Lcc48 LONDON COUNTY COUNCIL Interim Report of the County Medical Officer of Health and School Medical Officer for the year 1940 Published by the LONDON COUNTY COUNCIL, And may be purchased, either directly or through any bookseller, from P. S. KING AND SON, Limited, 14, Great Smith Street, Victoria Street, Westminster, S.W.I, Agents for the sale of the publications of the London County Council. 1941. No. 3494. Price 6d. Post Free 7d. London County Council INTERIM REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1940 By W. Allen Daley, M.D., F.R.C.P., County Medical Officer of Health and School Medical Officer. INTRODUCTION Staff shortage and preoccupation with more urgent matters result in the annual report for 1940 being, like its predecessor, very attenuated. An attempt has, however, been made to indicate in these pages that, despite the difficulties of the times, the health of London has not been unsatisfactory and that the vast and complex organisation, known as the Public Health Department, has continued without intermission, not only to provide care and attention for the sick of London who apply for treatment at its hospitals, but also to carry on all its other activities for the prevention of illness and the preservation of health. This has been possible only because of the devotion to duty of the staff of the department. Brief accounts have been published in the London Gazette of the bravery of those of the staff who have received awards for gallantry. They were: Mr. Albert Dolphin, porter, South-Eastern Hospital, awarded (posthumously) the George Cross ; Dr. F. D. Murphy, acting medical superintendent of Fulham Hospital, who was appointed to be an Officer of the Order of the British Empire; Miss Mary Fleming, staff nurse, Miss Ruby E. M. Rosser, staff nurse, and Miss Aileen Turner, senior assistant nurse, all of Grove Park Hospital; Mr. George Goshawk, auxiliary ambulance attendant, and Mr. Bertram Matthewman, auxiliary ambulance driver, each awarded the George Medal; Miss Valentine Howell, assistant nurse, class I, Colindale Hospital, Mr. Philip Davey, Miss Betty Leverton and Mrs. Mabel Ann Armitage, auxiliary ambulance attendants, and Miss Ruby Gwendoline Sandford, Mr. Joseph Slipman and Mr. George Frederick William Tindall, auxiliary ambulance drivers, awarded the British Empire Medal; Miss Isabella Russell, matron, St. Matthew's Hospital, Miss Elizabeth Scully, probationer nurse, St. Giles' Hospital, and Miss Helen Annie Mason, auxiliary ambulance driver, who each received a commendation. The full story cannot be told, until peace is once more with us, of how every man and woman in the service has responded to every call and, by grim determination, when facing imminent and constant danger, has ensured that the vital health services, of this great community shall not fail. Very many of the Council's hospitals were hit during air raids by the enemy, and, unfortunately, 21 members of the hospitals' staffs were killed and 44 injured. In addition, 10 members of the auxiliary ambulance personnel were killed and a considerable number injured. The department sustained a heavy loss by the death, in February, 1940, of Miss D. E. Bannon, C.B.E., its first Matron-in-Chief. As from 1st May, 1940, the duties of the office were entrusted to Miss R. Dreyer, formerly a principal matron, with the title of Principal Matron-in-Charge. On 19th November, 1940, Dr. Andrew Topping, senior medical officer, was appointed Deputy Medical Officer of Health. Retirements during the year included Dr. W. B. Knobel, Senior Medical Officer, and Captain A. E. Reed, Officer-in-Charge of the London Ambulance Service. 400 (McO. 42088) 16-12-11 1616 (1) 2 Population VITAL STATISTICS The Registrar-General estimated the resident population of the county to be 4,062,800 at the middle of 1938. Exceptional movements of population have taken place since the outbreak of war and rates quoted in this report are based on estimates made by the Registrar-General of the average population amongst which the notification of disease or deaths occurred. In the absence of information as to the non-civilian population of the county it has been necessary to base the birth and marriage rates upon estimates of the civil population only. Marriages The marriages registered in London during 1940 numbered approximately 53,200 or 34.5 persons married per thousand of the civil population. Births The live-births allocated to London during 1940 numbered 46,213. The livebirth rate was 15.0 per thousand, the rate for 1939 being 13.0. Deaths The deaths in the total population of London during 1940 numbered 57,459. Of the total deaths 27,944, or 48 .6 per cent., were among females. Street accidents I here was an increase in the number of fatal street accidents—from 519 in 1939 to 543 in 1940. Infant mortality The deaths under one year of age per thousand live-births were 48, compared with 47 in the preceding year. The neo-natal death rate (ages 0-4 weeks) for 1940 was 22.5 per thousand live-births, the corresponding rate for 1939 being 22.4. Infectious diseases Particulars of infectious diseases during 1940 are set out below, corresponding figures for 1939 being shown in brackets:— Anthrax Smallpox Three (3) cases of anthrax were notified during the year. No case of smallpox was notified in London during the year. London has now been free from this disease since June, 1934. Cerebrospinal fever During the year 839 (169) notifications of cerebro-spinal fever were received, and 151 (34) deaths were registered. Encephalitis lethargica Eight (11) notifications of encephalitis lethargica were received during the year, the number of deaths being 48 (49). Poliomyelitis and polioencephalitis Measles During the year 20 (98) notifications of poliomyelitis or polioencephalitis were received and there were 10 (16) deaths. The notification of measles in the County of London came into force on 1st October, 1938, and during 1940 there were 5,447 (1,303) notifications. The deaths numbered 29 (4) and the death-rate was .01 per thousand. Whoopingcough Whooping-cough also became a notifiable disease on 1st October, 1938, and during 1940 there were 669 (10,537) notifications. There were 10 (134) deaths and the death-rate was .003 per thousand. Scarlet fever There were 2,498 (5,677) notifications of scarlet lever in 1940. The attack-rate was 0.8 per thousand, compared with 1.5 for 1939. The deaths numbered 5 (9), giving a death-rate of .002 per thousand of the population at all ages and a casemortality of .2 per cent. a similar rate to that for 1939. Diphtheria Notifications of diphtheria numbered 1,844 (3,671) m 1940. This gives an attack-rate of 0.6 per thousand compared with 1.0 for the preceding year. There were 67 (98) deaths, giving a death-rate of .02 per thousand living. The casemortality was 3.6 per cent., the corresponding rate for 1939 being 2.7. Diarrhoea and enteritis Diarrhœa and enteritis caused 263 (424) deaths among children under two years of age, or 6.13 per thousand live-births. The corresponding rate in 1939 was 8.36. The death-rates per 1,000 live-births in London and England and Wales in recent years are shown in the following table:- 1929 1930 1931 1932 1933 1934 1935 1938 1937 1938 1939 1940 London 10.96 9.89 9.71 12.55 11.74 12.80 11.31 14.47 12.29 13.23 8.36 6.13 England and Wales 8.26 6.15 5.90 6.60 6.98 5.36 5.56 5.75 5.54 5.30 4.60 4.76 3 There were 155 (163) notifications of puerperal fever and 472 (704) notifications of puerperal pyrexia in 1940. The deaths from puerperal fever numbered 42 (33) and from other puerperal causes 43 (67), the deaths per thousand live-births being .98 and l.00 respectively, giving a total maternal mortality rate of 1.98 (1.97). Puerperal fever and pyrexia: maternal mortality There were 158 (98) notifications of fevers of the enteric group in London in 1940. The deaths numbered 7 (6). In addition, there were 3 deaths recorded by the Registrar-General of cases belonging to London which had not been notified within the county. One of these was an inmate of a mental institution. Enteric fevers There were no notifications of typhus fever during the year. The deaths from influenza during 1940 numbered 569 (682). The deaths in London from rheumatic fever in 1940 numbered 49 (78), of which 14 (30) were among children under 15 years of age. There were 6,615 (6,994) deaths from cancer in 1940. The death-rate per thousand was 2.14. There was a decrease of 53 in the deaths among males and of 326 among females compared with the previous year. Typhus fever Influenza Rheumatic fever Cancer Tuberculosis The deaths from pulmonary tuberculosis in London during 1940 numbered 2,687 (2,650), giving a death-rate of .87 (.70) per thousand living. There were 318 (302) deaths from other forms of tuberculosis in 1940, the death-rate being .10 (.08) for the year. In England and Wales as a whole the corresponding deathrates for pulmonary and non-pulmonary tuberculosis, respectively, were .59 (.54) and .11 (.10). The number of primary notifications in metropolitan boroughs during the year 1940, after correction of figures within each metropolitan borough by the exclusion of cases notified as primary but subsequently found to have been previously notified, was 4,979 (5,496). The returns received under the Public Health (Tuberculosis) Regulations, 1930, from the medical officers of health of the metropolitan boroughs show that there were 22,356 (23,041) cases of pulmonary tuberculosis (12,908 (13,221) males and 9,448 (9,820) females) and 6,526 (6,737) cases of other forms of tuberculosis (3,263 (3,402) males and 3,263 (3,335) females) on the registers of the metropolitan boroughs at the end of 1940. ADMINISTRATION Housing Representation of unfit premises under Section 25 of the Housing Act, 1936, has continued in abeyance during 1940, but a few applications for preferential consideration for rehousing on the Council's estates on grounds of ill-health were received and appropriate recommendations were made thereon to the valuer. Tuberculous milk Milk sampling for the presence of tubercle bacilli was interrupted at the outbreak of war, but was resumed on 1st April, 1940. During the last nine months of the year 51 (9 per cent.) of 557 completed examinations of milk showed the presence of tubercle bacilli. None of the tuberculin tested milk yielded positive results, while accredited milk showed a ratio of 13.8 per cent., and ungraded milk of 8.1 per cent. positive. All these percentages show increases over the figures for 1939. The milk sampled was received from 14 counties; 25 cows were dealt with under the Tuberculosis Order, 1938. Of the 51 tuberculous samples the source of 4 infection of 21 was traced and of 11 not traced; examination of the remainder was not completed before the end of the year. Venereal diseases The facilities under the London and Home Counties Scheme for the free diagnosis and treatment of venereal diseases have been continued during 1940, except for the curtailment of certain in-patient and hostel accommodation. At the end of the year 17 hospitals and the London County Council (Whitechapel) Clinic were undertaking the necessary treatment and other work under the scheme. The Children's Medical Home, Waddon, opened for a brief period, but closed before the end of the year. The number of new patients attending the hospitals during the year (comparative figures for 1939 are given in brackets) was 17,165 (22,756), of whom 2,202 (2,477) were suffering from syphilis, 5,910 (7,634) from gonorrhoea, and 155 (169) from soft chancre, while 8,898 (12,476) were diagnosed as not suffering from these diseases. There were 437,068 (601,422) attendances and 21,143 (35,745) in-patient days. In all 189,249 (263,872) pathological examinations were made, of which 153,695 (223,696) were for the centres and 35,554 (40,176) for practitioners. Dispensary service Treatment of tuberculosis The number of patients' names on the dispensary registers fell during the year from 21,257 to 20,254. The dispensary service which had, immediately after the outbreak of war, experienced a certain amount of dislocation in the majority of the metropolitan boroughs, functioned satisfactorily, having regard to war conditions, during practically the whole of the year, there being no complaint with regard to the services of any dispensary. Evening sessions were recommenced either just before or after the commencement of statutory " summer-time." Two dispensaries were destroyed by enemy action, one being transferred to other premises and the other to another portion of the same building. Three other dispensaries were damaged, but it was possible for the services to be continued in the same premises, in one case after a temporary transfer elsewhere. After-care clinics for non- pulmonary tuberculosis After-care clinics held at County Hall were carried on more or less normally until September, when they had to be suspended. St. Luke's (Lowestoft) Clinic was later resumed, and ex-patients of Heatherwood Hospital in need of urgent examination have been invited to attend at the hospital. The after-care department at Queen Mary's Hospital, Carshalton, functioned throughout the year. Arrangements for repair or renewal of surgical appliances for clinic patients were not affected. Boarding- out of children— contact scheme Residential treatment The number of child contacts boarded out with foster-parents during the year averaged 130, compared with 160 during the year prior to the war. The effect of the war in reducing the number of recommendations for residential treatment continued throughout the year, although, as will be seen from the subjoined table, it gradually became less marked. The number of persons, particularly of children, evacuated either officially or otherwise will to some extent account for the decrease. 1st January to 31st August 1st September to 31st December Men Women Children Total 1940 1939 1938 1940 1939 1938 1940 1939 1938 1940 1939 1938 2,823 3,267 3,104 2,024 2,238 2,252 364 659 710 5,211 6,164 6,066 1,031 941 1,237 659 635 869 115 113 286 1,805 1,689 2,392 3,854 4,208 4,341 2,683 2,873 3,121 479 772 996 7,016 7,853 8,458 5 The number of beds occupied by patients under the tuberculosis scheme on 31st December, 1940, was as follows (corresponding figures for 1939 being given in brackets):— Adults Children Council's special hospitals and sanatoria 971 (853) 400 (496) Council's general hospitals 574 (787) 4 (8) Voluntary institutions 1,286 (1,128) 69 (55) Total 2,831 (2,768) 473 (559) The loss of beds in the Council's general hospitals owing to enemy action, and in the special tuberculosis hospitals due partly to this reason and partly to reservation for casualties or in consequence of evacuation, compelled the taking of a larger number of beds in voluntary institutions. Certain of these institutions situated near the east and south-east coasts were also evacuated. Additional beds were, however, obtained in other voluntary establishments normally used by the Council, but it became necessary to obtain beds in hospitals and sanatoria in other areas more distant from London—notably the West and North Ridings of Yorkshire. The number of beds obtained was roughly sufficient throughout the year. The provision for thoracic surgery previously made at centres within or near London had to be modified during the year owing to the disturbing effects of air raids on tuberculous patients undergoing surgical operations. Full use was made of the facilities for such treatment at King George V Sanatorium and Pinewood Sanatorium. The special accommodation for this form of treatment is limited, particularly for women, and has been under considerable pressure throughout the year, in spite of the fact that some relief has been given by a certain amount of this work being done in Emergency Medical Service hospitals. Thoracic surgery The facilities for observation of patients, for diagnostic and for treatment purposes, were necessarily reduced by the closure of wards at Brompton and the London Chest Hospitals as well as the complete closure of St. George's Home. The need for these facilities was largely met by the remaining available accommodation at Brompton and the London Chest Hospitals, and, in some cases, by admitting patients to King George V and Pinewood Sanatoria for diagnostic observation and to Colindale and Grove Park Hospitals for observation as to treatment necessary, or, in selected cases, direct to sanatoria. Observation of patients In December an enquiry of borough medical officers revealed that, although in September at the commencement of heavy enemy bombing a large number of tuberculous patients used public shelters, very few still continued to make use of them. Some patients had been persuaded by tuberculosis officers to remain in private shelters or otherwise at home ; others of their own accord preferred to remain at home. A number of these public shelter patients were admitted to general hospitals or to sanatoria. Efforts were being continued at the end of December to persuade the remainder of the patients having positive sputum to cease using public shelters, admission to residential institutions being offered, where necessary, as an alternative. Use of public air-raid shelters Mental defectives On 31st December, 1940, 11,666 defectives were being dealt with by the Council under the provisions of the Mental Deficiency Acts, 1913-38. Of these, 7,028 were at institutions, 459 under guardianship, 3,838 under supervision and 341 in places of safety awaiting action. The large number of defectives in places of safety was due to war conditions. During the year 882 persons were examined with the following results: feebleminded, 711; imbecile, 70; idiot, 9; morally defective, 2; not defective, 90. 6 Blind persons During the year, 1,420 applicants for registration or training under the provisions of the Blind Persons Acts, 1920 and 1938, were examined by the Council's ophthalmologists. Of these, 879 (377 male and 502 female) were certified as blind, and 541 (204 male and 337 female) were found not to be blind. In addition, 57 certificates (21 male and 36 female) from voluntary hospitals, outside authorities or private ophthalmologists were accepted as evidence of blindness, and one (female) as not evidence of blindness. Forty-five blind persons were examined as to suitability for training and 36 (24 male and 12 female) were found suitable. Midwives Acts, 1902 to 1936, nursing homes registration and maternity and child welfare contribution schemes to voluntary oraanisations Domiciliary midwifery service— London County Council midwives The gradual increase in the number of confinements undertaken by domiciliary midwives employed by the Council since the inception of the service on 1st January, 1938, became more marked at the beginning of the war. The weekly average number of confinements of 88 during the first eight months of 1939 rose to 133 weekly for the period 3rd September, 1939, to 31st December, 1939. The average weekly number of confinements throughout 1940 up to the time of the intensification of air raids on London on 7th September, 1940, was 166. Thereafter, the number fell rapidly until in November and December, 1940, a weekly average of 43 confinements was dealt with. Confinements undertaken in 1939 and 1940 were:— 1939 1940 Midwifery patients 4,803 6,396 Maternity nursing patients 535 552 Total 5,338 6,948 The highest number of domiciliary midwives employed was 137 on 7th August, 1940. At the end of the year there were 91 midwives on the books, of whom 23 were lent to the reception areas to assist with evacuated expectant mothers. Domiciliary midwifery service— voluntary organisations The number of confinements undertaken each year by voluntary organisations, with whom the Council has agreements under the domiciliary midwifery scheme, has remained at the same level. There was a very great decrease in the confinements dealt with after September, 1940, and, but for this, the figures for the year would have been considerably higher than those for 1938 and 1939. The average weekly number of confinements fell from 192 for the period 1st January to 7th September, 1940, to 53 for the months of November and December, 1940. The total number of district confinements dealt with in the last three years by the voluntary hospitals and district nursing associations were:— 1938 1939 1940 Midwifery patients 6,642 6,776 6,596 Maternity nursing patients 857 616 594 Total 7,499 7,392 7,190 The agreements entered into with the 15 voluntary hospitals and the 19 district nursing associations were reviewed and the payments considerably increased. At the same time the fees charged to patients booked as from and including 1st November. 1940. were also increased. Payment of medical fees Fees paid under the Midwives Act, 1918, to medical practitioners called in by midwives in emergencies amounted to £6,562, compared with £5,348 in 1939. Claims for fees were 5,110 in 1940, compared with 3,985 in the previous year. Registration of nursing homes There were 126 nursing homes on the register at the end of the year, compared with 144 at the end of 1939. 7 During 1940 many associations, which had suspended or ceased their work at the outbreak of war, re-opened in reception areas. Some associations ceased work during the bombing of London in September and October, 1940. At the end of the year, 23 associations were operating in reception areas. The work of 11 associations had ceased. Appropriate reductions were made in the grants payable under section 101 (b) of the Local Government Act, 1929. Maternity and child welfare work by voluntary associations Medical examination of staff The number of medical examinations of candidates and staff referred to the department was 11,135, compared with 14,076 in 1939. A number of these persons had left London in consequence of enemy action, and medical officers of health and superintendents of hospitals in various parts of the country have responded generously when asked to examine members of the staff unable to make the journey to London. In addition, medical examination of recruits for the Auxiliary Fire Service amounted to 10,976 (compared with 12,882 in 1939), and a further 2,036 auxiliaries were medically examined as to fitness for duty with the regular Fire Brigade, for which a more exacting physical standard is required. Under the provisons of regulation 298 of the Civil Defence (General) Regulations and the Police and Firemen (Employment) Order, 1940, 264 auxiliaries in the ambulance and fire services were allowed to resign on medical grounds. Chemical branch The work of the chemical branch, both statutory and otherwise, was carried on during the year at the three laboratories, the total number of samples examined being 18,059. Included in this total were a number of investigations in connection with A.R.P. work and various war activities. Advice was also given on matters involving scientific questions, e.g., the failure in use of certain building materials (paving slabs and glazed tiles), the provision of chlorinating plant for sewage treatment in the event of emergency, treatment for safeguarding the purity of water supplies in the event of emergency, and procedure for the cleaning of water storage tanks. The analytical work in connection with sewage treatment proceeded generally as described in previous reports. In addition, large-scale experiments were carried out on the secondary sedimentation of effluent from the weir chamber. The results were promising, considerable additional settlement being obtained. Sewage treatment HOSPITALS AND ANCILLARY SERVICES General hospitals The number of beds in the 27 acute hospitals under war conditions, indicated in the report for 1939, remained without major changes until the bombing of London commenced in September, 1940. Until the last quarter of the year there was, therefore, no call upon the accommodation for the treatment of air-raid casualties. After the seasonal increase in the number of patients in hospital during the winter months, which reached a peak at the end of February, 1940, with 10,660 patients in hospital, admissions decreased. From June until the onset of bombing the number of patients in hospital remained fairly constant at about 8,000. The air attacks on London resulted in a fall in the number of patients under treatment owing to the evacuation of a proportion of the population and the transfer of patients to the periphery of London. On 20th September, 1940, there were 6,400 patients in the acute general hospitals, including air-raid casualties, which fortunately did not reach the number anticipated and for which preparations had Acute hospitals 8 been made. The number of patients under treatment reached 7,600 on 15th October, 1940, and then fell again owing to an evacuation of chronic sick patients occupying beds in acute hospitals, until in early November only about 5,200 patients remained. After this the annual increase due to the onset of the winter months commenced and by the end of 1940, 6,108 patients were receiving treatment in the acute hospitals. The bombing of London reduced the number of beds available as many acute general hospitals sustained air-raid damage, some of which was serious and substantially reduced the bed accommodation. In addition, in the interests of the safety of the patients and staff, top floors of the hospitals were evacuated. At the end of the year only some 10,200 beds, about 50 per cent. of the peace-time accommodation were available. In spite of this, and even during the most intensive phase of the air attack, all cases of normal sickness seeking admission were admitted and among these were many who in peace time would have entered the voluntary hospitals, which had drastically cut down the number of beds available for the reception of ordinary civilian sick. Chronic sick hospitals By mid-October, 1940, approximately 5,800 cases of chronic sickness had accumulated in the general hospitals, some 2,200 of them occupying beds in the acute hospitals. This was due in part to relatives of patients leaving London not being able to take the sick with them to billets in the country, and to the fact that many chronic sick were unable to go nightly to the air-raid shelters. Owing to the reduction in the effective hospital accommodation the presence of this large body of long term patients was a matter of grave concern, and as a result of representations to the Ministry of Health, some 3,750 chronic sick patients were evacuated by the Ministry in hospital trains to the north and north-west of England. The relief effected was temporary, however, as this class of patient continued to seek admission, and by the end of the year the chronic sick hospitals, accommodation in which had also been reduced by air-raid damage and the closure of top floor wards, were again full, and this class of patient was again beginning to occupy beds in the acute hospitals. Epileptic hospitals Convalescent hospitals The two epileptic hospitals continued to provide treatment as before the war. In May, 1940, the military situation necessitated the closure of Princess Mary's Convalescent Home, Margate, for female convalescent patients, and the furniture and equipment were brought back to London for use elsewhere. A small number of female convalescents were sent to voluntary homes. A very restricted amount of accommodation for male convalescents was available at Queen Mary's Hospital, Sidcup, as air-raid casualties and other patients were treated there and reduced the number of beds normally available for convalescents. Admissions to general hospitals during 1940, compared with 1939, are shown below:— 1939 1940 Acute hospitals 157,174 143,296 Chronic sick hospitals 9,544 8,117 Convalescent hospitals 4,970 2,190 Epileptic hospitals 273 187 Venereal disease (Sheffield Street) 249 257 Children's hospital (Norwood) 620 * Vulvo-vaginitis and ophthalmia neonatorum 373 * Total 173,203 154,047 * Hospitals closed at outbreak of war—patients admitted elsewhere. The figures for the acute hospitals show that the reduction in the number of admissions is substantially less than the proportionate reduction in the population of London. The amount of operative work and the number of acute medical cases have, in particular, remained at a high level. 9 The number of patients under treatment in general hospitals during 1940 on the undermentioned dates were:— Date Acute hospitals Chronic sick hospitals Convalescent hospitals Epileptic hospitals Venereal disease 1st January, 1940 8,039 4,353 289 681 57 1st September, 1940 8,055 4,342 216 639 54 1st October, 1940 6,990 3,772 386 648 50 1st November, 1940 5,847 2,794 356 654 37 1st December, 1940 5,785 2,197 320 644 41 The number of births in the general hospitals fell from 19,328 in 1939 to 14,439 in 1940. Maternity The number of maternity beds available was 614 at the beginning of the year and was increased owing to demand until 801 were available in September. The onset of bombing was followed by a marked fall in the number of women seeking admission and some 480 beds were reserved for maternity cases for the remainder of the year. The maternal mortality rate in hospital was 2.81 per 1,000, compared with 2.84 per 1,000 in 1939. During the year, 46,152 persons were seen by the district medical service, while 59,379 persons were seen in 1939. The district nursing service visited 5,427 persons and made 215,882 visits, compared with 3,447 persons visited and 225,678 visits made in 1939. District medical service The arrangements with Queen Mary's Hospital, Roehampton (Ministry of Pensions), for the supply and repair of artificial limbs for Council cases, and the "following up" of patients at this hospital have been continued. During the year 153 applications from various sources were dealt with, a reduction on the number of 265 for the previous year. f Supply and , repair of artificial * limbs Special hospitals The year 1940 saw the taking into use under the Emergency Hospital Scheme of the accommodation at the special hospitals which, in most of the hospitals, had been re-allocated to meet the needs created by the war and also to admit the special classes of civilian sick for which they were established, e.g., fever and tuberculosis. The main problem was one of utilising the reduced accommodation for civilian sick, while at the same time keeping a reserve of beds to meet any eventuality which might arise as the result of a change in the character of the war. The accommodation set aside for the reception of casualties was not fully utilised as the number of cases fell well below the number anticipated. It was, therefore, possible when pressure was put on the reduced number of beds for tuberculosis and fever cases to supplement these by taking over beds earmarked for casualty cases; and, following this principle, three tuberculosis hospitals were released from providing any beds under the Emergency Hospital Scheme. Owing to the threat of invasion, two hospitals and one convalescent hospital were closed during the year. The loss of beds due to war conditions was offset largely by utilising wards closed at the beginning of the war when an attempt was made to reduce the population of hospitals. Throughout the year all demands for beds, both emergency and civilian, were met. The main factors which enabled this to be done were:— (a) The number of casualties falling below expectation. (b) Reduced admissions to children's and fever hospitals following general evacuation of children from London. (c) Low incidence of infectious disease throughout the year. 10 Infectious hospitals Details of the actual users of the three main groups of special hospitals are set out below. The authorised number of beds in the town fever hospitals at the beginning of the year was 965 for infectious patients and 2,450 for casualties, compared with the peace-time figure of 5,007 for fevers. About 1,000 beds were unavailable owing to war conditions, and these included the valuable isolation blocks. Early in the year a number of casualty beds were changed back for fever use, and, when pressure on the general hospitals became acute, about 1,500 general medical and surgical patients were dealt with in the casualty wards of the fever hospitals. Although the incidence of infectious disease was low during the whole year, there was a sharp epidemic of german measles in the early part of the year. Cases of cerebrospinal meningitis were also fairly numerous in the early part of the year, and later there was a clearly defined general rise in the number of all diseases due mainly to the seasonal increase in infections generally. To meet this increase in infectious cases, the casualty beds at the fever hospitals were reduced to 675. The highest number of fever patients under treatment during the year was 2,176 on 27th December. The lowest figure was 580 on 28th June; but, during the first six months of the year, the number under treatment never rose above 1,060 and indeed was as low as 700 on the first day of the year, indicating the effect of the evacuation from London of about half the children of school age, whose drift back to London did not for some weeks seriously influence the previous decline in infectious disease. At the end of the year 80 infectious patients were being admitted daily. This compares with 85 admissions daily in December, 1938, when there were 3,000 patients under treatment. The total number of infectious patients admitted to the fever hospitals during 1940 was 18,000, compared with 39,000 in 1938, which was a year of measles epidemic. The two-year cycle, under which the incidence of measles has hitherto regularly assumed epidemic proportions, was not followed in 1940. In addition, a fairly large number of Service sick patients were dealt with in certain hospitals during the early months of the year. Smallpox No patients were admitted to the smallpox hospitals during 1940. As South Wharf Receiving Station ceased to be available, arrangements were made with the Surrey County Council for the admission to the Clandon Hospital of any sporadic cases of this disease which might occur. Tuberculosis hospitals As stated above, St. Luke's Hospital, Lowestoft, Millfield Convalescent Hospital and St. George's Home were closed, and the accommodation for tuberculosis was further diminished by the allocation of beds for casualties at each of the tuberculosis hospitals. Owing to pressure on this reduced accommodation for tuberculosis patients, it became necessary to utilise some of the beds earmarked for casualties, and finally Grove Park and Heatherwood Hospitals and Pinewood Sanatorium were released from the obligation of reserving beds for casualties. The number of Emergency Medical Service patients admitted to the tuberculosis hospitals was small, but all available accommodation for tuberculosis patients was fully utilised. Children's hospitals The scheme whereby the Council makes grants to the invalid Children s Aid Association towards the cost of providing convalescent accommodation for children has continued, and a considerable number of children were sent away by this means. No convalescent accommodation for children was available in the Council's hospitals. At Queen Mary's and the Downs Hospitals for Children, where for various reasons the accommodation available was less than normal, the available beds were fully occupied, but were adequate to meet demands. Units for the reception of healthy nursery children and children of expectant mothers, evacuated under the Government scheme, were established at the Downs Hospital for Children and adult chronic sick patients were also accommodated there. On the outbreak of war, the vulvo-vaginitis unit at St. Margaret's Hospital and the congenital syphilis unit at St. John's Hospital were transferred to Queen Mary's 11 Hospital for Children and the ophthalmia neonatorum unit at St. Margaret's Hospital was transferred to White Oak Hospital. The transferred units have continued to operate at these hospitals during the year. The hutted additions to Pinewood and King George V Sanatoria, built for the Ministry of Health under their emergency hospital scheme, were taken out of the scheme during the year and used by the Government for other hospital purposes. Hutted hospitals Late in the year proposals of the Ministry of Health that the hutted hospitals at King George V Sanatorium and High Wood Hospital should be handed over to the authorities of St. Thomas's Hospital and the London Hospital, respectively, who would, in each case, be responsible for administration, were under consideration, and have since been implemented. The work of adaptation of the special hospitals included in the emergency hospital scheme of the Ministry of Health as casualty hospitals was proceeded with. Works Staff When medical practitioners became liable for calling-up for service in H.M. Forces arrangements, satisfactory for the time being, were made with the Ministry of Health and the Central Medical War Committee for the retention, for treatment of civilian sick, of the Council's staff of medical officers at its hospitals. In addition, arrangements were made with the Ministry and in conjunction with the Group Officers of Sectors for the appointment of a number of Emergency Medical Service medical officers at hospitals to deal with casualties. Especially were these necessary at fever hospitals to which surgeons are not normally allocated. In the early part of the year there were a number of vacancies for medical officers which it had not been possible to fill owing to other demands upon the medical profession ; but, as the number of civilian casualties resulting from aerial bombardment was not so heavy as was anticipated and as arrangements were made for the Council's and Emergency Medical Service staff's at hospitals to act in co-operation when necessary in dealing with both civilian sick and war casualties, no difficulties arose. Ten American ambulance first-aid units were attached to five hospitals, two at each hospital; and ten medical officers-in-charge were appointed, five from hospital staffs, their places being taken by Emergency Medical Service officers, and five selected by the appropriate Borough Councils from among local practitioners. The pre-war scheme for utilising the services of consultants at hospitals was continued, but on a reduced scale. A simplified procedure was adopted for the appointment and promotion of staff to fill vacancies. With the exception of appointments of clerical staff and probationer nurses, appointments and promotions made during the war are on a temporary basis and are subject to review at any time, and in any event on the conclusion of hostilities. Except in respect of certain specified positions, delegated powers were granted to medical superintendents, matrons and stewards to recommend appointments and promotions, and in the case of a few subordinate grades to make appointments and promotions direct, subject to formal approval by the Hospitals and Medical Services Committee. The staffs of "bombed" hospitals which were so badly damaged as to be put out of commission for a considerable period were transferred to other hospitals— to fill existing vacancies as far as possible. Nurses were transferred in many instances with the patients, but the male and female domestic staff were retained for some time after general evacuation for the purpose of clearing up or salvaging. The number of staff serving with H.M. Forces on 31st December, 1940, was as follows: medical, 15 (including 1 medical superintendent); nursing, 60 female (including 1 matron) and 157 male nurses, probationers and orderlies; domestic, 322 porters, etc.; clerical, 101 (including 1 steward); radiographers, 7; laboratory technicians, 8; miscellaneous, 7. 12 Pathological laboratory service At the outbreak of war, at the direction of the Ministry of Health, certain of the staffs of the group laboratories were transferred to laboratories outside London more appropriately situated for serving the outlying hospitals in which it was expected that most of the casualties were to be accommodated under the Emergency Hospital Scheme. A large amount of the equipment from the group laboratories was also transferred. As the declaration of war did not produce the state of affairs expected, and there were a large number of patients in the Council's hospitals, most of the staff and equipment were brought back early in the year by arrangement with the Ministry, and the Council's pathological service was re-established to the extent necessary. The arrangements were made subject to review from time to time as circumstances might require. Subsequent movements of staff have taken place, and, of a total laboratory staff of 175, only nine members were working in the Sector laboratories under the Ministry at the end of the year. In order to meet the needs of the Emergency Medical Service, laboratory facilities have been extended and pathological staff provided by the Emergency Medical Service at the Brook and Southern Hospitals and King George V and Pinewood Sanatoria. The group laboratory, established at Joyce Green Hospital under the supervision of the pathologist in charge of the group laboratory at Lewisham Hospital, continued to provide pathological services for the hospitals in the Dartford area. Owing to the diminution in the requirements of the Council's infectious diseases hospitals, supplies of diphtheria and streptococcal antitoxins, manufactured at the laboratories, have been made available to local authorities who are receiving financial aid from the Council for evacuated children. The production of tetanus antitoxin was continued at the laboratories and the manufacture of gas gangrene antitoxin was commenced during the year. A reserve of these products is being accumulated to meet the possible needs of war casualties. The Council continued throughout the year to supply the Ministry's pathological service in the London region with all standard " consumable " requisites, such as glassware, etc., and with materials such as culture media, vaccines, stains, etc. In order to cope with the greatly increased amount of work involved, extensive additional storage accommodation was provided at various premises in the vicinity of the group laboratory. On account of the reduced demand for products from the existing laboratories, it was decided that the taking into use of the Serum Institute at Carshalton should be deferred. In November, the Ministry of Health advised that the immunisation against diphtheria of London school children should be undertaken on a large scale and asked the Council to provide the material for the purpose. The Council has supplied large quantities in response to the Ministry's request. LONDON AMBULANCE SERVICE IN WAR TIME The London Ambulance Service was greatly expanded on the outbreak of war in order to convey casualties arising from air raids to first-aid posts or to hospitals. The expansion was brought about by the grafting of the London Auxiliary Ambulance Service on to the existing organisation. The peace-time service was supplemented by some 112 auxiliary stations, about 1,600 auxiliary vehicles, and between 6,000 and 7,000 men and women auxiliary drivers and attendants. The vehicles originally used for the auxiliary service were requisitioned vans which were for the most part unsuitable for the purpose. They have now been replaced by vehicles consisting of ambulance bodies fitted on to the chassis of private cars or by specially built light ambulances. In addition to these ambulances for recumbent patients, there are private cars used to convey sitting patients. 13 The vehicles and their personnel are accommodated in garages, schools, or other premises where the vehicles can be conveniently parked and the staff can find shelter, rest room, and feeding facilities. Many of the premises earmarked for this purpose before the war had to be replaced, as opportunity arose, by more suitable accommodation, and a standard has now been attained which is generally satisfactory from the point of view of operational convenience and comfort and health of the personnel. In order to meet war-time needs, the headquarters staff was supplemented by a number of units, including two divisional officers and their assistants, who act as peripatetic inspectors of the service and exercise general supervision, under the officer-in-charge, of the service. The accident section of the service, comprising 16 stations, is in charge of the headquarters superintendent. There are also six general ambulance stations, each under the control of a superintendent, from which is operated the fleet of peace-time vehicles used for hospital removals, etc., and which form the local administrative centres for the control of the auxiliary service. A small body of station officers of the regular service, under the direction of the superintendent at each general section station, visits the auxiliary stations and exercises supervision in detailed matters of operation and administration. At each auxiliary station an auxiliary station officer is in charge, and is assisted by a deputy and by shift leaders. The arrangements for paying the large auxiliary staff are in the hands of visiting pay officers whose duties are supervised and co-ordinated by a senior officer of the hospital finance division of the department. In the period from September, 1939, to August, 1940, the auxiliary personnel of the service received training in their duties by means of lectures and demonstrations in first-aid and anti-gas measures, and exercises in the operation of vehicles, including co-operation with other civil defence services, notably the stretcher parties which are controlled by the metropolitan borough councils. The service under conditions of intensive aerial warfare has functioned satisfactorily. The staff have responded with alacrity and courage to the calls made upon them. The service has operated without delay, in spite of many difficulties imposed by damage to roads, telephones, stations and vehicles; the joint working with other services has proceeded in the main without hitch. Casualties have been sustained both by regular and auxiliary personnel, and damage has been done to stations and vehicles. On the outbreak of war the operational control of all ambulances during periods of "alert" was brought under the direction of the London civil defence region (operating through group and borough controls). The group ambulance officers are Council officials and form a useful link between the ambulance service and the regional organisation. While this system works satisfactorily, so far as the movement of auxiliary vehicles for air-raid purposes is concerned, it resulted in serious delay in the handling of normal or "peace-time" patients (removals to and from hospitals, etc.); and, after representations had been made to the London regional authorities, the control of the peace-time ambulances was resumed by the Council so far as the general section (i.e., non-accident) of the service is concerned. This has resulted in a speeding-up of the service, and removed the delays which were occurring. SCHOOL MEDICAL SERVICE Government evacuation scheme Broadly speaking, the Government's schemes during 1940 provided for the evacuation of children in three groups: (a) a "trickle" every few days of school children unaccompanied by an adult relative; (b) a mass evacuation carried out over six days in June of 61,000 "unaccompanied" school children consequent upon the events on the Continent; and (c) an evacuation in the last months of the year 14 of pre-school and school children accompanied by their mothers, consequent upon the intensive aerial bombardment. In all, 150,256 children were evacuated under these plans, and the great majority were medically examined before departure from London. Also 31,951 mothers were evacuated, a large number of whom submitted voluntarily to medical examination. In addition, 114 London children were evacuated to Australia, Canada, New Zealand and South Africa. These children were all medically examined. The evacuation scheme provided also for the evacuation (originally in school units) of mentally defective, physically defective, blind and deaf children, and children in nursery schools. These "special parties of handicapped and very young children" are accommodated, in the reception areas, in camps or large country houses of the mansion type, and, with two exceptions, are managed directly by the Council. In December, 1940, there were, for London school children, 59 such parties (25 from nursery schools, 15 for the physically defective, 10 for the mentally defective, 3 for the blind, 4 for the deaf, 1 for tuberculous children, and 1 for diabetics), accommodating in all approximately 3,300 school children, of whom 2,292 were " handicapped " children. Frequent visits were made to these special parties by the Council's school medical staff for purposes of advice, decertification of defectives, etc. As far as possible, these parties are linked up with the local school medical services. Staff seconded to reception areas At the end of the year 5 of the Council's permanent full-time medical officers, 67 of the school nursing sisters and 15 of the organising staff of the children's care service had been seconded for service under the local authorities in the reception areas. In addition, 66 of the school nursing sisters were employed for nursing duties with the "special parties" of evacuated handicapped and very young children accommodated in camps and large houses in the country districts, for whose management the Council has accepted responsibility. Medical inspection The number of children of school age still in London at the beginning of 1940 was computed at 180,000 and at the end of the year at 85,000. In the first three months of the year, parents of children out of school were invited by means of postcards to present their children for medical inspection. Under this scheme, 57,665 children were examined. During the same period, emergency schools were being re-opened at which comprehensive medical inspections were made of children of all ages. By Easter 37,144 children had been inspected at these emergency schools. Particulars of detailed examinations at schools are as follows:— Children in special schools 400 Children inspected at emergency schools ... 37,144 "Postcard" examinations 57,665 Children not in the four prescribed age groups 39,045 134,254 "Age groups" inspections, viz.: — Entrants 7,377 Children aged 7 8,830 Children aged 11 15,884 Leavers aged 13 15,146 47,237 181,491 No doubt, owing to disturbed school conditions, there must have been a number of duplicate examinations. These conditions also interfered with the re-inspection of children formerly noted to have defects, as the number of re-inspections totalled 246 only. In addition, 2,007 re-inspections were made of children who were being 15 given school meals (including milk and cod-liver oil) on the advice of the school doctors, head teachers or school care committees. Children who were specially examined at the request of the teachers, care committees, etc., numbered 6,903. The following comparisons are made in regard to the 47,237 children who were examined in the four age groups in 1940 and the 169,995 examined in the same age groups in 1938, the last complete year of medical inspection. The figures in brackets relate to the whole year 1938. The nutrition of the children was assessed as satisfactory in 93.3 (93.4) per cent. The percentage of children found with nits or pediculi in the hair was 31 (2.3). This shows some deterioration. Up to 1938 the results of these inspections showed progressive improvement, so that there is no doubt that war conditions have produced a retrograde effect in this respect. Medical inspection showed that 65.2 per cent. of the children were found to have sound dental conditions compared with 70.2 in 1938. On the other hand the percentage of children with normal vision increased from 67 .8 to 77.3. The following figures relate to findings of general health conditions:— Percentage 1940 1938 Adenoids and enlarged tonsils 3.5 9.2 Skin diseases 1.7 l.0 Enlarged glands, 0.8 1.5 External eye disease 1.5 1.7 Ear discharge and hearing— Otitis media 0.3 0.6 Defective hearing 0.2 0.2 Heart disease 1.1 1.4 Anaemia 0.3 0.4 Lung disease 0.6 1.5 Tuberculosis (pulmonary) 0.02 0.04 „ (other lesions) 0.05* 0.02 Rickets (boys—entrants)1.5 l.0 „ (girls—entrants) 1.2 0.4 * Some of the children concerned would no doubt have been in attendance at special "P.D." schools under peace-time conditions. In making a comparison between the figures of 1938 and 1940 important considerations must be kept in mind. Firstly, the children in London were a remnant and evacuation might have had a selective influence. Secondly, the age groups in 1940 were not of equal weight as older children were attending school in much larger numbers than younger children and conditions which normally appear more often in older children would be exaggerated, and conversely those appearing more often in younger children would be artificially diminished. With regard to the "postcard" examinations in the first three months of the year of children of all ages not attending school, 10.8 per cent. were reported as showing defective nutrition, 91.2 were noted as clean and 63.8 as being sound in dental condition. Corresponding figures for the children seen in the same period at emergency schools were 7.9, 94.1 and 72.6. These comparisons are interesting as showing how regular school life leads to greater care being taken. Much importance is attached, in examination of leavers, to the question of choice of employment. For the first time this report is able to give some information as to contra-indications. Of 7,395 leaver boys examined 90.2 per cent. were fit for any employment. Of 7,751 girls 89 per cent. showed no contra-indications. Work involving heavy normal tasks was contra-indicated in 1.89 per cent. of the boys and in 2.24 of the girls. "Prolonged standing "was deprecated in .87 per cent. of the boys and in 1.44 of the girls. The biggest groups of contra-indications were in work involving eye strain (4.44 per cent. boys and 5.29 girls) and in work requiring acute distant vision where the percentage for boys was 4.49 and for girls 4.98. "Contraindications" of leavers 16 Examinations in connection with special schools In December, about 40 special classes for defective children were functioning in London. In all, 864 children were examined in London or in the reception areas as to their suitability for special education. Of these, 127 and 291, respectively, were certified as fit for instruction at day schools for the mentally or physically defective. Of the children attending and seen in special schools and at the special parties for handicapped children, 165 were sufficiently improved to justify return to elementary school instruction, and 128 children over 14 years of age were excluded from special schools as being no longer certifiable. Higher education institutions Dental inspection At higher education institutions 3,273 students were inspected. In addition, 200 reviews and re-inspections were carried out. During the year, 57,341 children were submitted for inspection by the school dental surgeons and 44,818 were found to need treatment, a percentage of 78*1 compared with 69.7 in 1938. Medical treatment In all, 63,158 children received treatment at the various centres, of whom 31,180 were dental cases. During the year, 302 children were admitted to the Council's hospitals as in-patients for the treatment of rheumatism, and 335 were discharged therefrom. Thirteen of the rheumatism supervisory centres functioned, at which 432 children were seen at some time during the year. At the nutrition centres 166 children were specially examined. Personal hygiene scheme Owing to enemy action some of the records relating to personal hygiene examinations in schools by the nursing staff were lost, but, of 329,697 examinations, records of which are extant, 7.9 per cent. showed verminous infestation, including some very slight cases, compared with 6.6 in 1939 and 7.3 in 1938. During the year, 37,696 children were dealt with at the children's bathing centres. Milk in schools scheme The education officer has given the following figures as to the " milk in schools " scheme— Date No. of school children in London No. of children having milk Percentage receiving milk Percentage of "free " cases of those receiving milk 1. 3.40 31. 5.40 15.11.40 19. 2.41 200,000 (estimated) 161,126* 23,473* 65,948* 53,578 (includes 30,000 out of school) 96,544 14,015 43,717 Actually attending school 265 59.9 59.7 66.3 59 7.7 6.9 4.17 Effect of air raids on school children Enquiries as to the effect of air raids on school children were, in November, made from the doctors who had been daily working among the children in the schools and in the rest centres and in the examination of the children registered for evacuation. The unanimous response was that no evidence had been found of nervous disorder or shock arising from air-raid experience, but that the children were standing up to it as well as, or better than, the adults. It is of interest to record that the routine examinations of 15,000 children were carried out in school during the last four months of the year, in spite of the attempts by the enemy to interfere with our normal routine. Infectious disease in schools The usual arrangements were made regarding the control of infectious diseases in such schools as were open in the year, but the figures which are available as to incidence of diseases are vitiated by reason of the great movements of the school population due to the various evacuation schemes.