LONDON COUNTY COUNCIL Lcc 66 Report of the County Medical Officer of Health and Principal School Medical Officer for the Year 1960 By J. A. SCOTT, o.b.e., m.d., f.r.c.p. county medical officer of health and principal school medical officer PUBLIC HEALTH LIBRARY. LONDON COUNTY COUNCIL. THE COUNTY HALL WESTMINSTER BRIDGE, S.E.I CONTENTS London Administrative County—Vital Statistics (Summary) page 3 Vital Statistics 4 Infectious Diseases 20 Tuberculosis 29 General Public Health 39 Scientific Branch 43 Health Service Premises 55 Care of Mothers and Young Children 58 Domiciliary Midwifery 65 Health Visiting 67 Home Nursing 68 Home Help 70 Immunisation and Vaccination 71 London Ambulance Service 74 Prevention of Illness: Care and After.Care 78 Mental Health Services 88 School Health Service 93 Dental Services 114 Staff 118 Finance 120 Visitors to the Department 121 Reports by the Divisional Medical Officers 122 Appendices: (a) The Domiciliary Midwifery Service and the Cranbrook Report 139 (b) The School Dental Service—A National Perspective 151 (c) Statistics of work carried out by the Metropolitan Boroughs 159 (d) Staff of the Public Health Department 160 Index 161 LONDON ADMINISTRATIVE COUNTY VITAL STATISTICS, 1960 Figures in brackets are for 1959 Population: Area comparability factors: Males 1.494,000 3,194,000(3,204,000) Births 0.90(0.90) Females 1,700,000 Deaths 0.98 (0.98) Number of marriages registered: 32,677 (32,356) Live births: Legitimate 50,838 (49,426) „ ,, Illegitimate live births Illegitimate .. 6,530 (5,765) 57,368 (55191) per cent, of total live births: 11 .4 (10.4) Live birth rate per 1,000 population: 18.0 (17.2) (adjusted rate 16.2 (15.5)) Stillbirths: Legitimate 911 (918)1,052 (1,085) Illegitimate 141 (167) Stillbirth rate per 1,000 live and stillbirths 18.0 (19.3) Total live and stillbirths: 58,420 (56,276) Deaths: Males 18,534 (19,471) Females 17,987 (18,756) 36,521 (38,227) Death rate per 1,000 population: 11.4 (11.9) (adjusted rate 11.2 (11.7) ) Deaths of infants: Legitimate Illegitimate Total Under 1 month 761 (750) 125 (116) 886 (866) 1 month to 1 year 307 (337) 39 (35) 346 (372) Total under 1 year 1,068 (1,087) 164 (151) 1,232 (1,238) Infant mortality rate (per 1,000 live births) 21.01 (22.00) 25.11 (26.19) 21.48 (22.43) Neo.natal mortality rate „ „ „ „ 14.97 (13.59) 19.14 (21.02) 15.44 (15.69) Early neo.natal mortality rate: „ „ „ „ 13.04 (13.21) 16.39 (17.52) 13.42 (13.66) Peri.natal mortality rate (per 1,000 total births) 30.42 (31.21) 37.18 (45.18) 31.19 (32.68) Maternal mortality: Rate per 1,000 Post. Other pregnancy live and abortion and childbirth Total stillbirths Deaths from sepsis 9 (8) — (—) 9 (8) Deaths from other causes 2 (4) 15 (22) 17 (26) Total 11 (12) 15 (22) 26(34) 0.45 (0.60) 3 VITAL STATISTICS* Population Table (i)—Home population (a), 1951.60 (Figures in thousands) Year Mid.year 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+ 1951 3,358 274 381 419 1,101 812 371 36.5 1952 3,363 256 400 416 1,091 822 378 36.7 1953 3,343 244 413 410 1,072 826 378 36.7 1954 3,322 234 425 394 1,056 827 386 36.9 1955 3,295 230 421 391 1,037 829 387 37.1 1956 3,273 229 427 384 1,018 829 386 37.1 1957 3,254 230 425 383 974 843 399 37.4 1958 3,225 231 418 387 949 843 397 37.5 1959 3,204 236 409 394 925 842 398 37.5 1960 M 1,494 124 205 185 447 390 143 35.7 F 1,700 117 198 213 458 456 258 39.2 3,194 241 403 398 905 846 401 37.6 (a) Resident civilian population, plus any British, Commonwealth or Foreign Armed Forces stationed in the area. There was a net loss of 10,000 in the population from the previous year's figure; the major fall was again in the 25.44 years age group. There was also a drop in the 5.14 age group, but all the others shared increases, particularly in the under fives (the last is a consequence of the increased birth rate of recent years). Fertility Table (ii)—Live births and stillbirths—1951.60 Live births Stillbirths Year No. Rate per 1,000 population No. Rate per 1,000 total births (live and still) 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 49,826 151 1,034 20.3 1956 52,171 15.9 1,070 201 1957 52,733 16.2 1,083 20.1 1958 54,152 16.8 1,102 19.9 1959 55,191 17.2 1,085 19.3 1960 57,368 180 1,052 180 * 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. 4 Live births—There were 65,617 live births registered in London in the year; after correction for residence the final figure of births allocated to London was 57,368, an increase of 2,177 over 1959, giving a birth rate of 18.0 per 1,000 population compared with 17.2 in 1959 and 16.8 in 1958. The post.war trend in London followed closely that for England and Wales until 1956 when the rise in the London rate preceded a similar rise in the country as a whole; in 1957 the two rates were again almost identical, but since then the crude London rate has continued to exceed the national rate: the major factor contributing to the increased birth rate, both local and national, appears at present to be the increased proportion of women of child.bearing age who are married. 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 area comparability factor for London births (0.90) the rate becomes 16.2. The crude birth rate for the past 10 years is shown in Figure 1 below, together with the national rate and the adjusted birth rate. 1952 1954 1956 1950 I960 5 Illegitimacy— Table (iii)—Illegitimate live births in London (A.C.) and percentages for London and England and Wales, 1951.60 Year Illegitimate live births Illegitimate live births as a percentage of total live births London A.C. England and Wales 1951 3,597 6.9 4.7 1952 3,607 70 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 1957 4,686 8.9 4.8 1958 5,343 9.9 4.9 1959 5,765 10.4 5.1 1960 6,530 11.4 5.4 The percentage of illegitimate births in London has shown a marked upward movement over the last five years whilst nationally there has been a relatively slight increase. Boroughs with particularly high percentages were Paddington (21.9), Kensington (16.8), Lambeth (15.1), Chelsea (14.1) and St. Pancras (14.0). The only other large town in England and Wales with an illegitimacy rate approaching that of London is Manchester, where there has been a rise from 6.6 in 1951 to 9.3 per cent, in 1959. A complex of factors probably accounts for the phenomenal rise in London—proportionately more single women, a continuous influx of unmarried women, many of whom are already pregnant, and the facilities which London can offer to an unmarried mother in the way of anonymity, ante.natal care and support from moral welfare organisations. Information as to the extent of some of these factors will only become reliably known when the results of the 1961 census are available. The table below gives details of women seen by the moral welfare organisations in the twelve months ended September, 1960, from which it will be seen that 864 (26.2 per cent.) were pregnant on arrival in London and that in all 1,426 (43.3 per cent.) were not British. It should be remembered that these components of the illegitimate births are minima—the moral welfare organisations do not deal with all unmarried mothers, though doubtless they will tend to deal with proportionately more of the non.Londoners. Table (iv)—Unmarried mothers seen by moral welfare associations in London, 1st October, 1959.30th September, 1960. (Figures in brackets are for 1959) British (U.K.) Eire European West Indian Other Total Non.Londoners pregnant on arrival in London *Non.Londoners not 424 (383) 272 (183) 50 (39) 85 (64) 33 (19) 864 (688) pregnant on arrival in London Resident in London 71 (93) 87 (96) 8 (17) 33 (20) 3 (6) 202 (232) one year or more 1,371 (1,270) 454 (455) 76 (85) 267 (236) 58 (39) 2,226 (2,085) 1,866 (1,746) 813 (734) 134 (141) 385 (320) 94 (64) 3,292 (3,005) * Had lived in London less than 12 months before making contact with moral welfare association. 6 Mortality The total death rate at 11.4 per 1,000 population was lower than the previous year (11.8) but about the average of the last decade. Leading causes of death—The leading causes of death in London in 1960 were as follows Deaths Rate per 1,000 population Diseases of the heart 11,205 3.51 Cancer 8,079 2.53 Bronchitis, pneumonia* 4,277 1.34 Vascular lesions of the central nervous system 4,085 1.28 Other circulatory 1,833 0.57 Violent causes 1,580 0.49 Digestive diseases 1,199 0.38 Diseases of early infancy (international classification Nos. 760.776) 709 0.27 Congenital malformations, 0.4 weeks 144 Tuberculosis (all forms) 269 008 All other causes 3,141 0.98 Total 36,521 11.43 * Excluding pneumonia of the new born (under 4 weeks) which is included in ' Diseases of early infancy The ranking order of the leading causes of death remains unchanged from 1959. Heart disease was discussed in detail in my report for 1956 and cancer in 1958; a discussion of bronchitis and pneumonia is given in later pages of this report. Cancer—The cancer death.rate for all ages was 2.53 per 1,000 in 1960—an increase over the previous year and a continuation of the upward trend which was only slightly interrupted in 1959. Cancer is, however, largely a disease of the later half of life and in order to eliminate variations caused by a changing age/sex composition of the population, rates for specific age/sex groups are shown below: Table (v)—Cancer mortality rates per 1,000 living, 1951.60 Age and Sex 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 Males: 0.24 009 0.12 0.14 0.12 0.11 0.14 0.11 0.09 0.10 0.12 25.44 0.45 0.45 0.46 0.41 0.40 0.43 0.37 0.42 0.40 0.38 45.64 4.28 4 19 4.28 4.31 4.50 4.51 4.55 4.52 4.46 4.75 65+ .. 15.64 15*50 15.69 15.29 15.73 15.77 15.29 16.01 15.20 15.74 All Males 2.60 2 61 2.68 2.64 2.73 2.76 2.77 2.85 2.76 2.90 Females: 0.24 008 0.07 0.07 006 0.07 0.09 0.07 0.10 0.07 0.07 25.44 0.46 0.47 0.51 0.43 0.45 0.50 0.47 0.52 0.51 0.52 45.64 2.80 2.85 2.85 2.85 2.93 2.77 2.97 2.71 2.63 2.82 65+ 8.79 8.77 8.73 8.39 8.43 8.75 8.34 8.50 818 8.44 All Females 1.99 2.02 2.04 2.02 2.08 2.12 2.16 2.15 2.09 2.20 All Persons 2.27 2.30 2.34 2.31 2.39 2.42 2.44 2.47 2.40 2.53 7 Lung cancer—The lung has become the principal site for cancer in males and the table below shows, for three age groups, the steep rise that has occurred in the last decade together with, for comparison, the corresponding figures for females. Table (vi)—Deaths and death rates from cancer of the lung by age and sex, 1951.60 (Rates per 1,000 population) Year Age 25.44 45.64 65+ No. Rate No. Rate No. Rate Males: 1951 63 0.12 696 1.90 523 3.68 1952 73 0.14 673 181 580 4.03 1953 81 0.15 734 1.96 614 4.26 1954 64 0.12 773 2.06 625 4.34 1955 62 0.12 810 2.14 651 4.55 1956 65 0.13 853 2.25 718 5.06 1957 37 0.08 891 2.31 723 4.95 1958 52 0.11 883 2.29 786 5.46 1959 61 0.13 907 2.34 788 5.51 1960 55 0.12 958 2.46 857 5.99 Females: 1951 . 17 0.03 91 0.20 144 0.63 1952 19 0.03 127 0.28 137 0.59 1953 18 0.03 119 0.26 139 0.59 1954 19 0.04 137 0.30 164 0.68 1955 13 0.02 151 0.33 174 0.71 1956 13 0.03 109 0.24 154 0.63 1957 19 0.04 142 0.31 176 0.70 1958 22 0.05 124 0.27 183 0.72 1959 22 0.05 134 0.29 157 0.62 1960 26 0.06 157 0.34 190 0.74 8 Bronchitis and pneumonia The mortality from these two diseases for males and for females (all ages) for the last ten years is shown separately in the graphs on page 10. From the graphs three things are apparent—first that male mortality exceeds female for both diseases; secondly that in general the pattern of fluctuations in mortality over the decade is common to both sexes; and thirdly the major difference between the mortality of the sexes and the major contributor to this mortality group is the high male death rate from bronchitis. Bronchitis will, therefore, be dealt with in somewhat greater detail in later paragraphs. Mortality is, however, only the terminal event and bears no general relationship to the incidence or prevalence of pneumonia and bronchitis. Sufferers from pneumonia will either recover or die in a comparatively short space of time; persons suffering from bronchitis on the other hand will rarely be completely cured and may have the disease for many years with varying degrees of ill health. Pneumonia—As far as pneumonia is concerned the fairly consistent slight male excess in the death rate is due largely to a greater sex differential in middle age (45.64) as is common also in heart disease. Table (vii) shows the average annual number of deaths and death rates over the decade reviewed. In total the number of deaths is slightly greater for females but this is offset by their greater numbers particularly for 65 onwards—between ages 45 and 64 the male rate is more than double that of the female. Table (vii)—Pneumonia—Average annual number of deaths and death rates per 1,000 population by age and sex 1951.60 Age (years) O.4 5.44 45.64 65 and over No. Rate No. Rate No. Rate No. Rate Males 92* 0.74 28 003 191 0.51 743 4.88 Females 75* 0.64 24 003 97 0.22 884 3.61 * Excluding pneumonia of the new born (under 4 weeks). Bronchitis—The male excess shown in the graph is not peculiar to London; there is a similar difference in the figures for England and Wales. Male death rates from bronchitis for both London and the country as a whole are double the corresponding rates for females. The following table shows the average annual number of deaths and average annual death rates from bronchitis for the decade, together with the male/female ratio for death rates: Table (viii)—Bronchitis—Average annual number of deaths and death rates per 1,000 population by age and sex, 1951.60 Age (years) 0.4 5.44 45.64 65 and over No. Rate No. Rate No. Rate No. Rate Males 31 0.26 24 003 551 1.46 1,375 9.58 Females 21 018 14 002 126 0.28 895 3.69 Ratio Male/Female rates 1.44 1.50 5.21 2.60 9 Figure 2 MORTALITY FROM BRONCHITIS AND PNEUMONIA. LONDON (A.C.)» 1951.1960 10 With bronchitis the sex differential is much more in evidence at all ages, though the rates below 45 years are based on small numbers of deaths and are not statistically significant. At ages 45.64 years the male rate is five times the female rate and at age 65 years and over it is two and a half times—both highly significant differences. This large sex differential appears to be a characteristic of this century; the following figures giving a more detailed age split show how it has developed: Table (ix)—Ratio of male female death rates from bronchitis, 1922.59, by age Age—years Year 45.54 55.64 65.74 75 and over 45 and over 1922 2.41 1.57 1.37 0.81 1.07 1931 3.50 2.50 1.26 1.06 1.17 1937 3.81 3.23 204 1.19 1.59 1947 5.58 4.29 2.51 1.43 2.12 1953 5.07 4.48 3.67 1.68 2.16 1959 4.83 6.00 4.27 2.76 2.78 These figures are matched by somewhat similar, though slightly lower, ratios for England and Wales. A partial explanation may lie in the factor of smoking habits, particularly cigarette smoking. The association between lung cancer and smoking has been clearly demonstrated in the last decade and more recently smoking has been under suspicion as an aggravating factor in bronchitis. Smoking received a tremendous impetus in the first world war and the consumption of tobacco again increased between 1938 and 1945. Although the figures above for the age group of 45 and over as a whole show that the sex differential is continuing to increase, a glance at the figures for individual age groups indicates that the differential is tending to shift towards the later ages; for the 45.54 age group there has in fact been a decline since 1947, whereas for the age group 55.64 there has been an increase of about one half, for 65.74 an increase of about seven.tenths and for 75 years and over the differential has doubled. This relative shift of the differential to later ages could equally well be associated with the extension of smoking among women—a practice which has followed that of men both as regards time and quantity. Other things being equal one might expect that the male/female ratio would, as time goes by, tend to decrease at later ages but as the bronchitis death rate for both sexes has been declining in recent years it is possible that this may affect the relativity. As indicated earlier, unlike pneumonia, bronchitis is a disease from which a person may have suffered for many years before death. This is evident from the morbidity statistics produced by the Ministry of Pensions and National Insurance, based on claims for sickness benefit. Certificates in support of such claims now cover practically the entire employed male population, but they are not so representative of the female population because only married women who follow a paid employment are eligible for national insurance and, of those that are, two.thirds of them ' opt out' of the scheme for sickness benefit. The latest Digest of statistics analysing certificates of incapacity ', relating to 1956.57, show that, for both sexes, bronchitis was one of the two most common causes of sickness absence (for which a claim was made) and was the reason for the highest number of days of absence. The other most important cause of absence was influenza, which fluctuated from year to year whilst bronchitis is more consistent. In terms of days, bronchitis was responsible for some 20 million days of sickness benefit or 11 per cent, of the total in Great Britain; the corresponding figures for females were some four million days, five per cent, of the total. Bronchitis and environmental factors in London—It is clear that bronchitis is important where both mortality and morbidity are concerned. As regards the latter it is not possible to compare London experience with national or regional figures but in relation to mortality 11 a valid comparison can be made by Standardised Mortality Ratios.* The Registrar General last calculated these for 1950.53 in relation to the census population of 1951. For the county the male figure for bronchitis was 153 and the female 140, in contradistinction to the figures for all causes of death of 106 and 97 respectively. There is not the same disproportion between these male and female ratios as there was between the rates of table (viii), because these ratios are relating the mortality of London males to all males in England and Wales; similarly with females. In other words, whereas mortality in general was not markedly different as between the county and the country, in the case of bronchitis London compares unfavourably. Although there is known to be an urbanisation gradient in mortality from bronchitis the striking difference between London and the national figures warrants further investigation. Accordingly table (x) sets out for the metropolitan boroughs the standardised mortality ratios for males and females, the percentage in social classes IV and V, the percentage of the population born in London and two indices of atmospheric pollution. Table (x)—Bronchitis. Standardised mortality ratio, social class, percentage born in London, and atmospheric pollution. Boroughs S.M.R. 1950.53 (England and Wales = 100) Percentage of social classes IVand V 1951 Percentage born in London 1951 Atmospheric pollution 1944.54 Solid deposit SO4 Male Female (a) (b) Chelsea 76 107 23 45 653 119 Fulham 160 159 27 64 1,028 188 Hammersmith 159 164 30 58 (c) (c) Kensington 118 86 23 39 504 109 Hampstead 84 85 15 37 (c) (c) Paddington 132 124 27 44 413 400 St. Marylebone 133 102 22 42 497 114 St. Pancras 150 138 32 58 516 (c) Westminster, City of 89 91 27 36 779 122 Finsbury 190 184 39 74 503 (c) Holborn 150 136 30 45 456 (c) Islington 170 178 31 70 521 (c) Hackney 167 158 26 75 425 98 Shoreditch 248 209 39 82 (c) (c) Stoke Newington 162 179 22 67 374 97 Bethnal Green 200 237 38 83 (c) (c) City of London 92 40 43 47 637 170 Poplar 205 174 44 80 982 210 Stepney 198 145 46 72 496 119 Deptford 181 164 35 75 (c) (c) Greenwich 124 144 32 69 1,300 240 Woolwich 110 106 25 59 593 138 Camberwell 193 182 30 75 378 373 Lewisham 134 110 22 66 432 104 Bermondsey 184 176 45 84 (c) (c) Lambeth 155 145 29 65 614 107 Southwark 236 188 42 76 2,658 188 Battersea 161 143 30 70 1,145 127 Wandsworth 135 126 21 60 (c) (c) London County 153 140 29 63 723 168 (a) Total deposited matter, grams per 100 square metres per month, winter months only. (b) Dissolved sulphate ion (SO4) per 100 square metres per month, winter months only. (c) No deposit gauge. * Standardised Mortality Ratios express the actual number of deaths at all ages in each geographical area as a percentage of the ' expected' number of deaths that would have occurred in the areas if the death rate in each age group had been the same as that of England and Wales. They are drawn from Table 1A of the Registrar General's Decennial Supplement—Area Mortality, 1951, H.M.S.O., 1958. 12 The pattern of male mortality for the metropolitan boroughs is also shown in Figure 3 on page 14. It will be seen that London is characterised by high ratios, except for a ' wedge ' of low ratios running from Hampstead, Paddington and Kensington in the north.west through St. Pancras, Chelsea, Westminster and the City of London to the river. (The ratio for the City of London, based on only 11 deaths in the four years, is not a very reliable measure and in this context and in what follows should be ignored.) On the south side of the river there are comparatively low ratios in the boroughs towards the periphery of the county—Wandsworth, Lewisham, Greenwich and Woolwich. The pattern of female mortality is similar. As regards the other items in the table, social class has been included because the Registrar General's census volume on Occupational Mortality* shows, in general, a steeply rising gradient of male mortality from bronchitis as social class descends from class I to class V. Strictly, the social class indicator relates only to the male population, since it is based on the census analysis of male occupations. Its use in relation to female mortality can probably be justified on the basis that wives and unmarried daughters, whether or not they are of the same social class as their husbands or fathers, will for the most part live in the same household and share the same social conditions. The percentage born in London is given as a very rough indication of duration of exposure to the London atmosphere and atmospheric pollution. The indices of atmospheric pollution which are taken from the twenty.seventh report of the Department of Scientific and Industrial Research are, as I have indicated before, somewhat unsatisfactory. To ensure as much homogeneity as possible readings from deposit gauge stations have been used—these relate to the ten years ended March, 1954, but only nine of the 51 stations operated over the whole ten years and 24 of them were in operation for one year only. However, the figures given in table (x) are the best available. The interaction of these various indices is perhaps best summarised by the calculation of the product.moment correlation coefficient (r) and these are given below for the standardised mortality ratios and the other indices listed (figures for the City of London have been excluded from the calculations). Correlation coefficients for standardised mortality ratios for bronchitis, London boroughs (excluding the City of London) and: For both males and females the two first are highly significant (P<.001). Such a highly significant relationship with percentage in social classes IV and V is to be expected because of the known social class gradient of mortality from bronchitis; the high correlation with percentage born in London conforms with the known increase in mortality from bronchitis with increase in the degree of urbanisation, though the index used here is only a crude measure of exposure to the atmosphere of various parts of London and takes no account of movement within the county for work, pleasure or residence. The poor correlation with the two indices of atmospheric pollution is not altogether surprising in view of the differing quantity and quality of the measurements, only the coefficient for males with solid deposit attains significance (P<.05). However, the percentage in social classes IV and V is also highly correlated with the percentage born in London (r = 0.702). It is therefore pertinent to enquire whether percentage born in London is a reflection of social class or whether duration of London residence has a separate effect—and, if the latter be true, which of the two factors is the more important. This can be done by a process of partial * Registrar General's Decennial Supplement (1951)—Occupational Mortality. Male Female Percentage in social classes IV and V Percentage born in London Solid deposit Sulphate ions (SO4) +0.780 +0.673 +0.825 +0.850 +0.380 +0.293 +0.213 +0.311 13 Figure 3 correlation which ascertains the degree of correlation between three variables when one of them is held statistically constant in all the boroughs. The results of this calculation are as shown below: Partial correlation coefficients between standardised mortality ratios for bronchitis and: Male Female Percentage in social classes IV and V when percentage born in London is held constant +0.469 +0.185 Percentage born in London when percentage in social classes IV and V is held constant +0.642 +0.682 For the first the coefficient for males is significant (P<.02) but the value for females (0.185) is not: with the second the coefficients are highly significant for both males and females (P<.001). This means that percentage born in London is more important than social class in relation to mortality from bronchitis—a conclusion which accords with the remark made in appendix B to my report for 1956 (page 209) dealing with atmospheric pollution that' There is little doubt that living in London for a long period increases the risk of dying from respiratory disease, particularly bronchitis B 15 Infant mortality Table (xi)—Infant mortality—1960 Cause of death Age at death Total Rates per 1,000 live births Under I day 1 to 7 days 1 to 4 wks. 4 wks. to 1 yr. No. Male Female Total Male Female Whooping cough Leg. — — . 3 3 2 1 0.05 0.07 0.04 Illeg. — — . Tuberculosis Leg. — — . 2 2 1 1 0.03 0.03 0.04 lleg. — — — Measles Leg — — — — — — — — — — Illeg. — — — Bronchitis and pneumonia Leg. 10 15 18 157 208 113 95 3.63 3.85 3.39 Illeg. — 1 7 Gastro.enteritis and diarrhoea Leg. — — 2 7 9 4 5 0. 16 0.14 018 Illeg. .. .. .. Congenital Leg. 34 50 46 104 248 121 127 4.32 4.12 4.54 malformation Illeg. 4 3 7 Injury at birth Leg. 75 49 6 — 146 95 51 2.55 3.23 1.82 Illeg. 14 2 — Post.natal asphyxia and atelectasis Leg. 111 61 .. 2 208 134 74 363 4.56 2.64 Illeg. 18 14 2 Haemolytic disease Leg. 21 8 — — 31 15 16 054 0.51 0.57 Illeg. 2 — —/ Immaturity Leg. 114 55 8 2 213 126 87 3.71 4.29 3.11 Illeg. 25 9 — Convulsions Leg. — — — — — — — — — — Illeg. — — —/ Accidental Leg. — — — 5 5 5 — 009 0.17 — mechanical Illeg. — — — suffocation Other causes Leg. 30 30 18 64 159 95 64 2.77 3.23 2.29 Illeg. 9 6 2 All causes Leg. M. 228 163 56 307 1,068 614 454 21 01 23.58 18.31 F. 167 105 42 Illeg. M. 44 24 9 39 164 97 67 25 11 29.05 21.00 F. 28 11 9 Total, 1960 467 303 116 346 1,232 711 521 21 48 24.20 18.61 Total, 1959 432 322 112 372 1,238 702 536 22 43 24.73 20.00 Leg. M. 202 179 49 337 1,087 620 467 22 00 24.34 19.49 F. 161 111 48 Illeg. M. 41 18 7 35 151 82 69 26.19 28.10 24.24 F. 28 14 8 The pattern of infant mortality remains much the same as in the previous year. The trend since 1951 is as follows: 16 Table (xii)—Infant mortality by cause—1951.60 (Rates per 1,000 live births) Cause of death 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 Whooping cough 0.17 0.08 0.27 0.06 0.06 0.04 0.02 — 0.05 0.05 Tuberculosis 0.08 0.04 0.14 0.08 — — — — 0.02 0.03 Measles 0.13 — 0.06 0.02 0.10 — — — — — Bronchitis and pneumonia 4.47 3.89 4.04 2.70 3.57 3.32 2.88 3.45 3.50 3.63 Gastro.enteritis 0.73 0.80 1.27 0.43 0.48 0.35 0.42 0.31 0.27 0.16 Congenital malformations 3.82 3.93 3.41 3.51 3.43 3.70 3.96 4.51 4.75 4.32 Injury at birth 2.98 2.82 2.71 2.34 2.59 2.64 2.98 2.27 2.46 2.55 Post.natal asphyxia and atelectasis 3.82 3.50 3.90 4.06 4.32 3.66 4.17 4.08 3.59 3.63 Haemolytic disease 0.86 0.72 0.53 0.55 0.58 0.61 0.51 0.44 0.51 0.54 Immaturity 4.71 4.20 3.98 3.70 4.67 4.10 4.27 4.69 3.86 3.71 Convulsions — — — 002 — 0.02 — — — — Accidental mechanical suffocation 0.25 0.17 0.14 0.12 0.06 0.21 0.23 0.13 0.16 0.09 Other causes 3.42 2.96 3.40 3.04 3.35 2.55 2.56 2.60 3.26 2.77 All causes 25 23 24 21 23 21 22 22 22 21 Mortality—A comparison with England and Wales for both neo.natal (deaths in the first four weeks) and infant mortality (deaths in the first year) is as follows : (Rates per 1,000 live births) Neo.natal mortality Infant mortality London England and Wales London England and Wales Year 1951 17.3 18.8 25.4 29.7 1952 15.8 18.3 23.1 27.6 1953 16.1 17.7 23.9 26.8 1954 151 17.7 20.7 25.4 1955 16.7 17.3 23.2 24.9 1956 15.9 16.8 21.2 23.8 1957 16.3 16.5 22.0 2.31 1958 16.6 16.2 22.5 22.5 1959 15.7 15.8 22.4 22.2 1960 15.4 15.6 21.5 21.7 As regards ne..natal mortality there were in London 886 deaths: of this number 528 occurred in premature infants. An analysis of the total number of premature births by birth weight and mortality is shown in the following table. Corresponding figures of domiciliary confinements are shown in the section on domiciliary midwifery on page 66. Table (xiii)—Prematurity and mortality by birth weight, 1960. Weight Number Proportion per 100 live premature infants Died within 24 hours Survived 28 days Number Per 100 live premature infants Number Per 100 live premature infants 3 lb. 4 oz. or less 443 10.5 195 44.0 161 36.3 3 lb. 5 oz. to 4 lb. 6 oz. 735 17.3 63 8.6 616 83.8 41b. 7oz. to41b. 15oz. 920 21.7 35 3.8 849 92.3 5 lb. 0 oz. to 5 lb. 8 oz. 2,139 50.5 30 1.4 2,083 97.4 All premature babies 4,237 100.0 323 8.8 3,709 87.5 17 B* Perinatal mortality—Comparative rates for perinatal mortality (stillbirths and deaths in the first week of life) per 1,000 total births are given below for London and England and Wales. Year London England and Wales Year London England and Wales 1951 34.6 38.2 1956 33.3 36.7 1952 32.6 37.5 1957 34.2 36.3 1953 34.7 36.9 1958 34.3 35.1 1954 32.8 381 1959 32.7 34.2 1955 34.8 37.4 1960 31.2 32.9 The causes of death in the first seven days of life are shown in table (xi) on page 16. It will again be apparent from the preceding section that premature babies provided the major share. The cause of stillbirth, the other component of perinatal mortality, was not known until certification was introduced on 1 October, 1960 under the Population (Statistics) Bill, 1960. The following table gives the causes for the last quarter of 1960, but they should be read with the cautionary note of the General Register Office* that only 63 per cent, of the certificates were signed by medical practitioners. Table (xiv)—Causes of stillbirth, last quarter of 1960. Code No. Cause Male Female Number Per cent. Number Per cent. Y.30 Chronic disease in mother 7 5.2 2 1.8 Y.32 Diseases and conditions of pregnancy and childbirth: (2) Haemorrhage 11 8.2 5 4.6 (3 and 4) Toxaemia 24 17.7 12 11.0 (5) Infection — — 1 0.9 Y.34 Difficulties in labour.. 7 5.2 3 2.8 Y.35 Other causes in mother — — 2 1.8 Y.36 Placental and cord conditions 27 200 22 20.2 Y.37 Birth injury 6 4.4 1 0.9 Y.38 Congenital malformation of foetus 11 8.2 27 24.8 Y.39 Diseases of foetus (1.4) 8 5.9 13 11.9 Y.39(5) Other ill.defined causes 15 111 10 9.2 Y.39(6) Cause unspecified 19 141 11 10.1 Total 135 100.0 109 100.0 † International classification of causes of stillbirth. A special enquiry, under Ministry auspices, into perinatal mortality was made in 1958.59, and the National Birthday Trust Fund also made a similar enquiry in March, 1958. The preliminary results of the latter are that intrauterine asphyxia, congenital malformation, intracranial birth trauma, resorption atelectasis, blood group incompatibility and pneumonia were the principal causes and that it was in the field of intrapartum asphyxia and birth trauma that improved obstetric care could most quickly yield better figures for foetal salvage. * The Lancet, 1961, (/), 455. 18 Maternal mortality— Table (xv)—Maternal mortality, 1951.60 Year Live births and stillbirths Deaths in pregnancy or childbirth excluding abortion Postabortion deaths Total maternal deaths No. Rate per 1,000 total births 1951 53,460 24 18 42 0.79 1952 52,433 35 15 50 0.95 1953 52,080 21 16 37 0.71 1954 51,774 28 6 34 0.66 1955 50,860 31 8 39 0.77 1956 53,241 16 11 27 0.51 1957 53,816 15 13 28 0.52 1958 55,254 14 19 33 0.60 1959 56,276 22 12 34 0.60 i960* 58,420 15 11 26 0.45 * For the fifth year running none of the deaths in pregnancy or childbirth was due to sepsis; nine of the 11 post.abortion deaths came under the category of 'abortion with sepsis Summary tables—Tables summarising the more important of these vital statistics (a) by metropolitan boroughs and (b) showing the secular trend for the county are to be found on pages 23 and 24. Air pollution There were no particular foggy incidents in 1960. Comparisons are now available for the past seven winters of the average levels of pollution based on the seven recording stations described in appendix B to my report for 1956. Winter averages (a) of air pollution Winter ' Smoke' (b) ' Sulphur dioxide' (c) Ratio smoke ISO 1954.1955 49 111 4.41 1955.1956 52 11.8 4.40 1956.1957 45 10.2 4.41 1957.1958 41 11.5 3.57 1958.1959 43 11.9 3.61 1959.960 32 9.6 3.33 1960.961 24 9.7 2.45 (a) Average daily readings of seven volumetric recording stations. (b) Milligrams of black suspended matter per 100 cubic metres of air. (c) Acidic gases in parts per 100 million parts of air. It will be seen that whereas there has been a downward trend in ' smoke ' since 1955.56 there has been less change in ' sulphur dioxide In a paper† read to the Clean Air Conference (1960) the reduction in smoke in London is reported as due mainly to a big drop in domestic coal consumption: the decrease in smoke emission in London has been much greater than elsewhere in the country. This has not been matched by a corresponding reduction in sulphur dioxide because ' the fall in the emission of sulphur dioxide from the domestic burning of coal is more than offset by the low.level emissions from the sharply increasing use of fuel oil in industry '. t Trends in the pollution of the air of Great Britain by smoke and sulphur dioxide, 1952.59 (Carroll et al), Clean Air Conference, October, 1960. 19 INFECTIOUS DISEASES Notifications of infectious diseases for the years 1951.1960 are shown in table V.5, page 27; those for certain such diseases by age and sex for the 13 four.weekly periods of the year 1960 are given in table V.6, page 28; and deaths from infectious diseases are included in table V.3, page 25. Diarrhoea and enteritis—There were 16 deaths under the age of two years from diarrhoea and enteritis, compared with 19 in the previous year. This represents a rate of 0.28 per 1,000 live births and shows a continuation of the low figures of recent years. Diphtheria—During 1960 diphtheria incidence fell considerably from the 1959 figure. This was to prove but a temporary respite, for during the last week of the year there were signs of renewed activity in Camberwell. In view of the wide publicity that has attended the occurence of diphtheria in the last year or two, it is necessary to point out that the average number of notifications in the years 1958.59.60 was only one fifth of that experienced ten years previously in 1948.1950, and one hundredth of that found 20 years ago. There has been more diphtheria than one would have wished, but many of the infected persons found have been symptomless carriers discovered as a result of the very thorough measures used in the attempt to limit the spread of infection. The amount of actual diphtheria occurring remains very low by past standards. It is also important to state that nothing that has happened in recent years has cast any doubt on the efficacy of diphtheria immunisation. The disease can still be severe and even fatal in un.immunised children. Immunisation confers a very substantial degree of protection, which must, however be reinforced at intervals. In spite of the success of diphtheria immunisation in reducing the disease to its present low level of incidence, it has been realised for some time that the existing level of immunisation in the community would not be enough to ensure the success of the next stage in the attack on this disease, viz. its elimination. Substantial progress was made during the year in increasing the level of acceptance of immunisation in the youngest age groups, and attention is also being given to the necessity to raise the general level of recent immunisation in the primary school age group. On the discovery of a case or carrier, swabbing of school and home contacts is carried out and repeated until the focus of infection has been eliminated. All positive cases or carriers are removed to isolation hospital. At the same time urgent immunisation of contacts is instituted. Un.immunised contacts are given a dose of diphtheria antitoxin followed later by a course of active immunisation. Immunised contacts are given a reinforcing dose of diphtheria toxoid. Dysentery—There was an increase in the incidence of dysentery from 3,571 in 1959 to 5,161 in 1960. The age and sex incidence of this disease continues to present interesting features. The marked excess in females aged over 15 years is what one would expect from the association of adult females with young children. The male excess below the age of five years, which has been noted also in other years recently, is more difficult to explain. Enteric fever—Incidence fell below the level of last year and no notable outbreaks occurred. The majority of cases in recent years have been single sporadic cases. Influenza—After the considerable outbreak in 1959 the number of deaths from influenza in 1960 was low, only 46 being recorded, the lowest figure for a number of years. Leptospirosis—For the fourth successive year there was no case of leptospirosis reported among the Council's sewer workers. Measles—Notifications of measles conformed to the customary biennial pattern. Incidence was low in the early part of the year, rising considerably with the onset of the colder weather. This rise was the beginning of what was to prove one of the biggest epidemics of recent years, in the early part of 1961. Although the disease appears to be as prevalent as ever, it has shown increasing mildness in the last ten years. 20 Ophthalmia neonatorum—There was a decrease in the number of notifications from 161 in 1959 to 89 in 1960—the rate (per 1,000 registered live births) changing from 2.53 to 1.36. Cases among children born to London residents totalled 73, a fall of 26 compared with the previous year: in 68 vision was unimpaired, four removed and one was still under treatment at the end of the year. Poliomyelitis—There was a considerable reduction in the number of notifications of poliomyelitis in 1960. Polio virus types I and III were isolated in roughly equal numbers. Once again a marked feature of the epidemiological picture was the high proportion of cases found in the age group 0.4 years. This was 59.8 per cent, of all cases and is the highest proportion ever recorded in this age group. Table (xvi)—Poliomyelitis notifications by age, 1949.60 Year 0—4 years 5.14 years 15 years and over Total No. % No. % No. % No. 1949 356 53.3 173 25.9 139 20.8 668 1950 150 34.9 149 34.6 131 30.5 430 1951 27 24.1 45 40.2 40 35.7 112 1952 95 30.7 105 340 109 35.3 309 1953 116 350 104 31.3 112 33.7 332 1954 42 33.6 41 32.8 42 33.6 125 1955 334 34.8 391 40.7 235 24.5 960 1956 88 31.5 115 41.2 76 27.3 279 1957 103 31.8 131 40.4 90 27.8 324 1958 40 37.4 36 33.6 31 29.0 107 1959 108 51.4 66 31.4 36 17.2 210 1960 52 59.8 17 19.5 18 20.7 87 It will be seen from table (xvi) that a high proportion of cases in the 0.4 years age group has been recorded previously only in 1949 and 1959. Cases were spread throughout the age group. The higher rate of incidence in the under.fives does not appear to be related to any difference between vaccination rates in this age group and the over.fives. The reason for the high proportion of cases in young children remains uncertain. As a result of scrutiny of the clinical and virological findings, a final diagnosis was made in respect of each notification. The diagnosis of paralytic poliomyelitis was made on clinical grounds, although virological confirmation was present in the majority of cases. A diagnosis of non.paralytic poliomyelitis was made only in cases in which poliomyelitis virus was present on the stool, or when serological evidence supported the diagnosis. Table (xvii) gives an analysis of the original notifications according to the final diagnosis. Table (xvii)—Final diagnosis of poliomyelitis notifications, 1960 Final diagnosis Notified as paralytic Notified as non.paralytic Total (all ages) 0.4 years 5.14 years 15+ years Total 0.4 years 5.14 years 15 + years Total Paralytic 36 8 14 58 2 . 1 3 61 Non.paralytic 1 . . 1 11 3 1 15 16 Not poliomyelitis (or not known) 2 2 1 5 . 4 1 5 10 Total 39 10 15 64 13 7 3 23 87 21 It will be seen that out of 64 cases notified as paralytic six proved to be non.paralytic or not poliomyelitis and that, out of the 23 cases notified as non.paralytic, three proved to be of the paralytic form and five were not poliomyelitis. Thus, on balance, the original notifications slightly overstated the extent of the paralytic form—64 against 61—and there were 10 cases which proved to be not poliomyelitis. The vaccinal state of the 61 cases finally diagnosed as paralytic poliomyelitis and the 16 non.paralytic cases is set out in table (xviii). Table (xviii)—Vaccinal state of confirmed cases of poliomyelitis, 1960 Age Vaccinated* Not vaccinated Not known Total No. % No. % No. % No. % (a) Paralytic cases 0.4 years 4 11 32 84 2 5 38 100 5.14 „ 1 13 7 87 . . 8 100 15+ 2 13 12 80 1 7 15 100 Total 7 11 51 84 3 5 61 100 (6) Non.paralytic cases 0.4 years 3 25 9 75 . . 12 100 5.14 „ — . 3 100 . . 3 100 15+ „ — — 1 100 — — 1 100 Total 3 19 13 81 — — 16 100 * Two or three injections. It is estimated that at 30 June, 1960—about midway point of the poliomyelitis season in 1960—70 per cent, of children aged 0.14 years had received two injections of poliomyelitis vaccine. Applying this percentage to the child population at risk gives the following incidence rates for the paralytic form of the disease: Cases per 1,000 Population Cases* population at 0.14 years risk Vaccinated 451,000 5 0.011 Not vaccinated 193,000 39 0.202 * Excluding two cases vaccinal state not known. Thus the incidence rate in the unvaccinated children was about eighteen times that in the vaccinated: even if the two cases in which the vaccinal state was not known are included in the figure of cases among vaccinated children (which is doubtful) the differential in the incidence rates becomes thirteen times. In similar previous analyses the corresponding differential between incidence rates in the unvaccinated and vaccinated was, for the last six months of 1958, five times and for the year 1960 seven times. The greater difference in the incidence rates in 1960 may be linked with tne fact that by the end of that year about three.quarters of the vaccinated child population had received a third injection of vaccine compared with one.half at the end of 1959. Smallpox—There was one case notified during the year in the City of Westminster; this was in respect of a visitor to this country. Fortunately no secondary cases resulted. Whooping cough—After the low figures of recent years there was a considerable increase in the notifications of whooping cough, the heaviest incidence being during the summer months. In spite of this increased incidence mortality remained gratifyingly low. 22 23 TablE V—Vital statistics—Metropolitan Boroughs ana tne Administrative county of London, 1963(a) [###[Metropolitan Boroughs Estimated home population mid 1960 Live birth rate Death rate (all causes) Infant mortality (per 1,000 live births) Cancer Vascular lesions of C.N.S. Death rates Notifications of infectious disease Heart disease Other circulatory Pneumonia Other respiratory (iexcluding tuberculosis) Violence Dysentery Food poisoning Measles Pneumonia Poliomyelitis Scarlet fever Whooping cough Tuberculosis Crude Adjusted Crude Adjusted Paralytic Nonpara lytic Pulmonary Non. pulmonary Division I Chelsea 49,140 14.5 11.0 14.8 11.5 17 3.32 1.89 4.78 0.83 0.83 0.75 0.88 1.40 0.31 0.31 012 0020 — 0.41 1.26 0.49 0.06 Fulham 112,960 16.7 16.2 11.1 10.9 22 2.40 1.10 3.14 0.66 0.64 0.89 0.58 1.17 0.23 0.27 013 0027 — 0.19 1.24 0.66 0.09 Hammersmith 108,290 20.5 19.5 11.1 11.5 22 2.73 1.19 308 0.65 0.47 0.87 0.49 0.94 0.32 2.93 0.64 0009 — 0.46 1.51 0.90 012 Kensington 167,240 18.6 13.4 9.9 9.9 21 2.07 1.23 2.88 0.54 0.42 0.56 0.55 0.42 0.25 2.73 010 0018 — 0.17 0.92 0.87 0.11 Division 2 Hampstead 98,080 17.1 12.8 10.4 10.5 20 2.53 1.25 3.20 0.40 0.49 0.55 0.59 0.49 0.23 0.88 012 0 031 — 0.18 0.59 0.66 0.10 Paddington 113,350 22.1 17.9 10.5 10.8 26 2.49 1.03 2.67 0.55 0.56 0.86 0.64 0.30 0.68 7.14 0.20 0 044 0.018 0.24 1 .03 121 0.12 St. Marylebone 69,640 10.7 8.3 15.7 11.6 27 3.42 2.21 5.20 0.70 0.66 1.05 0.65 027 O.11 2.08 010 — 0.014 0.23 0.76 0.79 004 St. Pancras 127,710 18.4 16.0 10.6 10.8 24 2.58 1.00 3.06 0.45 0.71 0.91 0.50 1.91 0.64 4.07 0.46 0 023 0.023 0.37 1.57 1.06 013 Westminster, City of 92,940 11.0 9.0 10.2 10.6 16 2.33 0.93 3.02 0.56 0.51 0.62 0.71 0.58 0.25 0.51 008 0011 — 0.19 0.46 0.99 0.04 Division 3 Finsbury 33,710 19.1 17.2 10.0 101 16 2.20 1.33 2.82 0.36 0.50 0.95 0.59 5.64 2.17 7.53 1.48 0030 — 1.36 2.34 0.92 0.15 Holborn 21,000 9.9 7.0 12.7 13.7 77 2.38 1.48 3.71 0.67 0.86 052 071 1.95 0.29 1.81 014 0048 0.048 0.19 0.43 0.86 0.05 Islington 222,940 23.4 21.5 11.1 10.7 21 2.48 107 3.27 0.66 0.71 1.00 0.55 3.57 0.55 6.42 0.26 0 054 0.013 0.58 2.54 1.09 0.14 Division 4 Hackney 163,050 20.1 18.9 10.9 11.8 16 2.49 1.44 3.58 0.50 0.37 0.88 0.40 1.40 0.21 2.87 0.17 0018 — 0.79 2.00 0.56 0.07 Shoreditch 42,870 16.0 14.6 12.8 12.2 22 2.78 1.47 3.27 0.47 1.40 1.28 019 2.54 0.21 1.66 012 0 047 — 0.79 2.64 0.89 0.05 Stoke Newington 50,240 22.2 20.0 11.3 12.9 18 2.59 1.29 3.38 0.86 0.40 0.82 0.44 0.84 0.28 6.41 0.20 0020 — 0.84 1.53 0.76 0.12 Division 5 Bethnal Green 47,580 17.1 16.2 11.3 11.0 27 2.86 1.39 3.13 0.32 0.78 0.97 0.46 0.90 0.36 0.99 008 — 0.084 0.23 3.45 0.71 0.04 City of London(b) 4,890 7.0 6.3 9.8 10.0 29 2.86 0.82 1.84 0.82 0.82 0.61 0.82 1.23 0.41 1.23 — — — — 0.20 1.43 — Poplar 63,340 18.3 17.6 10.5 11.6 26 2.23 1.01 2.64 0.63 0.73 106 0.43 1.01 0.96 3.90 0.69 0063 — 0.51 1.55 0.65 0.06 Stepney 93,850 18.5 16.7 11.1 11.9 18 2.27 1.03 3.37 0.46 0.58 1.29 0.70 1.44 0.20 0.58 0.86 0011 — 0.26 2.34 1.24 0.07 Division 6 Deptford 69,330 18.8 18.2 11.1 11.3 29 2.39 1.46 3.38 0.49 0.69 0.94 0.29 0.95 004 1.36 0.30 — — 0.66 2.16 1.15 010 Greenwich 88,310 14.0 13.2 10.5 11.8 18 2.46 1.31 3.19 0.48 0.74 0.66 0.39 1.69 0.48 0.53 014 0.045 — 0.50 1.90 0.53 0.08 Woolwich 145,470 150 14.9 9.8 10.4 17 2.23 1.10 3.35 0.45 0.67 0.68 0.24 0.37 0.15 013 0.31 0.007 — 0.45 0.74 0.47 0.03 Division 7 Camberwell 175,020 17.8 16.6 10.9 10.8 24 2.39 1.21 3.28 0.55 0.57 0.84 0.45 1.57 0.31 3.90 0.16 — — 0.50 1.12 0.94 0.09 Lewisham 221,330 16.3 15.5 11.3 11.3 19 2.57 1.61 3.56 0.51 0.61 0.72 0.37 1.89 0.14 1.18 0.15 0.014 0.005 0.78 1.50 0.54 0.07 Division 8 Bermondsey 53,510 16.1 15.3 10.6 11.3 27 2.45 1.08 2.45 0.65 0.62 1.01 0.47 6.56 0.80 4.07 009 0.019 — 0.47 1.46 0.49 0.07 Lambeth 224,080 21.5 19.6 10.7 10.9 21 2.35 1.10 3.22 0.52 0.66 0.68 0.46 1.61 0.24 2.42 0.20 0.018 0.013 0.43 1.61 0.61 0.04 Southwark 88,690 18.3 16.5 13.6 12.1 26 2.92 1.45 4.13 0.60 1.03 1.08 0.59 7.45 1.04 3.63 0.45 0.045 0.023 0.82 1.33 1.16 Oil Division 9 Battersea 107,120 18.2 17.7 10.6 10.1 18 2.47 1.22 3.33 0.42 0.54 0.69 0.44 0.63 004 1.74 0.31 0.009 — 0.24 1 .36 0.73 0.03 Wandsworth 338,800 16.4 15.7 14.7 10.9 23 2.88 1 .49 5.24 0.81 0.89 0.81 0.51 0.97 0.57 2.43 0.36 0.003 0.009 0.50 1.45 0.63 0.04 London, 1960 3,194,480 180 16.2 11.4 11.2 21 2.53 1.28 3.51 0.57 0.65 0.83 0.49 1.62 0.38 2.68 0.28 0.020 0.007 0.47 1.50 0.79 0.08 London, 1959 3,204,000 17.2 15.5 11.9 11.7 22 2.40 1.24 3.44 0.59 0.85 1.27 0.52 112 0.51 8.73 0.60 0.046 0.020 0.82 0.50 0.87 0.08 (a) Rates are per 1,000 home population, figures in italics are based upon fewer than 20 births, deaths or notifications. (b) Including Inner and Middle Temple. 24 Table V.2—Principal vital statistics—Administrative County of London, 1951.60 Year Annual rate per 1,000 living Annual mortality— Annual mortality per 1,000 living Infant (per 1,000 live births) Maternal (per 1,000 total births) Live births Deaths (all causes) Crude rate Adjusted rate Crude rate Adjusted rate Tuberculosis Cancer Vascular lesions of C.N.S. Heart disease Other circulatory disease Influenza Pneumonia (all forms) Bronchitis Other resp. diseases Violence Infants 0—1 Diarrhoea and enteritis 0—2 Pulmonary Non.pulmonary Suicide Road accidents Other violence 1951 15.6 140 12.6 12.7 0.34 004 2.27 1.22 3.87 0.46 0.24 0.64 1.14 0.12 0.13 (a) 0.09 0.24 25 0.8 0.79 1952 15.3 13.8 12.0 12.1 0.28 003 2.30 1.27 3.55 0.62 0.05 0.61 1.09 0.12 0.11 0.07 0.22 23 0.8 0.95 1953 15.3 13.3 11.6 11.5 0.21 002 2.34 1.20 3.25 0.59 0.15 0.64 1.07 0.12 0.14 008 0.21 24 1.4 0.71 1954 15.2 13.3 10.7 10.6 0.18 002 2.31 1.20 3.22 0.60 0.02 0.48 0.66 0.10 0.15 008 0.21 21 0.5 0.66 1955 15.1 13.3 11.5 11.4 0.16 0.01 2.39 1.25 3.37 0.61 005 0.63 0.88 0.11 0.14 0.10 0.22 23 0.5 0.77 1956 15.9 140 11.7 11.7 0.13 0.01 2.42 1.27 3.46 0.59 0.04 0.67 0.96 0.11 0.15 0.10 0.22 21 0.4 0.51 1957 16.2 14.4 11.4 11.3 0.12 002 2.45 1.19 3.34 0.56 0.12 0.65 0.83 0.10 0.15 009 0.21 22 0.5 0.52 1958 16.8 15.0 11.8 11.6 0.12 0.01 2.47 1.29 3.52 0.59 005 0.70 0.92 0.11 0.17 0.11 0.22 22 0.4 0.60 1959 17.2 15.5 11.9 11.7 0.10 0.01 2.40 1.24 3.44 0.59 018 0.85 0.98 0.11 0.17 0.12 0.23 22 0.3 0.60 1960 180 16.2 11.4 11.2 0.07 0.01 2.53 1.28 3.51 0.57 001 0.65 0.70 0.11 0.16 0.14 0.20 21 0.3 0.45 (a) Deaths from motor vehicles and other road traffic accidents. Table V.3—Deaths by cause—Administrative County of London, 1960 Cause Sex 0- 1- 5— 15- 25- 45- 65- 75+ Total 1960 1959 1. Tuberculosis—respiratory M — — — 1 20 78 52 25 176 239 F 1 2 - - 12 16 18 10 59 74 2. Tuberculosis—other M 1 1 - - 2 2 2 1 9 16 F - - 1 1 4 9 5 5 25 74 3. Syphilitic disease M - - - - - 25 17 20 62 63 F - - - — 2 5 11 18 36 36 4. Diphtheria M 17 - - - - - - - - - 5. Whooping cough r M 2 — — - - - - -- 2 1 F 7 - - - - - — — 1 2 6. Meningococcal infection M 1 3 - - - - - - 4 7 F 2 - 1 - — - 1 1 5 2 7. Acute poliomyelitis M J7 - - - - 1 1 - - 2 10 8. Measles M - - - - 1 1 o 3 F 1 9. Other infective, &c., diseases M 3 2 5 1 8 11 12 3 45 32 F - - 1 1 4 7 8 6 27 47 10. Malignant neoplasm: Stomach M - - - - 14 208 167 108 497 516 F - - - - 12 95 122 195 424 435 11. Malignant neoplasm: Lung, M - - - - 55 958 585 272 1,870 1,757 bronchus F - - - - 26 157 94 96 373 373 12. Malignant neoplasm: Breast M - - - - - 4 - 4 8 4 F - - - - 59 344 158 142 703 694 13. Malignant neoplasm: Uterus F - - - 1 31 123 82 72 309 293 14. Other malignant and M 3 4 12 27 90 647 558 509 1,850 1,771 tic neoplasms F 4 5 8 7 100 540 523 650 1,837 7,729 15. Leukemia, aleukemia M - 4 7 5 13 35 23 25 112 88 F - 8 2 3 11 28 17 27 96 93 16. Diabetes M 1 - — 2 5 22 17 25 72 58 F - - 1 1 2 21 52 68 745 148 17. Vascular lesions of nervous M 1 - 1 1 31 371 485 710 1,600 1,533 system F 7 1 2 5 28 343 649 1,456 2,4s5 2,425 18. Coronary disease, angina M - - - 2 129 1,431 1,253 1,042 3,857 3,599 F - - - - 8 355 829 1,419 2,611 2,458 19. Hypertension with heart M - - - - 1 50 72 131 254 289 disease F - - - - 1 31 98 266 396 464 20. Other heart disease M 1 1 4 6 60 215 346 871 1,504 1,556 F - - - 2 48 224 368 1,941 2,583 2,645 21. Other circulatory disease M - - - - 23 187 200 328 738 782 F 7 - 2 2 14 109 255 712 7,095 7,779 22. Influenza M - 1 1 2 3 8 5 1 21 261 F 7 1 — — 1 8 3 11 25 379 23. Pneumonia M 92 12 1 2 14 145 229 491 986 1,357 F 77 6 — 2 8 76 179 743 7,097 1,360 24. Bronchitis M 22 5 1 1 11 385 495 600 1,520 2,109 F 18 6 - - 7 76 151 469 727 7,077 25. Other diseases of respiratory M 1 3 3 1 11 73 71 89 252 244 system F 3 1 1 1 1 19 25 49 700 720 26. Ulcer of stomach and M - - - - 9 81 110 82 282 292 duodenum F - - - - 2 20 40 84 146 764 27. Gastritis, enteritis and M 4 6 3 1 1 16 22 12 65 71 diarrhoea F 5 2 1 1 3 16 37 59 724 725 28. Nephritis and nephrosis M - 2 3 5 20 46 27 16 119 113 F — 2 — 6 11 29 26 31 105 115 29. Hyperplasia, prostate M - - - - - 5 51 119 175 225 30. Pregnancy, childb., abortn. F - - - 8 18 - - - 26 34 31. Congenital malformations M 121 20 12 12 10 10 9 2 196 225 F 127 16 13 5 8 23 2 6 200 185 32. Other defined and ill-defined M 445 7 8 16 65 251 203 275 1,270 1,294 diseases F 276 19 17 17 67 247 293 702 1,638 7,627 25 Table V.3 (contd.)—Deaths by cause—Administrative County of London, 1960 Cause Sex 0. 1. 5. 15. 25. 45. 65. 75+ Total 1960 1959 33. Motor vehicle accidents M — 3 16 77 60 68 39 44 307 254 F — 4 8 13 19 30 24 42 140 129 34. All other accidents M 13 10 16 25 76 111 40 68 359 365 f 4 4 5 5 23 42 47 117 247 339 35. Suicide M . . . 33 91 120 28 31 303 318 F . . . 9 16 90 32 12 199 211 36. Homicide, operations of war M . 1 1 6 6 1 1 . 16 19 F . . . 1 5 2 . 1 9 19 ALL CAUSES M 711 85 94 226 829 5,566 5,119 5,904 18,534 19,471 F 521 77 63 91 591 3,085 4,149 9,410 17,987 18,756 Table V.4—Weather during 1960 (as recorded at Kew Observatory) Temperature Difference from Rainfall Difference from Sunshine Difference from Month Mean (a) average (6) Total average (b) Total average (c) °F °F ins. ins. hrs. hrs. January 41.0 + 1.3 1.76 .0.20 45.0 + 3.2 February 41.5 +1.2 1.66 +0.11 81.2 +22.8 March 44.8 +20 1.60 +0.06 72.5 .34.2 April 49.5 +20 0.52 .119 172.9 +23.7 May 57.0 +3.4 1.65 .0.10 189.1 .8.4 June 62.4 +30 1.21 .0.77 256.4 +55.9 July 60.6 .21 3.37 +0.99 163.2 .32.3 August 60.6 .1.2 1.81 .0.43 176.0 .9.0 September 57.4 00 3.43 + 1.44 145.7 +4.8 October 52.2 + 1.9 5.20 +2.69 87.5 .5.7 November 47.3 +3.1 3.79 + 1.45 71.8 +20.6 December 41.5 +0.8 1.98 .0.18 49.2 + 11.9 Year 51.3 +1.3 27.98 +3.87 1510.5 +53.3 (a) Average of the daily means of 24 hourly readings. (b) Average over the 80 years ended 1950. (c) Average over the 70 years ended 1950. 26 Table V.5—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—Administrative County of London, 1951.1960 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 Rale Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Paralytic Non.par. Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate 1951 1 0 0003 30 0 .009 4,069 1.212 19 0 006 66 0020 496 0.148 23 0 007 49,148 14.64 108 0.032 93 (b) 1.56 2,409 0.717 61 0.018 51 0.015 911 (b) 14.96 572 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 3.36 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 2.76 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 1.92 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 0.034 361 0.110 40 0.012 49,110 14.90 98 0.030 106 1 85 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 2.95 94 0.029 83 1.39 1,633 0.499 183 0.056 96 0.029 1,792 29.49 703 0.21 2,198 0.67 — — — — 5,450 1.67 1,327 0.41 1957 — — 4 0. 001 2,356 0.724 27 0.008 47 0.014 269 0.083 44 0.014 36,952 11.36 70 0.022 102 1 69 2,185 0.672 201 0.062 123 0.038 2,008 32.42 630 0.19 2,177 0.67 — — — — 3,982 1.22 1,189 0.37 1958 — — 38 0.012 4,502 1.396 38 0.012 42 0.013 257 0.080 10 0.003 16,664 5.17 81 0.025 132 1 99 1,735 0.538 80 0.025 27 0.008 1,680 24.85 635 0.20 2,716 0.84 — — — — 1,595 0.50 1,300 0.40 1959 — — 75 0.023 3,571 1.115 31 0.010 84 0.026 240 0.075 4 0.001 27,970 8.73 69 0.022 161 2.53 1,914 0.597 146 0.046 64 0.020 1,666 25.64 544 0.17 2,621 0.82 — — — — 1,607 0.50 1,639 0.51 1960 — — 16 0 .005 5,161 1.616 23 0.007 51 0.016 229 0.072 10 0.003 8,561 2.68 71 0.022 89 1 36 882 0.276 64 0.020 23 0.007 1,416 21.20 498 0.16 1,500 0.47 1 0.0003 — — 4,794 1.50 1,229 0.38 (a) Rate per 1,000 live births registered in London, (b) Rate per 1.000 total births registered in London. 27 Table V.6—Notification of certain infectious diseases—distribution by age and date of notification—Administrative County of London, 52 weeks commencing 4 th January, 1960 Four. weekly periods 1960 Dysentery Measles Meningococcal infection Pneumonia Poliomyelitis Scarlet fever Whooping cough Paralytic Non.paralytic Ages Ages Ages Ages Ages Ages Ages Ages 0—4 5—14 15+ Total 0—4 5—14 15+ Total 0—4 5—14 15+ Total 0—4 5—14 75 + Total 0—4 5—14 15+ Total 0—4 5—14 15+ Total O.4 5—14 15+ Total 0—4 5—74 75+ Total 1— 4 m 105 65 38 212 27 15 1 43 3 1 1 5 13 1 25 46 2 1 3 — — — — 36 53 5 96 84 74 1 159 F 104 66 85 257 26 8 1 35 4 — 1 5 7 7 34 48 — — 1 7 . . . 26 43 70 111 63 2 177 5— 8 m 136 128 69 338 56 39 — 95 2 — 1 3 19 10 41 70 2 — — 2 . — — — 27 63 3 93 96 48 . 144 F 87 121 135 345 49 43 1 93 3 — — 3 16 . 54 74 . . . . . . . 23 57 5 85 101 49 4 154 9—12 M 136 139 91 370 134 73 3 210 2 — 2 4 5 5 42 52 . . . . . i — 1 15 57 2 75 78 30 . 108 F 108 151 134 394 88 56 4 158 7 1 1 3 7 5 37 49 . . . . . . . 27 55 2 85 82 38 5 145 13—16 M 147 178 67 392 94 68 2 164 5 1 1 7 2 1 26 29 3 — — 3 1 i — 2 32 48 2 82 73 46 2 121 F 118 142 150 417 105 61 3 769 — — 7 1 3 2 31 37 . . . . . . . 30 56 3 89 89 69 . 108 17—20 m 95 57 90 244 123 73 10 206 3 1 1 5 3 3 31 37 — — — — 1 i — 2 22 39 5 66 99 89 1 189 F 78 70 134 282 112 71 8 794 3 — — 3 4 2 76 22 7 — — 1 1 . . 7 13 39 6 58 96 87 . 190 21—24 m 79 125 76 280 149 107 3 259 — 2 1 4 1 5 23 29 . . . . . . 1 1 17 30 7 56 120 73 6 194 F 80 121 106 309 136 104 5 245 — 1 — 1 7 7 18 20 7 2 — 3 5 . . 5 9 34 4 47 120 103 . 235 25—28 m 56 42 29 128 148 88 3 240 1 1 1 3 — — 11 11 2 — — 2 — 1 — 1 12 21 2 35 135 99 2 236 F 47 52 60 160 146 89 3 239 — — 1 / 5 — 77 22 . . . . . . 9 24 2 35 131 109 2 241 29—32 m 42 44 34 121 170 134 3 307 2 . — 2 3 5 15 23 1 — 2 3 1 1 — 2 13 30 1 44 140 110 4 255 F 49 46 49 144 150 117 4 27/ 7 1 1 5 7 — 7 8 — 7 7 2 — . 1 1 10 22 1 55 152 119 7 270 33—36 m 27 11 22 61 110 38 1 149 1 4 — 5 — — 14 14 2 2 1 5 — 1 — 1 8 5 — 13 141 83 6 231 F 18 18 28 64 117 33 2 152 1 — — 7 — 1 12 13 7 7 7 3 — . . 13 13 2 28 152 92 . 253 37—40 m 54 56 26 136 89 59 — 148 4 1 — 5 3 3 13 19 6 1 3 10 — — — — 15 19 — 34 144 52 . 196 F 36 35 49 123 83 56 2 141 — — — — 3 4 13 20 3 — 7 4 1 1 . 2 74 22 2 39 157 87 7 251 41—44 m 51 39 24 115 264 220 2 486 3 — — 3 3 5 35 43 2 1 . 4 1 — — 1 18 29 3 50 85 49 1 135 F 44 38 50 132 236 178 5 422 — — — — 2 7 24 27 1 — 7 2 1 . ~~ 1 27 59 3 65 121 65 4 190 45—48 m 32 23 21 77 399 336 2 738 2 — 2 4 7 8 27 43 2 — 1 3 — — — — 30 32 3 65 92 35 2 129 E 25 29 52 107 356 301 7 665 7 1 2 . 7 70 25 42 5 7 — 6 . . . 21 47 . 62 97 54 1 152 49—52 m 25 11 17 54 745 644 9 1,402 — — — — 7 4 35 46 4 — 2 6 — — 1 1 14 30 2 46 70 44 6 114 F 23 17 25 65 698 639 70 1,352 — 1 1 2 7 j 30 42 1 . . 1 1 . . 1 9 24 1 54 63 45 51 130 Total m 985 918 604 2,528 2,508 1,894 39 4,447 28 11 10 50 66 56 338 462 26 5 10 41 4 6 2 12 259 456 35 755 1,357 832 19 2,211 F 817 906 1,057 2,799 2,302 1,766 55 4,736 14 5 8 27 63 42 318 424 13 5 5 23 9 1 7 11 225 469 51 728 1,498 1,005 51 2,557 Notes: 1. Where the total figures are in excess of the sum of the age groups, the difference is due to cases ' age not known.' 2. The totals of these figures will not necessarily agree with the total notifications given in Table V.5 which relates to the calendar year 1960. 28 TUBERCULOSIS Notification rates of pulmonary tuberculosis were slightly lower than in 1959 and the death rate followed the same general trend. The diagram on page 30 shows the trend of notifications, deaths and numbers on the registers of chest clinics over the last decade. Deaths from non.pulmonary tuberculosis are now so few that considerable random fluctuations occur in the rates from year to year and therefore are not shown in the diagram. The number of cases on the registers is now 36,567. Tuberculosis is still a serious infectious disease. This year, in adults it accounted for more cases than were notified of any other notifiable infectious disease. The 269 deaths from tuberculosis (all forms both sexes) include 155 deaths from pulmonary disease in men aged 45 years and over. Services provided—The services provided by the Council as local health authority for the care and after.care of tuberculous patients and the prevention of tuberculosis are summarised in table T.10. 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. B.C.G. vaccination—The numbers of children vaccinated during the year under the Council's schemes for the B.C.G. vaccination of susceptible (tuberculin negative) child contacts of known tuberculous patients, diabetic children, thirteen.year.old school children, students at further education establishments and mentally subnormal persons at training centres are shown in table T.12. Preventive measures—In addition to the B.C.G. vaccination schemes other preventive measures include the chest X.ray of all newly appointed staff who are likely to work in close and frequent contact with children, staff at the Council's training centres for mentally subnormal persons and of tuberculin reactors discovered among thirteen.year.old school children, students and others tested with a view to B.C.G. vaccination. Epidemiological investigations are made among the contacts of cases of tuberculosis notified in children, staff or residents in the Council's establishments. Similar investigations are carried out at secondary schools where the reactor rates disclosed by tuberculin surveys are significantly higher than the average for secondary schools in the area (table T.9). Table T.l—Tuberculosis—Statutory notifications and deaths, Administrative County of London, 1951.1960 (a) Year 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 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 1.10 423 0.13 327 0.10 32 0.01 1957 3,460 1.06 378 0.12 294 0.09 50 0.02 1958 3,103 0.96 379 0.12 305 0.10 41 0.01 1959 2,794 0.87 313 0.10 244 0.08 30 0.01 1960 2,519 0.79 235 0.07 250 0.08 34 0.01 (a) Excluding posthumous notifications. 29 TREND OF TUBERCULOSIS LONDON A.C. 1951.60 30 Table T.2—Pulmonary tuberculosis—Notification and death rates per 1,000 living by age and sex, Administrative County of London, 1951.1960 Age 0.4 5.14 15.44 45 and over All ages Year M F M F M F M F M F Notification rates 1951 0.98 0.92 0.74 0.68 218 1.98 1.91 0.36 1.80 1.16 1952 0.65 0.70 0.53 0.61 216 1.90 1.88 0.43 1.73 111 1953 0.84 0.85 0.69 0.65 201 1.80 209 0.42 1.76 108 1954 0.64 0.55 0.48 0.55 1.79 1.71 202 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 1957. 0.43 0.40 0.30 0.32 1.60 1.27 1.92 0.38 1.44 0.73 1958 0.39 0.33 0.30 0.27 1.49 1.03 1.89 0.32 1.37 0.60 1959 0.47 0.43 0.24 0.28 1.30 0.95 1.66 0.32 1.21 0.57 1960 0.46 0.44 0.23 0.25 114 0.83 1.49 0.33 108 0.53 Death rates 1951 0.02 0.02 . 0.02 0.27 0.21 1.23 0.22 0.53 018 1952 — — — — 0.18 0.16 1.08 018 0.44 0.14 1953 0.02 0.03 0.00 0.00 0.12 0.21 0.81 013 0.33 010 1954 — 0.03 — 0.01 0.07 0.10 0.74 0.12 0.28 009 1955 0.02 — 0.00 — 0.07 0.06 0.66 0.11 0.25 0.07 1956 — 0.02 — — 0.07 0.05 0.52 009 0.21 006 1957 — 0 .009 — — 0.06 0.05 0.46 0.08 019 005 1958 — — 0.01 0.05 0.05 0.44 0.11 018 006 1959 0.02 0 .009 0.03 0.03 0.41 007 0.16 004 1960 — 0.03 — — 0.03 0.02 0.29 006 0.12 0.03 Table T.3—Non.pulmonary tuberculosis—Notification and death rates per 1,000 living by age and sex, Administrative County of London, 1951.1960 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 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 0085 0.141 0.165 1953 0.144 0.160 0.152 0182 0.138 0.175 0044 0070 0.109 0.135 1954 . 0.142 0.149 0.139 0187 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 0037 0.105 0.116 1956 0.111 0.089 0.078 0095 0.109 0.176 0.048 0.058 0084 0.114 1957 0.076 0.063 0069 0.100 0.105 0.168 0.034 0.052 0073 0.106 1958 0.126 0.116 0.075 0083 0.108 0.148 0047 0066 0.083 0.104 1959 0.050 0043 0.063 0.040 0.103 0.130 0.055 0041 0076 0.076 1960 0.065 0051 0.029 0.030 0.133 0.136 0.038 0041 0.079 0.078 Death rates 1951 0.071 0.067 0.031 0.048 0 040 0019 0.041 0039 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 0017 0.025 0029 0019 0.025 1954 0025 0.018 0005 0.016 0009 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 0014 0.013 1956 0.009 0.009 0 004 0.023 0.014 0.012 0007 1957 0 008 0.009 0.009 0005 0.011 0 004 0.030 0.027 0.017 0.014 1958 0.005 0.012 0 004 0.026 0.021 0.015 0.010 1959 0025 0 009 0.005 0.009 0001 0.011 0.017 0.011 0 008 1960 0016 ~ 0.005 0.003 0*007 0.009 0.027 0006 0.015 31 Table T.4—Tuberculosis—Statutory notifications by age groups, Administrative County of London, 1960 Form of tuberculosis notified Sex Number of notifications of new cases of tuberculosis by age Total all ages 0- 1- 5- lO- 15- 20- 25- 35- 45- 55- 65- 75+ Pulmonary tuberculosis m. 5 52 20 27 57 163 259 241 315 283 146 52 1,620 F. 8 44 7,2 11 55 151 212. 142 105 66 39 28 899 Other forms of tuberculosis m. - 8 3 3 7 10 48 19 14 2 1 3 118 F. — 6 3 3 8 25 39 19 8 9 6 6 132 All forms of tuberculosis m. 5 60 23 30 64 173 307 260 329 285 147 55 1,738 F. 8 50 25 30 63 176 251 161 113 75 45 34 1,031 Table T.5—Tuberculosis—Deaths in Administrative County of London, 1960 Form of tuberculosis Sex Age at death Total all ages 0— 1— 5— 15— 25— 45— 65— 75+ Pulmonary tuberculosis M. - - - 1 20 78 52 25 176 F. 1 2 - 12 16 18 10 59 Other forms of tuberculosis M. 1 1 — - 2 2 2 1 9 F. — — 1 1 4 9 5 5 25 All forms of tuberculosis M. 1 1 - 1 22 80 54 26 185 F. 1 2 1 1 16 25 23 15 84 Table T.6—Statutory notification of non.pulmonary tuberculosis—Distribution according to site and age, Administrative County of London, 1960 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 2 4 10 50 66 Abdomen — — 7 7 14 Peripheral glands 5 3 17 55 80 Meninges and C.N.S. 6 3 1 4 14 Skin and erythema nodosum — 1 — — 1 Genito.urinary — - 14 53 67 Other sites 1 1 1 5 8 All sites 14 12 50 174 250 32 Table T.7—Tuberculosis—Statutory notifications by occupations, London Administrative County, 1960 Registrar General's short classification of employment Population Census 1951 Notifications (a) Males Females Males Females No. Rate per 1,000 population (b) No. Rate per 1,000 population (b) 1. Fishermen 15 - - (-) - -(-) - 2. Agriculture, horticulture, etc. 3,829 283 4(1) 10 -(-) — 3. Mining, quarrying occupations 137 1 (-) 7.3 -(-) - 4. Non.metalliferous mining products 4,471 1,559 3 (—) 0.7 -(-) - 5. Coal, gas, coke, chemical workers 5,347 896 1 (-) 0.2 -(-) - 6. Metalwork, engineering 137,927 13,178 125(5) 0.9 3(1) 0.2 7. Textile workers 896 2,142 — (—) — 1 (-) 0.5 8. Tanners, leatherworkers, etc. 8,435 4,750 6(1) 0.7 1 (-) 02 9. Textile goods and dressmakers 26,475 71,908 23(1) 0.9 31 (3) 0.4 10. Food, drinks, tobacco makers 13,070 7,596 9(2) 0.7 2(1) 0.3 11. Wood, cane, corkworkers 35,998 1,206 34(5) 0.9 1 (.) 0.8 12. Papermakers, bookbinders, printers 21,803 11,709 14(1) 0.6 4 (—) 0.3 13. Other products (plastics, etc.) 7,876 4,485 4 (—) OS — (—) — 14. Builders and contractors 68,838 39 50(2) 0.7 .(.) — 15. Painters and decorators 34,964 1,023 41 (4) 1.2 1 (.) 10 16. Administrators, directors, managers 31,075 7,958 3(1) 01 -(-) 17. Transport and communications 162,138 18,140 168 (9) 10 11 (2) 0.6 18. Finance, insurance, commerce 103,875 58,813 80(4) 0.8 29(5) 0.5 19. Professional and technical 60,573 53,959 57(2) 0.9 43 (10) 0.8 20. Defence services 38,934 1,173 32(1) 0.8 1 (-) 0.9 21. Entertainment and sport 12,417 5,549 7 (—) 06 3 (—) 05 22. Personal services (hotels, etc.) 72,919 195,271 160 (11) 2.2 118 (18) 0.6 23. Clerks, typists, etc 96,115 167,721 94(6) 10 113 (8) 0.7 24. Packers, warehousemen, etc. 40,674 21,317 43(1) 11 4 (—) 02 25. Stationary engine drivers, stokers 12,176 83 16 (—) 13 — (—) 26. Unskilled workers (not elsewhere specified) 79,229 31,703 184 (13) 2.3 31 (3) 10 27. Other and undefined workers 13,806 4,197 17(3) 12 2 (—) 05 Total (1.27) 1,094,012 686,658 1,176 (73) 11 399 (51) 0.6 Students 25,941 19,470 45(3) 1.7 14(1) 07 Children under 15 334,401 320,134 118 (14) 0.4 111 (12) 0.3 Occupation outside U.K. 6,458 1,720 3 (—) 0.5 .(.) — Retired 78,906 27,678 138 (4) 1.7 7(2) 0.3 Unemployed or no occupation stated 26,170 726,434 258 (24) (c) 106 (18) (c) Housewives - - -(-) - 394 (48) (c) (a) Numbers in brackets are non.pulmonary cases included in the total figure. (b) Figures in italics are based on fewer than 20 notifications. (c) Rates cannot be quoted because of different uses of the terms unemployed, no occupation and housewives, in the context of census classification of employment and notifications. C 33 Table T.8—Patients on the registers*—1951.1960 At 31st Dec. 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 Pulmonary Males 19,119 17,336 18,475 18,897 19,300 19,715 19,946 20,308 19,553 19,380 Females 15,556 14,672 14,930 15,576 15,846 15,928 15,836 15,597 14,858 14,497 Other forms Males 2,520 1,530 1,508 1,442 1,371 1,339 1,274 1,293 1,158 1,163 Females 2,954 1,850 1,820 1,709 1,704 1,710 1,709 1,674 1,555 1,527 Total 40,149 35,388 36,733 37,624 38,221 38,692 38,765 38,872 37,124 36,567 No. per 1,000 of population 120 10.5 10.9 11.3 11.6 11.8 11.9 12.1 11.6 11.4 * Since 1952 figures are taken from chest clinic registers; for 1951 they represent Borough M.O.H. register. Table T.9—Summary of investigations into tuberculosis ' incidents * at Council establishments in 1960 Establishment Notified case Children Adults Tuberculin tested Positive reactors X-rayed Abnormal X-rayed Abnormal Day school Teacher 148 17 8 8 Pupil 1,044 85 85 — 171 1 Pupil — — — — 61 — Teacher — — — — 17 Pupil 356 10 10 — 15 — Teacher 69 — — — 7 Cook 91 17 17 4 — Pupil 34 1 1 — 7 — Teacher 179 11 11 1 5 — Total (9) 1,921 141 132 5 291 1 Training centre Trainee 44 4 4 Trainee 47 4 4 — — — Total (2) 91 8 8 — — — Residential school Pupil — — 185 — 62 2 College Teacher 31 9 9 2 — — Welfare home Porter — — — — 12 — Grand Total (14) 2,043 158 334 7 365 3 34 Table T.10—Summary of services provided for tuberculous patients, Administrative County of London 1956.1960 1956 1957 1958 1959 1960 Clinic registers Total on registers at the end of the year 38,695 38,765 38,872 37,124 36,567 Work of local tuberculosis care organisers Patients assisted for the first time with: Beds and bedding 240 176 165 210 123 Clothing or footwear 847 734 571 558 500 Patients at the end of the year receiving: Extra nourishment 2,183 1,938 1,875 1,714 1,558 Home help service 624 528 467 465 462 Home care and treatment At the end of the year, patients: Awaiting admission to hospital 22 34 16 16 14 Under treatment in their own homes 334 329 238 143 140 Receiving attention by home nurses 405 371 368 331 283 Home visiting by tuberculosis health visitors— Total visits (including contacts) 83,137 80,302 78,953 86,680 77,861 Diversional therapy At the end of the year, weekly classes at chest clinics 175 147 157 131 110 Receiving instruction in their own homes 239 259 262 200 180 Rehabilitation At the end of the year the Council was financially responsible for rehabilitants at: British Legion Village, Maidstone 33 29 30 19 11 Papworth Village Settlement, Cambridge 26 19 15 10 6 Enham.Alamein Village Centre, Andover 10 9 10 5 4 Barrowmore Hall, Chester — 1 1 1 1 Correspondence courses arranged through the British Council for Rehabilitation for patients undergoing prolonged treatment at home 33 20 14 10 9 At boarding open.air schools Children convalescent from tuberculosis: At the beginning of the year 12 8 6 1 — Admitted during the year 3 — — — 2 At the end of the year 8 6 1 — 2 Awaiting admission at end of year 2 — — — 1 Boarding.out of child contacts Children in nurseries and foster homes at the beginning of the year 279 172 136 94 79 Placed during the year 272 229 173 154 152 Boarded.out at the end of the year 172 136 94 79 53 Average number boarded.out at any one time 215 164 116 100 76 Boarding.out of child contacts for segregation during B.C.G. vaccination Children in nurseries and foster homes at the beginning of the year 7 4 3 9 3 Placed during the year 28 24 20 35 22 Boarded.out at the end of the year 4 3 9 3 2 Average number boarded.out at any one time 13 7 4 8 6 Hostels for homeless infective tuberculous men 103 101 In residence at the beginning of the year 58 69 77 Recommendations approved during the year 82 60 81 63 74 In residence at the end of the year 69 77 103 101 107 35 c* Table T.ll—Principal tuberculosis statistics—Metropolitan Boroughs and the Administrative County of London, 1960 Metropolitan Boroughs Estimated home population mid 1960 New notifications New notifications per 1,000 population 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 31.12.60 Cases on register per 1,000 population Pulmonary Tuberculosis of Meninges and C.N.S. Other non. pulmonary tuberculosis Total Pulmonary Non. pulmonary tuberculosis Total deaths Total Percentage of pulmonary cases positive during 1960 Division 1 Chelsea 49,140 24 1 2 27 0.55 2 - 2 0.04 0.05 361 4.8 7.3 Fulham 112,960 74 — 10 84 0.74 4 - 4 0.04 0.04 1,229 1.0 10.9 Hammersmith 108,290 98 — 13 111 1.03 6 l 7 0.06 0.07 1,528 2.1 14.1 Kensington 167,240 146 1 17 164 0.98 11 3 14 0.08 0.08 1,541 3.0 9.2 Division 2 Hampstead 98,080 65 — 10 75 0.76 4 - 4 0.04 0.05 1,180 2.9 12.0 Paddington 113,350 137 — 14 151 1.33 8 - 8 0.07 0.09 1,369 3.6 12.1 St. Marylebone 69,640 55 — 3 58 0.83 5 3 8 0.11 0.08 949 3.9 13.6 St. Pancras 127,710 135 — 17 152 1.19 12 1 13 0.10 0.11 1,143 0.7 8.9 Westminster, City of 92,940 92 1 3 96 1.03 10 1 11 0.12 0.12 739 1.2 8.0 Division 3 Finsbury 33,710 31 — 5 36 1.07 2 2 4 0.12 0.08 271 3.1 8.0 Holborn 21,000 18 — 1 19 0.90 1 - 1 0.05 0.06 261 2.4 12.2 Islington 222,940 242 2 29 273 1.22 11 2 13 0.06 0.06 2,497 1.5 11.2 Division 4 Hackney 163,050 92 — 12 104 0.64 15 1 16 0.10 0.12 1,822 2.4 11.2 Shoreditch 42,870 38 — 2 40 0.93 5 - 5 0.12 0.15 350 5.3 8.2 Stoke Newington 50,240 38 — 6 44 0.88 8 - 8 0.16 0.21 807 1.4 16.1 Division 5 Bethnal Green 47,580 34 — 2 36 0.76 3 1 4 0.08 0.08 768 1.9 16.1 City of London 4,890 7 — - 7 1.43 - - - - - 62 5.1 12.7 Poplar 63,340 41 — 4 45 0.71 10 2 12 0.19 0.21 551 1.8 8.7 Stepney 93,850 116 — 7 123 1.31 8 - 8 0.09 0.11 1,280 1.9 13.6 Division 6 Deptford 69,330 80 3 4 87 1.25 7 - 7 0.10 0.13 1,066 2.6 15.4 Greenwich 88,310 47 1 6 54 0.61 4 - 4 0.05 0.06 1,061 1.6 12.0 Woolwich 145,470 69 — 5 74 0.51 9 - 9 0.06 0.08 1,672 0.8 11.5 Division 7 Camberwell 175,020 164 2 14 180 103 15 3 18 0.10 0.11 1,012 2.3 5.8 Lewisham 221,330 119 — 15 134 0.61 10 1 11 0.05 0.06 2,669 0.7 12.1 Division 8 Bermondsey 53,510 26 — 4 30 0.56 3 - 3 006 007 636 0.8 11.9 Lambeth 224,080 137 1 8 146 0.65 15 6 21 009 009 3,407 1.5 15.2 Southwark 88,690 103 — 10 113 1.27 14 14 016 0.20 1,472 2.7 16.6 Division 9 Battersea 107,120 78 1 2 81 0.76 6 - 6 006 007 1,128 2.5 10.5 Wandsworth 338,800 213 1 11 225 0.66 27 7 34 010 010 3,736 2.8 11.0 LONDON .. 3,194,480 2,519 14 236 2,769 0.87 235 34 269 008 009 36,567 20 11.4 Table T.12—B.C.G. vaccination under L.C.C. schemes in 1959/60 1. Day schools— No. of schools visited 1959/60 373 No. of 13.year.old children at school *49,170 No. of consents *36,452 No. tuberculin tested *33,172 No. of reactors *2,706=8.2 per cent. No. given B.C.G *30,425 No. vaccinated June, 1954 to December, 1960 148,098 2. Further education establishments (colleges, etc.) No. of establishments visited during 1960 26 No. tested 2,583 No. of reactors 1,258 No. given B.C.G 1,322 3. Residential establishments— No. of establishments visited during 1960 3 No. of children tested 115 No. of reactors 13=11.3 per cent. No. given B.C.G. 102 4. Training centres— No. tested 417 No. of reactors 139 No. given B.C.G 272 5. Notifications of tuberculosis (all forms) in 14. and 15.year.old children in 1954 82 1955 (first full year after starting B.C.G.) 45 1958 38 1959 20 1960 31 6. Tuberculosis contacts— No. of contacts given B.C.G. vaccination in London in 1960 5,156 No. of contacts given B.C.G. vaccination in London since inception of scheme in 1950 41,483 7. Diabetics— No. tuberculin tested — No. given B.C.G. in 1960 — No. given B.C.G. since inception of scheme 68 * Divisional figures are shown in Table T.13 37 Table T.13—B.C.G. vaccination of school children in Administrative County of London, 1959/60 (sixth year)—Divisional figures Division No. of 13.year. old 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 0among (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 4,911 3,684 — 3,379 1,532 31.2 326 9.6 3,046 (7 negatives not vaccinated) 2* 7,669 5,724 1 5,203 2,465 32.1 616 11.8 4,579 (8 negatives not vaccinated) 3 3,507 2,104 3 1,834 1,670 44.1 186 10.1 1,641 (7 negatives not vaccinated) 4 4,205 3,290 32 2,933 1,240 29.5 248 8.4 2,679 (6 negatives not vaccinated) 5 3,913 2,737 2 2,518 1,393 35.6 208 8.2 2,308 (2 negatives not vaccinated) 6 4,540 3,357 41 3,066 1,433 30.1 179 5.5 2,885 (2 negatives not vaccinated) 7 8,267 6,283 44 5,578 2,645 32.0 348 6.2 5,230 8 5,496 4,115 17 3,848 1,631 29.7 280 7.3 3,568 9 6,662 5,158 38 4,813 1,811 27.3 315 6.5 4,489 (9 negatives not vaccinated) Totals .. 49,170 36,452 178 33,172 15,820 32.3 2,706 8.2 30,425 * Includes remainder of 1958/59 programme. GENERAL PUBLIC HEALTH Housing The Council has set aside a small number of dwellings for the rehousing of families on purely medical grounds. The following table shows the cases dealt with in the four years the scheme has been in operation in its present form: 1957 1958 1959 1960 (a) Tuberculous persons Recommendations received 421 321 275 232 Nominated for rehousing 185 151 185 209 Recommendations not qualifying for rehousing 135 132 114 93 Under consideration at end of year 101 139 115 45 (b) Persons with severe medical conditions Recommendations received 2,484 2,474 2,689 3,357 Nominated for rehousing 226 478 418 607 Recommendations not qualifying for rehousing 1,904 1,617 1,951 2,503 Under consideration at end of year 354 733 1,053 1,300 Work in connection with unfit houses during the past five years is summarised below: 1956 1957 1958 1959 1960 Slum clearance Areas represented as unfit for human habitation. 70 90 77 27 48 Houses in such areas 3,436 2,409 1,830 660 1,356 Areas surveyed but not represented by the end of the year 111 81 11 13 39 Houses in such areas 3,255 2,004 312 641 1,291 Public local inquiries 37 28 36 37 42 Informal hearings 4 4 2 1 1 Orders confirmed (i) after inquiry or hearing 28 45 33 42 41 (ii) without inquiry or hearing (no objection received) 9 13 14 28 15 Orders not confirmed by Minister 1 1 1 3 1 Improvement grants Surveys following applications to the Council 92 68 119 160 1,178 Searches following applications to metropolitan borough councils 193 158 103 346 572 Dangerous structures Premises scheduled as dangerous—searches made 1,439 1,094 1,229 1,013 * * The functions with regard to dangerous structures were, by the London County Council (General Powers) Act, 1958, transferred to the metropolitan borough councils as from 1 January, 1960. During the year surveys in connection with the preparation of the third post-war quinquennial (1961-65) slum clearance programme were completed. Approximately 11,000 houses were agreed with the metropolitan borough councils as suitable for inclusion in the programme. Public Health Laboratory The facilities at the Medical Research Council's Public Health Laboratory at the County Hall and the close co-operation with its staff have continued to be of great value. Milk sampling Since 1908 it has been the practice of the Council to take samples of liquid milk arriving by road or rail from the provinces and to submit them to biological examination to ascertain the extent to which the milk on its arrival in London is infected with tuberculosis. The medical officers of health concerned have been informed of any samples found to be infected. In view of the Tuberculosis Eradication Scheme which now covers most of the 39 areas from which London milk comes and of the fact that the majority of milk is pasteurised before sale, it was decided at the end of 1959 that in future sampling should be concentrated mainly on farm bottled milk. A representative number of samples of pasteurised milk, however, is taken and submitted to a phosphatase test. If this test fails a biological test is carried out. The following table shows the results of tests during the year: Designation Samples examined T.B. bacillus isolated T.B. bacillus NOT isolated Passed phosphatase test Tests not completed* Tuberculin Tested (Farm Bottled) 49 — 47 — 2 Tuberculin Tested† 4 — 4 — — Pasteurised 20 — — 20 — Total 73 — 51 20 2 * Milk curdled or guinea pigs died before completion of test. † Samples from a residential school which has its own farm. Milk purchased for use in Council establishments: 1957 1958 1959 1960 Liquid milk: samples taken by boroughs and county councils 1,162 947 910 589 Number found to be unsatisfactory 3 7 11 — Dried milk: samples submitted to bacteriological examination 4 4 4 3 No samples contained more than 100,000 organisms per gramme, nor was staphylococcus aureus isolated. Sanitary inspection The public health inspectors dealt with the following matters in Council establishments: 1957 1958 1959 1960 Reports of infestation by a variety of pests 178 190 207 274 Visits and re.inspections involved 294 347 472 506 Inspections of school meals centres 420 375 362 341 Investigations of illness following consumption of school meals 15 12 7 8 Occasions when the meal was found to be the cause 2 3 2 2 Blind and partially.sighted persons During the year, 1,758 examinations—17 more than in the previous year—were made in connection with certification under the National Assistance Act, 1948, of blind or partially.sighted persons and 44 persons were found to be neither blind nor partially.sighted. In addition, 439 certificates were accepted from other local authorities, hospitals and private ophthalmologists—69 more than in the previous year. The percentage of new registrations recommended to obtain treatment was 57.7 per cent, compared with 57.0 per cent, in 1959. The results of examinations of persons newly registered during the year are given in tables (i) and (ii). 40 Table (i) Number of new registrations during the year with percentage recommended to obtain treatment Age Principal cause of defective vision Cataract Glaucoma Retrolental fibroplasia Other conditions Total 0-4 years 3 - - 5 8 5-15 years 1 — 2 5 8 16-64 years 47 27 — 161 235 65-74 years 84 28 — 185 297 75 years and over 224 34 — 357 615 Age not known 1 — — 4 5 (a) Total No. of persons 360 89 2 717 1,168 (b) No. recommended to obtain treatment 252 69 2 351 674 (b) as percentage of (a) 700 77.5 100.0 49.0 57.7 Table (ii) Number of treatments recommended in respect of newly registered persons* No. of patients examined Treatments recommended Optical Hospital supervision None Medical Surgical Early Later V general condition permits Cataract 360 108 30 56 28 25 15 148 Glaucoma 89 20 16 1 — 1 5 63 Retrolental fibroplasia 2 — — — — — 1 1 Other conditions 717 366 70 19 19 8 50 249 Total 1,168 494 116 76 47 34 71 461 * Includes cases recommended more than one form of treatment. Persons recommended to obtain treatment are re.examined at intervals after the initial registration. The number of persons re.examined for this reason in 1960 is shown in table (iii) Table (iii) 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 180 47 1 352 580 No. found to have had treatment 139 41 — 187 367 Percentage treated 77.2 87.2 — 53.1 63.3 As a consequence of successful treatment, 15 persons previously registered as blind were found, on re.examination, to be partially.sighted and 11 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 27. 41 Registration of nursing homes 1956 1957 1958 1959 1960 Registered at beginning of year 41 39 38 37 34 New homes registered 1 — — 1 — Homes registered on change of keeper — — 1 2 3 Registrations cancelled—voluntary closure or change of keeper 3 1 2 6 4 Regist ered at end of year 39 38 37 34 33 Inspections medical officers 60 51 41 42 35 public health inspectors 102 96 50 63 84 Homes exempted from registration 37 39 38 38 40 The 33 homes registered at 31 December, 1960 provided the following accommodation; Number of beds in homes Number of homes Number of beds provided Maternity* Others† Total 25 or over 9 206 219 425 20 to 24 5 25 82 107 15 to 19 7 17 100 117 10 to 14 7 12 75 87 5 to 9 4 13 16 29 Under 5 1 — 4 4 Total 33 273 496 769 * 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. Welfare Committee establishments Medical supervision of establishments of all types under the control of the Welfare Committee was continued. The number of designated chronic sick in welfare homes has remained fairly constant. Close liaison with geriatric units of the hospital service is maintained by the visiting medical officers of the homes with a view to making arrangements for the exchange of suitable cases. The problem, however, is complex. Men and women who have been resident for many years in a welfare home and ultimately become chronically sick would not necessarily benefit from transfer to a hospital ward, even if sufficient beds were available. An experimental scheme of regular visits by a consultant geriatrician to one of the Council's homes seems to confirm this view. Invalid meals for London For many years the Council has made a grant.in.aid to Invalid Meals for London, a voluntary body providing meals for invalids and sick persons. Meals are supplied, on the production of a medical certificate, to sick persons including the aged, expectant and nursing mothers, persons discharged from or awaiting admission to hospital, cripples and invalids, etc. e.g. diabetics, requiring special diets. Meals are delivered by motor van to the homes of patients unable to attend the dining rooms attached to five centres. Details of the service provided is shown by the following figures: 1956/7 1957/8 1958/9 1959/60 1960/1 Grant.in.aid £11,500 £11,500 £17,500 £17,163 £21,500 Meals served 187,578 174,011 167,134 172,637 180,291 42 SCIENTIFIC BRANCH This branch provides a scientific advisory service for all departments of the Council. It has, therefore, to cover a very wide field, not only in chemistry and physics, but mycology, microbiology and other applied sciences. The work required to answer the questions and provide a solution of difficulties may vary from simple analysis of material to lengthy research into the problem. The type of ' domestic' question that occurs in the service cannot be answered from a text.book and only those with both a knowledge of how science can be applied and the conditions in the service are in a position to help. The headquarters laboratory at the County Hall covers the following main subject headings: (i) Research and development, noise, air pollution, environmental radioactivity, ventilation, fire precautions and investigating industrial hygiene. (ii) Building materials and development work, flooring and floor maintenance, insecticides and fungicides, plastics, metals. (iii) Trade wastes, drinking water, boiler water, inleakage water and other water problems, steam raising plant, fuel, heat insulation materials. (iv) Paint and decorative materials. (v) Detergents, laundries, swimming baths and all ancillary problems. (vi) Food, drugs, medical and general supplies. 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 process and ancillary plant together with research on projects potentially useful to this branch of the service. Close liaison is maintained with officers in Government departments, research organisations and scientific societies, and the Scientific Adviser and other senior officers are members of a number of committees under the auspices of other bodies. The staff of the branch numbers 73, comprising 33 graduates, 34 ancillary staff and six in a clerical section. A summary of the activities of the branch which have a direct or indirect application to the field of public health is given below. This year the summary is not in such an abbreviated form as usual and mention is made of some of the more uncommon facets of the work. Full particulars may be found in the annual report of the Scientific Adviser.* Synopsis of work done The total number of samples examined was 42,090, approximately 6,800 more than in 1959; nearly all the increase is due to the analysis of air samples made necessary by the safety precautions taken at the new plant at the Northern Outfall Works against the possibility of leakage of inflammable sludge gas. The general distribution otherwise is roughly the same as in previous years, showing a fairly constant demand for information over the whole wide field. The figures exclude much advice, not necessarily associated with analytical work, which is an important function of the branch and is given by the senior professional officers. Liaison with user departments is of prime importance, because it is essential that the branch should be consulted at an early stage when difficulties occur and only by an understanding of users' problems can answers be found which can be applied economically. The number of samples examined is summarised below: following sections deal in greater detail with some aspects of the work. * Annual Report of the Scientific Adviser for the Year 1960, The London County Council, price Is. 3d. 43 Air—Safety tests (Northern Outfall) 5,940 Air—tunnels 255 Building materials 872 Chemical, drugs and medical supplies 63 Clays, sub.soils and borehole waters 2,580 Detergents and soaps 170 Fertilisers and feeding stuffs 83 Floor oils 83 Foods 596 Gases from sludge digestion plant 371 Instrument sets (ambulance) for sterilisation 114 Lamps, gas detector 605 Laundry tests 102 Liquor (effluent from Beckton Gas Works) 721 Meals 56 Miscellaneous 570 Oils, lubricating and fuel, etc 48 Paints, varnishes and distempers 1,905 Petroleum and allied samples 58 Rain water (atmospheric pollution deposit gauges) 80 Rubber and rubber substitutes 144 Sewage and effluent 2,800 Sludge, primary and digested 1,996 Sludge, activated 1,946 Smoke in air, determinations 4,153 Sulphur gases in air, determinations: Lead peroxide cylinder method 129 Volumetric method 4,255 Trade effluents 2,178 Water, etc., from steam raising plants 1,054 Water, chemical and bacteriological examinations: Drinking water 841 Swimming baths 2,112 River water 2,955 Water, miscellaneous 59 Research and investigation samples at Northern and Southern Outfall Works 2,196 42,090 Sewage treatment The scientific work on this subject is carried out in close collaboration with the staff of the Chief Engineer. Officers of the two departments work side by side at both outfall works and have daily consultations and exchanges of information; the Scientific Adviser and the Divisional Engineer in charge of main drainage hold weekly meetings, at which analytical results and research progress are discussed and policy of operation and ways and means of improving efficiency are considered. Early in the year the modernising of laboratories and offices at the Northern Outfall Works was completed and up-to-date and time-saving equipment installed. This greatly improved the facilities for investigating, on both laboratory and pilot plant scale, problems associated with the operation of new and greatly enlarged treatment works. A brief survey of the work carried out at the laboratories at both outfall works follows: NORTHERN OUTFALL WORKS LABORATORY— Primary sedimentation—This is effected mainly in the new tanks installed in 1955. An exceptionally rainy summer caused a marked increase in the average daily flow to the works, and it was necessary to settle about one.sixth of the total flow in the old sedimentation channels. The sewage admitted to these channels is considerably stronger than that entering the new sedimentation tanks because of the position of the incoming sewers. Although the detention period in the old channels is sufficient to permit of a high percentage 44 removal of solids, the effluent is of appreciably poorer quality than that from the new plant. The very substantial improvement in the primary sedimentation effluent since the installation of the new tanks has been continued, a slight increase in the primary effluent suspended solids load reflected the incidence of increased flows of slightly stronger sewage. The percentage removal of suspended solids was similar to that in the previous year and there was an appreciable increase in the percentage of the biochemical oxygen demand load which was removed. Secondary treatment—The paddle-type activated sludge plant continued to operate throughout the year. The influent to this plant was supplied from the old sedimentation channels and was of much greater suspended solids content and strength than in the previous three years; this caused some deterioration in the quality of the effluent from the paddle plant, although the total removal of pollution load was greatly increased. For most of the year the activated sludge solids concentration in the mixed liquor was appreciably greater than the average and this increase in sludge solids was probably largely responsible for the increased removal of polluting material from the influent. At the beginning of the year two units of the diffused air plant, which had been brought into service in September, 1959, were in operation. Other units were added at short intervals and by the middle of February the whole installation of six units was in use. Few difficulties were encountered in operating this plant and the results over the whole year were very satisfactory. The activated sludge was generally of very satisfactory settling characteristics, of good colour and smell, and contained good numbers of representative activated sludge organisms. Sludge digestion plant—The new sludge digestion plant was in full operation by the second quarter of the year; each of the 16 primary digestion tanks treating approximately 200 tons of mixed crude and activated sludge daily. The starting up of the plant occasioned little difficulty, partly because the use of stored seeding sludge on a large scale and the daily addition of only small amounts of fresh sludge avoided the occurrence of an acid phase of digestion. In the early weeks of operation gas production was unusually high in relation to the charges as a result of gas evolution from the seeding sludge, but a short time after all the primary digestion tanks had been in service under normal operating conditions the gas production stabilised at about 2.5 million cubic feet per day but occasionally reached nearly 3 million cubic feet. This performance, except during periods of temporary reduction of charges, was well maintained during the year. The results from this plant differed appreciably from those of the earlier plants; the total solids content of the ingoing sludge was appreciably less and the organic content considerably greater, because of the increased proportion of activated sludge in the daily charges, and the organic content of the digested sludge was correspondingly greater. The new digestion plant appeared to be very efficient; after conditions had stabilised the volume of gas produced per pound of organic matter digested was about 25 per cent, greater than in the original pilot plant and over twice as great as in the old reservoir plant, although the carbon dioxide content of the sludge gas showed a slight increase. Regular daily gas safety tests were carried out at all potentially hazardous points at the sludge digestion plant and in the new power house. These tests, for which a portable detecting device was used, gave early warning of small leaks and enabled them to be corrected before they became dangerous. Special investigations on the sludge digestion plant and the power house, connected with problems of safety, corrosion, foaming and on the composition of the gas used in the turbines, were undertaken as required. Effluent liquors from the North Thames Gas Board—The daily examination of effluent liquors discharged into sewers from the Beckton Products Works of the North Thames Gas Board was continued. 45 SOUTHERN OUTFALL WORKS LABORATORY— The work at this laboratory consisted of analysing sewage, effluent and sludge for works control and calculating the load placed on the river by the discharge. Advice was also given on any scientific problems which arose with the ancillary plant and samples submitted included waters and scale deposits. This laboratory has specialised in the determination of hydrogen sulphide in the atmosphere and in solution and of small concentrations of metals in sewage, effluents and sludge. River Thames The condition of the river is a matter of great importance to the Council and since 1893 samples of the water from midstream off both sewage outfall works have been collected daily for analysis. In recent years a systematic scheme of sampling and examination had been built up whereby, in addition to daily samples from both outfalls, weekly samples were taken at twenty.four other points from Kew down to the sludge dumping area in the Black Deep in the estuary. In the early part of 1959 a modification was made in the sampling arrangements for the lower river; instead of weekly examination at high water at all points below the Southern Outfall Works, examinations have been made of high water samples one week and low water the next, collected at various points between the Northern Outfall Works and Mucking. These runs were designed to obtain information about the condition at Mucking, as nearly as possible at dead high or low water. On one week in each month the examination is extended from Mucking to the dumping area on a high water run in one of the Council's sludge vessels. Once a fortnight the fresh water coming over Teddington Weir into the tidal portion of the river is analysed. In order to assess the condition of the water at any time and compare its state as it varies between the seasons of the year and over periods of years, a full chemical analysis is made. Bacteriological work is also carried out. This information is necessary to ascertain changes in the general condition and to determine trends when factors such as the flow of fresh water are taken into account. The most important determination made is that of the dissolved oxygen. This dissolved oxygen is continuously being absorbed by any oxidisable matter present in the water, whilst the rate of solution of oxygen from the air by the water depends on the temperature, the wind, the presence of impurities and other factors. If the former process requires more oxygen than is present or can be absorbed, putrescent conditions will arise and then the sulphate.reducing bacteria present will produce hydrogen sulphide from water soluble sulphate. The summer of 1960 was unusually wet, with the result that, at all times, the fresh water flow over Teddington Weir was above average and towards the middle of September began to rise to volumes which were well above those expected for the last quarter of the year. The summer quarter, July to September, with its higher air temperatures and reduced upland flow, is normally the critical period; in both these respects the summer quarter of 1960 was exceptional. The average daily fresh water flow over Teddington Weir was 602 million gallons—52 per cent, greater than the average flow taken over the past fifteen years. At no time did it fall to 300 million gallons a day and by September it had risen to above 1,000 million gallons a day, a flow reached in September in only one year, 1958, in the past 30 years. A survey of the analytical results during the year leads to the following conclusions: (a) By comparison with conditions during the previous ten years the river showed an improvement throughout the year, particularly during the summer quarter. At both high and low water dissolved oxygen was present at all points, a condition not equalled during any of the previous ten years. 46 The year was similar as regards weather to 1958, but compared with that year, the river showed a noticeable improvement. The improvement in the condition of the river off the Northern Outfall, first noted in 1958, has continued and the suspended solids, permanganate value and biochemical oxygen demand have all continued to decrease, whilst the nitrate shows an increase. (b) The incidence of sulphides in water devoid of oxygen was the lowest recorded since regular determinations of sulphide were started in 1953. The total number of samples, taken at high and low water off both outfalls, which were found to contain sulphide was the lowest recorded, with the exception of 1958. (c) The numbers of sulphate.reducing bacteria in river muds were very much smaller than in 1959, and appreciably smaller than in 1958. This was due in part to the large upland flow and in part to the generally improved condition of the river. (d) For the summer quarter the average temperature of the river water off both the Northern and Southern Outfall Works, at both high and low water, was unusually low. The high fresh water flows and low temperature during the summer quarter, July to September, were undoubtedly responsible in some measure for the improved condition of the river. They were, however, insufficient to account wholly for the improvement, which was, in some measure, quite certainly due to the improvement in the effluent discharged from the Northern Outfall Works. Sewers Trade waste discharges—It has become evident from contacts and from enquiries following the publication of last year's Annual Report of the Scientific Adviser that manufacturers are keenly interested in the requirements of the Council with respect to trade waste discharges. The Act which gives the Council powers to control the discharge of trade effluents to sewers is the London County Council (General Powers) Act, 1953, Part II and under the heading ' Certain matters not to be passed into Sewers ' section 5 gives general definitions of such matters. With few exceptions the provisions are stated in the widest terms and have to be interpreted by those concerned with its administration in the light of their knowledge and experience. It is a guiding principle that, while the limits imposed shall ensure the safety of men in the sewers and of the structure of the sewers, they shall not be unduly restrictive to the operations at traders' premises. In this respect also, the size and extent of the London Main Drainage system permits the reception of some matters such as metals in solutions in much greater quantity than would otherwise be the case. The 400 miles of L.C.C. main sewers and 2,000 miles of local sewers act in effect as balancing tanks, so that the sewage arriving at the two treatment works remains of relatively constant composition and is not subject to sudden surges of trade waste. The remainder of the provisions of the Act are mainly concerned with preventing damage to sewers and danger to men working in the sewers near to or downstream of the sewer connections discharging trade wastes. During the year under review 2,600 samples in connection with trade waste discharges were examined. Of this total, 294 were from or to the river Wandle and also from the river Ravensbourne and its tributaries. There was no recurrence during the year of discharges to the Wandle which in 1959 caused odour nuisance. The condition of the Wandle showed some improvement and, with improvements at sewage works on its banks and of the diversion of a works discharge to the main drainage system, further improvement in the condition of the water can be expected. Sampling of the river Ravensbourne was started during the year consequent on the London County Council assuming responsibility for the river within the county limits. Generally the river shows the presence of some well oxidised sewage effluents: the strength is about a quarter that of the river Wandle. 47 In addition to samples of trade wastes discharged from premises, 98 samples were obtained from sewers in connection with unsatisfactory discharges from premises, in order to determine the effects of such discharges when diluted in the normal flow of sewage. Besides the samples of discharges to the Council's main drainage system, samples of discharges to local sewers were submitted by eleven metropolitan boroughs. Foodstuffs The many varieties of foods submitted for examination fall into three main groups; tender samples for contracts, ordinary deliveries (including a number examined at the request of certain hospital boards) and samples of doubtful quality, or giving rise to complaint, received from the Supplies department or user departments. Tender samples are examined for conformity with London County Council specifications or recognised standards, in order to select the cheapest satisfactory offer or to secure the best value for money. Where a specification is not thought desirable the examination is directed to secure good quality combined with any particular property desired by the department concerned. An exhibition of foodstuffs was arranged by the Children's and Supplies departments in conjunction with their catering conference on 1 April and the branch contributed a stand showing methods of analysis of school meals as well as specimens under microscopes. School meals Fifty.two samples of midday meals classified under three age groups were examined in the course of the year. The minimum standards applied to the three age groups are: Age Calories Protein Fat Calcium Above 11 years 800 20 gm. 25 gm. 400 mgm. 7.11 years 650 Under 7 years 500 The average amounts of the principal nutrients contained in the meals showed very little change from last year and exceed or satisfy all target requirements, except for slight deficiencies in the calorific values for the two older groups. Second helpings are generally available and children taking them will naturally obtain higher amounts than those mentioned, which are based on the analyses of single portions. Two series of meals covering 24.hour periods at residential schools were analysed as part of routine inspections by the Education Officer's department. Milk Samples of milk purchased by the Council for consumption in its schools, nurseries, hostels and other establishments are examined regularly to ensure compliance with the standards prescribed by the regulations under the Food and Drugs Act, etc. Enforcement is the responsibility of the local food and drugs authorities and reports are received from the metropolitan borough councils and several local authorities outside London; where supplies to Council establishments are not otherwise reported, samples are obtained regularly and examined in the County Hall laboratory. Drinking water Care is taken to ensure that the water supplies to Council establishments are of a satisfactory quality, by regular monthly inspection and sampling at 15 establishments where the supplies are drawn from private wells. Before use the water from these wells is chlorinated by means of automatic dosing apparatus. Well supplies at some of the hospitals formerly under the control of the Council have continued to be inspected and sampled. 48 Visits were also made to other premises to investigate particular complaints, to check the suitability of water supplies from other sources and to give advice. Of the total samples 402 were examined bacteriologically, 65 chemically and 374 for free chlorine content. In spite of long periods of wet weather there was no serious contamination of well supplies due to percolation of ground water. In only one case was it found necessary to take the well out of service because of heavy contamination. Air pollution The Council continued its long.standing co.operation with the Department of Scientific and Industrial Research in investigating the incidence of air pollution, by maintaining regular observations of the degree of pollution of the atmosphere over the county. Measurements at the Godalming site were discontinued but responsibility was taken for the analysis of samples from a new site in south.east London; the number of sites remained at 21. The following instruments were in use: Eleven of the lead peroxide type, which measure the amount of sulphur dioxide absorbed on a reactive surface during a month's exposure. Seven deposit gauges, which collect falling dust, soot, rain and constituents carried down by the rain. Twelve instruments of the daily volumetric type, which provide an accurate measure of the average concentrations of sulphur dioxide and ' smoke' in the air over much shorter periods than a month. The usual sampling period is 24 hours, but this may be shortened when required, as during fog. Opinion is consolidating that the volumetric method provides the most useful index of pollution. Experiments are now in hand to see if volumetric apparatus, controlled by a process timer to run intermittently over long periods, might be used to replace the lead peroxide instrument at sites where monthly averages only, obtained with a minimum of labour, are deemed sufficient. Results obtained by the volumetric method during the year show that the steady reduction in the smoke pollution of London's air, noted since the inception of the Clean Air Act in 1957, has continued. The average concentration of smoke was about 30 per cent, below the levels of 1955 and 1956; if the winter months alone are considered the reduction was about 35 per cent. Undoubtedly a succession of mild winters has contributed to this success, but it remains to be seen how far the figures would revert in the event of a hard winter. The reduction in the average sulphur dioxide concentration over the same period has been much smaller, less than 10 per cent (nearly 15 per cent for the winter months); there was no appreciable difference between this and the previous year. The Clean Air Act was not expected to influence the sulphur dioxide level, which must remain largely dependent upon the quantity and sulphur content of the fuel consumed. At St. Paul's Cathedral, where volumetric measurements have now been in progress for over two years, the reduction in sulphur dioxide during the winter months has been slightly greater than the general average over the same period. This is ascribed to the closing down of the old Bankside ' A ' power station, the flue gases from which were unwashed. There was no occurrence during the year of the conditions known as ' smog '. On only two occasions, during fog in January and December, did the concentration of sulphur dioxide exceed 40 parts per hundred million in parts of central, south and west London. There was far less smoke than has been associated with such concentrations in the past and the fogs persisted for less than two days. Other fogs occurring during the year did not become badly polluted. Regular visits were made in company with the District Alkali Inspector of the Ministry of Housing and Local Government to test the efficiency of the flue gas washing plants at Battersea and Bankside power stations. 49 D Environmental radioactivity Experimental studies were continued with the object of obtaining reference data on environmental levels of ionizing radiation and to determine the extent of any contamination which might arise through the widespread applications of nuclear science. Such contamination could result from reactor accidents in this or neighbouring countries and more locally from unguarded use of radio.isotopes or careless disposal of wastes, quite apart from fallout from nuclear weapons. Continuous monitoring of the atmosphere was again maintained and no significant additions of radioactivity or other disturbing features were observed during the year. Compared with previous years, there was a marked reduction in the amount of radioactive matter reaching the lower atmosphere from the residue of old fission products still suspended in the stratosphere. A national survey undertaken by the Agricultural Research Council has provided figures for the amount of strontium.90 which occurs in human diet. The determinations have been made on particular classes of food such as meat, vegetables, cereals, milk and its products, etc.; by making allowance for losses in preparation, and the average quantities used in diet, an estimate can be made of the amount consumed. It was thought that the alternative approach of making direct determinations on complete meals would be of value and a limited investigation on these lines was undertaken in the L.C.C. laboratories during the year. The samples examined were complete two.course midday meals taken at random from those being served to L.C.C. schoolchildren. Meals from three different kitchens were bulked for the analysis. The figures applying to samples taken in 1960 were lower than those calculated from national data for the preceding two years; this difference probably reflected the decreased deposition of strontium.90 during 1960, and also the fact that the strontium content of foods available in the London area tends to be lower than the national average. Another direct responsibility of the Council is that of ensuring safe conditions in sewers receiving radioactive discharges. Hospitals are at present the largest users of such disposable matter in the London area, although there is growing use in industrial and research laboratories. Investigations on these aspects were undertaken. Swimming baths and ponds The Council has under its control 13 swimming baths and three bathing ponds for public use and 30 baths situated at schools and institutions: of these 24 are sited outdoors and 22 indoors. It is the Council's policy to equip all the baths with complete purification plants and during the past year three further complete purification plants were installed, bringing the total to 33. Two of the new installations have diatomaceous earth filtration, installed by parent.teacher associations and taken over by the Council for running and maintenance. Three more baths have plant for gas chlorination and circulation only and seven are chemically treated by hand. The Scientific Branch collaborates with the staff of the Chief Engineer, the Chief Officer of the Parks department and other interested departments to ensure efficient water treatment. A careful check is kept on the condition of the water by means of daily tests by the bath attendants. These results are embodied in weekly returns made to the branch. Visits by officers of the branch to each bath are made at four.weekly intervals for inspection, testing and sampling. During 1960, 348 samples of water were examined chemically, 690 bacteriologically and 984 chlorine and clarity tests were made. As an example of the efficiency of treatment the figures obtained from 13 fully equipped public baths during the five months summer season may be quoted. These baths are filled with water from the Metropolitan Water Board mains and are emptied and refilled only once a year. The weather during the summer of 1960 was not as good as the previous year and consequently the baths were not so heavily used. During this period about 800,000 people used the baths compared with a figure of 1,750,000 during 1959. The minimum recorded clarity was 10 feet, whilst the maximum was 150 feet. 50 Open air swimming baths in London Parks (Summer 1960) Summary of bacteriological examinations Standards Agar count 1 ml. 37°C. 48 hrs. Presumptive coliform pollution without faecal Faecal coliform pollution 0-10 11-100 Over 100 Number of samples 106 12 2 4 4 The incidence of coliform pollution was due to temporary features such as plant breakdown and was speedily rectified. During the 1960 winter season 10 of the open air baths were in constant use. These baths were regularly treated with the supernatant liquid extracted from bleaching powder. The total number of bathers during the winter season was about 30,000 and it is of interest that at this level of bathing concentration the treatment used could regularly ensure waters with clarity of more than 20 feet. The baths at schools and institutions vary in size from 10,000 to 100,000 gallons. Many of them are used by other organisations and councils. The annual lectures to bath superintendents and attendants on swimming bath water treatment and testing were given by a member of the Branch. These lectures proved most useful, particularly as an opportunity for discussing possible improvements and problems which have arisen during the preceding summer season. The treatment and testing of the water at the 45 paddling pools in the Council's parks has been standardised and research work has commenced to investigate the possibilities of improving this treatment by the use of quaternary ammonium compounds. Ventilation of vehicular tunnels Weekly tests are made of atmospheric conditions in Blackwall and Rotherhithe tunnels at times when the tunnels are carrying heavy traffic. This information assists the Chief Engineer to assess the degree of forced ventilation needed. More than 1,000 vehicles an hour pass through each tunnel during much of the day. In periods of congestion vehicles are subjected to frequent braking and acceleration; these conditions favour an increased output of exhaust pollutants, thus making great demands upon the ventilation system. The measurements made during the year showed that, in general, the exhaust gases in the atmosphere of each tunnel were diluted to a tolerable level in respect of toxic components. The amount of black suspended matter, for which there is no recognised standard, was unpleasantly high at times in both tunnels. Heavy vehicles of the diesel type, though producing relatively little carbon monoxide, can be prolific sources of smoke unless properly maintained and correctly driven. A bad form of driving, which has a particularly marked effect on the confined atmosphere of a tunnel, is the use of excessive fuel injection instead of the appropriate gear-change when mounting long upward slopes. Towards the end of 1960 the Minister of Transport stated that he was considering amending the law to prevent the misuse of the excess fuel device. Disinfectants Samples of disinfectants supplied under contract were regularly examined to ensure conformity with specification in regard to germicidal power, emulsion stability and freedom from staining action on linen. 51 D* Certain proprietary bactericides were considered for use in sterilising babies' nappies and soiled clothing with a view to obviating the necessity of boiling. They depend primarily on the action of chlorine, but may be assisted by the presence of detergents and chlorophenolic compounds. The effectiveness of any such chemical depends on the complete removal of solid matter adhering to the nappies. If this is not achieved, chemicals in solution are unable to penetrate or will be inactivated by the organic matter encountered. With properly conducted boiling there is no such uncertainty; any suspended matter left behind is rendered harmless. The value of some recently introduced ingredients in germicidal soaps and creams for pre-operational use was discussed in a memorandum to a hospital management committee. Plastic containers designed for sterilising feeding bottles and teats in a chlorine solution were of high density polythene and were considered perfectly suitable for this purpose as such solutions are always used cold. At the temperature of boiling water slight softening would occur and prolonged boiling or higher temperatures could lead to appreciable deformation. Insecticides and fungicides Many different insects and a few examples of moulds and fungi were submitted during the year for identification and for advice as to eradication or control as necessary. Frequently the insect concerned is completely harmless but the enquirer naturally wants to know what it is and whether any action is desirable. In case of undesirable infestation the Chief Inspector is normally approached and his help sought in dealing with the trouble. For general use fly-sprays based on synergised pyrethrine and dieldrin have again been used and are still found to be effective. For treatment of wood-borers ('woodworm', 'furniture beetle','powder-post beetle', etc.) continued use has been made of preparations based on chlorinated phenols and other chlorinated hydrocarbons rendered penetrating and long lasting by the addition of certain oils. For eradication of fungi, pentachlorphenol preparations have again been used successfully. During the year an exceptionally large number of enquiries were received concerning the removal of lichen or algae growths from roofs: though they may be considered unsightly such growths are, on the whole, harmless. In bad cases they may hinder run off of rain water and certainly delay drying out of the roof covering: this could result in increased frost damage in winter. Removal was usually effected by treatment with sodium pentachlorphenate solution. Chemicals, drugs and medical supplies Many types of article and substances are received for investigation and analysis and information is often sought on the suitability of materials for special purposes. A number of requests for assistance were made in handling chemicals involving an element of danger to persons or property if appropriate precautions are not taken. Some examples of investigations are: (a) Samples of halibut and cod liver oils and other vitamin preparations were examined to check potency and acceptability and, in one or two instances of old stocks, suitability for use. (b) An investigation was made of the properties of teats for artificial feeding of infants. Several well known makes of rubber teats were examined with a view to selecting those which most nearly approached the ideal. The features taken into consideration were— (i) quality and elasticity of the rubber, (ii) the rate of flow of water through the teat both before and after boiling for an hour, (iii) uniformity of size and weight, (iv) the ease of cleaning. 52 Different teats tested when new and at a similar pressure showed a wide variation in flow rate; boiling tended to reduce the rate of flow. The presence of rims and flanges was found to be a hindrance to cleaning. The effect of different methods of sterilisation in the useful life of a teat was also studied. Teats placed in a covered jar on a rack in a domestic pressure cooker showed the least deterioration but some teats developed a rather unpleasant smell. The use of hypochlorite solution for sterilisation caused less damage than did boiling. For the purpose of contract the quality and useful life have to be considered in relation to the price. (c) Sterility tests were carried out on the components of maternity sets with satisfactory results, but sheets of various types of cellophane, which were being considered as temporary covers for burned surfaces, were found to carry a few aerobic organisms on receipt from the makers. They were not, however, heavily contaminated. Industrial safety and hygiene Advice was given on several matters coming under this general heading. Amongst these may be mentioned the following particular cases: Crayons and pencils—The observation, published last year, that crayons and grease pencils sometimes included poisonous ingredients roused considerable interest amongst other authorities concerned with the health of school children and the supply of educational equipment. Enquiries were also received from the makers of certain crayons and pencils as to whether wood-cased pencils were under discussion as well as unprotected crayons. It is now apparent that instances have occurred where both coloured and black lead pencils in wooden cases have been lacquered externally with paints containing large proportions of lead chromate. As there is a common tendency for children to suck or chew their pencils there can be little doubt that in these cases pencils could be responsible for some part of the intake of lead which may ultimately develop into symptoms of lead poisoning. As an indication of the seriousness of this matter it may be mentioned that the lacquer on a single pencil has been found to contain up to 250 mgm. of lead. There is of course no need to incorporate any poisonous ingredient in these lacquers and no difficulty has been found in securing innocuous supplies by asking for them specifically. For this reason consideration has been given to formulating tentative limits for the amounts of certain poisons that would be permissible, and it is thought that a limit of 10 mgm. of metallic lead in the lacquer of a pencil would be reasonable. This would be in close alignment with practice in the United States of America where there is prohibition of all paints containing more than one per cent of lead in the 'ready for use' condition. A similar limit would be desirable for soluble chromium, thus allowing the use of insoluble chromic oxide; and also for soluble barium (allowing insoluble barium sulphate as extender). It is further suggested that the lacquer of a pencil should not contain acidsoluble antimony, arsenic, soluble cadmium, or selenium in excess of 10 mgm. These limits may be reduced if more than one poisonous constituent is present. Disposal of dangerous chemicals—Surplus chemicals including cyanide from schools and colleges which had undergone reorganisation were collected for safe disposal or other use. Considerable quantities of dangerous chemicals were removed from a disused pharmaceutical chemical works. At another works a large quantity of cyanide in solution was destroyed by careful oxidation with bleaching powder. Dangerous chemicals must not be put into the sewers and in some cases burning is not a safe means of disposal. Disposal of unwanted chemicals cannot be undertaken by refuse collection services of local authorities and it would appear that a special service is required. 53 Noise and acoustics During the last few years there has been growing public concern about the increase in the volume of noise in everyday life and in November, 1960 the Noise Abatement Act came into force. Measurements of noise have been made by officers of the Scientific Branch for some time but recently there has been a very large increase in this type of work. The Town Planning Committee of the Council considered, in the autumn of 1960, that the time had come to measure background noise in order to obtain some objective knowledge which would be of help in dealing with certain planning matters, e.g., proposals affecting London that might emanate from the Government Committee on helicopter sites and other problems, such as the construction of elevated road and multi-level junctions in built-up areas. Surveys of noise have been made in other countries, particularly Germany and the United States, but not on a large scale. Except for a pilot investigation, no noise survey has been made in this country so far. The decision was reached that the Council and the Department of Scientific and Industrial Research should collaborate to carry out large-scale research in London over a period of about a year. Measurements of existing background noise levels are being made at about 500 sites, approximately a quarter of a mile apart, distributed uniformly over an area bounded on the west by the boroughs of Wandsworth, Fulham, Kensington and Paddington; on the north by Hampstead, St. Pancras, Islington and Hackney; on the east by Poplar, Greenwich, Deptford and Camberwell; and on the south by Wandsworth and Lambeth. This area is approximately 36 square miles in extent and contains a fair sample of all the various activities in the County of London. Two vans have been fitted up with recording apparatus by the Building Research Station and the Scientific Branch has an estate car containing portable recording equipment. The former are employed in recording the background noise on magnetic tape at each site of the 500 mentioned above, for about two minutes in every hour throughout a twenty-four hour period. Detailed surveys of sound levels in selected areas are being made by the Scientific Branch, using the estate car carrying portable recording apparatus. Noise measurements were made during the demolition of part of the carriageway at Marble Arch. The macadam and concrete were broken up by means of explosive charges, pneumatic breakers and rock drills and the opportunity was taken to observe the effect of using the breakers behind a screen and also the effect of fitting mufflers. There is little doubt that screening can be used to reduce the noise of pneumatic breakers and compressors and would be expected to be more effective in open areas, such as in these tests, than in a narrow street with tall buildings on both sides. A survey was made of the noise levels existing in 37 various offices in County Hall and in a machine room in County Hall where card punching and card sorting machines are operated. The sound insulating properties of different types of floors were measured with regard to impact and air-borne noise. Floors embodying sound insulating materials are much more effective in reducing the transmission of impact noise than are ordinary floors, but in the case of air-borne noise little additional benefit is obtained by the use of such materials. Noise surveys were also made at the Council's mechanical works depot and at a school dining hall where the ceiling was relatively low. 54 HEALTH SERVICE PREMISES Building programme Programme for 1961-62—As a result of the usual annual review of the five-year building programme, the Council approved a programme for 1961-62 providing for estimated expenditure amounting to £413,173, including acquisition of sites. Details of the schemes in the programme are given in table (i). General \ In connection with the divisionalisation of the mental health services, accommodation had to be found for additional staff in each division. This involved the acquisition and adaptation of office premises in two instances and one major and three minor schemes of conversion of existing premises. Details of works completed during the year, works in hand and works approved but not yet commenced are set out in tables (ii), (iii) and (iv). During the year freehold or leasehold interests in some properties were acquired; details are shown in table (v). Table (i)—Health Service building programme 1961-62 Health Division Premises Works proposed 1 Hurlingham Lodge hostel for tuberculous men, Fulham Improvements to kitchen. 1 St. Quintin day nursery, Kensington.. Extension to existing building to provide additional places. 1 Additional day nursery in North Kensington area. Conversion of standing property if acquired. 3 Basire Street, Islington. New junior training centre. 3 Cromwell Lodge hostel for tuberculous men, Hornsey. Small annexe for occupational therapy. 4 Morning Lane, Hackney New elder boys' training centre to replace an unsatisfactory centre. 4 Additional child guidance unit in Hackney area. Conversion of standing property if acquired. 5 Old Church Road day nursery, Stepney Replacement nursery. 6 Blackwall Lane, Greenwich Adaptation of existing building as an additional industrial training centre. 6 Garland Road, Woolwich New child guidance unit. 6 Maze Hill, Greenwich New junior training centre to replace an unsatisfactory centre. 7 Brockley Rise, Lewisham New mental health hostel. 9 Stormont Road, Battersea New maternity and child welfare and school treatment centre to replace unsatisfactory premises. 9 Additional child guidance unit in Putney/Wandsworth area. Conversion of standing property if acquired. — Conversion of three premises for mental health hostels One in Putney (premises already acquired) and two more premises being sought. — Oval accident ambulance station, Lambeth Extension to accommodate additional ambulances. — South Western general ambulance station, Lambeth Provision of workshops and extra garage space. 55 Table (ii)—Works completed in 1960 Health Division Premises Work involved MATERNITY AND CHILD WELFARE 2 St. Albans welfare centre, St. Albans Road, St. Pancras Provision of centre in ground floor of block of flats (built by St. Pancras Metropolitan Borough Council). 4 West Hackney welfare centre, Evering Road, Hackney New church hall with special provision for maternity and child welfare sessions. 7 Bellingham welfare centre, Bellingham Green, Lewisham Adaptations to tenants' clubroom for use for infant welfare sessions. 9 Welcome Hall welfare centre, Doddington Road, Battersea New hall built by Shaftesbury Society incorporating accommodation for health service purposes. SCHOOL HEALTH 3 South Islington welfare centre, 6, Clephane Road, Islington Conversion of basement to form school health suite. MENTAL HEALTH 3 Camden Road training centre, Camden Road, Islington Church hall built to incorporate Council's requirements for use as a training centre for elder girls. 4 Clifton Lodge day rehabilitation centre, 96, Dalston Lane, Hackney Conversion of former day nursery into a day centre for the mentally ill. LONDON AMBULANCE SERVICE — Brook general ambulance station, Woolwich Improvement and re-arrangement of staff quarters. — Fulham accident ambulance station, Fulham Adaptations to provide additional accommodation for staff". — Western general ambulance station, Chelsea Enlargement of office accommodation. Table (iii)—Works in hand Health Division Premises Work involved MATERNITY AND CHILD WELFARE 2 Hallfield Estate, Paddington Provision of maternity and child welfare and school treatment centre in ground floor of housing block (being built by Paddington Metropolitan Borough Council). 8 Keeton's Road, St. Crispin's Estate, Bermondsey Provision of maternity and child welfare and school treatment centre in ground floor of L.C.C. housing 9 Plough Road, Battersea Provision of maternity and child welfare and school treatment centre in ground floor of housing block (being built by Battersea Metropolitan Borough Council). DAY NURSERY 1 Ladbroke, Kensington Additional toilets and new heating and hot water systems. MENTAL HEALTH 1 Letchford Gardens, Hammersmith Adaptation of former maternity and child welfare centre to a new training centre for elder girls. 4 Iceni Sports Ground, Hackney New junior training centre. 9 42, Clapham Manor Street, Wandsworth Adaptation of premises to form an industrial training centre. PREVENTION OF ILLNESS—TUBERCULOSIS 3 Cromwell Lodge hostel for tuberculous men, Hornsey Provision of new boilers. 56 Health Division Premises Work involved GENERAL PRACTITIONERS' CENTRE AND CHILD GUIDANCE UNIT 7 South East London General Practitioners' Centre and Peckham child guidance unit, St. Mary's Road, Camberwell Major adaptations to third floor to provide general practitioners' centre and improved accommodation for existing child guidance unit. LONDON AMBULANCE SERVICE Battersea accident ambulance station, Battersea Replacement of building destroyed by enemy action. Table (iv)—Works approved but not yet commenced at end of 1960 Health Division Premises Work involved MATERNITY AND CHILD WELFARE 6 Abbey Estate, Woolwich New maternity and child welfare and school treatment centre in housing block to replace temporary welfare centre on London County Council estate. 6 Burney Street, Greenwich Provision of maternity and child welfare centre in ground floor of housing block. (To be built by Greenwich Metropolitan Borough Council.) DAY NURSERY 1 Eridge House, Fulham Resurfacing of play space. 3 Scholefield Road, Islington Conversion of boilers to oil firing. MENTAL HEALTH 8 Draper Street, Southwark New day centre for the mentally ill to be constructed in London County Council housing development. LONDON AMBULANCE SERVICE – Eastern general ambulance station, Hackney Improvement and re-allocation of accommodation and improvements to entrance. Table (v)—Acquisitions and leases completed Health Division Property Interest obtained MATERNITY AND CHILD WELFARE 1 9-11, Holland Street, Kensington, W.8 Leasehold. 2 St. Albans Villas, St. Pancras, N.W.5 Leasehold. 9 William Harvey Centre, 313-315, Cortis Road, Wandsworth, S.W.15 Indefinite tenancy (from Housing Committee). DAY NURSERY 1 466-468, Uxbridge Road, Hammersmith, W.12 Freehold. 8 2 and 4, St. John's Crescent, Lambeth, S.W.9 Leasehold. 8 351-369, Coldharbour Lane, Brixton, S.W.9 Freehold. 9 Summerley Street, Wandsworth, S.W.18 Hutted buildings. MENTAL HEALTH 4 Shoreditch Training Centre, Thurtle Road, Shoreditch, E.2 Freehold interest appropriated from Education Committee. 9 42, Clapham Manor Street, S.W.4 Leasehold. MISCELLANEOUS 7 S.E. London General Practitioners' Centre and Peckham Child Guidance Unit. St. Mary's Road, S.E.15 Lease from Education Committee. 57 CARE OF MOTHERS AND YOUNG CHILDREN The main features of the Council's services for care of mothers and young children remained as in previous years. Day-to-day administration of the services is the responsibility of the nine divisional health committees; details are given in the reports of the divisional medical officers. Changes in centres during the year are reported in the section on health service premises. Maternity and child welfare Particulars of sessions and attendances are given in the following table: Table (i)—Clinics for mothers and young children 1956 1957 1958 1959 1960 Ante-natal, post-natal and combined clinics: Number at end of year 116 118 112 111 109 Sessions per month 805 786 799 797 793 Ante-natal: First attendances 23,379 23,918 25,673 23,905 25,455 Total attendances 122,662 121,579 134,684 129,731 133,062 Percentage of pregnant women attending an ante-natal clinic 44 44 45 42 43 Post-natal: Number of women attending during the year 4,543 3,887 3,714 3,524 3,369 Child welfare clinics: Number at end of year 178 178 179 179 179 Sessions per month 1,953 1,990 1,991 1,957 2,034 Attendances under 1 year First 44,910 46,387 49,229 49,610 50,202 Total 595,690 613,147 611,057 606,042 578,250 Attendances over 1 year 189,388 183,538 177,283 152,627 163,845 Attendances at special toddlers clinics (not included in above) 41,055 40,848 38,940 38,361 37,533 Percentage of infants attending a centre at least once in the first year of life 86 86 88 89 88 Family planning—Advice on family planning is provided for married women for whom further pregnancy would be detrimental to health. 1958 1959 1960 Attendances at sessions provided by the Council First 1,011 975 945 Total 4,392 4,260 4,337 Women referred by the Council to Family Planning Association 702 705 741 National welfare foods Average weekly issues 1956 1957 1958 1959 1960 National dried milk (tins) 25,413 19,839 15,791 15,328 13,817 Cod-liver oil (bottles) 6,156 5,191 3,620 3,469 3,442 Vitamin tablets (packets) 2,952 2,788 2,736 2,775 2,837 Orange juice (bottles) 48,163 48,925 31,360 30,412 28,864 58 Day accommodation for children Table (ii)—Day nurseries and child minders At 31 December 1956 1957 1958 1959 I960 DAY NURSERIES: Maintained 86 81 76 75 74 Grant-aided 5 5 5 4 4 Total 91 86 81 79 78 Places 0-2 1,775 1,747 1,690 1,693 1,649 Places 2-5 3,368 2,988 2,631 2,499 2,420 Total places 5,143 4,735 4,321 4,192 4,069 COUNCIL'S CHILD MINDER SCHEME (Voluntary registration): Child minders registered 777 838 824 875 989 Children minded 886 954 973 1,039 1,187 NURSERIES AND CHILD-MINDERS REGULATION ACT, 1948: Private day nurseries registered (including part-time nurseries) 58 60 59 60 59 Places 1,646 1,701 1,742 1,620 1,595 Child minders registered 102 132 141 167 202 No. of children authorised to be minded 611 699 781 939 1,023 Occasional creches—These creches provide for the children of mothers attending a clinic or class on the premises and also give occasional relief to mothers who, for various reasons such as visits to hospitals, shopping, laundering and other domestic duties, wish to be relieved of their young children for two or three hours during the day; they also present an opportunity for the only child to associate with other children of similar age. During the year the Council approved an extension of the service and at 31 December a total of 82 sessions a week was being held, providing for 1,420 child-attendances weekly. Prevention of break-up of families It was possible during the year to provide caseworkers to undertake the support and intensive care of problem families in a sixth division. By 31 December nine full time social caseworkers were undertaking this work in the county and nine assistant organisers were working with one or two families each. As in previous years, the Council made a grant to Family Service Units in London towards the cost of their work with families in difficulty. The amount of the grant for the financial year 1961/62 (divided equally between the Health and Children's committees) was £12,715. Home-making courses for selected mothers During the year authority was given for an increase, where necessary, in the grants made to voluntary committees providing home-making courses, to enable them to pay the travelling expenses of voluntary workers minding the children of mothers attending the classes, or to employ paid minders if suitable volunteers cannot be obtained. Institute of Child Health The Council, which is associated with the Institute in the running of Province of Natal centre, Holborn, made a contribution of £5,000 towards the cost of the Institute's new building on a site adjoining the centre. 59 Mental health education Further development of the arrangements made for intensive training of medical officers and health visitors in mental health education, following the report of a study group in 1954, was approved. This development (foreshadowed in paragraph VI (b) of Appendix B to my report for 1959) was based on the view expressed by the departmental committee, set up in 1955 to advise on general developments in this field, that the work could no longer be regarded as experimental but should be expanded as necessary and put on a permanent basis. Arrangements were approved which had the threefold aim: (a) to set up in those parts of London which lack them at present case conference groups, where medical and nursing staff of the child welfare centres will receive training and guidance from psychiatrists and other professional workers attached to child guidance clinics; (b) to bring all child welfare medical officers and health visitors into the groups; and (c) to develop the case conference groups into a permanent consultative service under the leadership of the psychiatrist from the local child guidance unit. Implementation of these arrangements must necessarily be spread over a period of time, depending mainly on the availability of the psychiatric staff to lead the groups, but discussions with hospital authorities about their professional staff taking part in the work were in hand at the end of the year. Welfare of children in hospital The Ministry of Health, in a circular letter (LHAL 2/59), drew attention to the need for co-operation between the hospital, general practitioner and local health authority services in securing the welfare of children in hospital and on discharge, and the nursing of children at home as an alternative to their admission to hospital. There are, of course, general arrangements for ensuring co-operation between the three branches of the health service, irrespective of the age of the patient. Hospital authorities are asked to arrange that when a patient who is likely to require the Council's health or other services is about to be discharged from hospital the necessary information, including a report on the patient's condition on discharge, is given to the Council's divisional medical officer. Hospital almoners are invited to attend meetings periodically with the divisional health office staff to consider matters of mutual interest and the use of the Council's services. The divisional medical officers also meet the local general practitioners as and when necessary and a booklet about the Council's health service, with a local appendix showing details of maternity and child welfare and school health clinics, etc., is issued to all general practitioners. The importance of co-operation and personal contact between the health visitor and the family doctor is encouraged. In London, co-operation between the school health and hospital services dates back to the earliest days of the school health service; as long ago as 1911 a children's care organiser was appointed to the London hospital to direct the flow of young patients and act as a liaison officer between the voluntary school care committees and the hospital. Today, the co-operation takes several forms, in all of which the children's care organiser in the Public Health department plays an important role. At some hospitals special sessions are held for the treatment of school pupils and the care organisers make the appointments and attend the sessions; at other hospitals the organiser, although not present at the sessions, makes the appointment for the children to attend. At certain 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 care committee organisation. St. Mary's hospital scheme—In 1954, St. Mary's hospital, Paddington, after consultation with the Council, organised a scheme whereby a team of paediatricians and nurses visits and treats selected sick children in their own homes at the request of the general practitioner. 60 In the beginning the hospital met the whole cost of the experimental scheme from its endowment income, the Council's contribution being restricted to the provision of home help and the loan of equipment where necessary. From 1 November, 1959, however, the Council assumed financial responsibility for the nursing staff salaries through the agency of the Paddington-St. Marylebone District Nursing Association. The hospital authorities continue to meet the other expenses (medical staff, transport, etc.) and from voluntary monies have agreed to reimburse the district nursing association the seven per cent. of the expenditure by the district nursing association on nursing staff salaries which does not rank for the Council's grant. The aims of this home-care scheme are to: (a) avoid the separation of the sick child from its home environment, (b) improve liaison between the family doctor and the hospital, (c) prevent cross infection, (d) reduce the cost of treatment while maintaining a high standard, and (e) educate the families in preventive methods. The team consists of a paediatrician and three nurses. A part-time physiotherapist and an almoner are available. Student nurses and medical students can be attached to the team for experience. The nurses, who in addition to being state registered nurses hold certificates in sick children's nursing, carry out treatment, assist with technical procedures, instruct the mothers in bedside nursing and infant feeding and keep the usual nursing records. They are available for night duty, which is reassuring for parents, although seldom required. The catchment area for the scheme includes most of Paddington and part of Marylebone, some 28 square miles of mainly working class development with a population of more than 75,000. When a family doctor wants to use the scheme he telephones the hospital. A consultation between him and the paediatrician is then arranged in the patient's own home, or the patient is visited by the paediatrician and the situation is discussed over the telephone. An important point about this scheme is that the patient remains under the care of the family doctor throughout, although specialist investigations and treatments will be carried out by the doctor attached to the home-care team. Most of the diagnostic and therapeutic resources of the hospital can be made available in the patient's home. Between 300 and 400 children are cared for in their own homes each year under this scheme, thus preventing admission to hospital and separation from parents at a time when the experience could be highly traumatic. The most suitable groups for home-care have been found to be: (a) infants with medical conditions such as feeding difficulties and gastric enteritis, which provides for education in preventive measures, (b) children under five years with acute illnesses, (c) older children with chronic or incurable illnesses who would otherwise be parted from their families for long periods. This scheme also enables children who have had to be admitted to hospital for, say, surgical operations, to be discharged home earlier and remain under supervision. Nursing at home—The district nursing service and the home help service are always available when the nursing of the child at home is possible as an alternative to admission to hospital. Vital considerations are the presence of the mother, her aptitude and the willingness of the family doctor to treat the child at home. The mother who must go out to work for economic reasons can be helped to nurse her child at home by the offer of employment by the Council as a home help in her own home. The standards of care given to each child by the various services involved does depend on each individual concerned being aware of the need, not only to do his or her part, but also to bring in other services promptly and for each to keep the other informed of important developments in the case. 61 Preparation for admission to hospital—The divisional medical officers, the health visitors and treatment organisers are closely concerned in the preparation of parents and children for the latter's admission to hospital. They also keep the hospital staff informed of any home conditions likely to affect the child while in hospital, or to influence the after-care given after discharge. The voluntary care committee workers and the children's care organisers in the Education and Public Health departments also play their part in the preparation for the admission of school children to hospital and return home on discharge, as well as in meeting after-care and special educational requirements. Residential establishments for young children Residential establishments under the direction of the Children's Committee are visited regularly by the Council's medical officers. The care of the children suffering from physical handicap or mental retardation, whether due to innate defect or emotional disturbance, is carefully reviewed. A register is also kept and reviewed periodically by a medical officer so that constructive plans for the future of these handicapped children can be made. New problems are arising as a result of early diagnosis of congenital handicaps and children are often moved into the county so that they may more easily obtain appropriate special educational treatment. Adoption and boarding out Every child whom it is proposed to board out with a view to adoption is given a full medical examination by his doctor and the Medical Officer of Health is asked for his observations on the proposal. The number of children referred by the Children's Officer is shown below; the increased number of medical examinations for boarding out reflects increasing activity in boardingout work in that department. Observations of M.O.H., etc. 1956 1957 1958 1959 1960 1. Unsuitable for either adoption or boarding out .. 4 3 3 1 — 2. Adoption cases Suitable for adoption 147 178 167 228 267 Suitable for adoption subject to certain conditions 7 8 2 1 2 Unsuitable for adoption but suitable for boarding out 15 7 17 5 21 Withdrawn by Children's Officer 1 8 3 2 1 Under consideration at 31 December 3 4 1 2 5 173 205 190 238 296 3. Boarding out cases: Suitable for boarding out 324 310 320 290 447 Withdrawn by Children's Officer 2 7 3 3 6 Under consideration at 31 December — 5 1 3 7 326 322 324 296 460 Total 503 530 517 535 756 Care of the unmarried mother and her child Mother and baby homes—One mother and baby home is managed by the Welfare Committee together with two units in larger establishments. Other homes are provided by voluntary organisations supported by grants in aid from the Council under the National Health Service Act, 1946. 62 1956 1957 1958 1959 1960 Number of voluntary homes receiving grant at 31 December 18 17 16 15 15 Number of expectant and nursing mothers admitted 1,306 1,141 1,191 1,072 1,136 Total grants £10,758 £11,360 £10,476 £10,237 £8,865 Moral welfare associations—Financial assistance to the five large moral welfare associations of the major religious denominations was continued. 1956 1957 1958 1959 1960 Total grants £9,625 £9,625 £12,531 £13,555 £12,800 Number of expectant and nursing mothers advised 2,908 2,684 2,975 3,005 3,292 The following statistical tables relate only to cases dealt with by the five moral welfare associations (London Diocesan Council, Southwark Diocesan Association, Westminster Catholic Social Welfare Committee (Crusade of Rescue), Southwark Catholic Rescue Society, Jewish Board of Guardians). Table (i)—Mothers seen for the first time during the 12 months ended 30.9.60, by age No. % Under 13 1 0.0 14 5 0.2 15 29 0.9 16 107 3.3 17 166 5.0 18-19 561 17.0 20-24 1,363 41.5 25-29 607 18.4 30-34 264 8.0 35-39 126 3.8 40 or over 46 1.4 Not known 17 0.5 3,292 100.0 Table (ii)—Nationality by normal residence London (Administrative County) Elsewhere Total British (United Kingdom) 1,371 495 1,866 Eire 454 359 813 West Indian 267 118 385 European 76 58 134 Any other 58 36 94 2,226 1,066* 3,292 *864 were pregnant on arrival in London. During the year special consideration was given to the complex problem of providing suitable accommodation for expectant mothers still receiving full-time education, whose numbers, regrettably, have increased in recent years. In the majority of cases these are girls committed by the courts into care of the Children's department, taken into care because of pregnancy or found to be pregnant after being taken into care. For obvious reasons it is not desirable that these children should be placed in mother and baby homes with adult unmarried mothers. Furthermore, the mother and baby homes run by voluntary bodies do not normally accept expectant mothers until six or eight weeks before the expected date of confinement and a special placing for the mother-to-be of school age is, of course, necessary much earlier than this. 63 Following representative meetings of the departments and voluntary bodies concerned it was arranged that a mother and baby home in South London, administered by the Church Army, should be made available early in 1961 for the sole use of young expectant mothers in receipt of full-time education. The home is being adapted to meet the special needs of the girls and a full-time teacher is to be appointed to the home by the Education Officer. Illegitimate babies— Table (iii)—Care of babies three months after birth (a) Living with mother No. % Mother married to putative father or another man 72 3.5 Mother cohabiting with putative father 103 4.9 In grandparents' home, lodgings, residential post, mother and baby home, etc. 889 420 — 1,064 — 50.4 (b) Separated from mother Adopted or placed for adoption 569 26.9 With foster parents or in residential nursery 303 14.3 In care of local authority 52 2.5 — 924 — 43.7 (c) Miscellaneous Mother and child moved away, etc. 124 5.9 2,112 100.0 At the end of the year 471 women were still awaiting confinement and in 22 cases the arrangements for the child had not been settled. In 69 cases the woman married the putative father before the birth, 523 moved to another area or returned to their own country, etc. and 95 cases resulted in miscarriages or stillbirths. 1,213 women (37 per cent.) were reported as admitted to mother and baby homes before their babies were born—this figure is a minimum, as complete details were not available in all cases. The total number of illegitimate live and stillbirths in London (Administrative County) during 1960 was 6,671 and the number of women reported as admitted to mother and baby homes represents about 17 per cent. of this total. Child protection The visiting of foster children under the Children Act, 1958, and the inspection of the premises in which these children are living is undertaken for the Children's Officer by health visitors who are designated as 'child protection visitors.' During 1960 the Children's Officer assumed direct control of the work in two areas in London, viz., in health divisions 5 and 8. In the seven remaining divisions the number of children supervised by child protection visitors on 31 March, 1960 was 624. Marriage guidance Grants totalling £6,500 for the year ending 31 March, 1961 were made to the London Marriage Guidance Council, the Catholic Marriage Advisory Council and the Family Discussion Bureau. 64 DOMICILIARY MIDWIFERY The duty to provide adequate domiciliary midwifery service is discharged through the Council's own midwives and those employed by district nursing associations and hospitals. Table (i)—Staff District midwives employed by 1956 1957 1958 1959 1960 The Council 92 87 87 89 94 District Nursing Associations (including supervisory staff) 46 44 48 45 46 Hospitals 44 39 40 46 43 182 170 175 180 183 Table (ii)—Domiciliary confinements attended 1956 1957 1958 1959 1960 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 No. % No. % (a) Doctor not booked L.C.C. 193 3,500 172 3,325 201 2,899 232 2,761 178 1.6 2,197 20.1 D.N.A. 68 1,790 68 1,624 75 1,577 58 1,360 47 0.4 1,193 10.9 Hospital district 25 1,944 29 1,711 23 1,693 41 1,574 — — 286 7,234 269 6,660 299 6,169 331 5,695 225 2.0 3,390 31.0 7,520 6,929 6,468 6,026 3,615 33.0 (A) Doctor booked L.C.C. 847 1,293 996 1,548 1,135 1,966 1,340 2,405 1,563 14.3 2,848 26.0 D.N.A. 134 197 152 294 182 389 194 505 280 2.6 692 6.3 Hospital district 103 148 68 196 144 225 132 313 202 1.8 1,745 16.0 1,084 1,638 1,216 2,038 1,461 2,580 1,666 3,223 2,045 18.7 5,285 48.3 2,722 3,254 4,041 4,889 7,330 67.0 10,242 10,183 10,509 10,915 10,945 100.0 All hospital district cases are now shown as 'doctor booked', because all such cases are ante-natally under the direct care of a hospital doctor and medical aid during labour and the puerperium is available to them on call to the hospital. The difference in recording only partially accounts for the marked increase in the number of home confinements in which a doctor was booked for maternity medical services. The total increase was from 4,889 (45 per cent.) in 1959 to 7,330 (67 per cent.) in 1960, while the corresponding figures for 1956 were 2,722 (27 per cent.). Taking only those cases attended by London County Council and District Nursing Association midwives, the increase was from 4,444 (51 per cent.) in 1959 to 5,383 (60 per cent.) in 1960. Table (iii) 1956 1957 1958 1959 1960 Premature babies: Number 509 501 482 555 517 Per cent. of live births 5.0 5.0 4.6 5.1 4.7 Stillbirths: Number 90 87 89 100 79 Per 1,000 total births 8.8 8.5 8.4 9.2 7.2 The corresponding rates for domiciliary confinements for England and Wales in the year 1959 (the latest available) were for prematurity, 4.3 per cent., and for stillbirths, 9.9 per 1,000 total births. 65 E Particulars of domiciliary premature live births are set out below. The difference between the total (524) shown in this table and the number (517) quoted above represents the number of cases attended by doctors and midwives independently of the Council's domiciliary midwifery service. Table (iv) Weight Number Proportion per 100 live premature infants Deaths in 24 hours Survivors at 28 days Number Per 100 live premature infants Number Per 100 live premature infants 3 lb. 4 oz. or less 27 5 9 33.3 13 48.1 3 lb. 5 oz. to 4 lb. 6 oz. 63 12 7 11.1 54 85.7 4 lb. 7 oz. to 4 lb. 15 oz. 95 18 4 4.2 88 92.6 5 lb. to 5 lb. 8 oz. 339 65 1 0.3 335 98.8 All cases 524 100 21 4.0 490 93.5 These figures, especially those relating to infants surviving at 28 days, compare favourably with those for all live premature infants born in the administrative county during 1960, (see table (xiii), page 17). Table (v)—Inhalation analgesia administered 1956 1957 1958 1959 1960 Gas and air 70% 84% 35 % 87% 17% 88% 9% 87% 8% 86% Trilene 14% 52% 71 % 78% 78% Each of the Council's midwives had been equipped with a portable trilene inhaler by the end of 1957. A marked reduction has resulted in the use of the more cumbersome gas and air apparatus which, nevertheless, is still delivered by the London Ambulance Service on a midwife's request for use when in her, or a doctor's, clinical judgment it is required. Midwives Act, 1951 Notifications received of intention to practise: 1956 1957 1958 1959 1960 As midwives 1,164 1,193 1,160 1,285 1,404 As maternity nurses 144 137 121 110 25 (1.2.60-30.6.60) As a result of amendments to the Rules of the Central Midwives Board, which became effective on 1 July, 1960, the distinction between practising as a midwife and acting as a maternity nurse has been removed. In the past a midwife who only acted as a maternity nurse was required to notify her intention to practise as a maternity nurse but was not required to attend compulsory refresher courses. The meaning of the term 'practising midwife' has been altered to include the former maternity nurse and, as a consequence of this change in definition, any person who wishes to attend maternity cases must notify her intention to practise as a midwife and attend compulsory refresher courses required by the Central Midwives Board. In accordance with section G.l of Rules of the Central Midwives Board, 120 midwives in the county attended a refresher course during the year. Fees to medical practitioners called in by midwives in emergency: 1956 1957 1958 1959 1960 Number of claims 2,554 2,479 2,626 2,653 2,350 66 HEALTH VISITING Home visits 1956 1957 1958 1959 1960 Expectant mothers: First 23,143 23,482 24,131 22,940 24,013 Revisit 21,422 21,994 23,213 23,161 22,546 Percentage of notified live and still-births 44 43 42 40 41 Stillbirths 1,173 1,080 979 960 1,024 Children under 1: First 51,960 52,171 53,557 53,224 55,226 Revisit 173,774 169,760 176,428 173,932 168,669 *Percentage of live births 100 98 96 95 96 Children 1-5 357,215 354,643 368,845 372,622 369,122 Care of old people 12,842 12,465 13,331 14,366 14,350 Miscellaneous 66,823 74,513 80,978 80,948 80,026 Unsuccessful 103,600 100,250 100,648 101,503 104,014 TOTAL 811,952 810,358 842,110 843,656 838,990 * The true percentage may be somewhat less, but it is not practicable to exclude from the year's figures a small number of immigrants and of children visited in the year but born in the previous year. 67 E* HOME NURSING Details of the work done by the 26 voluntary grant-aided district nursing associations who acted as agents for the Council are given below: Table (i)—Staff (numbers employed at 31 December)* 1956 1957 1958 1959 1960 State registered nurses 491 533 506 512 517 State enrolled assistant nurses 42 30 33 34 34 Total number of nurses employed 533 563 539 546 551 Male nurses (included above) 38 41 41 39 39 Full-time equivalent of nurses employed 487 522 496 507 508 Students 75 52 65 78 27 Male students (included above) 8 4 6 6 — * Exclusive of administrative and supervisory staff. The drop in numbers of students is due to an adjustment of the training period so that courses no longer overlap. Table (ii)—Types of case nursed and visits paid Type of case Number of patients nursed Percentage of total Average number of visits to each patient Total visits Medical 41,914 81.7 32 1,351,815 Surgical 5,735 11.2 41 232,988 Infectious diseases 144 0.3 11 1,506 Tuberculous 1,134 2.2 52 59,415 Maternal complications 1,047 2.0 7 7,626 Others 1,351 2.6 27 36,734 51,325 100.0 33 1,690,084 The total visits for 1958 and 1959 were 1,893,553 and 1,763,296 respectively. Table (iii)—Types of treatment and location Visits for At patient's home Elsewhere (e.g.. Nurses' Homes) Percentage of total visits Injections only 614,053 32,992 38 Injections plus other treatment 85,571 313 5 Other treatment only 953,950 3,205 57 1,653,574 36,510 100 During 1960 the proportion of visits for 'Other treatment only' rose by five per cent. compared with 1959, whilst visits for 'Injections only' fell by four per cent. Table (iv)—Long-term cases (i.e., those visited more than 24 times during year) Number Percentage of total patients nursed 9,628 18.8 The percentage of long-term cases shows a decline of 0.8 per cent. from the previous year. 68 Table (v)—Age distribution of patients Age No. of patients Percentage of total 0-5 years 2,548 5 5-64 „ 21,131 41 65 years and over 27,646 54 51,325 100 The number of patients was smaller than in 1959 (57,368) and the proportion of patients 65 years and over increased by two per cent. Table (vi)—Nursing treatments and case load 1956 1957 1958 1959 1960 Number of completed treatments 60,772 56,395 53,359 49,299 43,118 Number of patients being nursed at end of year 12,806 13,749 12,099 11,352 11,118 Average case load per equivalent whole-time effective* nurse at end of year 24 27 24 23 24 * Allowing for holidays and sickness. 69 HOME HELP Statistics of the service provided during the last five years are shown in the following table. 1956 1957 1958 1959 1960 Cases assisted* 34,557 35,737 34,600 36,056 38,031 Applications deferred or refused because home helps were not available 76 25 25 13 23 Hours worked 4,779,600 4,896,000 4,651,500 4,919,200 5,129,000 Home helps employed at end of year 3,326 3,388 3,529 3,706 3,830 Equivalent of whole-time staff† 2,089 2,116 2,033 2,150 2,242 Night helps for chronic sick patients‡ Applications met 37 44 55 40 28 No. of new families assisted‡ Child help (resident) 5 4 6 20 8 Early morning and evening help 180 153 197 200 244 Special help (problem families) 110 116 * 1955-1957, number of times assistance given; from 1958, number of households assisted. † From 1958 excludes staff on annual and sick leave. ‡ These are included in total cases assisted. From September, subject to the submission of a medical certificate, free home help was provided for expectant mothers suffering from toxaemia of pregnancy to ensure complete rest for the patient. During the first four months of the scheme, 1 September to 31 December, 53 cases of toxaemia of pregnancy received free home help. The total amount of service given was 2,841 hours. 70 IMMUNISATION AND VACCINATION Diphtheria, tetanus, whooping cough— Table (1) 1956 1957 1958 1959 1960 Diphtheria immunisation: Primary course— Under 1 year 23,927 24,325 23,385 29,534 38,210 Age 1-4 13,907 12,643 10,560 10,693 10,973 Total under 5 37,834 36,968 33,945 40,227 49,183 Age 5-14 6,403 5,856 4,742 5,022 7,648 Reinforcing doses 43,866 39,268 38,725 33,237 40,511 Immunity Index 1-4 years 68.4 70.4 69.9 70.6 74.1 Tetanus immunisation* — 12,405 15,092 32,531 48,605 Whooping cough vaccination 36,556 35,648 34,133 38,917 48,539 * Started January, 1957. The number of children referred to in table (i) who received multiple antigens is as follows: Table (ii) 1956 1957 1958 1959 I960 Diphtheria/whooping cough 32,091 19,464 7,623 4,925 1,536 Diphtheria/whooping cough/tetanus — 12,405 15,092 32,382 46,650 Diphtheria/tetanus — — — 42 1,734 The year 1960 was the first full year in which all divisions were operating the standard schedule of immunisation introduced in 1959 and referred to in detail in my report for that year (page 73). It will be seen that the number of children given a primary course of immunisation against diphtheria, whooping cough and tetanus showed a distinct increase over the figures registered in 1959. In fact the number of infants immunised was higher than in any year since the National Health Service came into being. Unfortunately, the same cannot be said about smallpox vaccination, the figures for which showed a reduction compared with 1959 (table (iii)). A reduction was not unexpected, in view of the fact that smallpox vaccination was put back from its former position of the first immunising procedure to be given to the child to its present position between the triple vaccine and the poliomyelitis vaccine; but this does not completely explain the very marked drop in the vaccination rate and steps are being taken to improve this figure in 1961. Some children do not begin their immunisation at the correct time and advice was given to divisional medical officers on modifications to the schedule appropriate to various ages. The modifications depend upon the fact that as the child grows older the urgency of whooping cough protection grows less and that of poliomyelitis vaccination greater. Thus from the age of seven months onwards poliomyelitis vaccination will precede the course of triple vaccine. The personal record card introduced in 1959 continued in use and has proved a popular innovation. It is used to introduce the subject of immunisation to mothers and thereafter as an appointment card and a personal record of immunisation. During the year new sterilisation arrangements were brought into operation. Enough syringes and needles were supplied to provide for each child a separate syringe and needle to be boiled for 20 minutes in a single well-supervised operation before the immunisation session began. Quick re-boiling, with the possibility of insufficient sterilisation, was thus no longer necessary. A separate syringe and needle are now used generally throughout 71 the county for each child immunised. Observations are also being made in one area on the use of syringes supplied from the central sterile syringe service of a local hospital and on disposable plastic syringes. Both the hospital-sterilised syringe and the plastic syringe are considerably more expensive to use than the syringe sterilised by boiling in the clinic. Smallpox— Table (iii) 1956 1957 1958 1959 1960 Number vaccinated under 1 year 25,734 29,677 30,865 30,489 23,057 Percentage of live births 49 56 55 55 40 Mention is made above of the possible reasons for the decline in smallpox vaccination during the year. One child with post-vaccinal encephalitis was reported during this year. This child, aged 12, who had a severe constitutional reaction nine days after primary vaccination, was admitted to hospital. The cerebro-spinal fluid was at this stage normal and he recovered in 48 hours. On the fourteenth day after vaccination he developed symptoms of meningoencephalitis. He made a complete recovery. No cases of generalised vaccinia were reported. Poliomyelitis—During the year the main tasks in the poliomyelitis vaccination scheme were the vaccination of those born in 1932 or earlier and under 40 years of age and the administration of third doses to those who had received the second dose seven months previously (380,499). At the same time children under one year of age were vaccinated as part of the routine of immunisation described above. In division 6 arrangements were made to participate in a trial of oral vaccine (using live attenuated strains of virus) organised by the Medical Research Council. The final report of this trial is not yet available. The number of persons who have received protection against poliomyelitis is as follows: Table (iv) Number of persons who have received Two injections A third injection (cumulative total) In 1960 Since the commencement of the scheme Born in: 1953-60 43,834 228,511 156,872 1943-52 11,185 319,085 246,370 1933-42: Londoners 25,374 202,691 154,523 Others 4,209 56,737 44,775 1932 or earlier (under 40): Londoners 59,460 73,511 27,388 Others 15,858 16,138 4,256 Other priority groups (over 40) 2,939 22,018 11,885 TOTALS 162,859 918,691 646,069 Given by general practitioners and hospital doctors and included in the total above 52,642 236,023 169,844 72 Yellow fever vaccination—Facilities were provided at a number of centres throughout the country, as part of the hospital and specialist services under Part II of the National Health Service Act, 1946, for vaccination against yellow fever for persons travelling to certain countries where the possession of a certificate of yellow fever vaccination was a condition of entry. In London this service had been provided at the Hospital for Tropical Diseases, the West London Designated Vaccination Centre and at the Medical Department of Unilever, Ltd. At the request of the Minister of Health the Council accepted responsibility for providing such facilities in London and the Minister in due course approved an amendment of the Council's proposals under section 28 of the National Health Service Act, 1946. Vaccination against yellow fever had previously been provided free; no charge is made for vaccinations under section 26 of the Act and it was decided that no charge should be made for yellow fever vaccination. It was considered that the small amount that would be receivable if a charge were made would not warrant the cost of collection. Arrangements were made with the authorities of the centres mentioned above for the service to be continued on and after 1 July, 1960, when the Council became responsible for the administration of this service. Persons wishing to be vaccinated against yellow fever are requested to make prior arrangements with a centre. All centres are on the telephone and appointments can be made at any time during normal office hours. A proportion of the persons using the clinic at the Hospital for Tropical Diseases are seamen. Before July, 1960 the practice had been to see some at the clinic and, to meet the convenience of shipowners, send a vaccinating team to the London docks to vaccinate other seamen on board ship. As there is no power to provide this service outside the county, negotiations were entered into with the Shipping Federation, Ltd. (the representative organisation of the shipowners) which resulted in their providing a service at their clinic at King George V Dock as from 1 August, 1960. As this clinic is situated inside the docks, and is not available to the general public, the Federation obtained from the Ministry of Health the designation of the clinic as a private centre. Private centres (of which there are six others in the London area) do not receive financial assistance from public funds, have to find their own vaccine, and can charge the applicant for the services rendered (which some centres do). The establishment of this dock clinic relieves the pressure of work at the Hospital for Tropical Diseases and reduces the amount of medical time needed thereat. In consideration of this free vaccine was supplied (as is the case with the three centres for which the Council is responsible), on the understanding that no charge for vaccination was made to the seamen using the clinic and that the international certificate prescribed by the World Health Organisation was supplied without cost to the applicant. The numbers of persons who received yellow fever vaccination or re-vaccination at the Council's clinics and at the King George V Dock clinic during 1960 are as follows (numbers since 1 July in brackets): Clinic No. 1 (Hospital for Tropical Diseases) 10,571 (5,194) Clinic No. 2 (Unilever House) 1,249 (678) Clinic No. 3 (West London Centre) 4,031 (1,825) King George V Dock Clinic (commenced 1.8.60) 809 (809) Total 16,660 (8,506) 73 LONDON AMBULANCE SERVICE The tables below show some aspects of the work of this Service and of its agency and supplementary services in 1960. Table (i) illustrates the continuing increase in the numbers of patients carried and of journeys performed. For the directly provided service the figures for 1960 are of especial interest in view of a serious staff shortage which became increasingly acute towards the end of the year. Despite these difficulties the general section alone carried over 24,000 more patients than in 1959, although the average number of ambulances on the road at any given time in 1960 was probably less than in 1959. The number of general section journeys increased slightly but the mileage decreased considerably, from 3,980,327 in 1959 to 3,960,964 in 1960. These results reflect a gratifying reduction in the average mileage per patient and journey and an increase in the number of patients carried per journey. In short, the intensity of the work has increased. There have been corresponding changes in the work of the agency and supplementary services. The figure on page 75 shows these trends since the inception of the National Health Service. Table (i)—Work performed by the directly provided service and by the agency and supplementary services, including both general and accident section work 1956 1957 1958 1959 I960 Patients: Accident Section 88,608 91,801 94,079 99,834 103,497 General Section 905,089 911,303 991,263 1,009,128 1,033,909 Total—directly provided service 993,697 1,003,104 1,085,342 1,108,962 1,137,406 Joint Committee 24,358 25,090 24,382 26,582 32,593 Hospital Car Service 217,527 201,436 201,161 193,523 189,337 West Ham C.b.C. 378 499 409 496 338 Total—agency and supplementary services 242,263 227,025 225,952 220,601 222,268 Total patients 1,235,960 1,230,129 1,311,294 1,329,563 1,359,674 Journeys: Accident Section 97,823 97,535 99,188 104,983 109,551 General Section 463,158 457,976 482,863 488,336 488,422 Total—directly provided service 560,981 555,511 582,051 593,319 597,973 Joint Committee 10,837 11,745 9,710 10,250 10,877 Hospital Car Service 76,756 71,556 70,724 69,672 58,441 West Ham C.b.C. 378 494 403 489 335 Total—agency and supplementary services 87,971 83,795 80,837 80,411 69,653 Total journeys 648,952 639,306 662,888 673,730 667,626 Mileage: Accident Section 491,929 485,431 495,913 524,009 556,390 General Section 3,736,550 3,687,353 3,982,374 3,980,327 3,960,964 Total—directly provided service 4,228,479 4,173,784 4,478,287 4,504,336 4,517,354 Joint Committee 436,927 430,373 394,145 411,823 441,468 Hospital Car Service 1,399,355 1,292,177 1,224,817 1,212,580 1,207,439 West Ham C.B.C. 4,152 5,052 4,953 5,121 4,061 Total—agency and supplementary services 1,840,434 1,727,602 1,623,915 1,629,524 1,652,968 Total mileage 6,068,913 5,900,386 6,102,202 6,133,860 6,170,322 74 LONDON AMBULANCE SERVICE, 1947-60 GENERAL SECTION, INCLUDING AGENCY AND SUPPLEMENTARY SERVICES From 1955 onwards the figures of patients conveyed are based on the Ministry of Health definition of a 'patient' which differs somewhat from that formerly used by the Council. 75 Rail journeys—An increasing number of patients who have to travel relatively long distances are being conveyed by rail. These arrangements not only ensure speedy and comfortable journeys for the patients but also relieve the pressure upon the resources of the ambulance services and thanks are due to the railway authorities for their co-operation, which often extends to the provision of special rolling stock to enable particular types of case to be accommodated. As London is the nodal point of railway communication, this Service is frequently asked by other authorities to convey between terminal stations patients travelling by these 'ambulance-train-ambulance' arrangements. Of a total of about 25,000 such patients conveyed in 1960, only 5,749 travelled under arrangements originated by this Service, the remainder being conveyed at the request of other authorities. The following tables give a cross-section of the work of the general and accident sections of the directly provided service in 1960 and some comparisons with earlier years. Table (ii)—General section 1956 1957 1958 1959 1960 Average mileage per patient 4.12 4.04 4.02 3.94 3.83 Average mileage per journey 8.07 8.05 8.25 8.15 8.11 Patients carried per 100 journeys 195 198 205 207 212 Delays to ambulances at hospitals of over half an hour's duration 745 334 283 336 465 Table (iii)—Accident section Year Number of calls received Ambulance not required Average time to incident (in minutes) Average time from incident to hospital (in minutes) 1956 97,823 7,106 6.7 5.8 1957 97,535 7,213 6.4 6.0 1958 99,188 7,746 6.5 5.7 1959 104,983 8,640 6.6 6.2 1960 109,551 9,644 6.8 6.4 notes—1. These numbers include some urgent parturition cases and patients removed by general section ambulances when passing the scene of an accident. 2. Some accident calls are answered by vehicles from general stations, usually when an ambulance from the nearest accident station is not available. Table (iv)—Accident section—Source of calls 1956 1957 1958 1959 1960 Public and l.c.c. staff 64,647 66,039 68,134 72,793 76,705 Police 14,707 15,546 15,468 16,430 16,505 Midwives* 4,621 1,564 714 420 326 Doctors 6,734 6,781 6,815 7,092 7,522 Hospitals 1,887 1,917 2,032 2,021 2,186 Railway officials 2,535 2,775 3,030 2,931 2,896 Local calls† 930 892 870 923 893 London Fire Brigade 827 841 928 1,067 1,055 Out county 935 1,180 1,206 1,306 1,463 Total calls 97,823 97,535 99,188 104,983 109,551 * Fewer calls for gas-and-air analgesia apparatus because of the introduction of trilene apparatus which is portable by midwives. † Made personally at ambulance stations. 76 Operational—Since the closure of the Battersea accident ambulance station in 1956 for rebuilding, the new Upper Richmond Road accident station has provided cover for the Putney, Wandsworth and Battersea areas. The rebuilding of the Battersea station began during the year and will provide an enlarged station from which three vehicles will operate instead of two as formerly. It is anticipated that the new station will be completed towards the end of 1961. In the meantime an ambulance has been stationed at the Battersea General hospital in order to provide a flexible 24-hour accident service in the borough of Battersea, and I am most grateful to the Battersea and Putney Group Hospital Management Committee and to the Secretary of the Battersea General hospital for making this temporary arrangement possible and for helping to ensure its continued successful operation. Radio-telephony—During the year the installation of radio-telephony equipment was extended to all the accident section vehicles operating from stations north of the Thames. Vehicles—By the end of the year a total of 64 Daimlers, located at the North Western ambulance station and at a number of accident stations, had been replaced by new-type Austin ambulances in accordance with the vehicle replacement programme and six new 15/16 seat Bedford coaches were brought into service. The vehicle strength for the year 1960/61 was: Large ambulances 250 Single stretcher, sitting case ambulances 62 Sitting case cars 25 Ambulance coaches 6 Tenders 2 345 Staff—The service is under the supervision of an Officer-in-Charge and is staffed by 28 administrative and clerical staff, 77 ambulance control clerks and 783 supervisory and operative staff. There was a steady fall in recruitment during 1960, resulting in a deficiency at the end of the year of 70 ambulance driver/attendants. Award of resuscitation certificates—Two drivers in the accident section of the service were awarded the Royal Humane Society's resuscitation certificate during the year. Safe driving—60 per cent. of the 765 drivers who entered the National Safe Driving Competition held by the Royal Society for the Prevention of Accidents in 1959 gained awards, 23 per cent. were disqualified and 17 per cent. were accounted for by resignations and by exemption owing to prolonged sickness. Civil Defence In the course of the year the strength of the Ambulance and First Aid Section increased from 1,600 to 1,678. During the year, 411 persons were enrolled but 333 persons resigned. The following courses were held during 1960: Introductory 7 First-aid 12 Ambulance section—part (1) 13 Ambulance section—part (2) 11 Driving and maintenance 9 Officer selection 6 First-aid practical revision 1 After a total of 1,035 hours' instruction by the British School of Motoring 38 volunteers passed the Ministry of Transport driving test. A total of 2,564 hours' driving practice on various types of ambulance was put in by volunteers holding driving licences and 185 tests were passed on such vehicles. Volunteers visit the Council's accident ambulance stations to see casualty work at first hand and the number of such attendances in 1960 was 566 covering 1,362 hours. Members of the Section took part in many exercises and displays and, in addition, an internal competition between teams of the Ambulance & First Aid Section of the County of London division was organised. 77 PREVENTION OF ILLNESS: CARE AND AFTER-CARE Chiropody In 1948 a total of 26 foot clinics were transferred to the Council under the National Health Service Act, 1946. These had been established by the metropolitan borough councils under section 227 of the Public Health (London) Act, 1936. The Council proposed to continue the existing service and to augment it where necessary in the light of experience. The Minister approved the continuation of the existing facilities but did not feel able at that time (1948) to agree to any increase; although he said he would be prepared to consider new proposals for extending the service in the light of any recommendations which the Executive Council or the regional hospital boards might make. Cope Committee—In May, 1949 the Minister of Health set up a series of eight committees under the Chairmanship of Mr. V. Zachary Cope, M.D., M.S., F.R.C.S., to consider the supply and demand, training and qualifications of certain medical auxiliaries employed in the National Health Service. I had the honour to be appointed a member of the committee on chiropodists. The committees invited evidence from interested parties and in its evidence to the chiropody committee the Council pointed out that chiropody was essentially a preventive service; that experience had shown that it had done, and could do, much to prevent the development of serious foot trouble and ill-health arising therefrom; that since the services of medical staff were not needed at foot clinics there appeared to be no justification for regarding them as coming within the province of either the hospital and specialist services or the general medical service; and moreover, that the hospitals were not always conveniently situated and that most of them were already overcrowded. For these reasons the Council expressed the opinion that the provision of foot clinics could properly be held to be a function of the local health authority which, under section 28 of the National Health Service Act, 1946, is empowered to make arrangements for the prevention of illness. In their report (April, 1951) the Committee recommended (inter alia) that: 'Local Authorities should be enabled to provide chiropody in the National Health Service, possibly in the exercise of their powers under section 28 of the National Health Service Act, 1946.' Negotiations for the expansion of the service—In the circumstances then prevailing the Minister was unable to adopt the recommendations of the Cope Committee, nor did he feel able to approve the provision of additional facilities for chiropody. The lack of facilities in certain areas of the county, e.g., in East and South-West London was, however, brought to the attention of the Minister. He was asked to permit some extension of the existing facilities with a view to mitigating the hardship experienced in certain parts of London, but in the financial circumstances at that time he felt unable to authorise any extension of the service. An expansion by 40 sessions a week for the benefit solely of the priority classes (expectant and nursing mothers and the elderly) was, however, approved as a result of a discussion between a deputation from the Council and the Parliamentary Secretary on 28 March, 1952. This small increase allowed an expansion from 425 to 465 chiropody sessions a week (sessions are calculated on the number of chiropodists working at a clinic, e.g., two chiropodists working together at one session equal two chiropody sessions). The pressure on the facilities for foot treatment continued to grow and at the end of 1953 it was estimated that to meet all reasonable needs an increase in the level of the service of some 112 per cent, would be required. Further approaches were made to the Minister of Health in 1954 and 1956 for approval to an expansion in the service, stress being laid on the following points: (i) The existing service was inadequate to meet the demand. 78 (ii) It was difficult to convince the public in areas without facilities that the Council could not provide them with a service, when it was known that treatment was provided elsewhere in London and subsidised out of the county rate levied on all areas. This applied particularly in South-West London. (iii) The pressure of work at the existing clinics was such that there were long waiting lists, and appointments had to be made at intervals of up to three months. It was impracticable, therefore, apart from the distances which would have to be travelled by patients, for existing clinics to serve the areas at present without facilities. (iv) The service was most beneficial for old people. Amongst those attending the existing clinics were those with limited joint movements, as well as those suffering from other degenerative diseases associated with old age. It was the opinion of field workers, based on their experience, that adequate foot treatment was of great assistance in maintaining a degree of mobility in old people which materially assisted in preventing deterioration in their condition which would result in their needing hospital or institutional care. (v) Some cases were referred to the Council's foot clinics by general practitioners and a few by hospitals. In areas where no clinics were available it was assumed that similar cases were referred to hospitals. (vi) There was evidence, therefore, that the service, where it was available, was fulfilling a valuable preventive function and that expenditure on it relieved to some extent the hospital services of reference to them of persons with minor foot complaints. The deputation from the Council which attended the Ministry in 1954 were informed that, whilst the Minister was not averse in principle to an expansion of the chiropody service throughout the country, there was no prospect of his being able to agree to its extension in the near future because of its cost and the prior needs of other services. It was suggested, however, that it might be possible for the Council to make increased contributions to the funds of voluntary organisations prepared to run chiropody clinics. The Council and the metropolitan borough councils are empowered by section 31 of the National Assistance Act, 1948 to make contributions to old people's organisations and the Welfare Committee expressed their willingness to consider on its merits any application for a grant towards the cost of a chiropody service. In the event, however, it was left to the metropolitan borough councils to make such grants. In 1956 the Minister of Health, while still unable to approve of any expansion of the service, suggested that the existing service in London might be more evenly spread so that some provision could be made in areas which had no facilities for chiropody. It was emphasised that the total number of sessions should not be increased nor additional expenditure incurred and that any clinics established in new areas should be used exclusively for the priority groups. The Health Committee agreed to a redistribution, transferring 30 sessions a week from division 6 (covering the boroughs of Deptford, Greenwich and Woolwich) and three sessions from division 8 (covering the boroughs of Bermondsey, Lambeth and Southwark). With some re-allocation of sessons in other divisions it was possible to provide a minimum service over the whole county, including the establishment of 15 new clinics. This re-allocation naturally was not easily accepted in those areas where a full service had been provided by the borough council prior to 1948, particularly in division 6. The Woolwich Borough Council made representations regarding the reduction of the service in that borough by 17 sessions a week. Whilst regretting the necessity to re-allocate the sessions the Council informed the Borough Council that when the opportunity occurred, steps would be taken to press the Minister of Health again to agree to an extension of the service. 79 Circular 11/59—On 21 April, 1959 the Minister issued a circular (11/59), stating that he was prepared to approve proposals by local health authorities who wished to establish or extend a chiropody service and reminding them that under the Local Government Act, 1958 his approval was no longer required to contributions by local health authorities to the funds of voluntary organisations providing chiropody services. The following addition to the Council's proposals under the National Health Service Act was then submitted to the Minister and received his approval: ' The Council proposes to extend its chiropody service as may be necessary, priority being given to the needs of old people, of the physically handicapped and of expectant mothers. The service will be provided at foot clinics established by the Council and/or at surgeries of private chiropodists, by means of a domiciliary service and/or by utilising on a grant-aided basis the services of approved voluntary organisations.' In recommending the adoption of this proposal the Health Committee stated that it was not then proposed to start a domiciliary service or to use the surgeries of private chiropodists, but that they thought it desirable that the amended proposal should provide for the Council to be able to do so. Detailed enquiries disclosed that it was not possible to estimate the total number of persons in the priority groups who were likely to require chiropody treatment, but as a first step the Council decided in July, 1959 to authorise an additional 100 sessions a week. So far as old people were concerned, a survey carried out by the National Corporation for the Care of Old People indicated that 20 per cent. of those over retirement age required an average of six treatments a year. On this basis some 94,000 old people in the county would require 564,000 treatments a year. Additional facilities would be needed to serve expectant mothers and the physically handicapped; no estimate of the numbers in these two groups was available but it was thought to be relatively small. With the 100 additional sessions approved in July, approximately 213,000 treatments a year were available at the Council's clinics for all classes (134,000 for old people and 79,000 for other age groups). In addition, voluntary organisations provided some 82,000 treatments a year, mainly for old people. To meet in full the estimate of 564,000 treatments a year for old people would have meant that the combined facilities provided by the Council and by the voluntary organisations would have had to be more than doubled. Apart from the difficulty of obtaining sufficient chiropodists, an expansion to this level was impracticable on financial grounds. It was therefore decided that the Council's service should be extended by another 100 sessions a week from 1 April, 1960 and the position reviewed at the end of a year's working. Voluntary organisations—The voluntary associations providing a chiropody service are (with the exception of the Deptford Central Mission which provides a service for the physically handicapped) concerned solely with the welfare of old people. Their funds are derived from a variety of sources but (until March, 1960) came mainly from grants made by the metropolitan borough councils under section 31 of the National Assistance Act, 1948. Some of the organisations received a grant during the three years ended 31 March, 1959 from the National Corporation for the Care of Old People, in order that they could extend their chiropody services. It was agreed with the Metropolitan Boroughs' Standing Joint Committee that the Council should accept responsibility, as from 1 April, 1960, for grants to the voluntary organisations in respect of their chiropody services and that consideration would be given to the need to make grants for 1959/60 in lieu of any lost income (e.g. from National Corporation for the Care of Old People) which was used to cover expenditure on chiropody. After consideration of the accounts of the voluntary organisations the Council made grants totalling £1,300 to seven organisations in respect of the year 1959/60. On the basis of estimates submitted by the voluntary organisations it was calculated that to maintain the service at its existing level grants totalling some £12,000 would be necessary for the year 1960/61. The payment of grants was made subject to the conditions that: 80 (i) No expansion of the existing service should be undertaken without prior approval by the Council. (ii) The appropriate Whitley Council scale of payments to chiropodists should be observed. (iii) The accounts of the association should be kept in such a way as to show the expenditure and income on the chiropody service separately from the general account of the association and in such detail as the Council might require. (iv) Patients should be required to contribute towards the cost of treatment as in Council clinics, i.e., 3s. per treatment, subject to abatement according to means. Most of the voluntary organisations had previously made a flat rate charge, but, in some instances, allowed free treatment in case of great hardship. Representations were made by some of the associations that individual assessment under the Council's scale would be an administrative task they could not undertake. It was therefore agreed that a simplified method should be adopted. It soon became clear, however, that few, if any, of the old people would be liable to make any contribution towards the cost of treatment under the Council's scale. In December, 1960 the Council decided that no charge should be made for treatment in its foot clinics to persons receiving old age or normal retirement pensions and voluntary organisations were asked to implement this decision in respect of the services provided by them. Towards the end of the year it was apparent that the combined effect of the implementation of the Council's scale of charges (as against the flat rate charge) and the under-estimation of expenditure by some organisations (mainly on account of fees to chiropodists) would cause the estimate of £12,000 for grants to be exceeded. Although final figures will not be available until all accounts have been submitted and scrutinised it is anticipated that the final figure will be of the order of £19,000 and authority was given for payments up to this amount. Treatment—The Cope Committee defined chiropody as the treatment of superficial ailments of the feet and the maintenance of the feet in good condition. That the Council's chiropodists follow this definition is evident from the fact that the majority of treatments provided at the foot clinics are for superficial excrescences (corns, callosities, etc.) and for malformed nails. Advice is also given on shoe fitting, foot hygiene and exercises. As will be seen from the table below the majority of treatments are given to elderly persons and the aim is to enable them to remain mobile. For those who are unable to reach a clinic by any other means and for whom a domiciliary service is not available, arrangements are made for transport to and from the clinic. The continued demand on the ambulance service makes the provision of transport a matter of increasing difficulty and every effort is made to economise in its use for the chiropody service. The following tables show the attendances at the Council's foot clinics since 1949 with an analysis according to age groups for the last three years: 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 1957 8,149 166,987 44.2 1958 6,994 172,005 44.2 1959 7,074 169,847 46.2 1960 9,405 186,735 57.7 81 F Analysis in age groups of treatment given at clinics Group 1958 1959 1960 Children 0-4 years 100 137 129 5-14 years 6,381 6,390 7,062 Males 15-64 years 14,805 14,442 14,766 65 years and over 15,435 15,410 17,613 Females 15-59 years 59,217 56,581 57,980 60 years and over 76,067 76,887 89,185 Total 172,005 169,847 186,735 It will be noted that 57 per cent. of the treatments were given to old people. Attendance at the clinics by persons in other age groups, except in so far as they concern expectant mothers or the physically handicapped, are confined to clinics which were in existence in 1948. Besides attending some of the foot clinics, school children are treated also at school treatment centres. The fluctuation in total attendances over the 12 years under review was due in the main to inability to recruit sufficient chiropodists to staff all the sessions all the time. A contributory cause was the non-attendance of patients for whom an appointment had been booked. It is difficult to assess in advance the wastage likely to arise from this cause and to counteract it by overbooking, but at all clinics an effort is made to secure a good attendance. The voluntary organisations in receipt of grants from the Council provided in the year 1960/61 a total of 76,321 treatments (55,955 at clinics, 7,841 at private surgeries of chiropodists and 12,525 at patients' homes). Staff— Difficulty has been experienced in maintaining a full staff in the Council's clinics and it has been particularly difficult to get full-time staff. At the end of the year the equivalent of 57.7 full-time chiropodists (35 full-time and 79 part-time staff) were employed against an establishment of 62.5. Conclusion—Experience has shown that a chiropody service, particularly for old people, helps to prevent the development of serious foot trouble and ill-health arising therefrom and by keeping old people mobile reduces demands on hospital beds, the home nursing service and the home help service. It is impossible to forecast with accuracy the future needs for chiropody but it is apparent that, apart from limitations imposed by financial and staffing considerations, the service could be considerably expanded. Recuperative holidays Admissions to recuperative holiday homes 1956 1957 1958 1959 1960 Expectant and nursing mothers 141 138 111 123 109 Other adults 2,590 2,510 2,289 2,457 2,175 Children under 5 not at school 602 660 575 571 512 School and nursery school children 2,842 2,852 2,507 2,597 2,357 6,175 6,160 5,482 5,748 5,153 The Council maintains a recuperative holiday home at Littlehampton, Sussex, for 36 children from 3 to 8 years of age and leases another home at Bognor Regis, Sussex, for 44 children from 8 to 15 years old. Children who could not be accommodated in these homes and all adults have been placed in homes under private ownership or maintained by voluntary organisations. 82 Venereal disease Treatment of venereal disease at London out-patient 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. 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 1957 701 562 78 2 8,943 2,003 9,722 2,567 20,554 8,102 223,821 97,149 1958 733 490 66 3 10,619 2,307 11,418 2,800 21,906 8,857 215,934 89,407 1959 799 493 93 — 11,722 2,599 12,614 3,092 24,013 9,179 229,368 88,232 1960 908 410 68 2 13,077 2,905 14,053 3,317 26,494 10,647 240,303 96,113 1956 1957 1958 1959 1960 Percentage of patients resident in County of London 79 81 82 83 81 Number of patients completing treatment and of defaulters— Syphilis—patients completing treatment— Males 818 828 631 579 526 Females 645 627 554 508 434 patients not completing treatment— Males 639 675 870 672 677 Females 326 294 292 336 431 Gonorrhoea—patients completing treatment— Males 3,663 4,938 5,237 4,941 5,700 Females 780 985 1,165 1,199 1,334 patients not completing treatment— Males 3,172 3,501 4,128 4,900 6,536 Females 801 900 1,161 1,312 1,485 Tracing of contacts of patients— Analysis of work undertaken by Council's welfare officers 1956 1957 1958 1959 1960 Contacts referred by hospitals, medical services of the Armed Forces and by local health authorities 370 384 297 246 282 Insufficient information for following-up 277 276 191 102 91 Contacts brought to treatment 44 27 43 57 72 Contacts traced but not brought to treatment 6 14 3 7 13 Contacts not traced 43 67 60 80 106 In addition the female welfare officers attended clinics at St. Paul's, St. Mary's, St. Thomas' and London hospitals and at H.M. Prison, Holloway, and followed-up persons defaulting in attendance at these clinics. Health education Health education activities followed the general lines of recent years—the direct approach to individuals being supported by divisionally arranged group lectures and displays and centrally organised exhibitions and campaigns. 83 F* Lectures and discussions—The basis of work in the field centres on day-to-day contact with members of the public and a regular series of talks and discussions held mainly at welfare centres. Most of the work falls naturally to the health visitor. The volume and varied nature of the talks, arranged under the direction of divisional medical officers, is shown in the following tables: Health education talks Table (i)—Speakers Divisions 1 2 3 4 5 6 7 8 9 Total Medical officers – 66 7 – – 2 – – 75 Nursing officers – 1 — – – — 1 – – 2 Health visitors and school nursing sisters 533 1,663 216 319 514 879 580 175 503 5,382 Domiciliary midwives 16 13 1 — 4 — 13 — — 47 Public health inspectors – – – – – – 1 — — 1 Teachers/instructors 19 12 47 123 115 — 9 — — 325 Fire prevention officer (L.F.B.) – – – – – – – – 1 1 Physiotherapists — 2 – – – – – – – 2 Lecturers from outside the Council's service—Nursing – – – 5 – – 3 – – 8 Other 75 17 9 4 — — 61 2 1 169 Total 643 1,774 280 451 633 879 670 177 505 6,012 Table (ii)—Audience groups Divisions 1 2 3 4 5 6 7 8 9 Total Expectant mothers 506 1,072 137 296 408 825 358 155 234 3,991 Mothers, mothers' clubs, etc. 137 697 133 155 223 54 275 11 268 1,953 Parent/teacher associations – – – – – – 4 1 — 5 Schools* — — 5 — — — — — — 5 Day continuation classes — — 4 — — — — — — 4 Voluntary organisations — 5 1 — 2 — 33 10 3 54 Total 643 1,774 280 451 633 879 670 177 505 6,012 * Lectures by medical officers. 84 85 Table (iii)—Subjects of talks and attendances Divisions 1 2 3 4 5 6 7 8 9 Total Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Talks Attendances Care of mothers and young children 526 3,895 1,102 7,734 146 990 256 1,834 430 3,802 879 9,453 340 4,642 147 962 317 2,382 4,143 35,694 Care of older children 8 79 137 898 10 444 2 8 17 122 — — 27 392 4 82 16 149 221 2,174 General family health topics 3 30 149 892 14 156 10 111 10 98 — — 33 436 2 62 60 494 281 2,279 Environmental hygiene 3 25 51 527 3 56 — — 2 20 — — 12 119 — — 7 53 78 800 Infectious diseases and prophylaxis 44 419 130 809 3 33 5 24 25 206 — — 28 329 6 59 20 174 261 2,053 Prevention of accidents 10 128 80 556 8 129 3 75 23 179 — — 26 464 7 50 12 135 169 1,716 Smoking and lung cancer — — 7 40 3 1,000 — — 2 19 — — 2 24 — — 1 13 15 1,096 Cancer education (other than above) — — 2 8 – – – – – – – – – – – – 1 10 3 18 Mental health — — 23 213 — — 1 10 2 20 — — 8 97 — — 5 36 39 376 First aid — — 6 38 2 24 1 7 4 16 — — 24 290 — — 7 48 44 423 Other 49 412 87 840 91 1,111 173 3,072 118 868 — — 170 2,338 11 165 59 527 758 9,333 Total 643 4,988 1,774 12,555 280 3,943 451 5,141 633 5,350 879 9,453 670 9,131 177 1,380 505 4,021 6,012 55,962 Talks are necessarily recorded according to the principal subject of each talk. Topics such as prophylaxis and the prevention of accidents, besides forming the basis of separate talks, are also included within the scope of many general talks on the care of mothers and young children. A valuable supplement to the efforts of the health visitor is provided by leaflets and posters and the department stocks a changing supply of about 400 different leaflets and 260 kinds of posters. The services of the divisional staffs are always available to head teachers for advice and assistance in planning health education in schools and for giving special talks. At the invitation of head teachers school health visitors give a regular series of talks in many schools. While primarily on mothercraft, the talks extend over a broad range of health subjects. Over 4,000 such talks were given during the year. A series of lectures was also given in connection with the National Nursery Examination Board Certificate and the Home Office Senior Child Care Reserve course, as well as talks to hospital student nurses and medical students. Films and filmstrips—There has been an increasing demand for films and filmstrips in the presentation of talks and discussions, as indicated in the following table of requests received from divisions: 1957 1958 1959 1960 Films 270 325 364 473 Filmstrips 477 446 977 1,094 The department's own library provided films on 90 occasions and all the filmstrips. In addition to those supplied centrally, divisions hold a number of filmstrips for exclusive local use. Special campaigns and exhibitions—For several years the Council has participated in the Ideal Home Exhibition at Olympia for the purpose of publicising means of reducing high fire risks and of escape in case of fire. This year the Council's theme was widened to include safety in the home and this department joined with the Architect's department in mounting and staffing the stand. Over 40,000 copies of a specially prepared leaflet embracing both aspects of the display were distributed, as well as some 42,000 leaflets on specific aspects of home safety. The Council's stand attracted much attention from visitors to the exhibition and the staff had many opportunities of discussing individual problems. The Council again took part in the annual country-wide 'Safety in the home' campaign. A special feature was the production, in co-operation with the Home Counties, of a 60-second home safety film which was shown on Independent Television during the campaign week. The potential viewing audience was estimated at 1,700,000 families. Home safety week in the divisions stressed particularly falls and poisoning. The co-operation of the metropolitan borough councils and other organisations was sought and the amount of material distributed—21,000 posters, 560,000 leaflets and 90,000 bookmarks— is some indication of the intensive work undertaken locally. At a 'Be safer in your home' exhibition organised by Islington Borough Council the department provided exhibits on hazards to children and the stand was manned by health visitors from local welfare centres. A fully equipped accident ambulance was stationed at the exhibition for inspection by the public. As a contribution to World Mental Health Year members of the public were specifically invited to attend open days at training centres for the mentally subnormal. A specially prepared leaflet, which described simply the changes brought about by the Mental Health Act, 1959 and outlined the provisions made by the Council for the care of the mentally disordered, was widely distributed. During April and May a six-week poliomyelitis vaccination publicity campaign was mounted, directed particularly at those between 25 and 40 years of age. Extensive use 86 was made of special posters, leaflets and bookmarks, as well as display advertisements in the London evening and local newspapers. The campaign, supported by adjacent health authorities with large numbers of residents working in London, coincided with the period during which Ministry of Health announcements were made on radio and television. In view of the varied publicity media used it was decided to record the motivating agency of a sample of persons presenting themselves for vaccination. The survey covered 2,116 persons, 67 per cent. of whom were in the older age group; the media most frequently seen were posters and press advertisements. Over 40 per cent. did not admit to having seen any publicity. A number of this group, however, were apparently influenced by relatives and friends who may themselves have been influenced by the publicity campaign and no doubt this large uncommitted category were influenced directly or indirectly by the day-to-day background work of divisional staffs. Safety handbook—With the co-operation of other bodies, distribution of a further edition of a safety handbook was commenced. The handbook is a commercial publication, distributed free of charge. Material relating to 'safety' is either provided or approved by the Council. County Hall display window—The department was allocated the use of two display periods in the North Block window. The first was used to feature various activities of the London Ambulance Service, while in the two months preceding the Christmas holidays the display was based on safety at home, with special emphasis first on 5 November and then on Christmas festivities. Special publications—A leaflet 'One out of eleven', drawing attention to the link between smoking and lung cancer, was produced for the general public, after consultation with the London Local Medical Committee and medical officers of health of the metropolitan boroughs. Some 120,000 copies have been distributed; through the good offices of the London Executive Council copies were sent to each medical practitioner and dentist in London, copies were also sent to schools, welfare centres and public libraries. The leaflet excited considerable interest and press references led to a number of requests for copies from individuals far removed from London. Early in the year, two fires involving drip-feed radiant oil heaters occurred, in which children died. A leaflet with a powerful human approach on the dangers of fire arising from misuse of this type of appliance was prepared and 100,000 copies distributed through divisions and Old People's Welfare Committees. When publication of the new British Standards Institution standard and the passing of the Oil Burners (Standards) Act resulted in more general publicity for these risks, a further leaflet was produced in which the emphasis was placed on the proper care of these appliances and the improvement of existing models. The leaflet had the general approval of the Oil Appliance Manufacturers' Association, some members of which gave assistance in the distribution of the leaflet within the county. Nearly 300,000 copies were distributed, including a copy sent to all the Council's housing tenants whether living in or outside the county. Staff visual aids competition—This annual competition produced 60 entries. In the poster and display section an entry from a team of health visitors in division 6 was placed first; in the teaching aids section the first prize was awarded to an entry by a team of health visitors from division 4. All the entries were on display at County Hall for three days. 87 MENTAL HEALTH SERVICES Mental Health Act, 1959: the Council's proposals—The Council's proposals for the reorganisation and development of its mental health services in the light of the provisions of the Mental Health Act, 1959 and the recommendations of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency were submitted to the Minister of Health and approved by him without amendment. The following is a brief summary of the main features: Organisation and staffing—Day-to-day responsibility for mental health work to be delegated to the nine Divisional Health Committees. A mental health social worker team to be formed in each division under the immediate direction of a divisional mental welfare officer responsible to the divisional medical officer. Extension of arrangements for staff training, both whole time and in-service. Junior training centres—Replacement of church hall centres by purpose-built premises and provision of additioual accommodation as necessary. Provision for children requiring special attention because of physical handicap or behaviour difficulty and for children from three years and upwards to be made in new centres where appropriate. Provision of play centre service to afford relief to parents during long centre holidays. Adult training centres—Unsuitable premises to be replaced and considerable expansion in provision of industrial training and sheltered workshop facilities envisaged, for both men and women. Day centres for the mentally ill to be provided and provision of occupational therapy at day hospitals proposed. Residential accommodation—To be provided in the light of need as revealed by experience with 'pilot' schemes and in accordance with broad priorities as follows : (i) For persons discharged from psychiatric hospitals and considered likely to benefit from rehabilitation or for other persons needing a period of hostel care to avoid admission to a psychiatric hospital; (ii) for young adults leaving residential schools for the maladjusted and needing extra care and guidance; (iii) for short term care of subnormal and severely subnormal persons to avoid hospital admission at times of particular domestic difficulty; (iv) for short term care of high grade subnormal persons on discharge from hospital; (v) for long term care of employable subnormal and psychiatrically disabled persons. Full use to continue to be made of hostels and homes provided by voluntary associations and of arrangements for placing in private homes. Home training—Necessary expansion of existing home teaching service for the mentally subnormal and extension to other classes of the mentally disordered as necessary. Social clubs—Continuation of assistance to voluntary clubs and direct provision of such facilities where necessary. Home visiting—Progressive integration, within each local division, of social work for all classes of mentally disordered persons. Development of liaison and co-operation with the hospital service. Decentralisation—As envisaged in the Council's proposals, the bulk of responsibility for day-to-day operation of the mental health services was placed on the nine health divisions of the county on 24 October, 1960 eight days before the coming into operation of the main parts of the Mental Health Act, 1959. Some initial social worker staffing difficulties were experienced but, on the whole, the new organisation had begun to settle down well by the end of the year. 88 Training centres—Two new centres for adult subnormal and severely subnormal persons were opened. Both are housed in new church halls, the design of which took into account the proposed use of the premises as training centres. One (in Deptford, for men and older boys) replaced an older centre in unsatisfactory premises whilst the other (in North Islington, for women and older girls) was an additional centre. Work continued during the year on the building of a new junior centre in Hackney and on the adaptation of premises in Clapham and North Hammersmith to provide a large industrial training centre for men and a more advanced type of centre for women and girls. All three new centres were expected to be available in the spring of 1961. Sites were also acquired and preliminary work done on plans for three more purpose-built junior centres and two centres for adults. At the end of the year there were nine junior centres with accommodation for 725 children; seven with accommodation for 330 older girls and women; and five with accommodation for 260 older boys and men for whom there was also an industrial training centre with 20 places. The total of 1,335 places is an increase of 60 over the previous year. The industrial training centre again produced goods valued at over £1,000 for use in the Council's service. Day centres for the mentally ill—The Council's first day centre for mentally ill persons, Clifton Lodge, Hackney, was opened in July. This centre provides training and occupation for up to 40 persons of both sexes, under the supervision of a resident supervisor and deputy supervisor with training and experience in the provision of occupational therapy for mentally disordered persons. Activities are varied to suit the needs and interests of those attending and include carpentry, gardening, cookery, typewriting and lampshade and basket making. Although the prime purpose of the centre is the rehabilitation of recoverable patients after discharge from hospital and to give a preventive service for sufferers from mild mental disturbance, the Council decided that psychiatrically disabled persons might also be admitted, if suitable, provided they proved to be capable of remunerative work. Patients attending Clifton Lodge continue under the supervision of the referring doctor and a psychiatric social worker is also in frequent touch with them. Fourteen patients were attending this centre at the end of the year. Earlier in the year the Cane Hill Hospital Management Committee, in association with the Council, had set up a day hospital in premises at St. Olave's hospital, Bermondsey. The Council's share in this venture is the provision of occupational therapy and some social worker services. The day hospital was firmly established and operating very successfully by the end of the year. Fifty-one London patients commenced attendance at the rehabilitation centre run by the Institute of Social Psychiatry at Blackfriars during the year; of these, and 38 already attending at the end of 1959, 14 were discharged to work, one to further training and 36 were discharged as unsuitable, or because of non-attendance or admission to a mental hospital. At the end of the year 38 London patients were attending the centre. The Council also agreed to bear the capital cost of adaptation and equipping of premises to provide a second rehabilitation centre for the Institute of Social Psychiatry in Southwark and, as at the Institute's existing centre at Blackfriars, to contribute 90 per cent. of the cost of attendance of London patients at the new centre when available. Work on the building was well in hand at the end of the year. Residential accommodation—Shortly before the end of the year the Council acquired a large residential property in Putney, for adaptation as a hostel for about 20 patients discharged from psychiatric hospitals needing a period of hostel care. In addition the Council approved of the erection of a larger purpose-built hostel for a similar purpose on a site in Lewisham which was already in its possession. The latter proposal was to be the subject of a local enquiry under the Town and Country Planning Acts. 89 Residential care of the mentally ill—During the year 203 chronic and senile cases (compared with 181 during 1959) were maintained by the Council in residential accommodation; 185 at homes owned or sponsored by the Mental After-Care Association, nine at hostels of the Jewish Board of Guardians, five at Parnham House (National Association for Mental Health) and four at other establishments. Recuperative holidays for psychiatric patients— During the year 128 persons recovering from mild psychiatric illness were granted recuperative holidays of two to three weeks in general recuperative holiday homes; seven who had had more serious mental breakdown were sent for similar periods to homes owned or sponsored by the Mental After-Care Association, and four were accommodated for somewhat longer periods at Mental AfterCare Association homes for rehabilitation. The total of 139 compares with 164 in 1959. Home teaching—A third home teacher for the mentally subnormal was appointed during 1960 and at the end of the year tuition was being provided for 48 persons who were unable through physical handicap to attend training centres. Community care of the mentally ill—Up to 24 October, 1960, whilst this service was provided by a small team of psychiatric social workers based on the central offices, 388 cases were dealt with, compared with 361 during the whole of 1959 when, however, there were considerable periods during which the full complement of staff was not available. From 24 October until the end of the year the divisional teams dealt with 307 references for community care of the mentally ill. Not all these cases were, however, undertaken by psychiatric social workers. Guardianship—A further review of guardianship cases took place, as a result of which 24 patients were discharged and placed under voluntary supervision. Following the full implementation of the Mental Health Act, 1959 on 1 November, 1960 responsible medical officers, approved for the purposes of section 28 of the Act, commenced the review and classification required within six months of this date of the 92 patients remaining under guardianship, to decide whether they should be retained under guardianship or, alternatively, discharged and placed under community care. Lunacy and Mental Treatment Acts, 1890-1930 and Mental Health Act, 1959 The following statistical tables relate to persons alleged to be suffering from mental illness referred to the Council's mental welfare officers. References to sections are to the Lunacy Act, 1890 unless otherwise indicated. Table (i) Persons referred in the year 1959 1960 Total persons 5,578 5,224 Number of separate investigations 6,880 6,256 The 1960 total includes 319 persons normally resident outside the county. Table (ii) Referring agency 1959 1960 No. % No. %. General practitioner 3,137 45.6 2,744 43.9 Psychiatrist* 613 8.9 565 9.0 Hospital ward 620 9.0 437 7.0 Hospital casualty department 686 10.0 545 8.7 Non-medical 1,824 26.5 1,965 31.4 6,880 100.0 6,256 100.0 * These numbers exclude cases referred for a psychiatrist's advice by the mental welfare officer after seeing the patient and before taking action. 90 Table (iii) Initial action* 1959 1960 No. % No. % None possible or necessary 1,583 230 1,564 25.0 Admitted for observation 3,476 50.6 2,979 47.6 Other action 1,821 26.4 1,713 27.4 6,880 100.0 6,256 100.0 * After visit by mental welfare officer. Table (iv) Closure 1959 1960 No. % No. % No initial action possible or necessary 1,583 26.3 1,564 29.0 No further action possible or necessary 224 253 Discharged from ward after observation 1,222 17.8 846 13.5 Transferred to general hospital ward 71 1.0 56 0.9 Other continued care 90 1.3 83 1.3 Out-patient (psychiatric) and miscellaneous action recommended by psychiatrist 103 1.5 133 2.1 Admitted to psychiatric hospital— (a) as voluntary or informal patient 2,307 33.5 2,238 35.9 (b) on temporary certificate 25 0.4 2 0.0 (c) on urgency order 66 1.0 63 1.0 (d) absentee returned to hospital 9 0.1 6 0.1 (e) court order 8 0.1 27 0.4 (/) certified (sects. 14/16) 1,121 16.3 829 13.3 (g) for treatment (sect. 26, Mental Health Act, 1959) — — 106 1.7 Died 51 0.7 40 0.6 Miscellaneous — — 10 0.2 6,880 100.0 6,256 100.0 Mental Deficiency Acts and Mental Health Act, 1959 (Subnormal and severely subnormal persons) Persons referred during the year—The following table shows the sources from which persons were referred under the Mental Deficiency Acts (up to 31 October, 1960) and under the Mental Health Act, 1959 as subnormal or severely subnormal. Source of information 1959 1960 Local education authority— Reported under section 57 of the Education Act, 1944 396 231 Referred for voluntary supervision (or community care) 176 300 Police or Courts 24 32 Hospitals, residential nurseries, etc. 80 80 Miscellaneous 193 182 Total referred 869 825 91 Community care—At 31 December 4,389 subnormal or severely subnormal persons were receiving community care from the mental health service. The types of service provided are shown in the table below; many persons were receiving more than one type of service. Under 16 years 16 years and over Total Attending training centre (day) 689 538 1,227 Home training 24 24 48 Resident in L.C.C. home or hostel — 4 4 Resident in private residential home at L.C.C. expense — 24 24 Boarded out at L.C.C. expense — 5 5 Under guardianship (of persons other than a local health authority) 3 92 95 Receiving visits from mental welfare officer 1,181 3,143 4,324 Other types of service 14 16 30 1,911 3,846 5,757 Number of persons receiving community care at 31.12.60 1,208 3,181 4,389 Hospital admissions 1959 1960 Persons admitted to hospital 340 357 Persons awaiting admission to hospital at 31 December 247 230 Short-term residential care 1959 1960 Persons admitted temporarily for residential care— To hospitals 219 205 To approved homes and private homes 157 169 376 374 SCHOOL HEALTH SERVICE Pupils on school rolls—In January, 1961 there was a total of 428,591 pupils on the day school roll; 231,025 in primary schools, 187,250 in secondary schools, 1,759 in nursery schools and 8,557 in special schools. In January, 1960 there were 433,415 pupils on the roll. Ministry of Education circulars—Administrative memorandum 9/60 relating to handicapped pupils with parents in the armed forces and circular 12/60 dealing with changes in procedures relating to educationally subnormal pupils are discussed on pages 104 and 105 respectively. Medical inspection Details of medical inspections during 1960 are summarised and compared with those for earlier years in the tables below. Non-routine inspections, particularly ' specials ', are now recorded under more specific descriptions and the source of reference is given for the first time. Since 1958 periodic general medical inspections have been analysed by year of birth to conform with Ministry of Education requirements, but to facilitate annual comparisons the year of birth has been turned into 'age' (by subtracting year of birth from year of inspection) in the tables throughout this section of the report. The Council's revised scheme for the medical inspection of school children came into operation on 1 January, 1959 and one effect was to make the intermediate periodic inspections a year later in the child's school life. Consequently fewer inspections were carried out during 1959 than in 1958; in 1960 the normal pattern was resumed, but on the new time-table. It will be seen from the following table that intermediate inspections now are each spread over two age-groups because the school year begins in September. Compared with 1958 there were 21,481 fewer periodic inspections carried out in 1960, the largest drop being in the 11/12 age group, although that in the 7/8 group is considerable. The 11-year olds in 1958 were, however, born in 1947—the well-known 'bulge' year. The number of children seen at routine medical inspections in 1960 was 35.2 per cent. of the school roll, compared with 31.4 per cent. in 1959 and 39.4 per cent. in 1958. Another effect of the revised scheme was to abolish nutrition reinspections. Ordinary reinspections showed a fall of almost 17 per cent. from the 1959 figure and fewer 'special' inspections were carried out. It is of interest that of the 13,056 special inspections, half were requested by head teachers, a quarter by school health visitors and just over oneeighth by parents. Periodic general medical inspections Age groups 1958 1959 1960 No. % No. % No. % 4 and less 7,690 4.5 7,660 5.6 7,674 5.1 5 29,514 17.1 29,317 21.6 27,435 18.2 6 6,508 3.8 7,069 5.2 7,511 5.0 7 30,775 17.9 13,278 9.7 9,744 6.5 8 5,086 3.0 8,540 6.3 19,322 12.8 9 1,709 1.0 3,128 2.3 3,227 2.1 10 2,455 1.4 1,817 1.3 1,897 1.3 11 44,635 25.9 15,424 11.3 10,549 7.0 12 6,126 3.5 8,744 6.4 19,634 13.0 13 1,930 1.1 2,896 2.1 4,884 3.2 14 8,812 5.1 8,204 6.0 9,418 6.2 15 and over 27,031 15.7 30,186 22.2 29,495 19.6 172,271 100.0 136,263 100.0 150,790 100.0 93 Non-routine medical inspections 1958 1959 1960 Reinspections—nutrition 46,293 3,622 — Reinspections—other 87,275 97,401 80,631 Secondary school reviewals 8,934 2,771 1,785 Other non-routine inspections (see next table) 48,245 47,924 50,648 Total 190,747 151,718 133,064 Total inspections 363,018 287,981 283,854 Analysis of non-routine medical inspections Nature of inspection Number inspected Bathing centre inspections—scabies 79 Bathing centre inspections—other 92 Employment certificates 5,288 Licences for theatrical employment 447 School journeys 21,032 Recuperative holidays—prior to holiday 1,188 Recuperative holidays—on return 396 Candidates for higher awards 47 Nautical school entrants 111 Outward Bound and Adventure courses 157 T.B. contacts 58 Boarding schools for the delicate— Pre-departure inspections 246 On return 85 Other handicapped pupils— Statutory examination 944 Periodic special defect examination 5,490 Research investigations and enquiries 383 — 36,043 Specials, at request of: Head teacher—special book 1,659 Head teacher—others 4,854 School nurse—after health survey 1,722 School nurse—others 1,539 Divisional officer (Education) 888 District care organiser or care committee 725 Parent 1,669 — 13,056 All other non-routine inspections 1,549 Total 50,648 Pupils found to require treatment at periodic general medical inspections (excluding dental and infestation) Age groups inspected For defective vision (excluding squint) For other conditions Total individual pupils 4 and less 30 665 687 5 167 2,201 2,347 6 152 743 876 7 690 845 1,471 8 1,400 1,373 2,661 9 238 215 436 10 168 144 299 11 1,071 608 1,612 12 1,763 1,116 2,770 13 481 278 726 14 896 337 1,184 15 and over 2,890 1,037 3,786 9,946 9,562 18,855 94 Defects noted at routine medical inspections—The overall percentage of children referred for treatment of a defect was 12.5 in 1960 compared with 12.4 in 1959 and the comparative percentages for sex and age are shown in the following table. (In total the percentage referred for vision defects has increased but for other defects has decreased. The percentage of girls increased, whereas that of boys declined.) Of the age groups containing the largest numbers (viz. 5, 8, 11, 12 and 15), girls aged 11, 12 and 15 showed a marked increase over the 1959 figures, largely accounted for by the increase in vision defects. For boys of these ages, except age 12, a decrease was recorded. Vision defects are dealt with in a later paragraph. Percentage of children noted for treatment Age and sex All defects Vision defect Defects other than vision 1958 1959 1960 1959 1960 1959 1960 4 and less Boys 9.6 10.1 9.6 0.4 0.5 9.8 9.3 Girls 8.1 8.9 8.3 0.4 0.3 8.6 8.0 5 Boys 10.4 9.6 9.2 0.6 0.5 9.1 8.7 Girls 8.6 8.3 7.9 0.5 0.7 7.9 7.3 6 Boys 12.9 13.2 12.5 1.3 2.1 12.1 10.8 Girls 11.3 11.2 10.7 1.0 2.0 10.3 9.0 7 Boys 15.4 15.7 15.2 7.2 6.6 9.2 9.2 Girls 14.1 15.3 15.0 7.5 7.6 8.5 8.2 8 Boys 16.8 14.8 14.0 6.9 7.2 8.5 7.5 Girls 14.7 14.0 13.5 7.7 7.3 6.8 6.7 9 Boys 16.8 15.5 13.7 7.2 7.3 9.0 7.1 Girls 17.8 14.1 13.3 8.4 7.5 6.1 6.2 10 Boys 18.0 17.2 16.0 8.6 8.7 10.0 7.8 Girls 17.3 16.8 15.5 8.7 9.0 8.6 7.4 11 Boys 13.7 14.1 13.3 8.5 9.1 6.2 4.6 Girls 14.3 16.1 17.3 9.8 11.3 7.0 6.9 12 Boys 14.3 11.6 13.0 7.1 8.3 5.0 5.2 Girls 16.4 13.9 15.3 8.8 9.8 5.8 6.2 13 Boys 17.1 14.9 13.4 9.1 8.7 6.5 5.2 Girls 17.2 17.1 16.3 9.7 11.0 8.0 6.2 14 Boys 12.0 12.0 12.1 9.1 8.9 3.2 3.5 Girls 13.4 12.9 13.2 9.3 10.2 4.0 3.7 15 and over Boys 12.1 11.9 11.4 9.0 8.9 3.2 2.8 Girls 13.2 13.0 14.3 9.8 10.7 3.6 4.2 Total Boys 13.1 12.4 12.1 5.8 6.1 7.0 6.3 Girls 12.8 12.5 12.9 6.3 7.1 6.6 6.4 Total Both sexes 13.0 12.4 12.5 6.1 6.6 6.8 6.3 note: A child can be noted as requiring treatment of vision and another defect, hence the percentage requiring vision treatment plus the percentage requiring treatment of other defects exceeds the percentage referred for treatment of all defects. The following table shows the percentage of children of all ages noted for treatment or observation of the defects listed for the years 1958 to 1960. These percentages remain fairly stable over the period. The slight but steady yearly decrease in the incidence of enlarged cervical glands continues. The slight upward trends in defective speech and defective hearing noted last year now appear to have levelled off. 95  1958 1959 1960 Numbers examined 172,271 136,263 150,790 Percentages Skin diseases 1.19 1.22 1.22 External eye diseases 0.48 0.55 0.56 Defective hearing 0.77 0.91 0.85 Otitis media 0.57 0.67 0.56 Enlarged tonsils and adenoids 4.91 5.11 4.28 Defective speech 0.81 0.93 0.88 Enlarged cervical glands 0.95 0.89 0.68 Heart and circulation 0.75 0.88 0.83 Lung disease (not T.B.) 1.25 1.49 1.38 Orthopaedic defects 4.12 4.16 3.93 Defects of nervous system 0.40 0.39 0.43 Psychological defects 0.93 0.93 1.02 Anaemia 0.10 0.17 0.12 Enuresis 1.59 1.75 1.80 A child can be noted for more than one defect. A new method of recording, introduced on 1 January, 1960 permits new defects discovered at special medical inspections to be related to the source of reference. The following table shows clearly how certain types of defect are most often brought to notice through a particular source of reference. Defects found at special medical inspections—1960 Head teacher School health visitor Referred by. Divisional officer (Education) Care committee Parent Number of pupils seen 6,513 3,261 888 725 1,669 Number of defects found 3,177 1,834 231 244 1,010 Number of defects per 1,000 pupils: Skin diseases 26 98 1 4 16 Defective vision 133 558 20 57 98 External eye diseases 28 33 3 1 22 E.N.T. conditions 90 99 24 32 122 Orthopaedic defects 52 69 18 19 40 Defects of nervous system 37 15 10 6 20 Psychological defects 284 26 29 39 61 Enuresis 23 19 5 26 55 Speech defects 54 29 3 6 25 Nutritional defects 21 33 11 19 28 All other defects 202 153 135 128 119 Attendance of parents and care committee representatives at periodic inspections—The percentage of medical inspections at which a parent is present decreases as children get older (range 90.5 per cent.—7.7 per cent.). The overall percentage was 50.6, slightly lower than in 1959, when it was 52.7 per cent. Care committee representatives attended 85.9 per cent. of all periodic general inspections and in the infant and junior school age groups the figure was over 90 per cent. 96 Attendance of parents and care committee representatives Age Group Number of pupils inspected Parent present Care committee representatives present at inspection % % 4 or less 7,674 90.5 81.0 5 27,435 88.5 94.7 6 7,511 79.4 95.8 7 9,744 74.3 94.6 8 19,322 69.9 96.2 9 3,227 58.4 96.3 10 1,897 54.6 94.6 11 10,549 40.4 73.7 12 19,634 33.5 82.8 13 4,884 25.1 76.0 14 9,418 11.5 80.7 15 and over 29,495 7.7 74.6 As a result of the triennial reconstitution of care committees in 1959, 601 care committees (covering 913 schools) had been reconstituted by January, 1960 and another 66 (covering 134 schools) were pending. Only 96 schools were then without any voluntary workers; of these 57 were grammar and technical schools and 33 of the remaining 39 were situated in two of the largest South London districts where there were many new schools. The total number of voluntary workers at the end of the year was 2,527. Physical condition of pupils The percentage of pupils whose condition was classified as satisfactory and unsatisfactory and the percentage who were noted as requiring treatment or observation on account of nutrition during 1960 are set out below, with similar figures for the four preceding years. This table suggests a continuous improvement over the five years, but the steadying of the percentage noted with a nutrition defect may mean that the end of this improvement is near. Physical condition Nutrition defect noted for Satisfactory Unsatisfactory Treatment Observation % % % % 1956 95.0 5.0 0.9 0.9 1957 97.3 2.7 0.6 0.6 1958 98.1 1.9 0.5 0.6 1959 98.8 1.2 0.2 0.5 1960 99.0 1.0 0.2 0.5 As indicated in my report for 1959, the newly introduced basis of tabulation by years of birth permits the comparison of samples of children of the same age group and is analogous to a 'follow-up ' survey. The first three years' figures are: Percentage unsatisfactory physical condition Year of birth Year of examination 1958 1959 1960 1943 and earlier 1.0 — — 1944 1.1 0.6 — 1945 1.5 0.9 0.4 1946 1.4 1.3 0.6 1947 1.7 1.3 0.8 1948 3.0 1.2 0.9 1949 3.7 2.9 0.9 1950 3.9 2.0 2.2 1951 2.4 1.2 1.6 1952 3.3 1.4 11 1953 2.0 2.4 1.8 1954 2.1 1.4 1.8 1955 — 1.4 1.2 1956 and later — — 1.0 97 g School meals and milk The Ministry of Education asked for a return for a typical day of the total number of (i) day school children who had school dinners and (ii) children who had school milk. The day selected for the census was 20 September, or the nearest normal school day thereto. The figures are set out below with those for 1959 in brackets. Number of Number who took Type of school children school dinners present On payment Free Total % Secondary 173,092 105,855 7,237 113,092 65.34 (175,991) (107,078) (7,068) (114,146) (64.85) Primary 202,240 103,145 11,880 115,025 56.88 (213,110) (101,842) (11,766) (113,608) (53.31) Special 5,545 4,473 1,011 5,484 98.90 (5,728) (4,647) (1,023) (5,670) (98.98) Nursery 1,480 933 95 1,028 98.66* (1,551) (982) (106) (1,088) (97.84) 382,357 214,406 20,223 234,629 61.37 (396,380) (214,549) (19,963) (234,512) (59.22) * Percentage of 1,042 children, as 438 children attended half time and did not have school dinners. The Ministry was informed that 318,678 children in Council maintained schools took milk on the selected day(s) compared with 337,825 in September, 1959. Of 30,532 children present in independent schools 22,776 had milk under the scheme. The percentages for the several types of school for the corresponding days were: 1959 1960 Secondary 69.23 66.05 Primary 96.82 96.32 Day special 98.83 98.47 Nursery 98.64 98.51 Boarding 98.12 98.51 Independent 76.67 74.60 Vision Visual acuity standards expressed as percentages of the numbers of children whose eyes were tested are set out in the following table. Compared with 1959 the same general pattern is evident. At all ages except nine, proportionately fewer girls than boys have 6/6 vision without glasses and proportionately more girls are referred for treatment, a customary feature of this aspect of school medical inspection. The rate of reference for treatment is highest at age 11 for both boys and girls, after which it declines slightly. The peak age for reference of children without glasses is 10 but for children wearing glasses the rate tends to increase with age. The vision of children under seven years of age is not tested as a routine, hence this age group is a biased sample and too much reliance should not be placed on the results. The difference in the percentage referred for treatment in this group compared with that reported in 1959 is due to a different method of calculation. In 1959 all children referred for treatment were included but in 1960 the table has been restricted to those children whose visual acuity was recorded. Of the children medically inspected 0.6 per cent. were noted for treatment of squint, the same as in 1957, 1958 and 1959. The percentage ranged from 1.4 in the entrant group to 0.1 in the leaver group. 98 Age Group Boys Not wearing spectacles Wearing spectacles 6/6 6/9 6/12 or worse Referred for treatment 6/6 6/9 6/12 or worse Referred for treatment Under 7 76.4 14.9 7.3 6.4 0.3 0.2 0.9 0.2 7 780 12.3 6.1 5.7 1.0 0.8 1.8 1.2 8 80.5 9.6 5.8 5.8 1.3 1.1 1.7 1.4 9 80.2 8.2 6.1 6.1 2.1 1.6 1.6 1.4 10 81.9 6.0 7.7 7.4 1.7 0.6 2.1 1.6 11 80.8 5.0 6.2 6.0 3.5 2.1 2.4 3.1 12 80.5 6.1 5.8 5.8 3.7 2.0 1.9 2.5 13 81.0 4.6 5.3 5.2 4.3 2.3 2.5 3.5 14 79.2 4.4 6.3 5.6 5.2 2.1 2.8 3.4 15 and over 77.5 4.4 6.1 5.2 6.5 3.1 2.4 3.7 Total 79.2 6.8 6.1 5.7 3.8 2.0 2.1 2.6 Age group Girls Not wearing spectacles Wearing spectacles 6/6 6/9 6/12 or worse Referred for treatment 6/6 6/9 6/12 or worse Referred for treatment Under 7 75.2 15.1 7.1 6.5 1.0 0.7 0.9 0.5 7 77.2 12.2 7.0 6.9 1.0 1.2 1.4 1.2 8 78.9 11.1 5.5 5.8 1.5 1.5 1.5 1.6 9 80.5 8.3 6.7 6.2 1.6 1.4 1.5 1.5 10 77.4 9.7 7.3 7.4 2.3 1.3 2.0 1.9 11 76.3 7.2 6.2 7.2 4.5 2.8 3.0 4.0 12 77.6 6.4 6.3 6.7 4.4 2.5 2.8 3.1 13 76.5 5.9 5.5 6.2 6.0 3.5 2.6 4.8 14 78.1 5.4 5.5 6.2 5.1 3.3 2.6 4.0 15 and over 73.9 5.5 6.0 6.2 7.1 4.0 3.5 4.5 Total 76.5 7.8 6.1 6.4 4.3 2.7 2.6 3.1 note: The percentages of children referred for treatment differ slightly from those quoted in the defects for treatment table on page 95 in which the percentages were based on the number of children medically inspected. Personal hygiene As was foreshadowed in my report last year, the use of Lorexane No. 3 cream hair shampoo for cleansing at home was introduced throughout the whole of the county during January. There is no doubt that the scheme is a success; not only has there been a marked fall in the number of attendances at bathing centres, but what is more important, there was a steep fall in the rate of infestation, as measured by the number of pupils found to be 'verminous ' on inspection in school by the school health visitors. Health surveys—As stated last year, the hygiene inspection of each child once a term was replaced in January, 1959 by an annual comprehensive health survey of each pupil, plus such additional health surveys as may be thought necessary or desirable at selected individual schools or departments. Details of findings at these surveys in 1960 follow, with 1959 results in brackets: 99 G* Total No. of pupils No. of No. with Other found to be verminous No. examined verminous nits only verminous % of No. heads cases No. examined Annual comprehensive health surveys 326,372 1,190 1,838 — 3,028 0-93 (359,715) (2,247) (2,251) (—) (4,498) (1-25) Additional health surveys 435,166 2,194 3,217 2 5,413 1-24 (473,294) (3,652) (3,334) (2) (6,988) (1-48) To assess the comparative level of infestation amongst schoolchildren, only the findings for comprehensive health surveys (each child seen once a year) can be compared with the former hygiene inspections (each child seen once a term). As will be seen in the following table, the percentage found to be verminous at comprehensive surveys in 1959 was very much the same as that found at hygiene inspections in recent years, but the percentage in 1960 shows a marked decrease, indicating that the new approach using Lorexane hair shampoo has made an impact on the 'hard core' of 'verminous' cases which had resisted the methods used in previous years. Percentage found to be verminous Hygiene inspections Comprehensive health surveys 1956 1957 1958 1959 1960 1.26 1.25 1.27 1.25 0.93 The number of individual children found to be verminous in 1960 was 4,870, a reduction of 1,494 from the number in 1959. The average annual reduction from 1955 to 1959 was 450. Cleansing scheme—The introduction of Lorexane No. 3 has caused an alteration in the layout of the following table, making comparison with past years difficult. The new cleansing scheme itself is fundamentally different from past practice, in its emphasis on the children being cleansed at home by the parents. It appears, however, that more than four out of every five 'first' (slight) infestations, were given a tube of Lorexane No. 3 and nearly two-thirds of the 'seconds'. The percentages of children returning to school clean after the issue of a notice only in earlier years and a notice with Lorexane No. 3 in 1960 are not comparable, as the school health visitor has exercised some selection in the cases before deciding the action to be taken. Cleansing scheme 1956 1957 1958 1959 1960 'First' advices issued— notice only N/A N/A N/A N/A 1,022 with Lorexane No. 3 4,575 'Second' advices issued— notice only 9,614 8,830 8,054 6,723 1,359 with Lorexane No. 3 1,977 Pupils returning to school clean after issue of— notice only 1,690 1,559 1,468 1,277 879 Lorexane No. 3 3,021 Percentage of pupils returning clean after issue of— notice only 17.6 17.7 18.2 19.0 36.9 Lorexane No. 3 46.1 Pupils attending bathing centre voluntarily after issue of 'second' advice— number 6,452 6,183 5,527 4,552 1,628 percentage 67.1 70.0 68.6 67.7 48.8 Statutory cleansing notices issued 1,223 998 964 764 320 Pupils cleansed after service of statutory notice— voluntarily 325 243 240 259 84 compulsorily 853 704 628 458 197 Total 1,178 947 868 717 281 100 This table demonstrates very clearly three effects of the introduction of the concept of cleansing at home with Lorexane No. 3 shampoo: (i) the marked increase in the percentage of pupils returning to school clean, which has more than doubled; (ii) a corresponding reduction in the percentage of pupils voluntarily attending bathing centres; and (iii) the marked drop in the number of statutory notices served. Bathing centres— The number of cases of infestation with vermin treated at bathing centres showed a reduction of 51 per cent. compared with 1959 and the number of treatments a reduction of 63 per cent. There can be little doubt that these reductions are directly attributable to the introduction of Lorexane. 1956 1957 1958 1959 1960 Scabies Pupils treated 762 697 768 660 637 Vermin Pupils treated 9,669 8,175 7,473 7,025 3,441 Treatments needed 14,770 13,787 13,647 11,799 4,345 Impetigo Pupils treated 2,776 2,433 1,478 1,187 1,020 Ringworm New cases . 17 22 20 10 Employment of schoolchildren Medical examinations were carried out divisionally of 5,288 children with a view to the issue of employment certificates, and 447 medical examinations were carried out at the County Hall in respect of employment under licence in public entertainments. Choice of employment The percentage of school leavers advised against particular forms of employment was 12.9 per cent. of those inspected compared with 13.8 per cent. in 1959. For boys the figure fell from 15.5 per cent. in 1959 to 14.6 per cent. and for girls from 11.9 per cent. to 11.1 per cent. As in recent years, normally acute vision and eye strain headed the list of contraindications followed by colour vision (boys only) and heavy manual work: Contra.indications Boys Girls Occupations involving: Heavy manual work 226 172 Sedentary work 63 48 Indoor work 11 10 Exposure to bad weather 124 128 Wide changes of temperature 79 72 Work in damp atmosphere 119 114 Work in dusty atmosphere 148 96 Much stooping 45 67 Climbing 101 92 Work near moving machinery or moving vehicles 92 87 Prolonged standing, much walking or quick movement from place to place 112 161 Eye strain 760 727 Normal vision 987 607 Normal colour vision 407 8 Normal use of hands 16 21 Exposure of hands to moisture, chemicals, etc. 38 43 Handling or preparation of food 70 62 Normal hearing 75 58 note: The total number of contra.indications is greater than the number of pupils with contra.indications since an individual may be noted for two or more contra.indications. 101 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. These notifications are uncorrected for diagnosis, but form the best available index of the trend of infectious disease in the school community; they 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 necessary. The numbers of cases of infectious diseases reported during 1960 and the preceding years are given below: 1956 1957 1958 1959 1960 Chicken.pox 8,424 4,496 8,901 5,399 8,357 Dysentery, diarrhœa or enteritis 1,458 414 1,170 1,148 1,557 German measles 1,775 2,081 2,549 1,325 631 Impetigo 354 301 265 192 194 Influenza N/A N/A N/A N/A 229 Jaundice 132 75 11 19 253 Measles 2,903 13,039 5,045 9,326 2,544 Mumps 6,059 5,509 2,778 3,788 8,783 Ophthalmia and conjunctivitis 280 291 319 264 299 Ringworm (scalp) 5 8 13 13 8 Ringworm (body) 44 55 38 46 51 Scabies 53 61 61 57 76 Scarlet fever 1,020 1,037 1,251 1,264 721 Sore throat and tonsilitis 897 864 994 1,299 905 Whooping cough 1,857 1,372 485 508 1,454 Prophylaxis—The new system of recording medical inspection findings by years of birth permits an analysis of the percentage of school pupils, according to age, who have received prophylaxis, based on the findings at periodic general medical inspections. These figures may be compared with the separate estimates, prepared for the Ministry of Health, given on pages 71 and 7 : Age group Number of pupils inspected % vaccinated against smallpox % immunised against diphtheria % immunised against whooping cough % vaccinated against poliomyelitis 4 or less 7,674 58.8 84.3 78.1 77.1 5 27,435 56.6 82.1 72.6 73.5 6 7,511 501 74.1 611 63.6 7 9,744 511 85.2 64.9 68.5 8 19,322 51.8 85.9 62.8 68.7 9 3,227 47.6 75.1 50.3 59.5 10 1,897 48.5 69.2 421 50.6 11 10,549 48.4 86.9 48.5 71.8 12 19,634 44.3 87.8 46.2 67.6 13 4,884 56.0 83.5 42.1 68.3 14 9,418 56.9 84.8 34.4 75.0 15 and over 29,495 58.2 86.5 29.8 75.3 102 Working party on school health service A working party of teachers and officers of the Education and Public Health departments was set up in 1959 with the following terms of reference: 'To review the requirements of the school health service (including the dental service) with special reference to its effect on the educational work of schools and its demands on their staffs, teaching and non.teaching; and to recommend any means whereby essential health services may operate with minimum interference with school work and calls upon staff'. The pattern of medical inspection work had been reviewed by the departmental committee on school medical inspections (see pages 106 to 110 of my report for 1958), and the working party was therefore concerned with the practical details of the work in the schools. The working party reported in the autumn of 1960 with a number of recommendations for reducing the upset caused by the requirements of the school health service on the work of the schools. These recommendations were accepted by the Education Committee, who decided that a letter should be sent to the head of every school conveying the views of the working party on how, by attention to a number of details, this reduction could be achieved. In addition the recommendations dealt, inter alia, with arrangements for securing that children were completely protected by immunisation before entry to school; increased 'helper' assistance in primary schools; the provision of 'general assistantswith first aid qualifications, in large secondary schools; clinic appointments at times which least interfered with school hours, etc. There is no doubt that the full implementation of the various recommendations made by this working party should benefit the relationships between the schools and the school health service. The School Physician's Handbook In any large organisation the problem of communications is a very real one. As an illustration of the size of the problem in London, it may be mentioned that when the medical inspection arrangements were reviewed in 1958 it was necessary to apprise over 5,000 people of the nature of and reasons for the changes. This was the total number of school physicians, school health visitors, head teachers and care committee workers whose day.to.day duties were affected. An associated problem is that of the induction of new staff, a particularly acute one in these days when there is a rapid turn.over. It was in this context and to improve communications, that during 1960 the School Physician's Handbook was issued. The concept was that of a loose.leaf pocket book, to facilitate revision of sections, containing succinct guidance on the administrative procedures and complexity of forms used in the school health service. The handbook has been favourably commented upon outside the Council's service. * Medical treatment of schoolchildren Organisation—My report for 1954, page 94, referred to an experimental withdrawal of assistant organisers of children's care work from certain school medical treatment sessions. By 1959 these social workers had been withdrawn from the majority of doctors' minor ailment sessions, and an experiment was being carried out in their withdrawal from certain vision sessions. By 1960, these latter trials having established the practicability of the scheme, it was decided to withdraw the organisers from all vision sessions held in Council premises. Savings in such professional workers' time are relevant to the terms of the Younghusband Report (see Appendix A to my report for 1959) and have permitted the re.deployment of the organisers, who are trained social workers, in fields such as social casework with problem families; with home bound children; at day schools for the maladjusted, etc. *See Medical Officer, page 109, 12 August, 1960. 103 Treatment statistics—The number of sessions, new cases and total attendances at school children's clinics during 1960 (including sessions held in hospital premises) were as follows: Type of clinic Sessions New cases Attendances Minor ailments (nurse) 20,569 56,468 477,236 Minor ailments (doctor) 2,486 31,329 Special investigation 2,243 2,244 15,015 Dental 30,055 77,781 256,983 Vision 4,904 29,968 77,778 Orthoptic 1,691 1,069 6,839 Ear, nose and throat 646 2,763 6,536 Audiology 291 1,199 2,727 Rheumatism (supervisory) 187 103 1,189 Enuresis 269 191 1,255 Handicapped pupils Form 5 H.P.—Ministry of Education administrative memorandum 9/60 introduced a new form, 5 H.P., for use in connection with handicapped pupils who have parents serving in the armed forces. The object of the form is to endeavour to ensure that the special needs of handicapped children of service personnel are not overlooked if the family is to be posted overseas. By means of the form, at the 'ascertainment' stage, the service department is notified, subject to the agreement of the parents, of the child's handicap, so that this factor can be taken into account when overseas postings are under consideration. New ascertainments—During 1960 the numbers of new ascertainments of pupils fo special educational treatment were as follow: Day Boarding Blind - 9 Partially sighted 36 2 Deaf and partially deaf 49 5 Delicate 313 441* E.S.N 699 81 Epileptic - 4 Maladjusted 295 295 Physically handicapped 175 11 Speech defect l,309† 42† Dual defect - 60 * Including diabetic and E.S.N./delicate. † Including pupils attending special schools for other defects. Special educational provision—At the end of 1960 special educational treatment was being provided for over 12,000 pupils. The following table shows the main categories of handicap and numbers of pupils receiving full.time special education: Day special schools Boarding special schools Non.council boarding schools, hostels, foster.homes hospitals, etc. Total Blind - 67 38 105 Partially sighted 256 - 12 268 Deaf and partially deaf 270* 34 121 425 Physically handicapped 923 67 439 1,429 Delicate 1,429 179 107 1,715 Educationally sub-normal 3,380 595 74 4,049 Epileptic† - - 25 25 Maladjusted 178 317 509 1,004 6,436 1,259 1,325 9,020 * Includes 89 pupils in partially deaf units. t A number of epileptic children (apart from those in ordinary school) are placed in schools for the delicate, physically handicapped or educationally sub-normal. 104 In addition, part-time special education at day special classes was provided for 407 maladjusted pupils and 2,757 pupils with speech defects. Educationally sub.normal pupils—Ministry of Education circular 12/60 dealt with a number of changes in procedures relating to educationally sub.normal pupils consequential upon the implementation of the Mental Health Act, 1959, with effect from 1 November, 1960. The most important of these changes were the amendments to section 57 of the Education Act, 1944, which provided the following simplifications in procedure: (i) to secure the prior approval of the Special Education sub.committee to the issue of a notice for examination is no longer necessary. (ii) the transmission to the mental health service of information about school leavers is placed on an informal basis. The extension of this latter procedure to leavers from schools for the maladjusted is discussed on page 110. In addition, the Act now provides a legal procedure for the review of a decision that a child is unsuitable for education, with a parental right of appeal to the Minister. Until 31 October, 1960, section 57 dealt with the examination and reporting to the local health authority of children considered incapable of receiving education at school; of children whom it was considered inexpedient to educate with other children; and school leavers needing supervision under the enactments relating to mental health. From 1 November, 1960 there is no provision for children to be reported to the local health authority on the grounds that their disability of mind makes it inexpedient that they should be educated with other children. A further amendment of this section provides that all supervision of school leavers reported to the local health authority shall be on a voluntary basis in the form of community care. The phrase 'incapable of receiving education at school' has been replaced by ' unsuitable for education at school The following table therefore gives (a) details of children dealt with under section 57 up to 31 October, 1960 with comparable figures for the previous two years and (b) details of children dealt with under this section as amended from 1 November, 1960: 1958 1959 1960 (a) Section 57(3)—Incapable of receiving education: Children not in any school 118 86 71 Children in normal schools 9 6 - Children in special schools 83 97 49 Children receiving home tuition 2 1 - 212 190 120 Section 57(3) and (4)— Inexpedient to educate with other children 3 3 3 Section 57(5)—School leavers 305 272 124* (b) Section 57 (as amended)—Unsuitable for education: Children not in any school 13 Children in special schools 8 21 * Another 191 school leavers were in need of voluntary supervision only. Section 8 of the Education (Miscellaneous Provisions) Act, 1948 enabled a review to be made in the case of any child who had been reported to the local health authority under section 57 (3), and gave authority for the cancellation of the report where the child, on re-examination, was found to be suitable for education. During the year one case was dealt with under this section. From 1 November, 1960 section 8 of the Act of 1948 was superseded by the amended section 57 of the Education Act, 1944, under which section cancellation of reports will be made in future. No reports were cancelled between 1 November and the end of the year. 105 Home bound children—Consideration was given how best to ensure that the small group of home bound children, including those having home tuition, and their families could have the opportunity of availing themselves of any of the medical or social services which can help them in their problems. It was decided that, in general, social support could most suitably be provided by an assistant organiser of children's care work, who would act as the 'link' with the family and work in close co.operation with other field workers, such as health visitors and care committee workers, if the family were not already receiving the necessary support from other agencies. Children with impaired hearing—The work done by the Council in the field of the special educational treatment of children suffering from impaired hearing was discussed at length in my report last year. During 1960 a fifth peripatetic teacher of the deaf was appointed for work in audiology and auditory training centres. Routine audiometer testing—The numbers of children given 'rapid.sweep' audiometer tests during 1960 are as follows: Pupils given screening tests 44,835 Pupils failing screening tests given pure tone tests 3,558 Pupils failing pure tone tests referred to otologists 1,413 Speech therapy—The year saw the completion of the 3.year programme for the provision of magnetic.tape recording machines for speech therapy. One ' high.fidelity' static machine is available at a central clinic and the peripatetic speech therapists have available a total of 26 portable machines, which are carried from clinic to clinic. One of these portable machines is a battery.operated transistor model, for use in premises without an A.C. electricity supply. By the end of the year 289 sessions a week were being held, 171 in 57 clinics and 118 in special schools. During the year 1,351 pupils were ascertained as requiring speech therapy, whilst 624 were discharged from treatment and 229 ceased to attend. The number of pupils under treatment at the end of the year was 2,658, whilst 242 were on the waiting list. Telescopic visual aids—Reference was made last year (page 106) to the provision of telescopic visual aids to partially sighted pupils. Miss Irene Gregory, F.R.C.S., the Council's consultant ophthalmologist, has made the following analysis of the eye conditions suffered by the 43 pupils who, at the end of the year, were using these aids: Congenital cataract 11 Albinism 7 Retrolental fibroplasia 6 Optic atrophy 5 Macular degeneration 5 Nystagmus 4 Subluxated lenses 1 Old choroiditis 1 Cerebral defect 1 Aniridia 1 Coloboma 1 Delicate pupils During 1960 results were available* of a survey of pupils taken off the rolls of day special schools for the delicate during 1958. The survey included 564 pupils—353 boys and 211 girls—a sample of 38 per cent. of the children on the rolls, which is sufficiently large to be accepted as representative. Medical reasons for admission to schools for the delicate are often expressed in terms, such as 'delicate' debility', 'nutrition' neglectetc., which are not susceptible to classification on such a rigorous basis as that of the International List used for the survey * Copithorne and Palmer. A survey of pupils from schools for the delicate in London. Medical Officer 104, pp. 323.325 (25.11.60). 106 of physically handicapped children, the results of which were given in my report for 1957 (page 125). In addition, in nearly a quarter of the cases two or three conditions were stated on the returns. To overcome this difficulty and to secure uniformity of classification as between schools, Dr. R. E. C. Copithome, assistant principal medical officer, who is familiar with the work of the schools for the delicate, undertook a scrutiny of the diagnoses given for each individual pupil in the survey, devised an ad hoc scheme of classification, and indicated which condition should be regarded, for the purposes of the survey, as the primary diagnosis. As can be seen from table (i), two.thirds of the pupils fall into the 'respiratory' group of conditions and half of these suffer from asthma. A quarter of the pupils come into the 'nutrition' group, whilst the remainder, some ten per cent., have a wide range of miscellaneous conditions. Table (i)—Primary medical reasons for admission to day schools for the delicate Reasons for admission Boys Girls Total Numbers with dual defect Numbers with triple defect No. Per cent. No. Per cent. No. Per cent. Group 1—'Respiratory' Asthma 128 36.2 58 27.5 186 32.9 31 2 Bronchitis 52 14.7 24 11.4 76 13.5 20 2 Bronchiectasis 10 2.8 13 6.2 23 4.1 3 - Primary T.B. Other respiratory .. 36 24 10.2 6.8 18 11 8.5 5.2 54 35 9.6 6.2 6 9 1 2 Sub-total 250 70.7 124 58.8 374 66.3 Group 2—'Nutrition' Debility, etc 48 13.6 56 26.5 104 18.4 34 1 Malnutrition 14 4.0 9 4.3 23 4.1 4 - Coeliac disease 2 0.6 - - 2 0.4 - - Sub-total 64 18.2 65 30.8 129 22.9 Group 3—E.N.T. Otitis media 2 0.6 - - 2 0.4 - - Recurrent catarrh 3 0.8 - - 3 0.5 1 - Group 4—C.N.S. Epilepsy 2 0.6 3 1.4 5 0.9 5 - Meningitis 2 0.6 2 0.9 4 0.7 1 - Maladjusted 1 0.3 2 0.9 3 0.5 1 - Pink disease 1 0.3 - - 1 0.2 - - Group 5—Blood conditions Anaemia 1 0.3 4 1.9 5 0.9 1 1 Leukaemia - - 1 0.5 1 0.2 - - Group 6—Rheumatism and heart disease 3 0.8 3 1.4 6 1.1 2 - Group 7—Other conditions T.B. contact 11 3.2 5 2.4 16 2.8 4 1 Non-pulmonary T.B. 3 0.8 - - 3 0.5 - - Orthopaedic 3 0.8 1 0.5 4 0.7 - - Adenitis 3 0.8 - - 3 0.5 - - Fibrocystic disease 2 0.6 - - 2 0.4 - - Renal 2 0.6 1 0.5 3 0.5 1 - Grand Total 353 100.0 211 100.0 564 100.0 123 10 107 In table (ii) the pupils taken off the rolls are grouped into three main categories: (a) special education completed (b) special education continuing elsewhere (c) special education neither completed nor known to be continuing. The table shows that over 90 per cent. of the pupils come into the first two of these groups, over 60 per cent. having completed their special educational treatment. More than half of those continuing their special education elsewhere were transfers to other day schools for the delicate. This figure is higher than it would have been had the survey taken place at another time, because during 1958 there were changes in catchment areas consequent upon reorganisations following the opening of John Keats school. Table (ii) records two deaths, both of boys. The particulars are as follows: (i) boy aged 10 years, who had been in the school for three years, suffering from coeliac disease. (ii) boy aged 6 years, who had been in the school for four months, suffering from fibrocystic disease of the pancreas, Table (ii)—Reasons pupils taken off rolls of day schools for the delicate Number Percentage Group A—Special education completed Transferred to ordinary school 284 50.3 Died 2 0.4 School leaver 62 10.9 Group B—Special education continuing elsewhere Boarding school for the delicate 50 8.9 Hospital school 2 0.4 School for maladjusted 1 0.2 Day school for the delicate 98 17.3 School for E.S.N. 8 1.4 School for physically handicapped 2 0.4 Home tuition 1 0.2 Group C—Special education neither completed nor known to be continuing elsewhere Parental request 10 1.8 Removal 44 7.8 Total 564 100.0 In the following tables the list of diagnoses has been abbreviated. Table (iii) shows that there is no general age of admission for any of the conditions listed, on the contrary children are admitted at all ages, whatever the medical reasons for their admission, even as late as their final year at school. Table (iii)—Ages on admission to day schools for the delicate by reasons for admission Reasons for admission Ages on admission (years) 4- 5- 6- 7- 8- 9- 10- 11- 12- 13- 14- all ages Asthma 5 27 29 30 25 26 15 14 7 6 2 186 Bronchitis 4 15 17 17 9 4 3 3 4 - - 76 Bronchiectasis 2 3 2 4 4 1 3 - 3 1 - 23 Primary T.B 4 8 13 6 5 6 5 2 1 3 1 54 Other respiratory - 7 7 9 4 2 3 1 1 1 - 35 'Nutrition' group 1 14 18 24 19 13 14 12 8 2 4 129 All other conditions 5 8 12 10 6 3 4 5 5 1 2 61 Totals 21 82 98 100 72 55 47 37 29 14 9 564 108 In table (iv) the two groups of 'special education completed' and 'special education continuing elsewhere' are analysed according to the medical reasons for admission. The numbers in the two groups are shown as percentages of the numbers admitted with the particular conditions listed. The table shows that approximately three.quarters of the pupils admitted for each condition are discharged (de.ascertained) as ' special education completed either on transfer back to ordinary school or on finally leaving school. The percentages for 'special education continuing elsewhere' are broadly the same for each of the medical reasons for admission. Had there been a large proportion of pupils in any particular group it would have implied that the day school was unsuited to that group. Therefore the result obtained is of importance in that it establishes that there are no conditions which could be singled out as inappropriate to be dealt with in a day school for the delicate. Table (iv)—Reasons for leaving day schools for the delicate by reasons for admission Reasons for admission Special education completed Special education continuing elsewhere Number Percentage Number Percentage Asthma 108 76.1 18 12.7 Bronchitis 50 78.1 6 9.4 Bronchiectasis 13 72.2 3 16.7 Primary T.B. 41 85.4 4 8.3 Other respiratory 21 72.4 4 13.8 'Nutrition' group 84 73.0 22 19.5 All other conditions 31 62.0 7 140 Total 348 74.7 64 13.7 Note:—In this table the pupils transferred to clay schools for the delicate have been excluded, both from the numbers whose special education is continuing and from the numbers upon which the percentages are based. This is necessary to make allowance for the inter-school transfers due to change of catchment areas. Table (v) is based only on the 348 pupils who constitute the 'special education completed ' group, since, obviously, durations of stay would not apply to the other two groups, whose special education was not completed. No average durations of stay have been calculated because the periods of stay are spread over a very wide range, so that averages would be of little value. It may be seen from the table that overall just over half the children stay between one and three years—those with the more lengthy duration tending to be those suffering from bronchiectasis and primary tuberculosis. Table (v)—Period of stay in day schools for the delicate by reasons for admission Reasons for admission Duration of stay (years) 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- Total Asthma 17 27 20 22 6 7 4 1 4 - - 108 Bronchitis 7 25 7 5 3 3 - - - - - 50 Bronchiectasis - 2 3 3 2 2 1 - - - - 13 Primary t.b. 2 12 8 9 5 3 1 - 1 - - 41 Other respiratory 5 6 5 3 1 - 1 - - - - 21 ' Nutrition ' group 18 33 13 14 2 2 1 - - - 1 84 All other conditions 3 7 10 6 4 1 - - - - - 31 Total 52 112 66 62 23 18 8 1 5 - 1 348 109 What conclusions can be drawn from this survey ? In the first place, the medical conditions listed in table (i) show that the schools for the delicate do not overlap the work of other schools, such as those for the physically handicapped.* Second, table (iii) shows that the schools accept children at all ages, and that, whatever the diagnosis, over half the children are likely to be ready for discharge in about two and a half years. Third, table (iv) shows that over three.quarters of the children admitted are discharged as ' special education completed Maladjusted pupils Circulars 347 (Ministry of Education) and 3/59 (Ministry of Health)—In last year's report it was stated that, in accordance with these circulars, negotiations were taking place with hospital authorities on future planning of child guidance facilities. The review completed in 1960 showed that no less than 19 of the 34 clinics and units providing child guidance facilities in the county were located in north and west London, due largely to the concentration there of teaching hospitals. Other areas were less well served and proposals were made for the establishment by the Council of three new units, one each in the districts of Shoreditch, Putney and Woolwich. These proposals were accepted by the three metropolitan regional hospital boards concerned, who agreed to provide the necessary psychiatric staff when the units were opened. Search for suitable premises was proceeding at the end of the year. Hostel for maladjusted boys—During the autumn the Council opened at Elm Court Road, West Norwood, its first hostel for the maladjusted. The hostel provides for 13 boys, aged 10 to 13 years on admission. Boys at the hostel attend local primary and secondary schools; some may attend part.time at a day special class for the maladjusted, while an occasional boy may attend the adjacent Elm Court school for the delicate. After.care for leavers from schools for the maladjusted—It is the Council's responsibility as local health authority, under the provisions of the Mental Health Act, 1959 and the National Health Service Act, 1946, to provide community care for all classes of mentally disordered persons. Consideration was therefore given to the best way in which the education authority could discharge its responsibility of informing the mental health authority which children leaving schools for the maladjusted were likely to need such care in the future. It was decided to introduce a special report form upon which the head of the school, the psychiatrist and the social worker could give their opinions, and these are forwarded, via the Education Officer, to the Principal Mental Welfare Officer in the health department. An attempt can then be made to effect whatever community care, if any, is considered to be necessary. The social worker concerned with these reports is the child welfare officer for children in the care of the Council; the psychiatric social worker at boarding schools for the maladjusted; or the assistant organiser of children's care work attached to the day schools for the maladjusted. Less than half the children placed as 'maladjusted—boarding' are in Council schools. As explained in my report for last year (pages 150 to 153), at any one time there are some 450/500 children placed in the very wide range of over 100 differing non.Council establishments, and some of these children are the most seriously disturbed pupils. The majority of these establishments have no visiting psychiatrist or psychiatric social worker, so that the special form described above is inapplicable. However, the school health and education services do have certain basic records relating to the children, and in some cases these contain a considerable amount of information. For example, some children regularly attend London child guidance clinics during school holidays, whilst others are seen, during their school holidays, by a psychiatrist at County Hall. * Palmer and Pirrie. Survey of pupils in schools for the physically handicapped in London. British Medical Journal, 29 November, 1958, Vol. ii, pp. 1326.1328. 110 It is therefore possible, on receipt of information that a child has left a non-Council establishment, for the same basic procedure to be adopted as for children leaving Council establishments, i.e. the name and fullest possible documentation is forwarded to the Principal Mental Welfare Officer, for consideration as to whether community care is needed. Child guidance units—Details of the work done during 1960 at the five child guidance clinics maintained by the Council follow: Battersea Brixton Earl's Court Peckham Woodberry Down Total Patients At 1 January, 1960 On waiting list 41 40 67 12 98 258 In attendance 70 161 144 54 206 635 During 1960 Applications received 128 299 227 108 190 952 Applications withdrawn 52 70 31 36 58 247 Cases closed 44 207 53 77 119 500 At 31 December, 1960 On waiting list 48 67 98 27 57 297 In attendance 95 156 256 34 260 801 Visits During 1960 Home visits by staff 6 29 92 6 268* 401 School visits by staff 127 26 202* 40* 142* 537 * Includes visits by students. School refusal The problem of school refusal—the so-called 'school phobia'—has been much in the public eye recently, and an attempt has been made to co-ordinate the various types of action —medical, educational, and administrative—taken in London in dealing with individual cases. The problem appears to be two-fold—first, and of paramount importance, is the diagnosis, and following that, the choice of appropriate action. To supplement the diagnostic services provided by the child guidance clinics in London, and in an attempt to find and carry through the most appropriate recommendation for children who fail to attend clinics or whose cases have proved too complex for the divisional services to handle, a special arrangement has been made for such cases to be seen by a psychiatrist and a psychologist at the County Hall. During the year 18 cases were dealt with, all previously regarded as more or less insoluble. These 18 cases seem to represent a fair cross section of the types of problem involved— always excepting the 14.year.olds in their last year in school, amongst whom the occurrence of truancy appears to be of almost epidemic proportions. Six of the children were found to be true cases of anxiety and their non.attendance was part of a deep psychological disorder. They were all referred to child guidance clinics and were still under treatment at the end of the year, maintaining occasional attendances at day special schools or classes. 111 Four children were of the mildly neurotic and anxious type, unable to face up to the demands of the large classes in ordinary schools. They have all settled down very well in the more sheltered environment of day special schools either for the delicate or for the maladjusted. Four of the cases—all boys—were considered to be real truants. Following Court action all are now attending school regularly under probationary supervision. The remaining four cases fitted into no category but were each unique. They included a 14.year.old girl with a wig who refused to attend school because the other children pulled it off; and a girl who had not been allowed to attend school for four years, and had been under a child guidance clinic for two years. Her parents disapproved of school on principle, but now that she attends an 'open.air' school the parents are amongst the school's most vocal supporters. The most acute cases of separation anxiety under child guidance clinic treatment are placed on home tuition for limited periods. There were some 15 such cases during the year, of whom over half were back in school or attending special classes at least part.time after a few months on home tuition. The Council is fortunate in having the co.operation of the Bethlem Royal Hospital Adolescent Unit, where seven intractable non.attenders were admitted during the year, all of whom are now back in day or boarding schools. Experimental student health scheme It has never been the Council's practice to arrange for the routine medical inspection of the older students, many part.time, who attend the very wide range of establishments for further education in London. At one time, however, certain of the polytechnics and technical colleges included junior technical departments attended by pupils of compulsory school age, so that school doctors visited the establishments for the purposes of medical inspection of these younger pupils. Inevitably the school physician who visited came to be regarded as the college visiting medical officer and was consulted on a wide range of problems, including those of the older students who were technically outside the scope of the school health service.* In recent years the junior technical schools have been moved from further education establishments into secondary schools, so the school physicians' visits have ceased. During 1960 the Education Committee decided that a trial should be made of a student health scheme at Barrett Street technical college, where, inter alia, hairdressing is studied. The experimental scheme, which started at the beginning of the 1960/61 session, is not the routine inspection of all students but an attempt to provide a consultative service. At the beginning of the session all new entrants are asked to complete a simple personal medical questionnaire, based on that used in Cardiff.† Scrutiny of the completed questionnaires by the college medical officer enables her to pick out some students to invite for interview, but the main concept of the scheme is that the physician visits the college at a fixed time each week and is available for consultation by students or staff on problems relating to students. The following table gives statistics of the first term's work under this experimental scheme: * Sections 48 and 114 of the Education Act, 1944, taken together, limit the school health service to pupils under the age of 19 years. f Vide : A Technical College Student Health Service, Medical Officer, 4th December, 1959, pages 295.296. 112 No. of new students under 19 years 134 No. returning questionnaires 134 No. invited for interview after scrutiny of completed questionnaire .. 17 No. of students seen by doctor: (a) following invitation—first attendances 14 —subsequent attendances 6 (b) voluntary—first attendances 83 —subsequent attendances 17 - 120 Students referred for treatment: to skin hospital 8 to gynaecologist 4 to orthopaedic hospital 3 to general physician 1 to surgeon 1 for visual defect 3 for dental treatment 2 No. of doctor's sessions 11 No. vaccinated against poliomyelitis 48 These figures show that the scheme has made a very promising start and in particular the number of students voluntarily seeking advice is most encouraging. 113 H DENTAL SERVICES (A special article, Appendix B, reviews the school dental service since the inception of the National Health Service.) The Chief Dental Officer and Principal School Dental Officer reports as follows: School dental service The routine statistical tables show some slight improvement in 1960. A reduction of the equivalent of one full.time dental officer is shown, but it is noteworthy that the staff position was maintained only by the continuance of the services of a number of dentists beyond the normal retirement age of 65. Nine officers were aged between 65 and 72 in 1960. In total the number of sessions worked in treatment centres fell slightly but was offset by an increase in the number of inspection sessions held in schools. It is significant that the increase in inspections was necessitated by the generally weaker response of new patients to attend for treatment when they were invited to do so. For many years this response lay around 50 per cent. of the numbers invited but in 1960 was about 38 per cent. Of the failures (62 per cent.) it is known that in many cases a desire and an intention was expressed to have necessary treatment carried out by private arrangement. At dental inspections in schools, however, large numbers of children were found to be in need of treatment and it is certain that a vast amount of reparative or preventive dentistry remained undone for lack of staff and/or co.ordination of total available dental manpower. NUMBER OF INSPECTION SESSIONS AT SCHOOLS 114 NUMBER OF TREATMENT SESSIONS In 1960 the percentage (57.2) of the school population inspected showed an increase of seven per cent. over the previous year. It is, however, encouraging to note that in those inspected there was apparently a continued improvement in the mass picture of dental health. For the third successive year there was a three per cent. reduction in the percentage found requiring treatment and the figure quoted (for 2,473 inspection sessions) of 67.6 per cent, is the lowest on record (table (ii)). It would be wrong however to regard this apparent improvement with greater satisfaction than it deserves. There is little room for complacency in a picture revealing two out of every three children at any given date in need of dental treatment ! The professional aspect of the matter is that all children should receive a thorough dental check at least once a year. With the staff and facilities available the best the service was able to do in 1960 was to inspect rather cursorily a little over half of the children and treat only 77,781 (table (ii)). It is to be hoped, for the sake of children's dental welfare, that many parents and guardians did indeed obtain 'private' treatment, as the service discharged as ' dentally fit' only 50,584. In table (iii) a welcome symptom may be noted—the rising quality of the service for the children accepting treatment. The ratio of permanent teeth filled to permanent teeth extracted improved for another year and reached the highest level recorded, viz., 7.57 filled to one extracted. Although revisional treatment cannot yet be officially countenanced, it is well known that in some treatment centres a measure of unofficial revision was in fact operating to the benefit of some patients, if to the exclusion of others, perhaps less co.operative in their attendances and response. This degree of unofficial revisional treatment casts doubt on the validity of the discharge figure (50,584), as at least some of this number may be duplicates. 115 H* Table (i) 1956 1957 1958 1959 1960 Dental officers Number employed (i) full-time 52 44 42 35½* 36½* (ii) part-time 70 74 97 94 84 Total 122 118 139 129½ 120½ Full-time equivalent (i) School service 73.3 65.7 72.5 64.4 64.6 (ii) M & CW service 6.4 6.8 6.3 6 4.9 Total 79.7 72.5 78.8 70.4 69.5 Establishment (temporary) 95 95 95 95 95 Weekly sessions School service (i) by full-time dental officers 561½ 460 437 364 373 (ii) by part-time dental officers 246 263 361 355½ 337½ Total 807½ 723 798 719½ 710½ M & CW service (i) by full-time dental officers 42½ 46 41 29 31 (ii) by part-time dental officers 27½ 29½ 28 37½ 22½ Total 70 75½ 69 66½ 53½ Grand Total 877½ 798½ 867 786 764 * ½ full-time officer accounted for by appointment of half-time Assistant Chief Dental Officer Table (ii) 1956 1957 1958 1959 1960 Number of inspection sessions held at schools 2,111 1,354 1,952 2,177 2,473 Number of children inspected at schools by dental officers 213,957 120,440 196,573 215,637 244,630 Number found to require treatment 163,414 91,868 144,050 152,131 165,439 Percentage requiring treatment 76.4% 76.3% 73.5% 70.5 % 67.6 % Additional number inspected at centres 44,078 56,598 36,067 27,576 23,229 Total number found to require treatment 207,492 148,466 180,117 179,707 188,668 Total cases treated 115,587 102,568 97,300 82,448 77,781 Attendances 332,785 308,862 298,342 267,781 256,983 Ordinary treatment sessions 31,257 31,841 31,322 29,637 29,006 General anaesthetic sessions 1,708 1,594 1,431 1,180 1,049 Temporary teeth extracted 83,341 69,247 58,223 46,461 42,343 Permanent teeth extracted 19,992 18,273 19,342 14,973 14,467 Temporary teeth restored by fillings 43,474 45,509 40,994 39,861 38,164 Permanent teeth restored by fillings 129,931 117,148 122,558 110,934 109,586 Fillings in temporary teeth 46,088 48,477 43,176 42,656 40,996 Fillings in permanent teeth 144,746 131,071 136,811 125,053 124,821 Other operations: temporary teeth 58,808 58,021 54,884 49,109 43,889 permanent teeth 68,972 64,675 64,995 61,835 63,835 Local anaesthetics for extraction 16,195 14,404 13,320 12,354 12,165 Local anaesthetics for conservative treatment 9,494 10,718 13,964 11,667 13,082 General anaesthetics 38,740 34,019 30,861 24,367 21,753 Cases for whom immediate treatment was completed 11,614 10,415 10,566 9,414 8,407 Cases discharged as dentally fit 79,994 71,260 66,990 54,474 50,584 116 Table (iii)—Average number of permanent teeth restored for each permanent tooth extracted 1951 3.43 1952 3.86 1953 4.69 1954 5.32 1955 7.39 1956 6.50 1957 6.41 1958 6.34 1959 7.41 1960 7.57 Orthodontics There was little change in 1960 from the preceding year, but it is regretted that acceptances by hospitals fell. It is appreciated that demands on hospital facilities for this type of dental treatment preclude acceptance by them of large numbers referred specifically from local health authority school services. Increases noted within our own service are stimulating. Table (iv) 1956 1957 1958 1959 1960 Number of special orthodontic sessions 290 321 282 229 237 Number accepted at special orthodontic sessions 252 108 199 138 152 Number accepted at routine sessions 427 403 474 371 401 Number referred to hospitals 182 158 186 279 154 Total number of patients accepted or referred 861 669 859 788 707 Maternity and child welfare dental service The 'priority service' of the National Health Service for another year had perforce—if the school dental service was to be spared—to continue at a low level and remained undeveloped. The 10 per cent. of total dental effort tacitly agreed upon some years ago by all concerned continued to operate and table (v) shows the considerable volume of useful work produced by the equivalent of about five full.time officers operating 2,592 sessions. Table (v)—Attendances and treatments of maternity and child welfare patients 1956 1957 1958 1959 1960 Number of sessions 3,169 3,293 3,135 2,764 2,592 Number of appointments offered 36,711 36,636 34,740 30,456 27,368 Attendances—bv appointment 27,640 26,006 24,691 21,995 19,651 —other 1,799 1,717 1,539 1,122 1,060 Silver nitrate treatment 4,716 5,423 5,065 4,415 5,858 Fillings 13,465 11,310 11,491 10,031 8,716 Extractions 9,561 7,809 5,873 5,114 4,513 Dentures supplied—new full 538 508 422 380 351 —new partial 778 820 685 649 468 Number made dentally fit 7,492 6,010 5,014 4,784 4,165 Dental service in boarding schools and residential establishments Every permissible means was again employed to give the best service possible to these establishments, but it proved impossible to obtain at all of them the standard and continuity of service desired. Agreements with local practitioners, assistance from other local health authorities, visiting dental officers, transport of children to surgeries, and the deployment of school dental officers from their normal treatment centres were all utilised, but dental treatment and supervision at some establishments left much to be desired. 117 STAFF The following statement shows the number of staff employed in the Public Health department at the end of the year (part-time staff are expressed as whole-time equivalents). The principal officers of the department at that date are shown in Appendix D. Types of staff Location Central office Divisional offices and establishments (a) Other establishments (b) Total Administrative and clerical (including ambulance control clerks) 209 639 79 927 Medical officers (c) 34 162 (c) 196 Dental officers 2 58 1 61 Scientific branch staff 31 - 13 44 Inspectors 15 - - 15 Medical auxiliaries (d) 31 155 20 206 Social worker grades (e) 26 338 9 373 Nursing and midwifery staff 10 1,801 198 2,009 Ambulance service operational staff - - 780 780 Manual workers, home helps, domestic grades, telephonists, etc. 7 3,258 23 3,288 Totals 365 6,411 1,123 7,899 (a) Including divisional health offices, home help offices, welfare centres, school treatment centres, training centres for the mentally sub-normal, etc. (b) Including residential schools and nurseries, Welfare department homes, recuperative holiday homes, ambulance stations, outfall works laboratories, central dental laboratory. (c) There are 120 visiting medical officers employed at residential establishments on a part-time basis whom it is not possible to compute in terms of whole-time staff. They have therefore been omitted from the table. (d) Including physiotherapists, speech therapists, dental attendants, dental technicians. (e) Including psychiatric social workers, mental welfare officers, local tuberculosis care organisers, child care organising staff, etc. and workers in allied fields (e.g. home help organisers). Training of health visitors—The Council appointed 45 student health visitors for training in 1959.60 under its standing arrangements. Theoretical training was provided by the University of London Institute of Education (35 students), the Battersea College of Technology (6 students) and the Royal College of Nursing (4 students), arrangements for practical instruction in the department's divisional establishments being arranged and co.ordinated with the theoretical training under the direction of the Council's principal health visitor tutor. The course was completed and the examination taken by 44 of the students, of whom 43 were successful. Mental health service—As I have mentioned elsewhere in this report, the Council's proposals for the reorganisation and development of its mental health services in the light of the Mental Health Act, 1959 involved the delegation of day.to.day responsibility to the nine health divisions. Teams of mental health social workers responsible to the divisional medical officer have been set up in each division to undertake the local mental welfare services, each team including a qualified psychiatric social worker who by virtue of specialised training is able to carry out special case work and to advise colleagues. The reorganisation has brought together, under the principal mental welfare officer and her deputy, social workers who had hitherto specialised almost exclusively in work either with the mentally ill or with the mentally sub.normal, and for the first time the Council's women social workers are undertaking the arrangements for removal of mentally disordered persons. 118 Medical examinations—Numbers of staff medically examined for various purposes, with the result of the examination, follow: 1957 1958 1959 1960 Candidates fit for appointment 6,286 7,531 7,399 8,252 Candidates unfit for permanent appointment 285 401 343 250 Referrals (ill.health) 7,268 6,719 7,252 8,032 Permanently unfit to carry out their ordinary duties 245 323 331 418 Advice given (without examination) 1,378 1,621 1,595 1,034 Eligibility for spouse pensions 26 24 29 66 Staff casualties 240 315 309 289 Candidates for out.county authorities 65 100 111 84 Candidates examined for the Council by out.county medical officers of health 77 138 111 102 Food handlers—During the year 624 food handlers were referred for investigation because they had been in contact with or had suffered from certain infectious diseases. Bacteriological examination was arranged where appropriate. 1957 1958 1959 1960 Contacts 107 137 167 205 Ill 270 266 302 419 Allowed to resume work after examination or fixed period of exclusion 360 388 451 578 Resigned - 9 8 23 Excluded from work and referred to own doctor for treatment 17 6 10 23 The 23 cases referred to their doctor had been found to have the following microorganisms: Condition Organism isolated Diarrhoea convalescent Shigella sonnei Diarrhoea and vomiting contact ” ” Dysentery convalescents (7) ” ” Dysentery contacts (2) ” ” Enteritis convalescents (2) ” ” Enteritis contact ” ” Food poisoning convalescent ” ” Gastro-enteritis canvalescents (2) ” ” Gastro-enteritis contact ” ” Dysentery convalescents (2) Shigella boydii Gastritis with diarrhoea and vomiting convalescent Salmonella typhimurium Gastro.enteritis convalescent ” ” Scarlet fever contact Streptococcus pyogenes Appointments and retirements—In consequence of the changes in the organisation of the department in respect of mental health work, Dr. C. W. J. Ingham, Principal Medical Officer, who had combined this work with responsibility for staff medical examinations, relinquished the latter duties in July to enable him to concentrate on the work in the mental health field. Dr. R. Cove.Smith was appointed a Principal Medical Officer (half.time) in charge of the staff medical examination work. On 26 December Mr. A. J. Cridland, Divisional Administrative Officer for health division 5 since 1948, retired after nearly 48 years' service, his place being taken by Mr. E. L. Hannant. On 25 November Miss E. M. Hazell, Divisional Nursing Officer for health division 4, who had been seconded to the World Health Organization since 1958, resigned from the Council's service to undertake further duty with the Organization. She was replaced by Miss L. E. Arrow. 119 FINANCE Capital—The total capital expenditure on the health services of the Council in the year ended 31 March, 1960, was £40,095, details of which are as follows: Ambulance stations—erection £ 11,460 Day nurseries—erection 476 Health centres—debt repayment, etc 3,285 Maternity and child welfare centres—acquisition, erection, equipment, adaptation 393 Training centres—adaptation, erection, etc. 24,481 £40,095 Maintenance—The gross cost of the various services in 1959.60—including central administrative and debt charges—and the contributions recovered from recipients of the services were: Service Cost Amount recovered in contributions £ £ Ambulance service 1,186,982 - Day nurserie 1,041,586 159,452 Domiciliary midwifery service 267,093 - Foot clinics 57,320* 17,880 General health services (including health education) 60,282 - Health centres 34,461 - Health visiting 339,892 - Home nursing 553,174 - Home help 1,177,944 63,955 Maternity and child welfare 937,311 69,656 Mental health 308,560 6,557 Prevention of illness, including care and after.care of tuberculosis 432,762 14,780 School health 1,034,873 - Vaccination and immunisation 221,856 - £7,654,096 £332,280 *Excluding central administration. The net cost of the services, before allowing for Government grant, expressed in terms of rate in the £ was 16.5d. 120 VISITORS TO THE DEPARTMENT During the year 465 visitors were received through the central office—an increase of 49 on the previous year. Of these, 409 came from overseas. Individual overseas visitors included a member of the Indian Parliament, the Ministers of Health for Yugoslavia and Nepal, the Chief Medical Officer for Tonga, the Deputy Director.General of the Health Service in India and 62 doctors, 5 dental officers, 2 members of the judiciary, 3 members of local authorities, 31 central and local government administrators, 30 social workers, 12 nurses, 4 university lecturers, 7 teachers, 7 journalists, 3 speech therapists and 6 students. Parties included a delegation, led by the Vice.Minister, from the Polish Ministry of Health, the President of the People's High Court and three leaders of national associations in China, a party of 35 federal government officers and a group of 30 doctors, dentists, social workers and administrators from the U.S.A., 30 psychiatrists from Holland, 15 midwives from France and Italy, 7 local government members from Sweden, 7 members of the Canadian Nurses' Association, 5 social workers from Yugoslavia and a party of 27 doctors, physiotherapists, public health administrators and nurses, representing 13 European countries, on a World Health Organization course on the rehabilitation of the physically handicapped adult. Altogether visitors were received from 64 overseas countries. Other visitors were received at divisional offices, Woodberry Down health centre, the London Ambulance Service headquarters and the Council's training centres for mentally subnormal children. The health centre was visited by 1,149 people, 166 (including 68 students) from overseas and 983 (887 students) from the United Kingdom; the Ambulance Service headquarters received 187 visitors and training centres 719 visitors including 542 students. Facilities were again provided for medical, nursing and social science students to study the health services. Courses of ten or twenty visits of observation and talks were arranged for 109 post.graduate students preparing for the Diploma in Child Health. Members of the department's nursing staff gave talks to student nurses at hospitals and programmes were arranged to enable 4,519 of these students to gain practical experience. Talks by members of the staff and/or visits of observation and periods of attachment were also arranged for students from the following training centres: Health visitor students Other students {medical, nursing, teaching and social science) Battersea College of Technology Battersea College of Technology Royal College of Nursing Battersea Training College of Domestic Science Surrey County Council Kingsway Day College Middlesex Hospital North.Western Polytechnic Speech Therapy students Royal College of Nursing Royal Institute of Public Health and Hygiene Central School of Speech and Drama King Edward's Hospital Fund for London— Kingdom.Ward School of Speech Staff College for Ward Sisters Therapy University of London— Oldrey.Fleming School of Speech Bedford College Therapy Institute of Education Speech Therapy Training School of the London School of Economics and Political West End Hospital for Neurology Science London School of Hygiene and Tropical Medicine Queen Elizabeth College Women Public Health Officers' Association 121 REPORTS BY THE DIVISIONAL MEDICAL OFFICERS (A statistical summary of work done in the divisions will be found at the end of this section.) DIVISION 1, comprising the boroughs of Chelsea, Fulham, Hammersmith and Kensington Dr. Bertha E. A. Sharpe reports: Prophylaxis—The scheme whereby protection against whooping cough, diphtheria, tetanus and smallpox could be obtained at certain infant welfare sessions, as well as at the ad hoc sessions held at the centres, has been extended to nearly all the centres in the division. In addition, mothers and children may be vaccinated against poliomyelitis at these sessions. Vaccination against poliomyelitis—The demand for vaccination against poliomyelitis declined steadily throughout the year and many of the open sessions were discontinued. During the year 17,023 persons had two injections and 31,232 received a third injection. College Park welfare centre—College Park welfare centre, which served a small and isolated area of Hammersmith, was closed on 27 May, 1960, as attendances had been very low for some time. Facilities for mothers attending the centre were provided at St. Quintin welfare centre and, by arrangement, at the Middlesex County Council clinic in Purves Road, N.W.10, both of which are within easy reach of the College Park district. The premises used formerly for the welfare centre are being adapted for use as a training centre for elder girls. Occasional creches—During the year additional creche sessions were instituted at Lancaster Road, Raymede, Tavistock and St. Quintin welfare centres and St. Dunstan's Road school treatment centre. The demand for places at Raymede and Tavistock centres later decreased and these sessions were discontinued. The creche at St. Quintin welfare centre thrived however, and an additional creche session was started there in October. At the end of the year ten creche sessions were being held weekly. Family planning—Two very successful clinics have been operating in Fulham for several years and an additional session at Glenthorne Road welfare centre, Hammersmith, was started in December. School health service—The withdrawal of organisers from vision clinics was extended to Milson Road centre in February. A reduction in attendances at Sedlescombe Road bathing centre meant that these premises were not being fully used; it was therefore arranged that minor ailment treatment facilities should be transferred in April to the bathing centre from unsatisfactory premises in Munster Road school. The Sedlescombe Road premises are used now as a bathing centre in the mornings and a minor ailment treatment centre in the afternoons. Arrangements for the cleansing of schoolchildren at the Hammersmith cleansing station ceased on 31 March, such children as needed these facilities being dealt with at Sedlescombe Road centre. Prevention of break.up of families—Two part.time social caseworkers were appointed, bringing the total to one full.time and four part.time workers of whom one did not start work before the end of the year. There were four policy meetings of the divisional co.ordinating committee and 41 case conferences at which 49 families were considered. Case work was undertaken on seventeen families, thirteen of which were referred to caseworkers during the year. Two of these 122 have been rehoused outside the division as part of the process of rehabilitation and one left London of its own volition. One family was sent to a residential rehabilitation centre. Children at risk—The register instituted in 1959 of children regarded as being specially at risk, because of circumstances at birth or later, continued to be kept and to provide a valuable indication of the need for supervision or treatment. Menial health—A meeting of general practitioners, social workers and hospital and divisional staff was held in October at Parsons Green welfare centre, with the twofold purpose of publicising the facilities available for the Council's activities for the mentally ill, as a part of World Mental Health Year, and to acquaint them with the arrangements that would follow the operation of the Mental Health Act, 1959 and decentralisation of the Council's mental health services. The Chairman of the Divisional Health Committee presided and introduced the speakers—the physician superintendent of one of the psychiatric hospitals serving the division, the Council's principal medical officer for the services for the mentally sub.normal, the principal mental welfare officer and the divisional mental welfare officer. Their talks covered the whole range of the services for the mentally ill and the mentally sub.normal and were followed by a lively discussion. Representatives of the general practitioners expressed appreciation for the opportunity afforded of discussing problems arising from the implementation of the new Act. A number of other activities in connection with World Mental Health Year took place in the division. As part of his programme for World Mental Health Week the Minister of Health, the Rt. Hon. Derek Walker.Smith, visited the recently completed Kensington training centre, Wallingford Avenue; open days for parents and others interested, which were widely publicised and well attended, were held at this and other centres in the division. The psychiatric hospitals whose catchment areas cover this division have been visited and a good relationship has been established between the hospital and divisional staffs. Chiropody—An additional twenty sessions for the benefit of the priority classes, i.e. the elderly, the physically handicapped and expectant mothers, were allocated to the division during the year as part of the Council's interim extension of the chiropody service. This enabled two new clinics to be established at Westway, W.12 and Bagleys Lane, S.W.6. The total number of sessions available in the Council's foot clinics at the end of the year was 87 a week. Health education—The divisional team continued to meet and suggest subjects for action and to advise on methods of putting them over to the public. A very full programme was undertaken but special attention was given to the risks occasioned by the misuse of oil heaters and to mental health education. Oil heaters are widely used in homes in the division and divisional staff took every opportunity of emphasising the importance of their proper use. To reinforce their efforts, two warning leaflets issued by the Council, one early in the year, the other in the autumn, were given a very wide distribution. Arrangements were made with Dr. C. W. Kesson, consultant paediatrician at St. George's hospital, for him to give a series of three talks to health visitors which began in October, and a talk to medical officers in November. Staff of the division continue to promote and take part in a large number of activities. A development which is worthy of record arose out of the participation of the divisional nursing officer in a brains trust at a secondary modern school for boys. The subject was the responsibility of citizenship, and in the discussion she gave an account of the day nurseries and problems connected with running them. This resulted in an offer by the boys to keep in good order the toys used in a neighbouring day nursery. At the end of the year this arrangement had been in operation for some months and the toys were being maintained in excellent condition. 123 DIVISION 2, comprising the boroughs of Hampstead, Paddington, St. Marylebonc, St. Pancras and the City of Westminster Dr. H. L. Oldershaw reports: Maternity and child welfare—An increase of 467 in the number of births taking place in the division compared with 1959 was a factor in the higher attendances at the ante.natal clinics and the increase in the home visiting carried out by the health visitors in 1960. In January a purpose.built welfare centre opened on the ground floor of a borough council block of flats at St. Alban's Road, St. Pancras. This centre replaces the South Highgate welfare centre formerly held at the Highgate New Town Clinic, Chester Road, St. Pancras. The Divisional Health Committee authorised the provision of facilities at this centre for the educational activities of the South Highgate Parents' Club. Creches—As a result of a review of the occasional creches provided at a number of welfare centres, authority was given to increase the number of sessions from 16 to 23 a week. By the end of the year 20 were being held, one additional session having been closed through lack of demand, and two others had not yet begun because of lack of suitable staff. Day nurseries—The total provision remained almost unchanged and the service was again marked by high occupation of the places available. The table of divisional statistics gives details of child minding, but it should be noted that there has been an increase in the number of premises registered under the Nurseries and Child Minders Regulation Act, 1948, from 22 in 1959 (471 places) to 26 in 1960 (641 places). These establishments involve regular visitation by the Council's medical staff and lengthy statutory procedures between the Divisional Health Committee and the applicants. During the year the committee dealt with fourteen separate reports affecting persons and premises registered in accordance with this legislation and made orders imposing or varying requirements in each case. Prophylaxis—The process of integrating the work of inoculating young children against poliomyelitis with the routine already established at the maternity and child welfare centres for general vaccination and immunisation developed during the year. Nevertheless, attendances justified continuation of the special ' open ' poliomyelitis vaccination clinics for persons of all eligible age categories to attend without prior appointment. Systematic follow.up, by postcards, of persons due for repeat injections has also been undertaken with a degree of success. In the autumn additional facilities were made for vaccination against smallpox at Alhambra House, Charing Cross Road, and Bessborough Street welfare centre, in collaboration with the Public Health department of Westminster City Council, following the diagnosis of the disease in a Westminster resident newly arrived from the Far East. School health service—The radical improvement over the years in the general well.being and cleanliness of children has made possible further reduction of facilities for cleansing verminous children. The cleansing station at 12 Maida Avenue, W.2, closed at the end of 1959 and the use of the borough council bathing station at Lithos Road, Hampstead, was discontinued in March, 1960. A school nursing sister was withdrawn from stand.by duty at the St. Pancras bathing centre. Chiropody—Local authority foot clinics have not in the past been provided on a large scale in the boroughs forming the division, the bulk of chiropody work for the elderly being conducted by the Old People's Welfare Associations. An expansion of the Council's service from seven to 25 sessions a week, authorised to take place in 1960, developed as quickly as the availability of suitable staff permitted. At the end of the year, at five different centres, 21 sessions were being held and attendances had improved to an average of 6.3 per session. 124 Prevention of break-up of families—The divisional co.ordinating committee met 23 times under the chairmanship of the deputy divisional medical officer, Dr. Mary T. Paterson. The work of the committee has been aided by the publication of a revised directory of all the local statutory and voluntary agencies with, an interest in the co.ordination of services designed to prevent neglect and ill.treatment of children and juvenile delinquency. Further, a whole.time social case worker, and an assistant organiser of children's care work (seconded for half.time duties) have been available under the general direction of the committee to do intensive work with problem families. DIVISION 3, comprising the boroughs of Finsbury, Holborn and Islington Dr. W. G. Harding reports: Maternity liaison committee—In accordance with the recommendations of the Maternity Services (Cranbrook) Committee a maternity liaison committee was set up locally and met for the first time on 30 September. Consultations between family doctors, hospital consultants and the medical staff of the two local health authorities concerned—London and Middlesex—previously took place regularly through the medium of the National Health Service liaison committee for North Central London which covers the Northern and Archway hospital groups. It is particularly encouraging that on the new liaison body the two teaching hospitals most closely associated with the area, i.e., the Royal Free hospital and University College hospital, are also represented. Maternity beds—In spite of the relatively high provision of maternity beds in London, the placement of priority cases and especially of patients in social need of hospital confinement continues to present great difficulty in this area, and in many instances beds are only secured via the Emergency Bed Service when labour commences. In June it was decided to investigate 100 successive such cases resident in this division. The cases occurred between 27 June and 17 December and can be summarised as follows: Ante-natal care Status Moved into district late Booked late Booked for home confinement but developed complications Booked for hospital but defaulted No ante.natal care .. 24 married 11 4 - - - single 13 1 - - - General practitioner 28 married 22 5 5 2 1 single 6 3 2 - - Local authority clinic 48 married 42 9 16 11 9 single 6 1 4 1 - Total married 75 23 27 14 10 single 25 Some cases are recorded under more than one heading. It will be seen that in only 14 of these 100 cases complications arose which rendered a previously booked home confinement undesirable. In the remaining 86 cases the Emergency Bed Service was used in order to secure hospital beds which were required on social grounds. 125 It is interesting that no less than 24 had not received ante.natal care of any description, though all but five of these had resided in the area for over six weeks, and that 27 presented themselves to general practitioner or clinic within less than six weeks of the expected date of confinement. There is evidence that an increasing number of women fail to present themselves in good time because they think that they stand a better chance to enter a hospital near their home via the Emergency Bed Service. This division is extremely fortunate to be able to receive considerable help with maternity beds from hospitals in the East End of London, but their relative remoteness from this district acts as a deterrent. This is borne out by the fact that ten patients who were booked for these hospitals defaulted in the antenatal period and had to be placed via the Emergency Bed Service. Conversely, there is evidence that a small minority of general practitioners are using the Emergency Bed Service for cases for whom beds might have been obtained by other means; six of the ten general practitioner cases who had received ante.natal care for over ten weeks attended a firm of two general practitioners and three of the remaining four were referred by another general practitioner. Out of the forty.eight cases who were known to our clinics—almost half of the whole series—thirty only presented themselves within six weeks of the expected date of confinement and in twelve unforeseen emergencies arose. Clinics invariably attempt to find hospital beds for cases requiring them on social grounds before referring them to a general practitioner obstetrician with the request to invoke the emergency bed procedure when labour starts. The findings, that out of 100 consecutive cases 23 had moved into the area less than six weeks before the expected date of confinement, that another 27 though resident for a longer period did not seek advice earlier and that 25 were single women, are interesting sidelights on the special social problems which are encountered. It seems essential for the hospital authorities not only to review the maternity bed situation in the area but also to ensure that hospitals adjust their admission policy to cover late and urgent maternity bed requirements. The Royal Free hospital maternity beds—The number of referrals for placement via the Emergency Bed Service would have been even larger but for an arrangement made between Dr. F. J. Fowler, o.b.e., t.d., Senior Administrative Medical Officer, North West Metropolitan regional hospital board, and Miss Jocelyn A. Moore, f.r.c.s., f.r.c.o.g., Director of the Department of Obstetrics and Gynaecology, Royal Free hospital, by which a number of maternity beds at that hospital were offered to this division for cases requiring hospital confinement on social grounds. Ten beds can now be allotted directly by our welfare centres to cases in urgent social need and all of them are allocated relatively late in pregnancy, two during the seventh and eight during the eighth month, in order to make some provision in the area for later bookers whom it is practically impossible to place otherwise, however great the need. I wish to place on record my appreciation to Dr. Fowler and particularly to Miss Moore and her colleagues at the Royal Free hospital for their generous and far.sighted assistance. It is encouraging that this has led to much closer local co.operation. Appointment systems at ante.natal sessions—Appointment systems were introduced experimentally at ante.natal sessions in two centres, as recommended in the report of the Maternity Services Committee. For sessions staffed by a medical officer and two midwives two patients were booked at intervals of 15 minutes. It was found that waiting times were reduced and sessions became more orderly. The chief difficulty encountered was from patients arriving considerably before their appointment. Only firmness in keeping examinations to the times booked will overcome this initial difficulty. In view of the satisfactory results of these experiments it was decided to try out an appointments system at all antenatal sessions in the division. 126 Fires caused by oil heaters—In February and March, 1960 two fires in Islington caused by oil heaters resulted in the deaths of four children, all under five years of age. Apparently the oil heaters were overturned while the children were left unattended by an adult. In the second of these fires three children died and four were rescued, but there was no evidence that the provisions of the Nurseries and Child Minders Regulation Act, 1948 had been infringed, since the children were being minded as a neighbourly act and not for reward. Consideration was given to various ways of making the public more careful in the use of these heaters. Apart from warnings displayed in public exhibitions on accidents in the home, the most practicable course was for health visitors during their home visits and talks at welfare centres persistently to stress the inherent dangers and to advise on precautions. As an aid a warning handbill was produced by the Council. Bathing centres—The number of schoolchildren needing cleansing at bathing centres had fallen considerably in the division, as in other parts of the county. For many years they had been referred under agreements with the Metropolitan Borough Councils of Finsbury and Islington to either the bathing centre at Finsbury Health Centre or the Islington centre in Seven Sisters Road. From 31 March the referral of schoolchildren to the centre at Finsbury Health Centre ceased. This rationalisation of the use of cleansing stations was facilitated by the use of Lorexane, which was issued throughout the year from welfare centres, school treatment centres and day nurseries for home treatment. Economies in the deployment of nursing staff were effected by a revision of the forms and procedure used for referring children to the centres and following up their treatment. This permitted school nursing staff formerly working at these centres to be withdrawn and diverted to other work. Vaccination against poliomyelitis—The response to the extension of eligibility for vaccination to persons up to 40 years of age was, on the whole, disappointing. Special sessions which had been instituted for persons up to 26 years of age were kept in being to serve the new age group. A special series of lunch.time sessions was arranged in the Kingsway Hall from the end of May to mid.July for the benefit of office workers in Holborn. Letters were sent again to firms in the division inviting staff to these sessions and offering a visit by the mobile immunisation clinic. During 1960 a total of 19,465 injections was given to the new age group (9,242 first injections 7,910 second injections and 2,313 third injections), while 1,934 records of completed courses were received from general practitioners in the division. The greatest response from the public was in May and June. Mobile immunisation clinic—The bringing into use of a mobile immunisation clinic on 28 September, 1959 was mentioned in my previous annual report. The results of the work of this clinic were analysed for the first nine months of its use with the following results: Places visited Times No. °f visits* No. of injections A verage per visit 1 2 3 Total Arsenal football stadium late Saturday afternoon 10 293 106 23 422 42.2 Schools and further education establishments mornings, afternoons and evenings 21 210 214 357 781 37.2 Youth clubs evenings 4 48 19 3 70 17.5 Market places lunch times 8 427 - 20 447 55.9 Firms mornings and afternoons 85 1,312 728 228 2,268 26.7 Housing estates evenings 9 141 21 39 201 22.3 Total 137 2,431 1,088 670 4,189 30.6 * Including revisits to same establishments for second injections. 127 Diphtheria prophylaxis campaign in schools—In my reports for 1958 and 1959 I dealt with the detection of a number of carriers of C. diphtheria mitis and of some mild cases of diphtheria in some schools in the division and referred to plans for an intensive campaign aimed to raise the immunisation rate in the primary schools. During 1960 there was no further incident in the division and the intensive campaign in the primary schools, which had been started in the previous autumn, continued throughout the year with a total of 125 sessions held in 72 school departments. In these departments there was an average of 36 per cent. of children fully protected before the campaign started; this was raised by the end of the year to 85 per cent. The table below, which shows the percentage immunisation state of the departments started and completed during 1960, excludes 20 departments either started in 1959 and completed in 1960 or started in 1960 but not completed by 31 December. 0.20% 21.40% 41.60% 61.80% 81.100% Before 10 J 24 13 5 Nil 47 schools below 60%, 5 above After Nil Nil 1 13 38 school below 60%, 51 above To achieve this result 909 primary courses were completed and 4,140 children received a 'booster' at school, and in addition 408 schoolchildren received primary courses and 403 ' boosters ' at welfare centres. Foot clinics—The Minister of Health's decision to allow local health authorities to expand or start chiropody services for the priority classes resulted in allocation to this division of 36 more sessions during the year, raising the number of authorised chairside sessions to 109. At the end of the year 16 chairside sessions were not operating, due to the shortage of qualified chiropodists and to loss of staff to other authorities. Mental health service—With the coming into operation of the provisions of the Mental Health Act, 1959 the divisional staff was augmented by the addition of a team of mental welfare officers. A vacancy for a psychiatric social worker had not been filled at the end of the year. Three training centres, Archway, Camden Road and Islington, also came within the scope of the divisional organisation. In order to acquaint general practitioners with the changes following the coming into force of the Mental Health Act, 1959 and the divisionalisation of the Council's mental health services, the City division of the British Medical Association arranged a meeting and discussion held at Woodberry Down health centre in association with Dr. King, Divisional Medical Officer, division 4. Some 70 people attended the meeting, including general practitioners in the City division practising in divisions 3 and 4, senior staff of the two health divisions and members of their mental health teams. Dr. L. Greenfield, Chairman of the City division of the British Medical Association, took the chair and I introduced the subject. The sections of the Act dealing with the new procedures for the admission of patients to hospital were explained by the divisional mental welfare officer, division 4, and the role played by the hospital and the consultant was reviewed by Dr. J. de Bastarrechea, Friern hospital. A lively discussion followed. Premises—The general falling off in attendances at minor ailment treatment sessions for schoolchildren led to infrequent use of the accommodation allocated for this service at the Province of Natal centre. At the same time the Institute of Child Health was in need of more space for its laboratories. The accommodation was therefore reallocated; the portions of the second floor at the centre occupied by the Council were handed over to the Institute and converted into additional laboratories. 128 At the end of the year major improvements of the heating installation were nearing completion at Cromwell Lodge hostel for tuberculous men. The old coke-fired boilers were replaced by oil-fired boilers in a new boiler house; rooms previously without radiators were provided with them and a consistent standard of space heating now obtains throughout the building. Staff— Not infrequently visitors to divisional establishments were unaware of the identity of staff whom they had seen—the nearest description being 'someone in a white coat'. was decided accordingly that all staff interviewing visitors in clinics and at home help offices should be identifiable by cards bearing their names and fixed to small desk stands. These desk stands were made by the Council's industrial workshop for the mentally subnormal in Stepney. This innovation has proved popular with visitors and staff alike as a means of rendering a more personal service. DIVISION 4, comprising the boroughs of Hackney, Shoreditch and Stoke Newington. Dr. S. King reports: Woodberry Down health centre—The clinics at the centre and the general medical and dental work continued on existing lines, but there were some interesting extensions in the use of the accommodation. After twelve months experience of housing a sub-office of the Children's department, it is clear that the ease and regularity of contact between health visitors, psychiatric social workers and child welfare officers has facilitated the work of both departments and cooperation generally has been greatly strengthened. The Welfare department opened, early in the year, two weekly classes for the rehabilitation of physically handicapped persons. Transport is arranged for the more severely disabled. Instruction is given in hand weaving, basket work, glove puppet.making and other handicrafts. In the demonstration kitchen members of the class are taught easy methods of cooking and the use of simple appliances designed to help handicapped persons to carry out routine kitchen work. Towards the end of the year the Welfare department opened a class for the training of young blind persons. Another development has been the holding of an ante.natal clinic by one of the general practitioners at the centre. During the summer the London Ambulance Service began Civil Defence training classes in the lecture hall, and similar training classes were organised by Stoke Newington borough council. Other activities at the centre are mentioned in later sections of this report. Some structural work has been carried out during the year. An existing waiting.space in the child guidance suite has been partitioned off and converted into an office, and in the audiology room wall insulation has been provided to improve the sound.proofing. The number of visitors to the centre continued at a high level, over 1,100 being received during the year, including nearly 200 from overseas. Three one.day in.service training courses for clinic nurses were held at the health centre for staff from all nine divisions. About 25 nurses attended each course. Mental health—The team of mental health officers, based upon the Shoreditch health centre, started their work in late October and by the end of the year had established a good relationship with many of the general practitioners in the area. In addition to three training centres for mentally sub.normal persons the division has a day centre, opened in June, for the rehabilitation of patients recovering from mental illness. Places for 40 patients are provided. An experimental scheme in the social rehabilitation of psychiatric patients is also being conducted from Woodberry Down health centre. 129 I Health education—A committee of staff, representative of all grades involved in health education, has continued to meet to discuss and co.ordinate arrangements for this work and to decide the monthly topics for the concerted publicity effort. Local maternity liaison committees—These have been established by both hospital management committees of hospitals providing maternity beds in the division. Arrangements have been made for some of the patients booked to enter the Bearsted Memorial hospital to receive ante.natal care, mothercraft instruction, relaxation exercises and other facilities at Woodberry Down health centre and a health visitor attends the hospital weekly to see the mothers during the lying.in period. Chiropody—In January a new foot clinic was opened at Elsdale Street welfare centre and a second chair was later installed there. Two chiropody sessions were transferred from Shoreditch health centre to the Salvation Army Goodwill Centre, New North Road, N.l, to facilitate the treatment of old people living in that area. Occasional creches—There was an expansion of this service, additional sessions being held at Shoreditch health centre and at Cranston, Elsdale Street and Richmond Road welfare centres. Premises—It was necessary to vacate the accommodation at the Old Town Hall, Milton Grove, N.l6, which had housed a welfare centre and a home help office for a number of years. The home help office was transferred to Barton House welfare centre and the maternity and child welfare services were shared between Barton House and West Hackney welfare centres. The West Hackney centre was transferred from the former church hall to the newly erected church hall, where greatly improved facilities are available. Prevention of break.up of families—There were six meetings of the divisional coordinating committee and 17 intermediate case conferences at which 53 families were discussed. No less than 25 of these families were referred by the Council's Housing Management department because there was a possibility of their eviction for arrears of rent. Two five.day courses of training for work with problem families were conducted for selected home helps from divisions 3, 4 and 5. At the second of these courses two home helps, who had attended a previous course, were invited for one period to present problems which they had encountered in their field.work and to indicate how these problems had been solved. Special investigation clinics—A marked increase has been noted in the number of children referred to the special investigation clinics as overweight; at one clinic the number of obese children has increased by almost 50 per cent. The 'ring-a-bell' alarm apparatus for cases of persistent enuresis has been in use with some measure of success. On occasions this form of treatment has been specially requested by parents or children, who have heard of other cases where alarm apparatus has been obtained from the clinic or purchased privately. Loan of equipment—The demand for home nursing equipment continued to increase, and in the course of the year 124 commodes and wheelchairs were issued on loan, besides tripod and quadruped walking sticks, bed cradles and hoists, hospital beds, mattresses and rubber sheets. The fact that ten fireguards were issued on loan seems to indicate that this new service is fulfilling a need. 130 DIVISION 5, comprising the boroughs of Bethnal Green, Poplar and Stepney and the City of London Dr. G. O. Mitchell reports: Auditory training—An auditory training centre was inaugurated at the Bethnal Green school treatment centre in November and 30 children, both under.5's and schoolchildren, were in attendance at the end of the year. Chiropody—From September an additional session has been held each week, bringing the total weekly number of sessions to nine. Prophylaxis—At the beginning of the year free vaccination against poliomyelitis was extended to include all persons under 40 years of age, but despite extensive publicity response was disappointing. The special lunch.time clinic at the Guildhall continued to function, in addition to sessions held at welfare centres, and further sessions were also held in business houses in the City. During the year the Council's revised schedule for the protection of young children against infectious diseases was put into operation in the division. The figures for primary diphtheria immunisation are an encouraging reflection of this schedule, which aims to protect all children by the time they are between 15 and 18 months old against diphtheria, whooping cough, tetanus, smallpox and poliomyelitis and to reinforce this protection just prior to school age. Prevention of break.up of families—The divisional co.ordinating committee and its intermediate case conference met on 19 occasions during the year and dealt with 73 families. A full.time case worker was appointed to the division in February and two assistant organisers of children's care work also worked with problem families; 11 families were referred to these workers. The services of specially trained home helps were supplied to four families to assist with budgeting, cooking and general household management. DIVISION 6, comprising the boroughs of Deptford, Greenwich and Woolwich Dr. F. R. Waldron reports: Abbey estate, Woolwich—A temporary maternity and child welfare centre was opened on this new estate in March to meet the initial demand for local health services. Attendances at the ante.natal, infant welfare and toddlers' sessions have been satisfactory. The available temporary accommodation is necessarily restricted; additional sessions have been planned to relieve congestion should the need arise pending permanent clinic provision for the estate as a whole. B.C.G. vaccination—Divisional arrangements for operating the scheme for the B.C.G. vaccination of 13.year.old schoolchildren were continued and by the end of December 3,402 children had been dealt with, together with 265 students at five training colleges in the division. Fireguards—Twenty.one applications were met under the scheme for the loan of fireguards to necessitous elderly or handicapped persons, or householders with children under 12 years of age. Health education—This was continued as an integral part of the day.to.day activity of each welfare centre. Group discussion and demonstrations with film strips and other media were a regular feature of the programmes arranged at the larger centres. Much of the material used for health education purposes was produced by the health visitors who continue to show ingenuity and skill in this field. 131 I* Housewives' clubs—The two clubs sponsored by the Woolwich Council of Social Service continued to meet weekly at the Lionel Road and Garland Road welfare centres. Grants to assist towards the expenses of the clubs were authorised by the Divisional Health Committee. The activities at both clubs, which are now well established, include cookery, dress.making demonstrations, talks and films. Liaison with general practitioner obstetricians—Arrangements were made in January, at the request of a group of general practitioner obstetricians, for the group to co.operate in the ante.natal care of patients on their lists and to attend by rota the midwives' booking sessions at three welfare centres in Greenwich. Similar provision was made later in the year at the centre on a new housing estate in Woolwich. The arrangements have worked very smoothly at all four centres. All general practitioners practising in the vicinity of the centres concerned were informed of the activities of the two groups and of the procedures they had agreed to follow in order to safeguard the practices of other practitioners. Mental health service—In anticipation of the coming into force of the Mental Health Act, 1959, a series of informal monthly meetings was held in the division to examine and discuss in broad terms the many varied problems of mental health and community care work. The meetings, attended by representatives of the mental hospital service, general practitioners, hospital almoners, health visitors, district nurses and local authority and voluntary agency social workers, not only provided a useful forum for the exchange of information but also an opportunity for fostering close liaison between all likely to be concerned with the operations of the new legislation at field level. Oral poliomyelitis vaccine—The divisional area was one of a limited number in the country selected for the trial of a new oral poliomyelitis vaccine. The test, sponsored by the Medical Research Council, commenced in April and was conducted by a local paediatrician with the co.operation of general practitioners and health visitors. The parents of children qualifying for the test were given a full explanation of both the objects of the trial and the methods by which it was to be carried out; in all some 40 children participated in the scheme. The result of the trial will be made known when the data obtained from all areas have been collated and assessed. Prevention of break.up of families—The co.ordinating committee continued to meet regularly to consider policy and subjects of common concern in addition to measures to help particular families, the allocation of social case workers and of specially trained home helps. Of the 115 families discussed, many had been referred after intermediate case conferences at which a number of departments of the Council and the majority of other statutory and voluntary agencies in the area took part to a greater or lesser degree. Health visitors and other field workers continued to support and supervise the large group of potential problem families, of which relatively few reach the level of the special conferences. Voluntary workers—About nine voluntary workers assisted each week at various infant welfare sessions; I am most pleased to acknowledge their generous service. DIVISION 7, comprising the boroughs of Camberwell and Lewisham Dr. Ann Mower White reports: Premises—The Peckham child guidance unit was moved temporarily from Queen's Road centre to Alpha House, Rye Lane during alterations undertaken as part of the building work on the South East London General Practitioners' Centre. 132 To meet the expansion of the Council's chiropody service adaptations were carried out to provide a second chiropody chair at each of the two Lewisham foot clinics. Full use of the new sessions could not be made owing to shortage of chiropodists. New boilers and radiators were installed at Rushey Green day nursery to improve the hot water supply to the laundry and main nursery building and to provide improved heating for offices on the floor above. At the divisional health office, improvements to the medical examination room were carried out to provide adequate heating, lighting and sterilization and the committee room was converted into offices for use by new mental health staff. By arrangement with the Camberwell Borough Council, committee and other meetings were transferred to the Town Hall. Diphtheria—The year was marked, after a lapse of nine years, by two outbreaks of diphtheria centred in schools in North Camberwell, both localised with no apparent connection one with another. The first began in mid.November 1959, and a description of the action taken was given in my report for that year. Swabbing of the pupils of three schools involved was continued in the New Year, and special immunisation sessions were held at school. The incident closed in mid.March, 1960. There were, in all, six clinical cases of diphtheria, mild in character. As a result of swabbing 76 positive carriers were found; with one exception (an only child treated at home by her doctor) all carriers were admitted to hospital, and, after discharge, were required to show a further negative swab result before returning to school. The Report of the Ministry of Health for 1959 (Part II, page 79) notes that this outbreak followed a somewhat similar series of events to an outbreak at the same time in North London caused by a similar type of organism. The second outbreak had its onset in mid.December, but was not confirmed till the eve of the school holidays. In rapid succession four pupils from Camelot school, Peckham were confirmed as cases of diphtheria. Immediately the homes of class contacts were visited by school health visitors and swabs taken. Twelve positive results were reported and family doctors reported other positive results. The borough medical officer of health followed up and swabbed the home contacts of all pupils found to be positive. There was close cooperation with family doctors, to whom anti.toxin and antigen were issued, and guidance on protection of the unimmunised family contacts of a case or carrier was given on request. Frequent consultations were held with the physician.in.charge of the infectious disease hospital and with the group pathologist. A special immunisation session was held for family contacts and further swabbing visits were paid immediately after Christmas. A full programme of swabbings and immunisations was instituted in the New Year. Up to that time 28 children had been removed to hospital, of whom 11 were clinical cases. The organism (C. diphtheriae mitis) that caused this outbreak was of a different strain from the previous one; some of the children had severe attacks of the classical type and I regret to report that one little girl aged seven years died on 7 January, 1961; she was unimmunised. Maternity and child welfare—The statistical records were examined to ascertain the effect of discontinuing the routine weighing of each baby at each attendance at a child welfare session. As was expected, the total number of attendances had fallen. Attendances for essential purposes, however, had not fallen; the number of babies coming and the number seen by the clinic doctor had been maintained and more use had been made of the educational classes, discussion groups and demonstrations given at the centres by the health visitors. Health visiting—The allocation of part of the time of a health visitor for special duties with the King's College hospital diabetic unit was continued. She attends the unit once a week, and visits the homes regularly to advise on general management, insulin therapy, special diet and any family problems. The senior physician in the unit is very satisfied with the arrangement, but it will be due for review in the light of the report of the Ministry of Health Working Party on Health Visiting. 133 Day nurseries—The nurseries were in the main used by children in need of daily care owing to the health of the parent or to adverse home circumstances. Occasional creches—The occasional care of children at creches was extended. There are now nine sessions each week at five centres, and two more are planned. Prophylaxis—The outbreaks of diphtheria, reported above, resulted in an increase in immunisations. The number of poliomyelitis vaccinations diminished after the bulk of the special categories had received their third injections. Towards the end of the year, it was possible to reduce the number of special 'polio sessions' and at some centres to merge all the prophylaxis into one session. Loan equipment—The demand for equipment for the nursing of patients at home increased both in extent and in the range of articles provided. Auditory training—The auditory training unit at Lewisham hospital, which started in December, 1957, is the first L.C.C. clinic of its kind. Children from the age of nine months, who have suspected deafness, are referred and 59 patients had been treated by the end of 1960. Cases were referred from child welfare clinics, school treatment centres, hospitals and general practitioners. A survey of the causes of deafness was most revealing. Of the 59 patients referred, the known causes of deafness were found to be due to one of the following:—the Rhesus factor, birth injury, meningitis, premature birth (2), influenza during pregnancy, or cerebral palsy. Patients taken on for conditioning and/or auditory training numbered 40, hearing aids were given to 30 and eight were referred for admission to schools for the deaf. It is hoped that this type of unit will be extended in the future. Social case work for maladjusted schoolchildren—The children's care organisers in the Public Health department are now working as social case workers in the day schools for the maladjusted. One organiser from the division is working at Willowfield and the experiment is being tried in other divisions. Health teaching in schools—Health education in schools has for some years been given by health visitors in the course of their regular visits, if specially requested by head teachers. In the girls' schools mothercraft is the principal topic and meets with considerable success. At one school, the Council's inspector highly praised the teaching given and stated that ' the course has a direct influence over the girls and the advice given is entirely acceptable to them.' A photograph taken at one of the classes was published in The Times. Measures were taken to make available fuller provision for health education in the schools and, after discussions with the divisional medical officer, the district inspectors sent letters to all heads of primary and secondary schools in the division. The letter referred to the part played by health education in the building up of right attitudes and habits on health matters, and the learning by the child of health knowledge appropriate to his age. Groups of topics were suggested for the various departments, infants, junior and secondary. The divisional medical officer received invitations from the Camberwell and the Lewisham Head Teachers' Consultative Committees in order to discuss the projects, and the advice and help of the Public Health department staff was offered to any school who needed them. A dozen schools responded; a number of talks were given, literature was provided and films were shown. At three senior boys' schools anti.smoking campaigns were carefully planned in consultation with the head. During a selected week various forms of propaganda on the subject of smoking were used, and the deputy divisional medical officer visited the school to show a film and give a talk to selected pupils. Mental health—The division shared with other divisions in the establishment of the new mental health service under the Mental Health Act, 1959. The team of mental health social workers was accommodated in the divisional office. As part of World Mental Health Year, assistance was given to the Lewisham Society for Mentally Handicapped Children, who organised a public meeting in November. 134 Two very successful meetings were held, one in Camberwell in association with the local B.M.A. division and the Cane Hill hospital medical staff, the other in Lewisham in association with the local B.M.A. division and the Bexley hospital staff. Over 80 persons attended, including 25 general practitioners, seven psychiatrists and other hospital and L.C.C. staff. Discussion covered generally the new procedures in mental health as they affected the general practitioner. Particular reference was made to the work done at the hospital psychiatric out.patient departments at St. Giles and Lewisham hospitals, and to the Council's provision and plans for community care. The work of the mental welfare officers, while following the broad pattern of emergency arrangements for the mentally ill and community care for the subnormal and mentally ill, had distinctive developments due to the establishments situated in the divisional area. The emergency wards at St. Francis hospital, Dulwich have proved the most active in London for admitting patients from all parts of the county. The mental welfare officers in the division, in addition to their duties for their own patients, provided liaison for those from other divisions. For the subnormal, Dover Lodge hostel and three training centres are sited in the division, and for day.to.day administration have been incorporated in the divisional set.up: the mental welfare officers undertake social work for the residents at Dover Lodge and the training centre pupils. DIVISION 8, comprising the boroughs of Bermondsey, Lambeth and Southwark Dr. W. H. S. Wallace reports: Maternity and child welfare—Attendance at the maternity and child welfare clinics has been well maintained. The areas served by the welfare centres have been revised to meet the changing needs that have resulted from the large number of new buildings in the division. It has been possible to provide an additional infant welfare clinic at the Brixton school treatment centre and this has proved most valuable for mothers living in the vicinity. There has still been heavy demand for maternity beds but St. Thomas', Lambeth and the General Lying.in hospitals have been able to meet the needs in the division. Day nurseries—The demand for day nursery accommodation has continued to diminish. The average daily attendance at nurseries in the division during the year was 578, compared with 594 in 1959. The site of Marine Street day nursery, Bermondsey was required for road widening and consequently the nursery was closed in July. All children in the priority groups attending the nursery were given vacancies in the other nurseries in Bermondsey. Prophylaxis—The new scheme for immunisation in childhood, which involves commencing the immunising injections at a much earlier age, has proved most successful and has resulted in a great increase in the number of children being inoculated. The cases of diphtheria that occurred in schools fortunately had the effect of bringing the need for immunisation to the notice of parents and a considerable increase in the number of booster doses given in schools resulted. Infectious disease—Six cases of diphtheria were notified and confirmed in the division during the year. The first case occurred in a Lambeth infant school in February. In following up this case one further case was discovered and seventeen children and two adults were found to be carriers. In October and November four cases of diphtheria were notified in different schools in Southwark and North Lambeth. These cases were separate and no direct connection between them was discovered. All the children in the schools concerned were swabbed and nine carriers were found. 135 School health service—The health of the schoolchildren has remained good and there has been no great change in the numbers of children referred for treatment. The Brixton minor ailment clinic was closed and nursing treatment made available for an hour in the morning before school hours at the Loughborough welfare centre. This has proved a more satisfactory way of dealing with the small number of children concerned, as the health visitors do not have to give up time to attend a special session. The enuresis clinic held at All Saints' hospital was closed in November. The current cases were transferred to other sessions in the division without any difficulty. The number of children attending the Eye and Ear, Nose and Throat departments of Guy's hospital now is relatively small and their social needs no longer justify the presence of a treatment organiser, who has therefore been withdrawn. The closure of the two small schools for physically handicapped children, the Caldwell and Venetian, and their replacement by the new Thurlow Park school has greatly improved the services for handicapped pupils in the division. The new school is situated on the same site as the Elm Court school for delicate children. Medical services for the two schools can thus be integrated. In particular, the physiotherapy services provided by King's College hospital have given great assistance to the children at both schools. Mental health—The transfer of the mental health services to the division was carried out in October. It was, fortunately, possible to accommodate the new staff at the divisional office, so that a satisfactory integration of the services could be effected. The total number of staff authorised has not yet been appointed but the existing staff have so far been able to meet the immediate demands for dealing with mental patients. The provision of a day hospital for mentally ill patients at St. Olave's hospital has proved of great value in the community care of the mentally ill. The day centre provided at Blackfriars by the Institute of Social Psychiatry is also doing most valuable work in the rehabilitation of the mentally disabled. Co.ordinating committee—The work of the co.ordinating committee in connection with problem families continues to grow in scope and difficulty. Once families get into difficulties their problems frequently develop further complexity. One of the main causes of difficulty at the present time are the debts, evictions and prison sentences for fraud that result from involvement in excessive hire.purchase agreements. The South London Family Service Unit continues to make a valuable contribution and the intensive case workers employed by the Children's department have carried out most useful work. The special home help services have also played a most valuable part in conjunction with the other services. Housing clearly plays an important part in the difficulties of many problem families and I am glad to report that the majority of families re.housed following nomination by the co.ordinating committee have responded well and are no longer pointed as problem families. DIVISION 9, comprising the boroughs of Wandsworth and Battersea Dr. J. T. R. Lewis reports: Premises—The Welcome Hall welfare centre, Battersea, opened in the Shaftesbury Society's new building in December, replacing a temporary building on park land. With the divisionalisation of the mental health service an office for eight mental welfare officers and clerical staff was opened in October at the divisional sub.office at 89 Trinity Road, Upper Tooting. 136 To meet the needs of the expanding home help service the division was separated into four areas instead of three and a fourth home help office was opened at Riggindale welfare centre, Streatham in November. The opening of the purpose.designed William Harvey centre in Roehampton in July, 1959 made it possible to close in March the Eastwood welfare centre, which occupied a clubroom. A plaque was unveiled at Putney Health Centre to commemorate the services rendered by Miss Eileen Lecky, M.B.E., and the Voluntary Committee of the Putney Children's Health Centre from 1916 to 1958. Prophylaxis—Extensive publicity was given to the Council's campaign designed to publicise the extension of the age limit for inoculation against poliomyelitis to 40 years. Sessions were arranged at industrial and commercial premises, at Clapham Junction railway station, and a departmental store. At the latter 598 injections were given. From September inoculations against poliomyelitis were added to other forms of prophylaxis available at all infant welfare sessions. In the evening and Saturday morning sessions arrangements were also made for all types of prophylaxis to be available where, previously, only poliomyelitis inoculation had been offered. Mothercraft and relaxation classes—Additional classes combining mothercraft instruction and relaxation were started and were functioning at four centres. Creche—An occasional creche for one session a week was opened at Putney health centre in December. Visiting of old people—An experimental scheme for clinic nurses to be employed exclusively for visiting the elderly was expanded. Health visitors continue to make initial visits and deal with any exceptional problems. The number of visits to old people carried out by health visitors and clinic nurses during the year was 4,306. Mental health services—A weekly clinic was commenced at the William Harvey centre in June for out.patient treatment of the mentally ill. The new approach to mental health as made in the Mental Health Act, 1959, taken together with the divisionalisation of existing mental health services, provided a stimulus to which the staff responded fully. The mental welfare officers were integrated in the health team as a whole; useful preliminary work was undertaken towards developments which will come into being in 1961. Staff— Dr. D. M. O. Lowry, deputy divisional medical officer, who joined the division in August 1957, left in December to take up a public health appointment in Bermuda. He rendered excellent service, notably in connection with housing. 137 Statistical summary 1960—health divisions Health division 1 2 3 4 5 6 7 8 9 Total Health division 1 2 3 4 5 6 7 8 9 Total Estimated population—mid 1960 437,630 501,720 277,650 256,160 209,660 303,110 396,350 366,280 445,920 3,194,480 Foot clinics Births and associated mortality Sessions 3,645 611 3,395 3,964 401 1,641 1,941 3,611 1,692 26,907 Live births 7,931 8,300 6,074 5,079 3,737 4,724 6,712 7,293 7,518 57,368 Total attendances 25,474 3,388 23,390 28,866 2,574 58,327 11,226 23,694 9,796 186,735 Rate per 1,000 population 18.1 16.5 21.9 19.8 17.8 15.6 16.9 19.9 16.9 18.0 Deaths under 1 month 122 144 95 57 55 73 112 115 113 886 Day nurseries Rate per 1,000 live births 15.4 17.3 15.6 11.2 14.7 15.5 16.7 15.8 15 0 15.4 Number of places at 31 Dec. 624 975 346 379 325 55 294 634 437 4,069 Total attendances 143,904 226,939 80,501 90,217 67,116 12,456 63,369 146,784 90,923 922,209 Deaths All ages 4,846 5,602 3,070 2,897 2,289 3,120 4,412 4,156 6,129 36,521 Child minders Rate per 1,000 population 111 11.2 111 11.3 10.9 10.3 111 11.4 13.7 11.4 Statutorily registered 31 Dec. 30 13 23 21 5 43 39 1 27 202 Children minded (authorised no.) 95 83 86 88 14 232 200 12 213 1,023 Health visiting Voluntarily registered 31 Dec. 154 150 139 81 74 116 146 113 16 989 Effective visits 106,402 102,959 65,991 62,390 63,547 67,704 86,629 108,961 70,393 734,976 Children minded 213 153 180 96 86 122 170 138 29 1,187 Staff at 31 Dec. W/T equivalents 48 53 38 29 33 38 48 56 55 398 Home help Welfare centres Households attended 4,469 4,850 2,862 4,413 3,044 3,505 5,599 4,586 4,703 38,031 Children— Households attended per 1,000 Sessions 2,816 3,963 2,546 1,859 2,031 2,918 2,959 2,884 2,582 24,558 population 10.2 9.6 10.3 17.2 14 5 11.6 14.1 12.5 10.5 11.9 Total attendances 88,185 119,248 74,909 65,780 55,452 83,012 95,825 95,201 102,016 779,628 Age 0.1—First attendances % of live births 80 90 90 93 87 97 87 82 87 88 Home nursing Total visits 224,068 244,258 141,436 138,568 136,430 187,495 211,828 217,461 188,540 1,690,084 Expectant mothers— Visits per 1,000 population 512 487 509 541 651 619 534 594 423 529 Sessions 1,567 1,612 1,146 333 327 1,924 1,638 670 760 9,977 First attendances 4,344 5,354 4,024 1,004 622 2,831 2,747 2,421 2,108 25,455 School health service % of live and still.births 54 63 65 19 16 59 40 32 28 43 Medical inspection, routine, special, reinspection 34,137 29,599 28,369 20,877 28,065 34,746 36,932 29,105 40,624 282,454 Total attendances 18,968 25,599 19,465 5,042 4,424 18,164 16,608 12,668 12,124 133,062 Health surveys 95,797 89,410 82,091 45,996 54,056 75,735 147,685 62,926 107,842 761,538 Prophylaxis Hospital/specialist clinics— Poliomyelitis— New cases 3,892 3,995 4,551 2,617 3,208 3,642 4,576 3,417 4,196 34,094 Two injections Total attendances 9,096 12,078 14,118 6,585 7,810 8,494 10,206 10,709 14,501 93,597 born 1953.60 5,285 6,189 4,709 4,220 2,757 3,804 4,953 5,211 6,706 43,834 bom 1943.52 895 1,754 1,547 1,358 517 1,087 1,251 1,268 1,508 11,185 Dental services born 1933.42 3,567 6,153 3,691 2,415 3,819 2,340 2,250 2,172 3,176 29,583 Schools— born 1932 or earlier and under New cases 7,297 10,211 7,165 12,932 7,217 6,585 8,030 8,873 9,471 77,781 40 years 7,006 13,237 9,364 5,018 10,652 5,892 6,719 8,801 8,629 75,318 New cases per 1,000 population age 5.14 163 230 203 375 235 147 140 176 155 193 over 40 years 270 1,051 41 190 52 232 862 87 154 2,939 Total 17,023 28,384 19,352 13,201 17,797 13,355 16,035 17,539 20,173 162,859 Total attendances 27,135 35,776 22,090 37,815 21,652 20,487 26,706 32,349 32,973 256,983 Third injections 31,232 52,097 30,848 21,736 31,293 23,346 33,689 27,485 28,773 280,499 Maternity and child welfare— First treatment 646 606 346 1,096 302 377 246 357 285 4,261 Smallpox—Vaccinations 3,525 4,261 3,163 2,395 1,455 2,636 3,899 3,141 3,856 28,331 Total attendances 3,749 3,152 3,899 4,208 1,353 1,429 653 1,269 999 20,711 Re.vaccinations 293 1,062 255 389 167 295 359 294 460 3,574 Diphtheria—Primary course 7,872 7,498 6,687 4,649 4,021 4,549 6,896 7,940 6,719 56,831 Reinforcing injections 5,001 5,419 5,218 1,750 3,634 3,250 3,980 9,620 2,639 40,511 Whooping cough—Primary course 6,620 6,272 5,178 4,347 3,216 4,147 6,133 6,325 6,301 48,539 Reinforcing injections 805 607 288 560 196 799 1,079 697 599 5,630 Tetanus—Primary course 6,964 6,124 5,510 4,386 3,311 4,126 6,109 6,177 5,898 48,605 Reinforcing injections 973 549 446 337 117 805 1,010 998 483 5,718 138 APPENDIX A THE DOMICILIARY MIDWIFERY SERVICE AND THE CRANBROOK REPORT Before the Mid wives Act, 1936, came into force the domiciliary services in London were provided either by independent midwives or by midwives on the staff of hospitals or voluntary nursing agencies. The 1936 Act laid on the Council the duty to provide an adequate service of midwives for attendance on women who wished to be confined at home. The Council at that time took over a number of independent midwives of the required professional standard and entered into agreements with hospitals and district nursing associations already undertaking domiciliary midwifery practice by which these bodies were paid by the Council for each confinement attended. This pattern was not substantially changed by the passing of the National Health Service Act, 1946. The Council's domiciliary midwifery service is administered centrally and is supervised by four non.medical supervisors of midwives. A supervisor of midwives is always on duty to answer calls for assistance from general practitioners, midwives, hospitals, the Emergency Bed and ambulance services, police and the general public. It is necessary to maintain this 24.hour service in London with its considerable floating population and influx of numbers of pregnant women, some of them unmarried. The domiciliary midwifery service is at present provided by the following means: Direct service—The Council employs between 90 and 100 midwives. Most of them live in flats provided by the Council or made available by the metropolitan borough councils; some live in their own homes. Midwives work in groups of three, four or five, each midwife covering a defined area and acting as relief to her colleagues. In addition there is a hostel in North London, which provides an opportunity for newly qualified midwives to gain district experience under the guidance of a superintendent midwife, before they take over an area of their own. Midwives are not provided by the Council with motor cars but there is an assisted purchase scheme and since 1960 they also qualify for a grant for driving lessons. Midwives who use their own cars, motor scooters or bicycles for their professional work receive allowances. Agency services—(i) Twelve district nursing associations undertake midwifery and employ 59 midwives for this purpose. Their midwives can now be called upon to provide relief for the Council's midwives and each midwife is responsible to the Supervisor of Midwives for her own supply of drugs, keeping of records, etc. The Council provides a car to all but two district nursing associations and reimburses the associations for 93 per cent. of their approved expenditure. (ii) Hospital districts—In 1938 agreements were made with sixteen hospitals which then employed district midwives to undertake domiciliary midwifery on an agency basis; these arrangements were continued when the National Health Service Act, 1946, came into force. In some areas senior medical staff from the hospital attend the Council's ante.natal clinics and provide medical aid on the district when required. In others, hospital midwives call in medical aid from the general practitioner services and also act as midwives to cases booked by general practitioners for maternity medical services. During the Second World War the volume of domiciliary midwifery was considerably reduced; several hospitals gave up their districts and did not resume this work when the war was over. There has been, too, a pronounced trend towards institutional midwifery, clearly illustrated by a comparison of figures of place of birth in London in 1938 and 1960: 139 Table (i)—Hospital and domiciliary births in London 1938 1960 Institutional births 45,561 (69%) 55,959 (83%) Domiciliary births 20,757 (31%) 11,363 (17%) 66,318 67,322 Council midwives in 1960 had an average case load of 72. The overall average case load for all midwives, including those in hospital district practice, was 60. Hospitals are finding it increasingly difficult to maintain district services of their own; in 1960 St. Bartholomew's hospital requested the Council to take over its district commitments and 11 hospital districts now remain in operation. table (ii)—Hospital district midwifery Hospital No. of midwives Place of ante-natal care (Hospital or Councils A.N. clinic) No. of deliveries in 1960 General Lying.in 3 Hospital and A.N. clinic 202 Guy's 4 Hospital 115 King's College 2 Hospital 97 London 5 Hospital 277 Mother's Hospital, Hackney Queen Charlotte's 11 Hospital and A.N. clinic 500 6 Hospital and A.N. clinic 230 St. Mary's 1 A.N. clinic 13 St. Thomas' 1 Hospital 44 South London 6 Hospital and A.N. clinic 304 University College 2 Hospital and A.N. clinic 36 Westminster 3 Hospital and A.N. clinic 121 St. Bartholomew's* 4 Hospital 8 48 1,947 * Ceased 31 January, 1960. Payment is made by the Council on a per capita basis—at present generally £17 10s. per case. Duties under the Midwives Act, 1951 In 1960 the Council as local supervising authority received notifications of intention to practise from 1,404 midwives. Table (iii)—Notifications of intention to practise Midwives practising in hospitals 1,105 Midwives practising in nursing homes; employed by district nursing associations, nursing co.operations, etc. 197 Midwives employed by l.c.c. 98 Supervisors of midwives 4 1,404 Under section 14 (i) of the Midwives Act, 1951 the Council pays fees to general practitioners for medical aid rendered to cases for which a doctor had not been booked to give maternity medical services. For purposes of supervision a record is also kept of medical 140 aid calls to doctors who had undertaken to give maternity medical services. Comparison of the number of medical aid notices in 1956 and 1960 shows a substantial shift from statutory medical aid to calls to booked doctors—a trend which may be expected to continue. Table (iv)—Medical aid 1956 1960 Statutory medical aid notices 3,860 2,350 Medical aid calls to booked doctors 1,410 3,088 5,270 5,438 Training of pupil midwives The Council does not provide a midwifery training school, but facilities for district experience, with midwives approved by the Central Midwives Board for this purpose, are available to Part II training schools in the county; 79 of the Council's midwives are approved teachers and every year some 300 pupils receive training on the district. The majority of these pupil midwives live in the home of the midwife during the three months' training period; a maintenance allowance is paid by the hospital authorities which also pay each midwife a teaching allowance of £30 annually. Maternity medical services The London Executive Council is responsible for making arrangements with general practitioners who undertake maternity medical services. There are some 2,250 general practitioners in London; only about 590 are general practitioner obstetricians, but all are entitled to render these services under the National Health Service Act. General practitioner obstetricians may give maternity medical services to patients not on their list and receive a higher rate of remuneration. The London Obstetric Committee is responsible for laying down standards for admission of doctors to the general practitioner obstetrician list and for the retention of names on the list. The committee comprises both consultant obstetricians and general practitioners; since it was set up in 1950 the County Medical Officer of Health has been its chairman. Originally the committee required general practitioners either to have been responsible for 30 confinements within a period of three years or to have held a post.graduate resident obstetric appointment. Since May, 1957 stricter criteria have been applied which require, save in exceptional circumstances, that general practitioners who qualified since 1951 must have held a six months' resident obstetric appointment before they can be admitted to the list. Health education Ante.natal care is given in the Council's ante.natal clinics by directly employed midwives, by midwives employed by some hospitals and with one exception by midwives employed by the district nursing associations. Thus they work in close association with the clinic doctor and health visitors who are mainly responsible for health education and mothercraft teaching. Health education activities in the clinics, particularly through the medium of group instruction, have been developed and improved in the last decade. Nevertheless, the most important single factor remains the direct approach by doctors, health visitors and midwives to the individual mother in her own home and in the clinics. Group talks and discussions on mothercraft, diet and physiology of labour and relaxation are arranged for expectant mothers booked for home or hospital confinement, and evening sessions for fathers are sometimes included. Relaxation classes are generally held by health visitors. 141 The midwives give lecture.demonstrations on inhalation analgesia. In the main mothercraft and relaxation classes are attended by primigravidae, many of whom are booked for hospital delivery. There are, however, some maternity hospital units which still do not provide comprehensive mothercraft training either at the hospital or by referring mothers to the Council's centres. Divisional medical officers have been asked to provide local maternity hospitals with programmes of mothercraft training held in their centres so that hospitals can ensure that mothers are enabled to attend classes at the clinics. Out of a total of 6,012 talks given in the Council's centres in 1960 no less than 3,991 talks (66.4 per cent.) were given to groups of expectant mothers. Domiciliary practice The Council issues a handbook to all domiciliary midwives which sets the standard to which each must work. The book is issued in a loose leaf binding so that amendments on new procedures and techniques can be inserted from time to time. In the clinics midwives make routine examinations of expectant mothers. Every mother is given a green card on booking, which instructs her how to call her midwife or her reliefs. The midwife enters each booked patient in her register. Midwives make several home visits to advise the mother on preparations for the confinement and a maternity outfit is issued free to the mother at or about the 35th week of pregnancy. Special emphasis is laid on the early recognition of toxaemia and weight records are kept as a routine. Midwives are required to summon medical aid if there is a rising blood pressure or if the blood pressure reaches 130/90 mmHg at any time. During 1960 the preventive measures against toxaemia were further reinforced by making home helps available free of charge, where hospital consultants or general practitioners certify that rest at home is essential for this reason and admission to hospital is considered unnecessary or impracticable. Iron tablets are given as a routine to all mothers. Blood specimens are taken by the clinic doctor for haemoglobin estimations, Wassermann and Kahn tests, determination of rhesus factor and tests for Rh antibodies in appropriate cases. The tests are carried out at local hospitals or regional blood transfusion centres. The laboratories also carry out Coombe's tests on cord blood specimens sent in by midwives. Midwives must refer all cases with a haemoglobin level below 11.8 gm per 100 ml (85 per cent.) to the clinic or booked doctor and must call medical aid if the haemoglobin level is below 8.9 gm per 100 ml (70 per cent.). General practitioners who render maternity medical services are able to use the facilities for tests at the Council's centres, whether the mother receives ante.natal care at the clinic or not. Midwives hold and administer pethidine but are not permitted, in London, to give opium. From 1956 onwards trilene has been employed in the Council's domiciliary midwifery service and there has been a progressive reduction in the use of the more cumbersome gas and air apparatus; Talley and Minnitt apparatus can, however, be brought to the house by the London Ambulance Service at the request of doctor or midwife, if in their clinical judgment it is required. Table (v)—Inhalation analgesia administered 1956 % 1957 % 1958 % 1959 % 1960 % Gas and air 70 35 17 9 8 Trilene 14 52 71 78 78 Percentage of mothers who received inhalation analgesia 84 87 88 87 86 In the puerperium visits are made by midwives twice daily for the first four days after delivery and then once daily until the end of the 10 days lying.in period. A completed 142 record of pregnancy, labour and puerperium is then sent by the midwife to County Hall for scrutiny by a supervisor of midwives. Top priority is given by the home help service to domiciliary midwifery cases, but, in spite of this, the demand for home helps is no more than 15 per cent. of domiciliary confinements. Most families meet their own obligations either by the father taking time off or with the help of relatives or neighbours. The Emergency Obstetric Unit When an emergency arises in domiciliary practice, doctors or midwives call the London Ambulance Service which immediately alerts the nearest Emergency Obstetric Unit and dispatches an ambulance to collect them and their equipment which is always maintained in readiness. If the midwife attends the patient alone she must send a relative of the patient to summon assistance. In the excitement and anxiety of the moment the use of the term ' flying squad ' has sometimes led to an unfortunate confusion with the police. Nowadays the midwife gives the relative a simple card, on which is printed the telephone number of the ambulance service with the instruction to ask for the ' E.O.U.' The first Emergency Obstetric Unit in London was established by University College hospital in 1938. A year later 11 other hospitals, 10 of which were administered at that time by the Council, set up similar units. When the National Health Service came into force the four Metropolitan Regional Hospital Boards and the Boards of Governors of University College and Hammersmith hospitals agreed to continue the service. There are now 15 units operating in the county. In 1960 the average time taken to reach a case was twenty.two minutes; this includes the ambulance journey from station to hospital as well as the trip from the hospital to the patient's home. Table (vi)—Hospitals operating an E.O.U. dulwich. paddington. hackney. st. alfege's, greenwich. hammersmith. st. andrew's, bow. lambeth. st. giles', camberwell. lewisham. st. james', wandsworth. london. st. nicholas', woolwich. mile end. st. stephen's, fulham. university college. There were 249 calls to Emergency Obstetric Units in 1960. The most frequent reason was post.partum haemorrhage with or without retained placenta. It has long been a routine practice in the Council's service to give ergometrine by intramuscular injection at the end of the third stage of labour. Since 1959, as a preventive measure against P.P.H., midwives have also been permitted to give ergometrine during the second stage of labour with the birth of the head or anterior shoulder. All midwives who had not learned this technique in their training have now attended courses of instruction at Hammersmith or University College hospital. Ergometrine is not given during the second stage as a routine by all midwives. The decision in many cases rests with the doctor or may be influenced by the practice of local maternity hospitals. Care of the baby Medical aid is sought by midwives for babies showing signs of illness, sucking or feeding difficulties, birth injuries and for assistance in the resuscitation of the new.born baby. All of them carry intragastric oxygen outfits and have been instructed in their use at two London hospitals. For the past two years University College hospital has maintained a resuscitation team, comprising a consultant anaesthetist and nursing staff, which is constantly on call to local doctors. Midwives have been instructed in the factors predisposing to neo-natal cold injury and ensure in advance that rooms in which women are 143 to be confined can be adequately heated. Room thermometers and low reading rectal thermometers are part of their normal equipment. The decision that a premature baby born on the district should be removed to hospital must be made by the doctor, or if in an emergency no doctor is available, by the midwife herself. Midwives are advised to transfer a premature baby to hospital if the birth weight is less than 4½ lbs., or the baby's colour is poor or cyanotic attacks occur. The birth of a premature baby is notified to a supervisor of midwives as soon as possible. A few small premature babies, however, will always remain at home, either on medical advice or to meet the wishes of the mother. The hospital provision for the care of premature babies in London is adequate. A number of maternity hospitals have small units for premature babies born in their own maternity departments and only occasionally admit babies from elsewhere, but five large units will always admit babies born on the district—University College, Hammersmith, Mothers' and Lewisham hospitals and the British Hospital for Mothers and Babies. Admission is arranged directly with these hospitals. The London Ambulance Service collects the hospital team—a nurse proficient in premature baby care and sometimes a doctor—together with an electrically heated baby carrier which can be connected to the vehicle's batteries. During 1960 there were 524 premature babies born at home; 21 babies died in the first 24 hours after birth, five of them at home and the remaining sixteen in hospital, and 490 babies (93.5 per cent.) were alive 28 days after birth. Particulars of domiciliary premature live births are set out in table (vii). The difference between the total (524) shown in this table and the number (517) quoted on page 65 represents the cases attended by doctors and midwives independent of the Council's domiciliary midwifery service. Table (vii)—Domiciliary premature live births, 1960 Weight Number Per 100 live premature infants Deaths in 24 hours Survivors at 28 days Number Per 100 live premature infants Number Per 100 live premature infants 3 lb. 4 oz. or less 27 5 9 33.3 13 48.1 3 lb. 5 oz. to 4 lb. 6 oz. 63 12 7 111 54 85.7 4 lb. 7 oz. to 4 lb. 15 oz. 95 18 4 4.2 88 92.6 5 lb. to 5 lb. 8 oz. 339 65 1 0.3 335 98.8 All cases 524 100 21 40 490 93.5 Maternal deaths Four maternal deaths occurred amongst the 11,366 births in the domiciliary midwifery service in London in 1960, i.e., 0.4 per 1,000. Two women died as result of intercurrent disease: (i) inoperable abdominal carcinoma; (ii) malignant mediastinal tumour with cerebral secondaries. Two women, both para 5's, refused hospital admission, although both had attended hospital and had been advised to accept a hospital booking. In each case the midwife transferred the patient to hospital early in labour: 144 (iii) live baby delivered by Caesarean section; patient discharged home on 13th day, readmitted to hospital four weeks later—death due to ruptured uterus; (iv) live baby born in hospital as breech delivery; patient died of uncontrollable post.partum haemorrhage. Stillbirths There were 79 stillbirths in 1960, i.e., 7.2 per 1,000 live and stillbirths. The stillbirth rate in domiciliary midwifery for England and Wales was 9.9. In London the stillbirth rate in the domiciliary service has shown a gradual decline, with the exception of 1959. Table (viii)—Stillbirths in London in domiciliary midwifery service 1956 1957 1958 1959 1960 Number 90 87 89 100 79 Per 1,000 total births 8.8 8.5 8.4 9.2 7.2 An analysis of domiciliary cases Table (ix)—Stage of pregnancy at which women first attended 1956 % 1960 % Booked in first trimester 10.3 27.6 Booked in second trimester 60.6 53.5 Booked in third trimester 28.2 16.6 Unbooked 0.9 2.3 There has been some improvement since 1956, but only 27.6 per cent. of women book for home confinement sufficiently early to have adequate ante-natal care; 18.9 per cent. had totally inadequate ante-natal care. A higher proportion of West Indian women tend to book late than women born in the United Kingdom. In the following tables 2,765 cases confined at home during the first quarter of 1961 are analysed by age, parity and the stage of pregnancy when the first attendance was made. These tables show the extent to which the domiciliary midwifery service has had to deal with cases which should have had hospital confinement. Table (x)a—Age at confinement Age L.C.C. D.N.A. Hospital Total No. % No. % No. % No. % Under 20 51 3.0 13 2.5 17 3.3 81 2.9 20.24 445 25.7 151 28.9 138 26.8 734 26.7 25.29 632 36.6 184 35.2 192 37.2 1,008 36.4 30.34 368 21.3 108 20.6 122 23.7 598 21.5 35.39 192 11.2 55 10.5 39 7.6 286 10.4 40.44 28 1.6 12 2.3 7 1.4 47 1.7 45.49 11 0.6 11 0.4 1,727 1000 523 1000 515 1000 2,765 100.0 Total 62.5% 18.9% 18.6% 100 0% 344 mothers (12.5 per cent.) were over 35 years of age and 58 mothers (2.1 per cent.) were over 40 years of age. 145 Table (x)b—Age and parity Age Parity 0 1 2 3 4 5 6 7 8 9 10 and over Not stated L.C.C. Under 20 20 24 7 - - - - - - - - - 20-24 62 204 124 45 10 - - - - - - - 25-29 19 257 192 95 40 18 5 3 - 1 2 - 30-34 2 97 106 79 46 18 9 8 - 1 1 1 35-39 - 30 56 41 28 14 8 8 3 3 1 40-44 - 2 3 5 4 5 3 2 1 1 2 45-49 - 3 5 - 1 1 1 - - - - - Totals 103 617 493 265 129 56 26 21 4 6 3 4 Per cent. 5.9 35.9 28.5 15.4 7.5 3.2 1.5 1.2 0.2 0.3 0.2 0.2 D.N.A. Under 20 4 7 2 - - - - - - - - - 20-24 12 69 53 17 - - - - - - - - 25-29 5 61 57 31 22 3 4 1 - - - 30-34 2 16 31 26 19 4 2 5 - 3 - - 35-39 - 7 15 9 7 5 6 2 3 1 - - 40-44 - 1 5 - 2 1 2 1 - - - - 45-49 - - - - - - - - - - - - Totals 23 161 163 83 50 13 14 9 3 4 - - Per cent. 4.4 30.7 311 15 9 9.6 2.5 2.7 1.7 0.6 0.8 - - HOSPITAL DISTRICT Under 20 8 7 2 - - - - - - - - - 20-24 11 62 44 14 6 1 - - - - - - 25-29 6 73 60 29 19 3 - 2 - - - - 30-34 2 31 41 23 13 6 _ 1 1 - - 4 35-39 - 7 10 6 9 3 3 - 1 - - - 40-44 - - 1 2 1 2 1 - - - - - 45-49 - - - - - - - - - - - - Totals 27 180 158 74 48 15 4 3 2 - - 4 Per cent. 5.2 34.9 30.7 14.4 9.3 2.9 0.8 0.6 0.4 - - 0.8 Grand Totals 153 958 814 422 227 84 44 33 9 10 3 8 Per cent. 5.5 34.6 29.4 15.3 8.2 30 1.6 1.2 0.3 0.4 01 0.3 Of 153 women (5.5 per cent.) who were primiparae, only six were primiparae over 30 years of age. Several maternity hospitals in London do not regard primigravidae under 30 years of age as a priority group because of the demand for beds. A total of 410 women (14.7 per cent.) were para 4 and upwards and should have been confined in hospital. The figures were similar in cases attended by L.C.C., D.N.A., and hospital district midwives. All midwives are instructed to advise women para 4 and upwards to book a hospital bed. Table (x)c shows that in fact a third of these women were offered hospital confinement. The remaining 263 women, para 4 and upwards, who were not confined in hospital may have refused, may have been booked by doctors for maternity medical services before they were interviewed by the midwife or may have attended for the first time too late to book a hospital bed. 146 Table (x)c—Offer of hospital confinement by parity Parity Total confinements Hospital offered Per cent. 0 153 40 260 1 958 72 7.5 2 814 54 6.6 3 422 46 10.9 4 410 152 36.6 and over 2,757* 364 13.2 *Excludes eight cases in which parity was not stated. The Cranbrook Report The Maternity Services Committee was appointed under the chairmanship of the Earl of Cranbrook in 1956 to review the organisation of the maternity services in England and Wales, to consider what should be their content and to make recommendations. Their Report was published in 1959. In recommending that the tripartite structure of the maternity services should be retained the Cranbrook Committee stated that the real problem crystallised into one of co.operation and co.ordination between individuals providing the maternity services. In the early years of the National Health Service the number of domiciliary confinements in London booked by general practitioners for maternity medical services was low. In 1956 it was only 26.6 per cent. of all home deliveries. However, the Council's policy is summarised in a recommendation (360) of the Report—" A general practitioner obstetrician and a midwife should be booked for every domiciliary confinement and there should be close co.operation between them." In 1960, 60 per cent. of home confinements were booked by doctors, and it is expected that this figure will be increased during 1961. The Council has introduced forms by which doctors booking cases for maternity medical services inform the midwife of their intentions in regard to ante.natal care and attendance at the confinement, and may ask for blood tests. In 1958 the Council introduced a patient's personal record card which the mother carries herself, the card provides not only a means of interchange of information between doctor and midwife but also, if need arises, a clinical record readily available to the hospital. At its best, however, co.operation should extend to joint ante.natal care by doctor and midwife. To this end the Council arranged in the last few years, as an interim measure pending the publication and implementation of the Cranbrook Report, for 18 midwives to attend ante.natal clinics in doctors' surgeries. There were limitations to further expansion of the scheme, there being five times as many general practitioner obstetricians as domiciliary midwives in London, and the distribution of a doctor's practice, spreading out like spokes of a wheel involving a number of midwives areas, made it difficult and sometimes impossible to meet all demands. Holidays, sickness, attendance at refresher courses, and normal off.duty time, reduce the amount of time the midwife is available, and further improvements in conditions of service, e.g. one weekend off duty per month, have to be considered; in the past many midwives had to be content with mid.week off.duty periods only. Finally the Cranbrook Report itself made it clear that a fresh start would be necessary. Free facilities will be offered general practitioner obstetricians at Council clinics and the number of places where midwives attend will be reduced thereby. This will shortly be the subject of discussion with the Local Medical Committee. All this will mean a gradual change from the existing pattern and will have the merit of extending these facilities to all general practitioner obstetricians. In division 6, doctors from four practices form a rota 147 K to cover three of the Council's ante-natal clinics and provide a night and weekend ' on call' service. This particularly successful scheme is described by Dr. F. R. Waldron, Divisional Medical Officer, division 6, in his report (page 132). Plans to promote the fullest co.operation with general practitioner obstetricians are being discussed with the London Local Medical Committee. Hospital services In London, 83 per cent. of births took place in hospital during 1960, a proportion in excess of the national average of 70 per cent. recommended by the Cranbrook Committee. Maternity beds in London are provided by teaching and non.teaching hospitals, 44 maternity units providing a total of 2,153 beds: (i) 17 teaching hospital maternity units (894 beds) are administered by 14 Boards of Governors. (ii) 26 hospital units (1,249 beds) are administered by 16 Hospital Management Committees which are responsible to the four Metropolitan Regional Hospital Boards. (iii) One hospital (10 beds) 'disclaimed' by the Minister of Health has operated outside the National Health Service since its inception. The Cranbrook Committee recommend that local maternity liaison committees with a professional membership should be formed to ensure that local provisions for maternity care are utilised to the best advantage. These committees had been preceded by meetings held in 1956 on the advice of the Minister of Health to discuss the Memorandum of the Standing Maternity and Midwifery Advisory Committee on ' Ante.natal Care Related to Toxaemia.' Local maternity liaison committees have now been set up by all Hospital Management Committees and most Boards of Governors. It has long been the practice in the county for health visitors or midwives to make home visits to mothers seeking a hospital bed on social grounds, and to report on the suitability of the home for domiciliary confinement. When requested by hospitals, health visitors also follow up patients who fail to attend hospital ante.natal clinics. Local maternity liaison committees have discussed means by which health education and mothercraft training can be made available to all expectant mothers. Some hospitals now refer mothers to the Council's centres for this purpose and display posters provided by the Council in their own ante.natal clinics. Some hospitals refer mothers booked for hospital delivery to the Council's clinics for intermediate ante.natal care. The patient's personal record card, first introduced to aid co.operation between general practitioners and midwives, is now also used as a clinical record by the hospital and the Council's clinics. Maternity liaison committees have also tried to improve local arrangements to ensure a proper selection of mothers for hospital confinement. In some parts of the county, however, in particular in the north.west, divisions 1, 2 and 3, there is a growing problem which harasses everyone engaged in the maternity services. General practitioners, as well as doctors and health visitors in the Council's clinics, may be unable to book a hospital bed for women who need hospital delivery on grounds of age, parity or social conditions, if such women attend for ante.natal care for the first time during the second half of pregnancy. The older multiparous woman tends to seek ante.natal care late in pregnancy and is herself often unaware that she is unsuitable for home confinement. Moreover, in Northwest London, social conditions are often particularly unsuitable for home confinement. A number of main line railway stations bring immigrants and temporary residents, including unmarried mothers, to this neighbourhood, where many of them find accommodation in lodgings or boarding houses. 148 A procedure has been agreed with the Local Medical Committee to help such women. The general practitioner is asked to undertake the ante-natal care of the mother and, if no hospital bed can be found during her pregnancy, to visit her when in labour to arrange for hospital admission through the Emergency Bed Service. If the patient's doctor does not undertake maternity medical services and a general practitioner obstetrician cannot be found to give these services, the mother is given ante-natal care at the Council's clinics and a domiciliary midwife attends her when labour begins to arrange for her removal to hospital; the Emergency Bed Service cannot remove the patient to hospital until she has been examined by a doctor or midwife. Dr. W. G. Harding, Divisional Medical Officer, division 3, has analysed 100 such cases arising in his area. (See page 125.) The number of maternity cases removed by the Emergency Bed Service in 1960 was the highest yet recorded. Table (xi)—Maternity cases removed to hospital by E.B.S. 1958 1959 1960 1,125 1,433 1,767 Table (xii) shows the number of maternity cases admitted to hospital by the Emergency Bed Service in each division from April to September, 1960. The cases are divided into those admitted as emergencies and cases for whom maternity beds could not be found during pregnancy. It will be seen that over half of the latter arose in divisions 1, 2 and 3. Table (xii)—E.B.S.—Maternity cases removed to hospital, April-September, 1960 Month Total cases Emergencies Unable to book Divisions Total 1 2 3 4 5 6 7 8 9 April 175 49 27 32 22 5 1 2 17 7 13 126 May 164 36 24 40 25 4 - 7 12 2 14 128 June 157 39 34 23 17 6 - 2 16 3 17 118 July 189 58 30 38 18 2 - 2 22 4 15 131 August 128 38 22 17 15 2 - 1 17 2 14 90 September 136 37 34 24 10 3 - 2 10 3 13 99 Totals 949 257 171 174 107 22 1 16 94 21 86 692 This situation cannot be attributed to any single factor but is influenced by conditions arising from the pattern of the hospital maternity services in London. In divisions 1,2 and 3 there are 1,018 hospital maternity beds of which 626 (61 per cent.) are in teaching hospitals. The policies of these hospitals are influenced by their major function of undergraduate and post-graduate training, and they may of course draw patients from any part of the country. The non-teaching hospitals on the other hand primarily serve the needs of the community in which they are situated, though in London these hospitals, too, have no responsibility laid upon them to admit all cases requiring a hospital bed from a defined catchment area. In these circumstances it is not possible for hospital obstetricians to decide when the needs of all patients in priority groups have been met. Hence some of them make available a proportion of their beds without question to mothers who attend in the early weeks of pregnancy and only then allocate the remaining beds according to need. In London the proportion of maternity beds compares favourably with that in many other parts of the country. It is unlikely, therefore, that an increase of maternity beds to 149 K* 150 accommodate all confinements can be expected for some considerable time. A possible alternative is the early discharge of mothers (48 hours) for maternity nursing in their own homes. With the present establishment of midwives, whose case load is already high, it would be impossible to undertake these increased duties on any large scale. Experimental schemes have, however, been started together with four hospitals in divisions 1, 2, 7 and 8, where four midwives with long service with the Council are now engaged in this work, which relieves them of irregular hours and night duty. However, this work has no wide appeal to practising midwives. Mothers are selected during pregnancy for early discharge. The midwife makes a visit to assess home conditions and where these are suitable gives the mother a co-operation card which serves as the patient's clinical record. The hospital invites a general practitioner obstetrician to undertake the intermediate ante-natal care and to supervise the puerperium. Some of these mothers have been unwilling to forego hospital care during the lying-in period. Others may resent an arrangement by which they forfeit the home confinement grant although they must face some expenses which the grant would normally cover. Many require hospital confinement on social grounds and their accommodation is unsuitable for nursing the baby in the early neo-natal period. A preliminary review of the experimental schemes shows that in spite of the most careful selection by the obstetrician of cases for early discharge more than one-third of the mothers are found to be unfit to go home on the second day. It is to be remembered that the Cranbrook Committee recommended 10 days lying-in period in hospital. The present domiciliary services in London have been developed to provide a comprehensive maternity service for less than 20 per cent, of the total births in the county. Any extensive changes with the aim to secure early discharge from hospital would tend to overwhelm the services and to prove unpopular with midwives. It seems, therefore, that the problem requires much further consideration and understanding on the part of hospital services, general practitioners and the Council alike. 151 APPENDIX B THE SCHOOL DENTAL SERVICE—A NATIONAL PERSPECTIVE By virtue of section 80 of the Education Act, 1921, a statutory obligation was placed upon local education authorities to provide dental treatment for children attending elementary schools. The service was also permissive in higher education establishments and other schools. Ten years earlier, however, the London County Council had entered into an agreement to conduct an exploratory treatment service at two institutions to provide dental treatment for 6,000 children for a period of one year ' with a view to accumulating experience as to how best to deal with the matter ', the ' matter ' in this case being the generally acknowledged shocking state of dental disease amongst schoolchildren. Prior to the Council's exploratory service the deplorable state of children's mouths had been frequently commented upon in many knowledgeable quarters. From its incorporation in 1880 the British Dental Association has pressed persistently for greater dental care for children. Mr. W. M. Fisher, a dentist of Dundee, is credited generally with being the first individual pioneer in this field. He carried out in 1885 the first recorded detailed examination of the teeth of a number of schoolchildren, and first published results emphasising the urgent necessity for regular examination and treatment. The deplorable dental dilapidation amongst young recruits was commented upon strongly by many recruiting and medical officers at the time of the South African War, but not until Dr. William Hunter of Charing Cross hospital showed scientifically that dental disease is not entirely a localised disability, did officialdom begin to sit up and take notice. Hunter insisted, as had many dentists for many years previously, on the importance of oral hygiene in general preventive medicine. He affirmed that oral sepsis is a predisposing or causative factor in many systemic diseases and that through an infected blood stream oral sepsis may set up secondary infections in parts of the body remote from the mouth. The acceptance of these views by the medical profession in general and the quite obvious discomfort, disfigurement and distress of so many patients led, throughout the first years of this century, to a steady awakening to the need for proper care of the mouth if health is to be preserved. The Borough of Cambridge led the way in 1908 by setting up the first local authority dental clinic in this country. The medical and official recognition of the undermining of health by dental disease left three obstacles to be removed before there could be acceptable alleviation of the trouble: (i) the cost of the service required, (ii) staff to render the service, and (iii) the overcoming of public apathy—not' ignorance '— for with the widespread prevalence of dental disease there are few people so fortunate as to have escaped a personal realisation of the inconvenience—if nothing more—of dental disease. 'When fevers burn or agues freeze us Rheumatics gnaw or colics squeeze us Our neighbours' sympathy can ease us Wi' piteous moan But thee! thou Hell o' a' Diseases! They mock our groan ' So wrote Robert Burns: the italics are the writer's. Money was forthcoming, staff (at least in early days) was forthcoming but—' They mock our groanTherein lies the clue to the stubborn apathy of the public. Many diseases, apart from so-called ' killer' diseases, have the shadow of tragedy and suffering suspended over them, but dental disease, except sometimes to the actual sufferer, is frequently the butt of the wit (or the half-wit). ' They mock our groan ', but to the sufferer dental disease may indeed be the' Hell o' a' Diseases 152 More people, even now, seek the dentist's aid for the alleviation of pain, or the satisfying of personal vanity (where a noticeable gap in the front of the dental arch occurs), than do those with any realisation or intention of positively safeguarding their general health. Why should this continue to be so—albeit perhaps less so—up to date ? Perhaps because artificial substitutes for the natural teeth have been so successful; has the substitution led to indifference to the premature loss of the natural teeth? Certainly all dentists have met the patient who states he had no peace until he lost all his own teeth and acquired an artificial set! Has the school dental service been so successful in the virtual abolition of obvious gross dental defects from schools that this very improvement bolsters the contention that the school dental service, as given to children to-day, is excessive? Must we have children's mouths neglected until pain supervenes and distress is obvious to all before the aid of the dental practitioner is sought? To all of these questions I would say, it would seem to be so. In spite of some measure of success in reducing obvious distress and in providing artificial substitutes, dentists and dentistry are still, none the less, in some quarters second only to mothers-in-law as so-called comic material. The public appreciates the doctor but to many the dentist is merely a bore; yet he plays an essential part in maintaining public health. Amidst this cavalier attitude by the public towards their own dental well-being, the dental profession and officialdom strive to improve and build the public's health. In the past 50 years the public conscience has been aroused successfully to produce social revolutions in sanitation, in personal bodily cleanliness and in the personal care of skin, eyes, ears and hair, but not yet in the personal interest and care of the inside of the mouth and of the teeth. Lipstick for the girls and beards for the boys are apparently more important than toothbrushes for the toddlers. Attention is given to the outside of the mouth but the inside may literally stagnate. In 1911, in connection with the Council's exploratory scheme already mentioned for dental treatment of children, lectures on dental hygiene were given in five schools in the vicinity of each of the two treatment centres by one of the assistant medical officers and general information on the care of the teeth was disseminated amongst teachers, parents and pupils by means of pamphlets, etc. ' Lectures and pamphlets, etc.' have continued in ever-increasing volume each year since then, but have, in the main, aimed rather at dental education than at overcoming apathy. It is indifference and procrastination, not ignorance, that is the trouble. Dental health propaganda might be more effective were it in the form of simple advice on maintaining personal oral cleanliness, rather than education on how the decay spreads in a tooth, or dismal dissertations on ' dental' diet! A widely publicised slogan such as ' Have a clean mouth and a frequent dental check-up ' and a lucid explanation of how and where to get assistance, rather than why treatment should be obtained, might be more effective than have been all the lectures and pamphlets so far produced. To recommend diet changes, which mean a social revolution at the domestic table and in the public restaurant—to say nothing of between meals and school tuck shops—is to flog a dead, or at least an unwilling, horse. Dentists and dentistry become even more unpopular when the advocated dental diet—not followed even by dentists themselves—is found by individuals to be apparently quite unsuccessful in preventing their teeth decaying—even though it may be proved scientifically to reduce the extent or virulence of the disease. But a simple slogan, e.g., ' Have a clean face, outside and inside' is easily accepted, and if acted upon would do much to remove from the teeth the damaging stagnation of any food—sweets included. The stagnation in the mouth, not the food, is the danger—cleanliness is the cure. Advice on caries prevention must be as easy of assimilation as is 2 p.p.m. of sodium fluoride in drinking water, with the same end in view, namely the reduction of dental caries without the necessity for a social and dietetic revolution. So far nearly all the effort, thought and expense of a dental health programme has come from vested interest sources. Dentists and manufacturers of dental toilet requisites have produced nearly all the manpower, the ideas and the money. Contributions to the effort 153 from other sources have been relatively small. An annual practising (registration) fee is collected from dentists by the General Dental Council (formerly Dental Board of the United Kingdom), and a portion of the sum collected is expended on dental health education material. This in turn is distributed free or at low cost to public bodies interested or involved in dental care programmes. In like manner some industrial organisations set aside sums of money to expend on the same objects, a few actually producing quantities of posters, films, etc., many of them of a very good and expensive standard. Such activities from the dental profession and manufacturers, while highly praiseworthy, may possibly be suspected by some people as a measure of self interest, and it could be said that the task of overcoming public apathy to dental care is one to be tackled by the Government, as has been the case in other fields of preventive medicine. True, an advisory and co-ordinating committee on dental health education has been set up by the Ministry of Health, but this committee has no fund at its disposal and no remit to produce anything except comment. Were the Government prepared to embark on a widespread drive to alert the public, particularly young people, to the advisability of having clean mouths, much money and effort might be saved ultimately in the National Health Service. Some changes in the present general dental service organisation would be required to produce a better children's service, by diverting dentists' efforts to treatment for the younger section of the community. The main change necessary to achieve this end would be the curtailment of the free or assisted National Health Service to persons above a certain age, as is done, for instance, in New Zealand, where all persons over 16 years of age pay for their own dental treatment, thus intensifying the drive on children's dental care which, under 16, is free in that country. It is not, however, suggested that this change would be a popular one! In the initial planning and organisation of the dental section of the National Health Service, emphasis was placed by all concerned, and particularly by the dental profession, on the advisability, nay necessity, of establishing first a ' priority dental service ' for mothers and children. The decision was taken, however, to have as part of the National Health Service a comprehensive dental service for all. This decision was pressed forward in spite of the warnings of the dental profession that the number of dentists available was not sufficient to meet the foreseeable demand. A ' priority dental service ' was included in this comprehensive service and the duty of administering this most important section of the dental service was placed upon local health authorities. The Ministry of Health undertook the administration of the general dental service and of the hospital dental service and by offering to the dental profession remuneration on a scale of fees basis, an average aggregate far beyond salaries payable by local authorities, satisfactory recruitment for the priority dental service became virtually impossible. In the free-for-all for staff local health authorities cannot, without disrupting their entire salary and wage gradings, compete with the Ministry of Health and in the free-for-all for treatment, adult patients on higher scale of fees are more likely to be successful in obtaining it than are children for whose treatment payment is often less. The ' school dental service', which had been in steadily expanding existence prior to the advent of the National Health Service, suffered grievously after the appointed day (5 July, 1948) while a priority dental service for expectant and nursing mothers and for pre-school children failed to materialise. Local health authorities to-day, if they are able to run any dental service for mothers and pre-school children, do so in an extremely meagre form. The ' priority dental service' so far has gone, with other good intentions, to help pave that famous road; if in fact it has not already arrived at the road's termination. At the time public dental schemes, particularly those for schoolchildren, were initiated, two factors were present, widespread obvious gross dental neglect and the personal cost involved in seeking private treatment. Against that background a strong and relatively efficient school dental service was growing and working; working so effectively that, in the years immediately prior to 1948, in many schools grossly neglected mouths and acute dental distress had been virtually eliminated. Frequent dental inspections were carried out by dentists, followed in the vast majority of cases by treatment of the children found to be 154 unfit dentally. At first in some areas treatment was concentrated on extractions of teeth and cleansing of the worst mouths but in the better services, as money and staff became available, treatment was extended to embrace a growing measure of conservative treatment. The ratio of teeth conserved to teeth extracted is a fairly reliable indication of the efficiency and quality of the dental service offered. In a proper service the number of teeth extracted should be small indeed in comparison with the number conserved. The factor of personal cost to meet a dentist's bill was a potent one in deciding parents to accept' clinic ' treatment and much benefit accrued to the children. In early days there was substantial opposition to acceptance of ' fillings and it is due largely to the advice and persuasion of the earlier school dentists that this opposition has been almost completely eliminated. Dental care, as distinct from mere dental treatment, began to loom up as a probability—preventive treatment rather than mere pain relief—and many local health authorities planned to expand their dental services on which the public were making everincreasing demands. In 1948, however, the second part of the background changed. Most private dental surgeries quickly became nominally ' free ' treatment centres under the National Health Service and the financial barrier to treatment fell. Increasingly large numbers of patients clamoured for dental attention. The forebodings of the British Dental Association were realised. Dentists were swamped. Many patients were requiring and requesting artificial dentures and there was little possibility of relatively unremunerative child patients displacing valuable adult ones. At first all treatment was free but later (to curb demand and perhaps prevent abuses) measures were introduced by which partial cost was borne by the patient. These measures slowed down general patient demands, reduced the demand for artificial dentures and increased the amount of conservative treatment given. This did little, however, to divert dentists' efforts to children's needs; the younger children, at least, still being unremunerative in comparison with their elders. It should also be noted that while some aspects of children's dental treatment may be regarded in some quarters as ' easy ', the handling of children and the persuasion and enlightenment of mothers needs much time, skill and patience. Few general dental practitioners have the experience and aptitude of the school dental service careerist. Many dentists advise parents to continue to seek dental treatment for their children at the ' school clinic '. Alas! in many quarters where formerly there had been an efficient clinic staffed by an experienced school dentist they found the dentist gone and a closed door. The school dentists left in large numbers to join their professional colleagues in National Health Service general practice. Since 1948 the background against which local health authorities struggle to maintain a school dental service—as struggle they must since the obligation to do so is laid upon them by statute—the background has changed. Comparatively little obvious dental distress remains in the schools. Personal cost is no longer an obstruction to obtaining treatment, but a new factor has arisen. In former days parents in many instances accepted readily dental service for their children at the school treatment centre when, following an inspection at school, they were notified that treatment was required. Now that alternative sources of free treatment are available elsewhere, many parents indicate that they intend to seek treatment ' privately'. No doubt the intention is honest and is carried out properly by many parents, but unfortunately it is also a fact that many parents carry their intentions no further than speech. Treatment at the school clinic is evaded and is not replaced by early treatment elsewhere. Children are neglected dentally until pain supervenes, when extraction is usually the sequel. The number of extractions is rising again in the school service and conservation work is falling. Dental inspection of the children in schools is growing increasingly abortive so far as subsequent early treatment is concerned and inspections are growing less frequent and less systematic as staff dwindles. Children's dental care falls between the two stools of organised school dental service and parental intention to have treatment' privately '. The sooner the two stools are re-fashioned to form a solid structure the better. All children should have a regular 155 systematic dental check-up followed by any treatment necessary; that in turn should be followed by revisional checks and treatment if their developing mouths are to be aided to grow to healthy maturity. Parents desirous of looking after their child's dental health properly should strive to have their child accepted for regular dental treatment at either a school treatment centre or a private surgery. In the preceding sentence ' strive' may be the operative word. Private surgeries may be unable owing to pressure of work, or unwilling for a variety of reasons, to accept a child patient and a school treatment centre may be unable to offer regular dental attention because it has too large a school population for its limited resources. Most local authorities adopt a policy of a spreadover service for all their schools, which policy is dependent for its efficiency and effectiveness mainly upon the dental staff available. However necessary such a policy of spreading the butter' may be for political, financial or administrative reasons, it is most unpalatable professionally. Where staff is far below professional requirements, resultant patient-staff ratios render proper professional attention impossible for large numbers of patients. The service becomes one of haphazard treatment, much of it pain relief only, instead of systematic dental care and inspection of a number of patients within the potentiality of staff available. The computation of the potentiality of a full time dental officer is simple if the assumption is accepted (in fact an over-simplification and an under-statement) that on average a child can be kept dentally fit by the expenditure of one hour's professional dental attention per annum. As full-time dental officers with local health authorities under Whitley Agreement organisation function for 33 hours per week and have approximately five weeks holiday per annum, working hours per annum are 1,551. On the assumption advanced, a full-time dental officer's potentiality is about 1,500 children per annum. The figure is supported by the British Dental Association and the reports of many experienced dentists. In reply to a question in the House of Commons in 1952, the Minister of Education indicated the desirability of achieving a standard of 1-3,000, which was subsequently endorsed as ' reasonable ' in a report of the Chief Medical Officer to the Ministry of Education (Health of the School Child, 1954 and 1955). One must assume that the anticipation was that approximately 50 per cent, of the 3,000 would not attend the school treatment centre, but would seek dental attention elsewhere. This standard was accepted by the Council, which in 1952 laid down as its official policy to aim at a ratio of one full-time dental surgery for each 3,000 children of school population. In the Council's nine health divisions the policy gun was aimed and may even have been fired, but in no division has the target been hit. Present average staff-patient ratio for the county stands at 1-6,800. The disparity is even more ridiculous in many other local health authority dental services. The result of such a meagre spreading of ' dental butter' is that when children are rendered dentally fit, sometimes after a lengthy and expensive course of treatment, they are returned to school to wait far too long a period before there is hope of another official dental check. Without revision within not more than twelve months of the work carried out, much of the dental treatment given to children is unlikely to prove successful. In many instances long neglect between treatments must lead to dissatisfaction with and distrust in the treatment already given. It is thought that the lack of proper revisional treatment facilities does more to drive dental surgeons away from children's work in local health authority treatment centres than does the factor of differences in remuneration. No dental practitioner of quality could view with equanimity and complacency the prospects of attempting to give a service to six or seven thousand patients per annum, particularly when a good and co-operative patient is denied revisional treatment until perhaps two or three years have elapsed. A means will have to be found by which co-operative patients receive a much higher standard of treatment when their dental well-being is entrusted to the school dental service. Dentists are trained as individualists and to treat conscientiously the individual patient. Few dentists apparently gain much satisfaction from contributing to the 156 preliminary clearance of gross and general dental disease from large masses of patients, which is all that has been done so far for the school population. To meet the day-to-day haphazard demand for treatment is not of itself sufficient to produce dentally fit school leavers. Caries incidence is very high in schoolchildren and only a limited number of children can be cared for properly by limited staff. If the children of this country are to receive proper dental attention, there will have to be much fuller use of the general dental service on their behalf by their parents and the general dental service will have to be re-organised to meet such need; while the school dental service will have to be reorganised to give better attention than previously to the patients and children who trust themselves to that service. In a school dental service the location of treatment centres is of paramount importance. The generally adopted method at present of area clinics with potential patients in surrounding schools would appear to be out-moded. School-time loss and parental escort problems militate against attendances and many opportunities for treatment are lost and much administration effort is wasted by rejected or broken appointments. If, as far as possible, surgeries were housed in schools, dental education on prevention and reparative treatment could be given on the spot, with the minimum interference with the school curriculum and the maximum use of the dental staff and equipment. Frequent dental inspections or classifications of children en masse are anachronisms: by abandoning them much time could be saved for all concerned. Every child should have a regular check up, which could be carried out so easily with proper instruments and under proper conditions if the surgeries were located in schools. Mothers, so many of whom in addition to their domestic work are employed elsewhere, would be relieved of the problem of seeking ' time off'—not to mention the probable loss of earnings. An overall shortage of dentists has been repeatedly advanced as the causative factor in the inadequate service still given to children in dentistry, but the overall shortage is true only because priority of planning and consideration was given to producing a general service instead of the priority service for mothers and children. In the overloaded ship of dentistry the cry of' women and children first' should have been honoured! To combat the alleged overall shortage of dentists the Government has embarked (September, 1960) on an experiment, in conjunction with the General Dental Council, in utilising specially trained dental ' auxiliaries'. To train a dentist takes about five or six years and the intention of the experiment is to train girls as auxiliaries in two years. It is intended that after training they will be utilised by local health authorities to provide certain treatments under supervision for children. The idea is based on the assumption that much of children's dental treatment is ' simple ' and that, with specialised training in that section of the work, these girls will be beneficial to the local health authorities' under-staffed dental services. Unfortunately, the girls' operational activities are restricted by law and in many mouths they will therefore be unable to give all the treatment required. Who is to be available to complete the presumably ' difficult' dentistry is not yet clear, nor is it clear how the differing proportions of ' simple' and ' difficult' can be reconciled with the time, accommodation and staff factors involved. The practical application of partly trained dental operators restricted by law will present many problems. The experiment is under the direct guidance of the General Dental Council and is patterned largely on the New Zealand Dental Nurse Organisation where ' dental nurses' treat schoolchildren. These New Zealand nurses concentrate their efforts on the lower age groups commencing at age 2\ and are confined to a staff-patient ratio of 1-500. As there are not sufficient nurses at this ratio to cover the entire school population in New Zealand, older children who are not reached by the dental nurses are farmed out to local general practitioners who receive 157 government remuneration for their routine services for these patients, all of whom are under 16 years of age. The cost of appliances and/or specialised treatment is borne by the parents (for example, orthodontic treatment is not available free). In New Zealand the cost of all dental treatment over the age of 16 years is borne by the patient—it is not State-aided—a difference in the ' National' dental service in Britain and New Zealand surely not less important than the utilisation of dental nurses or auxiliaries. In New Zealand the efforts of most dental practitioners are deliberately deflected or attracted to treatment of the under 16's on a State-paid scale of fees basis. Treatment, mainly for the younger children, is also available in many schools at the hands of dental nurses. In Great Britain at present the attraction or deflection of general dental practitioners is towards the adult section of the general public and most dentists are so busily employed undertaking work for these patients that relatively few children can gain access to their surgeries. Parental apathy produces at some school treatment centres only a meagre acceptance of or demand for treatment and gives a false picture of sufficiency of dental services, which is construed by the unenlightened or complacent as a satisfactory state of dental affairs. The mouths of the rising generation, although for the present probably free of gross dental faults, are riddled with dental caries which, if left untreated, will lead to heavy demands on the general dental service in the not too distant future, as well as to an undermining of the younger people's health and efficiency. If the experiment now under way in this country to train dental auxiliaries for two years and then utilise them in the dental treatment of children is pronounced successful and their use in the local health authorities service of the future is contemplated, it will be necessary, in addition, to make drastic changes in the present general dental service organisation. Many more dentists than are at present forthcoming will still be required to undertake ' difficult' treatments in the mouths of children whom the auxiliaries have been unable to render completely dentally healthy. It is quite erroneous to assume that dental auxiliaries could supplant dental surgeons in the school service. Auxiliaries could in fact give support only if the dental surgeons are prepared to undertake deliberately only the more ' difficult' work and to accept the results of the auxiliaries' efforts. Much will depend on what is intended exactly by the auxiliaries' working under the supervision and direction of a registered dental practitioner' as laid down in the experiment now being conducted. A similar form of assistance with ' easy' dental work was tried out a few years ago by the training and use of dental hygienists who, like the now intended auxiliaries, were restricted in the scope of their treatment by law. The hygienists were permitted in their operative work only to scale and clean teeth. In clinic services, such as are run by local health authorities for a widely spread catchment area, it was soon found that from the hands of the hygienist came a stream of' clean ' but otherwise untreated mouths for which necessary further treatment was frequently not available owing to shortage of dentists. A dentist could not keep pace with a hygienist. Her output of patients still to be rendered dentally fit required the additional services of six or seven dentists; as had in fact been established in the Royal Air Force dental service where the use of hygienists originated. Hygienist services in civilian fields have been found useful in hospitals where their assistance in the general hygiene of bedridden patients—as well as perhaps with specific dental patients—sometimes justifies their employment. The contemplated use of dental auxiliaries is an improvement on the concept of the hygienist, but until there is further definition of' simple ' and ' difficult' work in children's mouths it is not possible to foresee how a dentist (supervising) can keep in step with his auxiliary or auxiliaries. Year after year since 1948, against the complex and changing background of dental effort and experimentation, local health authorities have struggled to keep alive their dental service and to make effective their various policies aimed at the ultimate provision of a comprehensive and efficient school dental service, but in very few authorities have they been able to even maintain their pre-1948 level. 158 In a very few areas the Ministry of Education ratio of 1-3,000 patients has been almost reached but the national average attained is in the region of 1-6,500—an impossible ratio if proper dental attention is to be given to children who attend a school dentist. In some areas ratios of 1-20,000 and upwards prevail, but such disproportion is not in dentistry really more absurd than is the present average of 1-6,500. Any ratio beyond the potentiality of an operator must result in indifferent or even bad dentistry for at least some of the patients who seek his aid. If the spread-over policy is adopted—that is, no revisional treatment for those already treated until all others have had their chance—the probability is that most patients who attend will be misled and served badly. The potentiality of a dental operator in a given time must be recognised and acknowledged if the patients he treats are to receive sound attention. Proper professional dental care is unlikely to be available to many children in this country until all trained dental personnel is mustered, until (possibly) dental auxiliaries and school dental officers are restricted to a proper professional ratio of patients, and the resources of the general and private dental practitioners are tapped to ensure that they will be deflected also in large part to serve that section of the public which the British Dental Association and other knowledgeable bodies have advised require priority, namely, the mothers and children. 159 APPENDIX C Statistics of the administrative work carried out by the Metropolitan Borough Councils in 1960. Borough DWELLING S CLEARANCE AREAS DWELLING HOUSES AIR POLLUTION CLEANSING AND DISINFECTION LICENSED OR REGISTERED PREMISES PUBLIC HEALTH INSPECTORS Erected by Borough Council Erected by other persons Total number in the Borough Inspections Repaired as a result of informal action Defects remedied after service of formal notice Houses closed in pursuance of owner's undertaking Demolition Orders made Persons displaced Closing Orders made in lieu of Demolition Orders Persons displaced Closing Orders determined Closing Orders revoked and Demolition Orders made Houses demolished as a result of formal or informal procedure Persons displaced Rooms closed Undertakings accepted Water supply provided to tenement houses Complaints Observations Intimation notices served Nuisance notices served Prosecutions Smoke Control Orders confirmed Adults cleansed Children cleansed Premises disinfected Premises disinfested Establishment Employed at end of year Assistants employed at end of year Unfit houses Other houses Initial visits on complaint With a view to action under Part 11 of the Housing Act, 1957. Other reasons Re-inspections Licensed slaughterhouses Other offensive trades Dairies and milk shops Ice cream premises Common and Seamen's Lodging Houses Public Health (London) Act, 1936 Housing Act, 1957 Underground rooms Other rooms Underground rooms Other rooms At home At cleansing station Demolished Persons displaced Demolished Persons displaced Male Female Total Male Female Total By owners By local authority By owners By local authority Made fit for occupation by number of families accommodated O vercrowding abated Number Persons displaced Number Persons displaced Number Persons displaced Number Division 1 Chelsea 12 16 16,441 — — — — 657 - 5,409 7,743 98 28 - - - - - - - - - - - - 1 2 1 - - - - - - 2 24 14 - - - 1 - 85 39 204 304 - - 46 123 - 9 6 2 8 - - - Fulham 449 18 29,796 33 86 — — 1,800 256 12,174 8,219 - 861 20 — — — 1 — - - 3 16 7. - - - 2 1 - - - - - "2 16 1 187 - - - 1 - 76 9 84 694 - - 123 228 - 16 12 1 13 3 — 3 Hammersmith 99 — 28,191 10 29 — — 2,574 — 2,029 4,134 1,058 382 26 - - - - - - - - - - - - - 1 - - - - - - - 63 139 4 - - 1 - 383 168 11 725 - - 128 357 - 11 7 1 8 1 — 1 Kensington 106 258 40,794 21 197 — — 2,631 625 4,516 18,319 616 378 16 — - 1 — — 9 37 3 49 — — — — 35 25 — — - - 1 3 21 32 1 - - 1 6 1Q5 514 111 1,181 - - 715 360 - 14 12 - 12 2 - 2 Division 2 Hampstead 27 55 23,702 — — — — 835 132 12,826 11,250 725 104 2 6 - - - - 4 - - - 2 5 6 11 - - 2 6 37 211 - - - - 10 - 124 350 - - 65 259 - 13 12 - 13 2 1 3 Paddington 32 128 38,215 — 123 — — 3,313 264 4,305 21,306 814 267 1 — — — — — - — 1 4 129 - - - 200 45 17 - - - - 18 30 86 11 5 - 1 39 86 9 63 714 - - 137 224 - 17 13 1 14 3 - 3 St. Marylebone 84 116 24,623 — — — — 743 467 472 2,739 328 58 2 — — — 6 — - - - - 19 - - - 4 7 - - 2 - - - 144 53 1 - - 1 - 466 155 65 188 1 - 89 196 2 15 12 3 15 - — - St. Pancras 160 — 29,129 12 34 — — 3,249 134 1,325 9,670 1,193 968 79 — — — — — 5 - 6 - 37 - 4 - 87 - 4 - - - - 79 52 69 - - - 1 - 768 256 339 448 - - 229 610 - 18 16 1 17 — — — Westminster, City of — 224 27,642 — — — — 761 136 2,809 5,811 272 7 - - - - - - 1 1 — — 11 — - — 12 28 6 23 - - - - 53 897 3 - - 1 - 717 9 714 611 - - 121 234 2 20 15 - 15 3 - 3 Division 3 Finsbury 240 101 9,980 3 103 — — 920 23 3,967 7,072 556 31 5 - - - - - 2 3 10 30 - - 1 - 11 - 1 - 1 - - 3 19 419 - - - - - 89 109 191 158 - 1 128 170 1 10 6 - 6 2 - 2 Holborn 142 3 6,016 - - — — 77 102 2,679 1,155 78 3 - — — — - - - - - - - - - - 5 - - - 4 - - - 41 405 1 - - 2 - 92 - 33 82 - 5 73 134 2 5 5 - 5 - — - Islington 221 234 46,547 14 14 — — 4,038 239 2,791 15,195 2,522 951 40 — — 3 — 3 3 2 52 259 63 1 18 - 41 93 10 52 - - - 18 40 457 56 - - 2 83 186 455 775 1,509 1 11 350 555 - 34 23 2 25 3 — 3 Division 4 Hackney 445 91 40,969 — 2 — — 2,740 213 11,353 19,763 111 1,206 37 3 1 — 8 — — — 1 3 12 - 1 - 137 80 15 15 - - - - 149 1,075 1 1 - 1 - 51 85 626 361 - 5 221 436 1 20 20 - 20 6 - 6 Shoreditch 205 30 11,865 38 11 8 12 1,641 109 4,683 5,203 903 132 — — — 1 1 1 20 54 5 14 - — 27 88 23 — — — 4 — 1 5 25 661 4 - - - - 7 - 47 733 - 1 88 122 - 9 6 - 6 - - - Stoke Newington 94 34 12,018 — — — — 1,312 — 1,134 3,670 220 151 4 - - - - - - - 1 5 7 - - - 3 - - - - - - - 31 54 - - - 2 - 19 4 58 86 - - 52 119 - 7 6 - 6 2 - 2 Division 5 Bethnal Green — 53 15,243 31 48 — — 2,037 294 5,550 6,242 1,077 453 8 — — 1 2 — — — 8 — - — - - 5 - 10 - - - 1 - 28 21 11 - - 1 173 68 6 - 580 - 2 95 142 - 9 7 - 7 3 - 3 City of London — — 1,006 — — — — 6 — — 10 — — — — — — — — — — - - - - - - - - - - - - - - 11 8 § § § § - 743 - 3 22 - - 21 81 1 20 19 - 19 - - - Poplar 84 758 16,879 — — — — 1,793 — 855 7,980 829 442 - - - - - - - - 4 12 - 1 4 11 4 5 - - - - - - 122 124 - - - - - 11 6 145 879 - 1 112 193 3 9 9 - 9 4 — 4 Stepney 139 317 25,934 9 21 — — 5,773 — 8,396 4,925 1,378 655 70 - - - - - - - 14 7 2 - 23 7 4 - - - - - - 2 60 53 3 - - 1 78 261 18 19 1,587 - 18 231 319 6 18 14 - 14 2 — 2 Division 6 Deptford 84 67 17,857 - - — — 1,230 - 3,711 10,112 492 260 - - - - - - - - 4 14 - - - - - - - - - - - - 30 406 1 1 - 1 - 171 401 51 776 1 - 95 193 1 8 6 - 6 2 - 2 Greenwich 50 77 24,788 — — — — 1,873 9 7,774 9,455 484 102 - - - - - - - - - - - - - - - - - - - - - - 3 - - - - - 1,287 570 158 55 1,723 - - 97 274 - 10 8 1 9 - — - Woolwich 284 872 44,779 69 113 23 66 990 172 8,153 5,005 462 213 — — — — 10 — 1 12 2 12 4 - 6 - 4 7 - - - - - - 20 32 - - - 4 70 119 340 91 461 1 2 123 332 - 19 18 1 19 2 - 2 Division 7 Camberwell 417 126 45,239 23 112 — — 4,215 998 27,978 12,220 1,558 1,394 4 11 — 2 - - 1 7 3 13 8 - 12 - 2 - 9 1 - - - - 45 152 1 - - - - 82 149 85 1,850 - 5 221 528 1 20 17 - 17 3 1 4 Lewisham 372 380 64,630 — 76 — 12 1,991 234 19,025 18,310 351 342 — 12 1 2 2 5 2 6 - - 6 - 6 13 - 13 17 - - - - 10 - - - - 2 - 60 125 440 397 1 - 108 329 - 20 20 - 20 3 - 3 Division 8 2 U 20 3 — 3 Bermondsey 172 228 15,400 120 515 9 55 1,785 6 1,633 13,492 614 288 1 - - - - - - - 5 28 1 - - - - - - - - - - - 8 86 - - 1 - - 35 19 18 154 - 8 117 204 1 11 9 - 9 2 - 2 Lambeth 198 367 56,462 4 13 — 1 2,333 79 2,383 5,571 1,119 775 139 3 - - - - - - 2 7 3 — — — 4 — — — — — - - 23 146 - - - - - 138 90 254 1,097 - 2 284 589 - 21 15 1 16 - - - Southwark 93 540 25.076 66 235 7 32 3.047 92 14.630 7.054 741 582 58 - - - - 2 2 13 5 15 1 - 7 30 104 32 37 42 16 12 - 25 18 207 14 - - - - 936 636 174 1,337 - 3 146 305 6 20 17 - 17 4 - 4 Division 9 Battersea 132 4 29,334 20 78 26 111 3,105 55 7,833 9,688 556 620 18 5 - - - - - - 17 79 3 - - - 10 35 - 9 - - - - 24 225 - - - - - 142 640 884 271 - 2 136 273 - 16 11 2 13 1 - 1 Wandsworth 98 455 118,606 40 107 — — 5,431 29 15,065 16,679 980 367 8 - - - - - - 2 3 2 7 — 1 — 4 8 13 - - - - - 95 558 2 — — 1 — 34 13 326 573 — - 296 700 — 22 16 - 16 4 4 LONDON 4,439 5,552 887,161 ,513 1,917 73 289 62,900 4,668 195,458 267,992 20,135 12,020 538 40 2 10 31 11 46 137 146 569 337 2 111 151 700 371 142 170 27 12 5 113 1,242 7,769 114 7 1 27 1,736 6,274 4,433 5,712 19,351 5 66 4,147 8,539 27 441 357 17 374 57 2 59 § The whole of the City of London is a Smokeless Zone under the City of London (Various Powers) Act, 1954. 160 APPENDIX D STAFF OF THE PUBLIC HEALTH DEPARTMENT AT 31 DECEMBER, 1960 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 Ian Taylor Tuberculosis W. Hartston Mental health C. W. J. Ingham Staff medical examinations R. Cove-Smith Chief Dental Officer and Principal School Dental Officer W. Ritchie Young Chief Nursing Officer Evelyn Robinson Scientific Adviser S. G. Burgess Establishment Officer R. H. J. Stronge Principal Clerks G. Berridge D. J. B. Cooper W. H.Joyce Officer-in-Charge, London Ambulance Service A. G. Hellman Statistician C. W. Shaddick Chief Inspector J. C. Clancey Principal Organiser of Children's Care Work Frances C. K. Gregson Principal Mental Welfare Officer Olive K. Bowtell Senior Officers of the Divisions Divisional Medical Divisional Administrative Divisional Nursing Division Officer Officer Officer 1. Bertha E. A. Sharpe T.A.Stone Joan A. Surr 2. H. L. Oldershaw N. A. Woodruff Eveline Beattie 3. W. G. Harding N. B. Chapman Margery D. Butler 4. S. King J. C. Minter Lilian E. Arrow 5. G. O. Mitchell E. L. Hannant Elizabeth J. Early 6. F. R. Waldron L. M. Longhurst Lilian Berry 7 Ann Mower White F. L. Clark Kathleen L. Sewell 8. W. H. S. Wallace D. E. Armstrong Bessie Thom 9. J. T. R. Lewis R. E. Haymes Winifred M. Winch 161 INDEX Page Page Accidents in the home 86 Guardianship of the mentally subnormal 90 Adoption of children 62 Air pollution 19,49 Handicapped pupils 104 Ambulance service 74 Health education 83, 141 Analgesia 66, 142 Health surveys of pupils 99 Analysis of samples 44 Health visiting 67 Ante-natal care .. .. .. 58,141,142 Home care scheme, sick children 60 Audiometry 106 Home help 70 Auditory training unit (Div. 7) 134 Home making courses 59 Home nursing 68 B.C.G. vaccination 29 Home safety 86 Births 3,4 Housing 39 Blind persons 40 Bronchitis 9 Illegitimacy 6,64 Building programme 55 Immunisation 71 Improvement grants 39 Cancer 7,8 Industrial training centres 89 Care committees 29, 96 Infant mortality 3, 16 Care of mothers and young children 58 Infectious diseases 20 Child guidance 110 Infectious diseases (in schools) 102 Child help 70 Influenza 20 Child minders 59 Institute of Child Health 59 Child protection 64 Child welfare 58 Leptospirosis 20 Children in hospital 60 Live births 3,4 Chiropody 78 Lunacy and Mental Treatment Acts 90 Civil defence 77 Cleansing scheme 99 Maladjusted pupils 110 Community care of the mentally ill 90 Marriage guidance 64 Community care of the mentally subMarriages 3 normal 92 Maternal mortality 3, 19, 144 Cranbrook Report 139,147 Maternity and child welfare 58 Maternity and child welfare (dental Day nurseries 59 service) 117 Dea.thS 3 7 Maternity beds, use on social grounds 125,148 Delicate pupils 106 Maternity hospital services 148 Dental services 114 151 Maternity medical services 141 Diarrhœa and enteritis 20 Meals (children) 48, 98 Diphtheria 20,71 Meals (invalid) 42 Diphtheria investigation (Div. 7) 133 Measles 20 (Div 8) 135 Medical inspection of pupils 93 Divisional medical officers'reports 122-136 Medical treatment of pupils 103 Domiciliary midwifery 65,139 Mental Deficiency Acts 91 Dysentery 20 Mental health education 60 Domiciliary confinements, an analysis 145 Mental health services 88,118 Metropolitan borough councils 159 Midwifery service 65,139 Educationally subnormal pupils .. 105 Midwives Act 66 140 Emergency Bed Service, maternity Milk sampling 39,48 admissions (Div. 3) 125,149 Mobile immunisation clinic (Div.3) 127 Emergency Obstretic Unit 143 Moral welfare associations 6,63 Employment of school children 101 Morning and evening helps 70 Entenc fever 20 Mortality 7 Exhibitions 86 Mother and baby homes 62 Expectant and nursing mothers 58 Neo-natal mortality 3,17 Family planning 58 Night helps 70 Fertility 4 Noise measurements 54 Finance 120 Nurseries (day) 59 Food handlers 119 Nurseries (residential) 62 Foot clinics 78 Nursing home registration 42 162 INDEX—continued. Page Page Occasional creches 59 Scientific branch 43 Ophthalmia neonatorum 21 Sewage treatment 44 Orthodontics 117 Sick children, home care scheme 60 Slum clearance 39 Perinatal mortality 3,18 Smallpox 22, 72 Personal hygiene of pupils 99 Special home helps 70 Physical condition of pupils 97 Speech therapy106 Pneumonia 9 Staff 118,160 Poliomyelitis 21,72 Stillbirths 3,4,18,65,145 Population 3,4 Student health scheme112 Premature babies 17,65, 143 Swimming baths 50 Premises 55 Prevention of illness 78 Tetanus 71 Problem families 59 Trade waste discharges 47 Prophylaxis 71,102 Training centre 89 Public health laboratory 39 Training pupil midwives 141 Pupil midwives, training 141 Training student health visitors 118 Tuberculosis 29 Radioactivity 50 Tuberculosis care committees 29 Recuperative holiday 82,90 Tuberculous milk 39 Rehabilitation of the mentally ill 89 Rehousing 39 Unmarried mothers 6,62 Residential establishments for young children 62 River Thames 46 Vaccination Venereal disease 83 Safety in sewers 47 Vision tests 98 Sanitary inspection 40 Visitors 121 Scabies 101 Vital statistics 3,4 School care committees 96 School dental service 114,151 Water sampling 48 School health service 93 Weather 26 School health service, working party .. 103 Welfare Committee establishments 42 School meals 48,98 Welfare foods 58 School medical inspections 93 Whooping cough 22,71 School physician's handbook 103 Woodberry Down health centre 129 School refusal 1ll School treatment centres 104 Yellow fever 73 References to local activities in the sphere of chiropody, health education, mental health education, home making courses, problem families, vaccination against poliomyelitis, etc., will be found in the divisional medical officers' reports, pages 122-136. 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