together families in danger of breaking-up. There has been continued close contact between the area children's office and the divisional health office to prevent the need for taking children into care. Full use has again been made of day nurseries, home helps and childminders, and in one case a child help. Handicapped children Physiotherapists from the London Hospital now attend daily to tend the physically handicapped children attending the Geffrye Primary School. Chiropody 77 chiropody sessions are held in the Division each week and a satisfactory level of attendances is maintained but the available resources are insufficient to meet to the full the existing demand for treatment. Priority is given to children and elderly people. During the year Stoke Newington Old People's Welfare Committee started a chiropody session for elderly persons at the Woodberry Down health centre on Saturday mornings. Prophylaxis During the year 2,433 children were vaccinated against smallpox, 4,245 completed a primary course of immunisation against diphtheria and 6,461 received reinforcing injections, and 3,209 were immunised against whooping-cough. Under the scheme for immunistion against poliomyehtis 1,022 children received the full course of two injections and 106 the first injection only during the two months when vaccine was available. During 1956 all 13-year-old schoolchildren in the division were offered B.C.G. vaccination, 67.5 per cent. of the children were tested and of these 84.6 per cent. were negative reactors and were given an injection of B.C.G. vaccine. The positive reactors to the skin test (328) were given appointments for chest X-ray and all but 17 attended. Diversional therapy for the tuberculous Three children were found to require further investigation. Diversional therapy for home-bound tuberculous persons first became available in November, 1955, when two whole-time therapists took up their appointments. They devote 15 half-day sessions a week to patients in Division 4 and spend the balance of their time in an adjoining division. Early indications that this was a welcome and useful addition to the tuberculosis service have been confirmed. Home nursing and loan equipment The three District Nursing Associations continue to give a high standard ol service to sick persons nursed at home. A steady demand for loan of items of home nursing equipment continues to be met. The Shoreditch and Bethnal Green District Nursing Association is now housed at the Kingsland Road welfare centre and this results in closer contact between the district nurses and the health visitors working in Shoreditch. Division 5, comprising the boroughs of Bethnal Green, Poplar, Stepney and the City of London. Dr. G. O. Mitchell reports: Premises The maternity and child welfare Services in the Borough of Bethnal Green had been working at a disadvantage since the formation of this division in 1948, because there was only one centre there for these services. The need for another centre in the western part of the Borough was obvious, and after a fruitless search for suitable premises the Education Committee agreed to release part of Rochelle Street School for adaptation, it having been at length decided that this building, which is separate from the main school, would no longer be required for use as a central dental laboratory. The building, part of which has been in use since 1944 as a school treatment centre, has now been adapted to provide additional accommodation for a maternity and child welfare centre and for the home help office for the northern part of the division. This latter office had remained temporarily at Cornwall Avenue after the maternity and child welfare centre, formerly housed there, had removed to the new Greenwood centre in 1955. 140 The Rochelle Street centre opened on November 26th and from the start has proved a popular and busy centre. To provide a more satisfactory centre the eastern district office of the home help service was transferred from East India Dock Road welfare centre to the welfare centre in Wellington Way, Bow, following the reinstatement of the extensively war-damaged front part of the latter building. Sessions Adjustments in the frequency and duration of clinic sessions are made from time to time, and during the year it was found necessary to institute extra toddlers' sessions at the Limehouse centre, largely, I feel sure, as a result of the publication in a local church magazine of a short article on 'the Home and the Family in Relation to Health' by the health visitor in charge of the centre. Relaxation classes for expectant mothers were also started at this centre during the year. To cope with increased attendances the sessions for toddlers at the Mary Hughes welfare centre were increased in number from two to four a month. Poliomyelitis Preparations tor inoculation against poliomyelitis began in the early part of the year, but because of the limited supply of vaccine the offer of inoculation was restricted to children of certain age groups selected by the Medical Research Council. During March some 29,000 letters together with consent forms were sent from the Divisional Office to the parents of children in the selected age groups, and completed consent forms were duly received on behalf of over 7,000 children, i.e., approximately a quarter of those eligible. Because of shortage of vaccine only a fraction of these could be dealt with, and by the end of the year 811 children had received a completed course of two injections each, and 166 had received their first injections. Childminders The number of voluntarily registered child-minders increased during the year from 92 to 112, and at the end of the year 90 children under the age of 5 years were being cared for by child-minders during the day. These child-minders are all recommended by the health visitors who keep them under constant supervision. Home helps Early in the year the Health Committee or the Council approved a scheme for the training and employment of selected home helps to teach housecraft to mothers in their own homes, where such help seemed to be called for to prevent the possible break-up of the family. 20 home helps from this Division were selected and received this training, The specially trained home help is sent to a particular family on the advice of the health visitor concerned, who then maintains close touch with the divisional nursing officer, the home help organiser, and, where school children are concerned, the Care Committee organisation, for regular consultation on the progress made with the individual mother. Ten families in this division were receiving this service during the year, and while no spectacular successes were anticipated, encouraging improvement was noted in five mothers and slight improvement in three others. Apart from these special activities the home help service had another busy year, but was still handicapped by the difficulty of recruitment in the Stepney area to which I referred last year. B.C.G. Vaccination of 13-year-old school children with B.C.G. continued during the year, and with the active support of the head teachers, parental consent was obtained for about 75 per cent.of the eligible children, and as a result 1,800 children received B.C.G. vaccination at school. Home nursing The calls on the services of the district nurses remained heavy, and throughout the year the number of visits per nurse was generally higher than in other divisions. In June it was possible to make available to the East London Nursing Society accommodation at the Hopetown Street bathing centre for use as a diabetic clinic, the Health Committee having approved in principle the letting, rent free, of health service premises for such use to District Nursine Associations. Health visitors During the year the services of health visitors were increasingly in demand for talks to old people's clubs on 'Accidents in the Home', young wives' groups, and to schools and parent-teacher associations on 'Safety First'. In conjunction with the 141 Council and the Central Council for Health Education a two-day course on 'Visual Aids and their Construction, Public Speaking and Group Leadership' was held at the Mary Hughes welfare centre, Underwood Road, E.l, on October 8th and 9th. Twenty health visitors attended this course which was much appreciated. Finally it was gratifying to note the steady improvement in co-operation between the general practitioners and the health visitors. Division 6, comprising the boroughs of Deptford, Greenwich, Woolwich. Dr. F. R. Waldron reports : New centres Ante-natal, infant welfare and toddlers' sessions were begun at All Saints' Church Hall, Tranquil Vale, Blackheath, to afford facilities for mothers and children living on the new Pond Estate. This centre, as well as that already operating at Merton Place, Blackheath, is in Division 7 and was used by arrangement for residents in Division 6 at separate sessions. Prophylaxis Special prophylaxis sessions were conducted at eight centres, but in addition the service was available at some infant welfare clinics, thus providing easy access for mothers in all areas; an average of 15 sessions were held each week. Most schools in the division had a 'booster' session each term. During the year, 3,992 children under 15 completed courses of immunisation against diphtheria and 3,549 received 'booster' doses, compared with 3,252 and 1,525 in 1955. Smallpox vaccination was carried out successfully in 2,495 cases and there were 439 re-vaccinations. The corresponding figures for 1955 were 2,308 and 561. 3,323 children were inoculated against whooping cough and 289 received reinforcing injections. The figures for inoculations generally were higher than in 1955, because of the outbreak of poliomyelitis in that year during which some sessions were suspended. A proportion of immunisations and vaccinations was carried out by general practitioners. Maternity and child welfare Ante-natal clinics were held at 20 centres with an average ot 25 sessions a week. Relaxation, mothercraft and parentcraft classes were held at varying intervals at 9 centres. Chest X-ray examinations were arranged during the year for about 1,200 expectant mothers. The popularity and success of fathercraft sessions was due largely to the keenness of the health visitors who gave up their time in the evenings to organise and conduct them. On average, 61 separate or combined infant welfare and toddlers' sessions were held weekly. Attendances totalled 85,651; the corresponding figure for 1955 was 89,705. The total number of children born during 1956 to mothers resident in the area was 4,278, compared with 4,299 during 1955. B.C.G. vaccination The Council's central B.C.G. unit operating south of the Thames successfully concluded their second visit to Division 6 for the B.C.G. vaccination of 13-year-old school children at the end of February. There were 4,327 children in the age group (3,453 in 1955) and the parents of approximately 77.4 per cent. (84 per cent. in 1955) consented to their children taking part in the scheme. Childminders The number of statutorily and voluntarily registered child-minders at 31st December, 1956, was 68, compared with 77 at 31st December, 1955. Approximately 180 children were minded each week-day. Welfare foods National welfare foods were distributed at 108 sessions every week at 30 establishments throughout the division. The Women's Voluntary Services conducted 26 sessions weekly at their own centres; their assistance was greatly appreciated. Of the remaining 82 sessions, 54 took place in association with infant welfare sessions and 28 at other times each week according to local need. 142 The distribution figures for the last two years were: Year ended National Dried Milk (Tins) Cod Liver Oil (Bottles) Orange Juice (Bottles) Vitamin A and D Tablets 31st December, 1955 111,996 30,662 231,682 12,643 31st December, 1956 112,636 26,439 242,619 13,465 Mentally retarded children The special welfare clinics for mentally retarded children under 5 years of age, at which parents are able to discuss their special difficulties with a doctor experienced in this field as well as in the field of maternity and child welfare, were re-arranged in order to cover the four main sections of the division, bearing in mind the districts where the children lived. Experience continued to prove the value of these clinics. Domiciliary diversional therapy Instructions in various crafts was given by an occupational therapist to persons suffering from tuberculosis and confined to their homes; reports on the first full year's working of the scheme, which was commenced in October, 1955, have been most satisfactory. Some patients showed great enthusiasm and nearly all benefited from the training and interest provided. Problem families Improved co-ordination of the work of the various departments of the Council and of outside authorities and agencies concerned with the prevention of child neglect and ill-treatment contributed materially towards the more effective use of the services available. The divisional co-ordinating committee continued to meet monthly to consider policy and review progress in particular cases. The Divisional Education Officer, the District Care Organiser, and the Area Children's Officer, were permanent members. Representatives of other social services attended when aspects of the work with which they were especially concerned were discussed. Field level conferences were broadened to include all parties concerned with a particular case and strengthened where appropriate by senior divisional medical and nursing staff. District nursing associations The Charlton and Blackheath District Nursing Association, the Nursing Sisters of St. John the Divine, the Ranyard Nurses and the Woolwich and Plumstead Nursing Association rendered valuable service during the year. District nursing in the North Woolwich area, formerly undertaken by the Silvertown and North Woolwich District Nursing Association, was successfully absorbed by the Woolwich and Plumstead Nursing Association and the Association's help in this connection has been greatly appreciated. Voluntary workers About 14 voluntary workers assisted each week at infant welfare sessions. I am pleased to acknowledge their generous service. Hospital nurse training Lectures on the work of the public health department were given to student nurses at five local hospitals by senior divisional staff. In addition to the lectures given, the arrangements were continued whereby student nurses from the five local hospitals were enabled to see the work of a welfare centre and school clinic and pay visits to homes with the health visitor or district nurse. The system entailed close co-operation between the sister tutor of the hospital concerned and the divisional nursing officer. Besides giving the student nurse some insight into the social services, this provided yet another valuable personal link between hospital and local health authority services. Co-operation and general The following brief account indicates some of the ways in which co-operation has been fostered. During the year regular meetings of senior divisional staff were held and also conferences with borough medical officers of health and chest physicians. Monthly meetings of health visitors, midwives, medical officers and hospital staff were conducted by the obstetric consultants at St. Alfege's Hospital and the British Hospital for Mothers and Babies. Health visitors organised informal meetings with general practitioners and the dayto-day contact with local doctors was very satisfactory. 143 K The role of the divisional co-ordinating committee and field level conferences in inter-departmental liaison and contact with voluntary bodies has already been referred to. The divisional nursing officer and her staff maintained cordial relations with hospital almoners and district nursing associations, and the divisional treatment organiser and her assistants likewise with voluntary committees and school care organisations. The home help organisers were other useful links with the general practitioner, hospital and home. Some 22 health visitors attended paediatric, asthmatic and diabetic out-patients' departments at local hospitals on a rota system. A treatment organiser regularly assisted for one session a week in psychological social work at a children's psychiatric outpatients' clinic. The links between the hospitals and outside agencies and the home were helpful to all and greatly appreciated by the consultants concerned. No administration could function without the loyal and willing services of all grades of staff: I most gratefully record the splendid efforts of everyone concerned with the work of this division. The ever helpful guidance of and the interest shown by the Chairman and members of the Divisional Health Committee during another eventful year are also cordially acknowledged. Division 7, comprising the boroughs of Camberwell and Lewisham. Dr. H. D. Chalke reports : Premises Two new centres have been started for child welfare, one in a church hall and the other in a recently built community centre. The child welfare sessions of two voluntary committees have been transferred to newly built church halls. These changes have improved the standard of accommodation in the division. The Lee and Blackheath School for Mothers discontinued its voluntary child welfare activities. The School had operated for 40 years in Lewisham and was a pioneer in the field. Over the years, much time, thought and labour have been given by a succession of devoted workers, some of whom have continued their associations with the centre by remaining as voluntary workers with the Council. The Downham Day Nursery was closed on 31st August, as a result of falling attendances. 7 nurseries remain with 358 places. Tuberculosis Routine tuberculin testing of pre-school children attending child welfare centres continues. 7,600 tests were carried out during the year. The steady decrease in the conversion rate is a useful index of the diminution in the amount of infection in the community. Previously unknown infection continues to be discovered by this means. Health visiting The links with other branches of the health services have continued to improve. In particular, the attachment part-time of one health visitor to a group of doctors, of another to the King's College Hospital Diabetic Unit and of a third to the St. Francis Hospital Geriatric Unit, has yielded good results. Special attention has been given to the scope and possibilities of in-service training and a paper by the Divisional Nursing Officer on the subject has been published* Problem families The care of problem families and the prevention of deterioration in the circumstances of potential problem families continue as a co-operative effort between all social workers, both official and voluntary, under the general direction of the divisional medical officer, who acts as chairman of the standing committee of all the workers concerned with each family which meets monthly for consideration. A home-making class is held for inexperienced young mothers, and a certain number of specially trained home helps work in the homes with the health visitors. Voluntary organisations A great debt is owed to voluntary committees and their workers who play an important part in maternity and child welfare, school treatment, home nursing, the care of the aged and of the tuberculous and innumerable other ways. The Women's *The Health Visitor in the Social Work Field—The Necessity for In-Service Training (Paper read before the Health Congress of the Royal Society of Health, April, 1956). 144 Voluntary Services share in the distribution of national welfare foods. The Downham Health centre voluntary committee lost the services of the Rev. Canon Youngman, who had served for many years on the Committee, latterly as its Chairman, on his removal from the area. Poliomyelitis The large scheme of inoculations in May and June was carried out smoothly and with no clinical complications. It was possible from the records held in the division to carry out an investigation to test the accuracy of a suggestion made that the incidence of paralytic poliomyelitis was considerably less among children who had been vaccinated against smallpox, than among those who had not been so vaccinated. 54 cases of paralytic poliomyelitis occurring in children aged 0-5 years between 1951—55 were surveyed, with examination of the actual scars in vaccinated children wherever possible, and set against selected controls of children who had not had poliomyelitis. The findings were published* and, whilst it was not claimed that they were statistically significant, it was shown that they afforded no evidence that smallpox vaccination has a protective action against paralytic poliomyelitis. The investigation attracted the interest of universities and scientific bodies in Europe and America; as a result it has been learnt that a similar investigation on a larger scale in Vienna bore out the findings in the division. Attendance at child welfare centres The findings of an investigation carried out in the division were published † and suggested ways in which improvements could be carried out. A large majority of mothers favour attendance at clinics because they provide a means of obtaining expert advice, checking progress and relieving anxiety. As the size of their families increases, the mothers find difficulty in attending, and many of them feel that the knowledge gained with the first child at the clinic equips them to deal adequately with those that follow. It was found that the ability to purchase welfare foods (including Ministry of Food preparations) was not as significant a reason for attendance as was suggested by investigators elsewhere. Criticisms of the service were few, and those relating to staff and premises were investigated. The demand for child welfare clinics continues, but their value is insufficiently appreciated and the atmosphere of the centre, if it has not changed with the times, may be largelv to blame for this. The aged The care and welfare of old persons in their own homes makes increasing calls on the time of medical and health visiting staff and on the home help service. There is close co-operation with the family doctors, district nurses and voluntary organisations. Particularly valuable has been the liaison with the geriatrician at St. Francis Hospital, who has set up regular conferences which the divisional medical staff attend. A health visitor acts as the link in social work between the hospital and her colleagues in the area served by the hospital. The much needed 'examination in health' clinic which has been established there is a progressive step. The medical staff of this hospital carricd out a useful investigation on the ability of older people to detect coal-gas. This was published in a British Medical Association report on accidental coal-gas poisoning, which also included the results of a survey undertaken by the divisional staff and the Gas Board on the potential dangers of gas poisoning in the homes of old people. This work has resulted in a very close and very necessary liaison between health visitors and officers of the Gas Board, which should help materially in preventing these accidents. In this, my last report, I should like to pay special tribute to the loyalty and support given me by all the divisional staff, both in the office and in the field. It is hoped that during the past nine years the work has been progressive and that many new fields have been explored. Any success that has attended these efforts is largely due to the collaboration and enthusiasm of the divisional staff, who have worked together as a team. *The Lancet (1956) ii. pp. 545-6. †The Lancet (1956) i. pp. 571-4. 145 K* Division 8, comprising the boroughs of Bermondsey, Lambeth and Southwark. Dr. W. H. S. Wallace reports: Welfare centres Several alterations and improvements have been made to the maternity and child welfare centres in the division. St. Anne's welfare centre, a voluntary centre in the Vauxhall area, has moved into entirely new premises. The new clinic is of attractive design and much more convenient. Extensive work was carried out at the North Brixton welfare centre where the structure of the building was in need of repair. The building was closed during the summer months and the clinic was temporarily held at the Brixton School treatment centre. The work was completed by the autumn and the clinic is now held in much improved surroundings. The Voluntary Committee of North Lambeth Babies' Care resigned early in the year. The premises in which the clinic had been housed were found to be unsatisfactory and, later, were closed and additional facilities were provided at the Moffat welfare centre, Alford House, not far away. The facilities are, however, far from adequate and the provision of a new combined maternity and child welfare and school clinic in North Lambeth is an urgent necessity. The work of combining the maternity and child welfare and school treatment services at the West Norwood welfare centre was completed during the year. Minor ailment and dental sessions arc now provided at the Centre. Immunisation We have had a most successful year tor diphtheria immunisation. In view or the tact that diphtheria is now almost never seen it is feared that parents may fail to realise the importance of immunisation. Efforts have therefore been made to intensify propaganda and these efforts have been very successful. The experimental system of sending letters to all parents when their children reach the age of five months and again four months later if they have not been immunised has been continued throughout the year. Fortunately, it was possible to carry this out systematically without a stop in 1956. In 1955, an outbreak of poliomyelitis stopped immunisation and propaganda ceased during the summer months. So few cases of poliomyelitis occurred in 1956 that it was possible to continue diphtheria immunisation throughout the year, and consequently 6,115 children were immunised in 1956, compared with 4,809 in 1955. Poliomyelitis inoculation Poliomyelitis inoculation was successfully begun during May and June. Inoculation was offered to all children in the division between the ages of 2 and 9, numbering 41,590, and of these 14,207 accepted. Unfortunately the supply of vaccine was very limited and only enough material was supplied to inoculate 1,876 children. This was carried out at the main welfare centres in the division and no ill effects or reactions were experienced among the children. Day nurseries lhe demand tor day nursery accommodation has varied in ditterent parts ot the division. In parts of Bermondsey and in Norwood there has been a fall in attendances and consequently Knights Hill nursery, in Norwood, was closed in March. In the central parts of the division, especially in the Brixton area, there has been an increased demand for nursery vacancies. This has largely been due to the considerable coloured population who are continuing to come to the Brixton area. The new day nursery at China Walk was opened in June. The nursery consists of the ground floor of a new block of flats in China Walk, North Lambeth. It provides a replacement for St. George's day nursery, in Southwark, which was closed. Although the new nursery is not in the same borough as the one it replaces, the distance between them is very small and no inconvenience has been caused. School health service The health ot the school children has continued to show an improvement, There has been a further fall in the number of minor ailment and rheumatism cases attending clinics. There has also been a drop in the number attending the enuresis clinic at All Saints' Hospital. Unfortunately this appears to be due to the increased facilities elsewhere rather than a decrease in the incidence of enuresis. The standards of cleanliness of school children have been well maintained. As such small numbers were in need of cleansing the arrangements for the cleansing of school children at the Bermondsey bathing centre have been terminated. 146 The B.C.G. vaccination of 13-year-old school children was successfully carried out in March and April. 67 per cent. of parents consented to the vaccination. Propaganda has been intensified to persuade the remaining parents to agree to vaccination. Chiropody The Council's decision to allow the spread of chiropody services has been most welcome. Chiropody clinics have been opened in Stockwell and Brixton and are serving a most valuable purpose. Arrangements are being made to open a session in Southwark. Domiciliary services The home help, district nursing and other domiciliary services have continued satisfactorily. The chief difficulties experienced in the homes visited have been occasioned by the problem families themselves, for whom much is being done. The specially trained home helps have already proved their value in assisting these families. The health visitors have done much to ensure that the public health services are fully utilised and that everything is done to prevent children being taken into care. I would like to thank the staff and voluntary workers 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 fifth year it is a great pleasure to give a short account of the work carried out in health division 9 for the past year. The year was again a busy one for it is one of the most interesting features of public health work that as some problems are solved, others arise. Indeed, one of the things which I think may not always be realized is that problems in public health and preventive medicine change, and possibly change quite quickly, as the social and economic conditions of the people change. We should be on our guard against applying standards which might have been applicable ten years ago to the problems and conditions which exist today. It is against this general background that I review brieflv the work in 1956. Premises There were no alterations or additions to the premises used for health service purposes other than as referred to under day nurseries below. Considerable time, however, was spent putting in final form plans for the new centres in purpose-built and adapted premises which it is hoped will be erected in the division in the not distant future. At the time of writing, however, no new centre has vet been opened. Day nurseries The Clapham Common day nursery was closed on 1st March, 1956, and the Larkhall Rise day nursery closed on 17th August, 1956. There were at the end of the year, therefore, 439 places in nine maintained day nurseries and of these day nurseries seven were classified as training day nurseries. This compares with 549 places in eleven day nurseries a year ago. Occasional creche The attendance of children at the occasional creche at Fairfield welfare centre has not yet reached an economic level, the highest attendance being fifteen. The creche, however, is being kept open. Child- minders At the end of the year there were fifteen registered child-minders and ten registered private day nurseries authorised to care for, respectively, a total of 104 and 230 children. In the previous year there were eleven registered child-minders and nine private day nurseries authorised respectively for 78 and 226 children. Maternity and child welfare There were no great changes in the maternity and child welfare services in 1956. Two weekly evening dental sessions for expectant and nursing mothers were provided, one at the St. Christopher's school treatment centre, Battersea, and the other at the Streatham school treatment centre. In order to absorb the increased attendances, the toddlers' session at the Putney infant welfare centre which was previously held fortnightly was made a weekly session, and the monthly toddlers' session at Riggindale welfare centre, Streatham, became a fortnightly session. Mental health education A second orientational course on mental health education was held in the division in November, 1956. A medical officer and health visitors have also continued to receive training under the guidance of the medical director of a child guidance unit. 147 52,785 consent cards were sent to parents, and 18,946 (36 per cent.) cards were returned. Inoculation against poliomyelitis For the first series of injections in May, 2,959 appointments were offered and 2,353 children attended, of whom 2,145 were immunised. During June 2,263 children were summoned mainly to receive their second injection. 1,993 attended and 1,921 had the second injection ; in addition, 157 children received their first injection. For the spring series as a whole 1,921 children received both injections and 381 the first injection. 663 children summoned did not attend at all, or 21 per cent. of those called. In December, 1956, 543 appointments were issued, 396 children attended and 388 were given injections, 182 being first injections and 206 the second injection. Over the year 2,708 children attended clinics, 2,127 children received both injections and 357 one only. 296 children attended but were rejected by the medical officer; this represented 8.7 per cent. of those attending for first injections, 3.7 per cent. of those attending for second injections, or 6.3 per cent. of all attendances. 80 sessions were held at 11 establishments and an average of 57 children received injections at each session. At two typical sessions attendances were as follows. In May, 84 children were summoned and 64 attended; 8 were deferred by the doctor, five being contacts of infectious disease and three on account respectively of tonsillitis, Sonne dysentery and asthma. The remaining 56 children were inoculated. During the corresponding session in June, 55 children were summoned, 46 attended and 45 were inoculated; one with a tonsil infection was deferred bv the doctor. Recuperative holidays 716 apphcations were received for recuperative holidavs during 1956, compared with 837 during 1955. Of the 716 applications, 521 were actually placed. 294 sessions were held with a total attendance of 1,530. Health education School health service— vision sessions During the early part of the year the waiting lists for vision sessions for school children became prolonged and to cope with this, seven additional sessions were held in the division during the quarter ended 31st March, 1956, under the National Health Service Act and from 1st April, 1956, the Regional Hospital Board provided three additional sessions a week. Special investigation clinics 1,455 attendance were made at 205 special investigation clinics, a substantial increase in the attendances (1,133) in 1955. There were 262 new cases compared with 196 in 1955. B.C.G. vaccination of school children The scheme was introduced in the Division during the autumn term of 1955, when skin tests and vaccination were carried out at the schools by an experienced team. Out of 4,949 eligible school children, 3,596 whose parents had signified consent were tested and results were read from 3,529. Negative reaction was obtained from 3,070 children, of whom all except one were given B.C.G. vaccination. 459 children (12.8 per cent.) were positive reactors. A letter was sent to the parents notifying them of this result and asking them to inform their family doctors. Fourteen children, being marked reactors, were referred by the B.C.G. unit directly to chest clinics. A mass chest X-ray at hospital was arranged for the remainder (445): 327 of these actually attended; results were satisfactory in 311 cases; in respect of the remaining 16 cases suitable follow-up action was taken. A further effort was made to secure the attendance of children who failed to attend for X-ray. A further series of vaccinations occurred from September to December, 1956. Diversional therapy for the tuberculous I made reference in my last year's report to the commencing of a diversional therapy service for home-bound tuberculous patients. This started in December, 1955, and has proved an undoubted success. A total of eight sessions is now devoted by the therapist to visits and in all about 30 patients are registered and receiving instruction weekly. Liaison is, of course, closely maintained with the various chest clinics concerned. Old peoples' foot clinic The weighing room at Fairfield welfare centre was released for one morning a week from May, 1956, for use by the Wandsworth Old People's Council as a foot clinic. 148 Chiropody As a result of a redistribution of sessions within the Council's area the introduction of chiropody sessions into Division 9 was finally effected on 7th January, 1957. During the latter part of 1956 all preparatory work was completed. Home helps 3,410 cases had domestic help provided during the year compared with 3,180 for 1955. Prevention of break-up of families Six home helps have now attended the special five-day training courses for home helps who are to teach housecraft to mothers of problem families. An experimental home-making scheme had been started in the previous year for mothers of problem families. Although its success was limited, it was felt that it would be justified to experiment further in a different part of the division. At the end of the year, the experiment was still in progress and a report will be made in due course. The investigation, in conjunction with the Medical Research Council, into the efficacy of a combined diphtheria/pertussis prophylactic in the prevention of whooping cough was completed in September, 1956. The figures and statistics are in process of being analysed and a full report will be made in due course. Organisation and personnel As I have on previous occasions stated, the basis of successful public health work is team work and the working together of everyone for the common aim is one of the first objects to be achieved. I am, therefore, very happy to express my thanks to all my colleagues in the division, particularly to my senior colleagues, for the continued help and assistance which they have given me during the year. It was a very great pleasure to welcome Mr. R. E. Haymes to the division on his appointment as Divisional Administrative Officer. He has fitted into our team most efficiently and we are very glad to have him with us. Towards the end of the year, one of my senior medical colleagues, Dr. W. G. Harding, was appointed to the position of Divisional Medical Officer for Health Division 3. Although he had not actually left the division at the end of the year, I should like to take this opportunity of congratulating him and wishing him every success in his new work. His promotion to this responsible position affords some measure of reflected glory to Division 9. 149 APPENDIX A PROBLEM FAMILIES IN LONDON An account of the position in London in 1956 Introduction in recent years increasing attention has been focused on the measures that can be taken to prevent neglect and ill-treatment of children and to avoid the break-up of families. Greater prominence has thus been given to the needs of what have become known as 'problem families'—i.e. those families who have not responded to the general improvement in social conditions, who are unable by their own efforts to raise the standards of their families and homes to a reasonable level and who have failed to make full use of the social services of which they are in need. It was stated in Ministry of Health Circular 27/54 that 'children in the "problem families", where one or both parents arc often handicapped by physical ill-health or are of low intelligence or suffering from mental instability, arc peculiarly exposed to physical neglect and risk of mental illness such as psychological disturbance and retarded mental development. Problem families thus tend to reproduce themselves in the next generation and cost the community an expense out of all proportion to their numbersThus, the continued existence of such families in the community, and their active or passive resistance to all attempts to improve their standards, constitutes a challenge to the social services and is a problem which must be tackled effectively by the statutory and voluntary agencies concerned with the health and welfare of the community. Many enquiries have been made into the reasons why these families remain apparently unmoved by the improved social conditions around them and efforts have been made to ascertain how best their living standards may be raised. In the event, the possibility may have to be accepted, and allowed for, that a number of the parents in these families will always remain an intermittent burden on society, despite intensive ease work, but the case worker, by prompting and subsequently sustaining the parents to provide the most they are capable of, may well achieve success with the children and so break the unhappy cycle which would otherwise lead to the production of new problem families in the next generation. To understand why there is such interest in this problem it is necessary, however, to refer to the development of the social services in this country in recent vears. The background to social legislation Up to the end of the war in 1945 our social services had been deployed mainly to serve the needs of individuals and there had been an emphasis generally on physical needs and the improvement of environmental conditions. After the war it became accepted that it must be the duty of the State to intervene and to overcome the five giant evils listed by Lord Beveridge as Disease, Want, Ignorance, Squalor and Idleness, so as to raise physical, mental and moral standards, and to afford greater opportunities for development to the nation. The measures of social legislation passed after the war—the Family Allowance Act, 1945, the National Health Service Act, 1946; the National Insurance and the National Insurance (Industrial Injuries) Acts, 1946, and the Children and National Assistance Acts, 1948—changed the pattern of the social and welfare services by transferring to the State the basic responsibility for the continued welfare of all members of the community and made available to all without distinction the benefits of these services. The expectation then was that these social reforms, supported by full employment and assisted by the post-war rehousing drives, would usher in a new era of progress and achievement based on a society whose basic needs were guaranteed by the State. However, it is apparent that this expectation is not to be realised in full immediately, for the new legislation, coupled with general advances in living standards and education, has thrown into sharp relief the continued existence of problems which the legislation itself was intended to solve. The needs of the family Reasons have to be found for the apparent failure of the new social services so far as a minority of families arc concerned, and here it may be apposite to quote from 150 the report of the Royal Commission on Population, issued in 1949. The Royal Commission said ' In the process of social advance, until recently, the family has been overlooked or given only a minor place in social policy', and again, 'No studied effort has been made to adjust social arrangement to the needs of the modern family group .... provision for family welfare still remains in a comparatively rudimentary stage'. It may thus be that the answer to the question 'Why problem families?' is to be found in the recollection that until recently the members of the family have been dealt with as individuals, and the concept of the family as an indivisible unit, albeit subject within to stresses and strains, has not been properly recognised. In the words of another Royal Commission, the Royal Commission on Marriage and Divorce, whose report was published in 1956, perhaps we should start 'from the conviction that the nation's well-being depends largely upon the quality of married life amongst its members . . . Children are profoundly affected by the conduct of their parents and the impressions formed in early childhood and in youth may strongly influence their attitude to the community If these arguments are accepted, then the approach to the problem family, and indeed to all families, should be not on the basis of the rights of the individual alone and the fostering of the individual without regard to others, but on the development of the individual within the family circle and of the family within the whole social order of the nation. In this way the individual will more readily come to accept that he has a responsibility towards others and will be encouraged to do his duty by the community. What is needed is family case work, and not case work with the individual in isolation. Family case work The concept of dealing with the family as a unit was not altogether new, but before the introduction of the National Health Service on 5th July, 1948, the statutory division of responsibility for individual members of the family between various authorities prevented its effective realisation. In London, for example, the health and welfare of schoolchildren had been the responsibility of the county council but the administration of the maternity and child welfare and allied services had been the concern of the 28 metropolitan borough councils and the corporation of the City of London. In this situation a unique feature of London's education service was its voluntary school care committee organisation, and through this organisation a form of family case work has existed within the framework of London's education and school health service for nearly 50 years. School care committee organisation The first school care committees were started in 1907, when the Education Committee renamed the Relief Committees, which had been formed in poor schools, 'Care Committees' and two social workers, known as children's care organisers, were appointed to set up the committees in poor schools. The province of the committees was to deal with all matters which affected the welfare of the child outside the school curriculum—home conditions, medical treatment and medical after-care. In 1914, the Council took the unprecedented step of appointing a child psychologist and care committee workers were responsible for referring children in need of investigation fo'r psychological examination. By this time organisers of children's care were attending hospital out-patients' departments and school treatment centres. In 1929 an organiser of children's care became the chief psychiatric social worker at one of London's first child guidance clinics and more of her colleagues were to follow her into this field. The care committee organisation, through its nucleus of paid organising staff and its army of voluntary workers, thus played an important and ever increasing part in safeguarding the welfare of London schoolchildren and incidentally of the welfare of the families to which those children belonged. On the passing of the Education Act, 1944, the care committee workers (together, where appropriate, with psychiatric social workers from child guidance units) were given the task of undertaking home visiting to bring about a better understanding by the parents of maladjusted children of the special educational 151 facilities which the Council now offered for such pupils and the purpose of those facilities, so that, with the parents' understanding assured, the chances of readjustment of the children might be improved. At the same time there was set up in each education division what became known as the 'Problem Case Conference' to co-ordinate the Council's resources in the sphere of child psychology and to consider the treatment and education of schoolchildren presenting special behaviour problems in relation to their home circumstances and environment, and the care committee organisation was ideally situated to play an important part in this new development. Integration of services it had always been an advantage to the council that as the school health authority, it was the local education authority with wide powers relating to both elementary and secondary schools. In the ascertainment, diagnosis and treatment of the physical and mental defects of schoolchildren it was unnecessary for the Council to decide whether education or health, or both together, or the one to a greater extent than the other, necessitated the making of different administrative arrangements. The National Health Service Act, 1946, gave the Council the opportunity to integrate the work being done with families through the school health service with the important work with mothers and young children that had been developed and expanded over the years by the maternity and child welfare authorities in London. Within a short time after 5th July, 1948, plans had been made to merge the school nursing and health visiting services and to bring about a closer association of the health visitor with the voluntary school care committee workers in the care of schoolchildren. These measures, the fact that the health visitor has now a new responsibility to be concerned with the care and welfare of all members of the family no matter what their age or sex, and the increasing co-operation and consultation taking place between the health visitor, general medical practitioner and the voluntary and statutory agencies serving the family, together with the expanded personal health services referred to below have provided the means in London whereby family problems could be tackled more effectively than had previously been possible. One result of this integration has been that all workers in the health and welfare services found that from dealing with individuals with problems they were increasingly being concerned with the problems of families. Health visitors, for example, who are particularly well-placed to recognise early symptoms of family break-down and likely neglect or ill-treatment of children, found that they were spending more and more time with the difficult families and it became important that this extra demand on their time should not divert them from their main duties, which are to support the work done in the field of maternal and infant mortality and child morbidity. By employing clinic nurses the health visitors were relieved of some of the less specialised work in the maternity and child welfare centres and in the schools, and the introduction of selective visiting allowed discretion in the frequency of visits so that more time could be given to the families who needed support by reducing the number of routine visits to those families whose standards were satisfactory. Further redeployment of staff was combined with measures for securing greater co-operation and co-ordination between departments of the Council and the statutory and voluntary organisations concerned, and attention was paid to the economic use of staff and the avoidance of overlapping and multiplicity of visiting. Multiple visiting Until a few years ago the general picture of the services available to meet the needs of all families, and of problem families in particular, was one of considerable diversity and specialisation, with nearly as many types of worker as there are different aspects of individual and family welfare. This situation arose out of the separate origins and character of each of the services and of their piecemeal evolution. There grew up a tradition of separately trained specialist workers (and organisations) owing allegiance to professional or quasi-professional bodies exacting a high standard of ethical conduct and qualifications and, whilst the need for specialist officers must be readily conceded, there was an understandable tendency for the workers concerned to regard themselves as separate groups. The boundaries of their activities however were not always clearly defined and, in some cases, overlapped. In this general situation, overlapping duties 152 and unnecessary or uncoordinated visiting of families were obstacles to the achievement of that integration and co-ordination of services and activities which was designed to ensure that the fullest and most effective use possible was made of the special skills of the individual workers. The need for a large number of specialist and semi-specialist officers will continue for some time to come, but this does not preclude the possibility that at some stage fuller co-ordination may be effected through giving major responsibility to some one particular worker. The integration of services begun after 5th July, 1948, led to a revaluation of those services and to the examination of the need for fresh means of co-ordination and co-operation. The position in London now is revealed by a survey undertaken in June, 1956, by the Clerk of the Council in association with chief officers of the departments concerned into the incidence of home visiting, based on samples of problem families drawn from areas thought to be representative in social content of the county as a whole and directed at the visiting of homes or interviewing of members of the family in places other than the home, in which some 112 staff (representing 34 different grades) and 38 voluntary workers took part. Multiple visiting (in the sense of the visiting of families by two or more workers during a defined period) occurred in 45 per cent, of the families included in the survey, and 14 per cent, were visited by three or more workers. In only 8 per cent, of the families in the survey were the visits paid considered prima facie to warrant further study on the ground that they were examples of a possible lack of co-ordination or an overlapping of duties, and the results of these further enquiries showed that in the great majority of instances apparent overlapping had occurred because of staff changes which had led to a break in the continuity of contact with the family. It seems that so far as London is concerned the incidence of multiple visiting is small and does not in itself connote material overlapping of functions on the part of the workers. Methods of co-ordination Problem cases conference Reference has been made earlier to the Problem Case Conference which is organised by the education service and meets regularly in each education division to consider the treatment and education of school children presenting behaviour, etc., problems in relation to their home circumstances and environment, and is attended by representatives of the divisional medical officer and the education officer and the children's care committee organisation. These conferences receive reports from the head teachers, the school inquiry officer, the social worker or voluntary worker in the children's care committee service, the child guidance clinic workers, the school medical officer and the health visitor as appropriate. N.S.P.C.C. conference Another formal conference concerned with casework is the education divisional N.S.P.C.C. conference. This is attended by representatives of the education officer and the National Society for the Prevention of Cruelty to Children for the division, the area children's officer and of the children's care committee organisation. Oral or written reports are made to the conference by the local inspector of the N.S.P.C.C., the social worker or voluntary worker in the children's care service, and the health visitor, as appropriate, about those children or families in whose case intervention by the N.S.P.C.C. has been or is considered desirable. Problem family register More recently, special action has been taken to intensify the efforts that can be made to deal with problem families and with neglected or ill-treated children. A central register of problem and near-problem families is now kept in each of the nine health divisions and the officers of the various statutory and voluntary agencies have been asked to notify the divisional health office of those families with which they are dealing which present special problems and to ascertain by reference to the register whether any family which they contemplate assisting is already receiving attention from some other body. Each voluntary organisation retains full discretion whether information at its disposal should be passed on and the register does not involve building up a dossier of confidential matters relating to the family but rather tends to encourage consultation 153 on any new problem. Further, when action is required all those interested can be consulted and if necessary brought together; their knowledge can be pooled and the next step planned and carried out by the most appropriate organisation. The general aim has been to reduce the number of workers visiting the family to a minimum, thus saving the family possible embarrassment and confusion resulting from overlapping visits, enquiries and advice. Directory of services Each of the health divisions has also produced and distributed in its area a directory containing particulars of all the statutory and voluntary organisations and workers who may have responsibilities or interests in the prevention or detection of neglect and ill-treatment of children. These directories conform to a common pattern and provide a ready reference to the numerous official and voluntary agencies who may be concerned, or can help, in any particular situation. A specimen (skeleton) directory is reproduced as Annex A. Divisional co-ordinating committees A further and more important step in the direction of co-ordination has been the establishment in each health division of a divisional co-ordinating committee of the Council's officers from the health, children's and education departments, and representatives of other departments and statutory and voluntary bodies as appropriate, to co-ordinate the case work and to consider what best can be done to help the families with the most complicated or intractable problems. These divisional co-ordinating committees meet regularly under the chairmanship of the divisional medical officer. The vice-chairman is the area children's officer. The divisional treatment organiser, a social worker in the public health department with close links with the care committee organisation in the education department, has been appointed secretary to the divisional co-ordinating committee, and this has had the effect as intended of bringing together more closely the work of the Council's departments and of ensuring greater co-operation from the voluntary bodies. Intermediate case conferences In addition to the divisional co-ordinating committees, and to the regular and frequent consultations which take place between the field workers, there is in each health division an arrangement by which the more senior officers meet as required to consider action in regard to families whose difficulties are or may soon be beyond the solution of the field workers. These conferences, intermediate between the field worker consultations and the divisional co-ordinating committees, are held most often in the public health department, but may be called on the initiative of officers of any of the Council's departments. Co-operation and co-ordination The conferences or committees referred to in the foregoing paragraphs represent focal points at which the converging interests of field workers in problem families and potential problem families are brought together. (Summarised case histories of typical families considered by the divisional co-ordinating committees are given as Annex B.) The committees serve a valuable purpose, not only in regard to their coordinating function, but also in that they give purpose and direction to practical case work and provide a means for the systematic review of cases. However, no administrative arrangement could function satisfactorily unless the officers concerned took emergency action to deal with problems outside meetings or conferences and this work goes on continuously in all the Council's departments concerned. No arrangements can be perfect where human beings are concerned and efficient functioning depends in the last resort upon the will to co-operate present in the field workers. The means of co-operation themselves are reviewed at regular intervals to make sure that they have not become stereotyped and that they remain flexible enough to meet changing circumstances in the area which they serve, and during pre-service and in-service training of staff special emphasis is placed on the need for co-operation in the field. Recent developments in co-operation and co-ordination There has been recently the more general adoption of the plan for health visitors to work in groups, and this has led to the pooling of ideas, abilities and experience, not least in the religious and linguistic fields and the transfer of families from workers not en rapport to those with whom a better relationship might be established. A distribution of the load of the more difficult families has also been facilitated. In addition, 154 where the father is the stable element in the household, the health visitor has made contact with him in the evenings or at week-ends, but where the father has been recalcitrant or sexual problems have arisen the need for a male worker has been apparent and much assistance has been afforded in such instances by male workers of the N.S.P.C.C. and the National Assistance Board. Furthermore, attempts have been made in several ways to increase the contribution which can be made by the general practitioner, for his influence can be immensely valuable, especially when an authoritative approach to the father is required. If the general practitioner normally responsible for the medical care of a problem family is unable to attend the meeting of the divisional co-ordinating committee when that family is under discussion, there is consultation between him and a senior member of the divisional medical staff or the health visitor concerned will call on him to obtain his views and his active co-operation. The co-operation of the general practitioner in this way is most helpful and is a development which both the Council and the Local Medical Committee for the County of London wish to see encouraged in every way. Services available to problem families The health visitor As has already been said, the health visitor now, as in the past, makes a major contribution to the work of improving the standards of problem families and for many years to come she must bear the burden of combating their inertia, apathy and resistance to changed social conditions and opportunities. In addition to the social work that she does in the home, she can use her special position to see that the appropriate personal health services and those of other statutory and voluntary agencies (including marriage guidance services) are brought to bear on any difficult family situation. The personal health services are able to play a very important part in the preventive and rehabilitation work with problem and potential problem families and they can be used very effectively to avoid the break-up of families and to help the family over times of difficulty when otherwise the children would have to be separated from their parents. In Annex C is shown in tabular form the use made of the personal health services during 1956 to avoid the need for children to be received into the care of the Council. Whilst many of the children so helped would not necessarily come from problem families the table does illustrate the value of the personal health services in making practical help available in a family emergency. The services used include the home nursing, home help, day nursery, child minder and recuperative holiday services. The home help service also provides child helps to attend at night, or whole-time, children in their own homes who are temporarily deprived of the care of their parent or guardian ; and other home helps who will attend in the early morning or in the evening and at week-ends where children have to be looked after during the daytime only when their parents are at work or to fit in with day nursery and school hours. In recent years new techniques have been evolved and scope has been given for experiment and for the implementation of new ideas. One approach to problem families has been on the basis of instruction in the home, including the Council's scheme for specially trained home helps ; the provision of mothercraft and home-making classes for selected mothers, the use of family service units, all aided where appropriate by the use of a scheme to relieve strain in the home by providing one or other of the parents with a recuperative holiday where this might avoid a breakdown in health or lessen friction in a family. Another approach has been on psycho-therapeutic lines through the use of the services of psychiatric social workers in the Council's mental health service. A third approach has been in the use of residential rehabilitation centres such as the Brentwood recuperative centre, the Mayflower home, or Spofforth Hall. A brief descriotion of these soecial services follows. Special home helps Towards the end of 1955 a scheme was prepared for the training of selected home helps to work with the health visitor in the homes of families thought to be in danger 155 of break-up. The aim is for the specially trained home help to teach the rudiments of housekeeping to the mothers of such families. Where necessary, basic household equipment is lent to the families, as an adjunct to the service, until they can obtain their own. The scheme was in operation throughout the County by May, 1956, and at the end of the first full six months' working 59 home helps had attended special training courses, each course lasting the equivalent of five whole days. Only three women were specially recruited for this work, the remainder being employed already in the home help service. Not all the trained personnel received assignments during the six months' period and some attended more than one family. In all, 49 families (212 children) were given the special service, the number of hours service ranging between one and eight a day. A feature of the schcme is that when a measure of improvement becomes apparent the amount of service is gradually reduced and so the mother progressively accepts more responsibility for the running of the home. The special home helps had difficulty in obtaining access to the home in only seven instances. In four of these it was the father who was unco-operative and in the others the mother was opposed to accepting help. One family refused further service after only two visits and another after two weeks. The service was provided subject to the usual charges, which are abatable in case of need, but where the success of this rehabilitation measure might have been in jeopardy if payment of the charges had been required, the divisional health committees had power to waive payments and recommend that the amounts outstanding should be written-off as irrecoverable. The closest liaison is maintained between the home help organisers, special home helps, health visitors and where appropriate the school care committee workers. The success of the scheme so far may be judged by the fact that all but four of the families helped showed signs of improvement in their homes. The number of trained home helps employed in the six months' period was equivalent to about eight whole-time units, and the cost, including training, was about 1,500. A selection of typical case histories of families dealt with under the special home help scheme is given in Annex D. Recuperative holidays Under arrangements made for implementing the Council's proposals under the National Health Service Act, 1946, recuperative holidays are provided for expectant and nursing mothers and for adults recovering from some illness which necessitated medical treatment for a recent definite condition. It is likely that there are some families who do not qualify for a normal recuperative holiday but where the strain on a mother or father of attempting to cope with exceptional difficulties is such as will lead either to a breakdown in health or to friction in the family. If the parent could be relieved of worry for a period by being sent away for a holiday the result might be to prevent a family crisis from arising. At the end of 1956 the approval of the Ministry of Health was successfully sought to an amendment to the Council's proposals under section 28 of the National Health Service Act, 1946, to enable the Council to provide recuperative holidays for adults where such holidays are recommended on a medical certificate to prevent mental or physical breakdown leading to possible neglect or ill-treatment of children in their own homes. A supplementary benefit of this schcme is the possible avoidance of the situation where excessive demands would be made on the other services of the Council. Mothercraft and homemaking classes for selected mothers What may be a useful, and is certainly an interesting, approach to the needs of the mothers in some problem and potential problem families has been the development of mothercraft and homemaking classes for selected mothers. The purpose of these classes is to improve the mother's standards by means of organised group activities in hoir.ekeeping, child management and allied subjects. The members of a class are young and inexperienced mothers and mothers from problem and potential problem families, selected by social workers, health visitors, voluntary organisations (including voluntary school care committees), housing welfare officers and so on. Each class meets once weekly and the group leader is chosen for her teaching aptitude and for her experience 156 in stimulating and encouraging group activities and discussion. The first such class in London was set up in health division 9 (Battersea and Wandsworth) in September, 1954. It ran for an experimental period of one year, and was reconstituted in October, 1956. Other classes were started in health division 7 (Camberwell and Lewisham) in May, 1955, in health division 1 (in North Kensington) in October, 1955, and (in Hammersmith) in May, 1956. The class in division 7 is run by the local health authority staff under the leadership of a health visitor, but the remaining classes are sponsored by the London Council of Social Service (through the Family Welfare Association in the case of the division 9 class) and a voluntary committee plans and guides the activities of the class, selects the group leader and arranges for financial support. A typical voluntary committee consists of the divisional medical officer, a senior health visitor, a member of the divisional health committee, representatives of the school care committee organisation, a housing welfare officer, and a representative of the London Council of Social Service in an advisory capacity. All the classes are given the free use of accommodation at a local maternity and child welfare centre, and the Council makes a contribution at the rate of £1 a session (£50 a year) towards the cost of the leader's fee. Other expenses are met from voluntary sources and grants have been received in one instance from a Mayor's Fund and in another from the Sunday Cinema Fund. The activities of the classes include cooking, budgeting, household management, needlework, making and mending clothes, first aid and aids to better health. Attendances at each class have ranged from 2 to 15, with an average attendance for all the classes of 4 or 5. Whilst spectacular results are not to be expected and progress will generally be found to be slow, experience has shown that the classes have a contribution to make. The expenditure involved is small, having regard to the potentialities of the scheme, and would be more than justified even if the result were only that the break-up of one family was avoided. Family service units A more intensive approach to the problem families than has already been described is made by the Family Service Units. These units, set up during the war, were known as Pacifist Service Units and their concern was the care of unbilletable bombed-out families on Merseyside. Since the war they have taken over work with problem families with the object of teaching and encouraging such families to cope with their difficulties. They achieve this by gaining the confidence of the families and offering them friendship and practical help. The units do not wait for families to approach them for help but instead go into the home and offer their services on referral from statutory and voluntary agencies. These would include the public health, children's, education and housing departments, hospital almoners, probation officers, the National Assistance Board, and voluntary organisations such as the Invalid Children's Aid Association and the Family Welfare Association. The first London unit started work in Kensington and Paddington in 1948, and other units were set up in Islington and Stepney in 1954. All three units are grant-aided by the Council, the grants being paid jointly under section 28 (3) of the National Health Service Act, 1946, and section 46 (2) of the Children Act, 1948. The total amount of grant paid to each unit during the financial year 1956/57, and the average number of families being assisted were as follows : Kensington and Paddington unit—,£2,000—76 families. Islington unit—£1,250—27 families. Stepney unit—£1,750—40 families. Other psychiatric services It is sometimes advisable to arrange for psychiatric advice to be given to parents in problem families and arrangements have been made for the psychiatric social workers employed in the Council's mental health service to provide, with the knowledge and consent of the general practitioner concerned, care and after-care for patients who are not for the time being in need of psychiatric treatment for nervous or mental disorders. Patients are visited in their own homes or are interviewed privately in the psychiatric social worker's office, and such help as is possible is given to enable them to cope with their problems in an effort to prevent serious breakdown or relapse. Where necessary, 157 and to ensure that treatment is sought early, the psychiatric social worker will endeavour to persuade patients to seek psychiatric treatment if they show no inclination to seek it themselves. Residential rehabilitation courses The Council has sent mothers with children to the following centres for rehabilitation courses lasting two months: The Brentwood Recuperative Centre for Mothers, set up by the community council for Lancashire at Marples, near Manchester; Spofforth Hall, near Harrogate, a residential rehabilitation centre established by the Elizabeth Fry Memorial Trust, under the auspices of the Society of Friends; The Mayflower Home, Plymouth, set up by the Salvation Army. Experience has shown that if a measure of success is to be achieved, the families selected must be those where the husband may be expected, with help and encouragement, to give support to his wife on her return home. His willingness to work and his ability to keep in employment are of outstanding importance, for the husband who is a casual worker and frequently unemployed figures often in those cases where improvement in the family situation is not maintained. It has also been observed that where intolerable housing conditions have given rise to the need for residential training no permanent good is likely from the training course except where the family can be rehoused when the mother returns home. It early rehousing cannot be arranged, it may often be better as an alternative to give the mother and children an ordinary recuperative holiday with the hope that this will result in a temporary improvement in their health. In those instances where intolerable housing conditions are not entirely the cause of the need for residential training, attendance at such courses appears to offer a chance of success if constant supervision in the home is provided when the mother returns home, and indeed unless it is possible to provide such supervision much of the value of the courses will be lost. Welfare department—special units for homeless families It would be appropriate here to refer to the successful scheme run by the Council's welfare department for the rehabilitation of homeless ' problem ' families. The work of that department differs from that of other departments in that when families apply for assistance they have already lost or are about to lose their homes. Families who apply because they expect to be rendered homeless arc first seen by the admitting officer, who examines the possibility of preventing the break-up of the families and in a considerable number of cases a solution other than admission to a welfare establishment is found. In many instances, however, no alternative can be found and the wife and children have to be admitted to a welfare home for a short period in order to enable the family to renew their efforts to secure accommodation. When, as in many cases, they fail to do so, the wife and children are moved to a halfway house, now designated short-stay accommodation, where they are joined by the husband. Here they are given any necessary guidance and assistance by the supervisor and remain until such time as they are able by their own efforts to secure alternative accommodation. Because it became increasingly apparent that there were a number of homeless families in large homes who might be termed 'hard-core'—shiftless, irresponsible people whom no landlord, however considerate, would accept as tenants and whom no one would want as neighbours, with a reputation for being bad payers and with children not under proper control—the Welfare Committee in 1953 approved the setting up of two special units for the rehabilitation of problem families. It was decided that the number of families at each establishment should be small in order to give the warden in charge a better opportunity of individual approach. The essential condition of residence is prompt payment of the weekly charges, and debts outstanding at time of admission are expected to be repaid by small weekly sums payable to the warden during their period of residence. The men, who are often work-shy, are encouraged to 158 attend their employment regularly; the wives are supervised in their domestic duties and shown how to fit their domestic budget to their weekly incomes. They are taught to cook, sew and 'make-do-and-mend' A high standard of hygiene and cleanliness, both in their personal habits and in the care of their accommodation, is insisted on. Families are expected to save a small sum from their weekly income towards the furnishing of their future home. Constant supervision of the families is maintained by the warden and her deputy who undertake alternate tours of duty of 24 hours on and 24 hours off. The warden of each special unit is a member of the local Care Committee and in this way the influence and help of the care committee organisation in the education officer's department can also be brought to bear. The health visitor makes regular calls on the families. Notwithstanding set-backs and frustrations, families over a period have in general responded to ordered routine; nearly all have been rehoused and have succeeded in retaining their accommodation. In addition to admitting families from the accommodation for homeless, 13 cases have been accepted on the recommendation of the children's officer, with the result that 45 children have been taken out of care and reunited with their parents, with gratifying results. A considerable saving in expense to the Council by reason of the children being removed from care is a factor deserving of consideration. In consequence of the results achieved the Welfare Committee have authorised the opening of two further units both of which will be brought into use in 1957. Since the units were opened in May, 1953, 48 families have been admitted; 29 have been rehoused and 16 arc in residence. In only three instances have the families failed to take advantage of the facilities offered to them. As a further experiment the Housing and Welfare Committees have agreed that a number of old houses shall be made available to the welfare department for occupation by families who are in urgent housing need but who need some training before they can be regarded as suitable for normal rehousing. This rehabilitation will be carried out by welfare department staff under arrangements similar to those adopted in the special units for homeless families. Problem family survey The Minister of Health in Circular 27/54 drew the attention of local health authorities to the importance of developing their work in the field of the prevention of the break-up of families, and suggested that this work might well be done through the redeployment of existing health visiting staff, rather than by an increase in the number of health visitors but that the employment of a trained social worker to study and meet the needs of these families might be helpful. The first task was to ascertain the number of families in London who required help on the lines suggested in the circular and to estimate the number of those who needed the intensive care which could only be undertaken by a case worker with a small case load or a combination of social case workers. A survey was therefore carried out in association with the education and welfare departments and covered all families with a child or children under the age of 15 years. The planning of this survey and the way in which it was carried out are set out in succeeding paragraphs. It was decided that the public health department would investigate all the families in which there was a child or children under the age of five years living at home, the education department would cover families in which all the children were five years and over, and the welfare department would deal with families in homeless family units or halfway houses: provision was made for the avoidance of duplication. As far as numbers are concerned therefore the data given is complete but the detail relates only to the families with which the public health department was primarily concerned. 159 Planning—Families may be classified broadly into five groups : (a) Above normal visiting standard. (b) Socially sound. (c) Families with problems. (d) Potential problem families, and (e) Hardcore problem families. It was with the selection of these two last groups that the survey was concerned. Potential problem families and hardcore problem families may be defined respectively as ' those in which there are early signs of failure . . . which may lead to disruption of normal home life with consequent risk to . . . the children ' and ' those which are unable, by their own efforts, to raise themselves from the state into which they have fallen or to take advantage of the social services of which they are in need There are, however, numerous other definitions and it was felt that any inquiry based solely on qualitative criteria would lead to subjective assessments by health visitors and others, and no valid conclusions could be drawn from the results. Some form of quantitative criteria had therefore to be applied. Accordingly the factors which were likely to be found in such families were listed and points allocated to each factor : this provisional pointing system was tested by application to the circumstances of a number of families and modified in the light of the tests. The factors and points awarded to them were chosen arbitrarily but they provide a clear and uniform basis for a survey ; moreover they enable comparable assessments to be made in later years. A maximum of five discretionary points was allowed for imponderables. The list of factors and the points awarded are set out below—for brevity certain detail has been omitted such as guidance on the interpretation of drinking, gambling and promiscuity as factors and the period over which they should have been operative. Factors likely to be found in problem families 1. In a parent (a) Low intelligence or mental deficiency. (b) Mental illness. (c) Physical handicap or illness which prevents work or permits of light work only, e.g., tuberculosis, heart disease. (d) Prolonged or recurrent unemployment of main wage earner from other causes than physical handicap or illness. (e) Excessive drinking. (J) Excessive gambling. (g) Sexual promiscuity. (h) Serving, or has served, a prison sentence. (i) Suspected cruelty to or neglect of children. (j) Known cruelty to or neglcct of children. 2. Other parental shortcomings (a) Persistent quarrelling. (b) Failure to call doctor for major illness. (c) Leaving young children unattended. 3. In a child (a) Repeated hospitalisation of one or more children for gastro-enteritis or respiratory disease, or two or more children for minor accidents. (b) Persistent truancy. (c) Juvenile delinquency (court cases only). (d) Attendance at child guidance clinic. (e) Under probation officer or committed to care by a court. 160 4. Housing (a) Statutory overcrowding. (b) Living in intolerable conditions (while not overcrowded) because of either lack of amenities such as piped water, damp or insanitary conditions and/or enmity of other occupants of dwelling. 5. Poverty and mismanagement (a) Chronic family debt. (b) Lack of minimal necessities of furniture and bedding. (c) Inadequate and irregular meals. (d) Domestic filth and disorder. (e) Wilful damage to property. (J) Lack of or inadequately maintained clothing of children. 6. General (a) Unnecessary crowding at night. (b) Gross personal uncleanliness. (c) Failure to take advantage of necessary help and service proffered. (d) Child or children taken into care other than as the result of court action, and who are frequently taken into or out of care. Allocation of points to factors 1. One point was allotted for the existence, whether one or more persons was affected, of each factor in the list except: (a) items 1 (a) to (/) where the pointing was for one parent .. .. .. .. .. .. 1 point, for both parents or the sole parent .. .. .. 3 points (b) item 1 (j) when the pointing was for one parent .. .. .. .. .. .. 1£ points for both parents or the sole parent .. .. .. 4 points. 2. Additional points or fractions of points up to a maximum of 5 could be added by the reviewing officer to deal with imponderable factors not listed, e.g., persistent sickness of children; mental or physical cruelty of one parent to another; racial differences between parents; spasmodic reappearances of deserted, divorced or separated parent (which upsets stability) ; a combination of items which do not of themselves merit points such as domestic disorder (without filth), poverty with spasmodic debt, large numbers of children under 5 and inadequate (but not irregular) meals. 3. The maximum pointing was 56 and for the purposes of classifying the families assessed the following arbitrary values were used : Hardcore problem family—11 points or more. Potential problem family—5-10 points inclusive. The differing social conditions in various parts of the County and the lack of any real knowledge of the numbers and location of problem families made it necessary to have a complete survey rather than a sample. At the end of the planning stage the nature and scope of the survey were discussed with the other departments and agreement to conform as far as possible was obtained. Operation The public health department survey—The County is divided into nine divisions each administered by a divisional medical officer. In each the health visitors were asked to make a provisional selection of the families falling under the two heads, i.e., potential and hardcore problem families. Family case histories selected by the health visitors, 161 L* supplemented by discussion, were considered by the divisional nursing officers in each division, who were appointed reviewing officers, to assess the factors and to grade families concerned. Health visitors made a note of the time actually spent for a period of four weeks on the families finally selected. Finally a central team, principal medical officer (maternity and child welfare), statistician and chief nursing officer, visited a number of centres in the divisions and interviewed the health visitors. Ten centres were visited and 39 health visitors were interviewed. The centres were chosen to represent a cross section of the London population so far as social class was concerned. The assessments were studied and a careful inquiry made into the work of the health visitors with the families concerned during the month under review. The relationship of health visitors with other field workers of both voluntary and statutory bodies called in to assist the family, the attitude of the family towards advice and help and the limitations imposed by their willingness or ability to accept advice were all taken into consideration in forming an estimate of the amount of time which should be spent on these families. Numbers Families with a child or children under Jive years of age (public health department) Table 1 sets out the number of families surveyed by the public health department; the number and percentages of families in the two categories of problem family, excluding those in halfway houses and homeless family units, sub-divided into those families in which all the children are under five years of age and those where there is a mixture of both school and pre-school children. The figures shown will tend to be an underestimate, because constant immigration will inevitably mean that at any given moment there will be new families in the County whose circumstances are not fully, if at all, known; additionally, with the turnover of health visitors there were some who, at the time of the assessment, could only judge from case papers, which, however well kept, were no real substitute for personal and comprehensive knowledge of the family. The average and maximum numbers of problem families in the care of a full-time health visitor are also shown in the table—some health visitors had no such families in their care. The difference between the average and the maximum confirmed the impression that problem families tend to be grouped in small areas. This had an important bearing on the time factor to which reference is made later. Problem families tend to move about—for example, out of 30 families in the case load of one health visitor, six had moved out of her district in three months. They may also move in and out of the various categories as their circumstances change—for example, in one division of the County there were at the time of the survey 314 problem families in all, whereas some six months later the total had fallen to 303. The net fall of 11 families was made up of a much larger fall in the number of potential problem families offset by a rise in the number of hardcore. Table 1—Numbers and percentages of problem families in families with a child or children under 5 years of age Number of families surveyed (a) with children under 5 only 103,172 (b) with school children also 68,699 (c) Total 171,871 Number of potential problem families (a) among those with children under 5 only 569 (b) among those with school children also 1,225 (c) Total 1,794 162 Number of hardcore problem families (a) among those with children under 5 only 146 (b) among those with school children also 516 (c) Total 662 Percentage of potential problem families (a) among those with children under 5 only 0.55 (b) among those with school children also 1.78 (c) All families surveyed 1.04 Percentage of hardcore problem families (a) among those with children under 5 only 0.14 (b) among those with school children also 0.75 (c) All families surveyed 0.39 Percentage of problem families of (a) those with children under 5 only 0.69 (b) those with school children also 2.53 (c) All families surveyed 1.43 Average number of problem families in the care of a full-time health visitor (a) potential problem families 4 (b) hardcore problem families 2 (c) All problem families 6 Maximum number of problem families in the care of a full-time health visitor (a) potential problem families 27 (b) hardcore problem families 18 (c) All problem families 33 The total number of families surveyed, as far as can be estimated, comprise virtually the total that exists. Percentage rates were also calculated for the various divisions of the County. These percentages for the two categories of problem family combined ranged from 0.52 in division 7 (Camberwell and Lewisham) to 2.28 in division 5 (Bethnal Green, City, Poplar and Stepney) compared with the County average of 1.43. The estimated percentage of problem families based on an investigation of 1,000 families in Newcastle-upon-Tyne was 2, but, as the authors of the report make clear, ' the difficulties of measurement and the way the families were selected should be borne in mind In a large urban county like London, which contains within its boundaries widely differing types of localities, it might well have been expected that the interdivisional differences would have been larger, but in fact the percentage incidence of problem families in the remaining seven divisions ranges from 1.04 to 1.80. The lowest figure merited further investigation. It appeared that it might have stemmed from the stable staffing in the division concerned; moreover, for a long period the senior nursing staff had given positive direction to the work with these families and home helps had been used to assist in more intensive efforts in the homes. It will also be seen from the table that, as might be expected, there are fewer hardcore problem families than potential problem families—662 as opposed to 1,794; secondly, that in both the potential and hardcore groups there are fewer families among those with children under five years of age only than families with children under and over five years of age—in total 715 as opposed to 1,741—this despite the fact that there were only 69,000 mixed families compared with the 103,000 families with children under five years of age; (despite fluctuations in numbers these findings are consistent among all divisions). Among families with a child or children under five years of age the percentage incidence of potential and hardcore problem families was 0.55 and 0.14 respectively; among families with children both under and over school age the corresponding percentages were 1.78 for potential and 0.75 for hardcore problem families. 163 It is assumed that the reason for the higher percentages of problem families among the 'mixed' ones is that they are probably larger and/or poorer so that the mother cannot cope—there seems to be a limit to the difficulties with which a stable but dull parent can compete after which one further adversity will produce a complete breakdown in domestic management. Families with no children under five years of age (education department)—Among the families cared for through the education care committee organisation were 427 potential problem families and 99 hardcore problem families. It is proper to note that an attempt had to be made by the care committee organisers to award points for the various factors as revealed by the case histories in the office files and, whereas the families where children had been reported to the N.S.P.C.C. or the education officer's problem case conference were reasonably well documented, full data was not usually available in other cases. The assessment of families into the two categories was therefore somewhat subjective. Overall the percentages, based on an estimated number of families, were of the order of 0.21 for potential problem families, 0.05 for hardcore and 0.26 for both. The overall rate is about 2/5 of that for families with children under five years of age only or 1/10 of these for families with children over five also. As the families reported on by the care organisers were not increasing and the children were all benefiting from the school and school health services it might have been expected that the percentage would be below that for the mixed families. The numbers reported may, because of the reliance mainly on case papers, be an understatement—i.e., in some households in which the children are all of school age the mothers' responsibilities arc lessened and the more obvious evidence of neglect may tend to disappear but there is a tendency for other manifestations of neglect such as truancy or juvenile delinquency to take their place, whilst factors such as low intelligence or housing difficulties remain. Families in Homeless Family Units and short stay accommodation (Welfare Department)— Within this select group of families the wardens of the Homeless Family units chose those which appeared to come within the definition of potential and hardcore problem families. There were in a total of 645 homeless families, 18 considered to be potential and 22 hardcore problem families. In terms of percentages therefore potential problem families amounted to 2.8 per cent, of the total, hardcore families to 3.4 per cent, and the two together 6.2 per cent. These figures are obviously not comparable with those obtained by more exact standards but it is interesting to note that the incidence of problem families so selected was slightly more than four times as high as that ascertained in the Public Health Department of families living in their own home. Total numbers—From all departments, there was reported a total of 3,022 families, 2,456 from those with a child or children under school age, 526 from those with children of school age only and 40 in welfare establishments. Details are in Table II below: Table II—Total numbers of potential and hardcore problem families Problem family Children under five only Children under and over five Children all over five In welfare homes Total Potential 569 1,225 427 18 2,239 Hardcore 146 516 99 22 783 Total 715 1,741 526 40 3,022 In five recent surveys in other parts of the country the figures of incidence range from 1.2 to 6.2 problem families per 1,000 total families—the bases of the various 164 inquiries were not uniform and the figures should be treated with some reserve. There are in London some 1,100,000 families, although only about 400,000 of them have a child or children under 16—the London total of problem families works out at about 2.75 problem families per 1,000 total families, although as will be apparent from preceding sections of the report the various components of the total number were not all arrived at in quite the same way and more reliance can therefore be placed on some than others. Public Health Department Survey Factors—An analysis was made of factors present in over 1,000 of the problem families included in the survey and the frequency of occurrence of the various factors taken into account in assessment is set out in Table III below. There were, as might be expected, a number of differences between the divisions in the incidence of such factors as prolonged unemployment or lack of amenities. The table again separates the families into the potential and hardcore categories: a further sub-division was made into those with all children under five years of age and the mixed families but this has been omitted from the table as printed partly to save space but largely because nothing of any importance was revealed. The salient features of the table are first the high amount of emotional instability in the families—if it be accepted that excessive drinking, excessive gambling, sexual promiscuity and persistent quarrelling are symptomatic of emotional instability. Although not shown in the table, the percentage of potential problem families in which emotional instability is revealed by one such symptom is 54.5 and in the hardcore 71.6. The second feature is the high incidence of low intelligence or mental deficiency which occurs in 42.2 per cent, of the potential problem families and 67.3 per cent, of the hardcore (it is admitted that low intelligence has not been defined and it is therefore a matter of judgment of the individual health visitor). Table III—Percentage incidence of factors among approximately 1,000 problem families with a child or children under five years of age Factor Potential problem families Hardcore problem families All problem families Parental— Low intelligence, etc. 42.2 67.3 50.9 Mental illness 16.5 13.8 15.6 Illness or handicap 18.2 18.1 18.1 Unemployment 26.5 46.7 33.5 Excessive drinking 13.8 25.5 17.8 Excessive gambling 8.3 14.3 10.4 Sexual promiscuity 19.1 32.1 23.6 Prison sentence 12.8 22.6 16.3 Suspected cruelty, etc., to children 21.1 31.2 24.6 Known cruelty, etc., to children 15.9 45.8 26.3 Parental shortcomings— Quarrelling 40.5 51.9 44.5 Failure to call doctor 2.8 12.0 6.0 Leaving children alone 13.8 37.0 21.8 Child— Repeated hospitalisation 18.8 26.1 21.3 Persistent truancy 4.3 10.3 6.4 Juvenile delinquency 20.5 11.2 7.3 Attendance at child guidance clinic 4.3 5.2 4.6 Under probation officer, etc. 8.7 15.8 11.2 165 Factor Potential problem families Hardcore problem families All problem families Housing— Overcrowding 28.4 35.5 30.9 Intolerable conditions, etc. 31.5 441 35.9 Mismanagement— Chronic debt 24.6 51.9 34.1 Lack of furniture, etc. 25.4 54.2 35.4 Inadequate, etc., meals 38.2 70.5 49.5 Filth and disorder 32.1 59.3 41.6 Wilful damage 5.2 20.1 10.4 Children inadequately clothed 27.4 60.7 39.0 General— Unnecessary crowding 9.6 20.6 13.5 Uncleanliness 16.5 41.5 25.2 Help refused or abused 30.4 51.0 37.6 Child (ren) taken into care, etc. 11.0 21.5 14.7 Imponderable factors 76.1 59.3 70.3 It is a matter for conjecture whether anything substantial can be done through the normal health services for the families in which emotional instability is combined with low intelligence. This group accounts for 19.1 per cent, of the potential and 45.8 per cent, of the hardcore, but instability as evidenced by the four symptoms chosen is in fact combined with normal intelligence or above in no less than 35.4 per cent, of the potential problem families and 25.8 per cent, of the hardcore. The third feature is the percentage of families in which there existed known or suspected cruelty or neglect which was 34.6 of the potential problem families and 77.1 of the hardcore. It will be appreciated that within this group there are families in which neglect may amount to cruelty, yet still the family remains an entity because there exists affection between parents and children. The fourth feature is the incidence of housing as a contributory factor—here the figures when one or other of the two aspects of housing (overcrowding or intolerable conditions, including enmity of neighbours) occurs in 44.3 per cent, of potential problem families and 60.2 per cent, of the hardcore. It cannot be inferred from these figures that housing is the root cause of problem families. Whether bad housing dragged the family down, or whether the unsatisfactory family inevitably gravitated thereto are matters which can be decided only after a careful scrutiny of the individual family circumstances. Finally 30.4 per cent, of the potential problem families and not less than 51 per cent, of the hardcore failed to take advantage of the help and services proffered. This is a fact which accentuates the difficulties experienced in supporting these families. Time—Table IV shows the average time spent per problem family per week by health visitors together with maxima and minima. The County averages were 20 minutes a week for a potential problem family and 28 minutes for a hardcore problem family. More time was spent on the hardcore families than the potential problem families in every division of the County though the divisional averages differed, not unnaturally, when the wide range of families and differing social conditions are taken into account. The maximum times are almost without exception the result of a crisis in one or more of the families concerned—such as a mother temporarily deserting her children, an economic crisis, infidelity, a child being in trouble for truancy, assault or theft, or illness 166 in a parent—which has caused the health visitor to devote perhaps the whole of her time for several days to the particular issue. It may seem surprising that the minimum times are nil but they are due to such causes as the absence of the family (hop picking), the temporary stability of the family or the occasional unwillingness to accept the health visitor. The fact that a visit would be unwelcome does not mean that the family is neglected. Quite apart from information garnered from other social workers, health visitors learn a great deal about their families as they go about their district which is not reflected in the times recorded—they may meet the mother in the street, the children at school and they see friends, neighbours and relations, and some mothers will seek out the visitor at the centre when they are in trouble. Another reason for low times spent is that, as was shown in Table I, a few health visitors had to deal with a concentration of problem families—a concentration too great in some cases for them adequately to carry. The information revealed by the survey has led to a certain amount of 'load spreading'. It is not possible wholly to equalise this particular burden because of the location of the families and the demands of other duties undertaken by health visitors. Table IV—Time spent by health visitors on problem families with a child or children under five years of age Average time (in minutes) spent by health visitors with problem families in their care per week per family on— (a) potential problem families 20 (b) hardcore problem families 28 Maximum time (in minutes) spent by health visitors with problem families in their care per week per family on— (a) potential problem families 270 (b) hardcore problem families 210 Minimum time (in minutes) spent by health visitors with problem families in their care per week per family on— (a) potential problem families 0 (b) hardcore problem families 0 Total time (in hours) spent weekly on— (a) potential problem families 606 (b) hardcore problem families 308 A decision of the average amount of time that could usefully be spent on families in the two categories was a matter of some complexity. There were variations in family customs, outlook, size, age, structure, housing and constantly changing family circumstances as well as the type of service provided for individual families. When all these matters are taken into consideration it is clear that more time could usefully be spent on both categories of problem family than the averages of 20 and 28 minutes a week. Extra time is required to rehabilitate some families of both categories where the total weight of these difficulties required intensive help but the number of health visitors is unlikely to be increased markedly in the near future. If such selected families could be passed to social case workers, who might on average give up to 90 minutes a week work on them, further progress should be made. The health visitors would, of course, continue to visit on health aspects but would be relieved of the intensive case work on these selected families. The time thus saved by the health visitors could be devoted to the balance of problem families for which they are responsible and should enable more progress to be made with these families also. Social case workers It is estimated that 20 social case workers would be required to take over 400 families nominated by the public health department and some 80 families nominated by the 167 education department. The Council has decided that in the first instance five social case workers should be recruited, if possible by secondment of suitably qualified staff who have a basic training in social science and the essential aptitude for family case work. The families to be referred to the social case worker will be selected by the divisional co-ordinating committee from those families where at present most time is given by the health visitor or where the committee judge that other factors point to the social case worker being asked to take over. It is envisaged that referral to the social case worker will result as part of the plan made by the divisional co-ordinating committee for dealing with the family situation, and which has been discussed with and agreed by all the field workers concerned. In this way the entry of the social case worker to the home will be made easier and her function and that of the other workers will be more clearly defined, for it is important that the number of visitors to the home should be kept to a minimum if the family are not to be confused and irritated by an excess of advice, admonition and exhortation from a variety of sources. The social case worker will work through the divisional treatment organiser (who is secretary to the divisional co-ordinating committee) and under the direction of the divisional medical officer (who is chairman of that committee). She becomes a member of the public health department ' team ', working under the direction of the divisional co-ordinating committee, and in this way further division of responsibility for preventive work is avoided and co-operation facilitated with the other workers in the public health, education and children's departments, where the Council's efforts in this field are concentrated. She will have direct access to all other field workers and they will maintain contact with her. She will attend meetings of the divisional co-ordinating committee whenever her own cases, or potential cases, are under discussion, and will report back to the committee as necessary and they will keep the progress of her work under review. Thus the committee will act as a court of referral for discussion, consideration and guidance, for experience has shown that there is a need for such support and direction for field workers dealing with difficult families. The social case workers will work in groups of two, so that team spirit may be fostered and continuity maintained should one worker be withdrawn for any reason. In the first instance two whole-time workers will be allocated to one division, and one whole-time and one part-time worker (together equivalent to one-and-a-half whole-time units) to each of two other divisions. The duties of the social caseworker will include giving practical help in the home on such matters as budgeting, home management, cleaning, care of children, etc., and an essential part of the work will be concerned with the adjustment and improvement of personal relationships within the family group. It may well happen on occasion that the social case worker will find it necessary to be on duty outside normal office hours—in the early morning, or in the evening or at week-ends, and so latitude in the hours of work will be observed. The cost of employing five social case workers is estimated to amount to .£3,450 a year. The work of the children s department Table III, on page 231, shows that neglect or cruelty to children is a factor which occurs in 26 per cent, of all problem families. The Council's officers, in dealing with cases of ill-treatment or neglect of children aim, whenever possible, to use to the full any Council or voluntary service which may already be in close touch with the family and, by co-ordination, to bring the other services which may be of use quickly to the scene. The action required would depend on what is discovered. In most cases the services concerned (e.g. health visitors, children's care committee organisation, probation officers, voluntary agencies, child welfare officers) can and do cope and try to remedy the family situation which gave rise to the complaint, and indeed, as already stated, 168 the personal health services play a large part in avoiding the need for the reception of children into care. There is ample evidence of the very high cost in terms of both human happiness and money which follows the reception of children into care, or their retention in care longer than is necessary, and of the consequent benefits which result from use of the existing social services directed to ensuring that the child can continue to live with its parents. The importance of the use and development of any services which will assist in the prevention of family breakdown or early rehabilitation of the family to the point where parents are able and willing to accept the return home of their children cannot be over emphasised and it is the Council's aim always, subject to the best interests of the children being so served, to develop activities which will on the one hand prevent children from having to be received or taken into care, and on the other will enable children to be restored to their parents. The Council has approved a detailed procedure, designed to facilitate the performance of its responsibilities under Section 62 of the Children and Young Persons Act, 1933, by which the public health, welfare and education departments notify the children's department of any cases involving cruelty, neglect, ill-treatment or abandonment of children or of any incipient cases of neglect etc. which it is thought may develop quickly and require court proceedings. Whatever action is taken by the children's officer on receipt of this information, the various departments continue to provide preventive and rehabilitation services so long as they are necessary in the interests of the child. Officers in the children's department share the experience of officers in the education, public health and welfare departments that their work has developed towards dealing with the disturbed or disintegrating family as a whole and to helping to prevent or repair family breakdowns, and away from dealing with the child in isolation from his family. Once the children are in care, rehabilitative work may often be necessary with families in an effort to speed-up the return home of the children. Between 3,500 and 4,000 children are discharged from the Council's care each year (most of them to their own homes) and at any one time some 400 children are at home 'on trial' under supervision, preparatory to discharge from care or revocation of the Court order which originally removed them from home. Many of these children will come from problem families, and the children's committee have experimented with intensive case work with these families and the success achieved has led to authority being given to the appointment of four intensive case workers in the children's department. One worker has been employed since 1955 and the remainder took up duty in 1957. Conclusions The fact that officers from several departments may be concerned about and have a statutory duty towards different members of the same family underlines the importance of the work done by the divisional co-ordinating committee in preventing overlapping of services and in securing continuity of casework with individual families. These committees are in the position to reduce fragmentation of family casework and to implement the activities of the various field workers so that they co-operate with each other and work together as a team. The divisional co-ordinating committee, or the intermediate conference of officers, can often arrange that one member of the team will act as the team leader and assume the main responsibility for the family. Particularly is there a need for this guidance when the care of a problem family is passed to an intensive case worker in the children's department or to the proposed social case workers in the public health and education departments, and a similar principle operates where families are accommodated in one of the special units operated by the welfare department. Workers in many fields both in this country and abroad are constantly seeking new ways by which problem families may be established as secure members of society. It is true to say that the field workers must develop special skills if they are to understand 169 the factors giving rise to the difficult personal relationships exhibited by problem families and this aspect is receiving increasing emphasis in pre-service and in-service staff training and education schemes. A point is often reached beyond which further improvements in a family situation can only be effected if the more deep-seated reasons for the family's failings can be ascertained and dealt with constructively and sympathetically. In many instances the field worker will find that the progress being made comes to an abrupt halt for no apparent reason: then she must try a fresh line and not be disappointed at her temporary setback. Indeed, no single technique can succeed, for what may be a good plan for one family may only alienate another. Society must support and protect its weaker members but it would not be proper to set a premium on anti-social behaviour by offering to problem families special advantages and benefits which are denied to the other and stable members of the community. Seen in perspective against the background of social advance in the last half-century, problem families are but a small residual part of what was many years ago a grave social evil, and the continuing improvements in the education, health and welfare services of this country would seem to promise that in time the number of these families will diminish still further. It cannot be denied that the children of today enjoy greater advantages than did their parents and grandparents, and our social services, being as they are amongst the best in the world, will afford to the generations to come even greater possibilities for development in all spheres of human activity. It is to this end—the constant improvement of existing conditions and the creation of wider opportunities for the future—that all concerned in the social and welfare services constantly strive. 170 ANNEX A LONDON COUNTY COUNCIL Directory of Organisations (Statutory and Voluntary) Undertaking Social Case Work published under the auspices of the divisional medical officer, health division no. Address (Telephone—) to whom all inquiries on child neglect or ill-treatment and juvenile delinquency may be addressed (Note: There is a Divisional Co-ordinating Committee which meets regularly to co-ordinate the efforts of the statutory and voluntary agencies in the area undertaking work with families. The aim is to prevent the break-up of family life and the neglect or ill treatment of children. The members are : Divisional Medical Officer (Chairman) Area Children's Officer (Vice-Chairman) Divisional Officer (Education) District Care Organiser Deputy Divisional Medical Officers Divisional Administrative Officer Divisional Nursing Officer Divisional Treatment Organiser (Secretary) To deal with the bulk of the case work, a case conference meets monthly and is attended by such of the foregoing as arc more immediately concerned with the cases to be reviewed. In addition, field workers with special knowledge of such cases are invited to attend. Furthermore, meetings are held at field worker level to deal either with an individual case or a group of cases. Where necessary representatives of voluntary bodies and of other public bodies concerned may be invited to attend any of the foregoing meetings at which they have a special contribution to make.) 171 Table of Contents PART I—STATUTORY ORGANISATIONS. (1) L.C.C. Public Health Department (2) L.C.C. Education Officer's Department (3) L.C.C. Welfare Department (4) L.C.C. Children's Department (5) L.C.C. Housing Management Department (6) Metropolitan Boroughs'—Public Health and Housing Departments (7) Metropolitan Police (8) Juvenile Courts and Magistrates Courts (9) National Assistance Board PART II—VOLUNTARY ORGANISATIONS Part I—Statutory Organisations (1) London County Council—Public Health Department (Name) Divisional Medical Officer, Division No. (Address and telephone number) Deputy Divisional Medical Officers Divisional Administrative Officer Divisional Nursing Officer Divisional Treatment Organiser (Names) 172 Clinic Medical Officers at maternity and child welfare and school treatment centres are concerned with the health and well-being of the children attending or referred to the centres. School Medical Officers are concerned with the medical examination of school children, with the referral and follow-up of children requiring medical or dental attention, and with advising head teachers on health matters. Health Visitor—Visits homes in her area for the purpose of giving advice as to the care of young children, persons suffering from illness, and expectant or nursing mothers, and as to the measures necessary to prevent the spread of infection. General enquiries to Divisional Nursing Officer : other enquiries to health visitors' offices.—Appendix A gives the address and telephone number of health visitors' offices, and the area covered by each officer. (Note—Health visitors are concerned with all families and all members of a family. Other officers of the Council, referred to below, are interested in particular groups of children or in specialised spheres. The references to these officers do not necessarily cover the whole range of their duties.) School Nursing Sister—Undertakes duties in connection with the school health service, which bring her into direct touch with school children and their parents. She is responsible for the health of the children at school and makes home visits where necessary. Enquiries to Divisional Nursing Officer. Domiciliary Midwife—A frequent home visitor during the months covering pregnancy, confinement and the lying-in period (about 20 per cent.—25 per cent, of births in London are attended by the Council's domiciliary midwives or by district midwives employed by district nursing associations or maternity hospitals within the Council's domiciliary midwifery scheme). Enquiries to duty supervisor of midwives (Telephone numbers). District Nurse—Visits to homes are made by district nurses employed by district nursing associations providing a home nursing service on behalf of the Council. District Nursing Associations operating in the division :— (District, District Nursing Association, Address and telephone number) More information as to districts may be obtained from Divisional Health Office. Tuberculosis Visitor—Visits the homes of all persons under supervision by the chest clinics and advises on family difficulties. Arrangements are also made for child contacts of tuberculosis to be boarded-out, including those undergoing B.C.G. vaccination. Chest Clinics in the Division (District, Chest clinic, address and telephone number) Divisional Treatment Organiser—A social worker concerned with the health of school children and who, in arranging for medical treatment, comes into direct contact with school children and their parents and also receives information on home conditions from the health visitors and voluntary school care committee workers. Complementary to the district care organiser in the Education Officer's Department (See Section (2) ), is secretary of the divisional co-ordinating committee. Home Help Organiser—Arranges normal home help service and special home help services to meet exceptional needs, e.g. child helps to sleep in the home and to take the place of the mother of children temporarily deprived of the care of both parents ; early morning and evening home helps to look after children where only 173 one parent is at home and children would otherwise not have proper care when the parent leaves home for work or before return from work and the children are not at school or in a nursery; specialist home helps for work with selected problem families where this can contribute to the prevention of break-up of the family and its rehabilitation. Enquiries to the Home Help Organiser, (Address and telephone number of office) Local Organiser (Mental Deficiency Acts)—Deals with ascertainment of and takes appropriate action with regard to all mentally deficient persons. Periodical visits are made to all mentally defective persons living at home under supervision by social workers employed by the Council. These workers are based on district offices, a local organiser being in charge of each office. Enquiries to :— (District, address and telephone number) Mental Welfare Officer—Takes action under Lunacy and Mental Treatment Acts among persons alleged to be of unsound mind. Enquiries to:— (Address and telephone numbers) Psychiatric Social Worker—Two such workers are based at County Hall, S.E.I. They give help and advice to persons suffering from psychiatric disabilities who do not need hospital treatment. Enquiries to:— (Address and telephone number) Personal Health Services which may be used in appropriate cases to meet the needs of neglected, etc., children include:— Day nurseries Applications to Divisional Medical Officer. Recuperative holidays (where the emphasis is on rest, fresh air and good food with no regular medical supervision and no organised nursing care) are arranged on medical recommendation of clinic or school doctor, hospital or family doctor. Applications to Divisional Medical Officer. Rehabilitation of mothers—Arrangements may be made in suitable cases, where physical recuperation is an important factor, for residential mothercraft training to be given to expectant and nursing mothers and mothers of children below school age; the mother may be accompanied by children under five years of age and by one child of school age where it would be undesirable to make separate arrangements for the care of the school child. Enquiries to Divisional Medical Officer. 174 (2) London County Council—Education Officer's Department (Name) Divisional Education Officer, Division No. (Address and telephone number) District Care Organiser—(Name) (see below). The Divisional Education Officer—is responsible for the enforcement of attendance (at school) and of the employment by-laws. He is concerned in cases referred to the N.S.P.C.C. He is also the Secretary of the Borough Youth Committees and the staff of the divisional office includes organisers of youth service whose duties are the encouragement and co-ordination of youth activities in the division. School Inquiry Officer—Makes inquiries at the homes of children who are absent from school or who are attending irregularly. He ensures that children who are absent owing to illness are receiving proper medical attention. He detects and reports infringements of the Council's employment by-laws and also reports on cases of neglect which come to his notice in the course of his duties. He advises parents who are in difficulties with their children. District Care Organiser (Name)—Undertakes social work connected with the wellbeing of school children and advises the voluntary school care committee worker who visits the homes. Complementary to the divisional treatment organiser in the public health department. (See Section (1) ). (Address and telephone number) Youth Employment Officer—Is concerned with vocational guidance and placing of youth up to the age of 18 years in employment. Acts in close co-operation with the district care organiser and her staff. Bureaux in division:— (Addresses and telephone numbers) (3) London County Council—Welfare Department WELFARE OF THE BLIND AND PARTIALLY-SIGHTED Home Visitor—Visits the homes of the blind and partially-sighted persons and assists generally in the promotion of their welfare. The home visitors for the division are based on the undermentioned branch office which is in the charge of a secretary. (Address and telephone number) WELFARE OF OTHER HANDICAPPED PERSONS Welfare services for handicapped persons, other than the blind and partiallysighted, in any part of the County of London, are at present dealt with at:— (Address and telephone number) ACCOMMODATION—Officers on the staff of the welfare homes deal with applications for residential accommodation for persons in need of care and attention not otherwise available to them and visit homes of the applicants. They also deal with applications for temporary accommodation for London women and children who are homeless. Enquiries to be made to Admissions officer. (Address and telephone number) 175 M (4) London County Council—Children's Department (Name) Area Children's Officer, Area No. (Address and telephone number) Child Welfare Officer—Deals with applications for children to be received into official care, including the work of visiting the homes and persuading the relatives or friends to look after the children rather than remove them from their home background. Also deals with the rehabilitation of homes so that children already in care can return home at the earhest possible moment. Supervises children who have been placed in private households for adoption. Duties include the finding of foster-homes and supervision of children in them, and the finding of lodgings, hostels and work for older children in the Council's care and the supervision of them. Also supervises approved-school children who have been allowed to live in their own homes, under licence. (Note :—Some of these officers are engaged for special duties in connection with Juvenile Court work, which sometimes include the making of ' home surroundings' reports.) (5) London County Council—Housing Management Department Certain officers of this department deal with applications for rehousing on Council estates, and in cases in which there are exceptional medical features reference is made by the department to the Medical Officer of Health (the appropriate Divisional Medical Officer). At each of the district offices, there are housing welfare officers whose duties include dealing with special housing cases and with social or domestic problems of the Council's tenants. The housing district offices for this division are :— (District, area covered, addresses and telephone numbers) (6) Metropolitan Borough Councils (Addresses and telephone numbers of Borough public health and housing departments) The Metropolitan Borough Councils are responsible for general public health, including sanitary functions, the prevention of the spread of infectious diseases and are also housing authorities. (7) The Metropolitan Police Police Constable—May visit the home for a variety of reasons and is likely to become aware of distress, cruelty and the exposure of children to moral and physical dangers. (District, address and telephone number) (8) The Juvenile Courts and Magistrates Courts Probation Officer—Is appointed by the Probation Committee and the Justices of the Peace and carries out duties in connection with the Juvenile Courts or Magistrates Courts, bringing him/her into close touch with the home. (Address and telephone number) 176 (9) National Assistance Board Provides financial aid and assistance in kind in cases of need. Deals with assessment of resources of applicants for legal aid. Enquiries to :— (District, address and telephone number) Part II—Voluntary Organisations The following voluntary organisations, set out in alphabetical order, are associated with home visiting and the welfare of parents and children. (Associations concerned with certain aspects of social work can, for ease of reference, be identified under the following numbers :— Adoption of children Marriage guidance Mental health Moral Welfare 6, 8, 19, 23. 4, 11, 13, 10. 18, 20. 7, 9, 25). 1. Board of Guardians and Trustees for the Relief of the Jewish Poor, 127, Middlesex Street, E.l. (BIShopsgate 1602)—Administers various Jewish associations and deals, among other things, with family case work in connection with general welfare. 2. British Legion, 49, Pall Mall, S.W.I. (WHItehall 8131)—In addition to main activities, provides help for after-care training of orphans and assistance towards maintenance of orphan children. 3. British Red Cross Society, 14, Grosvcnor Crescent, S.W.I. (SLOane 9151)—In addition to main activities, provides medical loan depots. British Red Cross Loan Equipment Depots in the division :— (District, address and telephone number) 4. The Catholic Marriage Advisory Council, 38-39, Parliament Street, S.W.I. (WHItehall 0817)—Promotes successful marriage and parenthood by means of education for marriage; also provides marriage counselling for those in difficulty about marriage and family relationships. 5. Catholic Social Welfare Committee—Is concerned with the rescue of Roman Catholic children. (Address and telephone number). 6. The Children's Aid Society, 55, Leigham Court Road, S.W.16. (STReatham 2131 /2)— Is a registered adoption society; makes up for the loss of a normal home life which any child in its care has lost through no fault of its own. 7. The Church Army, 55, Bryanston Street, W.l. (PADdington 9211)—Is a Society pledged to the doctrine and practice of the Church of England and undertakes social and moral welfare work. 8. Church of England Children's Society, Old Town Hall, Kennington Road, S.E.ll. (RELiance 2441)—Rescues and cares for children who arc orphaned, homeless, cruelly treated or in moral danger and also relieves over-burdened homes; is a registered adoption society and also arranges boarding-out with foster parents and in small family homes. 9. Church of England Moral Welfare Council, Room 251, Church House, Dean's Yard, S.W.I. (ABBey 6269)—Co-ordinates the moral welfare work of the Church of England throughout the country and the activities of local organisations engaged on this work. The following association functions in this Division:— (District, address and telephone number) 177 N 10. District Council of Children's Care Committees—A Council is formed for each educational administrative division and consists of two members nominated by each school care committee in the district, together with three members nominated by the local Consultative Committee of Headmasters and Headmistresses. The Council co-ordinates the activities of the children's care committee and advises on questions affecting the welfare of children in the district. 11. Family Discussion Bureau, 4, Chandos Street, Cavendish Square, W.l (LANgham 7045-6)—Under the aegis of the Tavistock Institute of Human Relations. Promotes casework, training and research in marital difficulties. 12. Family Welfare Association, Denison House, Vauxhall Bridge Road, S.W.I. (Victoria 7334)—Provides a service of advice and guidance in personal and family problems; helps those persons who are unable to take advantage of the resources provided by the community and who are in difficulties, either through their own or society's limitations, and assists such persons to take their place as useful citizens. Promotes close co-operation between family case-work agencies and government departments and provides the Citizen's Advice Bureaux. The area office for this Division is :— (Address and telephone number) 13. Invalid Children's Aid Association, 4, Palace Gate, W.8. (WEStern 3914)—Puts at the disposal of parents and others all information with regard to the care of invalid and crippled children and the facilities which exist for their treatment; co-operates with the doctors and hospitals, etc., by reporting on those aspects of the children's social background which are relevant to the understanding and treatment of the illness; assists parents to carry out the doctor's advice with regard to treatment by, if necessary, arranging admission to convalescent and recuperative holiday homes and by helping them to understand, and where possible rectify, any adverse social conditions which may exist. The Area Office for this Division is :— (Address and telephone number) 14. The London Council of Social Service, 7, Bayley Street, W.C.I. (MUS. 4864)—Is a central consultative advisory body on social service. 15. The London Marriage Guidance Council, 78, Duke Street, W.l. (MAYfair 2731)— Promotes successful marriage and parenthood, by means of education for marriage. Also provides marriage counselling for those in difficulty about marriage and family relationships. (Address and telephone number) 16. The London Police Court Mission, 2, Hobart Place, S.W.I. (SLOane 7538)—Provides assistance in cash, accommodation, clothing or tools for necessitous persons referred by probation officers. Also provides homes and hostels for boys and girls on probation and a home for children. 17. The Mental After-Care Association, 108, Jermyn Street, S.W.I. (TRAfalgar 5953)— Provides homes for the rehabilitation of persons recovering from mental illness. 18. The National Adoption Society, 4, Baker Street, W.l. (WELbeck 7211)—Arranges for the legal adoption of healthy babies and young children by suitable families. Co-operates with other welfare societies in all matters pertaining to the welfare of adopted children. 178 179 19. National Association for Mental Health, 39, Queen Anne Street, W.l. (WELbeck 1272)—Provides an advisory service on all aspects of mental health and manages holiday homes for mental defectives and epileptics and an approved school for adolescent girls needing psychiatric treatment. 20. National Society for Mentally Handicapped Children, Kingsway Chambers, 162a, The Strand, W.C.2. (TEMple Bar 0551/2)—Promotes facilities for the care and training of backward children. 21. National Children's Adoption Society, 71, Knightsbridge, S.W.I. (SLOane 7231)— Arranges for the legal adoption of homeless children by suitable adopting parents. 22. National Society for the Prevention of Cruelty to Children, Leicester Square, W.C.2. (GERrard 2774)—The primary object of this Society is to prevent ill-treatment, neglect or improper employment of children, also of conduct by which life, limb or health is wilfully endangered or sacrificed, or by which morals are imperilled or depraved. The Society is also prepared to help and advise parents and others in regard to difficulties they are experiencing with children. Inspectors are chosen to investigate cases of which complaint has been made and, if true, parents or guardians are helped constructively and are under constant supervision. If this fails, the Society prosecutes. But in every case prosecution is not resorted to until all other methods of improving the conditions of the children have failed. Local officers:— (District, name, address and telephone number) 23. The Salvation Army—Undertakes social and moral welfare work and provides holiday homes for poor mothers and children. (District, address and telephone number) 24. The Save-the-Children Fund, 20, Gordon Square, W.C.I. (EUSton 8591)—This is an international, non-political and non-sectarian body set up to preserve child life wherever menaced by conditions of hardship and distress and to raise the standard of child care and protection throughout the world. 25. The Shaftesbury Society, John Kirk House, 32, John Street, W.C.I. (CHAncery 6937)—Provides Christian social service for poor and crippled children and their families principally in the London area. Provides residential schools for crippled children, holiday and convalescent homes for children. 26. Soldiers', Sailors' and Airmen's Families Association, 23, Queen Anne's Gate, S.W.I. (TRAfalgar 4131)—Among its other activities, provides an emergency short-stay home for children. 27. Women's and Children's Protection Society, 29, Chester Way, Kennington Road, S.E.ll. (RELiance 1329)—Gives legal assistance in Metropolitan Courts, or advice generally in cases of desertion, cruelty or non-maintenance and, in affiliation cases, settles voluntary separation agreements. Strives for the improvement of Statute laws with a view to more effectual protection of women and children. 28. Women's Voluntary Services—Gives practical voluntary assistance to government departments and local authorities in schemes for the welfare of the community. (District, address and telephone number) A list of health visitors' areas, office addresses and telephone numbers follows. n* 180 ANNEX B Problem family case histories (Illustrating the work of the divisional co-ordinating committees) Family 1. Father (aged 50 years), mother (aged 49 years) and thirteen children. All children at home except eldest son aged 30 years and boy aged 18 years on National Service. Father, casual labourer, frequently out of work and addicted to drink. Mother admitted to mental hospital immediately before birth of baby in December 1953. Father then gave up work and family income was national assistance, children's allowances and contributions from two sons aged 25 and 20 years and daughter aged 16 years at work. (This girl also 'mothered' the family.) One son aged 21 years in sanatorium; baby in residential nursery; four children at school and two children in day nursery. In May 1954 daughter aged 16 years quarrelled with her father and ran away from home. Put on probation as being in need of care or protection and placed in a friend's home. Future of family then discussed at a conference between the district care organiser, special officer (education officer's department), divisional nursing officer, health visitor, area children's officer, child welfare officer and probation officer, to decide whether children should be received into care as eldest girl at home was only aged 13 years. It was thought justified to keep the family together and accordingly decided : (1) Health department to provide a home help, who would also take two youngest children to a day nursery. Health visitor to be the co-ordinating officer and to keep family under close supervision (working with N.S.P.C.C. inspector on this aspect). (2) District care organiser to arrange for the schoolchildren to have school dinners during term time and school holidays. (3) Position to be reviewed in one month. Father persuaded to resume work. Frequent visiting by health visitor and routine established for father to prepare tea before schoolchildren returned home from school and the girl aged 13 years to collect the two younger children from day nursery. This girl and her father to do the shopping together at weekends. Home help assisted in household management and budgeting, including budgeting for home help and day nursery charges payable on father resuming work. Progress reviewed at end of one month when it was decided that the arrangements made were satisfactory and could be continued. Clothing for children and some bedding obtained from W.V.S. and tuberculosis care committee provided bedding for boy who had now returned from sanatorium. Two weeks' holiday arranged for all the children (including, as a special case, the eldest girl who was now aged 14 years) through the Children's Country Holiday Fund. At one time all the children were verminous but health visitor persuaded father to take them to a bathing centre and subsequently, by following health visitor's advice, father kept the children clean himself. Arrangements made by health visitor with L.C.C. housing department for priority decoration of the flat. Health visitor also paid frequent visits to the home during school holidays. At this stage home looked much better, children were happier and the eldest girl (on probation) had started to return home at weekends to cook the family dinners. In November 1954 mother returned home on weekend leave from mental hospital and remained at home. Mother very unstable for a time and needed close supervision by the health visitor who also kept in close touch with psychiatric social worker. Mother soon dismissed the home help (although she was not really able to manage without) and shortly afterwards brought the baby home from residential nursery. Situation further complicated because husband became disturbed by wife's difficult and irritable attitude 181 and he resumed drinking. Violent quarrels between husband and wife and police called in more than once. Frequent visiting continued and situation improved as mother became more stable and better adjusted to resume household duties and after a while N.S.P.C.C. inspector ceased to call. Family became reasonably adjusted and self-supporting and children now look well-nourished and happy—physique good. Clothing sometimes rather inadequate, particularly for the girls. Where mother is inadequate, older children take over and help to keep matters from getting too much out of hand. Family still under close supervision as situation is likely to deteriorate if husband should be out of work for very long. Family 2. Father (aged 63 years), mother (aged 44 years) and nine children, aged 23 years to 2 years. Three other children (triplets) died after birth. Father lame and of only fair intelligence with a prison record (breaking and entering, receiving stolen goods). Mother of extremely low mentality, ineducable and almost unemployable; has no control over children and father takes charge of housekeeping matters and does household cleaning, etc. Family frequently receiving national assistance. Children, under father's influence, often before courts on charges of stealing. Family ostracised by neighbours, but efforts to give family a fresh start by arranging housing transfer failed because they were bad tenants. When father in prison, home conditions became deplorable. Services of home help refused, and health visitor needed to pay frequent visits and spend a great deal of time in supporting mother in household management and duties, feeding baby, etc. Early in 1955 one child was before court on theft charge and court asked for psychiatric report. Psychiatrist's interest extended to father and mother and most of children and he attended meeting of intermediate case conference in February 1955 and endorsed and supported opinion of all field workers that children should be received into care as a preventive measure. Action followed by children's department. Of the children of school age, six were received into care, the court sent one to an approved school and the youngest child remained at home. In April 1956, on decision of divisional co-ordinating committee, restrictions placed on the children in care visiting their home, but the parents continued to visit the children. Away from family influence, children have done better at school and one is, in fact, of above average intelligence. Oldest son now married and living at home with his wife, aged 17 years, who expects a baby in March 1957. He is work-shy and of low intelligence and his wife, too, is not very intelligent. Health visitor continues to supervise remaining child at home and to maintain contact with father and mother and married son and daughter-in-law. Family 3. Father, an Indian (aged 44 years), mother, English (aged 43 years) and five children aged 20 years to 7 years. One other child died aged 18 years. Husband, habitual drunkard, has spent much of his life in prison. When under the influence of drink he ill-treats his wife and children and smashes furniture, etc. Family well-known to social workers and agencies in the area for many years. Following summary of family history over past seven years shows the difficulties experienced in helping this family. In April 1949 health visitor greatly concerned as mother expecting sixth child in July, but no preparations made for confinement. Scarcely any furniture in home, bedding filthy, windows broken and floors bare. One child then in a remand home, one living with grandmother ; father in prison. Schoolchildren miserable-looking and ill-clad. Baby looked neglected, N.S.P.C.C. called in. Considerable help given to family and toddler admitted to day nursery. Eldest girl committed to Council's care under a 'Fit Person' Order in January 1950, but conditions improved enough for N.S.P.C.C. to close the case in July 1950. Health visitor continued visiting and from time to time children given holidays and younger ones taken into the day nursery. Home help offered but refused. 182 Case considered by divisional co-ordinating committee in April 1954 when reported that youngest boy (then 4½ years old) in hospital in very bruised condition and as result of N.S.P.C.C. action oldest son (then aged 19 years) had been sent to prison for three months. Committee concerned over bad home conditions but N.S.P.C.C. inspector felt that cruelty or neglect could not be proved against parent. He had called doctor to house but doctor did not say that children were neglected. Committee generally agreed that children would benefit from residential care and children's officer, together with care committee worker, was to look into possibility of admission to voluntary home. Oldest son out of prison in June 1954—his younger brother appeared quite happy with him. In August 1954 two youngest boys received into care and in September 1954 oldest son, who by this time had left home, committed suicide. In July 1956 divisional co-ordinating committee informed that mother looked ill and miserable and spent most of her time in bed ; home in a deplorable condition ; father in prison ; one child in mental hospital ; oldest girl with foster parents (girl over 18 years of age and spent much of her time on streets) ; two other children in care and boy of 13 at home. Agreed that services of a home help be offered ; children's officer to arrange for mother to visit children ; and holiday to be arranged for mother and the boy at home. Stated that National Assistance Board had offered to help with clothes. N.S.P.C.C. inspector to pay friendly visit to oldest girl to persuade her to adopt better way of life. At October 1956 meeting of divisional co-ordinating committee reported that health visitor had accompanied mother to visit her children in care—an event, as mother had hardly been outside her home for several years and the preparations and the journey were a great effort for her. The children had hardly recognised their mother and indeed had been loath to leave their play in order to talk to her. At first this had upset mother, but afterwards she felt relieved in the knowledge that they were happy. Home help working in home and accepted by mother because she felt it would help her to prepare the home so that the children could return from care. Mother and boy at home had two weeks' holiday at a holiday home in September 1956—boy enjoyed it enormously and mother returned looking brighter and happier. Husband home again. Home help finding it difficult to make any improvement in home conditions. Situation in January 1957 was father in prison, eldest girl in a mother and baby home, oldest boy (who has spent long periods in mental institutions) working spasmodically, two children still in residential school and one child at home. Mother again looked tired and depressed. Home help attending three times weekly. Child at home apparently happy and doing well at school. Of the two boys in care, one appears intelligent and is doing well at his lessons and the other is thought to be mentally dull although reported to be happy and responsible. Children in care have a very good foster aunt who keeps close contact with them and has them in her home for the holidays and it is hoped to continue this arrangement as it seems unlikely that the home conditions will ever be suitable for their return. 183 ANNEX C Personal health services.—Prevention of children being received into care Year 1st January, 1956 to 31st December, 1956 This table shows, by Divisions, the use made of the various personal health services to prevent the reception of children into the care of the Council, and the number of children concerned. Credit is given only to the service which was mainly responsible for enabling the child to remain at home with its parents or guardians. Division Population 30.6.55 estimate Home nursing Health visitor Child help Morning or evening help Home help Day nursery Child minder Recuperative holidays Other services Fostermother TOTALS 1 454,150 5 40 18 94 79 117 62 7 4 60 486 2 524,780 192 — 55 85 89 27 — — 38 486 3 286,960 — 118 — 65 21 35 5 — — — 244 4 263,150 — 47 5 44 56 46 3 1 — 6 288 5 227,480 9 66 — 51 88 60 14 10 1 16 315 6 310,880 — 35 3 11 42 32 42 — — 24 189 7 401,800 — 107 — 11 72 93 12 6 — 34 335 8 375,600 — 39 7 53 34 103 20 7 9 25 297 9 450,200 1 116 — 7 30 49 36 2 — 17 258 TOTALS.. 3,295,000 15 760 33 391 507 624 221 33 14 220 2,818 Note : For comparison, the number of children received into the care of the Council under the Children Act, 1948, during 1956 was 4,409. 184 ANNEX D Selection of families where a special home help was employed Family 1. Family consists of father, who is unco-operative and difficult to contact, mother whose intelligence is not very high, and five children aged from 17 years to 10 months. In the first few days the home help washed a pile of clothing which took 15 hours to clear ; she removed maggots and human and animal excreta from the kitchcn floor, as well as the remains of a Christmas party from behind the dressing table (it was then May). Two supposedly enuretic children have responded to habit training; the mother's health is so much improved that a recuperative holiday suggested by the divisional co-ordinating committee is now not necessary. A neighbour, on seeing the improvement in this family, has redecorated the common landing. The mother now has no debts and pays her rent regularly. Father is still unsatisfactory and has recently been summoned for a debt of £80. Help will be needed by this family for some time, but there has already been a marked improvement. Family 2. Mother unable to manage three small children. Home neglected. Husband worried and threatened to leave home. Special home help supplied for six hours daily, and three-year-old child admitted to a day nursery as being unmanageable. Progress in nursery, child settled down and played happily with other children. Mother is gradually gaining confidence in shopping and handling money. She is learning to cook with assistance from the home help, and is caring for the children. The home help's hours have been reduced to four hours daily, and will be reduced again shortly. The husband is pleased with the progress, the family relationship is happier and the mother's health has improved. Family 3. Family consists of father (aged 28), mother (aged 29), seven children (aged from 9 years to 6 months). Mother expecting another baby. A ' hard-core ' problem family known to all social agencies in the area for years past. The sole redeeming feature is the affection of the parents for one another and for their children. Both parents of low mentality. Father usually unemployed and family living on National Assistance and children's allowances. Home practically unfurnished with little more than two beds and two chairs. No table and not even a knife to cut food. Larder empty, food being bought and consumed as needed. Piles of clothing contaminated by faeces in cupboards and in kitchen. Rent heavily in arrears and electric light cut off because of non-payment. Following provision of special home help, all contaminated clothing washed by the mother and brought back into use. Much furniture, equipment and clothing given or lent. Father obtained work as a means of escaping household chores, and National Assistance terminated. Rent being paid regularly plus 7s. 6d. a week off arrears. It is hoped to get electricity bill paid and current restored soon. A shilling or two has also been paid off each week in reduction of various debts to tallymen. Under guidance, mother is doing her routine housework, washing and cooking for the family. She now makes out her own shopping list and she and her husband shop together. Mother's personal appearance has improved and children look better for regular and cooked meals in place of former diet of pies and chips. The children's toilet habits have improved and they have responded to the changed home conditions. Family 4. Family consists of father, mother and seven children aged 13, 9, 6, 5 and triplets born 6 April, 1956. Parents after much quarrelling separated in 1953, but father visited family at weekends and family reunited upon birth of the triplets. The babies were transfused shortly after birth (mother rhesus negative) and it was necessary to ensure that the instruction given the mother in hospital as to artificial feeding technique was continued on her return home. Mother bad manager and her mothercraft is poor. Apart from ensuring a clean and orderly home for the delicate triplets to come to on discharge from hospital and that they were properly fed and cared for in the first month of their home life, little was achieved by the provision of a special home help. The 185 parents continue to quarrel. The mother did not co-operate with the special home help and appeared to take little interest in her home or children. The special home help was withdrawn after five weeks and was replaced by an 'ordinary' home help. The triplets are doing well and gaining weight. Family 5. Family consists of father, mother and two children under three years of age. Dirty flat, undernourished family, wasteful spending, debts, and disharmony between father and mother. Income adequate, but both parents reckless and money mis-spent. Potential ' problem family ' in danger of breaking up altogether. Special home help was supplied from 30 April to 29 September, 1956, when the family had to vacate the furnished flat they were occupying, and despite every effort to help them they were unable to find alternative accommodation until 27 October, 1956. During the intervening four weeks the family lived in temporary accommodation of various kinds including a caravan, a homeless families' unit and even spent one night in the home of the special home help. Help in this case was required specially with budgeting and raising the standard of home keeping. As a result of the help and training given, real progress is being made in the general standards of cleanliness of both home and clothing, and in cooking. The mother and children appear to be healthier and happier, and the father more tolerant and less violent in temper and preferring his home now rather than the public house. Despite the setback due to housing difficulties, it is believed that this family have obtained lasting benefit from the special help they have received and both parents have expressed their appreciation for this. All their debts have been paid and their attitude towards life and towards each other has been completely changed. The home help has been a real friend to the family and gained the confidence of the father so completely that during the period of her service she was helping him to allocate all his earnings. Further special help to consolidate the immense improvements so far achieved has been supplied since the end of October 1956 and the improvement has been maintained. Family 6. Family consists of father, mother, three children under the age of seven years and another child living with the grandmother. Father is a coal porter with reasonably adequate but mismanaged income. Special help provided on account of mismanagement. Mother an epileptic; very good co-operation and willing to assist in any way to improve the condition of the home. Special help was received well by the mother and children, but the father was inclined to be aggressive at times. There has been improvement in the home which is cleaner and not so muddled, but it is a difficult and slow process, and a great deal of patience is required on the part of the home help. 186 APPENDIX B ATMOSPHERIC POLLUTION AND HEALTH A SURVEY IN LONDON Introduction Smoke has long been a matter of concern in this country ; Royal Proclamations of both King Edward I and Queen Elizabeth I prohibited the burning of coal in London during such times as Parliament was in session. As a local authority function general smoke abatement appears to date from the Town Improvement Clauses Act, 1847, and more generally from the Sanitary Act, 1866, and in consolidated legislation from the Public Health Act, 1875 [in London from the Smoke Nuisance Abatement (Metropolis) Act, 1853 (enforceable by the police), and the Public Health (London) Act, 1891]. These powers in London are exercised by the City Corporation and Metropolitan Borough Councils. Under the acts private dwellings are exempt from action although the City took special powers to create a smokeless zone in 1955 and Woolwich Borough Council has introduced a smokeless housing estate by making tenancy agreements conditional upon the use of smokeless fuels. The Alkali Works Regulation Act of 1906 also governs the production of noxious or offensive gases in certain chemical processes ; the control of such gases outside the scheduled processes resides in general public health legislation. It took a catastrophe of the magnitude of the London fog of 1952 [see Appendix A of my annual report for 1952 and Ministry of Health report, 1954, for a full description] to focus public attention on the seriousness of the effect of atmospheric pollution on health. The Report of the Committee on Air Pollution, 1954 (the Beaver Committee), led to the Clean Air Act, 1956, upon which great hopes are set for an improvement in the state of the atmosphere of the industrial cities of Great Britain. Medical literature, especially since 1952, abounds with references to the effect of atmospheric pollution on health, Pemberton and Goldberg (1954) have shown how the death rate from bronchitis increases with the degree of urbanisation and that there is some correlation between deaths from bronchitis and the amount of pollution in the atmosphere; Joules (1956) has referred to the differential death rate from bronchitis in middle-aged men between industrial cities and seaside resorts, although he reminds us of the importance of differences in social class in this context. The invaliding effect of fog as seen by a clinician has been described by Leese (1956) and Lawther (1956). The Standing Advisory Committee to the Medical Research Council in Social and Environmental Health has a sub-committee on atmospheric pollution with working parties engaged on various aspects, e.g. chronic bronchitis in relation to atmospheric pollution, the constituents of atmospheric pollution and means of prevention, mortality and morbidity statistics, etc. Atmospheric pollution The situation in London The main sources of pollution of the London air are the numerous domestic and industrial chimneys which emit smoke, grit and gases. Except in busy streets, contamination from vehicle exhausts does not contribute a large proportion of the total of impurities, and pollution from other sources such as chemical processes is generally small. Fuel can be burnt in more and in less satisfactory ways ; since the less satisfactory are prevalent the air contains respiratory irritants, and these have health effects which may range from a minor risk to a major disaster. Within this large built-up area, pollution shows no respect for administrative boundaries and the state of the atmosphere in any locality is affected by distant as well as by local sources. One of the most important controlling factors is the prevailing weather, in particular the degree of turbulence of the atmosphere. There are seasonal and short period fluctuations in the incidence of pollution, and a reliable comparison of the conditions can only be made through a long term survey. 187 The sources and distribution of the various components of atmospheric pollution have been widely studied, and the subject is well summarised by Meetham (1956). There are many individual chemical substances present, but to obtain data for comparative records the analytical examination must normally be limited to tests of relatively simple type. Mortality While the total death rate in London has, since the war, differed little from that of England and Wales as a whole, and the areal comparability factor has never been far from unity, there are wide differences in the effects of the constituent causes. In Table I are set out by sex and age groups standardised mortality ratios* for a number of different diseases and for all causes. These diseases account for four-fifths of the total mortality. The figures are taken from the published mortality statistics of the year 1955—a year in which there was no particular epidemic in either London or the country apart from poliomyelitis which causes relatively few deaths and has no significant effect on the death rate. Table 1—Standardised Mortality Ratios, London A.C.for all causes and certain diseases—1955 (England and Wales — 100) Age Groups All causes Bronchitis Other respiratory diseases including respiratory tuberculosis Lung cancer Other cancer Cardiovascular diseases Males 0-4 100 250 81 — (115) (50) 5-44 93 104 76 123 108 92 45-64 108 132 110 131 117 94 65 and over 102 149 139 155 113 86 All ages 103 145 120 143 114 88 Excess or deficiency of deaths + 548 +606 + 287 +458 + 321 -1,059 Females 0-4 97 (163) 78 — (109) (100) 5—44 97 (67) 82 (118) 102 93 45-64 96 107 99 186 106 82 65 and over 92 127 127 181 102 85 All ages 93 124 115 180 104 85 Excess or deficiency of deaths -1,337 +180 + 187 + 150 + 117 -1,621 Figures in brackets are based on fewer than 20 deaths in either actual or expected mortality and, thereFore, ratios are unreliable. The table shows that in London male mortality is higher and female mortality lower than in England and Wales; the excess male mortality is concentrated mainly in the middle-aged group, 45-64 years, whilst female mortality is lower at all ages and especially at 65 years and over. Examination of the disease pattern shows, for males, an excess of deaths in diseases affecting the respiratory system, an excess which increases with age. The excess is offset to some extent by fewer deaths from cardio-vascular * The ratios are calculated by expressing the actual number of deaths in London as a ratio of the corresponding 'expected' number based on the mortality experience of England and Wales and multiplying the result by 100 for ease in comparison of the figures, e.g., if the actual is the same as the ' expected* then the ratio will be 100, if the actual is in excess of the ' expected * then the ratio will be over 100 and similarly if mortality is lower than expectation the ratio will be lower than 100. 188 causes out the mortality ratio tor all causes, all ages, is 3 per cent. higher than in the whole country and at ages 45-64 years it is 8 per cent, higher. For females, a similar though not so pronounced pattern applies and the fewer cardio-vascular deaths more than offset the higher ratios from diseases of the respiratory system, resulting in a female mortality for all causes, all ages, lower than the national experience. Two possible explanations of the differences in the mortality pattern of the county and the country are variations in the choice of the underlying cause of death by the certifying medical practitioner, and a differing social class composition (bearing in mind that there is a class gradient in mortality from respiratory causes, particularly for bronchitis). The first has been dealt with in more detail by Hewitt (1956) but, even allowing for a difference in diagnostic fashion between town and country, differences of this magnitude cannot be explained away. As regards the second, as the following table shows, the relative proportions in the social classes for males (females are not tabulated by social class tor London) are not dissimilar as between London and England and Wales. Table II—Social class distribution of Males (occupied and retired), Census 1951 percentage i II III IV v England and Wales 3.3 15.0 52.7 16.2 12.8 London 4.2 13.6 53.2 12.2 16.9 It social classes I and II, and IV and V are combined to form a three-fold classification there is almost perfect correspondence between London and the country as a whole. Such differences in social class as exist, in particular the difference between social classes IV and V, are again insufficient to account for the differing mortality ratios in table I above. The lower London ratios for mortality from cardio-vascular diseases can only be explained by excess deaths from respiratory causes, leaving fewer available to die from heart disease. The excess mortality in London from respiratory diseases, the 'Smog' of 1952, and the general emphasis given to atmospheric pollution led to a decision to investigate matters more fully in London to see if any association could be found between pollution and mortality—whether smoke as well as smoking was to be condemned. Methods Two aspects of atmospheric pollution have to be considered—the long-term and short-term. As Wilkins wrote (1954) 'the problem of smog is, in some respects, a short-term magnification of the general problem of atmospheric pollution, and becausc the effects of normal pollution are ever present they undoubtedly represent, in the long run, a greater damage and loss to individuals and to the nation than does an occasional smog incident Areas In order satisfactorily to calculate any correlation between the effects of atmospheric pollution and local mortality the County had to be subdivided. In the event the basis chosen was a parliamentary constituency or a metropolitan borough, whichever was the smaller, which resulted in 46 areas of roughly equivalent population. There are in London numerous atmospheric pollution recording stations under the aegis of the Department of Scientific and Industrial Research but the methods of measurement differ not only as regards the instruments, which are a mixture of deposit gauges for the measurement of solid deposit, lead peroxide cylinders for the recording of sulphur dioxide and volumetric apparatus for the dual measurement of both smoke and sulphur dioxide, but also as regards the interval at which they are read. There is no way in which the readings from lead peroxide cylinders and deposit gauges can be reliably compared with the readings from volumetric apparatus, which is to be preferred for the quantitative assessment of the amount of smoke and sulphur dioxide in the atmosphere, and the two first tend to be influenced by weather conditions. The difference in the intervals of reading the instruments, while not affecting unduly any conclusions Atmospheric pollution records 189 about the long-term effect, make any assessment of the short-term effect somewhat difficult. A preliminary analysis of these mixed data showed that because of the differing methods, and the siting at different heights and for particular local purposes, it would be totally unjustified to accept any of these instruments as representative of the area and the averaging of the readings of several instruments to produce a representative index of pollution for any one area is of dubious propriety. Daly (1954) refers to the unsatisfactory nature of pollution records and used instead figures of the consumption of domestic coal per acre. At the appropriate time an automatic sampler was devised in the Scientific Adviser's laboratory. The apparatus consists of a multiple circuit set of volumetric apparatus for the dual measurement of smoke and sulphur dioxide with which up to six consecutive samples can be taken before filters and solutions need to be examined and renewed, thus facilitating the study of peak concentration of pollutants and enabling detailed observations to be made without manual attention during night and week-end periods. Seven of these instruments were installed at the end of 1954, one at each of the Council's six general ambulance stations and one at County Hall. As indicated earlier there are other pollutants such as oxides of nitrogen, sulphuric acid and polycyclic hydrocarbons; these have been identified and must be presumed to play an important role in the pollution complex but their measurement is too exacting to be made outside the research laboratory. As these seven sets of apparatus are under the direct control of the Council there is instant access to the records for an on-the-spot assessment of the extent and duration of a period of heavy pollution. Accordingly, it was decided to centre the investigation on these seven recording stations and to relate the mortality data in the areas immediately surrounding them to the figures of atmospheric pollution. The recording stations and associated areas are shown on the map, Figure 1; starting in the North-west corner and proceeding clockwise details arc as follows:— Recording station Area(s) North-western ambulance station, Borough of Hanipstead. Lawn Road, Hampstead. Parliamentary constituency of St. Pancras North. Eastern ambulancc station, Brooksby's Borough of Hackney. Walk, Hackney. Brook ambulance station, Park Row, Borough of Greenwich and Parliamentary Shooter's Hill Road, Greenwich. constituency of West Woolwich. South-eastern ambulance station, New Borough of Bermondsey. Cross Road, Deptford. Borough of Deptford and Parliamentary stituency of the Peckham Division of Camberwell. South-western ambulancc station, Parliamentary constituencies of the Brixton Landor Road, Stockwell, Lambeth. Division of Lambeth and the Clapham Division of Wandsworth. County Hall, Westminster Bridge, City of Westminster. Lambeth. The average of the Parliamentary constituency of the Vauxhall South-western Ambulance Division of Lambeth. and County Hall stations. Western ambulance station, 350 Kings Borough of Chelsea. Road, Chelsea. It is not for one moment suggested that these areas surrounding the recording stations are ideal—the Hampstead station may not be truly representative of St. Pancras North, the area of which extends beyond the high level contour of Hampstead and Highgate down the hill to Chalk Farm and Kentish Town with their concentrations of railway installations; the Deptford station may not be truly representative of the borough of Bermondsey; the river separates the County Hall station from Westminster and inclusion of the Knightsbridge area therein may not be justified, but the population of the latter is only 11 per cent, of the whole and therefore its inclusion is unlikely to have any significant effect on the mortality indices for the area. 190 However, with these three exceptions, all the recording stations listed are located within the defined associated areas. Having regard to the prevailing wind from the south-west they may not be recording the pollution generated within the area but the pollution blown over them; nevertheless this is the air that the residents have to breathe. On these grounds the association of the areas defined on the map with their respective recording stations is considered to be justified. Population The populations used as a basis for the investigation were, for complete boroughs, the Registrar General's mid-1955 estimates of the home population, i.e., populations current some 15 months after the investigation began and 9 months before it ended; for parts of boroughs the populations were estimated by a conversion of the numbers of electors as at November, 1955, into total population, on the basis of the ratio of electors to total population ascertained at the time of the census, and adjusting the numbers thus obtained so that the total for the complete boroughs accorded with the Registrar General's mid-1955 estimate. The age and sex composition of the area populations so assessed was calculated by modifying that ascertained at the census* in the light of overall changes (notably fewer children under five years and more in the age range 5-14 years) which, according to the Registrar General's mid-year estimate of population, had occurred in the County by mid-1955. The social class composition and the proportions born in London have been taken as those prevailing at the census date, again specially obtained for areas approximating to the parts of boroughs. Morbidity No study of the effects of atmospheric pollution would be complete without a consideration of morbidity. There are practically no pertinent data available collected on a consistent basis; of the respiratory diseases pneumonia is notifiable but there is reason to believe the notifications are incomplete. There are available the weekly number of first applications for sickness benefit from the local offices of the Ministry of Pensions and National Insurance, but they are not analysed at that stage by cause, age or sex and, relating as they do, to the insured population they are not representative of the total population; in fact the section of the population most vulnerable to the effects of fog, namely the aged, would be completely missed in statistics from this source. Moreover, the local offices of the Ministry are not coterminous with any local government boundary and, therefore, figures from this source are not particularly helpful from the epidemiological aspect. The most that can be obtained in the shape of morbidity data is a summation of impressions from various sources at the time of a 'smog' incident—Ministry of National Insurance figures already referred to, demands upon the District Nursing Service, demands for hospital beds, etc.; for a long-term assessment of the prevalence of respiratory disease there is no information available. From this aspect, therefore, the survey was confined to an examination of mortality. Mortality For the mortality data the published statistics of the Registrar General were inadequate because they are based on metropolitan boroughs. Accordingly in 1953, I approached the medical officers of health of the boroughs who kindly agreed to make available to the department copies of the death returns received by them from the local registrars; the collection, classification and tabulation of the data began in July, 1954. Deaths of London residents outside the county were obtained from the transferable death returns of the Registrar General. There are two aspects of mortality to be considered according to whether the longterm or short-term effects of atmospheric pollution are under examination. For the former we are concerned with the deaths of the residents of London, wherever they may have died, so long as London was their normal place of residence and for the latter all deaths occurring in London irrespective of place of residence. * For parts of boroughs, for which the sex and age composition was not tabulated in the census volumes, information for areas approximating to those under examination was obtained specially from the Registrar General. 191 The results that follow are based on the period 1st October, 1954, to 30th September, 1956, the choice of the period being designed to cover the experience of two complete winters. Results (i) The long-term effect The detailed figures of the atmospheric pollution records are given in Table III, by winters and summers separately and for the whole period of two years. Looking at the figures it will be seen that they are reasonably consistent, winter by winter and summer by summer; there is a difference in the proportions of sulphur dioxide to smoke in the figures from the Chelsea and County Hall stations as compared with the other five. Chelsea has a high content of both smoke and sulphur dioxide in the atmosphere, probably due to the proximity of three power stations, whereas the County Hall station shows the lowest figure for smoke but the second highest for sulphur dioxide; the South-western ambulance station has the highest average for smoke and a high average for sulphur dioxide (the last two stations are only 2½ miles distant from each other and the figures for each demonstrate the difference to be found in so short a distance). Indices other than the means of daily average figures have been suggested; Pcmberton and Goldberg (1954) experimented with means of the maximum daily readings. Consideration was given to using the proportion of days when pollution was about twice the winter average (taken as days when smoke exceeded 100 milligrams per 100 cubic metres of air and sulphur dioxide exceeded 20 parts per 100 million parts of air). The result of this exercise was that there was no significant difference in ranking order of the stations by the proportion of days when pollution was high and by the average daily figures (for smoke R (Spearman) = + 0.96 and for sulphur dioxide R = +0.88). In Table IV are set out, for the different areas, the populations by sex together with the percentage in the Registrar General's social classes IV and V, the percentage born in London, the average pollution during the whole period of 24 months and standardised mortality ratios* for the causes of death already listed in Table I; the sexes have been separated because of the different mortality experience already demonstrated in that table. Social class has been included as an index of socio-economic conditions and the percentage born in London as an index of duration to exposure—many people who die from respiratory disease will have suffered from it for a long time and as the ideal of having, in association with every death, the life history of the person concerned is wholly impracticable, the percentage born in London has been used as a rough index of the duration of exposure of the population of the areas to the London atmosphere. This index takes no account of migration inside the County nor do current figures of atmospheric pollution necessarily represent the past because of changes in the nature of the activities, commercial, industrial or residential, of the area, but they seem the best available measure. The atmospheric pollution figures for the 24 months have been used because of the consistency in the coefficient of variation over the periods shown in Table III and similarly (although the standardised mortality ratios were calculated for each winter and each summer separately) because the pattern of mortality was similar for both winters and both summers, it was decided to use the ratios calculated for the whole two year period, thereby reducing the error inherent in any such calculation. * These ratios are based on the mortality experience of London as a whole because the appropriate mortality data for England and Wales are not available over this period of 24 months. 192 Table III—Six-monthly and two-yearly means of atmospheric pollution recordings. Smoke in milligrams of black suspended matter per 100 cubic metres of air per day, sulphur dioxide in parts per 100 million parts of air per day Recording station Winter 1954-55 (a) Summer 1955 (b) Winter 1955-56 (a) Summer 1956 (b) Two-yearly Smoke SO, Smoke SO, Smoke SO, Smoke SO, Smoke SO, n.w. ambulance station, Hampstead 48(c) 9.6(c) 13 3.4 54 10.7 17 4.0 33 7.1 Eastern ambulance station, Hackney 56(c) 8.6(c) 14 3.8 60 11.5 16 4.2 37 7.1 Brook ambulancc station, Greenwich 37 (d) 7.7(d) 13 3.3 39 8.3 10 3.2 25 5.6 S.E. ambulancc station, Deptford.. 52(c) 10.1(c) 17 5.5 62 11.2 17 5.3 37 8.0 S.w. ambulance station, Lambeth 62(d) 13.6(d) 18 5.0 61 12.5 16 4.7 39 9.0 Western ambulance station, Chelsea 55(c) 15.6(e) 20 7.5 53 15.7 18 6.5 37 11.3 County Hall, Lambeth 31 12.6 11 6.2 34 13.0 11 5.8 21 9.4 (a) Winter = months of October—March inclusive. (b) Summer = months of April—September inclusive. (c) Commenced recording November, 1954, and mean is for five months. (d) Commenced recording December, 1954, and mean is for four months. (e) Commenced recording mid-November, 1954, and mean is for four and one half months. Six monthly means are means of monthly averages which in turn are means of the daily average figures and the two-yearly means are the means of the four seasonal averages. To assess whether there is any association between mortality and the various indices tabulated, the correlation coefficients of the several variables were calculated and the results are shown for the first eight areas listed in Table V. Clapham and Brixton and Chelsea were omitted because of the presence of several non-transferable institutions within these areas. In such institutions according to the Registrar General's rules of 1953-4 (see his Statistical Review for 1953), deaths are not transferable to the former place of residence and this results in completely unrepresentative death rates and ratios (for a detailed account of this effect see Hewitt 1957). The problem of non-transferable deaths also exists in the borough of Deptford but since this borough is joined with the Peckham Division of Camberwell the effect is less serious. On the basis of the six months October 1956—March 1957, which were somewhat unrepresentative because of the very low mortality in this mild winter, deaths in these institutions in Deptford amounted in total to about 13 per cent, of deaths for the joint Deptford/Peckham area. In Chelsea and in the joint Clapham and Brixton area the corresponding estimates were 38 and 19 per cent, respectively, so high as to invalidate the calculation of rates or ratios based on population. 193 Table IV—Various indices of population, atmospheric pollution and standardised mortality ratios for deaths from all causes and certain diseases for the two years ended 30th September, 1956. Area Sex Population Index of atmospheric Pollution Standardised mortality ratios (a) London A.C. — 100 Estimated number mid-1955 Percentage in social classes IV& V (census 1951) Percentage born in London (census 1951) Smoke SO, All causes Bronchitis Other respiratory (including respiratory tuberculosis) Lung cancer Other cancer Cardiovascular diseases Hampstead M 40,900 15.4 40 33 7.1 91 53 58 69 83 83 F 56,810 34 81 67 59 (74) 76 83 St. Pancras North M 40,700 32.5 64 33 7.1 99 108 120 105 99 94 F 45,300 64 92 88 85 (113) 102 89 Hackney M 78,900 26.0 76 37 7.1 96 133 69 88 103 99 F 88,300 75 96 108 83 78 106 99 Greenwich and West Woolwich M 82,970 28.4 63 25 5.6 80 71 85 82 85 78 F 87,020 65 79 84 89 (48) 78 77 Bermondsey M 28,320 45.1 81 37 8.0 99 93 98 106 99 99 F 29,260 85 93 97 71 (50) 102 95 Deptford and Peckham Division of Camberwell M 76,840 35.6 77 37 8.0 106 129 107 137 102 100 F 82,450 77 104 116 90 103 109 107 Westminster M 45,260 26.7 35 21 9.4 88 49 105 75 99 84 F 52,370 35 81 39 87 100 87 74 Vauxhall Division of Lambeth M 33,000 32.6 66 30 9.2 106 118 144 116 84 106 F 35,300 67 99 114 121 (131) 94 96 Clapham Division of Wandsworth and Brixton Division of Lambeth M 74,650 31.0 66 39 9.0 110 86 90 166 168 94 F 81,600 66 126 106 112 190 223 102 Chelsea M 21,420 23.2 49 37 11.3 123 67 104 88 146 126 F 30,030 41 123 92 143 (100) 107 125 (a) Nine age groups were used in the calculation of the standardised mortality ratios, viz., 0-4 years and ten-year-groups from 5-14 to 75+ years. Figures in brackets are based on fewer than 20 deaths in either actual or expected mortality and, therefore, ratios are unreliable. 194 Table v—Zero order correlation coefficients of various indices of population, atmospheric pollution and standardised mortality ratios for all causes and certain diseases All causes Bronchitis Other respiratory Lung cancer Other cancer Cardiovascular (a) (b) (c) (d) (e) (f) (1) Percentage in Social classes IV and V M 0.485 0.453 0.556 0.707 0.442 0.572 F 0.547 0.480 0.265 —0.025 0.641 0.474 (2) Percentage born in London M 0.532 0.828 0.193 0.710 0.398 0.681 F 0.707 0.848 0.252 —0.144 0.736 0.738 (3) Index of smoke M 0.645 0.680 0.169 0.511 0.368 0.632 F 0.688 0.715 0.271 —0.076 0.668 0.845 (4) Index of sulphur dioxide M 0.514 0.037 0.579 0.274 0.193 0.477 F 0.334 —0.106 0.408 0.903 0.249 0.153 All coefficients positive unless preceded by a minus sign. 5 per cent, level of significance with 8 pairs of variables r = 0.707 With only eight pairs of variables the value of the correlation coefficient has to be high (0.707) to reach a 5 per cent, level of significance. In only comparatively few instances do the values in the above table reach this level, they are:— Per cent. in social classes IV and V and lung cancer—males. Per cent. born in London and all causes—females. Per cent. born in London and bronchitis—males. Per cent. born in London and bronchitis—females. Per cent. born in London and lung cancer—males. Per cent. bom in London and other cancer—females. Per cent. born in London and cardio-vascular diseases—females. Index of smoke and bronchitis—females. Index of smoke and cardio-vascular causes—females. Index of sulphur dioxide and lung cancer—females. While these numerical expressions of association do not necessarily represent a causal relationship nevertheless it is worthy of comment that the percentage born in London is mentioned six times (counting each sex separately), index of smoke twice, index of sulphur dioxide once and percentage in social classes IV and V once. The obvious implication is that percentage born in London, as representing duration of life spent in London, has more bearing on mortality than any of the other indices listed. It will be appreciated that the various factors do not operate in isolation. Hewitt (1956) combined the index of sulphur dioxide with the percentage born in London to arrive at a composite index for the measurement of the degree of the atmospheric pollution and duration of exposure thereto, and found a significant correlation between deaths from all causes, respiratory causes, bronchitis, cancer of the lung and heart disease in the nine health divisions of London. A similar approach has been made with the data in this investigation by combining the percentage born in London with each of smoke and sulphur dioxide in relation to bronchitis. Bronchitis was chosen because, as can be seen from Table V, there is a significant correlation with the percentage London born of either sex, a reasonable correlation with smoke and virtually none with sulphur dioxide. The results are as shown below:— Bronchitis and percentage born in London X smoke males r = +0.824. females r = + 0.836. Bronchitis and percentage bom in London x sulphur dioxide males r = + 0.818. females r = + 0.800. 195 196 Figure 2—DAILY CONCENTRATION OF SMOKE AND SULPHUR DIOXIDE (Average reading of seven stations) AND HIGHEST AND LOWEST DAILY TEMPERATURE (Recordings from Kew Observatory) IN FOUR FOGGY PERIODS 197 Figure 3a—FIRST PERIOD: 4 NOVEMBER—4 DECEMBER, 1954 DAILY DEATHS AND SHORT-TERM TREND LINE—LONDON A.C. 198 Figure 3b—SECOND PERIOD: 1 JANUARY—3 FEBRUARY, 1955 DAILY DEATHS AND SHORT-TERM TREND LINE—LONDON A.C. I—4 8 Figure 3c—THIRD PERIOD: 21 DECEMBER, 1955—21 JANUARY, 1956 DAILY DEATHS AND SHORT-TERM TREND LINE—LONDON A.C. 200 Figure 3d—FOURTH PERIOD: 5 DECEMBER, 1956—5 JANUARY, 1957 ESTIMATED DAILY DEATHS AND SHORT-TERM TREND LINE 201 202 Figure 6—TOTAL DEATHS, DEATHS IN PERSONS AGED 70 YEARS AND OVER AND DEATHS IN PERSONS UNDER 70 YEARS : 24 DECEMBER, 1955—26 FEBRUARY, 1956— SEVEN-DAY MOVING AVERAGES 203 These results suggest something in the nature of a statistical artefact—sulphur dioxide which apparently of itself had no bearing on mortality suddenly becoming highly significant in association with length of residence. The part played by each component of the combined index of residence and smoke was tested by the calculation of first order correlation coefficients which are as follows:— r3b.2 = Males + 0.232. Females + 0.435. r2b.3 = Males + 0.667. Females + 0.726. [The subscript 3b.2 means the correlation between 3 and b (smoke and bronchitis) when 2 (per cent, born in London) has been held constant at a mean value similarly, 2b.3 means the correlation between 2 and b (per cent, born in London and bronchitis) when 3 (smoke) is held constant.] Thus in the first instance, when percentage born in London is held constant, i.e., the same proportions applied to all eight areas, there is no significant correlation between the index of smoke and bronchitis, but in the second case, when the amount of smoke is held constant, there is a much higher value of r for the correlation of bronchitis with percentage born in London, approaching significance in both instances. This is held to be a sufficient indication that duration of exposure to the London atmosphere is more important in relation to bronchitis than variations in the degree of pollution within London—London's air is bad for bronchitis no matter in what part of London a person lives. This is not to say there are not variations in total mortality within London, Martin (1955) has shown how mortality varies in London boroughs—a variation that has, however, declined over the past forty years. It could be argued from these figures that while the case against London is proven, that against its atmosphere is not, but it is difficult to see what other facet of London life could be pertinent in the context of bronchitis. Social class has already been discounted because of the near parity of London vis-á-vis the country as a whole, and as regards smoking habits although these doubtless play a part, it has been shown in the respiratory field, lung cancer and bronchitis, that the degree of urbanisation is a relevant factor. The coefficients for cancer of the lung are interesting (the figures for females can be ignored because the relatively small number of deaths on which the mortality ratios are based makes then unreliable); for males there is significant correlation with percentage born in London and near significance with social class. Stocks and Campbell (1955) found an association between cancer of the lung in males and urbanisation ; they estimate that three-eighths of male lung cancer deaths in Liverpool were due to this factor (one half of the deaths were attributable to smoking habits). Eastcott (1956) has drawn attention to the differential death rate from cancer of the lung between immigrants from the United Kingdom in New Zealand and native New Zealanders—a difference that increased with age at immigration, the inference being that there is something in the environment of the U.K. that planted the cause of the cancer early in life; the difference is unlikely to be due to smoking habits because there is a higher consumption of tobacco per head of population in New Zealand than in the United Kingdom though the author does not state the type of tobacco nor its method of consumption. The near significance with social class is in accordance with expectation; the occupational mortality tables of the Registrar General show a rising gradient in male mortality ratios for cancer of the lung with increase in the numerical social class (i.e., increase with lower social class) for men aged 20-64 years, and over half the deaths from this cause occur between ages 45-64 years. All the calculations have been based on mortality of London residents. It could be argued that total mortality is not the right index to use because any long-term effect of atmospheric pollution will be reflected in deaths at later ages. This aspect has been considered and the standardised mortality ratios calculated for ages 45-64 and 65+ years separately. With two exceptions (lung cancer in females aged 65+ and cardio-vascular diseases in males aged 45-64 years) there was no difference in the ranking order between the age group standardised mortality ratios and those for all ages. This is not surprising because only nine per cent. of male and seven per cent. of female deaths in 1955 for example, occurred at ages under 45 years. To sum up so far, the bare fact of long residence in London appears to be likely to increase the risk of dying particularly from bronchitis; the effect of a smoky atmosphere is also to increase the risk but while a brief sniff of sulphur dioxide is not particularly harmful the dual effects of both high pollution and long residence in London are associated with high mortality. Association is, however, not necessarily a matter of cause and effect. The reason for the poor numerical association of mortality with the indices of atmospheric pollution in London may be that the differences within London are not sufficiently large to demonstrate any difference in the areas shown in Table IV. It is noticeable, however, that Greenwich and West Woolwich, with the lowest but one index figure for smoke and the lowest for sulphur dioxide and a moderate figure for percentage born in London has the lightest mortality experience. (ii) The short-term effect In Figure 2 are depicted the daily concentrations of smoke and sulphur dioxide and the highest and lowest temperatures for four foggy periods since the beginning of this investigation, together with average levels of the pollution experienced in the two winters (October to March) of 1954-55 and 1955-56. Temperature has been included because, as will be demonstrated later, it too plays an important role in short-term mortality. There is no accepted definition of what constitutes a fog, the severity of the effects of which will vary according to the local circumstances—a fog in country districts may be nothing more than mist, a harmless moisture laden atmosphere, but the same phenomenon when charged with the fumes given off by the domestic fires and industrial processes of a large city may become a lethal 'smog'. Clearly the fog, or 'smog', with which we are concerned in this context is one in which atmospheric pollution is high so that criteria such as a fog service on British Railways or a mention of fog in the meteorological observations at Kew Observatory are insufficient : clearly also a 'smog' of sufficient importance to an enquiry of this sort must be reasonably widespread and long lasting. The criteria adopted, quite empirically, were a mean of the daily readings at all seven stations in excess of 100 milligrams of smoke per 100 cubic metres of air and 20 parts of sulphur dioxide per 100 million parts of air, i.e., about double the customary winter level, on any of two days within a period of seven consecutive days; in addition the days surrounding these high readings when there was any mention of fog in the meteorological reports from Kew Observatory were included. The practice of aggregating the readings of several stations was deprecated earlier in this survey but in mitigation it can be said these seven stations are all at or about the same level above ground (first floor level), they are not located for the express purpose of measuring a particular local source of pollution, and the measurements are carried out in precisely the same manner at each of them. Not all the seven stations were functioning throughout the four periods, two were not in operation during the first period and there were odd days when one or other of the stations was not in operation, but these minor defects should not invalidate the broad conclusions. In brief the characteristics of these four periods may be listed as follows ; a more detailed description is set out in the annex. Period Intensity of fog Duration Pollution Temperature Nov. 1954 Moderate Medium Moderate Warm in spite of night frost. Jan. 1955 Light Long Moderate Very cold. Jan. 1956 Thick Short Heavy Cold. Dec. 1956 Light— Long Moderate Cold. Moderate In Figures 3a, b, c and d are shown the daily deaths and a seven day moving average of daily deaths of persons dying in London during periods of about one month of which the foggy days form the central section. A preliminary analysis was made of Mortality in foggy periods 204 events in the individual areas around the recording stations (the areas used in the longterm analysis) but the number of deaths is so small that, even on a weekly basis, there is so much fluctuation that nothing useful could be extracted. Figures 3a-c give actual figures for the County as a whole whereas figure 3d gives an estimate based on the 8 areas used for the long-term consideration of the effects of atmospheric pollution— these areas, which by a happy coincidence are a representative cross section of the London population as regards sex and age structure and social class, gave rise on the basis of the first three periods, to about one-third of the deaths occurring in London.* A seven day moving average was considered to be the best way of showing the shortterm trend, avoiding any "favourite" day of the week there might be for dying and producing a reasonably smooth curve. The use, in contradistinction to the long-term analysis in which deaths of Londoners was considered, of mortality in London is justified because in the short-term we are concerned with those at risk at the time of the smog. The choice of deaths in London means that their number cannot be related to the population for the production of rates because, judging from the difference between deaths registered in, and allocated to London, there is a yearly net surplus of some 3,700 deaths of non-Londoners in London hospitals. Hence for the purpose of estimating the short-term effect of a smog one is forced to consider whether or not there was a rise in the level of mortality. Quite clearly there was a 'rise' in all four episodes but there is no apparent similarity between them. In period 1 deaths continued at the higher level after the foggy days were over and in period 4 the rise continued. These differences are only to be expected because level of atmospheric pollution is not the sole factor operating during the duration of the smog as defined, the temperature and, most difficult of all, the course mortality would have followed in the absence of a smog all render comparison difficult: more often than not cold and smog go handin-hand. Russell (1924) found this last difficulty in his survey of fog in Islington and St. Pancras over the years 1870-1900. However, the second and fourth smogs were comparable in intensity of fog, duration and level of pollution but the former was much colder than the latter. In Figure 4 therefore the daily moving averages of deaths for each of these two periods have been shown. The effects of the smog, judging from the slopes of the two curves within the limits of the days concerned, are practically identical but the level of mortality at the beginning of the smog is very much higher in period 2 than period 4 which prima facie is attributable to the lower temperature of the former and the mild winter of which the latter formed part. The continued rise in mortality after the smog in period 4 is probably nothing more than a rise to the normal winter level—for the two weeks preceding the smog mortality was exceptionally low for the season of the year; in fact throughout the mild winter of 1956-57 the number of deaths has remained at an exceptionally low level. The fall in the curve at the end of the smog in period 2 is probably due to the fact that concurrently there was a sharp rise in temperature which masked the rise in mortalitv attributable to smoe alone. Proportion of old people dying in smog The question also arises of whether a smog affects particularly any section of the community. A partial answer to this question is revealed in Figure 5 in which is shown the proportion of deaths in persons aged 70 years and over to total deaths in each of the second, third and fourth periods together with the month of February, 1956, following the third period when it was cold but not foggy. In the second period (January 1955) when there was a long, moderate but very cold smog the proportion of deaths in the over 70's was of the order of 55-59 per cent., in the third period (January 1956) when there was a short, heavy and cold smog the proportion was 65-69 per cent.; in the cold spell (February 1956) it was 55-59 per cent, and in the fourth period (December *By the time of the last episode it had been decided to concentrate solely on the seven multiple circuit volumetric stations and the surrounding areas. 205 Q* 1956) it was about 50-54 per cent. From figures calculated over the winter of 1956-57, a winter in which there was no undue 'external' influence of cold or epidemics, apart from the fourth period smog, the proportion of deaths in the over 70's was remarkably consistent month by month, beginning at 48 per cent, in October, rising to 53 per cent, in November and remaining at around the 50-53 per cent, level for the remainder of the winter. From Figure 5 we can see that, taking the moderate smog of the fourth period as our base, a very cold smog has more effect on old people, vide period 2, and the intense smog of the third period has more effect still. It is conjectural how much of the effect to be seen in the very cold spell following this smog is a delayed effect and there is yet another weakness in that, as will be seen, the rise in the proportionate mortality of the over 70's preceded the smog, even allowing for the fact that we are using seven day moving averages. The smog of Jan., 1956 In Figure 6 therefore has been shown the seven day moving average for all deaths, deaths of persons aged 70 years and over and persons aged under 70 for the period 24th December, 1955 to 26th February, 1956 (covering the third period which is generally admitted to be a smog even though there may be doubts about the others) with the object of trying to grapple with the question of the elusive base line from which to assess increased mortality due solely to smog. Mortality in the over seventies was rising sharply before the impact of the smog indicated by the vertical lines on the curves at 30th December (30th December because the seven day moving average centred on this day is influenced by 2nd January, the first day of the fog), but in the under seventies it was falling (with a resultant slight rise for total deaths) which accounts for the proportionate rise in the over seventies in Figure 5. How far these rises would have progressed without the intervention of smog is a matter of conjecture. On the assumption that, for total deaths, the rise was the beginning of a ' normal winter rise ' in mortality a line has been drawn from the point of impact of the fog to link up with the steep rise in February (shown by dotted line). Again, whether without the very cold spell the line would have taken this course we do not know—to obtain a satisfactory seasonal average is impossible because of the shifting incidence and severity of fogs, cold, epidemics, and the greater the number of years over which any average is calculated the more different does the pattern of mortality become. In the prevailing circumstances deaths above this line can reasonably be regarded as attributable to smog alone and in total they amount to 480 as compared with Logan's (1956) estimate of 440; the two estimates are, however, built up on difference premises—Logan took as his datum-line the average number of deaths (131) over the ten days 25th December to 3rd January, any deaths over this line were attributed to smog but he stopped counting 'excess' deaths at 14th January whereas the 480 'excess' deaths extends to 24th January on the moving average, or 27th January in fact. For the over seventies it is difficult to know where to draw any similar line; working backwards from the end of February the logical line would seem to link up with the 24th December at around 70 deaths daily and on this basis the area above the line represents 640 excess deaths in old people. On the other hand, if the datum-line is drawn horizontally from the point of impact of the smog at the level of 90 daily deaths then the excess becomes 370. In the preceding and following year a similar rise occurred following Christmas and the same kind of rise is suggested from the figures of weekly death registrations in four out of six preceding years. This post-Christmas rise appears to occur in deaths from cardio-vascular causes, the main cause of death in old people. If we assume that the total for all ages is about right we are left with a choice of a rise of 640 among old people offset by a fall of 160 in younger ones which would mean raising the trend line for them to start at 60 deaths a day; or starting our trend line for old people at the 90 level and leaving the young as they are. On balance the latter course seems more justifiable bearing in mind the post-Christmas phenomenon mentioned earlier. Total mortality and deaths from appropriate causes for all ages during the two months covered by Figure 6 are shown, by weeks in Table VI. 206 Table VI—Weekly deaths (occurrences)—all causes and certain specific causes— 25th December, 1955 to 25th February, 1956 Week ended Saturday All deaths Cardiovascular Cancer of the lung Bronchitis Other respiratory 31st Dec. 1955 908 400 31 81 103 7th Jan. 1956* 1,154 474 58 155 140 14th Jan. 1956 1,164 472 43 182 126 21st Jan. 1956 1,047 468 47 132 96 28th Jan. 1956 1,025 417 35 132 94 4th Feb. 1956 1,043 475 36 107 104 11th Feb. 1956 1,082 496 34 136 109 18th Feb. 1956 1,212 537 28 144 134 25th Feb. 1956 1,261 570 46 160 141 *Smog week. Over the period of the smog, and the two weeks immediately following, the biggest proportionate rise was in bronchitis whereas in the cold weather of February it was in cardio-vascular diseases: but it must also be mentioned that in the week in which the smog occurred there was a rise of 89 in the number of 'mentions' of respiratory conditions (not being the underlying cause of death) on death certificates. Although the inadequacy of such morbidity data as is available has been mentioned earlier brief comments on the three sources are made hereafter: in essence all that is demonstrated is that when mortality rises it is accompanied by morbidity which is not of itself a very startling conclusion. Morbidity in periods of fog (a) National Insurance First Applications for Sickness Benefit at Offices in London A.C. These applications relate only to a section of the population—the employed and relatively healthy section of the community. They do not of course indicate how many previous applicants would have 'signed off' had it not been for a smog. Weekly figures over the four periods of smog are shown in Table VII. Weeks in which a fog occurred have been underlined and the bracketed figures relate to Christmas periods in which, presumably, there is some delay in either the reporting of sickness or the claiming of benefit. Table VII—National Insurance First Applications for Sickness Benefit (figures relate to week ended Tuesday) Nov. 2, 1954 9,272 Dec. 6, 1955 11,324 „ 9, „ 9,259 „ 13 „ 10,829 „ 16, „ 9,622 „ 20, „ 9,048 „ 23, „ 10,819 „ 27, „ 5,045 „ 30, „ 11,680 Jan. 3, 1956 15,609 Dec. 7, „ 11,346 „ 10„ 18,561 „ 14, „ 10,099 „ 17, „ 17,426 " 21, „ 8,916 „ 24, „ 15,377 „ 28, „ 5,259 „ 31, „ 14,864 Jan. 4, 1955 16,888 Feb. 7, „ 15,765 „ 11, „ 19,929 „ 14, „ 17,027 „ 18, „ 19,085 „ 21, „ 17,215 „25, „ 19,884 „ 28, „ 18,220 Feb. 1, „ 18,905 „ 8, „ 16,981 Dec. 4, 1956 11,796 „ 15, „ 14,665 „ 11, „ 10,936 „ 22, „ 14,356 „ 18, „ 9,140 „25, „ 3,204 Jan. 1,1957 12,816 „ 8, „ 15,238 „ 15, „ 12,217 In the fog of November, 1954, there was a slight rise in the number of applications in the week of the fog and the two succeeding weeks; in January, 1955, applications 207 were at a high level before and continued so during the two foggy weeks after which they declined ; in January, 1956, there was a steep rise in the week of the fog (steeper than is indicated by the figures of the preceding week if due allowance is made for delay in claims over the Christmas period) after which there was a decline until the figures rose again in the cold weither of February; the December, 1956 fog was around Christmas and the figures are in consequence difficult to interpret. The evidence suggests a slight increase of morbidity in the fog of November, 1954, and a considerable increase in the fog of January, 1956; the figures for January, 1955, substantiate the claim made earlier that the increase in mortality on that occasion was due as much as, or more to, the prevailing cold weather than the fog. (b) Applications for Hospital Beds through the Emergency Bed Service for Greater London. These are held to be a good indication of the extent of the prevalence of acute sickness, on the assumption that general medical practitioners are uniformly making use of the service; though there is a possibility of a damping down of demand when it is known that supply, i.e., hospital beds, is very short. The figures are: Table VIII—Total Applications for hospital beds to the Emergency Bed Service (figures relate to week ended Saturday) Nov. 6, 1954 860 Dec. 31, 1955 1,410 „ 13 890 Jan. 7, 1956 1,760 „ 20, „ 960 „ 14, „ 1,650 „ 27, „ 1,030 „ 21, „ 1,470 Jan. 8, 1955 1,430 Dec. 15, 1956 1,090 „ 15, „ 1,500 „22, „ 980 22, „ 1,680 „29, „ 1,170 „ 29, „ 1,660 Jan. 5, 1957 1,430 Weeks in which fog occurred are again underlined. It is difficult to interpret these figures without regard to the background levels. November, 1954 and January, 1955, were part of a general rising trend which continued throughout the winter reaching a peak of 1,750 in late January. In January, 1956, the figures reached a peak level of 1,820 on the 10th, three days after the last day of fog and the highest since the winter of 1952-53; they did not reach this level again even in the following cold February. The December, 1956—January, 1957, rise was part of a general trend which reached a peak on 7th January, after which it fell until mid-January rising again to a peak in March. These figures do not suggest any alarming increase in acute sickness except for the fog of January, 1956, when the demand on the hospitals for beds was greater than in the very cold weather of the following February. (c) New cases taken on the hooks of District Nursing Associations—London A.C. These figures relate to a service catering mainly for the elderly, but the fact that they are unfortunately in respect of months means that they have but a limited value. Table IX—New cases taken on the books of District Nursing Associations 1954/55 1955/56 1956/57 October. . 5,082 4,999 4,850 November 5,305 5,541 5,086 December 5,720 5,738 4,943 January .. 7,242 6,587 5,579 February 6,210 6,680 5,010 March .. 7,123 6,104 5,487 The months of fog are again underlined and the figures do not demonstrate any particular association therewith, except in January, 1955, when it was also very cold. 208 This is not to say that they should be regarded as negative evidence of an increase in the amount of sickness, it is rather, for the reason stated, they are not sufficiently sensitive for this purpose and in any case they will be affected in part by the use made of hospital beds. The sum total of these three sources of information is that they corroborate the view that the smog of January, 1956, was the one which had the greatest effect on the health of London. Summary and conclusions There is little doubt that living in London for a long period increases the risk of dying from respiratory disease, particularly bronchitis : furthermore since these diseases are often suffered over a number of years morbidity too is associated with the length of residence. It must, however, be remembered that the index used—percentage born in London—is somewhat crude and gives no indication of internal migration. A significant relationship between mortality and the two types of atmospheric pollution chosen—sulphur dioxide and smoke—has not been demonstrated though smoke looks more dangerous than sulphur dioxide. This does not preclude there being a critical level of one or of both in combination that would be directly associated with increased mortality or morbidity, but equally there may be other types of pollutants more dangerous than either. In the short-term, whilst it is difficult to disentangle the effects of duration and intensity of atmospheric pollution and temperature from any seasonal trend, the effect of the smog of January, 1956, suggests that the threshold level above which a smog incident is likely to occur in London is when the mean level for London attains a daily value of 200 milligrams of black suspended matter per 100 cubic metres of air and 40 parts of sulphur dioxide per 100 million parts of air, i.e., about four times the customary winter level. The differential effect on old people when pollution reaches this level has been shown, though the overall effect was much less than the catastrophe of 1952. For the future it is proposed with the continued co-operation of the Medical Officers of Health of the Metropolitan Borough Councils, fully to document each smog episode as it occurs through the medium of this report but using as our criteria the higher levels of pollution indicated in the last paragraph but one. If, as to be anticipated, measures to diminish the amount of atmospheric pollution reduce the amount of smoke it may be possible to assess with greater clarity the respective parts played by sulphur dioxide and smoke which have both so far been present concurrently in the atmosphere in roughly the same proportions during different episodes of fog. References Daly, C. (1954). 'Air Pollution and Bronchitis'. Brit. Med.Jnl., 2, 687. Eastcott, D. F. (1956). 'The Epidemiology of Lung Cancer in New Zealand'. Lancet, 1, 37. Hewitt, D. (1956). 'Mortality in the London Boroughs 1950-52 with Special Reference to Respiratory Disease'. Brit. J. prev. soc. Med., 10, 45. Hewitt, D. (1957). 'Vagaries of Local Mortality Rates under the 1953-54 Rules for Transfer of Deaths'. Ibid, 11, 45. Joules, H. (1956). 'Health from the Health Service '. Lancet, 2, 1171. Lawther, P. J. (1956). 'The Clinical Significance of Dirty Air '. Public Health, October, 1956. Leese, W. L. B. (1956). 'An Investigation into Bronchitis'. Lancet, 2, 762. Logan, W. P. D. (1956). 'Mortality from Fog in London, January, 1956'. Brit. Med.Jnl., 1, 722. London County Council (1952). 'Deaths and Sickness in London in December, 1952'. Annual Report of Medical Officer of Health. Martin, W.J. (1955). 'Vital Statistics in the County of London, 1901-1951'. Brit. J. prev. soc. Med., 9, 126. Meetham, A. R. (1956). 'Atmospheric Pollution '. Pergamon Press, London. Ministry of Health (1954). 'Mortality and Morbidity during the London Fog of 1952'. Reports on Public Health and Med. subjects, No. 95. Pemberton, J. and Goldberg, C. (1954) 'Air Pollution and Bronchitis '. Brit. Med. Jnl., 2, 567. Registrar General for England and Wales—Decennial Supplement (1951) Occupational Mortality, Part I. Registrar General for England and Wales—'Statistical Review' (1953), p. xii. Russell, W. T. (1924). 'The influence of Fog on Mortality from Respiratory Diseases'. Lancet, 2, 335. Stocks, P. and Campbell, J. M. (1955). 'Lung Cancer Death Rates Among Non-smokers and Pipe and Cigarette smokers—An Evaluation in relation to Air Pollution by Benzpyrene and other Substances'. Brit. Med.Jnl., 2, 923. Wilkins, E. T. (1954). 'Air Pollution and the London Fog of December, 1952'. Jnl. Roy. San. Inst., 74, 1. 209 ANNEX Meteorological description of four ' foggy ' periods (Kew Observatory) November 1954 Fog was first mentioned on the morning of Monday, 15th November, it was thick from early morning until mid-day and again from 7.30 p.m. onwards. There was frost morning and evening. The following day the fog continued until 4 a.m. and it recurred in the evening. Similar conditions continued on the third day with frost morning and evening. On the fourth day the fog continued throughout the 24 hours, it was thick until mid-day and there was frost until 1.15 p.m. The fifth day was similar with fog all day, thick in the evening but there had been a rise in temperature and there was no frost. On the sixth and last day there was thick fog in the morning until it lifted by 9 a.m. and the evening of this day was fine. A characteristic of this fog was the prevailing high day-time temperatures—in the upper forties rising to 51.6°F on the sixth day with, on the first four days, low night temperatures around freezing point giving rise to frequent mention of frost. January 1955 The 12th January saw a sudden fall in temperature, from day-time temperature of 52°F the previous two days to near freezing all day and down to 26.4°F that night; there was fog, morning, afternoon and for a time in the evening. The second day the temperatures continued low with periods of fog and mist all day; the third day continued likewise. On Saturday, 15th, the day-time temperature rose to 43.9°F but the night temperature fell to 23.5°F, there was fog in the morning, late afternoon and evening, thick for two hours, and intermittent rain and snow during the day. Sunday saw a rise of about 5° in both maximum and minimum temperatures so that the minimum was only a little below freezing; there was fog again morning and afternoon and intermittent snow afternoon and evening. On Monday, 17th the highest temperature was 37.8°F. and the lowest fell to 27.3°F.; there was haze in the day and fog in the evening with frost morning and evening. Tuesday and Wednesday remained clear of fog until the evening of the latter; there was frost most of the day, temperatures from a maximum of 38.39°F. to a minimum of 28 and 25°F. respectively. On Thursday the fog from the previous evening continued until mid-morning followed by mist in the afternoon. The last two days of this period, 21st and 22nd January, saw a rise in temperature, of 16°F. at night to a minimum of 41.9°F., with practically continuous fog on 21st, thick at times, and again on the 22nd until mid-afternoon when it cleared. This was a protracted period of fog, eleven days in all, with mostly low temperatures and much frost. January 1956 On Tuesday, 3rd January, there was fog from early morning until late evening with frost morning and night, temperature ranged from 41.4 to 32.7°F. The following day saw mist in the early morning after a clear start followed by fog all day, thick from 7.30 a.m. to 1.15 p.m. and again from 5 o'clock onwards; there was frost all day with temperatures of maximum 41.2°F. and minimum 28.9°F. Thursday was a day of thick fog with frost in the morning, temperatures ranged from 36.1 to 29.8°F. The following day, Friday, was similar, except for a break from the fog in the evening, it was thick until 7 a.m. and again between 9 and 10 a.m. Saturday, 7th, started with some light drizzle followed by rain in the afternoon and evening ; there was some fog from mid-morning until early afternoon and from mid-afternoon until the evening: temperatures were—highest 38.8°F. and lowest 33.3°F. This was a period of intensive fog, relatively short in duration and not so cold as the incident of the previous January. 210 December 1956 Tuesday, 18th December, saw a fall in temperature from an unseasonably high level down to near freezing with fog formation in the late afternoon becoming thick from 8 p.m. onwards. Wednesday, 19th began cloudless, the sky becoming obscured by fog, dense from 7.00—11.30 a.m., until mid-evening. Thursday was a day of fog, thick from 4 a.m. onwards; Friday continued likewise, fog thick until 7.30 a.m. and again from 7 p.m. On Saturday there was an early fog for a short time followed by period of mist throughout the day. Sunday was misty followed by fog until midafternoon. Monday, 24th, was a day clear of fog with frost in the evening. Christmas Day was cloudy with snow in the evening and fog for a time. Wednesday, Boxing Day, was a day of light snow, drizzle and light rain with fog in the morning and afternoon and the last day of this period, 27th December, saw some fog in the afternoon and again in the evening. Throughout this period temperatures ranged from around 40°F. down to, or a little below, freezing. This was a protracted period of intermittently foggy days. 211 APPENDIX C ACCIDENTS IN THE HOME Fatal Accidents Figures of fatal accidents for England and Wales are published by the Registrar-General —unfortunately there is no reliable source of information for smaller areas, but there is no reason to assume that so far as those in the home are concerned London is markedly different from the rest of the country. The numbers of fatal home accidents by type for the years 1950 to 1955 inclusive are set out in Table I. In total, deaths have risen from 4,609 to 5,743—a rise of about 25 per cent. This net increase is due to a large proportionate increase in falls, burns and poisoning by various substances including coal-gas, which is only partially offset by a small decline in suffocation—deaths from other causes have fluctuated without revealing any pronounced trend. Not a lot can be gleaned from the bare facts presented in Table I—the main increase in falls is in the unspecified group; as regards burns there has been since 1952 a subanalysis as follows: Cause 1952 Year 1953 1954 1955 Domestic fires 154 132 162 212 Gas fire 62 47 52 53 Electric fire 75 61 92 75 Other 283 250 263 264 Total 574 490 569 604 These figures do not really point to any particular cause but it may reasonably be assumed, as some half the total number of these accidents each year are caused by fire for space heating, that the absence of a proper guard must be a factor in many of them. Home accidents involving poisons or coal-gas poisoning include 'open verdicts' at coroners' inquests and many of the cases of poisoning may not be truly accidental. Numbers and types of accidents as such are only broad indications of the direction which education should take because the age, if not the sex, of the sections of the population mainly affected by accidents both generally and specifically varies considerably. Of the total of 5,743 fatal accidents in the home in 1955 the age and sex distribution was: 0- 5- 15- 45- 65 and over Total Male 379 50 184 293 1,172 2,078 Female 284 61 130 315 2,875 3,665 Total 663 111 314 608 4,047 5,743 In terms of numbers about 70 per cent, of the accidents occurred to people over 65 years of age and over two-thirds of these were among women—there are, it is true, more elderly women than men but not twice as many. Over 11 per cent, of the accidents were among children under five years of age, and it will be noted that here the majority are among males. To make the position clearer the numbers of deaths in the sex and age groups have been set out below in rates per 100,000 population in the respective groups: 0- 5 — 15- 45 — 65 and over Total Male 2.3 0.1 0.2 0.6 5.8 1.0 Female 1.8 0.2 0.1 0.5 9.3 1.6 All persons 2.0 0.2 0.2 0.5 7.9 1.3 The rates clearly demonstrate that the very young and the very old are the groups which are most prone to fatal accidents. The higher rate among the older women is doubtless due in part to the greater age to which they live—often alone. 212 In order to establish the type of accident to which various age and sex groups are particularly prone it is necessary to combine the data in Table I with the facts revealed in the table set out above—the results for 1955 are set out in Table II. In the case of falls, which are the most numerous type of fatal home accident (58 per cent.), it will be seen that they occur almost wholly among older people, that as many as 90 per cent, relate to those aged over 65 and that 65 per cent, of the total falls are among women of this age group. In fact 38 per cent, of the total fatal accidents are falls among women aged 65 and over. It is interesting to note that an inquiry into accidents occuring to patients in hospital conducted recently showed that out of 653 accidents during the years 1953 and 1954, 86 per cent, were attributable to falls and they were more common in patients over 60 years of age. The second most frequent cause of death—coal-gas poisoning (13 per cent.)—again affects the aged most (68 per cent.). Burns account for 10 per cent, of the total and again the bulk (58 per cent.) are among those aged 65 and over. It will be noted, however, that in the younger age groups, particularly among children from 5-14 there is a preponderance of female deaths from burns—this may well be due to the differences in clothing—it is unlikely that fashions can be altered, but more attention might be paid to the flammability of materials used in dresses and especially night-dresses. It would be of assistance if these garments and party frocks had to be clearly labelled so that the purchaser would accept them knowing the risk. It seems clear also that pyjamas, though it may be that they are more costly than nightdresses of similar material, are safer in design than nightdresses which because of the long full skirt are a considerable hazard. It is also relevant to note that during the four years 1952-55 there were 70 prosecutions under the Children and Young Persons Act, 1933, as amended by the Children and Young Persons (Amendment) Act, 1952, in cases where a child under 12 was seriously injured or killed as the result of an unguarded fire. It still does not seem to be widely known that any person over the age of 16 years becomes criminally liable, should a child under the age of 12 years be killed or sustain serious injury as a result of burns whilst in their care in any room containing an open-fire grate or any heating appliances liable to cause injury to a person by contact. In its new dwellings in recent years the Council has provided adequate fireguards for gas and electric fires, but many fires of earlier installation arc only provided with dress guards which do not now conform to British Standard Specification. Only very few accidents on the Council's estates have been reported over a period of very many years which might have been prevented by adequate guards. A circular has been sent to all tenants by the Director of Housing drawing their attention to the statutory position and pointing out that tenants should ensure that risks are not taken through the absence of adequate fireguards. In connection with the new British Standard Specification for guards for solid fuel fires introduced in November 1956, the Ministry of Housing and Local Government has recently drawn the attention of all housing authorities to the importance of providing suitable fixtures for fireguards in Council houses. Now that it is possible to have standard guards it is proposed to make provision for fixings for these in the Council's dwellings now under construction and in future schemes. Fatal cases of domestic carbon monoxide poisoning still occur from time to time. It is dangerous to use a stove in a confined space, even though it is in good order with a clear chimney and coal of good quality is used, unless adequate positive ventilation is ensured at all times, whether doors and windows are closed or not. Similarly, danger may arise from gas fires even if they are in perfect order and appear to be burning satisfactorily if there is not adequate ventilation and extraction of the products of combustion. The Gas Council and the Gas Boards take a lively interest in home safety both from the point of view of improving the design of their apparatus and also of the maintenance of existing apparatus, especially where old and handicapped people are concerned. Representative members of the Council's staff concerned with home safety from all 213 divisions have visited the Gas Council's laboratories and health visitors and others making domiciliary visits have been asked to report unsatisfactory gas installations in the homes they visit. The British Medical Association in 1955 set up a sub-committee to enquire into the problem of accidental death and ill-health from coal gas poisoning. As part of the inquiry a field survey was conducted in health division 7 (Camberwell and Lewisham) of the gas appliances used by a representative sample of aged and infirm people receiving assistance from the home help service, as a result of which it was considered that because of age and special disabilities some 10 per cent, of the people visited were likely to be especially prone to accidents with gas appliances. Nearly all the old people used gas cookers, some 19 per cent, of which required some attention but only 1½ per cent, were so seriously defective as to need to be replaced. A further inquiry showed that nearly half the old people may be unable to identify the smell of coal gas until a highly toxic concentration is reached. In a Tenants' Handbook issued to tenants of the Council's houses and flats by the Housing Management Department, information is given on home safety generally, including the correct use of gas and electric appliances and boilers. The other major groups of fatal accidents are suffocation and inhalation of food which affect mainly children under five years of age. The Council has agreed to help in an inquiry sponsored by the Ministry of Health under the direction of Professor Banks of the Department of Human Ecology at Cambridge University into sudden deaths in infancy. It is understood that an interim report to the Ministry is in course of preparation. One of the few encouraging features ascertainable from the various facts and figures is that the number of fatal accidents to children under five has been falling—from 871 in 1950 to 824 in 1952 and to 663 in 1955. The number of children concerned has also fallen by some 12 per cent, but the reduction in the number of accidents is of the order of 24 per cent. In this age group, although the figures for individual causes fluctuate from year to year the number of deaths from poisons and scalds, over which some direct control can be exercised, has roughly halved over the period of five years. The reverse of the medal—the increase in falls among the aged is not so susceptible to reduction because, as will be seen later, 60 per cent, are due to old age and infirmity. To summarise the data on fatal accidents—diree-fifths are falls affecting almost wholly persons over 65 years of age and of this age group mainly women; coal-gas poisoning and bums are next—about one-tenth each and again affect mainly the aged ; some way after come inhalation of food and suffocation and these affect mainly the under fives. The causes of these accidents are discussed more fully in the next part of this report which deals with non-fatal accidents. Non-fatal accidents Information about non-fatal accidents was collected from three sources, i.e.: (a) The London Ambulance Service. (b) Health Visitors. (c) District Nursing Associations. The information provided by these sources, while not complete either as to numbers or causes, would, it was assumed, provide a substantial sample of home accidents. As the prime duty of the London Ambulance Service is to remove the patient, detailed enquiries could not be pursued, but the particulars obtained suffice as a general index of trends (generally for the more serious cases) as regards the age and sex of the person concerned and type of home accident. The other two sources, health visitors and district nursing associations, cover respectively children under 5 and (mainly) old people, the two groups which provide over 80 per cent, of fatal home accidents. In these cases more detailed information has been sought about the underlying cause of the accidents in order that propaganda could be directed to the right people and deal with the right objects. Whereas the reports from district nursing associations cover all (completed) cases for whom care is provided, those from the health visitors relate only to those 214 accidents which have come to their notice in the ordinary course of their duties. It was emphasised in the instructions to health visitors that no special inquiries should be made and that the information should arise spontaneously because any special drive, which would doubtless be less energetically pursued in due course of time, would nullify any trends that might be revealed. In short, it was hoped that the Ambulance Service would provide an index for the population as a whole, and that data from the health visitors about the under 5's and the district nursing association about the aged, would be of use for propaganda purposes. The three categories are not exclusive in relation to each other; e.g., after an accident a child may be removed to hospital, be treated subsequently by a home nurse and later become known to a health visitor—nevertheless as the data has been used for different purposes a small degree of overlapping will not affect the validity of any conclusions. London Ambulance Service During the year ended 31st March, 1956, a total of 7,795 home accidents was reported by the Ambulance Service—an average of just over 21 a day—details are set out in Table III. The types of accident listed in this appendix do not correspond wholly with those used in Tables I and II. This is partly because the exact criteria used by the Registrar-General for classification are unknown, but mainly because it was desired to isolate particular apparent causes which seemed important in the non-fatal field. Certain basic comparisons are, however, possible between Tables II and III and the most apparent difference is in the incidence of falls which accounted for 58 per cent, of the fatal accidents and 73.2 per cent, ot the non-fatal. The reverse applies to burns, gassing and suffocation where, as might be expected, the fatal proportions are higher. Table III being based on different age groups (to give greater detail) may give the impression that the incidence is higher among the adult, but not aged section of the community. The respective populations at risk must, however, be taken into account. In the table below the figures given in Table III have been related to the estimated populations at risk for falls and for all other accidents. It is clear first that falls are still predominantly a feature of the older sections of the population, but that for all other types of accident added together it is the children under 5 who arc most accident prone particularly when they first begin to toddle about. Home accidents reported by the London Ambulance Service—Year ended 31st March, 1956 Rates per 10,000 population by age groups Age group Under 1 1- 2- 3&4 5- 20- 60— 70— 80+ Falls 4 16 29 24 10 8 25 67 215 Other 12 32 34 17 8 4 4 8 16 Total 16 48 63 41 18 12 29 75 231 From the data in Tables II and III it can be ascertained that whereas old people (over 65) accounted for 90 per cent, of all fatal falls they (over 60) only accounted for 54 per cent, of the non-fatal—this supports the view that the risk to the aged of a fatal outcome to a fall because of their brittle bones and the possibility of complications is greater than in the rest of the community. Apart from unspecified falls it will be seen from Table III that the most common types are those occurring on stairs and on the same level, e.g., tripping over a rug. Again women are in the majority—in part this can be attributed to the greater length of time spent in the home by women and the wide range of their activities therein and in part to the greater number of women at older ages. This is illustrated by the following table which gives the number of falls which occur to 10,000 persons in the age and sex groups specified. 215 Falls—Accident rates per 10,000 population by age and sex groups 0- 5- 60- 70- 80+ Males 18 7 17 41 130 Females 14 10 32 83 281 One possible explanation of the roughly doubled rates for elderly women is that there are many more of them living alone and in consequence they have to do many things for themselves that a spouse or other relative can do for those who are not alone. (In the 1951 census of 98,800 single-person households where the person was aged 60 or over no less than 78,500 were women.) It does not follow, of course, that a large proportion of these elderly women would relish help—many of them cling almost unreasonably to their ' independence In a few areas it has been found possible to provide, to a limited extent, evening help where necessary and where no other agency is available, to persons living on their own through the home help service. This arrangement helps to ensure that the old person is at the outset safe for the night. A divisional breakdown of the types of accident is set out in Table IV—in view of the gross inequalities of population as between one division and another accident rates per 10,000 population have been added at the foot of this table. The low rate in Division 5 is particularly noticeable—some small part may be due to lack of opportunity, e.g., falls in gardens, but the major part of the discrepancy may be due to a combination of a lower proportion of one-person households than in the county as a whole and a greater feeling of neighbourliness in the somewhat insular communities involved. Seasonal variation The total numbers of accidents were remarkably constant over the four quarters (in the 12 months ending 31 March 1956)—1,842, 1,817, 2,055 and 1,981—and for some causes it was also constant, e.g., falls from ladders were 49, 45, 42 and 44. The number of falls outside or in the garden naturally rose in the summer being mainly due to children playing outdoors. Accidents involving fires also rose understandably in the winter jumping from 19 and 30 in the first two quarters to 74 and 94 in the last two. Children also tended to have more accidents in the summer—1,029 in the period April to September inclusive compared with 617 in the winter, whereas the reverse applied to old people. For those aged 60+ the figures in each quarter were 708, 710, 967 and 1,028. An analysis was also made of accidents by day and time. So far as days were concerned Saturday was worst for men, but taking the week-end as a whole the period was no worse than any other during the week. As regards time the only certainty is the time at which an ambulance was called and there will have been a time lag of unknown duration between the accidents and the summons. Subject to this limitation there was a peak incidence between 12 noon and 1 p.m. and another lesser one between 6 p.m. and 7 p.m.; there was no difference between the sexes except the greater incidence of accidents sustained by women; the evening was the worst time for children. There is nothing particularly surprising about the results of the analysis which are clearly explainable in terms of the occupancy of the home coupled with the incidence of meals and their preparation—the absence of a breakfast peak may be due to its often being scanty and hable to be eaten in relays. It is proposed to continue to scrutinise data from the ambulance service in order to have a running measure of incidence. This will also provide a means of evaluating the effects of the various campaigns and of the more persistent propaganda based on the data collected on causes (to which reference is made in the next section of the report). Health visitors Details of the 336 home accidents reported by the health visitors as occurring to children under five years of age are set out in Table V. It will be noted first that most of the accidents occurred at ages one and two when the children were beginning to find 216 their feet and explore the world around them although the smaller numbers reported among the other children may in part be due to less frequent visiting; secondly, that boys had 26 per cent, more accidents than girls—this is probably due to greater inquisitiveness rather than clumsiness or fragility; thirdly, that burns and scalds accounted for the bulk of accidents. Details of the immediate agencies of burns were: Open fire 29 Electric iron 21 Kitchen stove 9 Hot object 7 Electric fire 5 Gas fire 2 Oil stove 2 Lotions 2 Miscellaneous 16 93 In practically all cases arising from open fires there was either no fireguard or it had been temporarily removed to make up the fire; in one instance the guard had been placed round the sink to prevent the children playing with the water! As regards electric irons few children pulled the flex—the burn almost always came from touching the iron, which shows no visible sign of heat. Although reliance has to be placed on the mother's account of the circumstances of the accident it was noticeable how many accidents were stated to have occurred whilst she was answering the door. As regards scalds the accidents arose mainly from tea (35), kettles (33) and other hot liquids (20)—in only two cases were baths concerned. Most of the incidents involving tea concerned children who managed to reach cups or pots on the table—there were few cases of pulling the cloth; a fair number of the kettle incidents however were due to pulling on the flex of an electric kettle. As regards the 72 falls these included falling from windows (unguarded), down stairs (gate unlatched), from high chairs (child unsecured), but most were due to play, cramped conditions or the action of another child. The poisons and foreign objects include aspirin (5), turpentine (3), disinfectant (2), iron tablets (2) and a number of individual items such as a cigarette end, toadstool, furniture polish, toy, surgical spirit and so on ; in the great majority of instances the items were, as they should not have been, accessible to the child—there was one case where a mother forgot to wash out a disinfectant from a feeding bottle. 'Hitting or hit by object' concerned doors which were run into or caused pinched fingers, assaults (by other children), mangles, swings, furniture, etc. Cuts, though comparatively few, were severe—milk bottles were the most common agency—children fell on them and fell with them. The miscellaneous group included such things as a child pushing a nail up its nose and a match into its ear—it also included assault by another child. The greater proportion of these accidents to children were, it is considered, preventable—it is appreciated that mothers have many distractions, that housing conditions are often far from ideal, that one cannot always stop a healthy inquisitive child from getting into mischief or from falling, although the provision of suitable playthings may help. Lack of fireguards, leaving hot liquids and poisons accessible to children, failing to secure them in high chairs or leaving gates on stairs unfastened are all due to thoughtlessness and/or negligence. This is an aspect of the danger to small children that needs to be stressed. Material precautions, by way of fireguards, etc., are designed to protect children against sudden risks and for short periods when adult supervision may be removed. Active toddlers if left for any considerable length of time completely without supervision are likely to find ways and means of getting into danger even in circumstances of reasonable security. A most serious example of this occurred in April 1956 when two children aged 3½ and 2 years were left for upwards of two hours and as a result met their deaths from a fire which was discovered about 1½ hours after their parents had left them. The older child, a boy, was found to be dead on admission to hospital (asphyxia due to carbon monoxide poisoning), whilst the younger, a girl, died shortly after admission (shock due to extensive burns). 217 District nursing associations The age range covered by the district nursing associations was wider than might have been expected—for children under five the pattern of accidents and the reasons therefor were similar to that revealed by the health visitors. The following comments are therefore confined to the 196 accidents reported to have occurred to people aged 60 and over. The make-up of the total was as follows: Falls 105 Scalds 52 Burns 30 Miscellaneous 9 196 An analysis of the immediate and underlying causes of the 105 falls is set out in Table VI. The underlying causes can be grouped into four categories—e.g., age (40 per cent.), infirmity (20 per cent.) miscellaneous including poor housing conditions (30 per cent.), and old equipment, untidiness or over-cleanliness (10 per cent.)—this last group probably comprises the truly preventable accidents. When the immediate causes are examined the misuse of chairs is apparent also ; the reasons given for standing on chairs included hanging curtains, cleaning windows and in one case putting money in a meter. The gas and electricity authorities are prepared to remedy the position when a meter is so placed that an elderly person has to climb to get at it. It is understood that the alteration is made first and the question of payment is considered on its merits later and according to the means of the old person. (In many cases it is free of charge.) In planning the Council's dwellings it is the Council's policy to arrange for gas meters and electricity meters and fuses to be placed at a reasonable height and in an accessible position. As regards scalds and burns there is an overlap in that some common agencies caused both—notably hot water bottles. If the two types of accident are considered together the more common agencies were: Hot water bottles 22 Kettles 21 Boiling liquid in other containers including saucepans and teapots 16 Fires 8 As regards hot water bottles, accidents arose because of splashing when filling, perishing or bursting, or being too hot. There does seem a real need to advise people, particularly the aged and those who care for them about the temperature of the water with which bottles are filled and the best method of so doing together with the need for covers (for those which are not of the serrated rubber type) and of replacement at the earliest sign of perishing. Rubber washers on hot water bottles made of earthenware or metal may also need to be replaced. It is relevant to state in addition that among the accidents to persons under 60 years of age reported by the district nursing associations 16 were due to hot water bottles. There was nothing startling about the data on scalds involving other containers such as kettles, saucepans and teapots—some were due to an unsteady hand, failing eyesight or a combination of both, and others to protruding handles ; of the burns from fires, five were caused by sitting too near—presumably the fire burnt up and the old person concerned was unaware in time of the greater heat being thrown out—possibly because they were dozing or because of their lower sensitivity to heat—it could perhaps be emphasised that warmer clothing is better than sitting too close to the fire. Summary and conclusions (1) Over four-fifths of home accidents, whether fatal or non-fatal, occur among the population aged under five years or 65 years and over. (2) The most important single cause in either group is falls, which affect predominantly elderly people, particularly women. 218 (3) Most accidents are caused among the elderly through old age and infirmity and in the younger age groups by preoccupation or lack of foresight on the part of the mother. (4) The general pattern is: Inexperience of the young; Inattention of the adult; Infirmity of the aged. In the circumstances: (a) propaganda should be directed not only towards the taking of precautions such as the provision of fireguards and keeping dangerous articles away from children but also towards— (i) avoidance of the use of chairs, etc., for standing purposes particularly by the aged; (ii) proper care, maintenance and wrapping of hot water bottles; (iii) the use of clothing rather than proximity to a guarded fire for keeping warm; (iv) the safeguarding of electric irons in use, and (b) emphasis should be placed on the need where active toddlers are concerned for intelligent adult supervision, and in the case of the elderly, forethought and watchfulness, in addition to the precautions indicated in (a) above. Health education in home safety Training of nursing staff Because of the heavy calls upon their time, in-service training for the school nursing sister/health visitor service has had to be given a broad basis and the amount of time given to any one aspect is limited. It has not been practicable to proceed with the suggestion that a series of one-day training courses on home accident prevention should be held for nursing staff. The need for further action has, however, been appreciated and a number of other activities have been arranged which in part serve the same end. The Central Council for Health Education has arranged a number of in-service training courses for departmental staff on aspects of health education which have been applicable to accident prevention. Representatives of the nursing staff have attended the Central Council's summer school and the home safety session of the annual congress of the Royal Society for the Prevention of Accidents. Officers concerned with health education in each division have visited the laboratories of the Gas Council where they were able to see at first hand the very careful checking to which appliances are subjected and the experimental work which is carried out on safety appliances, which is directed, inter alia, towards the prevention of coal-gas poisoning. Information about accidents and accident prevention in reports, journals, etc., is made widely available to staff in the field. In one division, as has already been stated, the Council's staff have co-operated with representatives of the Gas Board concerned to conduct a survey of gas apparatus in the homes of elderly people. This has been of immediate usefulness and in addition of instructive value to the staff concerned. Talks by experienced officers have been arranged at welfare centres, for Old People's Welfare Committees, home helps, schools and other organisations. On some occasions speakers from the Royal Society for the Prevention of Accidents have given talks; on other occasions, members of the Council's staff. Such talks have been useful from the point of view of the technique of teaching accident prevention to the Council's staff. When health education activities of an instructional nature are carried out for departmental staff the importance of giving facilities for the staff of district nursing associations to participate is borne in mind where this is appropriate. 219 B It is considered that these arrangements provide adequately for the in-service training of nursing staff in accident prevention whilst the broader basis of instruction maintains a balance between this aspect of health education, important as it is, and other important matters. Instruction in schools Health education in schools, which is the responsibility of the Education Committee, features regularly in the curriculum. In many schools talks on mothercraft, etc., are given by school nursing sisters/health visitors, whilst housecraft and education in citizenship also have a health education content. This generally contains an element of instruction on the need to prevent accidcnts in the home. The curriculum in each school is under the control of the headmaster or headmistress and, speaking generally, it is doubtful whether the instruction could be greatly extended, having regard to the competing claims of the many subjects in the school syllabus. Heads of schools have co-operated willingly by the display of posters, distribution of leaflets and by giving talks or facilities for talks by health department staff in the home safety campaigns that have been arranged. Road safety training is a recognised part of the school curriculum and encourages, as indicated elsewhere in this report, the general' safety mindedness' of school-children, thus helping to get them into the habits of forethought and care which will promote their own safety and that of others in many ways. Exhibition and demonstration material The Council has continued to acquire material but experience has made it clear that mechanical apparatus such as turntables and page turning machines need considerable care to keep them in good order. Larger material is not wholly satisfactory as it tends to suffer damage at the hands of the public and in transit whilst the opportunities of using it are limited because welfare centres and other establishments do not have room for it to be used to the best advantage. Generally all apparatus of these two types needs to be so placed that the public cannot interfere with it and this limits further its usefulness. Provision of flannelgraphs, flip charts, and triptychs with pegboard backs has been made. This has proved more useful as they can be adapted to various subjects and local circumstances by individual members of the staff. The courses provided by the Central Council for Health Education already mentioned have been concerned, inter alia, with demonstration techniques. A portable exhibition?—The provision for use in health service premises or elsewhere as opportunity occurred, of a portable exhibition which would form a comprehensive whole whilst being capable of being used in sections in premises of varying size has been proposed. The intention was to portray the various health services available and to provide a medium of health education generally to supplement the daily work of field workers. This has received full and careful consideration in the light of experience gained in the various publicity campaigns and exhibitions in which the public health department has been concerned and by health visitors in their daily work. It was found to be difficult to evolve an exhibition of a general nature which would at the same time provide an effective medium for health education on specific subjects. The size of the exhibits would have to be limited to enable it to be used in welfare centres, etc., whilst opportunities of using it as a whole would be few. The initial cost would be very considerable and there would arise the continuing expense of maintaining the exhibits in good condition. Damage arising in transit and the cost of transport were all factors that had to be taken into account. The exhibits once designed would not necessarily be adapted to local conditions and because of considerations of space would in many cases be handicapped from the point of view of display. 220 For these reasons it has been concluded that the present arrangements whereby a central pool of material is maintained which can be supplied to divisions for use in arranging local displays is a better one. The pool has been augmented in many ways. Consideration is at present being given to its further expansion by the addition of more material and the possibility of adopting a simple standard display unit. It is felt that this is a less costly and at the same time more effective way of stimulating local initiative than by providing a set exhibition. Film strip—A film strip dealing with the sensory development of the young child for use by health visitors and other members of the staff throughout the service has been made by members of the staff under the direction of the Divisional Nursing Officer of Division 7. It is entitled Three Years and Five Senses and is designed to assist parents and others responsible for the care of young children to encourage and assist the developing senses by the provision of toys and other play materials and by the right kind of play activity. It is felt that it may be useful to other authorities and negotiations are at present in hand as a result of which the Central Council for Health Education may undertake to market it on behalf of the Council. Loan to other bodies—Health education in London is being furthered by lending material on a variety of health subjects for exhibition by other authorities. The Council has recently participated in an exhibition given by the Islington Metropolitan Borough Council to celebrate the centenary of the anniversary of the first appointment of a medical officer of health in that district. It also played a part in other exhibitions in Islington and elsewhere. The Council hopes to reach a wider section of the public effectively by continuing to take part in such exhibitions as opportunity occurs. Safety handbook—With the approval of the Health Committee an illustrated safety handbook has been prepared by a publishing firm for distribution to the public free of charge through the Council's divisional health organisation. This in addition to giving much useful information on the subject of home safety and safety generally also gives particulars of the Council's health service. The handbooks are prepared on a divisional basis but to facilitiate distribution a separate edition is available for each metropolitan borough and some 72,000 handbooks will have been distributed when publication is completed. Safety in the Home campaigns Safety week campaigns have been held for the whole county annually since 1954 and they will continue to be held on the same general lines. Last year's campaign began on 5th November, 1956. Press publicity by way of press releases was obtained on a wide scale and London newspapers gave approaching 300 inches of column space. The response of weekly, daily and evening newspapers having regard to the calls upon column space occasioned by the troubled international situation was generous. In addition more specialised publications also gave column space as did a number of provincial newspapers. The Royal Society for the Prevention of Accidents were able to arrange for a number of other authorities to hold campaigns at the same time and took the opportunity of securing some press publicity. On the opening night of the campaign, the medical officer of health was given the opportunity of making a broadcast in the B.B.C. Town and Country programme on its objects and the problems which are met in conducting education against accidents in the home. The co-operation of general practitioners, hospital management committees and boards of governors, town clerks of metropolitan boroughs, midwives, district nurses and moral welfare workers was readily forthcoming. Emphasis was placed on preventable accidents to old people because, as has been said, old people arc the victims of an overwhelming majority of fatal and non-fatal accidents. Old People's Welfare Committees were circulated and made a number of suggestions which in turn were passed to divisional medical officers and to the district nursing associations for their practical guidance. 221 R* The assistance afforded by general practitioners, public health inspectors, midwives, health visitors, district nurses and other workers who have occasion to visit homes is particularly valuable. They are in a position to notice accident hazards at first hand and to advise about remedying them. The housewife has come to have confidence in their judgment in these respects and there is the more likelihood that their advice will be taken. The importance of accident prevention in younger age groups was not forgotten. A card warning the public to keep medicines out of the reach of children has been supplied to pharmacists through the London Executive Council, whose good offices were also available in the distribution of posters and leaflects to each general practitioner. Two posters were selected by the Local Medical Committee for display by each general practitioner, one dealing with accident risks to the aged, the other to children. A film called Fiery Accidents provided by the Central Office of Information was shown in 69 cinemas controlled by the Circuits Management Association, Ltd., and in 15 cinemas controlled by Essoldo Cinemas, Ltd., whilst slides dealing with the need to guard fires were shown at 33 cinemas belonging to Associated British Cinemas, Ltd. Both film and slides stressed the need to protect very young children against injury by burning. The education officer invited head teachers to co-operate by displaying posters and distributing leaflets which it is hoped in this way will find their way into the hands of parents and other relatives. The services of divisional staff were offered to head teachers and as a result a number of lectures were given. A similar offer was made to Old People's Welfare Committees. The Royal Society for the Prevention of Accidents also undertook to provide speakers where necessary. Divisional medical officers were asked to arrange local displays, talks, etc., to display posters, distribute leaflets and take whatever steps were possible to secure publicity for the campaign, whilst arrangements were made for a display of posters to be arranged in the main entrance to County Hall and for the Architect of the Council to mount a small display in the window adapted for health education displays at the sub-office of Division 8 at 376 Brixton Road. A small display was also staged by the W. V.S. in the window of their headquarters in Westminster. It is difficult to assess the effectiveness of campaigns such as this, but in 1955 the campaign week saw a reduction in the number of patients removed to hospital by the London Ambulance Service because of home accidents of the order of 23 per cent., and the succeeding two weeks a reduction of 23 per cent, and 17 per cent. A similar drop occurred during the week of the 1956 campaign and in the following week but it was not so marked as in the previous year and in the absence of further information it might be unwise to regard it as having too great a significance. As an additional means of focusing public attention on the problem the Council during a period covering the campaign used for the first time envelopes for its correspondence bearing a home safety slogan. This method of approach had previously been used in connection with diphtheria immunisation and B.C.G. vaccination. Proposed legislation At the request of the Metropolitan Boroughs' Standing Joint Committee provision for the grant of powers for Metropolitan Borough Councils and the City Corporation to conduct home safety propaganda have been included in a general powers Bill now before Parliament*. The effect of this provision will be to give these authorities powers concurrent with those of the Council as a local health authority to incur expenditure in this field. There cannot be too many hands to undertake this important work and this addition to the number of authorities able to undertake it may be welcomed. It is understood that Home Safety Committees may be set up on the lines of the Road Safety Committees which are already in existence. *The Bill received royal assent on 31st July, 1957. 222 General conclusions Home accidents may be regarded from the point of view of their susceptibility to prevention. Those which happen to children under five years of age could be averted in a large number of cases when the responsibility for their occurrence is due to a failure in parental vigilance. Habit training begins to be of, and increases in, importance as the child develops and approaches the age when he or she (and this applies more to boys) gets into his own scrapes. Above the age of five years education against accidents should be directed increasingly to the child and it would appear that the parent and the teacher are in the best position to do this. From this age onwards it is probably true to say that a higher proportion of accidents occur which could not so readily be prevented, because they are due to growing adventurousness coupled with incompletely developed faculties and, an important factor, lack of experience. At this age children are instructed in road safety and this should reinforce, and be reinforced by, the lessons of home safety ; the two together should inculcate and encourage care and foresight which will be applicable in the industrial and commercial field later in life. It is probably more difficult, however, to make a child see danger in the familiar everyday objects of home and garden to which he has become thoroughly accustomed than to make him aware of the dangers arising from large and rapidly moving objects which make up road traffic. The accidents which occur in adolescence, early and middle adult life are somewhat of the same kind, and although forethought and care would undoubtedly reduce their incidence, they are due in many cases to the nature of the activities undertaken. It is only when the increasing weight of years has had its effect in reducing alertness, whilst increasing the stubborness, opposition to change and senility which unfortunately are often associated with advancing years, that accidents which could be prevented are again met in any large proportion. Here again the keyword is watchfulness and it is the relatives, friends and neighbours of the elderly person who can do most to spare them the unhappy consequences of accidents. It must, however, be accepted that a proportion of accidents and probably a fairly high one, to the aged is inevitable and is attributable directly to physiological disabilities. Certain forms of accident would appear to be more capable of prevention than others. Burns and scalds could by taking precautions and the exercise of care be considerably reduced. Poisoning whether by coal-gas or other toxic substances could be reduced by maintaining appliances in good condition and ensuring proper ventilation in the first instance, and by locking away medicines or other toxic substances when not in use and making sure that such things are kept in properly marked containers. Health education against accidents should be addressed to the parents of infants and young children, particularly as the parents of first children are likely to be inexperienced in the ways of young children. It should also be increasingly directed towards the developing child both from the point of view of immediate effect, and also because if it is well received and the lesson is learnt it will bear fruit at all later stages in life. Although children are much less accident prone than the aged, from this point of view and from the point of view of the community inasmuch as they have the whole of their productive life to live, their safety is very important. Health education towards accident prevention can therefore be directed at young and middle-aged adults in their capacity as guardians of children and because of their responsibility for the welfare of older people. It is generally they who are mainly responsible for such activities in the home as building, decorating, gardening, repairs and handyman's work and propaganda in this connection can be addressed to them on their own account. The problem of the aged is very difficult. Undoubtedly their care when they meet with accidents imposes a very considerable burden on the community whilst it may mean that the victim's last years instead of being healthy and happy are made wretched by ill-health and an unwelcome dependence upon others. So many accidents occur to the aged that the reduction in their incidence is most important from the point of view of 223 the burden that collectively they impose on the community. Accident prevention measures likely to be most successful are those directed towards making their surroundings safe, their younger relatives, friends and neighbours vigilant and so far as a direct approach is concerned it needs to be simple, often repeated and not such as will antagonize the people to whom it is directed. Table I—Fatal home accidents in England and Wales 1950-1955 Type of accident Year 1950 1951 1952 1953 1954 1955 Falls on stairs 630 712 724 709 832 852 off ladders 35 41 43 43 47 35 from one level to another 417 475 314 263 267 255 on same level 1,018 1,009 883 1,034 813 736 unspecified 463 513 596 912 1,442 1,476 Total falls 2,563 2,750 2,560 2,961 3,401 3,354 Bums 468 577 574 490 569 604 Coal-gas poisoning 387 459 461 552 612 740 Drowning 64 54 32 50 66 51 Inhalation and ingestion of food 328 302 294 253 290 273 Poison 149 166 180 195 193 209 Scalds 109 105 93 94 85 103 Suffocation 303 303 258 225 226 194 Miscellaneous 238 248 234 412† 220 215 Grand totals 4,609 4,964 4,686 5,232 5,662 5,743 †Includes flood disaster victims. 224 Table II—Fatal home accidents in England and Wales, 1955—By age, sex and wain causes Age group Falls Burns Coal-Gas Drowning Inhalation Poison Scalds Suffocation Miscellaneous Total M F T M F T M F T M F T M F T M F T M F T M F T M F T M F T 0-4 22 16 38 23 43 66 7 9 16 7 5 12 130 89 219 14 8 22 19 14 33 117 66 183 40 34 74 379 284 663 5-14 9 3 12 14 50 64 5 — 5 1 2 3 2 1 3 1 1 2 1 — 1 — 1 1 17 3 20 50 61 111 15-44 42 16 58 16 34 50 44 31 75 1 4 5 9 3 12 35 29 64 — 1 1 6 1 7 31 11 42 184 130 314 45-64 119 122 241 28 48 76 72 69 141 2 15 17 13 8 21 40 33 73 2 4 6 — 1 1 17 15 32 293 315 608 65 + 817 2,188 3,005 111 237 348 162 341 503 5 9 14 10 8 18 18 30 48 29 33 62 1 1 2 19 28 47 1,172 2,875 4,047 Total 1,009 2,345 3,354 192 412 604 290 450 740 16 35 51 164 109 273 108 101 209 51 52 103 124 70 194 124 91 215 2,078 3,665 5,743 Per cent. 58 10 13 1 5 4 2 3 4 100 225 Table III—Details of accidents reported by London Ambulance Service during year ended 31-3-56 Under 1 1- 2- 3 and 4 5-19 20-59 60-69 70-79 80+ Males Females Total Falls on stairs 1 4 20 24 102 514 213 226 169 409 864 1,273 off ladders — — — 1 11 103 40 21 4 115 65 180 from chair — 18 10 15 16 100 39 42 36 52 224 276 outside stone steps, windows, balconies, roofs, etc.) — 8 17 38 124 131 38 29 10 226 169 395 in garden — 5 23 35 112 129 64 82 60 197 313 510 in bath — — — — 2 11 1 5 3 12 10 22 from one level to another (i.e., tables, boxes, beds, etc.) 18 17 21 27 36 65 33 98 141 164 292 456 on same level (i.e., in room over objects, etc.) — 11 24 29 57 174 110 220 223 243 605 848 unspecified — 12 17 41 89 393 254 479 422 426 1,281 1,707 Sub-total 19 75 132 210 549 1,620 792 1,202 1,068 1,844 3,823 5,667 Burns 4 7 11 6 45 82 14 29 19 80 137 217 Coal-gas poisoning — 2 3 3 8 49 17 14 14 41 69 110 Poison (including foreign objects and inhalation) 20 39 42 24 35 57 15 9 4 109 136 245 Scalds at cooking stove 3 19 11 11 25 54 6 8 3 52 88 140 teapot 1 23 15 11 10 8 3 3 2 45 31 76 other boiling water 5 20 15 20 43 44 7 7 4 72 93 165 Sub-Total 9 62 41 42 78 106 16 18 9 169 212 381 Suffocation 8 2 — — — — 1 — — 5 6 11 Electric shock — 1 — — 2 20 — 1 — 9 15 24 Hit by object 9 20 33 47 120 167 22 27 9 241 213 454 Lacerations 2 13 20 19 138 217 17 11 2 247 192 439 Windows (trapping) — — — — 2 30 5 9 3 8 41 49 Not specified 6 5 2 7 27 85 22 23 21 89 109 198 Total 77 226 284 358 1,004 2,433 921 1,343 1,149 2,842 4,953 7,795 226 Table IV—Home accidents reported by London Ambulance Service during year ended 31-3-56 Analysis of types and overall rates by Divisions Cause of accident Division Total 1 2 3 4 5 6 7 8 9 (Chelsea, Fulham, Hammersmith, Kensington) (Hampstead, Paddington, St. Maryle- bone, St. Pancras, Westminster) (Finsbury, Holborn, Islington) (Hackney, Shoreditch, Stoke Newington) (Bethnal Green, City of London, Poplar, Stepney) (Deptford, Greenwich Woolwich) (Camberwell, Lewisham) (Bermond- sey, Lambeth, Southwark) (Battersea, Wandsworth) Falls on stairs 165 243 145 99 74 112 146 155 134 1,273 from ladder 26 27 11 9 6 17 30 20 34 180 from chair 23 30 30 27 16 31 41 40 38 276 outside 69 67 34 30 23 33 40 49 50 395 in garden 47 46 43 41 24 92 98 49 70 510 in bath 4 4 4 2 1 3 2 — 2 22 from one level to another 50 76 32 29 33 50 62 54 70 456 same level 103 165 112 58 37 69 94 86 124 848 unspecified 265 203 147 140 79 158 212 221 282 1,707 Hit by object 59 53 34 35 22 63 61 50 77 454 Cooking stove 10 12 16 6 9 26 27 20 14 140 Tea pots 13 6 5 2 5 10 11 10 14 76 Other boiling water 16 17 19 12 9 25 17 20 30 165 Electric shock 1 9 3 2 — 2 3 1 3 24 Poisoning 28 36 25 11 19 26 40 22 38 245 Gassing 18 30 7 7 6 11 10 9 12 110 Knife-like wounds 55 65 43 25 23 56 50 54 68 439 Fires 23 42 25 15 14 25 20 27 26 217 Windows 6 8 3 2 — 4 7 11 28 49 Suffocation 2 3 — — 2 2 1 — 1 11 Not specified 34 41 21 10 12 18 22 18 2 198 Total 1,017 1,183 759 562 414 833 994 916 1,117 7,795 Rate per 10,000 persons 22 23 27 21 18 27 25 24 25 24 227 Table V—Home accidents to children under 5 years of age during year ended 31-3-56 reported by health visitors Cause 0- 1- 2— 3- 4— Boys Girls Total Burns 17 40 22 9 5 43 50 93 Scalds 15 40 21 8 8 58 34 92 Falls 5 29 25 7 6 41 31 72 Poison and foreign objects 4 5 11 5 — 11 14 25 Hitting or hit by object 3 7 7 3 4 16 8 24 Cuts 1 6 3 4 — 10 4 14 Miscellaneous 10 1 3 2 — 8 8 16 Total 55 128 92 38 23 187 149 336 Table VI—Falls in the home by persons aged 60 and over during year ended 31-3-56, reported by District Nursing Associations Immediate Causes Underlying Cause Stairs 20 Old age 43 Same level 17 Illness 12 21 Bed 10 Poor eyesight and blindness 9 Standing on chair 10 Poor lighting 4 31 Over objects 6 Over-reaching 2 Outside steps 4 High windows 1 Over mats 3 In other person's house 2 Polished floor 2 Miscellaneous 12 Miscellaneous 14 Unspecified 10 Unspecified 19 Polished linoleum 2* 10 Broken or light chair 2 Faulty stair carpet 1 Torn mat 1 Bad linoleum 1 Old slippers 1 Apple peel 1 Untidy house 1 Total 105 105 228 APPENDIX D STATISTICS (a) Table 1—Population (b)—Administrative County of London, 1901-56 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 2,405,000 137,700 234,500 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 3,295,000 230,000 421,000 391,000 1,037,000 829,000 387,000 37.5 1956 M. 1,531,000 117,000 217,000 173,000 503,000 379,000 142,000 35.9 F. 1,742,000 112,000 210,000 211,000 515,000 450,000 244,000 38.8 3,273,000 229,000 427,000 384,000 1,018,000 829,000 386,000 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 from 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. 229 Table 2—Live births and still-births—Administrative County of London, 1941-56 Year(s) Live births Still-births No. Rate per 1,000 population* No. Rate per 1,000 total births (live and still) 1941-45 209,909 15.4 5,652 26.2 1946 66,023 20.1 1,597 23.6 1947 70,685 21.2 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 1956 52,171 15.9 1,070 20.1 *1941-49—Total population. 1950—Home population. 230 Table 3—Vital statistics—Metropolitan Boroughs and the Administrative County of London, 1956 (a) Metropolitan Boroughs Estimated home population mid 1956 Live birth rate. Death-rates Notifications of infectious disease Deaths (all causes) Infant mortality (per i.ooo live births) Heart disease Other circulatory Cerebral vascular lesions Peptic ulcer Pulmonary tuberculosis Pneumonia Other respiratory diseases (inc. Bronchitis) Cancer Violence Scarlet fever Dysentery Poliomyelitis Food Poisoning Acute pneumonia Measles Whooping cough Tuberculosis Paralytic Nov Paralytic Pulmonary Nonr pulmonary Division 1 Chelsea 51,070 16.1 16.0 26 4.35 1.33 21.3 0.22 0.02 1.23 0.96 3.19 0.51 0.74 6.83 0.16 0.12 1.66 0.70 3.58 1.41 0.69 0.08 Fulham 117,100 15.0 11.3 26 3.18 0.65 1.21 0.14 0.10 0.57 1.04 2.30 0.49 0.38 1.00 0.09 0.05 0.12 0.16 0.46 1.76 1.11 0.09 Hammersmith 113,300 16.1 11.3 21 3.24 0.60 1.41 0.07 0.15 0.64 1.09 2.10 0.61 0.49 1.24 0.03 — 0.26 0.58 1.45 1.93 1.38 0.08 Kensington 168,800 16.6 10.5 21 3.06 0.53 1.13 0.19 0.11 0.63 0.80 2.16 0.57 0.27 0.52 0.08 0.04 0.37 0.39 2.12 1.40 1.38 0.14 Division 2 Hampstead 97,580 15.2 10.5 23 3.40 0.59 1.31 0.17 0.04 0.46 0.56 2.21 0.46 0.33 0.36 0.02 — 0.15 0.55 2.49 0.96 0.90 0.12 Paddington 121,200 18.9 10.4 24 2.77 0.47 1.25 0.19 0.12 0.54 0.84 1.91 0.74 0.21 0.71 0.02 0.05 0.42 0.35 2.80 0.84 1.82 0.18 St. Marylebone 73,040 11.1 15.6 15 5.94 0.58 1.90 0.15 0.11 0.49 1.23 2.81 0.68 0.42 0.75 0.01 0.01 0.18 0.12 1.59 0.59 0.90 0.07 St. Pancras 133,100 17.7 11.5 22 2.83 0.59 1.19 0.21 0.18 0.74 1.17 2.46 0 .59 0.51 0.68 0.03 0.01 0.47 0.52 6.31 1.31 1.32 0.11 Westminster, City of 96,100 11.9 9.9 23 2.68 0.41 1.04 0.16 0.17 0.42 0.57 2.35 0.81 0.30 0.96 0.06 0.01 0.47 0.12 2.13 0.56 1.07 0.07 Division 3 Finsbury 34,870 20.1 10.2 30 3.27 0.29 0.80 0.20 0.14 0.60 1.18 2.12 0.26 0.80 5.82 0.06 — 0.95 1.66 8.89 4.16 1.03 0.14 Holborn 22,640 11.3 11.5 51 3.27 0.35 1.15 0.13 0.09 0.75 0.71 2.65 0.49 0.18 0.31 0.18 0.09 0.04 0.13 3.14 0.97 1.46 0.13 Islington 228,300 18.9 11.2 21 3.31 0.53 1.04 0.20 0.15 0.78 1.12 2.26 0.50 0.71 1.55 0.04 0.00 0.65 0.40 8.76 2.32 1.31 0.15 Division 4 Hackney 165,800 15.1 11.1 18 3.62 0.47 1.12 0.14 0.11 0.51 1.14 2.36 0.43 0.78 1.15 0.02 0.01 0.19 0.33 2.75 2.38 0.69 0.05 Shoreditch 44,520 16.1 15.5 17 3.46 0.88 1.98 0.38 0.09 1.64 2.27 2.83 0.43 0.72 2.07 0.04 0.11 0.40 0.74 5.21 2.40 0.90 0.09 Stoke Newington 50,420 17.0 10.6 21 3.29 0.52 1.23 0.20 0.06 0.56 1.05 2.22 0.36 0.56 0.85 0.06 0.02 0.26 0.22 2.08 4.58 1.01 0.08 Division 5 Bethnal Green 52,280 17.2 10.7 25 2.70 0.65 1.15 0.25 0.10 0.61 1.22 2.31 0.38 0.52 0.48 0.10 — 0.13 0.15 3.90 2.77 1.15 0.08 City of London (b) 5,180 8.9 12.9 65 3.28 0.77 0.58 0.19 0.39 0.97 0.97 3.28 0.77 0.58 1.16 — — 0.19 0.19 3.67 0.77 0.77 0.39 Poplar 68,620 17.3 10.7 25 2.74 0.60 0.90 0.22 0.13 0.58 1.41 2.30 0.41 0.48 1.38 0.10 0.06 0.35 0.68 5.71 2.54 0.85 0.09 Stepney 98,160 19.4 12.1 23 3.49 0.56 1.09 0.15 0.17 0.78 1.31 2.38 0.57 0.35 0.17 0.02 0.01 0.22 0.80 5.85 2.39 1.18 0.11 Division 6 Deptford 71,840 14.8 13.3 25 4.26 0.67 1.22 0.17 0.21 0.88 1.17 3.10 0.26 0.85 3.73 — — 0.13 0.46 0.53 1.10 1.43 0.13 Greenwich 88,780 14.9 9.8 15 2.92 0.34 0.96 0.09 0.14 0.89 0.89 2.15 0.34 0.65 5.41 0.06 0.05 0.26 0.16 0.50 1.37 0.81 0.10 Woolwich 147,500 13.4 10.3 19 2.81 0.47 1.10 0.14 0.12 0.66 1.08 2.15 0.41 0.77 3.55 0.03 0.01 0.05 0.53 1.59 1.41 0.98 0.07 Division 7 Camberwell 177,800 15.4 10.8 24 2.98 0.64 1.19 0.19 0.13 0.51 1.18 2.26 0.47 0.87 1.39 0.02 — 0.49 0.30 0.82 1.99 1.73 0.13 Lewisham 222,100 14.4 11.3 19 3.63 0.51 1.35 0.17 0.13 0.60 1.06 2.18 0.36 0.85 2.70 0.12 0.09 0.23 0.40 0.93 1.09 0.88 0.08 Division 8 Bermondsey 56,200 16.4 10.1 22 2.63 0.87 0.78 0.18 0.18 0.71 1.12 2.08 0.30 1.44 2.92 0.04 — 0.34 0.53 2.65 0.77 1.07 0.11 Lambeth 223,900 17.8 10.7 21 3.06 0.58 1.26 0.12 0.10 0.75 0.96 2.15 0.35 0.70 1.35 0.04 0.03 0.27 0.55 2.55 1.54 0.80 0.08 Southwark 92,300 17.7 13.0 16 3.65 0.66 1.40 0.18 0.23 0.86 1.31 2.55 0.46 2.84 7.76 0.04 0.09 0.56 4.84 1.56 1.52 0.17 Division 9 Battersea 112,900 16.0 10.8 23 3.26 0.55 1.25 0.11 0.12 0.51 1.20 2.13 0.43 0.64 1.39 0.15 0.05 0.22 0.40 2.43 1.58 0.90 0.05 Wandsworth 337,600 14.4 15.6 17 5.03 0.78 1.71 0.15 0.13 0.68 1.08 3.49 0.46 0.60 2.22 0.07 0.04 1.07 1.05 2.01 1.63 0.83 0.07 London, 1956 3,273,000 15.9 11.7 21 3.46 0.59 1.27 016 .13 0.67 1.07 2.42 0.47 0.67 1.95 0.06 0.03 0.41 0.50 2.95 1.67 1.10 0.10 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 0.11 231 (a) Rates are per 1,000 home population. (b) Including Inner and Middle Temple. ho ho Table 4—Principal vital statistics—Administrative County of London, 1906-1956 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 (c) 0.29 1.22 1.49 0.22 1.26 1.11 0.10 0.12 (d) 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 15.1 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 0.14 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 1.04 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 0.15 0.51 1953 15.3 19.7 11.6 0.21 0.02 — 0.15 0.00 0.01 0.01 1.07 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 0.1l 3.37 2.39 0.07 0.14 0.10 0.22 23 0.5 0.06 0.55 1956 15.9 20.7 11.7 0.13 0.01 0.00 0.04 0.00 0.00 0.00 0.96 0.67 0.11 3.46 2.42 0.07 0.15 0.10 0.22 21 0.4 — 0.30 (a) Death-rates from 1939 to 1949 relate to the civilian population only. (b) 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. (d) Deaths from vehicles and horses 1906-10, 1911-39 estimated, and from 1940 actual deaths from motor vehicles and other road traffic accidents. 233 Table 5—Deaths by cause—Administrative County of London, 1956 Cause Sex 0— 1— 5— 15— 25 — 45— 65— 75+ Total 1956 1955 1. Tuberculosis—respiratory M — — — — 49 132 91 49 321 392 F — 2 — 2 35 25 25 13 102 125 2. Tuberculosis—other M — 1 — — 6 8 2 2 19 22 F — — — — 3 6 1 3 13 22 3. Syphilitic disease M — — — — 3 39 39 29 110 104 F — — — — 2 7 19 19 47 54 4. Diphtheria M — — — — — — — — — 1 F — 7 — — — 7 — — 2 1 5. Whooping cough M — — — — — — — — — 5 F 2 3 — — — — — — 5 2 6. Meningococcal infection M 2 1 1 1 — 1 — — 6 11 F 3 7 1 — 1 2 7 — 9 11 7. Acute poliomyelitis M — — 4 — — — — — 4 14 F — — — — 2 — — — 2 12 8. Measles M — — — — — — — — — 8 F — 1 — — — — 1 — 2 7 9. Other infective, &c., diseases M 2 2 1 — 8 15 1 5 34 40 F — 2 2 — 3 13 7 12 39 43 10. Malignant neoplasm: Stomach M — — — — 25 231 166 118 540 579 F — — — — 12 107 157 161 437 411 11. Malignant neoplasm: Lung, bronchus M — — — — 65 853 540 178 1,636 1,525 F — — 7 1 13 109 93 61 278 338 12. Malignant neoplasm: Breast M — — — — 1 4 3 1 9 8 F — — — 1 82 319 161 164 727 714 13. Malignant neoplasm: Uterus F — — — — 35 135 85 60 315 313 14. Other malignant and lymphatic neoplasms M 1 5 24 20 109 587 632 567 1,945 1,994 F 3 8 7 10 105 550 531 623 1,837 1,784 15. Leukemia, aleukemia M — 6 7 6 16 33 23 11 102 105 F 1 4 8 6 12 25 15 23 94 90 16. Diabetes M — 1 — 1 4 26 31 21 84 70 F — 1 — 1 3 32 50 71 158 160 17. Vascular lesions of nervous system M 1 — 2 3 31 360 497 699 1,593 1,590 F — — 2 4 36 354 682 1,487 2,565 2,523 18. Coronary disease, angina M — — — — 109 1,187 1,133 958 3,387 3,149 F — — — 1 18 290 777 1,081 2,167 2,016 19. Hypertension with heart disease M — — — — 2 76 145 203 426 414 F — — — — 7 61 183 356 601 560 20. Other heart disease M — — 2 8 60 255 401 1,129 1,855 1,913 F 2 — 1 7 69 290 482 2,031 2,882 3,066 21. Other circulatory disease M — — — — 25 181 212 377 795 831 F — — — 2 16 133 281 702 1,134 1,193 22. Influenza M — — — — 5 15 20 20 60 58 F — — 1 — 3 12 5 39 60 106 23. Pneumonia M 68 13 2 4 14 165 253 504 1,023 1,032 F 62 8 6 3 16 87 207 773 1,162 1,050 24. Bronchitis M 25 7 — 3 14 550 697 740 2,036 1,967 F 18 5 2 — 9 115 268 696 1,113 931 25. Other diseases of respiratory system M 2 1 1 1 7 74 85 58 229 249 F 2 4 2 1 7 23 29 58 126 123 26. Ulcer of stomach and duodenum M 1 — — — 16 128 129 111 385 390 F — — — — 1 18 48 88 155 166 27. Gastritis, enteritis and diarrhoea M 12 2 1 2 3 12 16 23 71 74 F 6 7 — 1 12 15 31 46 112 117 28. Nephritis and nephrosis M 1 2 2 6 29 66 37 41 184 142 F — — 1 4 22 31 35 32 125 117 29. Hyperplasia, prostate M — — — — — 13 62 187 262 275 30. Pregnancy, childb. : abortn. F — — — 5 22 — — — 27 .39 31. Congenital malformations M 106 11 8 4 13 11 6 5 164 166 F 87 4 12 1 7 14 3 6 134 135 32. Other defined and ill defined diseases M 392 9 17 23 95 261 218 341 1,356 1,394 F 282 15 16 7 88 294 325 671 1,698 1,627 234 Table 5 (contd.)—Deaths by cause—Administrative County of London, 1956 Cause Sex 0— 1— 5— 15— 25— 45— 65- 75+ Total 1956 1955 33. Motor vehicle accidents M _ 4 22 35 49 43 26 29 208 213 F — 1 5 8 9 32 22 32 109 96 34. All other accidents .. M 16 9 15 29 74 97 47 110 397 356 F 8 5 6 7 19 44 54 188 331 350 75. Suicide M _ - - 14 76 127 53 31 301 276 F - - 1 9 40 79 36 14 179 185 36. Homicide, operations of war M 1 1 2 1 4 4 2 - 15 14 F - 1 — 2 4 5 — 1 13 9 ALL CAUSES .. • .. M 630 75 Ill 161 912 5,554 5,567 6,547 19,557 19,381 F 476 67 74 83 707 3,228 4,614 9,511 18,760 18,496 Table 6—Infant mortality—Administrative County of London, 1956 Cause of death Age at death Total Rates per 1,000 live births Under 1 day 1 to 7 days 1 to 4 wks. 4 wks. to 1 yr. No. Male Female Total Male Female Whooping Cough Leg. — — 2 2 — 2 004 — 008 Illeg. — — —■ Tuberculosis .. Leg. — — —" Illeg. — — —< Measles • • Leg. — — — Illeg. — — —_ Convulsions .. Leg. — 1 — — 1 1 — 0 02 0-04 — Illeg. — — — Bronchitis and .. Leg. 3 16 291 118 173 93 80 3-32 3-49 3-14 Pneumonia .. Illeg. — 3 4 Gastro Enteritis Leg- — — r 17 18 12 6 0 35 0-45 024 and Diarrhoea Illeg. — — — Congenital Leg. 30 41 45* 71 193 106 87 3-70 3-98 3-41 Malformation Illeg. 1 3 2 Immaturity .. Leg. 99 80 7' 1 214 117 97 4 10 4-39 3-80 Illeg. 21 5 1 Injury at Birth ■ Leg. 53 64 2* 1 138 86 52 264 3-23 204 Illeg. 12 6 — Post-natal Asphyxia Leg. 92 77 3" 3 191 115 76 366 4-31 2-98 and Atelectasis Illeg. 10 6 — Haemolytic disease Leg. 15 14 3* — 32 12 20 061 0-45 0-78 Illeg. — — —^ Accidental 1 t«, 9 11 6 5 021 0-23 0-20 Mechanical ^ni8' 2 1 Suffocation J Illeg. —J Other causes .. Leg. 13 27 201 i 54 133 82 51 2-55 307 200 Illeg. 10 3 6J r All causes .. Leg. M. 156 196 62 1451 L 997 559 438 20 89 22-96 18-72 F. 149 124 50 115 Illeg. M. 34 18 7 12" I 109 71 38 24 58 30-59 17-98 F. 20 8 6 4J Total, 1956 359 346 125 276 1,106 630 476 21 20 23-62 18-66 Total, 1955 421 315 98 323 1,157 689 468 23-22 26-86 19-36 Leg. M. 210 165 46 1861 L 1,010 607 403 21-96 25-61 18-08 F. 143 111 41 108 Illeg. M. 36 23 6 17" 147 82 65 38 41 42-18 34-52 F. 32 16 5 72j Table 7—Infant mortality by cause—Administrative County of London, 1936.1956 (Rates per 1,000 live births) Cause of death 1936 to 1940 1941 to 1945 1946 to 1950 1951 to 1955 1955 ###] Whooping cough . . 1.69 1.49 0.55 0.13 0.06 0.04 Tuberculosis 0.54 0.49 0.26 0.07 — — Measles 0.82 0.30 0.08 0.06 0.10 — Bronchitis and Pneumonia 11.07 8.94 5.48 3.74 3.57 3.32 Gastro.enteritis 10.33 7.64 2.83 0.74 0.48 0.35 Immaturity 12.40 11.48 6.93 4.26 4.67 4.10 Congenital malformations 4.79 4.94 4.32 3.62 3.43 3.70 Injury at birth 2.22 2.40 2.33 2.69 2.59 2.64 Post.natal asphyxia and atelectasis 2.07 2.38 3.48 3.92 4.32 3.66 Haemolytic disease . . (a) (a) (a) 0.65 0.58 0.61 Convulsions 0.20 0.14 0.03 0.00 — 0.02 Accidental mechanical suffocation 0.54 1.08 1.10 0.15 0.06 0.21 Other causes 8.56 6.96 4.24 3.24 3.35 2.55 All causes 55 48 32 23 23 21 Table 8—Maternal mortality (excluding abortion)—Administrative County of London and England and Wales, 1946.56 (Rates per 1,000 total births) 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 Puerperal sepsis London 0.12 0.12 0.13 — — 0.06 0.15 0.02 0.06 0.06 — England and Wales 0.18 0.16 0.13 0.12 0.12 0.10 0.09 0.10 0.09 0.11 0.07 Other causes : London 0.80 0.55 0.37 0.40 0.53 0.39 0.51 0.38 0.48 0.55 0.30 England and Wales 1.06 0.86 0.74 0.70 0.60 0.56 0.50 0.54 0.49 0.43 0.39 (a) Included in other causes. 235 Table 9—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—Administrative County of London, 1934.1956 Year Anthrax 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 1934 3 0.0007 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 (") 12.91 (b) 18,238 4.32 144 0.034 — — . (b) (b) 1935 2 0.0005 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 — — 7,030 1.68 304 0.072 12 0.003 255 0.061 1,815 0.432 35 0.008 113 0.027 462 8.10 4,141 0.986 38 0.009 635 10.92 10,705 2.55 — — — — 1937 3 0.0007 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 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 — — — — (c) 1,891 1.87 1939 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 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 2,179 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 1,813 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 1,862 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 — 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 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. 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 Cases 267 Rate 0.079 Cases 163 Rate 0.048 371 6.78 (g) 14.96 823 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 — — 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 30.38 535 0.16 5,263 1.56 — — — — 5,587 1.66 612 0.18 1953 — — 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 28.72 527 0.16 3,425 1.02 — — — — 11,027 3.30 1,269 0.38 1954 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 32.51 669 0.20 2,444 0.74 — — 1 0.0003 4,691 1.41 1,060 0.32 1955 — — 16 0.005 3,019 0.916 20 0.006 111 0034 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 33.92 660 0.20 2,070 0.63 — — — — 4,709 1.43 1,530 0.46 1956 1 0.0003 11 0.003 6,392 1.953 54 0.016 73 0.022 297 0.091 31 0.009 9,651 2.959 94 0.029 83 1.59 1,633 0.499 183 0.056 96 0.029 1,792 29.49 703 0.21 j 2,198 0.67 — — — — 5,450 1.67 1,327 0.41 (a) Rate per 1,000 total births after correction for London residence 1934.50; from 1951 rate per 1,000 total births registered in London. (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 the years 1947.51. (f) Rate per 1,000 live births. (g) For cause of increase since 1950 see page 16 of Annual Report for 1951. Table 10 Notification of certain infectious diseases distribution by age and date of notification—Administrative County of London, 52 weeks commencing week ended 1th January, 1956 Fourweekly periods 1956 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—74 75+ Total 0—4 5—74 75+ Total 0—4 5—74 75+ Total 0—4 5—14 75+ Total 0—4 5—74 15+ Total 1— 4 M 58 45 19 122 29 19 3 51 3 1 - 4 31 12 115 158 1 1 3 5 1 5 1 7 36 46 5 87 86 51 1 139 F 63 36 49 150 21 17 2 41 1 1 1 3 16 74 772 142 - 1 2 3 - 2 1 3 24 47 3 75 81 55 1 139 5— 8 M 94 108 60 265 41 42 — 83 6 — 1 7 25 14 94 135 3 1 - 4 - 1 - 1 25 36 6 67 69 34 - 104 F 92 109 91 294 60 37 3 100 1 — 1 2 24 72 706 142 - - - - - - 2 2 22 48 3 74 74 72 4 150 9—12 M 197 222 69 494 53 59 6 118 3 — 3 12 15 97 125 1 1 - 2 - - - - 37 67 7 111 75 54 - 129 F 166 184 117 474 75 48 10 133 5 1 1 7 14 13 94 121 - 1 2 4 — 1 — 1 31 75 5 111 85 73 2 160 13—16 M 177 146 85 410 78 70 15 163 1 1 — 2 9 8 66 84 1 - - 1 - 1 - 1 31 42 7 80 84 56 2 142 F 160 151 162 485 97 75 16 189 2 1 2 5 5 - 53 59 1 — 1 2 -- - 1 1 24 48 8 81 87 60 2 150 17—20 M 141 183 58 386 131 162 11 304 3 1 2 6 2 9 34 45 - 1 1 - - 2 2 31 68 16 115 97 69 1 167 F 105 162 109 381 109 113 11 234 7 — 4 4 4 34 42 — — 1 1 — 3 1 4 75 65 11 89 96 76 2 174 21—24 M 129 113 54 299 298 243 6 551 6 2 1 9 4 4 31 39 1 - - 1 - - 22 54 5 82 92 91 1 184 F 122 102 94 324 328 263 79 611 3 — — 3 2 7 22 25 - — 1 1 — 1 1 2 20 70 2 92 78 91 5 174 25—28 M 105 143 65 315 350 274 6 632 2 — 1 3 5 25 31 2 2 2 2 1 5 27 57 4 88 132 140 1 277 F 96 150 135 383 319 307 77 638 2 7 7 4 — 7 27 22 1 1 2 4 - 2 1 3 21 67 4 87 128 137 3 269 29—32 M 66 64 34 165 299 240 3 545 2 — — 2 6 3 28 37 3 1 2 6 3 1 - 4 10 35 3 48 179 142 2 323 F 52 65 67 187 334 233 72 583 7 7 7 3 1 2 13 16 2 2 4 - 3 1 4 76 54 4 54 202 153 5 361 33—36 M 29 17 27 73 263 78 2 343 1 1 — 2 2 2 16 20 1 - 2 3 - 3 1 4 15 11 3 29 207 132 2 341 F 42 26 35 104 257 93 8 359 2 — 7 3 2 1 8 11 5 1 2 8 1 7 3 5 14 20 4 38 232 161 10 405 37—40 M 32 26 14 74 134 72 2 209 3 1 1 5 2 1 26 29 4 4 3 11 3 5 1 9 19 41 2 62 188 72 1 261 F 26 13 37 78 127 77 4 210 2 2 7 5 1 5 76 22 4 5 2 11 3 6 2 11 25 57 1 63 166 77 6 246 41—44 M 27 24 32 85 224 137 1 363 1 3 1 5 2 4 30 36 10 8 2 20 5 5 - 10 32 69 2 104 105 61 - 166 F 31 41 42 116 226 122 4 353 7 — 7 2 2 3 24 29 9 6 6 21 1 6 7 27 74 5 106 114 66 3 184 45—48 M 45 37 13 97 333 185 3 521 3 1 4 2 4 33 40 8 6 9 23 1 10 2 13 31 83 1 116 100 73 1 174 F 36 40 41 119 312 199 7 519 — 7 3 5 6 33 44 4 5 7 16 2 6 2 10 35 68 1 104 106 88 3 198 49—52 M 40 41 24 107 489 352 4 849 1 — 1 2 14 12 59 85 3 4 3 10 1 8 3 12 38 60 3 101 109 65 1 175 F 34 35 30 100 422 332 14 769 2 — 7 4 74 9 63 86 5 7 - 5 3 2 2 7 30 79 5 114 110 67 3 180 Total (52 weeks) M 1,140 1,169 554 2,892 2,722 1,933 62 4,732 35 10 9 54 116 88 654 864 38 26 25 89 16 41 11 68 354 669 64 1,090 1,523 1,040 13 2,582 F 1,025 1,114 1,009 3,195 2,687 1,916 121 4,739 23 8 16 48 90 72 599 761 32 23 26 80 10 33 17 60 304 724 56 1,088 7,559 1,170 49 2,790 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 figures will not necessarily agree with the total notifications given in Table 9 which relates to the calendar year 1956 and which includes bulk notifications from hospitals not notified individually. Table 11—Statistics of the administrative work carried out by the Metropolitan Borough Councils in 1956. Borough DWELLINGS CLEARANCE DWELLING HOUSES SMOKE NUISANCES CLEANSING AND DISINFECTION LICENSED OR REGISTERED PREMISES Restaurants, eating houses and canteens SANITARY OFFICERS Erected by the Borough Council Erected by other persons Total number in the Borough AREAS 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 year Unfit Houses Other Houses On complaint On notification of illness House-to-house Other reasons Section 11 Section 12 At home At a cleansing station Licensed slaughterhouses Other offensive trades Dairies and milk shops Ice cream premises Common Lodging Houses Public Health (London) Act Housing Act Housing Repairs and Rent Act, 1954 Demolished Closed by undertaking Rooms closed Undertakings accepted Demolished Persons displaced Demolished Persons displaced Underground rooms Other rooms U nderground rooms Other rooms Closing Orders made By owners By local authority By owners By local authority Section 11 Section 12 Number Persons displaced Number Persons displaced Made fit for occupation by number of families accommodated Overcrowding abated Number Persons displaced | Number Persons displaced Number Persons displaced Number Persons displaced Number Persons displaced Male Female Total Male Female Total Male le Total Division 1 Chelsea 8 58 15,929 - - - - 689 969 64 - 189 205 - 104 - - - 6 4 2 - 9 - 18 - - - - - 57 36 46 - - - 107 410 113 255 - - 52 118 - 198 7 2 9 6 2 8 - - - Fulham 111 52 30,553 23 32 - - 2,718 109 1 ,140 668 492 2,502 16 - - 1 1 - - 2 — - - 6 3 — 3 8 3 9 698 - — — 41 8 63 306 132 226 - 144 15 1 16 14 1 15 3 - 3 Hammersmith 43 90 28,447 - - - - 3 049 313 - 857 1,058 652 55 - - 3 3 - - 3 6 1 4 - - - - 1 16 88 2 — 1 139 639 11 109 2 — 101 312 - 270 14 1 1 5 10 1 11 2 - 2 Kensington 76 132 39,224 14 40 — — 3,166 2,485 203 2,040 1,031 614 4 — — 1 — 7 14 1 4 86 29 5 2 13 — — — 5 22 4 12 70 1 1 — 14 1,115 456 895 — — 198 374 — 263 19 - 19 15 - 15 - — - Division 2 Hampstead 156 197 22,104 - - - - 2 199 409 109 121 464 103 - - - _ _ 1 6 - 7 2 5 3 2 5 12 21 419 — — — 30 46 168 119 49 253 - 85 12 1 13 10 1 11 3 - - Paddington 106 118 31 ,444 4 - - - 4 ,207 885 367 718 1,090 349 - 25 3 5 — — — 269 — 13 — — — — — 4 24 9 8 — — — — 152 34 162 770 — — 128 199 1 136 17 1 18 14 1 15 - - - St. Marylebone 42 71 23 ,942 - - - - 985 567 128 106 285 183 2 - - - - - - - - 36 29 1 - - - - - - 11 39 119 24 — 958 311 88 366 1 — 78 229 2 784 11 3 14 9 3 12 1 - 1 St. Pancras 301 21 29 368 - - - - 4 ,919 326 231 2,489 1,803 1,694 9 - — — — 4 — 4 — 137 — — — 7 — — — 2 — 46 44 105 — — - 039 467 495 439 — — 230 525 - 650 21 1 22 21 1 22 - - - Westminster, City of 235 212 27,000 7 69 —- — 897 187 61 4,213 219 9 - - - - - - - - - 42 40 54 89 1 — — — 2 14 2 87 2,634 23 23 - 411 93 136 724 — — 119 243 2 3,077 20 1 21 19 1 20 — — — Division 3 Finsbury 104 163 9 ,732 19 83 - - 1,681 - 46 383 731 189 3 - - - 2 5 28 — — — — 6 — 3 10 211 9 — — >19 851 246 454 — 2 125 138 1 435 9 - 9 9 - 9 1 - 1 Holborn - 20 6,148 - - - - 138 86 2 229 151 19 - - - - - — — 2 — — — — — — — — 3 41 422 1 — — 17 1 49 75 — 5 70 116 2 507 5 5 5 - 5 - - - Islington 295 317 44,144 5 231 — — 7,675 + 17,619 - 2,600 1,886 87 2 1 1 2 11 — 3 3 158 128 25 16 15 — 4 7 16 47 64 36 335 9 1 46 I31 289 355 725 1 12 296 526 — 617 31 3 34 21 4 25 — — - Division 4 Hackney 328 166 40 455 15 64 - - 5, 768 92 52 180 279 2,345 29 1 - _ - 5 27 - 33 19 3 — 4 13 44 1,957 12 4 144 — 264 770 191 1 230 393 1 209 24 - 24 17 - 17 4 - 4 Shoreditch 229 - 11,984 - - - - 2, 394 447 304 3,994 1,671 296 - - - - — — 23 3 1 2 — 59 — 2 7 6 7 394 16 1 — 4 — 74 501 — 1 87 104 209 9 - 9 6 - 6 4 - 4 Stoke Newington 225 41 11,492 - — —- — 1,437 159 - - 240 207 8 — — — — — — — — 5 8 4 — — — — — — — — 9 — 1 1 — 18 116 73 74 — — 48 104 — 43 7 — 7 7 —- 7 1 — 1 Division 5 Bethnal Green - 1 15,478 7 6 - - 2,630 307 42 1,126 1 281 706 28 - - - 4 - - - - - - - - _ _ _ 8 5 - 21 1 1 - 13 24 5 20 515 1 3 116 162 - 155 9 - 9 7 - 7 | - - - City of London - - 1,110 - - - - 11 4 17 2 5 1 - - - - - - - - - - - - - - - - - - 15 + 5 - 25 463 188 5 12 — 29 69 1 — 957 20 20 20 - 20 - - - Poplar 262 96 18 ,145 - - - - 2, 036 60 163 174 1,099 600 - - - — — 4 11 1 2 8 5 — — — — — — 11 44 - 12 24 — — — 46 17 266 763 — 1 139 183 2 282 9 — 9 9 - 9 - - - Stepney 127 202 25,475 11 24 — — 3,058 176 21 1,265 2,019 534 4 — — — — 1 5 — — 67 4 2 2 — — — — 1 4 - 49 66 — — 62 493 33 80 643 — 21 235 294 5 905 18 — 18 14 — 14 2 — 2 Division 6 Deptford 120 175 17,610 - - - - 1,665 704 - 2,190 676 403 - - - - - - - - - - - - - - - - 1 4 - 1 2 — — — 123 929 89 370 2 1 94 192 1 141 8 8 8 _ 8 - - - Greenwich 177 134 23,895 1,955 563 1 603 956 147 - - - - - - - - - - - - - - - - - - - 22 + 3 - 69 209 501 304 380 — — 110 186 - 221 9 1 10 7 1 8 1 — 1 Woolwich 238 256 42,517 42 74 — — 1,972 988 2,114 533 909 494 — 2 1 — — 13 52 — — 1 13 — — — — — — 9 26 - 28 71 3 - 22 106 809 197 78 — — 134 312 1 296 18 1 19 16 1 17 — — — Division 7 Camberwell 325 500 43 ,500 18 83 - - 4 283 663 - 1,973 327 2,507 9 25 10 - - 24 5 1 - 11 4 41 21 3 _ 4 12 14 - 41 319 98 468 324 581 2 5 223 493 1 335 19 - 19 18 + 18 2 - 2 Lewisham 154 97 63,000 68 239 — — 2,994 89 254 2,398 485 374 43 3 1 — — 3 19 — — — — 9 27 — — — — 6 4 — 6 — — — - 56 291 363 48 1 — 111 362 — 250 21 — 21 17 — 17 3 — 3 Division 8 Bermondsey 219 34 15 ,014 93 469 2 4 2,525 592 - 3,278 778 545 3 - - - - _ _ - 22 - 8 25 74 6 1 — 10 161 12 265 - 8 138 204 2 284 12 - 12 10 - 10 - - - Lambeth 674 671 54,666 14 54 - - 3,306 396 64 2 ,571 1,883 1,410 182 1 - - - 5 4 37 116 43 67 4 5 — 5 13 2 32 17 4 1 — 19 50 767 787 - 2 263 527 240 17 2 19 15 2 17 - - - Southwark 149 159 24,677 38 128 — 3,708 1,219 582 2,059 1,019 897 173 - — — — 13 56 — — 147 2 12 — — — — — 2 8 — 14 242 11 — - 9 1,612 235 976 — 4 154 260 6 420 19 1 20 16 1 17 6 — 6 Division 9 Battersea 146 58 29 ,770 3 118 - - 3, 071 901 - 1,882 653 687 19 2 - 1 - - - - - 5 - - - - - - 6 17 _ 21 295 3 - 862 1,517 720 140 1 2 142 242 - 211 14 2 16 13 2 15 - - - Wandsworth 397 693 112,915 59 90 6 4 7,529 2,607 - 7,105 1,640 585 21 - - - - - - - - 12 - - - - - 1 2 — 43 375 11 1 — 3 12 403 175 — — 233 710 — 494 23 — 23 18 — 18 2 — 2 LONDON 5,247 4,734 859,638 440 1804 8 8 82,665 16,303 23,584 43,157 26,033 21,143 695 165 16 7 10 104 208 12 9 1123 417 264 235 48 5 67 7 116 306 223 724 8,984 145 34 357 001 11,237 7,044 11,736 11 97 4,104 7,988 27 12,818 437 21 458 371 22 393 35 — 35 t included in previous column. Notes : (1) Local Government (Miscellaneous Provisions) Act, 1953 : Two Closing Orders were determined in Islington and Woolwich and one in Kensington, Hackney, Bethnal Green, Camberwell and Lewisham. (3) Licensed Cowsheds : Camberwell—1. (4) Seamen's Lodging Houses : Poplar—1, Stepney—5 (2) Housing Act, 1949 : A DemolM Order was determined and Closing Order substituted under Section 3 (2) in Islington. (5) Prosecutions : Inadequate Water Supe^o Tbnement Houses : St. Pancras—15 (12 convictions). Rbstaurants, Eating Houses and Canteens : Kensington—1 (1 conviction), St. Marylebone—\ (1 conviction), Hackney—5 (5 convictions), City of London—2 (2 convictions) and Lewisham—1 (1 conviction). Dairies andIEkshops : St. Pancras—1 (1 conviction), Hackney 2 (2 convictions). 238 239 240 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 1956 691 493 72 4 7,468 1,718 8,231 2,215 19,802 7,468 222,695 101,034 Table 13—Weather during 1956 (as recorded at Kew Observatory) Temperature Rainfall Sunshine Difference from Difference from Difference from Month Mean (a) Average (b) Total Average (b) Total Average (c) °F °F ins. ins. hrs. his. January 40.3 +0.6 3.69 + 1.73 50 + 8 February 32.2 .81 0.23 — 1.32 64 + 5 March 44.3 + 1.5 0.76 —0.78 143 +37 April 45.4 —2.1 0.94 -0.77 146 — 4 May 56.0 —2.4 0.23 -1.52 257 +59 June 57.5 — 1.9 1.85 —0.13 146 —55 July 62.1 -0.6 5.92 +3.54 173 -23 August 58.3 -3.5 3.68 + 1.44 164 —21 September. . 59.5 +2.1 2.01 +0.02 111 -30 October .. 50.4 +0.1 2.11 -0.40 112 + 18 November 44.1 —0.1 0.39 -1.95 58 + 6 December 44.4 +3.7 2.56 +0.40 9 —29 Year 49.5 —0.5 24.37 +0.26 1,433 -29 (a) Average of the daily means of 24 hourly readings. (b) Average over the 50 years ended 1950. (c) Average over the 70 years ended 1950. APPENDIX E STAFF OF THE PUBLIC HEALTH DEPARTMENT Medical Officer of Health and Principal School Medical Officer J. A. Scott Deputy Medical Officer of Health and Deputy Principal School Medical Officer A. B. Stewart Senior Principal Medical Officer M. MacGregor Administrative Officer C. R. Geere Principal Medical Officers Maternity and child welfare Dorothy F. Egan School health G. D. Pirrie Epidemiology I. Taylor Tuberculosis W. Hartston Staff examinations and mental health C. W. J. Ingham Chief Dental Officer 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 Servicc 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 Division Divisional Medical Officer Divisional Administrative Officer Divisional Nursing Officer 1. Bertha E. A. Sharpe G. J. Newton Mary Sidebotham 2. H. L. Oldershaw H. J. Norton Eveline Beattie 3. W. G. Harding N. B. Chapman Catherine Walsh (seconded to World Health Organisation.) Margery D. Butler (from 15/3/56.) 4. S. King J. C. Minter Ellen M. Hazell 5. G. O. Mitchell A. J. Cridland Katherine M. Roe 6. F. R. Waldron D. E. Armstrong Lilian Berry 7. H. D. Chalke F. L. Clark Kathleen L. Sewell 241 t Senior Officers of the Divisions—continued Division Divisional Medical Officer Divisional Administrative Officer Divisional Nursing Officer . 8. W. H. S. Wallace W. H. C. Bishop Bessie Thom 9. J. T. R. Lewis R. E. Haymes Winifred M. Winch The following statement shows the number of staff employed in the Public Health Department in December, 1956 (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) 217 604 78 899 Medical staff 27 153 — 180 Dental staff 2 78 — 80 Scientific staff 23 — 10 33 Inspectors 16 — — 16 Nursing staff 12 2,061 94 2,167 Medical auxiliaries (c) 15 157 22 194 Social worker grades (including mental health) 34 170 121 325 Supervisory staff (ambulance service) 3 — 16 19 Manual workers, operative staff lance service), domestic grades, etc. 15 2,768 866 3,649 Totals 364 5,991 1,207 7,562 (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 88 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. 242 INDEX Page Accidents in the home 86, 212 Adoption of children 62 Air pollution 48, 78, 186 Ambulance service 77, 215 Analgesia 65 Annual moral welfare conference 63 Ante natal sessions 57 Anthrax .. 21 Analysis of samples 44 Appendices: A, 150; B, 186; C, 212; D, 229; E, 241 Audiometry 106 Bathing centres 103, 104 Births 8, 230 Blind persons 40 Bronchitis 16 Building materials examinations 44, 47 Building programme 52 Cancer 15, 87 Care of mothers and young children 57 Cerebral haemorrhage 16 Cerebral palsy 113 Child guidance 119 Child helps 72 Child life protection 63 Child-minders 62 Child welfare 59 Chronic sick 43 Civil defence 81 Dangerous structures 39 Day nurseries 54, 60 Deaths 11 Degenerative diseases 16 Dental services 123 Detergents 44, 47 Diabetes 16,107,114 Diarrhoea and enteritis 21 Digestive diseases 16 Diphtheria 22, 75 Disinfestation 40 District training of pupil midwives . . 66 Divisional medical officers' reports : Div 1, 131; 2, 133; 3, 135; 4, 138; 5, 140; 6, 142; 7, 144; 8, 146; 9, 147 Domestic help service 72 Domestic help service review 73 Domiciliary midwifery service 65 Dysentery 22 Educationally sub-normal children 112 Employment of children 104, 105 Enteric fever 22 Enuresis 107 Epileptic children 107 Erysipelas 23 Expectant and nursing mothers 57 Page Family planning 58 Family service units 157 Fertilisers and feeding stuffs 44, 50 Fertility 8 Finance129 Food poisoning 23,128 Foot defects 50, 85 General practitioners 5, 38, 64, 66, 68, 74, 155, 221 Guardianship of mental defectives 94 Handicapped persons 43 Handicapped children 112 Health centre 138 Health education86,219 Health visiting 68, 155, 216 Heart disease 11 Home nursing 69 „ „ equipment 70 Home safety 85,212 Homeless families units 42,158 Hospital car service 77 Hospital services 5, 38, 58, 89, 94, 107, 109, 110, 113, 115, 125, 134, 135, 143 Hostel for mentally defective girls 55, 95 Housing 38, 47 Hygiene inspection of school pupils 103 Illegitimacy 9, 63 Immunisation 75 Improvement grants 39 Industrial training centre 97 Infant mortality . . 17, 234, 235 Infectious diseases .. 21,111,236,237 Infectious diseases in schools 25 Intra gastric oxygen resuscitation 66 Insecticides 45 Influenza 23 Introduction 4 Leptospirosis 23 Live births 8, 230 Lunacy and Mental Treatment Acts 88 Maladjusted children 120 Marriages 9 Marriage guidance 60 Mass miniature radiography 34, 36 Maternal mortality 19,235 Maternity and child welfare centres 54, 57 Meals for children 45, 50, 101 Meals for invalids 43 Measles 23 Medical inspection of school children 98, 99, 104 Medical treatment of school children 107, 109 Meningococcal infections 23 Mental deficiency 92 243 INDEX—continued Page Mental health services88 Metropolitan borough councils 238 Midwifery service 64 Milk sampling39 Mortality 10,233 Mothercraft156 Neo-natal mortality 17, 66 Nephritis16 Night helps 72 Nurseries, day 54, 60 Nurseries, residential 62 Nursery schools and classes 105 Nursing home registration 42 Nutrition 102, 108 Occasional creches 61 Occupation centres55, 96 Ophthalmia neonatorum 24 Orthodontics 125 Perinatal mortality 19, 66 Pneumonia 16, 24 Poliomyelitis 24, 76, 116 Population8,229 Postural defects in school children118 Premature babies 65 Premises 53, 80 Prevention of illness 85 Problem families 67, 108, 150 Problem family survey 159 Public Health laboratory 39 Psychiatry 119, 155, 157 Puerperal pyrexia 20 Recuperative holidays 27, 85, 92, 150 Rehabilitation courses 155, 158 Remedial exercises 118 Residential establishments 62 Residential schools 122, 125 Rheumatic fever25 Rheumatism scheme 108, 116 River pollution 45 Road accidents17 Safety in sewers 47 Sanitary inspection 40 Page Scabies 25,104 Scarlet fever 25 School children under five years 105 School dental service 123 School health service 56, 98 School journeys 107 School meals 40, 50, 101 School treatment centres 109 Scientific branch 44 Sewage treatment 46 Sewers 47 Slum clearance 38 Smallpox 25, 76 Social case workers 167 Special home helps 73,155 Special investigations 107 Speech therapy 97,114 Staff 7, 81, 127, 241 Statistical tables 3,29-37,84,89,92,110- 123-5, 229-240 Stillbirths 10, 65, 230 Sunday cinema grants 60,157 Swimming baths. 45, 50 Trade waste discharges 47 Training pupil midwives 65 Training student health visitors 127 Tuberculosis 25, 26 Tuberculous milk 39 Unmarried mothers 9, 63 Vaccination 76 Venereal diseases 86,240 Very young deaf children 106 Violence 16 Vision tests 101 Visitors 79, 96, 130 Vital statistics 3, 8, 229-235 Voluntary organisations 58, 63, 69, 77, 85, 91, 94, 95, 97, 107, 133, 136, 140, 141, 143, 144, 148, 157, 218 Water sampling 45,49 Weather during 1956 20, 240 Welfare Committee establishments 40, 42 Welfare foods 60 Whooping cough25, 75 244