LCC 49 LONDON COUNTY COUNCIL Interim Report of the County Medical Officer of Health and School Medical Officer for the year 1942 Published by the LONDON COUNTY COUNCIL, And may be purchased, either directly or through any bookseller, from P. S. KING AND STAPLES, Limited, 14, Great Smith Street, Victoria Street, Westminster, S.W.1, Agents for the sale of the publications of the London County Council. 1943 No. 3518. Price 6d. Post free 7d. London County Council INTERIM REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1942 By W. Allen Daley, M.D., F.R.C.P., County Medical Officer of Health and School Medical Officer. INTRODUCTION This interim report sets out in an abbreviated, and mainly statistical, form the salient features about the health of Londoners during 1942, at the beginning of which we had already endured 28 months of war. Fortunately the intensive air bombardment of 1940 and 1941 was not resumed, but there were occasional raids and the medical and other civil defence services were manned and in a state of readiness for instant action throughout the year. The drain of man-power and woman-power into other forms of war work continued, and caused increasing strain on those remaining to carry out the work of the department. It is not possible to give the population of London, but the number of children in the metropolis increased substantially during the year and this was reflected in increased activity in the school medical and hospital services. As in 1941, the report gives only the numbers of deaths and of notifications from infectious diseases and not the rates per 1,000 of the estimated population. Rates based on births are, however, provided. The deaths relate to those with a domicile in London, independently of whether the death actually occurred in London or not. Similarly, the domicile of a mother, and not where the birth occurred, determined whether the birth of her child was counted as a London birth or not. The deaths of Londoners numbered 43,537 in 1941, and 36,057 in 1942. Deaths from violence, including air raids, and from street accidents showed a substantial reduction. Deaths from influenza were only 198, compared with 397 in 1941, and from rheumatic fever 29, compared with 40. Infectious diseases showed gratifying decreases: cerebro-spinal fever 105 to 46, enteric fever 17 to 5, measles 51 to 31, and diphtheria 82 to 51. There was also a reduction in deaths from pneumonia from 2,524 to 2,064. The increased numbers of children immunised against diphtheria have, no doubt, contributed to this decline, but many more will have to be immunised before we achieve the almost complete disappearance of diphtheria as a cause of death which has occurred in certain American cities. Scarlet fever again made only a negligible contribution to the death-rate, 1 death in 1942 and 2 in 1941. The births numbered 40,654, compared with 33,944 in 1941, the proportion of male to female births being 1,061 male to 1,000 female, compared with a proportion of 1,057 male to 1,000 female for the five pre-war years. Illegitimate births, included in the 40,654, numbered 3,015, a percentage of 7.4 compared with 6.3 in 1938. The rate of neo-natal mortality declined from 28.4 per 1,000 live births in 1941 to 24.7 in 1942, and the rate of infantile mortality from 57 to 50. The record low rate 47, was attained in 1939. The rate in 1917, the corresponding period of the last war, was 104. The rate of maternal mortality was 2.51 in 1942 and 3.05 in 1941, but the rates of 1940 and 1939, 1.98 and 1.97, respectively, remove any ground for complacency. No statistics are available relating to the total amount of illness among the population, not even among those entitled to medical benefit under the National Health Insurance Act, and our only information on morbidity is the number of cases 600 (M°C. 50301) 1969 (1) 2 of the diseases which are notifiable compulsorily. These do not assist in an assessment of industrial man-power and woman-power lost through illness, as the heaviest incidence of the notifiable infectious diseases is among children. They do, however, throw light on the trends of the epidemic cycles and on the value of measures taken to prevent their spread. As rates per 1,000 of the population at risk, cannot be given this year, it must be borne in mind, when studying the figures, that the child population of London was substantially higher in 1942 than in 1941. Notifications of measles increased from 11,039 in 1941 to 19,987, and of scarlet fever from 2,372 to 4,416 ; those of whooping-cough declined from 7,944 to 6,234, and of diphtheria from 2,179 to 1,813. Dysentery, which affects all ages, was notified in 749 cases compared with 610 in 1941, but enteric fever declined from 210 to 67. Tuberculosis is an important index of the well-being of a community. The notifications are still increasing—4,734 of lung cases and 796 of non-pulmonary, against 4,577 and 675 in 1941; but there has been a substantial fall in the deaths— 2,164 pulmonary and 283 non-pulmonary, compared with 2,552 and 343 in 1941. It may be that the adverse climatic conditions in the early months of 1941 and the effects of aerial bombardment (shelter life, etc.) in 1940-41 caused the deaths of a certain number of tuberculous persons in 1941 who, but for these factors, would have survived until 1942. This disease still takes a very heavy toll of health, and indeed of life, and steps are being taken to discover patients earlier, when there is more hope of a satisfactory result of treatment, by means of miniature radiography, but details must await the report for 1943. Comment on the venereal diseases is necessary in a war-time report. A casual glance at the statistics—1,369 cases of male and 917 of female syphilis attending the clinics for the first time, compared with 1,799 and 1,065 in 1938, and even greater reductions in the case of gonorrhoea, might give the impression that all was well, but it must be remembered that the clinics deal mainly with civilians, who, at the ages mostly concerned, 18 to 30 years, are not nearly so numerous, especially the men, as in 1938. New cases among women have increased year by year since 1940. There is little doubt, that, in each sex, the incidence rate is increasing. Another factor is that drug treatment of gonorrhoea is now so successful that many patients who would formerly have attended the public clinics are being treated by private practitioners. The publicity given recently to the dire effects of these diseases on the public health is to be greatly welcomed. The number of patients, 178,182, compared with 154,232 in 1941, admitted to the Council's public health hospitals continues to increase. The decline in admissions to the mental hospitals continues. There were 3,873 in 1942 and 3,966 in 1941. The school medical service has had to expand again in 1942, owing to the return of children to London. As the medical staffing is mainly by private practitioners, employed part time, the additional help required has been available. The results of routine inspections show that the health of the children is well maintained, and there has been no decline in the nutritional condition. Periodic weighing and measuring of groups of children have been resumed, and the results generally bear out the above findings. The social scourges, verminous infestation and scabies, which, at one time, appeared to be getting out of hand, are now beginning to decline in incidence. The deterioration of the children's teeth, compared with their pre-war condition, continues, but to a lesser degree. The increased birth-rate caused great pressure on both institutional and domiciliary maternity services. Institutional confinements in the Council's hospitals increased from 7,793 in 1941 to 12,230 in 1942, and domiciliary confinements under the Council's scheme from 6,543 to 11,323. In addition, arrangements were made under the Government's evacuation scheme, for a large number of expectant mothers, to be evacuated to the country for their confinements. 3 As a contribution to the "grow more food" campaign, the farming activities of the department have been very greatly extended, and some 6,000 acres are now under cultivation. It has been possible in this short review to bring to notice only the more striking features of a year in which all the peace-time work of a great and complex department continued unabated, and to which were added many new duties, often accompanied by anxieties and difficulties occasioned by the war. The work of a public health department is very largely "taken for granted." It is only when it fails that public interest is really aroused. It is a tribute to the staff of the department that, despite the unprecedented calls made upon them during the past few years, each has played his (and very largely her) part to respond to the call of duty and ensure that this vital service runs smoothly and efficiently. It is with pleasure that I record the award of the O.B.E. to Dr. P. J. Watkin, medical superintendent of Lambeth Hospital, and of the British Empire Medal to Mrs. Hilda L. Watts, station officer in the Auxiliary Ambulance Service. 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 it is considered inadvisable to give rates per 1,000 of the population. Actual figures of births and civilian deaths are alone given. To assist in their interpretation it can be stated that the population of London though much smaller than before the war, remained comparatively stable during 1942, and the numbers shown below for 1941 and 1942 are roughly comparable. Favourable features of the vital statistics are the smaller number of deaths, the recovery in the number of births and the reductions in the infant and neo-natal mortality rates, which have returned almost to the immediate pre-war level. Mortality from the common infectious diseases was light, and deaths from respiratory disease were relatively low. So far as morbidity is concerned, there was a substantial reduction in notifications of cerebro-spinal fever, enteric fever and diphtheria. For measles, 1942 was not a typical inter-epidemic year, probably owing to the continued movement of children to, but more especially from, reception areas. A temporary resurgence of measles occurred in the middle of the year. Pneumonia notifications were lower than in 1941. The incidence of whooping-cough was lower. The rise in scarlet fever notifications is almost wholly a reflection of the increase in the child population. There was a rise in notifications of dvsenterv. The principal vital statistics for 1942, together with the corresponding figures for 1941, are set out below. 1942 1941 Marriages (approximate) 33,246 35,165 Births 40,654 33,944 Deaths—All causes—Males 18,9721 36,057 23,133 43,537 Females 17,085 20,404 Infant mortality per 1,000 live births 50 57 Neo-natal mortality (0—4 wks.) do. 24.7 28.4 Cancer—Males 2,962 5,764 2,884 5,543 Females 2,802 2,659 Cerebro-spinal fever 46 105 Diphtheria 51 82 „ crude case mortality percentage 2.8 3.8 Encephalitis lethargica 29 51 Enteric fever 5 17 Heart disease 9,294 10,374 Influenza 198 397 Measles 31 51 „ crude case mortality percentage 0.16 0.46 Pneumonia (all forms) 2,064 2,524 4  1942 1941 Deaths—Poliomyelitis and polioencephalitis 3 9 Puerperal fever 46 40 „ „ per 1,000 live births 1.13 1.47 Other puerperal causes 56 43 „ „ per 1,000 live births 1.38 1.58 Total maternal mortality 2.51 3.05 Rheumatic fever 29 40 „ „ (0-15) 5 1 Scarlet fever 1 2 „ „ crude case mortality percentage 0.02 0.08 Street accidents 286 373 Whooping-cough 101 111 Infectious diseases Infectious disease notifications (civilians only) are shown below:— 1942 (52 weeks) 1941 (53 weeks) Anthrax 1 1 Cerebro-spinal fever 341 706 Continued fever 1 2 Diphtheria 1,813 2,179 Dysentery 749 610 Encephalitis lethargica 3 10 Enteric fever 67 210 Erysipelas 1,034 1,171 Malaria 16 13 Measles 19,987 11,039 Ophthalmia neonatorum 210 185 Pneumonia (acute, primary and influenzal) 2,246 2,518 Poliomyelitis and polioencephalitis 25 41 Puerperal fever 110 94 „ pyrexia 505 340 Relapsing fever — 1 Scarlet fever 4,416 2,372 Whooping-cough 6,234 7,944 Smallpox There were two notifications of smallpox, only one of which was confirmed, none of typhus fever during 1942, and none for either disease in 1941. Diarrhœa and enteritis Diarrhœa and enteritis caused 324 deaths, compared with 172 in 1941, among children under two years of age, or 8.0 per thousand five births. The death-rates from these causes per 1,000 live births in London and England and Wales in recent years are shown in the following table:— 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 London 9.71 12.55 11.74 12.80 11.31 14.47 12.29 13.23 8.36 6.13 6.30 7.97 England and Wales 5.90 6.60 6.98 5.36 5.56 5.75 5.54 5.30 4.60 4.76 5.08 5.22 Tuberculosis Particulars in regard to tuberculosis are given below (the figures for 1941 being shown in brackets):— Pulmonary Non-pulmonary Deaths 2,164 (2 552) 283 (343) Primary notifications 4,734 (4,577) 796 (675) Cases on the registers of the metropolitan boroughs (including City of London) at end of 1942:— Males 12,894 (12,677) 2,785 (2,916) Females 9,441 (9,119) 2,963 (3,044) Total on registers 22,335 (21,796) 5,748 (5,960) When the population at risk is taken into account there is reason to believe that the sharp upward trend in the rate of occurrence of new cases of tuberculosis which occurred in 1941 was considerably retarded in 1942. Mortality was much reduced. 5 GENERAL PUBLIC HEALTH Housing Representation of unfit premises under Section 25 of the Housing Act, 1936, has remained in abeyance during 1942, but there has been a substantial increase in the number of applications for preferential consideration for rehousing on the Council's estates on grounds of ill-health. Appropriate recommendations were made thereon to the Council's valuer. Tuberculous milk Milk sampling for the presence of tubercle bacilli has continued throughout the year, and 32 (4'4 per cent.) of 734 completed examinations of milk showed the presence of tubercle bacilli. No sample of tuberculin-tested milk (of which 8 were taken) yielded a positive result. Accredited milk showed a ratio of 4.5 per cent., and ungraded milk of 4.4 per cent. positive. During the five years 1937-41, 1,446 samples of accredited and 5,119 of ungraded milk were examined; 9.9 per cent. of the former and 6.6 per cent. of the latter were found to be tuberculous. The milk sampled in 1942 was received from 13 counties; 18 cows were dealt with under the Tuberculosis Order, 1938. The source of infection was traced in 53.1 per cent. Venereal diseases The work of the clinics and hostels included in the London and Home Counties Scheme for the free diagnosis and treatment of venereal diseases has, owing to the lull in enemy air-raids, proceeded under more normal conditions than in 1940 and 1941, and there has been no further reduction on account of enemy action in the facilities afforded. Endell Street Clinic, formerly part of St. Paul's Hospital, was officially taken over by the Council on 9th March. Work carried out at the clinics The following is a summary of work done at the London clinics for all areas from 1936:— Year New cases Total venereal cases Total non-venereal cases Syphilis 8. Chancre Gonorrhœa M. F. M. F. M. F. M. F. M. F. 1936 1,866 1,055 275 21 7,724 2,319 9,865 3,395 8,076 4,741 1937 1,783 1,144 211 8 7,636 2,316 9,630 3,468 7,718 5,009 1938 1,799 1,065 235 9 7,120 2,151 9,154 3,225 8,249 5,269 1939 1,573 904 164 5 5,982 1,652 7,719 2,561 7,468 5,008 1940 1,493 709 146 9 4,591 1,319 6,230 2,037 5,383 3,515 1941 1,381 773 205 12 3,862 1,425 5,448 2,210 4,675 3,709 1942 1,369 917 148 9 3,082 1,444 4,599 2,370 4,960 5,177 Year Total attendances In-patient days Pathological examinations for M. F. M. F. Clinic Practitioners 1936 807,397 294.981 23,214 34,128 263,050 37,748 1937 726,120 274,322 22,666 32,363 266,128 36,675 1938 588,815 263,908 20,608 32,303 263,710 48,763 1939 412,067 189,355 13,030 22,715 223,696 40,176 1940 305,693 131,375 9,907 11,236 153,695 35,554 1941 224,954 122,492 13,708 10,459 135,152 34,981 1942 222,864 155,559 16,991 13,787 164,459 61,897 Service patients During the year 653 service patients attended the clinics in the Scheme; 2,566 service attendances were made at the centres and 11,359 service pathological tests were carried out in the approved laboratories. 6 In addition to the above, the Council's Sheffield Street Hospital (78 beds) continued to take cases of pregnant women suffering from venereal disease, and at Queen Mary's Hospital for Children, Carshalton, the unit (36 beds) for children suffering from congenital syphilis and vulvo-vaginitis continued its work. Propaganda In order to reduce the dangers to public health and the drain on man-power caused by the spread of the diseases, an intensive publicity campaign was inaugurated by the Ministry of Health. The dangers of the diseases and the necessity for early and continuous treatment were publicised by radio, by posters and in the daily press. On 1st April, 1942, the Central Council for Health Education had, by arrangement with the Ministry of Health, assumed the functions hitherto discharged by the British Social Hygiene Council in relation to educational work on the prevention and treatment of venereal diseases. In a circular dated 8th January, 1943, to medical officers of health, the Chief Medical Officer of the Ministry of Health stated that it might be thought desirable to present information about V.D. as part of health education generally rather than in isolation. The practice and literature of the Central Council were devised with this in view. On 27th March the Ministry of Health informed medical officers of health of County Councils and County Borough Councils that the Minister of Health regarded the education of the public in the dangers of venereal diseases as particularly urgent, owing to the increase of the incidence of the diseases. Local authorities were asked to consider what further steps should be taken to meet the needs in their respective areas and to make full use of the services offered by the Central Council for Health Education. The subject of V.D. propaganda was discussed from time to time with representatives of the Central Council by officers of the department. The Central Council arranged many meetings and cinema exhibitions in London for various A.R.P. units and youth committees, in spite of some difficulty in finding suitable public halls. Open-air meetings were also held in Hyde Park. A letter, sent to the Central Council for use as an introduction to business firms, enabled a large number of employees of firms in the London area to be instructed. During the year all four main line railway companies agreed to display in conveniences at their stations posters giving details of the treatment facilities in London. In addition, the London Passenger Transport Board consented to affix similar posters in Underground Station lavatories. Posters are now in position in most of these places. With a view to giving further publicity to the facilities provided under the London and Home Counties V.D. Scheme, approval was obtained for the insertion of advertisements in the daily press stating the names and addresses of the hospitals and clinics. Defence Regulation 33 b The system of voluntary attendance for treatment under conditions of secrecy and free of charge, which has obtained since 1916, has met with a large measure of success; but, in order to deal with the problem presented by infected persons who decline to attend voluntarily for treatment and who consequently act as sources of infection, Defence Regulation 33B (providing for compulsory treatment of venereal diseases in certain circumstances) was added to the Defence (General) Regulations towards the close of the year. The instructions to local authorities were not received during 1942 and no action under this Regulation had therefore been taken at the end of the year. Dispensary service Treatment of tuberculosis The number of patients' names on the dispensary registers at the end of the year was 20,527, compared with 19,800 at the end of 1941, and 21,740 at the end of 1938. The dispensary service continued to function satisfactorily having regard to war conditions. The tuberculosis officers for Camberwell and Hammersmith joined His Majesty's Forces, entailing a revision of the arrangements in these boroughs. 7 Arrangements were made by the Camberwell Borough Council for the assistant tuberculosis officer to carry on the normal weekly sessions, and for the giving of artificial pneumothorax refills by the Southwark tuberculosis officer. At Hammersmith, where the dispensary is now established at the Council's Hammersmith Hospital, the tuberculosis officer's duties are being performed by a member of the staff of the British Post-Graduate Medical School. After-care clinics The after-care department of Queen Mary's Hospital for Children, formerly held at Carshalton, was transferred to the County Hall; those after-care clinics for other hospitals already held there continued to function on the usual lines. Boardingout of child contacts The Invalid Children's Aid Association experienced great difficulty in placing children under the age of 5 years, and arrangements were made for vacancies to be 1 allocated for this purpose in some of the Council's evacuated nurseries. During \ the year, 140 child contacts were boarded-out with foster-parents, or in children's homes or nurseries, an average number of 83 being maintained. At the end of the vear 98 children were still boarded-out. Open-air schools (type T) The children from the open-air school at the Riviera Lido Holiday Camp, Bognor, were transferred to a country mansion in Hertfordshire. An open-air school for children aged 2-5 years was opened in Devon in September, and one for older boys in Hertfordshire in November. A number of children were waiting for vacancies in residential open-air schools at the end of the year. Residential treatment The number of recommendations for residential treatment with the corresponding figures for 1941, 1940 and 1938 (the last pre-war year) were:— Year Men Women Children Total 1942 3,394 2,594 754 6,742 1941 3,356 2,310 630 6,296 1940 3,854 2,681 479 7,014 1938 (last pre-war year) 4,341 3,121 996 8,458 The large increase in the number of recommendations in respect of children in 1941 over 1940 continued in 1942. The decrease noted in the recommendations, both men and women, in 1941 compared with 1940, was not maintained in 1942, when the number of recommendations for both sexes increased, particularly for women. Pleural effusion unit Early in the year a ward of 30 beds was set aside at Queen Mary s Hospital, Sidcup, for the observation and treatment of adult male patients suffering from pleurisy, pleural effusion and symptomless minimal lesions of non-infectious pulmonary tuberculosis. Within a few weeks of the establishment of this special unit it was fully occupied. Subsequently the provision was increased and at the end of the year accommodation was available for 60 male and 48 female patients (exclusive of nurses from the Council's own hospitals, who are treated in accommodation reserved for sick nurses). It is intended that the experience gained at this unit should be specially noted for future guidance, particularly as to the proportion of the patients who ultimately develop lung lesions. The numbers of beds occupied by patients under the tuberculosis scheme on 31st December, 1942 (with corresponding figures for 1941 and 1938) were as follows:— Adults Children 1942 1941 1938 1942 1941 1938 Council's special hospitals and sanatoria 1,264 (129) 1,081 (65) 1,299 (1) 525 497 658 Council's general hospitals 654 (18) 577 (15) 1,010 (6) 10 15 13 Voluntary institutions 1,170 (106) 1,195 (78) 1,134 (16) 57 56 60 Total 3,088 (253) 2,853 (158) 3,443 (23) 592 568 731 The figures in brackets represent the number of ex-Service men (included in the figures) whose tuberculous condition has been accepted by the Ministry of Pensions as connected with war service. 8 Blind persons During the year, 1,011 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, 769 (331 male and 438 female) were certified as blind, and 242 (81 male and 161 female) were found not to be blind. In addition, 107 certificates (34 male and 73 female) from voluntary hospitals, outside authorities or private ophthalmologists were accepted as evidence of blindness, and 8 (1 male and 7 female) as not evidence of blindness. Thirty-six blind persons were examined as to suitability for training and 31 (22 male and 9 female) were found suitable. Domiciliary midwifery service— London County Council midwives Midwives Acts, 1902 to 1936, nursing homes registration and contributions to voluntary organisations for maternity and child welfare There was a gradual rise in the weekly number of domiciliary confinements attended by the Council's midwives during the second half of 1941. During 1942 this increase was maintained and 6,137 confinements were undertaken compared with 3,570 in 1941. At the end of the year the total number of midwives on the staff was 102, and the average number employed throughout the year (permanent and temporary) was 86.6. The following is a statement of the number of confinements undertaken by the Council's own midwives during 1942, compared with the year 1938, which was the first year of the Council's domiciliary midwifery service:— Maternity nursing cases M idwifery cases Total 1942 379 5,758 6,137 1938 449 2,924 3,373 Two non-medical supervisors' positions were substituted for that of one medical supervisor. Increasing difficulties were experienced by newly recruited midwives in establishing their homes, and it was necessary to make special arrangements for the supply of furniture and gas appliances. In one case a house was obtained by the Council and let to two midwives. Domiciliary midwifery service— voluntary organisations There was a similar rise in the number ot district confinements undertaken in 1942 compared with 1941 (5,186 against 2,973) by the voluntary organisations included in the Council's domiciliary midwifery scheme. The total numbers of confinements undertaken by the voluntary organisations during 1942, compared with 1938, were as follows:— Maternity nursing cases Midwifery cases Total 1942 Voluntary hospitals domiciliary service District nursing associations 109 3,279 3,388 369 1,429 1,798 Grand total 5,186 1938 Voluntary hospitals domiciliary service 251 5,484 5,735 District nursing associations 606 1,158 1,764 Grand total 7,499 It will be observed, from the number of maternity nursing cases undertaken by the Council's own midwives and by district nursing associations during 1942, compared with the number undertaken during 1938, that there has been a decrease in the number of confinements for which the midwife was booked as maternity nurse. Payment of medical fees 9 Fees paid under the Midwives Act, 1918, to medical practitioners called in by midwives in emergencies amounted to £6,032, compared with £3,344 in 1941. Claims for fees were 4,748 in 1942, compared with 2,168 in 1941. Registration of nursing homes There were 106 nursing homes on the register at the end of the year, compared with 109 at the end of 1941. These numbers include homes closed temporarily owing to the war. Maternity and child welfare work by voluntary associations Grants paid to voluntary maternity and child welfare organisations during the year 1942 under Section 101 (6) of the Local Government Act, 1929, amounted to £20,683 (with one amount still to be determined) compared with £23,494 in the year 1941. Thirty-four associations were grant-aided during the year, of which 6 were maternity hospitals, 16 mother and baby homes, 5 baby homes and 7 district midwifery practices. Of these 34 associations, 14 were functioning in London and 19 in the country. One was working in both London and the country. Medical examination of staff The number of references made to the department for medical examination or advice concerning the health of staff and of members of the civil defence services was 15,467, compared with 15,101 in 1941. The total for 1942 includes nearly 500 recruits to the National Fire Service and 97 examinations of staff discharged on medical grounds after service with H.M. Forces. The sick parade at the Council's hospitals, referred to in my Interim Annual Report for 1941, was continued for the civil defence services, and the numbers of medical examinations made at sick parades are not included above. Only cases of doubtful fitness for the civil defence services are referred to the Council's examining medical officer for a decision. In a few cases (at the request of provincial medical officers of health) I have arranged for the medical examination of individuals from their areas staying in London, and similarly some evacuated London staff have been medically examined in the provinces. This reciprocation serves a useful purpose and is much appreciated. Chemical branch The work of the chemical branch was carried on during the year at the three laboratories, the total number of samples examined being 20,588. Central laboratory War conditions have had a considerable effect on the work entailing, for instance, the examination of possible substitutes for materials in short supply : rubber goods (waterproof sheeting and surgical tubing) are examples. Specifications for compounded medicaments have been changed for similar reasons. In the case of human foods, too, variations have had to be allowed, such as the alteration in the specification for baking powder, admitting the use of the phosphatic type in view of the shortage of tartrate supplies. The claims made by manufacturers for some substitutes have been found not to be justified, instances being a starch substitute and a fuel economiser. Among other work directly arising from the war may be mentioned: (a) the analysis of meals as to their energy value and content of protein and fat (this examination was in the first place undertaken at the request of the chief officer, meals services, in regard to school meals and later was extended to include British Restaurant meals; at the request of the Ministry of Food the investigation was linked up with the scientific survey undertaken by that Ministry on the subject, and the results were communicated for inclusion in the Ministry's periodical reports); (b) the condition of emergency supplies of drugs after considerable periods of storage, e.g., solutions for hypodermic injection; (c) the scientific control of steam raising plants to effect economy of fuel; (d) the manurial use of sewage products; (e) the examination of possible sources of emergency water supplies. 10 The regular examination of the drinking water at Council's hospitals and institutions served by private wells was continued throughout the year. In all cases chlorination is applied, and four cases of temporary pollution of the untreated water were followed up until conditions again became normal. The regular examination of the air in the vehicular tunnels at Blackwall and Rotherhithe showed that the ventilating plant had maintained the atmosphere in a satisfactory condition, and on the basis of the results the chief engineer was able to make a further economy in the use of electrical energy by reducing the number of fans in operation. Statutory work under the Fertilisers and Feeding Stuffs Act, 1926, and the Petroleum Consolidation Act, 1928, was done as required, and the results of examinations on atmospheric pollution were communicated to the Department of Scientific and Industrial Research for inclusion in its reports on this subject. Other investigations and recommendations were made on: (a) corrosion and scale formation in a set of Diesel pumping engines; (b) corrosion of sterilisers at a hospital; (c) several materials claimed to have virtues as waterproofers for building surfaces, concrete, etc.; (d) the possible carcinogenicity of oils used for floor treatment; (e) the chemical destruction of weeds; (f) the vitamin content of concentrated fruit juices; (g) the use of cocoa husk as an ingredient of poultry food; (h) the corrosion of injection syringes when immersed in disinfectants for sterilisation purposes. Sewage disposal Analytical work in connection with the disposal of sewage proceeded as formerly. In addition to the primary sedimentation process by which the sewage was treated at both outfalls, parts of the flow at the Northern Outfall were further subjected to secondary sedimentation and activated sludge treatment. The sludge digestion plant produced a good yield of gas which was used for heating purposes. In order to obtain information as to the condition of the river Thames, into which the effluents are discharged, periodical samples of river water were examined, these being taken at various points from Kew down to the sludge dumping area, the position of which is fixed, during wartime, by Admiralty orders. The work on the manurial use of sewage products mentioned in the report for 1941 was continued, but difficulty was caused from the composting aspect by the very small organic matter content of the house refuse available; this was, of course, due to the intense salvage campaign. At the request of the chief engineer the cause of an explosion which occurred in a sewer was investigated: although it could not be definitely proved, since the direct evidence was destroyed in the actual event, the most probable cause seemed to be the ignition of benzole. The need for the most efficient possible ventilation of sewers was one of the principles recommended in the report on this matter. HOSPITALS AND ANCILLARY SERVICES General and special (other than mental) hospitals The almost complete freedom of London from air raids during the year and the consequent return to the metropolis of many children and adults from reception areas resulted in a large increase in the amount of work in the Council's hospitals. Throughout the year seven hospitals remained closed, namely, St. Luke's Hospital, Lowestoft; Millfield Convalescent Hospital; St. Anne's Home; Princess Mary's Convalescent Hospital; Norwood Hospital for Children; St. Margaret's Hospital; and the South-Eastern Hospital. St. Matthew's Hospital, which had been closed since October, 1940, was reopened on 9th November, 1942; St. Luke's Hospital, Chelsea, which had been closed since May, 1941, was re-opened as a hospital for chronic sick patients on 1st December, 1942; and St. George's Home, which had been closed since November, 1940, was re-opened on 2nd February, 1942. St. Peter's Hospital, which was formerly an acute general hospital, was transferred to the chronic sick group on 1st September, 1942. Acute general hospitals 11 Of the twenty-seven acute hospitals, one was closed for the greater part of the year. At the beginning of the year, 6,665 patients were undergoing treatment. As the winter advanced, the number increased to 7,770 on 18th March, 1942. The number of patients then fell steadily to 7,170 on 10th September, 1942. With the onset of the winter months, the numbers rose again until, at the end of December, 1942, there were 7,774 patients in the acute hospitals, 9,030 beds being in commission. The relatively small number of beds in occupation in the hospitals inside the county was due to the continuance of the arrangements for evacuation of patients under the Emergency Hospital Scheme to hospitals in the periphery and to the rapid turnover of patients. Many patients who would normally have completed their treatment in the inner hospitals were transferred to up-graded hospitals on the periphery, many of which are London County Council hospitals. Maternity patients The total number of births in the general hospitals during 1942 was 12,505 (live births, 11,991; stillbirths, 514), and there were 12,230 confinements. These figures show a considerable increase on those for 1941 (8,040 and 7,793 respectively). The number of beds was also increased, and 554 beds (plus 148 for ante-natal patients) were in occupation in thirteen units in the acute general hospitals. The total number of maternal deaths was 44, 29 being directly due to pregnancy or confinement after the twenty-eighth week and 15 to causes associated with these conditions. This represents a maternal mortality of 3.52 per thousand total births, an increase over the comparable rate for previous years (2.05 in 1941, 2.75 in 1940, and 2.84 in 1939). The proportion of abnormal cases admitted to the Council's maternity units during 1942 has, however, been higher than previously because of the greater degree of selection for hospital confinement and the absence from London of many of the voluntary hospital units. In addition, the social upheavals of the war have seriously interfered with the continuity of antenatal care. Chronic sick hospitals At the beginning of the year the number of beds provided in the chronic sick general hospitals was 2,155. This number was subsequently increased to 2,508 by the re-opening of St. Matthew's Hospital, by the opening of St. Luke's Hospital as a chronic sick hospital and by the transfer of St. Peter's Hospital from the acute to the chronic sick group of hospitals. This accommodation was full throughout the vear. Aoute infectious hospitals The South-Eastern Hospital remained closed throughout the year. The Eastern, Grove and Park Hospitals were suspended from the Emergency Hospital Scheme on 1st April, 1942. Owing to a shortage of nursing staff, it was necessary to restrict admissions of German measles, mumps and chickenpox during the latter part of the year. The highest number of fever patients under treatment during the year was 2,388, including 389 measles patients, on 16th December, 1942. The lowest figure was 1,549 on 7th January, 1942. The total number of infectious patients admitted to the fever hospitals in 1942 was 19,560, compared with 16,355 in 1941. In addition to cases of infectious diseases, accommodation was provided in the fever hospitals for scabies and other skin conditions, tuberculosis of the pulmonary type, and other general medical conditions, and during the year 2,465 patients were admitted to non-fever wards. The maximum number of such patients under treatment was 536 on 18th March 1942. Smallpox No case of smallpox was admitted to Long Reach Hospital, but one confirmed case and two suspected cases from London were admitted to the Clandon Isolation Hospital bv arrangement with the Surrev Countv Council. Typhus fever A small isolation block at the Eastern Hospital was adapted for use as a typhus unit to augment the accommodation provided for such cases at the North-Eastern Hospital in 1941. Fortunately it was unnecessary to use either unit. Tuberculosis hospitals High Wood Hospital was suspended from the Emergency Hospital Scheme on 1st August, 1942. The accommodation for cases of pulmonary tuberculosis 12 provided at Hackney Hospital was closed, and wards opened for such cases at the Eastern Hospital. A unit for early non-infectious cases of tuberculosis and cases of pleural effusion was opened at Queen Mary's Hospital, Sidcup, in January, 1942. Children's hospitals The return of children to London resulted in much fuller use being made during the year of the accommodation provided in the children's hospitals. Hospitals for epileptics The two hospitals for epileptics continued to provide treatment as before the war. The number of patients undergoing treatment remained fairly constant. Convalescent hospitals The scheme whereby the Council makes grants to the Invalid Children's Aid Association towards the cost of providing accommodation for convalescent children continued. No accommodation for convalescent children was available in the Council's hospitals. Princess Mary's Convalescent Hospital, Margate, remained closed throughout the year and only a restricted amount of accommodation for adult convalescent patients was available at Queen Mary's Hospital, Sidcup. A small number of adult male and female convalescent patients were sent to voluntary convalescent homes. Other hospitals The Northern, Southern and Joyce Green Hospitals continued to serve a useful function in receiving large numbers of patients from the inner hospitals. During 1942, 8,264 civilian patients were received into these three hospitals as transfers, mostly from other Council hospitals. Venereal diseases Beds for patients suffering from venereal disease were provided at Sheffield Street, Bethnal Green and St. Charles' Hospitals. Accommodation was also provided at Queen Mary's Hospital, Carshalton, for children suffering from vulvovaginitis. Admissions to publio health hospitals The numbers of patients admitted during 1942, compared with 1938 and 1941, are shown below:— 1938 1941 1942 Acute general hospitals 173,796 107,813* 125,782* Chronic sick hospitals 10,014‡ 5,696 5,090 Convalescent hospitals (adults) 4,698 — — „ „ (children) 4,257 — — Convalescent fever hospitals 2,942 13,614† 15,363† Acute fever hospitals (fever) 33,159 16,347 20,107 „ „ „ (general medical) — 2,601 2,518 „ ,, „ (tuberculosis) — 262 Tuberculosis hospitals (tuberculosis) 4,163 2,553 2,998 „ „ (general medical) — 920 1,055 Children's hospitals 5,489 4,097 4,277 Post-encephalitis lethargica unit 49 29 44 Venereal diseases hospitals 801 376 516 Epileptic hospitals 237 186 170 Total 239,605 154,232 178,182 * Includes Queen -Mary's Hospital, Sidcup, † Hospitals devoted now wholly to non-fever purposes. ‡ Includes 802 patients in social welfare establishments. Treatment of civil defence personnel The arrangements for the medical treatment at the Council's hospitals for civil defence personnel, including ambulance, fire, rescue and debris clearance services, continued throughout the year. District medical service During the year there was a slight increase in the amount of work done by district medical officers, 30,249 patients having been treated, compared with 28,785 in 1941. These patients made 124,055 attendances at relief stations or surgeries, and district medical officers paid 35,892 domiciliary visits compared with 112,558 attendances and 30,707 visits during 1941. District nursing service The arrangements under which district nursing associations undertake on the Council's behalf the nursing of district medical officers' patients and others were continued. The nurses made 220,082 visits (98,999 of which were to administer 13 insulin). These figures show an increase on the comparable figures for 1941. The amount of annual grant paid by the Council to the Central Council for District Nursing for distribution to the local associations was reviewed and increased. Ante-natal clinics—food demonstrations Demonstrations of an educative type designed to instruct in methods of cooking and food values were instituted in the ante-natal departments of two hospitals. They serve a useful purpose and are appreciated by the women attending the clinics. Reinstatement of bed accommodation Works were carried out which enabled three hospitals (St. Luke's, Chelsea, St. Matthew's and St. George's Home), which had been closed through conditions arising out of the war, to be re-opened. Repairs were also carried out at a number of other hospitals which enabled a large number of beds hitherto unusable owing to enemy action to be brought into use again. Emergency Hospital Scheme The work of adaptation of certain hospitals in the Emergency Hospital Scheme of the Ministry of Health was proceeded with. This included work at one hospital for the establishment of a special unit for the reception and treatment of Czechoslovakian patients. Regional preliminary training school for nurses Accommodation at the South-Eastern Hospital was adapted as a regional preliminary training school for nurses which will serve a group of hospitals. Fuel economy Measures to secure fuel economy at hospitals were undertaken, including limitation of heating of wards, etc., to specified temperatures, and in certain cases discontinuance of central heating in staff sleeping quarters. Equipment During 1942 the policy of meeting demands for hospital equipment, particularly furniture and textiles, by utilising surplus stocks from closed or partially closed hospitals was continued. In addition, it was found practicable to salvage and recondition many articles from bombed hospital buildings. Nearly all hospital furniture requirements during the vear were met from these sources. Medical education The peace-time arrangements for medical education at the Council's general and special hospitals were continued with such modifications as were necessitated from time to time by war-time conditions. In all, 682 students, of whom 110 were women, attended courses of instruction in infectious diseases at fever hospitals and one attended a fever hospital for a course of instruction in hospital administration for the Diploma in Public Health. In my Interim Report for 1941, reference was made to an innovation at a fever hospital whereby medical students become resident while receiving instruction in infectious diseases. The scheme was extended to a second fever hospital in 1942. Inter-Departmental Committee on Medical Schools In October, 1942, the Council submitted evidence to the Inter-Departmental Committee on Medical Schools appointed, under the chairmanship of Mr. (now Sir William) Goodenough, by the Minister of Health and the Secretary of State for Scotland to enquire into the organisation of medical schools, particularly in regard to facilities for clinical teaching and research, and to make recommendations, having regard to the Government's comprehensive post-war hospital policy. In its statement of evidence the Council pointed out that its interest in medical education flowed from its position as the major health authority for London; from the fact that it was the largest civilian employer of medical staff in the country; and from the facilities which its 100 or so hospitals of all types—general, special and mental—together with its health services afforded for a complete medical education. The statement included a comprehensive survey of the provision made by the Council, both in the pre-war period and during the war, for undergraduate and postgraduate medical instruction, including general clinical teaching and also teaching in obstetrics, fevers, psychiatry, venereal diseases and other specialised subjects. Reference was also made to the extensive facilities provided for post-graduate instruction at the British Post-Graduate Medical School at Hammersmith Hospital and at the Maudsley Hospital Medical School, and to the special provision (including, in some instances, residential accommodation) made during the war to assist the 14 London medical schools, particularly where the routine of general clinical and obstetrical teaching had been disrupted by the dispersal of students and patients in the teaching hospitals by the operation of the emergency hospitals scheme. A recommendation put forward by the Council to the Inter-Departmental Committee was that the complete medical service provided by the Council should be used, not only by augmenting the resources available for teaching in the London teaching hospitals, but also by the establishment of an undergraduate medical school based on one of the Council's larger general hospitals and utilising other hospitals and institutions of the Council for teaching purposes as required. It was assumed that the new school would become an internal school of the University of London which, in agreement with the Council, would provide the professorial and teaching staffs. Such an arrangement would be similar to that obtaining at present between the British Post-Graduate Medical School at Hammersmith Hospital and the Council. Alternatively, the Council itself might be responsible for the general direction of the school, as in the case of the school for teaching in psychiatry attached to the Maudsley Hospital. The Council felt that the experience which it had gained during the last seven years in the case of the British Post-Graduate Medical School (in which it had satisfactorily met any modifications required in the administration of Hammersmith Hospital) should be of great value in dealing with any new project on these lines. In so far as the Council's resources were, or might be, used to augment the teaching in voluntary teaching hospitals (apart altogether from the proposal to set up the new school), the Council pointed out the need for closer integration, particularly from the point of view of continuity of teaching. A method of securing this would be the appointment of an advisory board for each combination of linked hospitals to make recommendations to the hospital authorities concerned for the appointment of teaching staff, the personnel of the board to consist of representatives of the voluntary teaching hospitals and of the Council with whom representatives of the University would be associated. Teaching appointments should be regarded as including university chairs and readerships, and the recognition of holders of whole-time posts as teachers of the University, while part-time consultants and specialists would be available to work in either voluntary or municipal hospitals or both. In junior clinical appointments of the registrar and house officer class, relationship between the linked hospitals and interchangeability between their staffs should be arranged, and the Council indicated that, in the event of its being decided that a medical student after qualification, but before registration, should be required to hold a house appointment, it would be prepared to consider reasonable adjustments to its medical staffing arrangements to enable that to be done. The Council would also be prepared to extend after the war, so far as practicable, the arrangements under which medical students enter into residence at the Council's hospitals for general clinical, obstetrical or fever instruction. The Council also recommended that instruction in psychological medicine should play a more important part in undergraduate medical training in future and that post-war instruction in psychological medicine should be directed to the preventive, curative and rehabilitation aspects of that specialty. The services which the Council performs in the fields of public health and social welfare should also be brought more closely to the notice of medical students as a means of acquainting them with these wider aspects of social and preventive medicine, and the Council indicated its readiness to afford facilities for organised instruction in these services and for the appointment of its staff as lecturers. The Council also suggested co-ordination of the facilities for post-graduate medical education in London and the close linkage of any new centres of post-graduate instruction with the British Post-Graduate Medical School as the nodal point. 15 The suggestion was also made that the question of overcoming the difficulties experienced in obtaining places in London medical schools for London students should be considered, and the Council also intimated that any arrangements made by it for medical education would, so far as the Council is concerned, be open equally to men and women. Radiotherapeutie research unit The radio-therapeutic research unit, which, prior to the outbreak of war was situated at the Radium Institute, was transferred on 1st January, 1942, to Hammersmith Hospital. This unit is carrying out, under the auspices of the Medical Research Council, an investigation into the comparative curative effects of radium and X-rays in the treatment of cancer of the mouth and throat. Prevention of tuberculosis among hospital staff In October, 1941, a Committee of the department's staff was appointed to consider and report as to further measures to be taken for the protection of the Council's hospital staff against tuberculosis. As the result of the findings of this Committee, arrangements were made for routine X-ray examinations to be carried out on all new entrants to the service amongst nurses, ward orderlies and doctors, and for re-examination annually up to 30 years of age. Legacies to hospitals During the past year, nine legacies, making in total £2,403 11s. 8d., have been received for the benefit of certain of the Council's hospitals, viz., Archway Hospital (£25), Hackney Hospital (£266 1s. 8d.), Heatherwood Hospital (£500), Queen Mary's Hospital, Sidcup (£25), St. Giles' Hospital (£387 10s. and £1,000), St. Mary Abbots Hospital (£100), St. Mary, Islington, Hospital (£50), and St. Pancras Hospital (£50). In accordance with the Council's policy, the larger sums have been invested and the interest will be used for the benefit of the patients and staff of the hospitals concerned. Supply and repair of artificial limbs The arrangements with Queen Mary's (Roehampton) Hospital, for the supply and repair of artificial limbs for Council patients, the "following-up" of patients and provision of meals, where necessary, for patients and their escorts have been continued. In addition to patients referred from general and special hospitals, the district medical service and the mental health services, the supply and repair of limbs to children evacuated with the Council's camps for physically defective children has been included in the scheme and arrangements are made through Queen Mary's (Roehampton) Hospital for the children to attend the contractor's provincial limb fitting centres. The total number of patients dealt with from all these sources in 1942 was 229, compared with 193 in 1941. The Ministry of Health in November issued particulars of a new scheme under which certain classes of civilians may obtain artificial limbs through the facilities of the Ministry of Pensions' limb-fitting service at Roehampton. The question of the patient's eligibility under the scheme rests with the Ministry of Labour and a certificate is required from the head of the hospital concerned that the patient will be able to follow a useful occupation when a limb has been supplied. Staff Despite the grave shortage of nursing staff throughout the country and the gradual and continual withdrawal for national needs of experienced men and women of all grades, the hospitals staff have, by working longer hours in some cases, by more intensive application in others, and by cheerful acceptance generally of wartime stress and strain, successfully carried out their task of providing treatment for a substantial proportion of the sick population of the County of London. The methods which were adopted to meet the shortage of staff arising from wartime conditions, e.g., employment of women as substitutes for porters and laundrymen, employment of married women and of staff generally beyond the normal 16 age of retirement, to which reference is made in my Interim Report for 1941, have continued to be applied throughout the year. There have been a number of vacancies which could not be filled at once—amounting on an average to about five per cent. of the total positions. These vacancies increased during the winter months when a high proportion of staff were absent on account of sickness. As practically no casual labour was available, some of the hospitals were seriously short of domestic staff and had to work at times under considerable difficulties. Many members of the medical staff have resigned to join the Services, others have been called up. In some cases their places have not been filled and, in others, less experienced staff have been appointed, but, by dint of hard work by everyone, an adequate service has been maintained. The existing arrangements for the consultant and specialist service, which are normally subject to annual review, will be continued for the period of the war, subject to review, as may be necessary, at any time. During the year the call-up of 46 more male and female clerical officers from the already seriously depleted experienced staff has added considerably to the difficulty of carrying on efficiently the many and increasing duties of the stewards' offices. Temporary staff have been engaged as substitutes, but for the most part it has been necessary to recruit employees either under or over military age or married women, some on a part-time basis, with little previous experience of clerical work. Obviously, these, in general, lack the knowledge and training of the clerks who have gone, and it is therefore largely due to the willing acceptance of added responsibility by the stewards, assistant stewards and remaining experienced clerks that the service has been able to operate satisfactorily. About 1,000 members of the hospital permanent staff were serving with H.M. Forces on 31st December, 1942, including 40 medical officers, 70 female and 160 male nurses, 500 porters, 180 clerks and 50 miscellaneous grades. Nine members of the staff with experience in engineering have been released for work in war industry. In addition, 280 temporary staff of all grades had left to undertake war service. Ten members of the staff have been killed in action or have died on war service. Two preliminary training schools for female student nurses and one for assistant nurses have been opened, necessitating the employment of a few units of additional tutorial staff. The parks department and the mental health services have continued to supervise the food production work at hospitals, and further areas have been brought under cultivation, involving the employment of additional staff. Considerable use has been made of the Women's Land Army as a convenient and efficient source of labour. With a view to effecting economies of essential drugs in the hospitals and to increasing the use of alternative pharmaceutical preparations made in the hospital dispensaries, a new position of supervisory pharmacist has been instituted as a temporary measure. Arising out of representations made by the Chartered Society of Massage and Medical Gymnastics to the Council and other local authorities regarding the rates of pay and conditions of service of massage staff, consultations were held with representatives of the other authorities in the home counties. As a result, improved scales of pay were adopted for massage staff in the hospitals service, involving an annual cost to the Council of approximately £5,000. With a view to facilitating recruitment and fluidity of labour during the war, the rates of pay of domestic assistants in hospitals outside the London area were brought up to the London rate. At the same time it was decided to discontinue the division of the grade of laundry-women into two classes and to recruit no further laundry-women, class I. The rate of pay adopted for the grade of laundry-women in the hospitals service is the same as that for domestic assistants. The ultimate cost of these changes will be approximately £7,550 a year. 17 Group laboratories Pathological laboratory service The number of examinations (including post-mortem examinations) completed in the group laboratories during the year ended 31st December, 1942, as compared with the year 1941, is indicated hereunder:— Group laboratory 1942 1941 Archway 34,508 27,697 Lambeth 31,843 25,268 Lewisham 33,186 28,207 Joyce Green (subsidiary to Lewisham) 11,809 11,665 Mile End 26,209 19,494 North-Western 56,712 43,314 St. Mary Abbots 36,972 31,221 Southern 14,208 11,562 Total 245,447 198,428 The number of post-mortem examinations carried out by the Central Histological Laboratory staff during the year was 959 (847 in 1941) and the number of histological examinations carried out was 27,289 (24,997 in 1941). Research work in the group laboratories was, of necessity, reduced to a minimum, but the following subjects of investigation may be mentioned: survey of diphtheria and hæmolytic streptococcal carrier rates in school children; the value of tests for jaundice and liver function; the use of new culture media for the bacteriological diagnosis of intestinal infections. Continued investigation into air-borne infection and its prevention, including cross infection in hospital wards, was carried out by Dr. Joyce Wright for the Medical Research Council at the North Eastern and North Western Hospitals. Hospital laboratories As mentioned in last year's report, the work of a number of the hospital laboratories was greatly restricted and in some cases completely stopped on account of enemy action. During the present year adequate arrangements have been made in every case, either for the complete re-opening of the hospital laboratory or for the work to be undertaken at the group laboratory. The total number of specimens examined in the hospital laboratories, as distinct from the group laboratories, during the year was 268,156 (211,727 in 1941). In addition, 3,211 post-mortem examinations were carried out (2,912 in 1941). Belmont Laboratories Diphtheria and streptococcus antitoxin issued from the Belmont Laboratories during the year, compared with 1941, was as follows:— 1942 1941 Diphtheria antitoxin 20,000 units 3,381 ampoules 4,238 ampoules „ „ 8,000 „ 1,950 „ 4,069 „ „ 2,000 „ 1,361 „ 1,672 „ Streptococcus antitoxin 10 c.cs. 4,106 „ 3,530 „ „ „ 5 c.cs. 662 „ 875 „ In addition, supplies of various other materials, such as Loeffler's serum, Schick and Dick test toxins, and other diagnostic and prophylactic materials, were issued to the Council's hospitals and establishments. The laboratories continued throughout the year the arrangement with the Ministry of Health to supply materials to local authorities for the active immunisation of children against diphtheria. General Arrangements with the Ministry of Health were continued whereby glassware and other consumable laboratory requisites and materials were supplied at cost, for use in the Ministry's sector laboratories. The Council also continued the supply of culture media and certain other laboratory products to service departments and certain Crown Colonies. The agreement with the Ministry of Health was 18 extended during the year to cover all the provincial laboratories which were being set up under the Ministry's Emergency Pathological Service. In order to meet the increased requirements, a further media making establishment was authorised and additional storage and packing accommodation provided. Facilities were granted during the year for students of the London (Royal Free Hospital) School of Medicine for Women to obtain instruction in clinical pathology and morbid anatomy at the group and histological laboratories at Archway hospital. A visit was paid to one of the group laboratories in December by a number of American and Canadian Army pathologists and very successful demonstrations were given, which were greatly appreciated. A number of technical officers from the Canadian Forces have been permitted to attend certain group laboratories for short periods in order to study recent progress in pathological work. LONDON AMBULANCE SERVICE In May, 1942, the Council placed the London Ambulance Service under the control of Lieut.-Col. Andrew Topping, T.D., M.D., M.R.C.P., the Deputy Medical Officer of Health, and appointed him to be Director. Mr. A. G. Hellman, who had been Acting Officer-in-Charge since the outbreak of war, became the Assistant Director. Owing to the growing shortage of men available as drivers and attendants in the regular service; the Council approved the employment of women as war-time substitutes. Two women station officers and 90 women operatives were appointed during the year. Each woman station officer took charge of a training station where women operatives, most of whom had previously served in the auxiliary service, underwent a course of tuition in the duties of the regular staff and were subsequently posted to the various general and accident stations. By a decision of the Government, the hours of duty in the auxiliary ambulance service were increased in April from 72 hours a week for men and 48 a week for women to 84 hours a week for both sexes, subject to the granting to women of a privilege rest day once a fortnight during periods of lull. At the same time as the hours of duty were increased in April a reduction in the number of auxiliary personnel was effected. The opportunity was taken to standardise the shift systems operating in the auxiliary service and all staff now work 24-hour shifts. This resulted in many of them being at the stations for longer continuous periods, and it was necessary to extend and improve the sleeping accommodation. Additional furniture and equipment were also necessary, and the extensive plan of improvements which had been inaugurated in 1941 was continued as rapidly as shortage of labour and materials permitted. By the end of the year it was virtually completed. An important development in the duties of the auxiliary service took place when the Government agreed to allow auxiliaries to undertake duties normally falling to the regular service as well as a variety of other transport functions for the Council and other local authorities. This scheme, which did not become operative until the end of the year under review, was enthusiastically welcomed by the auxiliaries. During the year further endeavours have been made to secure the services of part-time auxiliaries in order to lessen the demands on the national man-power. At the beginning of the year the Civil Defence Employment and Offences Order (No. 4) 1942 provided for the compulsory retention of part-time auxiliaries in the service and prescribed penalties for part-time auxiliaries who disobeyed lawful orders or who absented themselves from duty without reasonable excuse. 19 During the dense fog on 11-12th November, 1942, heavy calls were made on the London Ambulance Service. In all 200 accident calls and 267 general calls were dealt with on 11th November, of which 96 accident calls and 21 general calls were received between 6 p.m. and midnight. Owing to the large number of calls and the length of time taken to reach the scene of many of the accidents, the regular fleet of vehicles proved insufficient and the auxiliary ambulances, at that time normally reserved for air-raid casualties, were brought into use. The density of the fog made it necessary to increase the numbers of many of the ambulance crews, so that one or more members could act as guides. All the staff responded with success to the heavy demands made on them, and the work was undertaken in an excellent spirit, and in no case was there any failure of an ambulance to reach the scene of the accident, though there was, of course, much delay. SCHOOL MEDICAL SERVICE Government evacuation scheme The following is a summary of the numbers sent to receiving areas under the evacuation scheme, comparable figures for 1941 being given in brackets:— Under Plan V (i.e., unaccompanied school children, and Plan VII (under fives accompanied by mothers)— Over 5 years of age 3,307 (14,136) Under 5 years of age 50 (7,386) Mothers of "under fives" 38 (6,894) Under Defence Regulation 31c (compulsory evacuation)— Over 5 years of age 1 (49) Under 5 years of age 30 (287) Total 3,426 (28,752) All those evacuated in 1942 were medically examined before leaving London. Arrangements continue for evacuating "handicapped" children, i.e., mentally and physically defective, blind, deaf, diabetic children and those with tuberculous history, and also for unaccompanied children under 5 years of age. These children are sent to special residential parties in the receiving areas. The particulars of these special parties in December were as follows:— Number of parties Number in residence Accommodation Residential nurseries (0-2 years) 23 650 774 „ nursery schools (2-5 years) 38 1,592 1,759 „ schools for the physically defective 11 677 810 „ „ for the mentally defective 8 614 826 „ „ blind, deaf, diabetic and those with tuberculous histories 9 353 436 Total 89 3,886 4,605 All these special parties remain under the administration of the education officer. A local visiting medical practitioner is appointed to each party and routine medical inspection and treatment of school defects is carried out through the auspices of the local school medical or maternity and child welfare services. Children requiring hospital treatment are admitted either to E.M.S. hospitals or to local infectious diseases hospitals. 20 At each of the special parties there is one or more of the Council's nurses, except in the case of one or two small parties where a nurse from an adjacent party or district makes frequent calls. In addition to the children under 5 years of age sent to receiving areas under Plans V and VII there was a total of 4,279 unaccompanied children under 5 years of age sent to special nurseries or nursery schools in the country during 1942. Of these children, 3,400 were from the county of London and 879 from out-county evacuation areas. The general medical supervision of all the evacuated nurseries and nursery schools has now been taken over by the appropriate local authority. The respective county medical officers of health kindly send reports on the welfare of the children and on the conditions generally of the premises, and in addition records of illness and of infectious disease and of other relevant matters are submitted by the matrons and commandants, and visits are made as occasion demands by the Council's officers. Medical inspection The estimated number of elementary school children in London in January 1942, was 148,000; by the end of the year this number had increased to about 220,000, with a school attendance rate of about 82 per cent.; the number of schools open in December was 674 compared with 552 at the end of 1941. The usual four age group inspections were continued throughout the year on pre-war lines, but the "nutritional survey" introduced as a war-time measure, and referred to in the last annual report, was suspended in October, 1942, since no difficulty was met in carrying out the usual age group inspections. Particulars of detailed examinations at elementary schools during 1941 and 1942 are as follows:— Age group 1942 1941 Entrants 27,726 20,698 Children aged 7 16,539 14,228 Children aged 11 20,748 19,202 Leavers aged 13 plus 23,312 18,404 88,325 72,532 Other ages 29,565 22,391 117,890 94,923 Children in special schools and classes 798 566 Total 118,688 95,489 The high number of "other ages" reflects the drift back to London. Children who returned and who were outside the usual age groups were examined if no recent medical records were available. Re-inspections of children previously noted with defects totalled 39,695. These inspections showed that 75.3 per cent. were treated or discharged as no longer needing treatment; the remainder were still to be followed up. In addition, 14,064 inspections were made of children who were being given school meals on the advice of school doctors, head teachers or school care committees, and 71,897 of children about whom advice was required by teachers, care committees, etc., and in connection with the nutritional survey. Including the evacuation examinations and the children seen in schools and at day centres for the treatment of rheumatism, vision, ear and nutritional defects, the total number of inspections made was 272,301 exclusive of 6,698 carried out at higher education institutions. 21 The following comparisons are made in regard to the children examined in the four age groups in the two most recent war-time years, and those examined in the same age groups in 1938, the last complete pre-war year of medical inspection:— 1942 1941 1938 Numbers examined 88,325 72,532 169,995 Percentages Nutrition unsatisfactory 6.2 6.3 6.6 Nits or pediculi—hair 1.9 3.0 2.3 Teeth—obvious decay 36.0 41.4 29.8 Vision—6/9 or worse 23.8 23.7 32.2 Adenoids and enlarged tonsils 7.3 5.0 9.2 Skin diseases 2.0 2.2 1.0 Enlarged glands 1.2 0.9 1.5 External eye disease 1.9 1.9 1.7 Otorrhœa 0.4 0.3 0.6 Defective hearing 0.3 0.2 0.2 Heart disease 0.8 1.0 1.4 Anaemia 0.2 0.2 0.4 Lung disease (not T.B.) 1.1 1.0 1.5 Tuberculosis (pulmonary) 0.03 0.01 0.04 „ (other lesions) 0.05* 0.07* 0.02 Rickets (boys—entrants only) 1.1 1.5 1.0 „ (girls—entrants only) 0.8 1.1 0.4 * Some of the children concerned would no doubt have been in attendance at special "P.D." schools under peace-time conditions. Nutrition The nutritional condition of the great majority of children still continues to be classed as satisfactory. The general opinion among the school doctors, nurses, teachers and care committee workers was that there were no signs of any physical or mental deterioration among London school children generally. At the request of the Ministry of Health, Dr. Sydenstricker, an American authority on deficiency diseases, examined 150 elementary day school children in a poor area, and found no recognisable clinical evidence of vitamin deficiency, and stated that he was favourably impressed by the general appearance and vitality of the children whom he saw. Further evidence of the well-being of the children has since come from an independent investigator who was visiting some schools in which she carried out an enquiry some 15 years ago. She remarks upon the general and physical improvement noticed in her recent visits as compared with her observations at her former investigation. The percentage of children in each age group where nutritional condition was unsatisfactory (either slightly or grossly subnormal) is shown below:— Age group—boys and girls— 1942 1941 1938 Entrants 6.90 7.03 6.46 7 year old 8.64 8.35 8.75 11 year old 6.26 6.28 6.75 Leavers (13+) 3.64 4.03 4.47 Thus, while the nutritional classification of the combined four age groups indicates that there were no apparent signs of any deterioration in the physical conditions of the children, the percentage assessments of subnormal nutrition of the separate age groups indicate that the "entrants" was the only group which showed no improvement over that recorded in 1938, although there was a slight improvement over the figure for 1941. Weighing and measuring A partial resumption of the pre-war six-monthly weighing and measuring was made in January, 1942, and 10,866 individual children were weighed and measured, most of them twice during the year, so that 18,123 measurements were available for statistical comparison with comparable data collected in 1938, and which formed the basis for the Council's report on the average heights and weights of London elementary school children.† † Report by the school medical officer on the average heights and weights of elementary school children in the County of London in 1938, published by the London County Council (Pub. No. 3464), price 9d., post free 10d. 22 The results of analysis of the heights and weights, as was to be expected from the disturbance of war time conditions, show more individual fluctuations in the increase of height and weight than in pre-war years when the children were living under more stable conditions. On the average, the rates of growth, age for age, which are a valuable indication of nutrition, have been maintained at the same level or are. in some areas, slightly above the pre-war rates. Speaking generally, there was less improvement among the younger than the older children. This is in keeping with the doctors' findings that nutritional progress of the entrants was not relatively so good as that of the older children. Vitamin investigation During the year an investigation into the value of giving capsules containing vitamins A, B, C and D was carried out among some 400 boys attending London elementary day schools, and about 200 boys in an evacuated special party in a camp school in the country. A capsule was given to alternate boys on each school day, and a similar, but innocuous and non-active capsule was given in the same way to the other boys. All the boys were medically examined and weighed and measured at the beginning of the investigation, and again at the end of about seven months by the same doctor. Detailed analysis of the results showed that taking vitamins under these conditions had no appreciable effect on the general health of the boys. It was, however, interesting to find that the boys living in the camp school in the country (who came from homes in London comparable with those of the boys attending the day schools) grew, on the average, slightly more in height and weight than the boys attending London day schools. Nutritional survey Reference has been made earlier in this report to the suspension of the term by term nutritional survey. The survey made serious incursions into the time of teachers, doctors and nurses, but the suspension was decided upon following careful consideration and after a special investigation had been made. The investigation concerned 218 children who were examined at routine inspections, and were within a few days of these inspections seen in a cursory survey by (a) a divisional medical officer, (b) an experienced school nursing sister and (c) the teachers in the same schools. It was found that cursory surveys, even by experienced people, failed to detect a number of important abnormalities which had been discovered by a full routine inspection. Dental conditions Dental conditions, which had retrogressed in the two previous years, now appear to be again improving, a fact which is borne out by the results of inspections with probe and mirror by the dental surgeons, who in 1942 found that of 103,285 children inspected by them, 77,692 required treatment or 75.2 per cent. as compared with 79.4 per cent. of 62,631 children inspected in 1941, and 69 per cent. in 1938 when 292,971 children were inspected. Cleanliness A welcome improvement is noted in the conditions of the hair and in the incidence of skin diseases. This improvement noted by the medical staff is confirmed by the results of the nurses' examinations for personal hygiene. Possibly the increase previously noted in war-time years of these "minor horrors of war" has been arrested, which may conceivably be due to the greater efforts on the part of the school and sanitary authorities reinforced by the Scabies Order, 1941, to combat these verminous infestations. Bathing of school children The Council in 1941 decided to accept the offer of a private firm to provide free of cost the use of a mobile bathing unit for bathing school children in the Bermondsey district; the facilities were extended later to schools in Deptford, Greenwich, Camberwell, Poplar and Stepney. The unit consists of a Diesel-engined wagon containing water-heating plant and a trailer for carrying the bathing booths, which are divided into undressing, shower-bath and dressing cubicles. Soap, towels, bathing caps and supervision 23 are provided by the firm. Since the inception of the scheme upwards of 20,000 baths had been given in schools in Bermondsey and Deptford. Two of the Borough Councils in West London provided facilities free of charge for school children to have shower baths at the borough first-aid posts. In 1942, 21,816 baths were given through these agencies. In both of these schemes, one of the Council's nurses is in attendance at the schools or baths in order to exclude those children found to be verminous or with any condition contra-indicating bathing of this nature. Medical treatment The following table gives for 1942, 1941, 1940 and 1938 the numbers of "new" cases treated (a) at the treatment centres and hospitals included in the Council's scheme; and (6) in the rheumatism (hospital) units:— (a) 1942 1941 1940 1938 Dental 56,890 33,074 31,180 138,639 Ear, nose and throat 261 — — 12,726 Vision (refraction and squint) 15,073 8,672 9,389 37,359 Minor ailments 59,167 24,348 21,828 128,819 Ringworm 10 3 3 103 "Special ear" defects 431 194 163 1,830 Rheumatism (supervisory centres) 733 409 432 1,885 Nutritional defects 464 360 166 641 133,029 67,060 63,161 322,002 (b) Rheumatism— Admitted to the Council's hospitals 358 248 302 2,026 Discharged 249 231 335 2,037 Stammering At the end of the year five centres were open with accommodation for 144 children for the treatment of stammering or other speech defects. Ear, nose and throat treatment The in-patient school centres for the treatment of defects of ear, nose and throat ceased to function at the outbreak of war, but in 1942 the pre-war arrangement with Belgrave Hospital for the treatment of such defects was re-introduced. Of the 261 children treated at this hospital, 109 were operated on for the removal of adenoids and/or enlarged tonsils. In 1938 the number of such operations carried out at 15 centres or hospitals included in the Council's school medical scheme was 8,894. Throughout the war, children in need of operative treatment for these conditions have been referred to the Council's general hospitals and dealt with there. Rheumatism Among the children admitted to the rheumatism units in the Council's hospitals, the incidence of cardiac involvement increased to 67.3 per cent. compared with 40.7 per cent. in the admissions in 1941. Choreic manifestations were present among 28 per cent. of those admitted in 1942, compared with 36.5 per cent. in 1941. It is thought that the explanation of the increased incidence of cardiac affections may possibly be the result of mass movements of the children, so that medical supervision for recognising early signs of rheumatism was not so readily available. The number of new cases referred by school doctors to rheumatism supervisory centres during 1942 was 733, compared with 1,885 in 1938, and the number of admissions to hospital rheumatism units in 1942 was 358, compared with 2,026 in 1938. The relatively smaller number of new cases referred to centres and hospital units during the year compared with pre-war years appears to indicate there has been some reduction in the incidence of juvenile rheumatism. Personal hygiene Efforts are now made to arrange for the school nursing staff to visit schools for "rota" examinations about once a month instead of the pre-war practice of once a term. There were 1,201,646 examinations in schools for personal hygiene by the school nursing staff. Of these, 76,062, or 6.3 per cent. showed verminous infestation, 24 including some very slight cases. The percentage is less than that for 1941 (7.9), and compares with 7.3 per cent. in 1938. During the year, 54,300 (40,595 in 1941) children were dealt with at the children's bathing centres; of these 25,247 (16,698 in 1941) were suffering from scabies or impetigo. There is evidence that the incidence of scabies and allied conditions has seriously increased under war-time conditions, though 1942 shows a reduction on the 1941 incidence. Handicapped children In December, 1942, about 35 special units for defective children were functioning in London. In all, 1,957 children were examined in London or in the reception areas as to their suitability for special education. Of, these, 505 and 474, 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, 63 were sufficiently improved to justify return to elementary school instruction, and 135 children over 14 years of age were released from special schools as being no longer certifiable. Training or placing and supervision in employment of children upon discharge from hospital schools In order to ensure that partially-sighted or physically-handicapped children of 13½ years and over, when discharged from hospital schools, secure further training and/or placing and supervision in employment as may be necessary, a procedure has been put into operation at the children's special hospitals whereby the secretary of the After Care Association for Physically Defective Children is informed of discharges, together with medical and educational opinion regarding the abilities of the children. A similar arrangement has operated for some years for children attending day schools for the physically defective. The number of London children accommodated in the Council's hospital schools at the end of December, 1942, was as follows:— Hospital school— Number Downs 102 Goldie Leigh 67 Heatherwood 90 High Wood 250 + 11 E.M.S. cases. Queen Mary's, Carshalton 643 St. Faith's 21 White Oak 81 Total 1,254 + 11 E.M.S. cases. Provision of meals The education officer has supplied the following figures:— No. of children attending elementary schools No. of children having school milk Percentage having milk Percentage of free cases to total number having milk Number of children having dinners Percentage having dinners Percentage of free cases to total having dinners June, 1942 169,909 128,983 75.9 3.9 35,517 22.0 4.9 October, 1942 183,141 136,065 74.3 4.2 42,191 23.25 5.6 In addition, about 2,649 teas and 57 breakfasts were provided daily at the war-time play centres. Infectious diseases in schools As in previous war-time years, the figures available as to the incidence of infectious diseases are vitiated by reason of the movements of the school population, but the usual control arrangements were made. Immunisation against diphtheria The co-operation with the Metropolitan Borough Councils referred to in the last annual report in the arrangements for carrying out in schools immunisation against diphtheria, was continued. Thus, in nineteen boroughs, the Council's school medical staff carried out the immunisation, while in nine boroughs this work was carried out in the schools by the medical staff of the Borough Councils. In 1942, the number 25 of children who received the full course from the Council's medical staff was 27,305, bringing up to 43,089 the total of children immunised in schools by the school medical staff since the issue in November, 1940, of a circular on this subject from the Ministry of Health and the Board of Education. Much heavy work has been thrown upon the teaching and attendance staff, etc., of the education officer's department, and the thanks of the service are due to them for the results achieved. Play corners and play centres As from 1st April, 1941, the Council undertook, as a temporary arrangement, the organisation of the play corners and play centres originally established by the Children's Play Centres Fund. Play corners were organised for children under school age, and were available for the most part during school hours. Play centres were provided for evening use for the needs of school children. Both types assumed importance in view of the drafting into war and similar industries of mothers, who were thus given some assurance that their children were kept under supervision. At the end of 1942, there were 18 play corners, with 600 children on the rolls and an average daily attendance of 550. These "pre-school" children are supplied on the premises with mid-morning milk and cod-liver oil and dinners, and are medically inspected on lines adopted for the smaller pre-war nursery schools, viz., a three-monthly inspection by the Council's medical staff and a daily visit by one of the Council's school nursing sisters. All facilities for medical treatment, and cleansing and infectious disease control are provided on the usual lines applicable in the Council's school medical service. These play corners will, as circumstances permit, be organised as war-time nursery classes and attached to an infants' department in a neighbouring school. These war-time nursery classes are in addition to the war-time nurseries organised in London by the Borough Councils for the care of children under five whose mothers are on war work. At the end of the year there were 100 play centres, at which 12,000 school children attended each evening. Tea is provided for those who require it. and at three of the centres, at the request of the Ministry of Labour and National Service, breakfasts are supplied to children who attend the centres before the normal school hours. Visits are made to the play centres after school hours by the school medical staff. MENTAL HEALTH SERVICES The following table shows the number of mental patients of all classes undergoing treatment in mental hospitals and institutions for the mentally defective during 1942 :— Lunacy and Mental Treatment Acts Uncertified senile patients M.D. Acts Total Certified Voluntary Temporary Sections 24 & 25 Patients at 1st Jan., 1942 19,278 1,440 23 3,399 944 7,349 32,433 Admissions in 1942— Direct 1,318 946 50 172 514 498 3,873 Indirect 231 84 3 57 — Exits in 1942— Discharged recovered 530 355 8 2 — 233 2,443 Discharged otherwise 514 624 53 57 67 Deaths 1,342 106 3 414 373 225 2,463 Total patients 31st Dec., 1942 18,441 1,385 12 3,155 1,018 7,389 31,400 26 In addition there were 3,574 mental defectives under statutory supervision in their own homes and 397 under statutory guardianship. The number of mental patients in London continues to fall, as it did in the last war, and at the end of 1942 there were nearly 3,000 fewer patients in London mental hospitals and institutions for the mentally defective than at the outbreak of war. The number of patients under treatment in the emergency hospitals attached to the mental health services during 1942 on the undermentioned dates were:— 1st January 3,245 1st April 3,456 1st July 3,437 1st September 3,462 31st December 2,947 In all, 30,280 patients passed through these hospitals during 1942. Treatment, etc. The new forms of treatment for certain types of mental disorder, electrical convulsion therapy and prefrontal leucotomy are continuing to produce promising results. War conditions of labour shortage have given a tremendous fillip to the work of socialising and placing in employment promising patients from the Council mental deficiency institutions. At the end of 1942, there were 340 mental defectives on licence from institutions in outside paid employment. An interesting incident during the year was the discharge from Bexley Hospital of a female patient who had been under continuous detention for 43 years. At the request of the Ministry of Health the Council has agreed to provide accommodation at Long Grove Hospital for allied ex-soldiers and refugees who need treatment for mental illness. The majority of the patients so far admitted are Poles. Research Notwithstanding war conditions, research work has continued. In the mental health service this has been aided by substantial grants from the Rockefeller Foundation. Staff During the year a preliminary training school for mental nurses was established at Claybury Hospital. This is believed to be the first of its kind in this country. The object of the school is to make the introduction of nursing recruits to the realities of mental nursing a gradual process, instead of a sudden plunge into a new and difficult profession. So far the results have been excellent. Cafeterias for staff meals have been established at a number of mental hospitals and have proved an outstanding success. Among the advantages secured are cheapness, variety of dishes, quick and efficient service of meals and economy of staff. The appointment of a chef-instructor to advise on the cooking arrangements at. mental hospitals has brought about not only marked improvements in patients' and staff meals, but has also resulted in economy. Farming operations During the year 1942, further areas were added to the land under cultivation by the mental health services, the acreage farmed on 30th September, 1942, being 5,983 acres (3,169 arable and 2,814 grass) compared with 5,144 acres (2,239 arable and 2,905 grass) on 30th September, 1941, and 2,789 acres (1,041 arable and 1,748 grass) at the outbreak of war. In addition, approximately 250 acres of land attached to general and special hospitals and educational and social welfare establishments are under the general supervision of the Mental Hospitals (Farming Operations Sub-) Committee.