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Public Health

The Nation’s Health in 1951

IN his report for 1951 on the state of the publichealth in England and Wales, Sir John Charles, chiefmedical officer of the Ministry of Health, says : " Wehave ... arrived at a time when the citizen himself mustactively participate in the campaign for better healthif further substantial progress is to be made." He

points out that most of the improvement in publichealth over the past century has been achieved withoutthe citizen having had to exert himself or put himselfto any great inconvenience ; for " a silent army of

sanitary technicians has unobtrusively worked thismiracle on his behalf." But now the era of sanitaryengineering was giving place to that of personal hygienewhen " each person must definitely contribute to thecommon weal."

VITAL STATISTICS

The fall in the birth-rate, which has been decliningsince 1947, continued : the rate for 1951 was 15.5 per1000 population. The report says that the lack ofprogress in reducing the stillbirth-rate in the last twoor three years must be regarded as disappointing anddisturbing, particularly when compared with the rapidreduction achieved between 1936 and 1948. The still-birth-rate rose from 22-7 per 1000 total births in 1950to 23-0 in 1951. The infant-mortality rate increasedvery slightly from 29.6 per 1000 live births in 1950 to29-7 in 1951.The total number of deaths was 549,380-an increase

of 39,079 over 1950. Almost all the increase could beattributed directly or indirectly to the severe influenzaepidemic during the early weeks of the year. Thecrude death-rate of 12.5 per 1000 population was thehighest for several years.

COMMON CAUSES OF DEATH

The list of the most important causes of death duringthe year is headed by diseases of the circulatory system(35-9%), followed by cancer (15-7 %), diseases of therespiratory system (14-7 %), and vascular lesions affectingthe central nervous system (12-5%).

Coronary Disease.-Deaths attributed to coronarydisease continued their " alarming and perplexingincrease, alarming because of the size of the increase,perplexing because it had by no means been establishedthat the increases arose solely from a changing fashionin certification, though it was undoubtedly a factor ofimportance." There were 58,309 deaths from coronarydisease in 1951, compared with 37,393 in 1947. Hyper-tension with heart-disease was also appearing more oftenon death certificates, and almost 17,000 deaths wereascribed to this cause in 1951. as compared with 7750in 1947.

Cancer.-The number of deaths from cancer and thecrude death-rates have increased each year for the pasteleven years. In 1951 the total was 80,080, which was810 more than in 1950. The increase in male deathswas again largely due to the deaths from primaryneoplasms of the lung, trachea, and bronchus, which wereresponsible for 25 % of all male deaths from cancer.

Tuberculosis.-There was a further considerable declinein deaths from tuberculosis : the total number from allforms of the disease was less than 14,000, giving a rateof 315 per million. Of this total, 12,000 were due torespiratory tuberculosis-2000 less than in 1950. Refer-ring to the welcome increases in nursing staff and in thenumber of beds available for the treatment of tuber-culosis and to the valuable work of mass miniature radio-graphy units, the chief medical officer concludes that" it is possible to register a qualified optimism withregard to tuberculosis ... the end of the battle may ...be in sight." But there were still some unsolved

1. Report of Ministry of Health (1st April, 1950, to 31st December,1951): Part III on the State of the Public Health (AnnualReport of Chief Medical Officer for 1951). H.M. StationeryOffice. Cmd. 8787. Pp. 222. 6s. 6d.

problems calling for further investigation before thefinal attack was launched.

INFECTIOUS DISEASES

Diphtheria, which caused only 33 deaths in 1951,was joining the rare causes of death ; and the new lowtotal (664) of notifications also illustrated the successof the immunisation campaign. 1951 was the worstmeasles year since notifications were introduced in 1940 :there were 616,192 notifications, with 317 deaths. Theinfection was again mild, and " the fall in -the case

fatality rate continued." In contrast, scarlet fevernotifications were the lowest on record. For the secondsuccessive year whooping-cough was ,very prevalent,and the total number of cases reported, 169,441, washigher than ever before. Deaths from whooping-cough totalled 457.The number of deaths from influenza in the first

quarter of the year was greater than in the same periodin any of the preceding fourteen years. It was estimatedthat 50,000 people died directly or indirectly as the resultof influenza during January and February. Influenza,was the certified cause of 15,809 deaths-about 12,000more than in 1950. Since 1918 the proportion of deathsat ages under 55 has gradually decreased: in 1951only 12 % of those who died from influenza were under55, while in 1918 no less than 86 % were under that age.For the first time in th;s country absence from work wasused as a measure of the progress of an influenza epidemic.The outbreak reached its peak in the third week ofJanuary when 438,159 people claimed sickness benefit.

Dysentery behaved as inexplicably as ever. Therewere 28,564 notifications, the highest number ever

recorded, and 71 deaths. A special subcommittee ofthe Public Health Laboratory Service has been formedto study the subject. Most cases were in outbreaks inday nurseries, residential nurseries, children’s hospitals,mental hospitals, and day and residential schools.The chief medical officer remarks : "Were all meatconsumed on the day it was cooked outbreaks in institu-tions or associated with catering establishments would-very soon cease." For the first time since 1942 thenumber of food-poisoning incidents decreased; but" food-poisoning, though less prevalent, was stillsufficiently widespread to give rise to continued misgivingon our present standards of food hygiene."

There were fewer new cases of syphilis and gonorrhcea.but, the report continues, " we must expect... theappearance of increased neuro- and cardio-vascularsyphilis consequent upon old and latent infections;in fact, the larger numbers of women attending the clinicsfor the first time for neuro-syphilis may represent thebeginning of the new host of the afflicted. Cardio-vascular syphilis arising from war-time infection has notyet appeared, but there is little doubt that it will makeits presence apparent in due course." Indeed, thelegacy from the last war was likely to be large, and anextension of routine blood testing would help to discoverthe thousands who must still be untreated in the lateand latent stages of syphilis.

NUTRITION

Since the late war, clinical surveys of the nutritionalstate of-the population have shown an almost completeabsence of definite evidence of malnutrition or under-nutrition. In order to provide evidence on which tobase future comparisons and with which to detect smalldeviations, data have been collected from specifiedgroups of children. In 1951 observations were confinedto boys aged 14 and 17. Boys from grammar schoolswere on the average taller and heavier than those frommodern schools, whatever the dietary pattern. Thefactors responsible for this difference seemed to beassociated with parental care, higher social grouping,and perhaps parental intelligence. Whatever the socialclass, school, and family size, boys who shared bedswere on the average lighter than those who did not; andboys whose mothers went out to work were heavier thanthose whose mothers did not.

ACCIDENTS IN THE HOME

Domestic accidents continued to take a heavy toll-between 5000 and 6000 deaths every year. The

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same age-groups were particularly affected ; about

20% of the fatalities occurred in children under five

years of age and about 60 % in people over sixty-five.More children under fifteen died from accidental causesin their homes than were killed on the roads ; and betweenthe ages of one and five a fatal home accident was stillone of the commonest causes of death.

SmallpoxAnother 2 cases of smallpox have been reported

from Lancashire and the West Riding during the weekending at noon on April 14. The total number of cases isnow 23; and 1 of the new patients, a boy, aged 8, living inLeeds, has died, bringing the total of deaths to 5. Theboy, who was unvaccinated, fell ill on April 6. A rashwhich appeared on April 8 was diagnosed as measles.He was admitted to hospital on April 11 and vac-cinated, but he died on April 14. A confident clinicaldiagnosis of haemorrhagic smallpox awaits laboratoryconfirmation. The source of infection has not yet beentraced. This is the first case in Leeds during the out-break. The second patient, a 17-year-old girl in Oldham,had already been in quarantine as a contact and had beenvaccinated on March 20. She became ill on March 29,and this illness has now been confirmed as modifiedsmallpox. In Todmorden, where workers at a cottonmill were the first to be infected, Dr. J. Lyons, medicalofficer of health, said on April 13 that all contacts wereout of quarantine in the area and the town might beregarded as free from the disease. Quarantine restrictionswere lifted’at Halifax General Hospital on April 13after the 2 remaining suspects had been found to be freefrom infection.

DiphtheriaLast year there were only 31 deaths from diphtheria

in England and Wales, the lowest figure ever recorded.This compares with 2480 deaths in 1940 when the nationalimmunisation campaign opened. But in telling localhealth authorities of the publicity material available forthis year’s campaign, the Minister of Health, Mr. lainMacLeod, stresses that the complete elimination of thedisease depends upon the maintenance of an adequatelevel of immunisation. Sustained publicity by localauthorities is essential if parents are to be helped torealise that diphtheria is still a deadly threat. Thetarget for this year is the immunisation of 500,000 childrenunder the age of one.

Metropolitan Water Board JubileeAfter the disastrous cholera epidemic of 1854, routine

chemical examination of London’s water-supply wasintroduced in 1858, and in 1871 the position of Govern-ment water examiner was established by statute. Fromabout 1882 onwards the isolation and examination ofbacteria provided a much more delicate test for assessingpollution or establishing purity ; and in 1885 routinebacteriological examinations of the Metropolitan water-supply were started. Then, in April, 1903, fifty years ago,the Metropolitan Water Board held its first meeting inthe council chamber of the Privy Council in DowningStreet.Today the board supplies approximately 320,000,000

gallons of water to a population, in round figures, of6,500,000-one-seventh of the total population of GreatBritain. The rivers Thames and Lee provide most ofthis water, but storage reservoirs are necessary to meetusers’ needs to’the full in a period of drought. Muchwork is being done to raise output, increase efficiency,and secure economy, and to ensure that methods ofwaste detection and suppression and of water examina-tion and treatment are of the highest standard. A largefiltration and pumping station, with a capacity of90,000,000 gallons daily, is being built in the Thamesvalley at a cost of over .64,000,000 ; and a 75-inch mainto carry raw water from the Thames to the Lee valley isbeing planned. A Government white-paper of 1944stated: "Not so many years ago it was thought inresponsible quarters that London would have to abandonthe use of the Thames and the Lee, but today 90 % ofLondon’s water-bacteriologically one of the purest inthe world-comes from these two rivers."

1. Times, April 14, 1953.

Although the increase in urbanisation and pumpinghas made it necessary to chlorinate all water from wells,in only a few cases isfiltration required. But the river-supplied water, polluted by domestic sewage, tradewaste, and plant life, needs elaborate methods ofpurification. After storage in the large reservoirs, allriver supplies are filtered. The ordinary slow sandfiltration, first used by the Chelsea Waterworks Co. in1829, was replaced in 1923 by rapid primary filtration,which removes the larger suspended matter before thewater is passed to the slow secondary filters. The boardnow uses nearly 200 slow sand filter beds, 100 primaryfilters, and 12 mechanical filters. The ultimate guaranteeof purity is conferred by chlorination. Chlorination wasfirst used in the early years of this century ; and in 1921the board began chlorinating filtered river water beforeit was passed into supply. After 1936 all water wastreated by the ammonia-chlorine process, and since 1948the latter process has been replaced by superchlorination,which has improved the physical quality of the waterand its bacterial purity more than any other measuresince the introduction of sand filtration.The board’s water examination department at New

River Head is divided into three sections : the biologicalsection concentrates on the conditions of the reservoirsand rivers and their treatment ; the bacteriologicalsection is concerned with the improvement in the bacterialquality of the water as it passes through the variousstages of purification and with the safety of the final waterfor domestic consumption ; and the chemical sectiondeals with chemical treatment and with the examinationof the chemical and physical quality of the water,including clarity, colour, and taste. During 1952 thetotal number of samples collected for all purposesexceeded 93,000.

Improved Physique of Glasgow ChildrenIn his report on the medical inspection and treatment

of school-children in Glasgow during the year endedJuly 31, 1952, Dr. James Ewan, principal medical officerof the education health service of Glasgow, refers to thegratifying results of routine inspection. Fewer childrenwere found to be abnormal; 42-8% of all the pupilsexamined were recorded as having no defect of any kind-the highest proportion since the establishment of routinemedical inspection of school-children in Glasgow in 1909.Moreover, of those children who were found to beabnormal, fewer than ever before had the less remediabletype of condition. Average measurements also showedimprovement, and only the weights of the 5-year-olds(particularly the girls) failed to conform to pattern.For example, in 1952 13-year-old boys were on theaverage 0-62 in. taller and 1-65 lb. heavier than boys ofthe same age in 1945 ; and for girls the correspondingincreases were 0.32 in. and 1-75 lb. During these 7 years,the average measurements for 9-year-old boys rose by0-56 in. and 1-02 lb., and for girls of the same age by 0-42in. and 1’08 lb. Defective vision was also less common,and the proportion (14%) of children whose sight wasbelow normal was less than in any previous year except1949.

Infectious Diseases in England and Wales