LCC 51 LONDON COUNTY COUNCIL Interim Report of the County Medical Officer of Health and School Medical Officer for the year 1945 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.I Agents for the title of the publications of the London County Council 1946 No. 3575. Price 2s. 0d. Post free 2s. 2d. London County Council INTERIM REPORT OF THE COUNTY MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER FOR THE YEAR 1945 By Sir Allen Daley, M.D., F.R.C.P., County Medical Officer of Health and School Medical Officer INTRODUCTION The most significant event in 1945, from the point of view of the public health as from every other standpoint, was the ending of hostilities—in Europe in May and elsewhere in August. The last day on which civilian casualties occurred was 27th March, but, between the beginning of the year and then, 2,878 casualties, resulting from rocket bombs, had been taken to hospitals or first-aid posts by the London Auxiliary Ambulance Service. This brings the total number of casualties conveyed by the Service to 48,709. From the beginning of the year to 27th March there were 25 incidents at 21 hospitals. Considerable blast damage was done, and unfortunately 3 porters lost their lives at the Brook Hospital, when two blocks, containing 96 beds but at that time no patients, were demolished. Many also were the gaps and scars remaining from the previous years. Shortages of staff were more acute during the earlier part of 1945 than they had ever been, and there was very little improvement even by the end of the year. Despite the most persistent efforts to begin to restore the hospital services to their pre-war state, the results were painfully small. Some of the patients evacuated to safer areas in 1944 returned at the end of that year; but it was not until the autumn of 1945 that any substantial number could be brought back, and there were many still awaiting return in 1946, including some hundreds who were evacuated from London in 1940 and 1941. The main reason for inability to receive them all back was shortage of nursing and domestic staff, though unrepaired damage to buildings would probably have prevented the return of all, even had staff been available. Such building labour and material as were available were used for first-aid repairs so as to restore ward and staff accommodation, and to remove blackout, blast walls and other reminders of the preceding six years. The evacuated schoolchildren and the general population also began to return, and this resulted in greater calls on the school health and hospital services. The aftermath of war brought to London smallpox of the oriental type, and typhus fever, but fortunately there was no spread. War casualties-Service and civilian-and Service sick were treated in the Council's hospitals in large numbers, and a special unit was established for the reablement of ex-prisoners of war suffering from neuroses (see page 60). The vital statistics are set out in somewhat fuller form than in recent reports (pages 3 to 19). The death-rate was the lowest of the war years and approaches the pre-war figure. The rate of infantile mortality was the lowest ever recorded in London. The rest of the report gives, under the various sections, a brief account of the work in which the department has been engaged. The death-rate from tuberculosis continued to decline from the year 1941, but was substantially above the pre-war figure. Recommendations for the institutional treatment of tuberculosis were fewer than in 1938, or even than in 1944, but the number awaiting beds continued to grow because of inability to obtain sufficient staff 800 (MºC. 61533-6) 28-10-46 3089A. (1) A 2 for the sanatoria and hospitals. The number of persons examined by the miniature radiography apparatus was 47,223, of whom 77 were recommended for sanatorium treatment. The incidence of venereal diseases is increasing, particularly syphilis, but it is well below that for 1918. Confinements attended by the Council's domiciliary midwives numbered 6,867, and by midwives of voluntary hospitals and district nursing associations, under agreement with the Council, 5,466. There were 12,619 births in the Council's hospitals. Admissions to the Council's hospitals (other than mental) numbered 174,812. In addition 21,343 general patients were dealt with in the mental hospitals under the E.M.S. scheme. Throughout the year there was pressure on the staffed accommodation in hospitals of all types. It was necessary to provide more accommodation in residential nurseries. Despite the difficulties, progress was made in developing schemes for rehabilitation and a considerable amount of research on a variety of subjects was in progress. An active part is taken in the provision of facilities for providing refresher courses for doctors demobilised from the Services. The School Health Service gradually expanded. The juvenile rheumatism scheme is again getting under way. It is gratifying that there is no evidence of a deterioration of the nutrition of the children compared with 1938. The report of the Mental Health Services shows that there are 4,500 fewer mental patients than at the outbreak of war. The Maudsley Hospital, with its associated medical school, re-opened in October. The work of the pathological services and of the department of the chemist-inchief continues to expand. The toll of war upon the staff of the department has been heavy. The Roll of Honour includes 274 names. Deaths in the Services numbered 102. Among the civilian staff, 172 lost their lives by enemy action. This includes 43 members of the London Ambulance and Auxiliary Ambulance Services. Retirements during the year included those of Mr. A. G. Wells, F.R.C.S., principal assistant medical officer, Dr. H. R. Kidner, divisional medical officer, and Miss G. M. Cordell, O.B.E., principal matron : all after a lifetime of valuable work for the local government medical and nursing services. During the year a central planning division was set up within the department. Its function is to study and advise on all major problems of planning and development. One of the first fruits of its work was the preparation of a comprehensive report on the hospital service, which was submitted to the Hospitals and Medical Services Committee early in 1946. The division is also engaged in collecting information and making plans for the discharge of the Council's responsibilities under any new legislation which may be approved by Parliament for a National Health Service. Dr. J. A. Scott was appointed a principal medical officer primarily for this branch of work, and the appropriate lay administrative staff were attached to the division. Other senior appointments during the year included Mr. A. Y. D. Penderel, administrative and establishment officer, and Mr. R. H. J. Stronge, M.B.E., principal clerk and deputy establishment officer. It is a pleasure to be able to record the following decorations and commendations received by members of the staff of the department during the year : Lt.-Col. A. A. W. Petrie, medical superintendent, Banstead Mental Hospital, C.B.E. ; Miss S. E. Jones, matron, Banstead Mental Hospital, R.R.C. (first class); Miss G. M. Cordell, principal matron (head office staff), O.B.E.; Mr. A. G. Naldrett, assistant officer-in-charge, London Ambulance Service (seconded during the war to be chief ambulance officer, London Civil Defence Region), O.B.E.; Mr. R. H. J. Stronge, principal clerk and deputy establishment officer (seconded to E.M.S. as a municipal lay administrative officer in the sector organisation), M.B.E.; Miss M. A. Warner, domiciliary midwife, 3 M.B.E. Mr. Alan R. Taylor, a member of the Friends Ambulance Unit attached to Lewisham Hospital, was awarded the B.E.M. Miss B. J. Smith, ward sister, and Miss W. A. R. Butler, staff nurse, Brook Hospital, received commendations. The Czechoslovak government appointed to the Order of the White Lion, Sir Thomas Carey Evans, medical superintendent, Hammersmith Hospital, and awarded a military medal, of the first class, to Dr. J. W. Healy, the deputy medical superintendent, and of the second class to Miss F. A. Campbell, formerly matron, Hammersmith Hospital (now a principal matron at head office); Miss G. M. Godden, matron ; Mr. W. Milton, steward; Miss I. Thomson, departmental sister; Miss J. Kennard, ward sister; Miss D. Fryatt, staff nurse; and Mr. D. T. Currie, pharmacist. VITAL STATISTICS The Registrar-General estimates the civilian population of the county in the middle of 1945 to have been 2,601,370, compared with 2,462,500 a year earlier. The corresponding estimates for metropolitan boroughs are shown in table 1 on page 12, and the rates given in this annual report are calculated upon these figures. Population The principal elements in population trend are shown in the following statement (rates per 1,000 living—civilians):— Year Marriages registered Live births (allocated) Civilian deaths No. Rate* No. Rate No. Rate 1945 36,395 28.0 45,532 17.5 36,748 14.1 1944 26,450 21.5 44,554 18.1 41,077 16.7 Marriages, births and deaths * Persons married. The birth and marriage rates quoted are related to the civilian population, in the absence of a figure for the total population. While these rates may be compared with those for other war years, it is not possible to assign any absolute significance to them. In England and Wales as a whole, the average birth-rate during 1945 at 16.1 five births per 1,000 living was lower than in 1944, when at 17.5, it corresponded to a reproduction rate of .996, i.e., the level of fertility which, if maintained, would ensure that the female infants would almost fully (99.6 per cent.) replace themselves during their future reproductive lifetime; but, at the end of 1945, the birth-rate again showed an upward movement toward the 1944 level. As far as can be judged, the true London birth-rate appears to have followed a similar trend. The marriage rate during 1945 for the country as a whole reached a high level of 18.6, after having fallen to a minimum of 14.1 in 1943. In notes to the return for the quarter ended 31st December, 1944, the Registrar-General emphasised that the maintenance of the high birth-rate then operating depended upon the continuance, inter alia, of a marriage rate at about 12 per cent. higher at each age than those at which women were marrying prior to the war, adding "such rates are higher than any hitherto recorded in this country in times of peace, and though, with the prospect of greater social and economic security in contemplation they cannot be regarded as outside the scope of practical attainment, it would be impossible at the present time to place any reliance upon their expectation." Experience during and after The war of 1914-18 showed that substantial changes in marriage and fertility rates can occur in a comparatively short time, and it is clearly impossible at the present time to regard the position as stable. 4 Illegitimacy There were 5,178 illegitimate births (11.4 per cent. of the total live births). Percentages in recent years are :— London England and Wales 1938 6.3 4.3 1939 5.9 4.2 1940 6.1 4.3 1941 7.4 5.3 1942 7.4 5.5 1943 8.2 6.3 1944 9.3 7.2 1945 11.4 9.4 Deaths under one year among illegitimate infants amounted to 63 per 1,000 live births compared with a rate of 42 for legitimate births. The corresponding rates in 1944 were 77 and 48 respectively. A detailed comparison of deaths in the legitimate and illegitimate groups is given in table 5, page 16. Still births There were 1,095 still births in 1945 or 2.35 per cent. of all births (legitimate 2.27, illegitimate 2.92). Rates in recent years are :— London England and Wales 1938 3.0 3.8 1939 2.9 3.8 1940 3.0 3.6 1941 3.0 3.4 1942 2.9 3.3 1943 2.5 3.0 1944 2.5 2.8 1945 2.4 2.8 Mortality With regard to mortality, detailed figures are shown in tables 1 and 2 on pages 12 and 13. Mortality from infectious disease is discussed below, under that heading. For other causes of death the trend in recent years is indicated by the diagrams on page 5. The discontinuity between 1939 and 1940 is attributable to two causes. In the first place, the Registrar-General abandoned the rules of selection which had hitherto operated in multiple causes of death, and, as from 1940, accepted the principal cause of death shown on the medical certificate. In the previous decade the increasing mention of heart disease on the death certificate of old people jointly with, for example, bronchitis, had led, under the rules of precedence, to an artificial increase in the number of deaths assigned to heart disease. One of the immediate effects of the revised procedure was a transfer of deaths from myocarditis to bronchitis. Similarly, the selective rules had given precedence to diabetes if mentioned as an associated (though only a contributory) cause, and the new procedure transferred deaths from diabetes to other causes. In addition, the International List of Causes of Death, which was revised in 1938, was applied in 1940 in accordance with international agreement. The chief movements resulting from these alterations are estimated* to be: Cause Approximate change as a percentage of those formerly assigned to this cause Influenza -11 per cent. Cancer - 3 „ Diabetes - 30 „ Heart disease - 10 „ Other circulatory diseases - 6 „ Bronchitis + 100 „ Pneumonia + 5 „ Other respiratory diseases + 50 „ Nephritis + 12 „ Diseases of pregnancy, etc. + 10 „ *Based on the dual classification of deaths for England and Wales, 1939. 5 6 The second cause affecting the statistics was the outbreak of war. A young and healthy section of the population was, from September, 1939, excluded from the mortality statistics, which henceforth related only to civilians. This selective factor was bound to inflate the death-rates, since the population in respect of which they were calculated was now on the average older and less healthy. To mark the discontinuity in the diagram, the curves have been broken at 1939. In so far as the slopes of the curves before and after 1940 are more important than absolute figures, it is possible to take the two parts of the diagram together and to observe continuity in trend. To reduce the confusing effect of the large-scale reclassification of deaths, heart disease and bronchitis have been combined. The death-rate from all causes, which, with the increasing age of the population, had been slowly rising before the war rose sharply in 1940. This rise was partly a feature of the war-time statistical basis as explained above, but the heavy toll of air-raids (2.59 per 1,000 in 1940) was an important contributory factor. Even in 1945 the fatality from V-bombs was 0.34 per 1,000, but for which the general death-rate would have fallen to 13-8 per 1,000. Tuberculosis Another cause of the rise in the death-rate, notably in 1941, was the increase in deaths from tuberculosis. This rise was only temporary and measured the effect of war conditions in hastening the death of those with advanced tuberculosis (a). When this source of increased mortality had been exhausted, the tuberculosis deathrate returned toward a normal level. A similar trend was observed in certain other European towns (b), Paris, Bucharest, Brussels, and in Belfast. In Paris (c), where the pre-war tuberculosis death-rate was twice as high as in London, the peak rise above 1938 (37 per cent.) was proportionately less than in London (72 per cent.). Paris suffered more privation from rationing, but endured less bombardment with its attendant shelter life, evacuation, loss of sleep, etc. In Prague, Budapest, Vienna and Amsterdam (b) tuberculosis mortality continued to rise throughout the war years. Information regarding Warsaw is incomplete, but in 1944 the death-rate for tuberculosis was over three times the pre-war value (d). Bronchitis and heart disease The death-rate for the bronchitis and heart disease group has followed a similar trend to that of the rate for " all causes " of which it forms a large part. Figures for the component diseases are shown in table 2 (page 13). Mortality from heart disease and bronchitis, after reaching a higher level in the early years of the war, subsided, and for the last four years has remained relatively stable. Pneumonia and other respiratory diseases Mortality from pneumonia rose sharply in 1940 and remained higher than formerly until 1943, when it began to fall, reaching in 1945 a level lower than the average of the immediate pre-war years. The rate for " other respiratory diseases " was distorted in 1940 by the statistical revision but has since declined fairly steadily. Diabetes Diabetes mortality has fallen steadily throughout the war. Food ratiomng has presumably been a contributory factor. Cancer Despite the ageing of the population, the cancer death-rate has remained comparatively stable in the last few years. Road accidents Deaths from road accidents are analysed by age in table 4, page 15. The re-issue of a basic petrol ration during 1945 and the corresponding increase in motor traffic is reflected in a rise in fatal road accidents, the increase being more noticeable among the very young and the very old. Infant mortality The infant mortality rate in 1945, 44 per 1,000 live births, constitutes a new low record, an improvement on the previous record of 47 per 1,000 live births in 1939. The movements of the death-rates from the principal diseases at ages below one year (a) Stocks, P. (1942) British Medical Journal 2.750. (b) Tuberculosis Reference Year Book (New York). (c) Maclouf, A., and Moine, M. Revue de Pathologie comparee et d'Hygtene generale, 1946. (d) U.N.R.R.A. Bulletin, IV, 7- 7 since 1911 are shown in table 6, page 16. The following diagram illustrates the contraction in the fatality of infants since the years 1911-14:- The increase in deaths assigned to congenital malformations is partly attributable to changes in classification following the adoption of the 5th revision of the International List of Causes of Death which added about 12 per cent. to the deaths which would formerly have been assigned to this group. For most diseases there has been a dramatic reduction in mortality over the last forty years, and, even since 1927, the improvement is substantial. Since evacuation disturbed the normal biennial sequence of epidemic outbreaks the incidence of measles in London has been comparatively light and this partly explains the low mortality, but there has also been a striking reduction in case mortality in recent years, not because the virus is less virulent but as a result of " improved nutrition together with other widely operating hygienic advancements " (a). Diarrhoea and respiratory infections too are now less (a) Butler, Lt.-Col. W. — J.R.S.S. 1945, 108/259. 8 Neonatal mortality frequently contracted, as a result of the efforts of health authorities in improving the nursing and nutrition of infants. Prematurity is also less fatal though much still remains to be done. Deaths in various periods of the first year of life are shown in detail in table 5, page 16. Deaths under 4 weeks numbered 1,047, or 23.0 per 1,000 live births compared with a rate of 23.1 in 1944. Comparative rates for London and England and Wales in recent vears are :—■ London Enqland and Wales 1931-35 25.1 31.4 1936-40 22.9 29.0 1941 28.4 28.5 1942 24.7 27.0 1943 23.4 25.3 1944 23.1 24.5 1945 230 24.7 The more intense degree of adversity in London during the war is reflected by the steep rise in the London rate in 1941, and the narrowing of the margin between London and the country as a whole. In the later years of the war, however, despite the continuation of difficulties, the mortality in London has been gradually brought down toward the pre-war level. Puerperal fever and pyrexia; maternal mortality The basic figures in respect of the hazards of childbirth are as given below. Detailed figures for the metropolitan boroughs are shown in tables 1 and 8 and comparative figures for England and Wales in recent years are shown in table 7, page 17. Year Live births Deaths Notifications Puerperal sepsis Other childbirth Puerperal fever Puerperal pyrexia No. Rate No. Rate No. Rate No. Rate 1945 45,532 32 0.70 56 1.23 188 4.13 472 10.37 1944 44,554 34 0.76 42 0.94 172 3.86 387 8.69 Rates per 1,000 live births. The maternal mortality rate (1.93) in 1945 was higher than in 1944 (1.70). There were more notified cases of puerperal sepsis (including post-abortion sepsis) but relatively less mortality from puerperal fever. The introduction of sulpha, drug treatment has led to a striking fall in the fatality from sepsis, as can be seen from the diagram on the next page which shows the trend of maternal mortality in London and in England and Wales in recent years. The sharp rise in London in 1941 was not shared by the country as a whole, and can be attributed to the effect of the bombardment, which reached its peak intensity in that year and rendered it difficult to maintain the normal high standard of hygienic control. Infectious diseases The attack-rates and death-rates of the principal infectious diseases in London during 1945 and earlier years, and for the constituent metropolitan boroughs in 1945, are shown in tables 1, 2 and 10. A comparison of the death-rates in London and England and Wales is given in table 9, page 18. Anthrax No case of anthrax was notified during the year. London has now been free from this disease since 1943. Diphtheria The attack-rate for diphtheria (0.49 notifications per thousand population) in 1945 was slightly higher than in 1944 (0.46), but the death-rate, at 0.0092 per thousand, was lower than in the previous year (0.015). Ten years ago mortality from this disease was seven times as heavy. Approximately 70 per cent. of London children have been immunised. While preventive inoculation does not give complete protection, it does greatly diminish the risk of death. In England and Wales, " out of every 30 children who died from diphtheria in the years 1942-43, 29 had not been immunised. In 1944 this death-rate among the unimmunised was about 9 27 to 28 times as great as among the immunised " (a). Of 1,273 notifications, no fewer than 351 were of persons over 15 years of age. The incidence of dysentery continues to increase. Figures for recent years are:- Year Notifications Deaths 1940 161 14 1941 610 33 1942 749 34 1943 1,103 14 1944 1,558 20 1945 2,082 16 Dysentery Many outbreaks occur in institutions in which patients are infirm or in low mental health, who cannot be expected to maintain clean habits, and among whom therefore the disease can rapidly spread, but too many cases occur among other members of the public. These would be prevented if the simple rules of hygiene were observed. The mortality from diarrhoea and enteritis under two years of age (318 deaths) amounted to 6.98 per thousand live births, compared with 9.58 in the previous year. This represents a return to the level of mortality experienced in 1940-41. The diagram on page 10 shows the trend of mortality in London and England and Wales in recent years. Diarrhœa and enteritis It appears that the gap between the London rate and the average for the country as a whole is again closing. Notifications of fevers of the enteric group (45) were more numerous than in Enteric 1944 (38), but there were only 3 deaths, representing a mortality-rate of 0.001 per fevers thousand—one hundredth of the rate experienced at the beginning of the century. There were only 171 deaths (0.066 per thousand) from influenza during the influenza year. During the war years the deaths were:- Year Influenza deaths 1940 569 1941 397 1942 198 1943 726 1944 206 1945 171 (a) Ministry of Health circular. 10 Rheumatic fever Deaths in London from rheumatic fever in 1945 numbered 28, of which 13 were among children under fifteen years of age. Corresponding figures in 1944 were 46 and 14, respectively. Scabies Scabies became notifiable in London in August, 1943. Notifications in 1945 numbered 14,753, compared with 16,450 in 1944. It is too early to measure the effect of improved control resulting from notification, but the reduction is gratifying. Scarlet fever The incidence of scarlet fever was approximately the same as in 1944-4,252 cases (1.64 per thousand), compared with 4,153 (1.69 per thousand). There was only one fatal case in 1945. Measles The dramatic reduction in the case mortality from measles has already been mentioned in connection with infant mortality. In 1945, 23,518 cases of measles were notified (9.07 per thousand), compared with 7,499 (3.05 per thousand) in 1944. The deaths numbered 31, i.e., 0.012 per thousand living (0.13 per cent. of cases). In 1944 there were only 7 deaths (0.003 per thousand living and 0.093 per cent. of cases). A precise measure of the fall in case mortality in recent years cannot be given, as the first complete year of notification was 1939, when the fatality had already been considerably reduced. Previously, information as to the number of cases was limited to the reports of school authorities based upon absences. Such dual records as exist and other evidence suggest that these reports cover only 40 per cent. of those cases which would have been notified had the regulations been in force. On this assumption, it is estimated that the comparable case mortality figures are:- 1931-35 0.80 per cent. 1936-40 0.47 „ „ 1941-45 0.20 „ „ The average death-rates per 1,000 living during the same periods were:- 1931-35 0.089 1936-40 0.043 1941-45 0.014 Smallpox If the light incidence of the war years is taken into account, these figures fit the trend indicated by the estimated case mortality percentages. There were four notifications of smallpox, only two were confirmed and neither was fatal. A soldier who had never been vaccinated and who had three times refused vaccination in the Army, returned to Camberwell from Italy by air. Ten days later he was admitted to hospital suffering from smallpox. All known contacts were recommended to be vaccinated. A sister, at the same address, was vaccinated on the day of admission of her brother to hospital, though she had already been in contact for several days and was admitted to hospital eleven days later with smallpox. Two neighbours in adjacent houses were later taken ill and admitted to hospital and notified as smallpox, but the final diagnosis was vaccinial malaise in one case and scabies in the other. 11 Four cases of typhus were notified to the metropolitan borough medical officers of health. The first of these was a member of a group of several London medical students who assisted in relief work at Belsen camp and contracted typhus ; in the other cases in the group the notifications were referred to home addresses outside London. Typhus The other three cases included a repatriated prisoner-of-war from Germany, a pathological laboratory assistant who became infected in the course of his work, and a doctor who had visited Siberia. There were 3,307 notifications of whooping-cough during the year, compared with 7,144 in 1944. The death-rate was 0.018 per thousand (case mortality 1.4 per cent.). Corresponding rates for 1944 were 0.047 per thousand and 1.6 per cent. It will be seen from table 2 that the fatality for this disease is now much less than it was a few years ago. Whooping cough Reference has already been made to the mortality experienced in respect of tuberculosis. Tuberculosis The civilian death-rates in 1945 in London and for the whole country were:- Tuberculosis deaths Pulmonary per 1,000 living Non-pulmonary London 0.782 0.086 England and Wales 0.515 0.099 Detailed figures in respect of notifications are shown in tables 11-13, on page 19. Excluding non-civilian cases, in order to relate the notifications to the civilian population, the rates of occurrence of new cases in recent years are as follows Year Pulmonary Non-pulmonary 1938 1.31 0.26 1939 1.26 0.23 1940 1.33 0.22 1941 1.87 0.30 1942 1.80 0.33 1943 1.87 0.31 1944 1.80 0.26 1945 1.69 0.23 While the rates are affected by the return of the civil population and to a very small extent by the demobilisation of military personnel, i.e., the selection of 1939 in reverse, nevertheless the incidence has clearly diminished. For non-respiratory tuberculosis there is on the whole an improvement on the pre-war position, except for the incidence of tuberculous glands, which is still higher than in 1938 (rate for children under fifteen 29 per cent. above 1938). The incidence of tuberculous meningitis was notably low (65 per cent. of 1938). The position continues to improve, and, though the upheaval of war has retarded the downward trend in the incidence of tuberculosis, it is well to remember that even in the worst of the war years the morbidity and mortality were much below the level of thirty years ago, and that the gains resulting from wise legislation, combined with public education and progress in preventive medicine, have not been so greatly discounted as may have been feared. The battle against tuberculosis is still the serious pre-occupation of health authorities, but the weapons are continually being improved. 12 Table 1—Vital statistics for the metropolitan boroughs and the County of London in the year 1945 (Rates per 1,000 of population) Metropolitan boroughs arranged in topographical order Estimated civilian population, 1945 Live births Deaths Infant mortality (per 1,000 live births) Measles Scarlet fever Diphtheria Whooping cough Typhoid fever Diarrhœa and enteritis age 0.2 (per 1,000 lire births) Pulmonary tuberculosis Pneumonia Other resp. dis. Cancer Maternal mortality (per 1,000 live births) Notifications of infectious disease (52 weeks) Scarlet fever Diphtheria Typhoid fever Erysipelas Acute pneu monja les Measles Whoop ing cough Western Paddington 99,790 17..2 13.7 61 0.04 - 0.02 0.01 - 7.6 0.59 0.95 1.05 2.03 4.09 1.28 0.51 0.03 0.31 0.08 0.96 10.53 0.54 Kensington 117,170 16.1 13.5 49 0.01 - 0.02 - 0.01 6.3 0.70 0.75 0.84 2.30 2.12 1.22 0.30 0.02 0.28 0.03 0.70 7.42 0.54 Hammersmith 96,100 18.1 13/6 45 0.01 - - 0.03 0.01 8.6 0.85 0.96 1.14 215 0.57 1.68 0.42 0.01 0.19 0.09 0.50 10.68 0.83 Fulham 99,790 17.8 13.0 42 - - - 0.02 - 6.8 0.74 0.84 1.24 2.13 1.69 2.46 0.66 - 0.31 0.10 0.70 11.38 1.60 Chelsea 35,310 15,8 15.2 45 0.08 - 0.03 - - 3.6 0.76 0.82 1.13 2.61 7.19 1.42 0.40 0.03 0.26 0.09 0.34 9.83 1.05 Westminster, 72,850 12,9 14.4 72 0.01 - - 0.03 - 11.8 0.78 0.67 0.93 2.55 4.28 0.66 0.33 0.01 0.12 0.08 0.15 6.36 0.78 City of Northern St. Marylebone 59,590 13.3 13.2 47 0.02 - - - - 11.3 0.60 0.67 0.96 2.65 3.78 1.26 0,22 - 0.47 0.10 0.84 7.37 0.35 Hampstead 74,390 16.2 13.4 42 - - - 0.01 - 5.8 0.66 0.66 1.13 2.38 1.66 0.81 0.15 - 0.28 0.07 1.31 6.54 0.63 St. Pancras 111,400 17.6 16.2 44 0.01 - - 0.03 - 13.3 1.05 1.01 1.47 2.90 2.55 2.17 0.93 0.05 0.54 0.07 1.21 9.23 1.64 Islington 195,770 18.9 14.6 46 0.01 - 0.02 0.03 - 7.6 0.80 0.91 1.35 2.34 0.27 1.87 0.45 - 0.35 0.05 0.34 9.08 1.08 Stoke Newington 37,030 19.0 12.8 38 - - - - - 5.7 057 0.81 1.81 2.27 1.42 1.44 0.08 - 0.32 0.11 0.43 11.54 1.46 Hackney 140,570 17.8 13.4 42 - - 0.01 0.05 - 4.4 0.58 0.55 1.43 2.21 2.40 2.00 0.64 0.03 0.38 0.04 0.39 7.81 1.68 Central Holborn 18,680 13.1 15.8 70 - - - - - 4.1 0.80 0.64 1.23 2.68 - 0.70 0.64 - 0.16 0.11 0.32 5.96 0.59 Finsbury 27,990 16.9 17.1 55 - - - 0.07 - 2.1 1.00 0.82 1.79 2.82 4.24 1.79 0.93 - 0.25 0.18 1.00 12.72 1.68 City of Lndn. (a) 4,420 8.6 13.6 - 0.23 - - - - - 0.68 0.23 1.58 2.04 - 0.45 0.23 0.23 0.45 0.23 - 4.76 - Eastern Shoreditch 36,760 19.0 16.4 39 0.03 - - - - 8.6 0.95 0.84 2.04 2.50 1.43 2.95 1.50 - 0.46 0.22 0.76 12.28 1.83 Bethnal Green 49,640 17.9 14.2 29 - - - 0.02 - 6.7 0.87 0.83 1.19 2.70 1.12 1.86 0.85 - 0.46 0.02 0.34 11.43 1.39 Stepney 77,610 18.6 18.9 56 0.01 - - 0.03 0.01 10.4 1.33 0.80 1.64 2.59 2.78 1.99 0.57 0.01 0.43 0.08 0.71 9.38 1.23 Poplar 57,670 21.2 14.6 47 0.02 - - - - 7.4 0.78 0.71 1.30 2.71 0.82 2.78 0.47 0.05 0.43 0.09 1.53 11.22 1.04 Southern Southwark 71,160 18.3 16.1 39 - - - - - 7.7 1.25 1.00 1.66 2.73 0.77 2.18 1.00 - 0.52 0.07 0.85 13.92 0.85 Bermondsey 47,040 18.0 14.5 52 - - 0.04 - - 14.2 0.94 0.55 1.32 2.15 3.54 2.05 0.64 0.04 0.28 - 1.41 11.60 0.90 Lambeth 173,280 18.6 14.9 47 0.01 0.01 0.01 0.02 - 6.8 0.91 0.63 1.25 2.29 1.86 1.52 0.30 0.01 0.17 0.06 0.43 10.43 1.48 Battersea 90,420 17.6 13.8 41 - - - 0.06 - 3.8 0.69 0.51 1.26 2.37 1.26 2.24 0.48 0.03 0.45 0.08 1.19 17.33 2.34 Wandsworth 264,480 16.3 12.8 39 0.02 - 0.02 0.00 - 4.4 0.59 0.51 1.06 2.09 1.63 1.52 0.44 0.04 0.33 0.04 0.91 9.36 1.34 Camberwell 135,460 18.0 14.5 37 0.02 - 0.01 0.01 - 4.5 0.87 0.80 1.28 2.27 2.46 1.03 0.40 0.02 0.19 0.07 0.58 8.21 1.01 Deptford 56,650 19.6 16.8 48 0.05 - 0.05 0.02 - 3.6 0.69 0.74 1.41 1.98 0.90 1.66 0.65 - 0.21 0.04 1.26 4.25 0.80 Greenwich 63,800 18.5 12.7 43 - - 0.02 0.02 - 8.5 0.80 0.50 1.07 1.83 1.70 1.23 0.77 - 0.38 0.06 1.01 5.34 2.09 Lewisham 171,280 17.7 12.1 34 - - 0.01 0.02 - 8.3 0.71 0.44 0.99 2.28 1.98 1.14 0.25 0.01 0.29 0.09 0.40 2.69 1.40 Woolwich 115,270 17.5 12.8 41 0.01 - 0.01 0.01 - 5.4 0.69 0.56 0.82 2.32 1.98 1.77 0.30 0.01 0.37 0.14 1.78 8.78 2.44 London, 1945 2,601,370 17.5 14.1 44 0.01 0.00 0.01 0.02 0.00 7.0 0.78 0.71 1.22 2.33 1.93 1.64 0.49 0.02 0.33 0.07 0.77 9.07 1.27 London, 1944 2,462,500 18.1 16.7 51 0 .00 0.00 0.02 0.05 0.00 9.6 0.84 0.87 1.19 2.35 1.70 1.69 0.46 0.02 0.38 0.08 0.92 3.05 2.91 (a) Including Inner and Middle Temple. 13 Table 2—County of London—Principal vital statistics, 1891-1945 Period Annua) rate per 1,000 living Annual mortality per 1,000 living Annual mortality pet 1,000 live births Live births Marriages Deaths (all causes) Cerebrospinal fever Diphtheria Enteric fever Scarlet fever Smallpox Whoopingcough Measles Influenza Tuberculosis Pneumonia (all forms) Bronchitis Other respdiseases Heart disease Cancer Diabetes Infants 0-1 Diarrhoea and enteritis 0-2 Puerperal fever Other acc. of ch. birth Pulmonary Non-pulmonary 1891-95 30.8 17.3 19.8 (a) 0.53 0.13 0.24 0.02 0.52 0.59 0.41 1.83 0.80 1.45 2.45 0.48 (a) 0.80 0.07 156 23.8 2.15 2.22 1896-1900 29.7 18.4 18.5 (a) 0.45 0.14 0.14 0.00 0.47 0.57 0.27 1.75 0.69 1.32 1.80 0.35 (a) 0.92 0.07 162 41.3 1.70 1.74 1901-05 28.6 17.7 16.4 (a) 0.20 0.08 0.11 0.07 0.36 0.45 0.17 1.58 0.57 1.46 1.41 0.26 1.31 1.01 0.08 139 30.4 1.64 1.52 1906-10 26.5 17.4 14.9 (a) 0.14 0.04 0.10 0.00 0.29 0.42 0.22 1.39 0.48 1.49 1.22 0.22 1.26 1.11 0.10 114 23.8 1.46 1.47 1911-15 24.0 20.0 14.8 0.02 0.13 0.03 0.05 0.00 0.22 0.43 0.16 1.39 0.39 1.33 1.29 0.21 1.54 1.16 0.11 108 28.0 1.40 1.57 1916-20 20.0 20.1 15.1 0.04 0.17 0.02 0.03 0.00 0.20 0.28 1.01 1.43 0.34 1.38 1.30 0.19 1.71 1.28 0.09 92 15.4 1.64 1.72 1921-25 19.9 17.9 12.3 0.01 0.17 0.01 0.04 0.00 0.15 0.17 0.32 1.01 0.19 1.14 0.97 0.16 1.66 1.38 0.10 71 11.7 1.36 1.63 1926-30 16.2 18.6 12.3 0.02 0.10 0.01 0.02 0.00 0.11 0.16 0.30 0.90 0.14 1.00 0.72 0.16 2.29 1.52 0.12 64 10.2 1.66 1.69 1931-35 13.8 19.5 12.1 0.03 0.08 0.00 0.02 0.00 0.07 0.09 0.26 0.79 0.11 0.85 0.47 0.14 2.99 1.66 0.14 63 11.6 1.50 1.66 1936-40 13.7 25.4 13.4 0.02 0.04 0.00 0.01 - 0.04 0.04 0.19 0.72 0.09 0.83 0.67 0.13 3.67 1.87 0.16 56 10.9 0.80 1.22 1941 14.6 30.2 (b) 18.7 0.05 0.04 0.01 0.00 - 0.05 0.02 0.17 1.10 0.15 1.08 1.37 0.18 4.46 2.38 0.13 57 6.3 1.47 1.58 1942 16.9 27.6 (b) 15.0 0.02 0.02 0.00 0.00 - 0.04 0.01 0.08 0.90 0.12 0.86 1.03 0.16 3.86 2.40 0.11 50 8.0 1.13 1.38 1943 18.0 21.7 (b) 15.7 0.02 0.02 0.00 0.00 - 0.03 0.02 0.29 0.88 0.10 1.04 118 0.18 4.02 2.46 0.11 51 9.9 0.95 1.18 1944 18.1 21.5 (b) 16.7 0.02 0.02 0.00 0.00 - 0.05 0.00 0.08 0.84 0.10 0.87 103 0.16 4.05 2.35 0.10 51 9.6 0.76 0.94 1945 17.5 28.0 (b) 14.1 0.02 0.01 0.00 0.00 - 0.02 0.01 0.07 0.78 0.09 0.71 108 0.14 3.63 2.33 0.08 44 7.0 0.70 1.23 (a) Comparable figures are not available for this period, (b) Provisional rate. 14 Table 3—Administrative County of London—Civilian deaths in 1945 Cause Sex All ages 0- 1- 5- 15- 45- 65 + 1. Typhoid and paratyphoid M - - - - - - - F 3 - - - 1 1 1 2. Cerebro-spinal fever M 20 9 6 - 2 2 1 F 25 10 6 2 4 2 1 3. Scarlet fever M 1 1 - - - - - F - - - - - - - 4. Whooping-cough M 18 13 5 - - - - F 29 22 6 1 - - - 5. Diphtheria M 7 1 3 2 1 - - F 17 - 6 7 2 2 - 6. Tuberculosis—respiratory M 1,338 5 7 4 563 589 170 F 695 - 6 4 504 130 51 7. Tuberculosis—other forms M 118 4 21 12 50 21 10 F 106 6 18 12 36 22 12 8. Syphilitic disease M 216 4 = - 16 105 91 F 114 4 - - 13 49 48 9. Influenza M 90 5 2 1 12 39 31 F 81 3 1 - 4 22 51 10. Measles M 19 5 12 2 - - - F 12 3 6 1 2 - - 11. Acute poliomyelitis and polioencephalitis M 2 - - - 2 - - F 4 - - - 3 1 - 12. Acute infectious encephalitis M 11 - - - 4 5 2 F 16 - - - 5 7 4 Cancer of— 13. Mouth and oesophagus M 314 - - 1 6 84 223 14. Uterus F 326 - - - 24 177 125 15. Stomach and duodenum M 567 - - - 36 242 289 F 420 - - - 20 133 267 16. Breast M 7 - - - - 4 3 F 571 - - - 50 282 239 17. All other sites M 2,314 1 3 6 137 1,021 1,146 F 1,536 1 1 7 101 570 856 18. Diabetes M 65 - - - 4 17 44 F 156 - - - 11 43 102 19. Intra-cranial vase, lesions M 1,266 2 - 1 17 344 902 F 1,667 - - - 23 409 1,235 20. Heart disease M 4,542 - - 5 148 1,086 3,303 F 4,902 = - 5 171 656 4,070 21. Other circulatory diseases M 732 1 - - 17 181 533 F 701 1 - - 19 164 517 22. Bronchitis M 1,758 36 6 2 59 620 1,035 F 1,051 30 4 - 24 186 807 23. Pneumonia M 1,030 173 32 7 61 274 483 F 817 118 18 4 42 142 493 24. Other respiratory diseases M 228 4 2 - 27 107 88 F 140 3 3 - 24 52 58 25. Ulcer of stomach or duodenum M 424 1 - - 58 194 171 F 106 - - - 5 34 67 26. Diarrhoea under 2 years M 188 181 7 - - - - F 130 123 7 - - - - 15 Table 3—Administrative County of London—Civilian deaths in 1945—continued Cause Sex All ages 0- 1- 5- 15- 45- 65+ 27. Appendicitis M 68 1 5 6 10 26 20 F 52 - 4 5 11 17 15 28. Other digestive diseases M 347 14 9 7 32 108 177 F 424 8 7 4 44 124 237 29. Nephritis M 379 - 1 3 56 133 186 F 356 - 3 2 39 123 189 30. Maternal sepsis F 32 - - - 31 1 - 31. Other maternal F 56 - - - 56 - - 32. Premature birth M 239 239 - - - - - F 184 184 - - - - - 33. Congenital malformation, birth injury, other infant diseases. M 427 366 7 3 25 21 5 F 309 248 7 3 20 20 11 34. Suicide M 164 - - - 43 80 41 F 128 - - - 47 61 20 35. Road traffic accidents M 225 - 15 34 40 47 89 F 92 - 9 17 11 22 33 36. Other violent causes M 889 64 47 98 195 219 266 F 1,000 49 36 50 256 204 405 37. All other causes M 1,290 43 25 36 156 300 730 F 1,187 25 14 17 160 293 678 All causes M 19,303 1,173 215 230 1,777 5,869 10,039 F 17,445 838 162 141 1,763 3,949 10,592 Table 4—Road deaths by age 1940-45 Year 0-4 5-14 15-44 45-64 65 All ages 1940 24 32 144 144 199 543 1941 11 28 77 116 141 373 1942 14 32 66 75 99 286 1943 9 28 47 66 79 229 1944 13 41 49 62 103 268 1945 24 51 51 69 122 317 16 Table 5—County of London—Infant mortality, 1945 Cause of death Age at death Total Bates per 1,000 live births Under 1 day 1 to 7 days 1 to 4 wks. 4 weeks to 1 year No. Males Females Total Male Female Measles Leg. - - - 8 8 5 3 0-18 0-21 014 Illeg. - - - Whooping-cough Leg. - - - 35 35 13 22 0.77 0.56 0.99 Illeg. - - - Influenza Leg. - - - 8 8 5 3 0.18 0.21 0.14 Illeg. - - - Tuberculosis Leg. - - - 15 15 9 6 0.33 0.39 0.27 Illeg. - - - Bronchitis Leg. - - 3 62 66 36 30 1.45 1.54 1.35 Illeg. - 1 - Pneumonia Leg. 1 10 40 227 291 173 118 6.39 7.41 5.32 Illeg. - 2 11 Diarrhoea Leg. - 1 12 286 304 181 123 6.68 7.76 5.54 Illeg. - - 5 Premature birth Leg. 159 138 37 25 423 239 184 9.29 10.24 8.29 Illeg. 30 25 9 Congenital defects, Birth injury and other diseases of early infancy. Leg. 178 196 69 105 614 366 248 13.48 15.68 11.17 Illee. 28 24 1.4 Other causes Leg. 6 3 10 193 247 146 101 5.42 6.26 4.55 Illeg. 32 1 2 All causes Leg. M. 196 220 96 479 1,683 991 692 41.71 48.03 35.09 F. 148 128 75 341 Illeg. M. 43 30 22 87 328 182 146 63.34 67.33 58.99 F. 47 23 19 57 Total 1945 434 401 212 964 2,011 1,173 838 44.17 50.26 37.76 Total 1944 411 358 258 1,223 2,250 1,272 978 50.50 55.35 45.33 1944 Leg. M. 192 203 134 575 1,932 1,104 828 47.81 53.07 42.23 F. 135 115 94 484 Illeg. M. 40 24 14 90 318 168 150 76.77 77.17 76.34 F. 44 16 16 74 Table 6—Infant mortality in London by cause 1911—1945 (Rates per 1,000 live births) Casue of death 1911 to 1914 1915 to 1918 1919 to 1922 1923 to 1926 1927 to 1930 1931 to 1934 1935 to 1938 1939 to 1942 1942 1943 1944 1945 Measles 3.40 3.84 1.64 2.02 2.07 1.44 0.95 0.22 0.20 0.51 0.09 0.18 Whooping-cough 3.63 4.45 2.50 2.60 3.14 2.27 2.01 1.43 1.48 1.15 2.13 0.77 Influenza 0.27 1.10 0.81 0.38 0.48 0.40 0.24 0.39 0.30 0.44 0.27 0.18 Tuberculosis 3.40 3.20 1.52 1.26 0.89 0.77 0.56 0.63 0.52 0.53 0.22 0.33 Bronchitis 6.41 6.72 4.42 2.91 2.30 2.16 1.97 1.81 2.19 1.67 1.39 1.45 Pneumonia 12.28 14.96 12.60 11.51 12.10 11.45 10.39 7.64 7.43 8.04 7.45 6.39 Diarrhoea 24.28 16.10 12.16 9.36 8.87 10.86 12.10 6.96 7.67 9.44 9.02 6.68 Premature birth 18.16 17.42 17.00 14.74 14.17 14.91 13.41 12.51 13.50 11.66 12.03 9.29 Congenital defects 14.69 14.66 11.26 8.39 7.38 7.22 6.35 10.08 11.54 11.44 10.10 13.49 Other causes 21.48 20.55 15.09 11.83 12.60 13.52 12.30 8.14 5.24 5.84 7.79 5.42 All causes 108 103 79 65 64 65 60 50 50 51 51 44 17 Table 7—Mortality in childbirth—London and England and Wales 1934-45 (Rates per 1,000 live births) 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 Puerperal fever :— London 1.34 1.15 0.75 0.84 0.79 0.65 0.98 1.47 1.13 0.95 0.76 0.70 England and Wales 2.03 1.68 1.39 0.98 0.89 0.77 0.82 0.85 0.80 0.75 0.62 0.50 Other causes :— London 1.46 1.43 1.23 1.45 1.12 1.32 1.00 1.58 1.38 1.18 0.94 1.23 England and Wales 2.57 2.42 2.41 2.28 2.19 2.16 1.88 2.01 1.76 1.60 1.38 1.34 Table 8—Maternal mortality in London 1931-45 Metropolitan boroughs arranged in topographical order Childbirth deaths (a) per 1,000 live-births Number or deaths (b) in childbirth 1945 1931-40 1941-45 Puerperal fever Other causes Total Puerperal fever Other causes Total Puerperal fever Other causes Total Western Paddington 1.9 2.2 4.1 1.5 1.2 2.7 4 3 7 Kensington 1.5 1.6 3.1 1.0 1.0 2.0 3 1 4 Hammersmith 1.0 1.2 2.2 0.6 0.9 1.5 - 1 1 Fulham 1.1 1.6 2.7 0.9 1.2 2.1 - 3 3 Chelsea 1.5 1.8 3.3 1.5 2.5 4.0 1 3 4 Westminster 2.0 1.4 3.4 2.4 1.6 4.0 1 3 4 Northern St. Marylebone 1.5 2.1 3.6 1.2 2.2 3.4 1 2 3 Hampstead 0.8 1.4 2.2 0.4 1.8 2.2 1 1 2 St. Pancras 1.4 1.7 3.1 1.3 1.5 2.8 3 2 5 Islington 1.2 1.5 2.7 0.8 1.2 2.0 - 1 1 Stoke Newington 0.6 2.9 3.5 1.0 1.0 2.6 - 1 1 Hackney 0.9 1.4 2.3 0.4 1.0 1.4 1 5 6 Central Holborn 2.1 1.4 3.5 2.9 - 2.9 - - - Finsbury 0.8 0.7 1.5 1.8 1.4 3.2 2 - 2 City of London 3.3 - 3.3 - - - - - - Eastern Shoreditch 0.8 1.4 2.2 1.6 0.9 2.5 - 1 1 Bethnal Green 1.1 1.0 2.1 0.7 0.7 1.4 - 1 1 Stepney 0.9 1.7 2.6 0.8 1.6 2.4 2 2 4 Poplar 1.4 1.1 2.5 1.5 1.2 2.7 1 - 1 Southern Southwark 0.9 1.7 2.6 0.8 0.8 1.4 - 1 1 Bermondsey 1.3 1.5 2.8 1.5 2.0 3.5 1 2 3 Lambeth 1.0 1.1 2.1 1.1 1.2 2.3 2 4 6 Battersea 1.2 1.5 2.7 0.7 0.4 1.1 - 2 2 Wandsworth 1.5 1.4 2.9 1.0 1.2 2.2 4 3 7 Camberwell 1.2 1.5 2.7 1.2 1.4 3.6 2 4 6 Deptford 1.1 1.3 2.4 1.0 0.8 1.8 - 1 1 Greenwich 1.2 1.5 2.7 0.4 0.6 1.0 1 1 2 Lewisham 1.1 1.6 2.7 0.7 1.6 2.3 - 6 6 Woolwich 0.8 1.1 1.9 0.4 1.3 1.7 2 2 4 London 1.2 1.5 2.7 1.0 1.2 2.2 32 56 88 (а) Including deaths due to abortion except that those legally determined to have resulted from criminal interference have been included only from 1940. (b) The deaths in childbirth in 1945 are shown in the above table but not the death-rates, as, owing to the smallness of the figure*, the rates for a single year in any metropolitan borough may be misleading. The maternal mortality-rates for each metropolitan borough in 1945 and for London as a whole are, however, sot out in table 1. C 18 Table 9— Death rates from certain infectious diseases—London and England and Wales—1933-45 Rates are per 1,000 living except for diarrhoea and enteritis where it is expressed per 1,000 live births Year Measles Whooping-cough Scarlet fever Diphtheria Diarrhœa & enteritis under 2 London E. & W. London E. & W. London E. & W. London E. & W. London E. & W. 1933 0.023 0.048 0.077 0.056 0.020 0.018 0.084 0.066 11.74 6.98 1934 0.202 0.093 0.069 0.051 0.016 0.024 0.114 0.101 12.80 5.36 1935 0.005 0.033 0.040 0.039 0 006 0.014 0.065 0.086 11.31 5.56 1936 0.141 0.067 0.067 0.051 0.010 0.012 0.055 0.075 14.47 5.75 1937 0.006 0.026 0.060 0.043 0.008 0.009 0.053 0.072 12.29 5.54 1938 0.058 0.040 0.025 0.027 0.007 0.009 0.050 0.071 13.23 5.30 1939 0.001 0.007 0.035 0.031 0.002 0.005 0.026 0.053 8.36 4.67 1940 0.009 0.021 0.003 0.017 0.002 0.004 0.022 0.052 6.13 4.76 1941 0.022 0.029 0.048 0.062 0.001 0.003 0.035 0.068 6.30 5.08 1942 0.013 0.012 0.042 0.021 0.0004 0.003 0.021 0.047 7.97 5.22 1943 0.020 0.020 0.034 0.029 0.004 0.003 0.023 0.036 9.86 5.15 1944 0.003 0.006 0.047 0.028 0.003 0.003 0.015 0.024 9.58 4.97 1945 0.012 0.019 0.018 0.018 0.0004 0.002 0.009 0.018 6.98 5.50 Table 10—County of London—Notifiable infectious diseases—Annual number of notifications and numbers per 1,000 of population—1933-1945 Year Anthrax Cerebrospinal fever Continued fever Diphtheria Dysentery Encephalitis lethargica Enteric fever Erysipelas Malaria Measles Ophthalmia neonatorum Pneumonia Polioencephalitis Poliomyelitis Puerperal fever Puerperal pyrexia Scabies Scarlet fever Smallpox Typhus Whoopingcough Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate 1933 3 0.001 216 0.050 5 0.001 9,557 2.229 31 0.007 22 0.005 164 0.038 2,766 0.645 21 0.005 (b) (b) 527 (a) 9.313 6,299 1.469 6 0.001 60 0.014 255 (a) 4.506 838 (a) 14.809 (b) (b) 21,911 5.111 531 0.124 - — (b) (b) 1934 3 0.001 137 0.032 4 0.001 11,782 2.793 58 0.014 29 0.007 109 0.026 2,586 0.613 30 0.007 (b) (b) 467 8.237 5,569 1.320 8 0.002 66 0.016 254 4.480 758 13.369 (b) (b) 18,238 4.323 144 0.034 — — (b) (b) 1935 2 0.0005 105 0.025 3 0.001 9,294 2.227 199 0.048 15 0.004 187 0.045 1,868 0.448 37 0.009 (b) (b) 382 6.867 3,787 0.907 4 0.001 81 0.019 241 4.332 652 11.721 (b) (b) 10,954 2.625 — — — — (b) (b) 1936 - — 113 0.027 4 0.001 7,030 1.675 304 0.072 12 0.003 255 0.061 1,815 0.432 35 0.008 (b) (b) 462 8.099 4,141 0.986 2 0.0005 36 0.009 175 3.068 635 11.132 (b) (b) 10,705 2.550 — — — - (b) (b) 1937 3 0.001 175 0.043 6 0.001 7,810 1.913 916 0.224 8 0.002 216 0.053 1,764 0.432 42 0.010 (b) (b) 453 8.257 4,798 1.175 13 0.003 95 0.023 228 4.156 793 14.455 (b) (b) 8,455 2.071 — — — - (b) (b) 1938 4 0.001 182 0.045 1 0.0002 7,611 1.878 1,049 0.259 5 0.001 191 0.047 1,829 0.451 16 0.004 282(c) 0.278 489 8.998 3,962 0.978 12 0.003 122 0.030 199 3.662 853 15.l696 (b) (b) 8,093 1.997 — — — — 1,891 1.867 1939 3 0.001 169 0.045 3 0.001 3,671 0.974 268 0.071 11 0.003 98 0.026 1,388 0.368 17 0.005 1,303 0.346 408 8.067 3,733 0.990 3 0.001 95 0.025 163 3.223 704 13.919 (b) (b) 5,677 1.506 — — — — (c) 10,537 2.795 1940 3 0.001 839 0.274 6 0.002 1,844 0.601 161 0.052 8 0.003 158 0.052 1,076 0.351 16 0.005 5,447 1.776 303 7.096 2,688 0.876 3 0.001 17 0.006 155 3.630 472 11.054 (b) (b) 2,498 0.814 — — — - 669 0.218 1941 1 0.0004 706 0.298 2 0.001 2,179 0.921 610 0.258 10 0.004 210 0.089 1,171 0.495 13 0.005 11,039 4.667 185 6.668 2,518 1.064 5 0.002 36 0.015 94 3.388 340 12.255 (b) (b) 2,372 1.003 — — — — 7,944 3.358 1942 1 0.0004 341 0.142 1 0.0004 1,813 0.756 749 0.312 3 0.001 67 0.028 1,034 0.431 16 0.007 19,987 8.333 210 5.180 2,246 0.936 1 0.0004 24 0.010 110 2.713 505 12.456 (b) (b) 4,416 1.841 2 0.001 — - 6,234 2.599 1943 4 0.002 231 0.093 1 0.0004 1,862 0.747 1,103 0.442 4 0.002 47 0.019 1,054 0.423 35 0.014 22,882 9.176 233 5.189 3,159 1.267 3 0.001 40 0.016 147 3.273 471 10.488 9,689 9.183 9,477 3.800 - — — — 6,661 2.671 1944 — — 195 0.079 2 0.001 1,126 0.459 1,558 0.634 4 0.002 38 0.015 924 0.376 78 0.032 7,499 3.054 211 4.762 2,252 0.917 2 0.001 18 0.007 172 3.882 387 8.734 [a) 16,4£0 6.698 4,153 1.691 2 0.001 — — 7,144 2.909 1945 — — 185 0.071 2 0.001 1,273 0.491 2,082 0.803 7 0.003 45 0.017 846 0.326 93 0.036 23,518 9.065 224 4.933 1,992 0.768 — — 70 0.027 188 4.140 472 10.395 14,753 5.687 4,252 1.639 4 0.002 4 0.002 3,307 1.275 (a) Rate per 1,000 live births. (b) Comparable figures not available for this period. (c) Cases relate to last quarter only — Rates are adjusted on an annual basis. (d) Cases relate to last 22 weeks only — Rates are adjusted on an annual basis. 19 Table 11—Tuberculosis—Primary notifications in London during the year 1945 Form of tuberculosis notified Sex Number of formal primary notifications of new cases of tuberculosis Total all ages Total notifica tions 0- 1- 5- 10- 15- 20- 26- 35- 46- 65- 65+ Pulmonary tuberculosis M. 9 70 69 67 272 368 576 441 425 343 178 2,818 3,238 F. 3 66 66 59 305 526 546 240 116 97 51 2,075 2,450 Other forms of tuberculosis M. 4 37 51 42 46 19 48 35 13 6 4 305 363 F. 3 29 48 31 41 49 48 30 15 4 11 309 350 All forms of tuberculosis M. 13 107 120 109 318 387 624 476 438 349 182 3,123 3,601 F. 6 95 114 90 346 575 594 270 131 101 62 2,384 2,800 Table 12—New cases of tuberculosis in London found by other means than notification Form of tuberculosis Sex New cases of tuberculosis coming to knowledge otherwise than by formal notification 0- 1- 5- 10- 15- 20- 25- 35- 45- 55- 65 + Total Pulmonary tuberculosis M. 1 9 13 17 30 114 180 117 93 83 58 715 F. - 7 12 13 48 122 170 73 32 15 13 505 Other forms of tuberculosis M. 2 11 13 16 11 6 23 6 10 2 4 104 F. 2 8 12 17 9 22 8 8 5 5 2 98 All forms of tuberculosis M. 3 20 26 33 41 120 203 123 103 85 62 819 F. 2 15 24 30 57 144 178 81 37 20 15 603 The sources of information as to the unnotified cases shown above were as follows:— Source of information Number of cases Pulmonary Non-pulmonary Death returns from local registrars 99 22 transferable deaths from Registrar-General 132 32 Posthumous notifications 51 23 " Transfers " from other areas 878 118 Other sources 60 7 Table 13—Numbers on the registers, for the whole county, 1940-1945 Cases on the register at the end of the year— 1940 1941 1942 1943 1944 1945 Pulmonary— Males 12,908 12,677 12,894 13,608 14,340 15,018 9,448 9,119 9,441 10,232 10,990 11,496 Other forms— Males 3,263 2,916 2,785 2,847 2,866 2,813 Females 3,263 3,044 2,963 3,074 3,185 3,123 Total 28,882 27,756 28,083 29,761 31,381 32,450 No. per 1,000 of population 9.4 11.9 11.7 11.9 12.7 12.5 20 GENERAL PUBLIC HEALTH Housing As in other years since 1939, very few notifications of intentions to declare clearance areas under section 33 of the Housing Act, 1936, have been received from the metropolitan borough councils, but conferences were held in connection with proposals from two boroughs. Enquiries have, however, been dealt with in respect of over 8,000 properties, originating from prospective purchasers or their agents, who wished to ascertain whether there were any relevant outstanding requirements or proposals under consideration by the Council. The records held in the department are a valuable source of information on such subjects. Details of a large number of properties subject to "dangerous structure" notices have also been received, and, where they have been comprised within any scheme for clearance, redevelopment or other activity with which the Council is concerned, information has been provided for the use of district surveyors. Over 450 applications for preferential consideration for rehousing on the Council's estates on grounds of ill-health were received, of which 242 were recommended for priority, 152 of them being considered of special urgency. There was a marked increase in the number of applications in the later months of the year. These figures do not include applications on grounds of tuberculosis, which, under the procedure agreed in 1940, are referred by the valuer to the medical officers of health of the metropolitan boroughs. Tuberculous milk The sampling of milk for the presence of tubercle bacilli was continued throughout the year, and 1,250 samples were procured for biological examination. These comprised :— (a) Milk supplied to London by road and rail, in churns 1,169 (b) Milk obtained at Council's farms 56 (c) Milk obtained at depots, after pasteurisation 25 The presence of tubercle bacilli was shown in 35 (3.1 per cent.) of 1,120 completed examinations, compared with 3.7 per cent. in 1944. As a result of inquiries by officers of the Ministry of Agriculture into the origin of 32 positive samples among the "ordinary" milk sampled, 19 cows were slaughtered. In the case of the three remaining positive samples (tuberculin-tested milk) the source of infection in two of the herds could not be traced. In the third herd, three cows were found to be affected with tuberculosis and were slaughtered. None of the positive samples was obtained from any of the Council's establishments. All the pasteurised samples were negative. Sampling has been spread as evenly as is possible over the whole of the consignors, and this has necessitated the taking of only one sample from a number of consignments. In the course of sampling it was noted that some graded milks were contained in unsealed churns. The attention of the medical officer of health of the particular county was directed to this failure to comply with the Milk (Special Designations) Order, 1936, and subsequent consignments were received in proper order. Although only a few samples of pasteurised milk were taken, they are, owing to bulking of milk and distribution from a limited number of depots, representative of a large quantity of milk supplied in London. The fact that all results were negative is significant, as it is known that before pasteurisation or heat treatment a large degree of infectivity exists in the milk brought to the depots in bulk. Dr. W. A. Lethem, M.C., of the Ministry of Health, has made some interesting inferences regarding the results of the extension of heat treatment of milk, based on the Registrar-General's statistics of death-rates from abdominal tuberculosis among children under five years of age. This variety of tuberculosis in young 21 children is generally due to the bovine type of bacillus, and, consequently, the death-rate of children under five from this variety of tuberculosis forms a reliable index of the varying extent to which human tuberculosis of bovine origin is prevalent in different areas at various periods. The statistics show that the death-rate per million from this source in London decreased progressively from 136 in 1921 to 6 in 1944, whereas the decrease in rural areas was from 252 in 1921 to 60 in 1944. Both in London and elsewhere, there has been a progressive improvement, which probably corresponds with the increase in and greater efficiency of heat treatment, and it is significant that in London, where all but about one per cent. of milk is now heat treated or pasteurised, and despite the extensive infection of the raw milk due to bulking, the death-rate in 1944 was only one tenth of that in rural areas, where heat treatment is not so extensively carried out. The relative accuracy of death certification in the areas compared must, however, be borne in mind. Venereal diseases The work of the clinics included in the London and Home Counties Scheme for the free diagnosis and treatment of venereal diseases has been carried on throughout the year, and full facilities have been provided. Work carried out at the clinics The following is a summary of work done at the London clinics for all areas during the undermentioned years :— Year New cases Total venereal cases Total non-venereal cases Syphilis S. Chancre Gonorrhoea M. F. M. F. M. F. M. F. M. F. 1918 3,764 3,002 116 13 4,844 1,940 8,724 4,955 1,345 1,348 1928 3,433 1,837 229 6 8,249 2,647 11,911 4,490 6,369 3,226 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 1943 1,362 1,107 104 15 2,839 1,442 4,305 2,564 7,627 8,867 1944 1.176 967 89 13 2,929 1,363 4,194 2,343 6,568 8,234 1945 1,417 1,176 102 3 3,962 1,738 5,481 2,917 9,517 9,849 Year Total attendances In-patient days Pathological examinations for M. F. M. F. Clinic Practitioners 1918 169,485 66,095 25,973 6,380 1928 544,969 218,566 23,821 41,285 107,410 29,785 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 1943 219,014 177,859 6,828 9,725 182,558 76,533 1944 188,450 155,332 6,605 7,861 170,861 73,784 1945 196,074 160,697 6,408 7,635 209,199 88,971 28 22 In my annual report for the year 1944, I mentioned that the number of V.D. patients treated under the Scheme had diminished during the war years owing to a large proportion of the population being in the Forces, and that it could not therefore be assumed from the figures that the incidence of V.D. had declined since 1939. This statement is borne out by the increase in work at the civilian clinics since the cessation of hostilities; and, towards the end of the year, when demobilisation was in progress, extra sessions were held at many of the clinics to meet the sharp rise in the number of new cases and attendances. Treatment by penicillin Penicillin has been available to civilian clinics in the Scheme, and 2,305 patients, 240 of whom were suffering from syphilis, 2,026 from gonorrhoea and 39 others, were treated by this method during the year. By its use the period of treatment has been considerably reduced compared with that by older methods, although it is still necessary for patients to attend for considerable periods for tests of cure. It is not yet desirable to trust to penicillin alone for the treatment of syphilis, and most clinicians use it in conjunction with a modified course of arsenical treatment. One advantage of the use of penicillin is, however, that it renders the patient quickly non-infectious, thus making default from treatment less dangerous to others and thereby helping to decrease the incidence of these diseases. Service patients During the year, 2,111 Service patients attended the clinics in the Scheme; 7,278 Service attendances were made at the clinics and 14,505 Service pathological tests were carried out in the approved laboratories. These figures are included in the above tables. Most of these patients were referred by the Service medical authorities in special circumstances to the civilian clinics for continuation treatment, and they represent only a very small proportion of the total number treated at the centres, viz., 7.6 per cent. of new cases, 2.4 per cent. of attendances and 4.9 per cent. of pathological tests. Additional in-patient treatment In addition to the in-patient treatment provided in direct association with the clinics, the Council's Sheffield Street Hospital (102 beds) continued to admit 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 Propaganda by means of posters and advertisements in the daily press has been continued throughout the year, and full use has been made of the services provided by the Central Council for Health Education, to which body the Council pays an annual grant, the amount paid in 1945 being £2,604. Hostels At the beginning of the year three hostels were included in the Scheme, viz., Highbury Quadrant and two Salvation Army hostels, Lower Clapton Road. At the request of the Home Office, the Salvation Army decided to use one of the hostels for the purpose of an "approved school" for the treatment of girls suffering from V.D. As a result this hostel was excluded from the V.D. Scheme at the end of February. The Salvation Army's other V.D. hostel had not been used to full capacity and the accommodation available has proved sufficient for the purposes of the Scheme. The accommodation provided at Highbury Quadrant hostel remained the same as in 1944, viz., 24 beds. Defence Regulation 33b There was again a large increase in the number of alleged contacts reported under Defence Regulation 33B—2,030 in 1945, compared with 1,344 in 1944. The difficulties in tracing those named were mentioned in my report for 1944, but much useful work has again been done and the results are summarised below. Since the inception of the arrangements, 151 certificates (form 5), certifying clearance from infection, have been received. 23 The following statement summarises the work of the past three years:— 1943 1944 1945 M. F. M. F. M. F. (1) (a) Total number of contacts in respect of whom form 1 was received 34 620 11 1,333 21 2,009 (b) Number in (a) transferred from other areas — — — — — 6 (2) Number of cases in (1) in which attempts were made outside the scope of the Regulation to persuade the contact to be examined before the latter had been named on a second form 1 20 190 7 528 15 856 Contacts found 10 94 7 328 13 473 Contacts examined or already under treatment 9 70 6 199 12 343 (3) Number of those in (1) in respect of whom two or more forms 1 were received - 60 - 172 3 292 (4) Number of those in (3) who were:— (a) found — 37 — 123 2 202 (b) examined after persuasion or already under treatment - - - - - 7 (c) served with form 2 — 32 — 123 — 195 (d) examined after service of form 2 — 29 — 103 2 170 (e) prosecuted for failure— (i) to attend for, and submit to, medical examination - 3 - 10 - 15 (ii) to submit to and continue treatment — - — 4 — 25 (f) transferred to other areas - - - - - 24 A summary of the results of the 40 prosecutions in 1945 is given below. The terms of imprisonment varied from 1 day to 3 months; the latter was the sentence in 5 instances. Result of prosecution for failure to attend for examination— Imprisonment 6 Probation 3 Bound over 2 Fined 2 Adjourned sine die 2 Result of prosecution for failure to continue treatment— Imprisonment 9 Probation 5 Bound over 9 Dismissed 1 Remanded 1 The team of U.S. Army nurses, who valuably assisted in tracing contacts named by American Service men, was disbanded in July, 1945, on the withdrawal of the American Services from this country. I have again to acknowledge with gratitude the co-operation of the Commissioner of Police for the metropolis in making available the services of police officers to assist in tracing alleged contacts named more than once. With the release of increasing numbers of men from the Services, arrangements were made for co-operation with the Service authorities to ensure the continued attendance at clinics after return to civilian life of men who, on discharge from the Services, were under treatment or surveillance for V.D. The arrangement is entirely voluntary, and, in cases where the patient has given his signed consent, notification of discharge is received from the Service authority and an approach is then made to ensure that treatment is being continued. The nature of the work makes it necessary for a large measure of tact to be exercised, particularly in cases where ex-Servicemen reside with relatives, but no exceptional difficulties have been experienced and it has been found that advice and offers of assistance have been appreciated. 24 Infestation with vermin Certain of the Council's sanitary inspectors have made a special study of modern methods of exterminating vermin, and their services are utilised by all departments of the Council controlling premises liable to be infested. A large number of visits have been paid by the inspectors, arising from the 339 reports of infestation, of which 57 were at hospitals or institutions. Londoners' Meals Service Thirty-five restaurants of the Londoners' Meals Service were inspected for the first time, and 154 other visits to such restaurants were made for inspection of the standard of accommodation and facilities for storage and preparation of food. The examination of foodstuffs for fitness for human consumption was also undertaken at 31 such restaurants. Inspections were also made at Rest Centres on 27 occasions. British Standards Institution During the year the chief inspector attended eight meetings of the British Standards Institution. At these meetings a number of specifications relating to sanitary fitments were considered, and specifications for the following were approved and published : (a) Asbestos-cement soil and wastepipes; (b) Sinks—fireclay and metal; (c) W.C. pans and seats; (d) Draining boards; (e) Flushing cisterns; (f) Rain-water goods. Blind persons Particulars of examinations under the provisions of the Blind Persons Acts, 1920 and 1938, during the year are set out below:— Examinations by the Council's ophthalmologists— Classification Certified blind Not blind Grand total Male Female Total Male Female Total New cases 168 313 481 43 64 107 588 Prev. blind, still blind 27 26 53 — — — 53 Prev. not blind, now certified 9 15 24 — — — 24 Prev. not blind, still not blind — — — 14 27 41 41 Prev. blind, now not blind — - — 2 5 7 7 Total 204 354 558 59 96 155 713 Persons examined as to suitability for training— Suitable Not suitable Grand total Male Female Total Male Female Total 14 13 27 2 — 2 29 In addition 98 certificates (45 male and 53 female) submitted by voluntary hospitals, outside authorities or private ophthalmologists were accepted as evidence of blindness. 25 Treatment of tuberculosis The number of names on the dispensary registers at the end of the year was 24,879, compared with 23,671 at the end of 1944, and 21,740 at the end of 1938. The work of the dispensary service has functioned satisfactorily throughout the year. Evening sessions were held during the summer, and Saturday afternoon sessions or other special sessions were substituted in some cases during the winter. The X-ray examination of patients has shown a steady increase during the past two years and it is anticipated that the increase will be maintained. The search for tubercle bacilli by examination of laryngeal swabs was extended during the year. Dispensary service The number of recommendations for residential treatment with the corresponding figures for 1944 and 1938 were:— Year For the first period of treatment For further treatment Total ExService Civilian adults Children Ex- Service Civilian adults Children Male Female Male Female *1945 286 1,873 1,782 707 209 1.035 915 104 6,911 1944 583 1,774 1,874 712 183 1,159 945 80 7,310 1938 2 2,610 1,960 796 58 1,671 1,160 199 8,450 Residential treatment *The decrease in the number of recommendations for the ex-Service men and women is due to the revised procedure authorised in Ministry of Health circular 127/45, 177/45 and 68/46 under which the discharge of patients is deferred for periods up to 30 months. Patients recommended for treatment during the year were dealt with as follows (the corresponding figures for 1944 and 1938 are also shown):— Adults Children 1945 1944 1938 1945 1944 1938 (a) Admitted to "observation" beds to determine diagnosis or suitability for treatment at sanatoria 838 713 1,338 235 227 202 (b) Admitted to Pleural Effusion Unit 278 271 — 14 20 - (c)Passed for admission direct to sanatoria or hospitals 4,841 5,317 5,963 517 503 749 (d) Not accepted for residential treatment 26 56 106 21 26 23 (e) Withdrawn after application but before decision was reached 117 161 48 24 16 21 6,100 6,518 7,455 811 792 995 N.B.—The treatment offered was refused in respect of 90 adults and 18 children in 1945, and 63 adults and 4 children in 1944. During the year special efforts were made in view of the Council's difficult position regarding institutional bed accommodation to select cases suitable for treatment at home under the supervision of local tuberculosis officers, and this is reflected in the reduced number of adults recommended. During the latter half of 1945, there was an increase in the number of recommendations for the treatment of children owing to their return from evacuation on the end of the war. The numbers of beds occupied by patients under the tuberculosis scheme on 31st December, 1945 (with corresponding figures for 1944 and 1938) were as follows; the figures in brackets represent the number of ex-Service men and women (included in the figures) whose tuberculous condition has been accepted by the Ministry of Pensions as connected with war service:— D 26 Adults Children 1945 1944 1938 1945 1944 1938 Council's special hospitals 1,233 (160) 1,419 (242) 1,299 (1) 437 416 668 and sanatoria Council's general hospitals 596 (23) 490 (30) 1,010 (6) 13 12 13 Voluntary institutions 1,316 (145) 1,399 (157) 1,134 (16) 127 55 60 Total *3,145 (328) 3,308 (429) 3,443 (23) 577 483 731 *Including 176 Service patients (165 in the Council's special hospitals and 11 in voluntary institutions). The decrease in the number of beds occupied, both in the Council's special hospitals and sanatoria and in voluntary institutions, is due to staffing difficulties prevalent throughout the country. Boardingout of child contacts The number of children boarded out under the tuberculosis contact scheme has shown a slight increase compared with 1944, when the average number boarded out was 152. During 1945, the average number was 155. The highest number at any one time during 1944 was 179, the corresponding figure for 1945 being 170. It was noticeable, however, that during the last quarter of 1945 the average was 160, whereas the average number for the same period during 1944 was 146. The Invalid Children's Aid Association, who arrange the boarding-out for the Council, reported that considerable difficulties were being experienced in securing suitable foster homes for children under the age of five. As a consequence some of these children were placed in the Council's nurseries, or if over five years of age in the Council's residential schools and homes. Open-air schools At the beginning of the year there were six residential open-air schools (type T) in operation outside the London area. By October, 1945, four had been closed and the children were transferred to the two remaining schools (Burrow Hill Colony, Frimley, and Balls Park open-air school, Hertford), and to the Kathleen Schlesinger Home near Henley, which was re-opened. During the year the distinction between open-air schools, types T and O, was abolished and it was decided that children, whether delicate (type O) or those with a tuberculous background (type T), should be admitted to these schools and also to the George Rainey Residential open-air school, St. Leonards-on-Sea; Wanstead House residential open-air school, Cliftonville; and the Horsleys Green Camp, Stokenchurch, Bucks. The number of children with a tuberculous background in attendance at these schools at the end of 1945 was 183. No child with "open" or infectious tuberculosis is admitted to these open-air schools. Surgical after-care During the year, financial responsibility was accepted for the supply, renewal and repair of surgical appliances and for X-ray examination of orthopaedic patients attending after-care departments of hospitals (whether maintained by the Council or otherwise) at which residential treatment had been provided under the tuberculosis scheme. Free treatment and appliances were also provided at the out-patient departments of the Council's general hospitals for those patients attending for after-care following residential treatment under the scheme at Grove Park Hospital or at voluntary hospitals not having after-care clinics. Rehabilitation Many of the Council's ex-patients have been employed at the "Spero" Workshops in Tower Bridge Road, S.E., which were established by the "Central Fund for the Employment of Tuberculous Persons." The Council buys a considerable amount of the output of the workshops, and has for some years provided financial aid by annual grants to the management committee. A medical officer of the Council acts as honorary medical officer at the workshops. Women ex-patients in whom the disease was in a comparatively early stage, and in whom, while under treatment, it became quiescent, have been accepted for employment as nurses or domestics in the Council's sanatoria. Arrangements also exist with many voluntary institutions for the employment of ex-patients in various capacities. 27 The policy of sending patients to the various tuberculosis colonies, such as Papworth Village Settlement, Cambridge, and Preston Hall, Maidstone, for treatment and rehabilitation, has continued during the year. The patients are specially selected, and eventually, if suitable, offered full-time employment and settlement in the Colonies. Mass miniature X-ray examination of sections of the general public continued throughout the year, and the unit continued to work at static centres, as, owing to the lack of mobility of the apparatus through the non-delivery of a special motor-van equipped with a generator and dark-room, it was not possible to visit various factories, industrial establishments, etc., to carry out examinations on the spot. Examinations were carried out at the following centres: Jewish Boys' Club, Hackney; St. Bartholomew's Hospital, E.C.1; Hospital for Women, Soho Square; and St. Luke's Hospital, Chelsea. Miniature mass radiography The borough medical officers, together with the tuberculosis officers, are responsible for selecting the groups of persons for examination in the respective areas. They arrange for employers to be visited, explain to the management the meaning of mass radiography, stress the voluntary nature of the proceedings and particularly emphasise that results are confidential and not divulged to anyone, whether employers or medical officers, without the prior consent of the individuals concerned. This procedure is regarded as essential to the success of the scheme, and it is also emphasised that the examination is primarily for the benefit of the employee. Particulars giving details of groups of persons for examination are forwarded by the borough medical officers to the County Hall, where all arrangements for booking of appointments are made. At each of the centres, factory, shop and office employees, and school children (fifteen years of age and over), were examined. The medical director is responsible for the reading of the miniature films, the full-sized films being interpreted by a consultative panel, comprising the consulting radiologist to the Council's hospitals, a general physician, the senior medical officer on the central staff in charge of tuberculosis work and the medical director. Tuberculosis officers and other experts are invited to participate in the panel's weekly discussions. The following is a summary of the work done during the year, with corresponding figures for 1944 shown in brackets:— Number Per cent. of tures Miniature films taken 47,223 (46,671) — — Large films taken 1,594 (1,795) 3.37 (3.85) (1) Details of conditions revealed by large films (i) Persons requiring further investigation— (a) For lesions probably tuberculous 437 (355) .92 (.76) (b) For lung lesions probably non-tuberculous 50 (21) .11 (.05) (c) For cardio-vascular lesions 79 (92) .17 (.20) (d) Previously known tuberculous cases 45 (54) .09 (.12) (e) Referred for a further X-ray examination in 3-6 months 24 (27) .05 (.06 635 (549) 1-34 (1.18) (ii) Radiologically inactive lesions 507 (676) 1.07 (1.45) (iii) No abnormality 452 (570) .96 (1.22) 1,594 (1,795) 3.37 (3.85) (2) Analysis of lesions probably tuberculous (437) Diagnosis confirmed 402 (298) .85 (.64) Doubtful cases 5 (28) .01 (.06) Awaiting report 12 (5) .02 (.01) Refused investigation 18 (24) .04 (.05) 437 (355) .92 (.76) 28  Number Per cent,. of miniatures (3) Summary of reports from tuberculosis officers or other doctors of advice given (pulmonary lesions probably tuberculous—437) Requiring no further medical action 9 (4) .02 (.008) Requiring a further examination later as a precaution 31 (21) .07 (.045) Requiring continued dispensary observation 274 (187) .58 (.40) Should cease work and remain under observation at home 16 (3) .03 (.007) Requiring sanatorium treatment 77 (111) .16 (.24) Information so far not available or refused investigation 30 (29) .06 (.06) 437 (355) .92 (.76) All persons in whom evidence of disease was shown were followed up. The patient's doctor was communicated with and the X-ray film and report forwarded to him. At the same time the patient was told to see his own doctor, who was asked to inform the medical director of the subsequent diagnosis and steps taken to obtain treatment. It was suggested that the patient should be referred to the local tuberculosis officer if necessary. The clinical findings of all cases were subsequently ascertained, including the ultimate diagnosis and the final disposal of each individual. During the year a survey was carried out at Long Grove Hospital (mental patients). The total number of patients examined was 2,341 (1,161 males and 1,180 females). In 4.13 per cent. males and 1.19 per cent females the presence of radiologically significant tuberculosis previously unsuspected was discovered and required further investigation. In addition 183 members of the staff were examined and two cases were referred for further investigation. The figures are not included in the above table. Maintenance allowances (Memo. 266T) Payment of maintenance allowances and grants under the Government's scheme, set out in memorandum 266T of the Ministry of Health, to patients undergoing prescribed treatment either in a hospital or sanatorium or at home under the tuberculosis officer's direction, continued throughout the year. The machinery of the dispensary service was utilised in connection with enquiries for the purpose of determining the amounts payable, and, where practicable, for the actual payment of the allowances. The tuberculosis officers are responsible for determining eligibility on medical grounds for any allowances authorised, and during the year approximately £123,000 was paid in allowances. About 1,750 patients were continuously in receipt of the allowances throughout the year. Midwives Acts, 1902 to 1936, nursing homes registration and contributions to voluntary organisations for maternity and child welfare Although the Council is not a welfare authority under section 250 of the Public Health (London) Act, 1936, it is responsible in London for the domiciliary midwifery service established under section 1 of the Midwives Act, 1936. The service is maintained (i) by midwives in the direct employment of the Council and (ii) by midwives employed by voluntary hospitals and district nursing associations which are subsidised by the Council. Patients attended by either the Council's midwives or by the midwives of the voluntary organisations are charged the same fees of £2 10s. for a first confinement and £2 for a subsequent confinement or maternity nursing, and common assessment rules are applied. The payments made to hospitals and district nursing associations for each confinement are £4 6s. 6d. and £4 19s., respectively. A free maternity outfit is provided by the Council for the patients attended by the midwives directly employed by the Council or by the midwives of district nursing 29 associations, and the hospitals are required to provide a free outfit for their patients. Details of the work done in 1945 appear below. In addition to its duties under section 1 of the Midwives Act, 1936, the Council is the local supervising authority under the Midwives Acts. The practices of midwives are supervised to ensure that the rules of the Central Midwives Board are observed, and an appropriate standard of midwifery maintained. All cases of raised temperature and skin affection are investigated and dealt with individually, appropriate action being taken to prevent the spread of infection. Eye affections in the new-born are treated regularly until cured or admitted to hospital. Fees, on the Ministry of Health scale, are paid to medical practitioners summoned by midwives under the Midwives Act, 1918, and no contribution towards the cost is sought from the patients. Post-certificate lectures and demonstrations are arranged for midwives. Certain sections of the Acts prohibit unqualified persons from practising as midwives or maternity nurses and steps are taken to see that these provisions are observed. Compared with 1944 there was an increase in the total number of confinements undertaken by the Council's domiciliary midwives. Domiciliary midwifery service— London County Council midwives The following are the figures for 1938, which was the first year of the Council's domiciliary midwifery service, and for the years 1944 and 1945:— Maternity nursing cases Midwifery cases Total 1938 449 2,924 3,373 1944 406 5,518 5,924 1945 440 6,427 6,867 The number of midwives employed on 31st December, 1945, was 122 compared with 114 at the end of 1944. The average number of midwives employed throughout the year (permanent and temporary) was 120, compared with 113 in 1944. The average annual number of confinements undertaken by each midwife, including sick and holiday reliefs, was approximately 57. This figure is somewhat lower than that mentioned in the Report of the Midwives Salaries Committee (66) and is accounted for by the dislocation caused by enemy action. There was an average, throughout the year, of about eight midwives absent owing to illness. The number of district confinements undertaken by the voluntary organisations included in the Council's domiciliary midwifery service also showed an increase compared with confinements for 1944. These numbers, together with those for 1938, were as follows:— Domiciliary midwifery service— voluntary organisations Maternity nursing cases Midwifery cases Total Grand Total 1938 Voluntary hospitals domiciliary service 251 5,484 5,735 District nursing associations 606 1,158 1,764 7,499 1944 Voluntary hospitals domiciliary service 83 2,948 3,031 District nursing associations 329 1,323 1,652 4,683 1945 Voluntary hospitals domiciliary service 53 3,502 3,555 District nursing associations 327 1,584 1,911 5,466 Fees paid under the Midwives Act, 1918, to medical practitioners called in by midwives in emergency amounted to £6,824 10s., and claims for fees paid were 4,530 in 1945, compared with £5,793 12s. 6d. and 3,875, respectively, for 1944. Payment of medical fees Two courses of five post certificate lectures and six courses of four ante-natal and post-natal demonstrations were arranged in conjunction with the Middlesex County Lectures for midwives 30 Council and Surrey County Council during the year. The number of tickets issued to midwives for attendance at the post-certificate lectures was 428, and 80 tickets for attendance at the ante-natal and post-natal demonstrations. Registration of nursing homes There were 108 nursing homes on the register at the end of the year, compared with 118 at the end of 1944. These numbers include homes closed temporarily during the war. Of the nursing homes registered at the end of the year, 40 were temporarily closed. Maternity and child welfare work of voluntary associations Grants paid to voluntary maternity and child welfare associations during the year 1945 under section 101 (6) of the Local Government Act, 1929, amounted to £20,967, compared with £20,806 in 1944. Thirty-two associations were grantaided during the year, of which 5 were maternity hospitals, 15 mother and baby homes, 5 baby homes and 7 district midwifery practices. Of these associations, 21 were functioning in London, 9 in the country, and 1 in both London and the country. One received a grant for upkeep of premises while temporarily closed. During the year, six associations returned to London from the country. War circumstances led to an increase in the number of illegitimate births, and the Ministry of Health in Circular 2866 of October, 1943, requested maternity and child welfare authorities and the Council to review, and if need be extend, the provision made for the unmarried mother and the illegitimate child. Meetings were therefore arranged, under the chairmanship of the Chief Officer of Social Welfare, at which the moral welfare associations, the borough medical officers of health and the social welfare and public health departments were represented. These meetings have continued regularly ever since. The grants from the Borough Councils to the moral welfare associations have been increased and centralised, institutional accommodation has been reviewed and steps taken to assist voluntary associations in meeting staff difficulties in their homes. Further, each borough has independently reviewed its own arrangements and strengthened its co-operation with its local moral welfare society. Moreover, the boroughs have arrived at a standardisation of payments to foster mothers on an improved basis. Salaries Committee (Rushcliffe) In Circular 32/44, dated 13th March, 1944, the Ministry of Health asked the Council to make payments on account of the government grant to district nursing associations, to certain mother and baby homes and to certain baby homes, towards the cost of applying the recommendations of the Midwives and Nurses Salaries Committees (Rushcliffe). This request was implemented, with the assistance of the Central Council for District Nursing in London in the case of the associations; and, in the year 1945, £6,336 10s. was authorised to be paid to associations for the year ended 31st March, 1946, and £553 1s. was paid to mother and baby homes and to baby homes for the years 1943/4 and 1944/5, part of which was on account of Government grant and part direct assistance from the Council. 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 14,900, compared with 15,072 in 1944. In addition 1,658 candidates were examined for the Ministry of Education scheme for emergency recruitment of teachers. The sick parade at the Council's hospitals was continued for the civil defence services, and the numbers involved are not included above, apart from 524 employees of doubtful fitness, who were referred to the Council's examining medical officer. These references ceased after July, 1945. Reciprocity has been maintained with provincial medical officers of health whereby London personnel staying in the provinces and provincial personnel temporarily resident in London are examined locally. Only 24 patients were so examined (18 in provinces and 6 in London), but the procedure serves a useful purpose and is much appreciated. 31 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 14,917, and Mr. C. J. Regan, the Chemist-in-Chief, has submitted the following report:— "A large proportion of the work was of a consultative or advisory nature and on the practical side much of it was of an investigational character. The great advances made during the past few years in the application of science, not only to the use of war but also in industry and medicine, have emphasised the help which it (and as far as this Branch is concerned particularly chemistry, physics, etc.) can give in solving numerous problems which arise in connection with the Council's service. The liaison made with many research associations and similar bodies has been a considerable aid in this respect. It is impossible to quote more than a few instances of the types of advisory work done during the year, but that of formulating or commenting on specifications for the supply of many materials or for the performance of operations of various kinds should be mentioned (e.g., supply of various foods, comments on painting specifications): also the frequent conferences with officers of the Chief Engineer's Department in connection with sewage disposal problems. Among other special cases involving advice or investigation were :— Central laboratory "(1) Rapid advances have been made in the field of insecticides during the war years and the materials developed were carefully studied throughout. Both D.D.T. and Gammexane were found to be great improvements on the types previously available and each has its special virtues. The use of these was developed in the service to replace the less efficient materials employed in the past. "(2) In co-operation with the Meals Service, work on the analysis and assay of meals in regard to various aspects of their nutritional value was continued. Special surveys were conducted as to the vitamin C content and a report was prepared including general considerations as to the quantity of the vitamin required, the ease of its destruction by incorrect methods of storage, cooking and subsequent treatment, seasonal variations, etc. "(3) The Architect requested that a report should be made on the general question of the utility of waterproofers in concrete. Both the 'integral' and the 'surface' type were considered and it was concluded that these were of use in certain cases. Particularly as regards the 'surface' type, it was recommended that the 'coloured' class was most likely to give satisfactory results as the 'colourless' type was still in an experimental stage. "(4) The submission for analysis of a proprietary substance sold for use as a mineral salts addition to cattle foods caused consideration to be given to the general question of the necessity or otherwise for such mineral supplements. Admittedly in the event of the diagnosis of a deficiency disease it can be valuable, but the opinion was expressed that, failing that condition arising, there is no need for the general adoption of the use of such supplements, providing that there are also no soil deficiencies at the farms in question in respect of the minerals concerned. "(5) Several failures in service of metals were investigated. (a) The corrosion of calorifier tubes (copper) at a hospital was attributed mainly to the inferior quality of the metal, the presence of zinc lowering the corrosion resistance. The condensate was potentially corrosive in view of its dissolved oxygen and carbon dioxide content. Remedies suggested were the use of a more resistant metal and the installation of a deäerator. (b) The failure of 32 top end bushes for connecting rods of Diesel engines was attributed to the use (due to wartime conditions) of a poor quality alloy; the grain size was also unusually large and the workmanship on the casting poor. "(6) In conjunction with the Public Control Department, several cases under section 143 of the London Building Act, 1930, were investigated, this referring to 'dangerous businesses' and the statutory requirements designed to protect public safety. The various premises were visited and their methods of operation inspected; samples of the materials used were also taken for examination in the laboratory. Considered opinions were expressed as to the degree of danger in each case. Instances were (a) premises dealing with the mixing and blending of waxes and oils; (b) premises using gas heaters in a cellulose lacquer spraying shop. "(7) The presence of plant-growth substances (auxins) in sewage products (e.g., sludge, composts, etc.) was investigated, and a paper on the subject was published in a scientific journal. The results showed that most products contained auxins in very small but measurable amounts : also that, although both crude and digested sludge may, in the wet state, contain a relatively high amount, most of these growth-promoting substances are decomposed during the normal drying of the sludges. "The regular examination of the drinking water at Council hospitals, etc., served by private wells was continued; in all cases chlorination is applied. Drugs and medical stores, foodstuffs and milk were examined as to quality, and as to compliance with specifications. The condition of the water in swimming baths and the effectiveness of the chlorination treatment were examined and the regular testing of the air in the vehicular tunnels at Blackwall and Rotherhithe as to its carbon monoxide, black suspended matter, lead content, etc., was continued; it was shown that the ventilating plant had maintained the atmosphere in a satisfactory condition. Statutory work under the Petroleum (Consolidation) Act, 1928, the Petroleum (Mixtures) Order, 1929, the Public Health (London) Act, 1936, the London Building Act, 1930, the Fertilizers and Feeding Stuffs Act, 1926, etc., was carried out as required, and the air examinations in various parts of the county in connection with the problem of atmospheric pollution were continued, in co-operation with the Department of Scientific and Industrial Research. Among the many other matters dealt with during the year were the analytical control of steam-raising plants, etc., at hospitals and institutions, the analysis of metals, building materials, paints, detergents, oils, clays and subsoils, the testing of safety lamps and the atmospheric conditions in the plants at licensed dry-cleaners' premises. "The development of new analytical methods was kept under review and, the use, for example, of the quartz spectrograph was widely extended. In connection with a suspected case of lead poisoning the methods available for the determination of lead in very small amounts were critically examined and a successful chemical technique was devised involving certain modifications of the usually accepted procedure. Sewage disposal "The necessary analytical work in connection with the control of sewage disposal was continued. In addition to the primary sedimentation process by which the sewage was treated at both outfalls, part of the flow at the Northern Outfall Works was further subjected to secondary sedimentation. At the end of the year preparation was being made for the recommissioning of the activated sludge plant at these works, a stock of activated sludge having been kept in condition over a long period by a small degree of mechanical agitation so that it would be available for the restarting of the plant at short notice. The sludge digestion plant continued to function satisfactorily and produced a reasonable yield of gas: it was recommended that economy might be obtained by lowering the operating temperature from 100° F. to 85° F. and, controlled comparative tests on one unit having shown that this could 33 be done, the whole plant was subsequently changed over to function at this temperature. In order to obtain information as to the condition of the water of the River Thames into which the sewage effluents are discharged, samples of river water were regularly examined, these being taken at various points between Teddington and the sludge dumping area. "Work in connection with the manurial use of sewage products was continued; the main product was a compost of household refuse and sludge screenings, but one of household refuse and sludge was also made. Close touch was kept with the scientifically controlled tests of these materials which were continued during the year on Mental Health Service farms in conjunction with the Agricultural Research Council. The results were very encouraging from the manurial value aspect and, particularly in view of the existing acute shortage of organic manures, the general question of the production and use of such composts is being actively pursued." HOSPITALS AND ANCILLARY SERVICES General and special (other than mental) hospitals The end of enemy action in this country, followed by the general cessation of hostilities, changed the character of the problems facing the Council's hospitals service. The evacuation of patients to the provinces had ceased in 1944 and the reverse process had begun, but not until the year now under review did the return flow reach its maximum dimensions and constitute a major administrative problem. The demand for beds continued to rise but the extreme shortage of staff prevented the utilisation of all the accommodation. Every effort was made to use the hospital beds to the best advantage by as rapid a "turnover" of in-patients as was consistent with their adequate treatment, by restricting admissions to those whose need of hospital treatment was most pressing, and by the generous provision of out-patient facilities for all capable of benefiting from them. The year saw the first moves towards a restoration of hospital buildings. The removal of blackout and brick protective structures made good progress and improved the living conditions for patients and staff alike. Some progress was made in the preparation of plans for structural repairs and developments. Besides recording such matters as the foregoing, which arose out of war conditions, the present report includes, in slightly more extensive form than has been possible during the war years, some account of wartime achievements in residential nurseries, clinical research, and other aspects of this branch of the service, but conditions are not yet such that a full-scale survey of the part played by the hospitals during the war is practicable. Introduction The return to London of evacuated hospital patients had begun at the end of 1944, and, even before any general return was authorised, a number of patients were brought back from certain special hospital units. In May, 1945, women suffering from pulmonary tuberculosis returned from Stannington Emergency Hospital, Morpeth, to Grove Park Hospital; children suffering from orthopædic conditions from Dryburn Emergency Hospital, Durham, to Queen Mary's Hospital for Children; tuberculous children from Stannington Emergency Hospital, Morpeth, to High Wood Hospital for Children; and children suffering from rheumatism and other general medical conditions from Scotton Emergency Hospital, Knaresborough, to Queen Mary's Hospital for Children. The Council expressed its high appreciation of the kindness of the hospital authorities who had given such a warm welcome to the patients evacuated from London. When hostilities ceased in Europe, the Council, at the request of the Ministry of Health, undertook the reception in London of hospital patients evacuated in 1940 and 1944 from all parts of the London civil defence region. A reception unit, capable of receiving and dispersing 400 patients a week, was set up at the Western Hospital, Fulham. Owing to staff shortage, only patients who had been evacuated from the Council's hospitals were accepted in the first instance, but this restriction Return of evacuated hospital patients 34 was lifted after a time. By October, 1945, 2,830 patients had passed through the reception unit, including 1,856 for Council hospitals, 939 for non-Council hospitals and 35 for their own homes. Throughout the year, ten hospitals remained closed, viz., Downs Hospital for Children, Sutton, Surrey; Millfield Convalescent Home, Littlehampton; Norwood Hospital for Children; Princess Mary's Convalescent Hospital, Margate; St. Anne's Home, Heme Bay; St. Clement's Hospital, E.3; St. Luke's Hospital, Lowestoft; St. Margaret's Hospital, Kentish Town; St. Peter's Hospital, Whitechapel; and the South-Eastern Hospital, New Cross. The following hospitals, which were closed in 1944, when their patients were evacuated to other parts of the country, were reopened on the dates stated:— St. George's Home 23rd May, 1945 High Wood Hospital 25th May, 1945 St. Benedict's Hospital 10th August, 1945 Hackney Hospital II 5th September, 1945 St. Luke's Hospital, Chelsea 5th September, 1945 St. Matthew's Hospital 5th September, 1945 Goldie Leigh Hospital 15th September, 1945 White Oak Hospital 1st October, 1945 Acute general hospitals At the beginning of the year 7,433 patients remained under treatment. The number rose to 8,158 on 7th February, 1945, and then fell to 7,298 on 22nd August, 1945. The number remaining at the end of the year was 7,652. Maternity patients The Council's maternity services were again subject to very disturbed conditions, inimical to satisfactory obstetrical care. Ante-natal care was broken by the evacuation scheme, and mothers were so uncertain of future plans that a large number refrained from early booking. For the first four months of the year evacuation to country homes and hostels under the Ministry's scheme was pressed because of enemy action, and the number of women confined in the Council's hospitals fell to the lowest figure since 1933. With the end of the war came a natural desire in the women to have their babies near home and a period of very heavy pressure on the Council's accommodation began. Although the number of beds in maternity units was raised from 460 on 1st January, to 630 on 31st December, 1945, it was not large enough to overtake the increasing demand. The great obstacle in the way of a prompt opening of more beds is the serious lack of midwives and domestic staff. In the effort to meet the shortage, arrangements were made with seven of the London voluntary hospitals to open more beds for which they had staff, on payment of a maintenance grant from the Council. These beds were filled with applicants sent on from the borough clinics in cases where the home circumstances were unsuitable for a confinement. The disorganisation of the maternity services due to abnormal movements of the population was reflected in the higher maternal mortality which occurred among "unbooked" cases (no return is yet made of the numbers of "booked" and "unbooked" deliveries, but it is known that the latter is very much higher since the war). The confinements in Council hospitals in 1945 numbered 12,435, the births 12,594 (including 447 still births, a rate of 3.55 per cent.). The maternal deaths among the women confined in hospital were 28 (or 2.21 per 1,000), 13 of these occurring among booked cases and 11 among the emergency admissions. Deaths directly due to pregnancy or confinement after the twenty-eighth week numbered 24 (1.91 per 1,000), and 4 women died from disease associated with pregnancy or confinement (.31 per 1,000). Two maternal deaths occurred in women confined before admission. Deaths from sepsis fortunately remained at a very low figure. There was one such death only among the booked cases, but three among the emergencies, two of the three being badly infected before admission. Next year 35 the returns from the hospitals should again permit an analysis of the abnormalities dealt with in the Council's wards. During the year interesting experiments into a new form of analgesia in childbirth were carried out with a trilene apparatus. The results were so satisfactory that the experiment is being extended. At the beginning of the year only three of the chronic sick hospitals were open, viz., St. Alfege's II, St. John's and St. Pancras. The number of patients was 566. With the return of the evacuated hospital patients later in the year the number rose to 2,227 on 5th December, 1945, and the number remaining at the end of the year was 2,188. Chronic sick hospitals Grave difficulties were experienced throughout the year, mainly owing to lack of nursing and domestic staff, in providing the hospital beds needed for the treatment of patients suffering from infectious diseases. At the period of greatest pressure on accommodation in 1945, only 1,400 beds were available for fever patients, none of which was in cubicle isolation accommodation. In the spring of 1938, there were 6,600 beds in use in fever hospitals, of which 570 were in single isolation cubicles. Acute infectious hospitals During the early part of the year, measles spread among the child population. The number of measles patients admitted to infectious diseases hospitals was, however, very small compared with pre-war epidemics, owing both to the dispersal of the child population because of continued air attack, and to the strict limitation of hospital admission to those who required hospital treatment by reason of clinical severity or very bad home conditions. Similar restrictions were introduced for scarlet fever, and only in the most exceptional circumstances were cases of chickenpox, mumps and german measles accepted. After the end of the war in Europe, action was taken to bring cubicle isolation blocks into commission. (They had to be closed during the war because of the danger from flying glass.) By 31st December, 1945, these had been brought into use as follows:— Eastern Hospital 30 beds Park Hospital 60 „ Brook Hospital 82 „ Western Hospital 77 „ North-Eastern Hospital 103 „ Total 352 „ Work proceeded in the blocks at the North-Eastern Hospital which will provide approximately 146 additional single cubicles. There remained, however, in other hospitals 120 single cubicles in blocks seriously damaged or destroyed by enemy action. The total number of infectious patients admitted during the year was 15,274, of whom 3,496 were measles cases. The maximum number of patients under treatment for infectious diseases was 1,244 on 21st March, 1945 (including 463 measles cases). Nine cases of suspected smallpox were admitted during the year to Clandon Isolation Hospital, where, by agreement with the Surrey County Council, London smallpox patients and those from certain other areas are received. Only two of these patients were finally found to be suffering from smallpox. Smallpox Eleven cases of typhus were admitted to the North-Eastern Hospital during the year. Of these seven were medical students, three service patients, and one civilian. Typhus St. Luke's Hospital, Lowestoft, remained closed throughout the year. All available beds in the tuberculosis hospitals were occupied, except a number at Grove Park Hospital and St. George's Home, which could not be opened owing to a shortage of nursing and domestic staff. Tuberculosis hospitals The Downs Hospital, Millfield Convalescent Hospital, Norwood Hospital for Children, and St. Anne's Home remained closed throughout the year. Queen Mary's Hospital for Children, which re-opened on 7th December, 1944, continued to provide Children's hospitals 36 accommodation for children but full use could not be made of the accommodation because of shortage of nursing and domestic staff. Goldie Leigh Hospital, which re-opened on 15th September, 1945, continued to provide limited accommodation for children suffering from ringworm and other contagious diseases of the skin or scalp and White Oak Hospital, which re-opened on 1st October, 1945, for children suffering from contagious diseases of the eye. 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 throughout the year. Convalescent hospitals Princess Mary's Convalescent Hospital, Margate, remained closed throughout the year and a few convalescent adult patients were sent to Queen Mary's Hospital, Sidcup. A number of male and female adult convalescent patients were sent to voluntary establishments. Convalescent children During the war, accommodation for convalescent children ceased to be available in the Council's hospitals and had to be provided from other sources. An agreement was reached with the Invalid Children's Aid Association, who have had long experience in caring for the needs of such patients, whereby children for whose medical care the Council was responsible and who needed convalescence were referred to the Association, by whom they were sent to convalescent homes. During 1945 a total of 531 children were dealt with in this way. In addition to the foregoing arrangements, the long-standing practice was continued of accepting financial liability for the convalescent treatment of children brought to the Council's notice by the Invalid Children's Aid Association themselves. During the year these children numbered 820 as compared with 640 in the previous year. Other hospitals The Northern Hospital at Winchmore Hill and Southern and Joyce Green Hospitals at Dartford, normally used to accommodate convalescent fever patients, were not available for this purpose. They continued, as in previous years, to serve a useful purpose by receiving numbers of patients suffering from general noninfectious conditions from the inner hospitals and were important units of the Government's Emergency Hospital Service. Venereal diseases Beds for patients suffering from venereal diseases were provided at Sheffield Street, Bethnal Green and St. Charles' Hospitals. Admissions to public health hospitals The numbers of patients admitted during 1945, compared with 1938 and 1944 are shown below:— 1938 1944 1945§ Acute general hospitals 173,796 127,184* 126,157* Chronic sick hospitals 10,014‡ 7,244 6,982 Convalescent hospitals (adults) 4,698 — — „ „ (children 4,257 — — Convalescent fever hospitals 2,942 17,076† 14,813† Acute fever hospitals 33,159 19,509 20,825†† Tuberculosis hospitals 4,163 2,496 1,873 Children's hospitals 5,489 3,929 2,814 Post-encephalitis lethargica unit 49 140** 23 Venereal diseases hospitals 801 527 438 Nursery units — 31 713 Epileptic hospitals 237 297 180 Total 239,605 178,433 ¶ 174,818 *Includes Queen Mary's Hospital Sidcup. † Hospitals devoted wholly to convalescent non-fever patients. ‡Includes 802 patients in social welfare establishments. Includes general medical patients. § The figures for 1945 are provisional only. **Includes 125 patients temporarily transferred during evacuation. ¶ In addition, 1,155 tuberculosis patients and 269 chronic sick patients were admitted to auxiliary hospitals administered by the Council in the north of England and Scotland ††Includes 3,000 patients passing through the Western Hospital in transit from evacuation to the provinces. 37 The arrangements for the medical examination and treatment at the Council's hospitals of Civil Defence personnel ended in July, when the Rescue and Auxiliary Ambulance Services were disbanded. The service continued to be provided throughout the year for the National Fire Service. Treatment of Civil Defence personnel The Council's administrative scheme for discharging its duties under the Local Government Act, 1929, divided the responsibility for the care of healthy children in its charge under five years of age in the following manner. The Education Committee were charged with the responsibility for the education and maintenance of children over three years of age; while the Hospitals and Medical Services Committee were responsible for the institutional care of those under three years of age if separated from their parents and the Social Welfare Committee of others under three. Residential accommodation for young children Before the war, children under three were accommodated in nurseries in London (some under the direction of the Public Health Department and others under that of the Social Welfare Department), until they were discharged to the care of their parents or were transferred to an establishment under the direction of the Education Committee. In war-time, all children were evacuated, as soon as possible after admission, to nurseries in rural areas maintained by the Council, the London nurseries being used primarily as receiving centres. The end of the war, the winding up of the Government evacuation scheme, and the provisions of the Education Act, 1944, combined to make considerable changes of practice desirable. The maintenance of most of the temporary country nurseries ceased to be essential and many were closed, alternative accommodation being found in London nurseries, but it was necessary to retain four. The coming into operation of the Education Act, 1944, converted the Council's power to provide for the education and nurture of children over three years of age into a duty to provide for children over two years of age; and the Council accordingly thought it wise to lower the age at which children were transferred to establishments under the control of the Education Committee from three to two years. It is to be the future practice to admit children under two to public health or social welfare nurseries, the accommodation of which is to be pooled, but to transfer them at the age of two to an education establishment; for administrative reasons this is not yet fully in force. At the beginning of 1945, out of 808 children in the Council's care and accommodated in residential nurseries, 705, or 87 per cent., were in country nurseries to which they had been sent in pursuance of the Government's evacuation policy. This figure included children of all ages up to five. The following table shows the accommodation of the nurseries and the distribution of the children at that time:— Total accommodation No of children in residence Age ranoe In the country—25 nurseries 897 705 0-5 years In London—4 nurseries* 166 103 0-3 „ Total 1,063 808 *1 Public Health, 3 Social Welfare. To provide the additional nursery accommodation which was needed, owing to the closing of country premises, public health nurseries were opened or extended at the following establishments:— South-Eastern Hospital, New Cross, S.E.14 ... Increase from 20 to 40 cots (3.6.45) Queen Mary's Hospital for Children, Carshalton New nursery—40 cots (26.8.45) St. Margaret's Hospital, Kentish Town, N.W.5 New nursery—84 cots (4.11.45) The Downs Hospital for Children, Sutton ... Newnursery—157 cots (16.12.45) (partially open only on 31.12.45) Total—321 cots 38 The four country nurseries retained were:— Basted House, Wrotham 36 cots Easneye, Ware 48 „ The Elms, Bourne End 20 „ Widbury House, Ware 34 „ 138 „ From 1st January, 1946, it was decided that they should be transferred from the control of the Education Officer to that of the Medical Officer of Health under the direction of the Hospitals and Medical Services Committee. The following summarises the position at the end of 1945:— Total accommodation No. of children in residence † In country—8 nurseries 367 260 In London—6 nurseries* 406 323 773 583 †In comparing these with the figures at the beginning of the year it must be remembered that they do not include children now transferred to residential nursery schools under the control of the Education Committee, i.e., the age range is no longer 0-5 but 0-2 years. ‡Includes 2 nurseries which were closed early in January, 1946. *2 Public Health, 4 Social Welfare. Out-patients departments: appointments system The scheme for arranging appointments for patients attending the out-patients' departments of the Council's hospitals was extended and developed during the year. It had become apparent that, particularly in the larger hospitals, far too much routine clerical work fell upon the nursing staff, interfering with their nursing duties and hindering the rapid flow of patients to the wards or treatment centres. At most hospitals the task of checking and arranging for the storage of property of patients admitted as in-patients also threw a burden on the nursing staff. In order to relieve the nurses, clerks were appointed for duty in the receiving wards and out-patients' departments of 18 hospitals; and the results so far have been entirely satisfactory. Rehabilitation Every effort has been made to co-operate as fully with the Ministry of Health "rehabilitation" programme as the difficult working conditions would allow. A number of medical and physiotherapy staff were sent to the special courses arranged by the Ministry. The almoners at the hospitals work in close co-operation with the disablement resettlement officers of the Ministry of Labour in arranging training and job-finding for the permanently disabled who cannot return to their own work and patients are advised to register if eligible under the Disabled Persons Act. Several hospitals have been able to offer full rehabilitation facilities including occupational therapy and physiotherapy for long-stay patients, viz., the Northern, the Southern, Joyce Green Hospitals and Queen Mary's Hospital, Sidcup. Medical lecturers for the training courses held by the Ministry of Labour for its disablement resettlement officers have been provided from the Council's staff. A psycho-neurosis unit, staffed by doctors and nurses from Mill Hill E.M.S. Hospital, was opened at the Southern Hospital in June for the psychiatric treatment and rehabilitation of repatriated prisoners of war and certain other patients. By the end of the year over 1,000 ex-Service patients had passed through the unit. Valuable co-operation was secured from employers in Dartford, who provided a large range of part-time employment. Subsequent enquiry in 500 cases revealed 92 per cent. in work or training. For further particulars, see pages 60-62. Linkage with voluntary hospitals The various forms of association between the Council's hospitals and voluntary hospitals are of advantage to both. They enlarge the scope of the services which can be rendered, while the staff benefit by the stimulus of teaching in the wards and of contacts with staff from other hospitals. The possibility of extending the co-operation is under constant consideration. 39 Besides the linkages for purposes of medical education referred to elsewhere, mention may be made of the ophthalmic department instituted at Lambeth Hospital in the clinical charge of medical staff from the Royal Eye Hospital. This has worked smoothly and well, and when fully developed should constitute a considerable addition to the facilities in South London for the treatment of diseases of the eye. In 1945 the volume of work done by district medical officers was generally much the same as in 1944, a small increase being shown in the attendances at medical relief stations or doctors' surgeries, as well as in domiciliary visits, and in persons seen by district medical officers. The numbers of attendances and visits were 101,652 and 31,612 respectively, compared with 100,992 and 30,172 in 1944. The number of persons seen was 27,647, compared with 26,640 in 1944. The number of admissions of district medical officers' patients to hospitals decreased, owing no doubt largely to the shortage of hospital accommodation for the chronic sick. District medical service The number of supplementary old-age pensioners included in permanent medical relief lists and so entitled to call on the services of a district medical officer at any time continued to increase, and a considerable proportion of the patients seen by district medical officers is composed of old people. During the year the arrangements by which district nursing associations undertake district nursing work on the Council's behalf were continued. The nurses made 269,245 visits to patients of the district medical officers and to other persons for whose nursing care the Council is responsible. Of these visits, 105,252 were to administer insulin to diabetic patients; the remainder were for general nursing. The comparable figure for 1944 was 239,151 visits (of which 97,453 were insulin visits). The amount of annual grant paid by the Council to the Central Council for District Nursing in London for distribution to the local associations was increased, because of the increased expenditure incurred by associations in implementing the Rushcliffe Committee's proposals regarding salaries of nurses. District nursing service The arrangements whereby the Council defrays the cost of insulin and similar drugs supplied by voluntary hospitals to patients unable themselves to pay for them have been continued. As a result of the Education Act, 1944, the obligation to provide treatment, whether by insulin or other means, for school children requiring it now falls on the School Health Service and it is provided without charge to the parents. Insulin In the pharmaceutical department of St. Alfege's Hospital supplies of medicaments and equipment for their administration are prepared for many branches of the service. These arrangements supplement those for the preparation of such items for their own use which exist in a number of other hospitals. At St. Alfege's Hospital the articles produced or maintained include infusion and transfusion fluids, oxygen therapy equipment, some 40 varieties of ampoules, and dressings in five medicated varieties. Pharmaceutical supplies The supply of artificial limbs under the arrangements with Queen Mary's (Roehampton) Hospital has continued during the past year. These arrangements, which came into operation in 1932, have enabled patients to benefit from the skill and exceptional experience of the staffs of this hospital and the associated fitting centres. Supply and repair of artificial limbs On the recommendation of an orthopaedic surgeon, patients, after amputation, are seen at the limb-fitting centre. The type of limb to be provided is decided by the limb-fitting surgeon. The type of patient varies considerably. The Ministry of Labour makes provision for the supply of artificial limbs for most people who would normally be able to return to work after the fitting of a limb; additional types of patient are elderly social welfare clients, mental, tuberculous and blind persons, as well as school children under the Education Act. The repair and maintenance of limbs is carried out for some 200 patients each year. In exceptional circumstances, e.g. after double amputation, they are admitted for walking instruction. 40 The total number seen at the limb-fitting centre during 1945 was 210, compared with 177 in 1944. War work by patients During the war, patients at Queen Mary's Hospital, Sidcup, and St. David's Hospital, Edmonton, carried out some useful and interesting work for firms engaged on Government contracts. When this came to an end it was found possible to secure other suitable work. The ex-Service patients at Sidcup undertook the manufacture of 2,000,000 artificial poppies for Earl Haig's Fund; and the St. David's patients did a certain amount of experimental work, which it is hoped will be developed, on the manufacture of domestic woodwork for priority needs. Legacies to hospitals During the past year, legacies have been received for the benefit of two of the Council's hospitals, viz., Bethnal Green Hospital (£78), and St. George-in-theEast Hospital (£50). These sums have been used for the benefit of the patients and staff of the hospitals concerned. Works The Government's policy of concentrating building labour and materials on the repair of war-damaged houses was continued in 1945; when hostilities ended, the construction of new houses constituted another priority claim and added to the obstacles in the way of the rebuilding or repair of hospital premises. There was no possibility of starting an extensive programme of reconstructing buildings destroyed or damaged by the enemy, of making up the arrears in the pre-war schemes of improvement, or even of decorating and repairing the hospitals on pre-war standards. Nevertheless, some progress was made and Ministry of Health authority was obtained to a small list of works of special urgency. The main building, etc., activities undertaken or sanctioned during the year were as follows :— (1) Repair of war damage not involving, save in one or two instances, major building work. The chief exceptions were the repair of the administrative block at Grove Park Hospital, which was authorised at an estimated cost of £4,780; the repair of C Ward Block at St. Mary Abbots Hospital (estimated cost £1,410), and the adaptation of existing buildings at Lewisham Hospital to provide extended accommodation for the outpatient department and ante-natal clinic (estimated cost £1,331). The restoration of the operating theatres at Hammersmith Hospital (which, being on a top floor, had been replaced during the war by theatres on the ground floor) was also sanctioned; the expenditure will be mainly for renewal of equipment (sterilisers, etc.) which had been transferred to upgraded E.M.S. hospitals where it was still in use. (2) Removal of air-raid precaution works (protective brickwork to windows, etc.). (3) Completion of a new ward block at St. Nicholas' Hospital, which was unfinished at the outbreak of war and work on which was then discontinued. (4) Reconditioning of St. Anne's Home, Herne Bay (which was closed in 1939) in preparation for re-opening. (5) Adaptation works, in certain wards of eight hospitals, to be used for treatment of the tuberculous. Visits, etc., by students and others A noteworthy feature of the year was the number of medical officers, medical students and others, not only from London and the provinces but also from overseas, who asked to be allowed to visit the hospitals on specific occasions or to work voluntarily in them for short periods to gain knowledge and experience of the unique facilities available in the Council's service. A considerable number of medical students, the majority from Scottish medical schools, worked in several hospitals during vacations and were provided with free board and lodging. Owing to shortage of staff, their services were greatly appreciated and found to be of considerable value. Similar satisfactory arrangements were made 41 for several medical officers, who wished, while taking a further qualification on demobilisation from H.M. Forces, to enlarge their experience. In addition, small parties of students visited hospitals on numerous occasions, receiving in many cases an explanatory lecture or demonstration from the medical superintendent, or other officer, on the organisation and working of the hospital as a whole or of some special department in it. Such visits included parties from the London School of Economics and the Battersea Polytechnic and comprised almoner students, sister-tutor students, school nursing sisters, health visitor students, postgraduate nurses of various types, and other similar visitors. The scheme whereby Ministry of Labour cookery trainees gain experience in institutional cookery by working in the kitchens of a number of the Council's hospitals was continued and extended. There is reason to believe that most of the visitors were favourably impressed by the service and made fruitful use of the opportunities presented. During the past year special attention has been concentrated on the preparation and service of meals to patients and staff in the Council's hospitals and a number of visits have been made by the responsible officers from County Hall for the purpose of investigating and advising on these questions. Hospital meals It has long been realised that the provision of meals for hospital patients requires a careful selection of the available foods, good cooking and attractive presentation, in order to provide an adequate dietary. Rationing restrictions and a severe shortage of domestic staff have, however, rendered the achievement of this result very difficult. Restrictions in supplies have also prevented very necessary improvements in the equipment of hospital kitchens. It has been decided to appoint a special catering officer, with an over-all responsibility, for all feeding arrangements for an experimental period at three hospitals of different types. When the necessary experience has been gained the question of an extension of the scheme will be considered. Medical education The provision of medical education in the Council's hospitals has been widely developed since the Council assumed responsibility for hospital administration in 1930. The educational facilities have been described in a number of annual reports; the most recent and comprehensive description is contained in the Council minutes for 20th October, 1942 (pages 823-843), where will be found the evidence submitted by the Council to the (Goodenough) Departmental Committee on Medical Schools. They include the provision of clinical instruction to undergraduates from the voluntary hospital medical schools as well as post graduate instruction not only at the British Postgraduate Medical School, which is located at Hammersmith Hospital, but also at several general hospitals where teaching and clinical experience are available for medical men and women aiming at the acquisition of the higher professional qualifications. These arrangements, modified to meet war-time conditions, were continued during the year under review. Courses of instruction in infectious disease at fever hospitals were attended by 586 students, of whom 124 were women. One of the two fever hospitals at which resident courses were held was closed to fever cases, but in the latter part of the year a resident course was introduced at the North-Eastern Hospital. Postgraduate courses were arranged at groups of general hospitals in north and south London, in collaboration with the local medical and panel committee for the County of London. Weekly clinical "rounds," to which private practitioners are invited, have been instituted for several years past at a number of the Council's general hospitals and have proved to be very successful and much appreciated. At St. James' Hospital, Balham, the numbers who attend vary between 20 and 30 practitioners each week. Clinical rounds Over six years have elapsed since the Clinical Research Committee was set up in June, 1939. The following account summarises its work since its inception:— It consists of thirteen members, membership of those elected is limited to Clinical Research Committee 42 three years. Elections to membership take place annually and are made by the Committee from nominations made by the medical officers in the Council's hospitals and laboratories. One member is appointed directly by the Medical Officer of Health. In electing members the Committee aims at maintaining a membership with a balanced and comprehensive collective experience. The Committee has power to co-opt members from within or without the service for special purposes. There is a separate research committee for the Mental Health Services; two representatives of this committee sit on the Clinical Research Committee and the two committees also exchange and discuss the minutes of each other's meetings. The Committee has met regularly since its inception and 33 meetings had been held up to 31st December, 1945. Among its objects are:— (1) To assist medical officers of the London County Council in research; (2) To advise medical officers in their researches and to assist in making available to them the resources of the Council hospitals and medical services; (3) To appoint sub-committees to make surveys of the results of treatment and to carry out special clinical investigations; (4) To report on the value of any particular line of research and the methods by which it could be assisted ; (5) To consider and report upon applications from outside workers for research facilities in the Council's hospitals; (6) To consider and report upon the use of new appliances and drugs; (7) To take any steps that may appear desirable for the furtherance of research in the Council's hospitals. Applications for the help of the Committee in research may be sent to the secretary of the Committee by any medical officer in the Council's service through the medical superintendent of his hospital; they are considered by the Committee, together with any recommendations made by the medical superintendent through whom it is transmitted, and the Committee have power to make any enquiries which they think necessary before deciding what action is appropriate. In order that the medical staff may be kept aware of the Committee's activities, copies of the Committee minutes are circulated to the hospitals and laboratories. During the past six years requests have been received from a number of medical officers, both from within the Council's service and from outside, for help in conducting research. Applications have also been received from firms of manufacturing chemists for trials of drugs. Careful consideration has been given to these requests and, when necessary, the applicant has been invited to attend a meeting of the Committee for discussion. In some instances facilities have been given to medical officers to carry out research in the Council's hospitals. In others, medical officers have either been given access to the hospital records of certain types of cases or been informed of their occurrence so as to permit of further investigation. In a few instances, applicants have been introduced to experts outside the Council's service or referred to previous literature on the subject. New forms of treatment have been given a trial whenever there was a reasonable prospect of success. Close liaison is maintained with the medical supplies branch of the Council's supplies department. The following list shows some of the matters considered by the Committee:— Facilities given to medical officers for research in certain hospitals in regard to:— Therapeutic action of sulphathiazole in acute staphylococcal infections. Vitamin K content of blood in new-born infants. Use of phenothiazine in urinary tract infections. Vitamin B complex deficiency and cases of retrobulbar neuritis. 43 Medical officers given access to hospital records or informed of cases :— Lateral sinus thrombosis (new modification of Toby-Ayer test). Gangrene following fracture of lower limb. X-ray studies of foetal development. Applicants introduced to experts outside Council's service or referred to previous literature:— Capillary microscopy. Cancer—treatment by diet deficient in vitamin C. Cancer—treatment with dibenzanthrazine. Drugs or forms of treatment or diagnosis tried or being tried at certain hospitals:— Cetavlon. Sulphabenzamide. Anethaine. Methionine. Promin. The following are the sub-committees, together with notes of the work upon which they have been, or are, engaged:— Sub-Committees Research work Anæsthetics Deaths under anæsthesia (proceeding). Statistical (medical) Pleural effusion—collaboration with tuberculosis section of the department in preparation of questionnaire for follow-up purposes. Statistical (surgical) Viability of strangulated bowel (proceeding). Vitamin deficiency (in co-operaVitamin deficiency in patients—biochemical tion with Mental Health Sersurvey. vices Research Committee) Alum precipitated toxoid Comparison of alum precipitated toxoid with other diphtheria prophylactics. Whooping-cough serum To consider subject and arrange for trials of serum for therapeutic purposes and possibly also for prophylaxis (proceeding—see below). The last item illustrates the way in which the Committee works. The medical officer of an eminent research laboratory stated that initial tests of the serum had given promising results but that clinical trials were desired. Representatives of the laboratory attended a meeting of the Clinical Research Committee, together with the medical superintendents of certain of the Council's fever hospitals. The matter was carefully considered and it was decided to set up a sub-committee consisting of representatives of (a) the Clinical Research Committee, (b) the medical superintendents of the fever hospitals, and (c) the laboratory, to arrange for trials and to report to the Clinical Research Committee from time to time. This account of the work of the Clinical Research Committee would not be complete without mentioning that the Medical Society of the L.C.C. Service (see next paragraph) owes its inception to suggestions made by members of the Committee and was sponsored by the Committee in its early stages. At the suggestion of certain members of the Clinical Research Committee a sub-committee was set up in 1944 to consider the formation of a Medical Society of the Council's Service. As a result of their labours an inaugural meeting of the medical staff was held on 11th January, 1945, and the Society came into being with the following aims:— Medical Society of the L.C.C. Service (a) To promote contact between the medical members of the medical service of the Council; (b) To encourage contact between the medical staffs of Council hospitals, and of neighbouring municipal and voluntary hospitals, and general medical practitioners; (c) To provide opportunities for the study and discussion of clinical problems: 44 (d) To collaborate with the Clinical Research Committee. Conditions of membership are as follows:— Membership of the Society is open to whole-time or part-time medical or dental officers of the Service who have completed at least six months' continuous service. Visiting membership is open to past members having three years' membership or such others as the Council of the Society decide and is subject to annual nomination and election by the Society. Honorary life membership is open to persons specially nominated by the Council of the Society. During the year the Society held nine clinical meetings at hospitals and two discussion meetings at County Hall; the subject at the first discussion meeting was the treatment of the bleeding peptic ulcer, and at the second it was subarachnoid haemorrhage. At the clinical meetings cases of wide variety and interest were shown. The lowest attendance at any meeting has been 74, and the highest was 135 at the meeting in December at Lambeth Hospital (with St. Giles' Hospital co-operating). Membership of the Society was 320 at the end of the year. Staff Staff on War Service Since the outbreak of war, 1,203 members of the hospitals permanent staff have been called up for service with H.M. Forces, including 51 medical officers, 79 female and 170 male nurses, 514 porters, 207 clerks and 182 other staff; and in addition 25 men and 15 women from the permanent staff have undertaken work in war industry, the Merchant Navy, the Women's Land Army or hospital nursing services. As regards temporary staff, 366 members of all grades left to undertake war service. Sixty-three members of the special and general hospital staff were killed in action or died on war service. By the end of the year, 322 members of the staff had been discharged from H.M. Forces and had returned to duty at the hospitals. The ending of hostilities did not alleviate staffing shortages to any extent and considerable difficulty continues to be experienced in obtaining nursing staff, medical auxiliaries and male and female domestic staff. With the progress of demobilisation, however, it is hoped that the difficulties in respect of male staff at least will largely disappear. Scales of salary and conditions of service From the point of view of the stair employed by the Council, one of the outstanding features of the year was the extension of the attempt to provide nationally accepted standards of pay and working conditions for many grades of staff, negotiated by joint committees of employers and employees. During the year further recommendations of the committees dealing with nursing and laboratory staff were adopted by the Council for its staff. The work of two further committees, dealing with domestic staff and medical auxiliaries, was nearing completion at the end of the year and national standard scales will doubtless be operative by the time this report is published. In addition, the Minister of Health and the Minister of Labour and National Service have recommended codes of working conditions and conditions of service for nurses and midwives and domestic staff at hospitals. Most of the conditions recommended were already observed in the Council's hospitals, but it is the intention that they should all come into force throughout the hospital service as soon as possible. Demobilised doctors Many medical practitioners are now being demobilised from H.M. Forces, and it has been realised that their conditions of work in the Forces and their limited experience in certain fields of medicine may have left many of them in need of refresher courses before taking up civilian work. The Minister of Health has accordingly asked voluntary hospitals and local hospital authorities to provide such facilities. The Council is providing for three classes of demobilised medical 45 practitioners. A series of intensive courses lasting a fortnight each has been arranged for general practitioners; medical men who were newly qualified before being called up are catered for by additional appointments as assistant medical officers in selected general hospitals for a period of six months; and, finally, more experienced men who are intending to become specialists have the opportunity of taking posts in some of the Council's hospitals as trainee specialists. These appointments are for six months in the first instance, and are renewable. The cost of making these three classes of appointments is being defrayed by the Ministry of Health. In the Highgate area the Council has three general hospitals, namely Highgate, Archway and St. Mary, Islington, Hospitals, which are quite close to each other. Hospital organisation In order to facilitate the redistribution and concentration of certain types of patients, and thereby promote the best use of the medical and nursing services and increase the scope and variety of the nursing training facilities, the Council decided to bring the three separate hospitals under the administrative supervision of a single medical superintendent. The obstetric and gynaecological work of these three hospitals was already in the care of one specialist with complete clinical responsibility. The scheme for unification and co-ordination of the three establishments also provided for the addition to the staff of a whole-time physician specialist and a whole-time surgeon specialist responsible for the medical and surgical work in the three hospitals. Although progress in the development of the scheme for the rehabilitation of sick persons in the Council's hospitals has been seriously handicapped by the lack of suitable accommodation and the acute shortage of fully trained staff, active rehabilitation departments have been firmly established at several hospitals; and, during the year, seven qualified occupational therapists, three auxiliary occupational therapists, and 12 handicraft instructresses have been employed on this work. Owing to the shortage of persons suitably qualified to conduct remedial exercises, it was not possible to appoint physical training instructors, but physical training under medical supervision was given to Service patients at two large hospitals by Army instructors temporarily allocated by the War Office. Attention has been given to the purely diversional side of rehabilitation by the appointment at two hospitals of paid full-time librarians who prescribe and convey suitable reading material to patients. This work was previously carried out on a lesser scale by voluntary helpers, and at most of the hospitals volunteers supplied by the Order of St. John of Jerusalem and British Red Cross Society are responsible for the library and do invaluable work. Rehabilitation At the request of the Pharmaceutical Society of Great Britain, the Council co-operated in a scheme originated by the American Forces and supported by the British Council, whereby American pharmacists serving in the American European Forces were attached to British pharmacists as unpaid "observers." Arrangements were made for observers to be allocated for three weeks in turn to each of 24 of the larger general hospitals over a period of about three months. Miscellaneous The remuneration of consultants and specialists visiting hospitals on the borders of or just outside the county was brought into line with the higher rate for visits to hospitals and sanatoria outside London, and the opportunity taken to codify as far as possible the rates for the same services at these hospitals and sanatoria. The services of an allergist were made available to the hospitals. The experiment, begun in 1944, of appointing clerks for work in out-patients' departments and receiving wards to ease the work of nursing staff and to effect a more rapid turnover and better organisation was very satisfactory and the principle was extended by the appointment of 14 additional clerks. Patholoaical laboratory service The number of examinations (including post-mortem examinations) completed in the group laboratories during the year ended 31st December, 1945, compared with the year 1944, is given below:— Group laboratories 46 Group laboratory 1945 1944 Archway, Highgate 45,889 38,115 Lambeth 40,028* 35,471* Lewisham (including Joyce Green, Dartford) 60,636 43,994 Mile End 35,334 29,802 North-Western, Hampstead 44,509 51,027 St. Mary Abbots, Kensington 31,584 27,007 Southern, Hither Green 16,676 12,613 Total 274,656 238,029 *Exclusive of 29,286 examinations in 1945 and 35,867 in 1944 undertaken for St. Thomas's V.D. clinic. The number of post-mortem examinations carried out by the Central Histological Laboratory staff during the year was 1,216 (1,101 in 1944) and the number of histological examinations carried out in the laboratory was 27,858 (26,512 in 1944). In addition to the bacteriological work, the Southern Group Laboratory provided culture media, etc., for the British, American and other allied armies and for the Ministry of Health's emergency pathological service, as well as for all the Council's own hospitals. The amounts supplied during the year are as follows:— Culture media 37,351 litres Stains and chemical solutions 6,952 „ Vaccines 52,284 c.c.s. Grouping sera for blood transfusion 26,296 tubes Sterile sulphonamides 16,496 bottles Tuberculin for Mantoux test 7,309 c.c.s. Intravenous solutions 46,729 litres Measles serum, Adult 24,560 c.c.s. „ „ Convalescent 2,450 „ Kahn and Wassermann antigen 81,305 „ Sterile distilled water for penicillin admin2,850 litres istration Hospital laboratories The total number of specimens examined in the hospital laboratories, as distinct from the group laboratories, during the year was 296,345 (230,935 in 1944), and 1,696 post-mortem examinations (2,340 in 1944) were carried out in addition to those by the pathologists. General During the year, 18 students of the London School of Medicine for Women attended the group laboratory at Archway Hospital for a two months' course of practical pathology and facilities were given for them to attend post-mortem examinations and to make use of the museum of collected specimens at the histological laboratory. Facilities were granted to a voluntary worker for experimental work at one of the hospital laboratories in the production of crude penicillin. In 1944, an investigation on the control of dust-borne streptococcal infection in measles wards was conducted by Dr. Joyce Wright of the Medical Research Council in co-operation with the pathologist in charge of the group laboratory and the medical superintendent of the North Western Hospital. Their report was printed in the British Medical Journal (6th May, 1944, Vol. i, p. 611). Early in 1945, the Medical Research Council asked that the investigation might be continued and facilities were granted for Dr. Joyce Wright to continue her work at the Eastern Hospital in co-operation with the medical superintendent. The investigation into gastro-enteritis which was begun at North Eastern Hospital in 1944 was continued throughout the year. The importance of Rhesus grouping, in connection with the blood transfusion service, has become more generally recognised and nearly 3,000 tests were undertaken during the year at the group laboratory at Lewisham Hospital. In addition to their ordinary work the group laboratories undertook the supply of penicillin to neighbouring hospitals. 47 LONDON AMBULANCE SERVICE The year 1945, bringing with it the end of the war, saw the disbandment of the London Auxiliary Ambulance Service and the reorientation of policy and organisation to meet the needs of peace-time conditions. The transition from war to peace is as great an upheaval as from peace to war, and the latter half of 1945 was concerned mainly with clearing up the aftermath of the exceptional conditions which obtained during the war years. Such matters included derequisitioning of premises, war damage claims, accounting for and disposal of civil defence uniforms, equipment and vehicles. At the same time new lines of policy, made possible by the termination of hostilities, were introduced. In addition, certain war-time legacies such as provision of transport for the Emergency Medical Service, conveyance of disabled war patients, both ex-Service and others, in need of hospital treatment, and duties in connection with the Hospital Car Service, the lineal successor of the Volunteer Car Pool, have devolved upon the peace-time service. The early part of 1945 saw the intensification of long-range rocket attacks on this country. The number of casualties conveyed to hospital and first-aid posts in the first three months of 1945 as compared with the last three months of 1944 was as follows:— 1944 October—December 1,734 1945 January—March 2,878* * 27th March, 1946, was the last day on which casualties were recorded. The highest daily number of patients conveyed to hospitals and first-aid posts as a result of V.2 attacks was 260, on 8th March, 1945. Auxiliary ambulance station 126 (Christ College, St. German's Place, Blackheath, S.E.3) and "G" (Poplar) accident station were extensively damaged by long-range rockets on 2nd January, 1945, and 7th March, 1945, respectively, but it was not found necessary to evacuate the stations, both of which remained in commission. The end of the war in Europe, in 1945, brought disbandment of the Civil Defence Services, including the London Auxiliary Ambulance Service, which for administrative purposes had been linked to the Council's peace-time ambulance service. The cordial relationship with the London civil defence regional headquarters and metropolitan boroughs, which had operational control in raids, greatly assisted in the smooth working of the civil defence organisation. The maximum strength of the London Auxiliary Ambulance Service at any one time was some 8,500 persons, and it is estimated that the approximate total number of personnel who served in the Auxiliary Service during the war period was in the region of 16,500. The maximum number of vehicles in commission was 900 ambulances and over 700 ambulance cars, while 112 auxiliary ambulance stations were in operation during the peak period of the Auxiliary Service's existence. The London Auxiliary Ambulance Service may be regarded as an outstanding development of a peace-time service for war-time needs. The peace-time organisation was utilised as a basis for the creation of the Auxiliary Service to deal with air-raid casualties. The peace-time general ambulance stations with their superintendents and staff were made the basis of the local organisation of the Auxiliary Service, the superintendents being in general charge of the administration of the auxiliary stations and dealing with all questions of personnel, equipment, vehicles, premises, etc. Each auxiliary station was thus attached for administrative purposes to a general section ambulance station; a station officer of the regular service was responsible for supervising a group of auxiliary stations and was the liaison officer between the auxiliary staff and the superintendents and gave general help and advice in running the auxiliary stations. Each auxiliary station was under the direction of an auxiliary station officer, who was assisted by a deputy and two shift leaders. The shift system of the auxiliary staff was on the basis of 24 hours on duty and 24 hours off duty. Comprehensive training, including instruction in first-aid and in air-raid precautions, including anti-gas training, was given to all 48 auxiliary personnel, while practice driving was provided regularly under the supervision of driving instructors. Operational exercises were arranged to familiarise the staff with the position of the hospitals and first-aid posts and to obtain general knowledge of the topography of their area. Calls for ambulances to deal with air-raid casualties were transmitted direct to auxiliary ambulance stations from the borough control centres under the direction of the London Civil Defence Region. With the cessation of intensive and prolonged air raids on London, the Auxiliary Service, in addition to routine training and exercises, undertook in suitable cases the removal of patients to and from hospital, as well as the conveyance of medical officers, midwives, hospital stores and equipment, etc., and thus rendered valuable assistance in " stand by " periods. The extent of the work carried out by the auxiliary service during 1945, and during the whole of the war is shown by the following figures:— Number of war casualties conveyed to hospitals and first-aid posts, period 1st January to 8th May, 1945 (last day on which casualties were recorded 27th March, 1945) 2,878 Total number of war casualties conveyed to hospitals and first-aid posts, period 3rd September, 1939, to 8th May, 1945 48,709 No mention of the war-time services would be complete without reference to the valuable contribution made by the Council's peace-time ambulance staff in administrative and operational matters and instructional duties to the auxiliary personnel. The services of the sanitary inspectors of the public health department were utilised during the war in connection with the maintenance of premises and repairs necessary as a result of enemy action. The inspectors, who made some 1,400 visits during 1945 also rendered very valuable technical assistance in the preparation of war damage claims and the reinstatement of premises on relinquishment. The following honours and awards were gained by members of the auxiliary service during their war service:—George Medal, 3; British Empire Medal, 11; Commendation, 5. A letter expressing the Council's appreciation of their services was sent to all auxiliaries on termination of their duties with the London Auxiliary Ambulance Service. London, indeed, owes a heavy debt to the members of the London Ambulance Service and the London Auxiliary Ambulance Service who served the capital and its inhabitants so well during the grim days of persistent enemy air attacks. At the end of the war the number of permanent operative staff in the regular ambulance service had been reduced from over 400 to 217, almost entirely as a result of the call-up. To fill the resulting vacancies in a temporary capacity, 92 men and 95 women had been recruited, mainly from the auxiliary service. The disbandment of the London Auxiliary Ambulance Service in July, 1945, meant not only the loss of a valuable source of assistance to the regular service, but also a most useful field for the recruitment of staff already familiar with the duties of the service. By the end of 1945, however, a small number of permanent staff had returned from service with H.M. Forces, and recruitment from demobilised ex-service men began to reverse the tendency, which was particularly noticeable in the later stages of the war, for the average age of the personnel employed to show a pronounced increase. Special arrangements were made to augment the facilities of the London Ambulance Service for V.E. Day and V.J. Day celebrations so that additional accident ambulances were available by day and night at the accident and general ambulance stations. The calls to accidents were:— V.E. Day V. J. Day 8th May, 1945 241 15th August, 1945 226 9th May, 1945 205 16th August, 1945 172 By comparison the daily average of accident calls for the first four months of 1945 was 127. 49 Owing to the disbandment of the Auxiliary Ambulance Service, several ancillary duties, hitherto undertaken by that service, had to be provided within the peacetime organisation. The Volunteer Car Pool, which had undertaken during the war the conveyance of out-patients to and from hospitals, was disbanded on 31st July, 1945; and arrangements were made under Ministry of Health circular 140/45 for this service to be taken over by the Hospital Car Service with effect from 1st August, 1945. In the County of London the British Red Cross Society is responsible for the provision of the hospital car service for the conveyance of sitting patients attending hospitals and clinics who need special transport other than a public conveyance. Owing to the acute shortage of volunteers and cars, however, it was agreed with the B.R.C.S. that all calls from the Council's hospitals in the London area to the Hospital Car Service should be referred to the London Ambulance Service, and only in the event of special urgency where no Council car was available, would the British Red Cross Society be asked to provide necessary transport. After some initial difficulties, owing to the number of ambulance vehicles under repair, the arrangements worked satisfactorily and the London Ambulance Service was able to meet all requirements. At the request of the Ministry of Health (Circular 116/45), the Council provided eight ambulances and twelve cars for inter-hospital removals, etc., following the disbandment of the auxiliary ambulance service on 2nd July, 1945. From time to time the number of vehicles has varied in accordance with the requirements of the Emergency Medical Service. For example, on the disbandment of the American Ambulance Great Britain Unit on 3rd November, 1945, the number reached a maximum of 27 ambulances and 22 cars. The Council authorised the provision by the London Ambulance Service of transport, as required on behalf of the Ministry of Pensions, of seriously disabled war patients, both ex-Service and others, requiring hospital and other forms of treatment, who reside in the County of London, upon payment by the Ministry at the rate of ls. a mile. Incorporating the suggestion contained in Ministry of Health circular 70/45 that local authorities should include in their peace-time ambulance service a number of motor cars which might be used for the transport of sitting patients, the Council authorised the acquisition of 30 cars from former auxiliary ambulance service vehicles for the conveyance of sitting patients, of domiciliary midwives when public transport is not available and in cases of urgency, of district medical officers, and for other purposes. Owing to the mechanical deterioration of the vehicles of the regular ambulance fleet, many of which are fifteen years old, and the length of time which must elapse before new vehicles can be obtained, the Council decided to act on the Ministry of Home Security circular 125/44 which authorised, inter alia, local authorities to purchase auxiliary ambulances for their own peace-time use. For this purpose 125 Bedford auxiliary ambulances were acquired from the former auxiliary ambulance service vehicles and these are being brought into service after considerable alterations have been made, to adapt them for the needs of the regular London Ambulance Service. The Council extended reciprocal arrangements in respect of accident section ambulances previously existing with the borough of Hornsey, to include the boroughs of Finchley and Wood Green and the urban district of Friern Barnet on the operation of a joint ambulance service by those four local authorities. As an offset to the additional duties falling upon the London Ambulance Service, it may be noted that the war-time responsibility for the maintenance and operation of a fleet of vehicles to take physically handicapped children to and from school was transferred to the education officer's department on 30th August, 1945. Thus 1945 was a memorable year in the annals of the London Ambulance 50 Service, and with the extension of free ambulance facilities and additional duties foreshadowed by the National Health Service Bill, the Service can look forward to a period of increasing activities, in which the experience gained during the war years will no doubt prove of great value. school health service Education Act, 1944 The most notable development during the year was the coming into operation on 1st April, 1945, of the Education Act, 1944. The relevant sections of the Act materially altered the previous practice both as regards the medical inspection of, and the provision of medical treatment for, school pupils. Under the Act the certification of children as mentally or physically defective was abolished and it became the duty of every local education authority to ascertain which children in their area require special educational treatment and for this purpose the local education authority have power to examine medically any child in their area who has attained the age of two years. It will be seen therefore that, for the first time, the local education authority is expected to examine medically, in the circumstances mentioned, children of pre-school age; and parents who, without reasonable excuse, refuse to submit their child for such medical examination, render themselves liable to a penalty. Moreover, whereas, under previous enactments the certificate of the examining medical officer was final, the Act prescribes in detail a procedure which has to be followed whereby it is for the local education authority to ascertain if the child is in need of special educational treatment after obtaining, in addition to the report by the doctor, reports from teachers, if the child is at school, or other persons with respect to the ability and aptitude of the child. Children for whom special educational treatment is considered necessary are described as "handicapped," and the various categories of "handicapped" children embrace descriptions not included within the scope of previous educational enactments. The complete list is as follows: blind, partially-sighted, deaf, partially-deaf, delicate, diabetic, educationally sub-normal (previously known as "mentally defective"), epileptic, maladjusted, physically handicapped and those suffering from speech defect. A somewhat similar procedure to that indicated above was also prescribed by the Act to determine which children in the area of the local education authority over the age of two years, are suffering from a disability of mind of such a nature or to such an extent as to make them incapable of receiving education at school, with a view to such children being referred for necessary action by the local authority under the Mental Deficiency Acts. Similar provision was made for ensuring that children in attendance at a special school who are suffering from a disability of mind shall, if necessary, receive supervision after leaving the special school. The important feature of the Education Act, 1944, in regard to the medical treatment of pupils in attendance at schools or colleges maintained by the local education authority is the requirement that such treatment shall be free, and moreover, that the facilities for the free medical treatment shall be comprehensive. In addition to making arrangements for securing the provision of free medical treatment, the local education authority also has the duty to encourage and assist pupils to take advantage of the facilities provided; but, if the parent of any pupil gives notice that he objects to the pupil availing himself of the treatment provided, the pupil shall not be encouraged, or assisted, so to do. In pursuance of this duty placed upon the Council as the local education authority, arrangements were made for free medical treatment in the Council's hospitals, which provide a comprehensive service covering every type of illness, at school treatment centres and at voluntary hospitals with which the Council, under previous enactments, already had arrangements for the treatment of certain specified defects or illnesses. Steps were also 51 taken during the year to ensure the free supply and repair of surgical appliances and spectacles and the free supply of insulin prescribed at voluntary hospitals for pupils for whom the Council, as education authority, was responsible. Authority was also given for the cost of emergency dental treatment by private practitioners for the relief of pain during the evenings, week-ends, and other times when clinics are not open, to be borne by the Council. The important changes in past practice brought about by the operation of the Education Act, 1944, became operative on 1st April, 1945; and, despite material alteration of the administrative procedures previously in vogue, were carried out smoothly. Government Evacuation Scheme At the end of 1944 the undermentioned "Special parties" were in the reception areas:— Number of parties Children in residence Accommodation Residential nurseries (0-5 years) 25 705 897 „ nursery schools (2-5 years) 38 1,516 1,749 „ schools for physically defective and delicate children 9 613 679 „ „ for the mentally defective 7 664 735 „ „ blind, deaf, diabetic and those with tuberculous histories 11 502 577 Total 90 4,000 4,637 The arrangements made for the medical supervision of these parties were set out in the report for 1943. There were also four nurseries in London, but these were used merely as receiving centres and the children were evacuated from there to nurseries in the reception areas as soon as possible after admission. With the end of the European War in May, 1945, it was necessary to prepare plans for additional nursery accommodation in London in which the children could remain until they were discharged to the care of their parents or were old enough to be transferred to nursery schools, and also to prepare for the closing of some of the establishments in the country. By the end of the year new nurseries were opened at three of the Council's hospitals and additional nursery accommodation provided at another, whereby provision was made for 301 more cots. The residential schools for handicapped children included in the "Special parties" were used throughout the year under review but it was possible, with the cessation of hostilities, to reduce their number. The position in December, 1945, was as follows:— Number of parties Children in residence Accommodation Residential nurseries (0-5 years) 5 141 206 „ nursery schools (2-5 years) 17 693 883 „ schools for physically handicapped and delicate children 5 345 465 „ „ for the educationally sub-normal 2 164 235 „ „ for diabetic, etc 2 113 146 Total 31 1,456 1,935 Medical inspection Under the Education Act, 1944, the junior departments of former elementary schools became primary schools and the senior departments and former central schools became secondary schools. The statistics which follow should be read with due regard to this change. The number of elementary school children on the rolls of elementary and central schools in London in December, 1944, was 175,445; by September, 1945, this had 52 increased to 265,965, with the return of children from the reception areas, and by the end of the year the number had further increased to 277,359, with a school attendance rate of 83.8 per cent.; the number of schools open in December was 741 compared with 668 at the end of 1944. The usual four age group inspections were continued throughout the year. Particulars of detailed examinations at these schools during 1944 and 1945 are:— Age group 1945 1944 Entrants 28,943 23,614 Children aged 7 19,227 16,118 Children aged 11 20,592 17,857 Leavers aged 13 plus 22,440 21,809 91.202 79,398 Other ages 21,762 16,004 112,964 95,402 Children in special schools and classes 941 827 Total 113,905 96,229 "Other ages" refer to the children outside the usual age groups who returned and were examined because no recent medical records were available. The increase on the previous year was due to the return of the children to London shortly after the termination of hostilities. Re-inspections of children previously noted with defects totalled 48,918. These inspections showed that, excluding dental cases, 87.5 per cent. were treated or discharged as no longer needing treatment; the remainder were still to be followed up. In addition, 28,234 inspections were made of children who were being given school meals on the advice of school doctors, head teachers or school care committees, and 26,466 of children about whom advice was required by teachers, care committees, etc. Including 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 250,281, exclusive of 17,060 carried out at higher education institutions. These compare with 352,169 and 12,683 for 1944. The smaller number of inspections compared with 1944, notwithstanding the increase in the school population, is explained by the fact that in 1944 there were 118,000 inspections in connection with the evacuation scheme and no such inspections in 1945. The following comparisons relate to the children examined in the four age groups in 1945 and 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:— 1945 1944 1943 1938 Numbers examined 91,202 79,398 96,902 169,995 Percentages Nutrition unsatisfactory 5.38 5.65 6.00 6.6 Nits or pediculi-hair 1.35 1.75 2.15 2.3 Teeth—obvious decay 27.67 26.33 31.01 29.8 Vision—6/9 or worse (excluding entrants) 22.58 23.76 22.61 32.2 Adenoids and enlarged tonsils 7.3 6.5 7.6 9.2 Skin diseases 1.6 1.5 1.8 1.0 Enlarged glands 1.2 1.0 1.2 1.5 External eye disease 1.3 1.7 1.9 1.7 Otorrhœa 0.3 0.5 0.5 0.6 Defective hearing 0.3 0.3 0.3 0.2 Heart disease 0.7 0.7 0.8 1.4 Anæmia 0.3 0.3 0.3 0.4 Lung disease (not T.B.) 1.3 1.2 1.3 1.5 Rickets (boys—entrants only) 1.0 1.2 1.4 1.0 „ (girls—entrants only) 0.8 0.9 0.9 0.4 53 It will be noted that the incidence of "heart disease" is declining. This has been the trend for many years. It may be associated with the general decline in streptococcal diseases but one likes to think that the Council's scheme for dealing with juvenile rheumatism has played a part. The nutritional condition of the great majority of children still continued to Nutrition be satisfactory. 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— 1945 1944 1943 1938 Entrants 5.55 5.90 6.67 6.46 7 years old 7.30 7.65 7.98 8.75 11 years old 5.13 5.83 5.75 6.75 Leavers (13 +) 3.75 3.75 3.86 4.47 Every age group showed an improvement over the 1938 assessments and, except for leavers which gave the same percentage as in 1944, over the assessments for the two previous years. Satisfaction can be felt in regard to the improved physical condition of the entrants who in the earlier war-time years had shown a deterioration on the 1938 estimations. Dental conditions noted at the routine age group medical inspections, which showed some retrogression in 1941, when the percentage of children with unsound teeth was recorded at 41.4, continue to show an improvement on the pre-war standard, except as regards the seven year old group. The results given below of the more exacting inspections by the dental surgeons, however, do not altogether confirm this finding but show an increase of 2.5 per cent. requiring treatment in 1945 over the 1944 figure. This increase is probably due to the mass movement of children back to London and to the more intensive dental inspections. Analyses of the results of inspections by the dental surgeons are as follows:— Children Percentage noted Year inspected for treatment 1938 292,971 69.7 1941 62,631 79.4 1942 103,285 75.2 1943 136,239 70.0 1944 105,968 67.4 1945 92,227 69.9 The children inspected by the dental surgeons are spread over all ages and are not confined, as are the medical inspection returns, to the four routine age groups. Dental conditions An improvement was noted, as a result of medical inspections, in the condition of the hair in each sex in each age group on the corresponding figures in the previous war years (except for two groups of boys in 1942), and also in every category compared with 1938, and these findings were borne out by the school nurses' inspections. The percentage reported by the latter as verminous was 6.06, compared with 6.39 in 1944. Skin diseases showed a slight increase compared with 1944, and the percentage (1.6) is still above that of 1938, which was 1.0 per cent. Cleanliness Two of the Borough Councils in west London continued to provide free shower baths for school children and 12,683 baths were thus given in 1945. One of the Council's school nurses attends these bathing centres and children found to be verminous are sent to be cleansed before they are allowed to use the baths. Bathing of schoolchildren Medical treatment The following table gives for 1945, 1944, 1943, 1942 and 1938 the numbers of "new" cases treated (a) at the treatment centres and hospitals 54 included in the Council's scheme; and (b) in the rheumatism (hospital) units:— (a) 1945 1944 1943 1942 1938 Dental 55,986 46,703 66,410 56,890 138,639 Vision (refraction and squint) 21,006 16,497 18,868 15,073 37,359 Minor ailments 83,947 63,790 82,142 59,167 128,819 Ringworm 88 51 39 10 103 Ear, nose and throat 1,332 689 601 261 12,726 "Special ear" defects 606 493 812 431 1,830 Rheumatism (supervisory centres) 907 845 921 733 1,885 Nutritional defects 526 451 584 464 641 164,398 129,519 170,377 133,029 322,002 (b) Rheumatism- Admitted to the Council's hospitals 335 418 555 358 2,026 Discharged 313 496 466 249 2,037 Speech defects At the end of the year, 9 centres were open with accommodation for 260 children for the treatment of stammering and other speech defects. The number of children who attended these centres at some time during the twelve months was 361, of whom 42 were discharged as cured or very much improved. 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 the pre-war arrangements for the treatment of such defects were re-introduced at Belgrave Hospital in 1940, the South-Eastern Hospital for Children in 1943, and the Princess Louise Hospital for Children in 1945. Of the 1,332 children treated at these hospitals during 1945, 914 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 had been referred to the Council's general hospitals and dealt with there and these facilities continue. No record is available of the number of school children so dealt with. Rheumatism The unit from Queen Mary's Hospital, Carshalton, was transferred (with 156 patients) to Yorkshire in July, 1944, owing to enemy attacks, and did not return to Carshalton until May, 1945, by which time the number of patients had decreased to 143. By the end of the year the number had risen to 181, and there was a waiting list. During the whole year, 335 children were admitted for treatment at the unit. There were also at the end of the year 21 rheumatism supervisory centres in operation which was the same number as in the early part of 1939. In the autumn of 1945 a trial was begun at certain of the supervisory centres of the method of preventing rheumatic recurrences by the administration during the winter months of small doses of sulphanilamide, and at the end of the year an investigation was begun at Carshalton, in conjunction with other hospitals of the Council, into blood concentration levels of vitamin A in rheumatic children. Personal hygiene There were 1,378,910 examinations in schools for personal hygiene by the school nursing staff. Of these, 83,605, or 6.06 per cent. showed verminous infestation. Every infestation, however slight, was counted. The percentage is less than that for 1944 (6.39) and compares with 7.3 per cent. in 1938. During the year, 46,863 (48,727 in 1944) children were dealt with at the children's bathing centres; of these, 15,349 (15,785 in 1944) were suffering from scabies or impetigo. The reduction in the incidence of scabies continued. This may be due to the operation of the Scabies Order, 1941. Under the provisions of the County of London (Scabies) Regulations, 1943, scabies was made a notifiable disease in London as from 1st August, 1943. During the year 14,753 cases (all ages) were notified to the borough medical officers of health, compared with 16,450 in 1944. 55 Lethane "384 special" is now commonly used for dealing with verminous heads, but towards the end of the year satisfactory results were obtained from the experimental use of a 2 per cent. D.D.T. emulsion. Benzyl-benzoate is still the main treatment agency for scabies. Cleansing agents Handicapped children In December, 1945, 53 special schools for handicapped children were functioning in London. Children numbering 2,277 were examined in London or in the reception areas as to their being in need of special education. Of this number, it was advised that 1,540 were in need of special educational treatment. The division between the various categories of handicap was as follows: blind, 7; partially sighted, 96; deaf, 54; partially deaf, 27; physically handicapped, 627; educationally subnormal, 698; epileptic, 31. In addition, a few children were found to be suffering from diabetes, 8 were considered to be maladjusted and 228 were provided with special training and treatment in respect of speech defects. Of the children attending and seen in special schools, excluding the special schools for delicate children, and the special parties for handicapped children, 87 were sufficiently improved to justify return to ordinary school instruction, and 83 children over 14 years of age were released as being no longer in need of special educational treatment. The number of London children accommodated in the Council's hospital schools at the end of December, 1945, was 1,096. Steps were taken during the year to renew provision in London of special education for delicate children. By December, 1945, there were eight special day schools for these children, with accommodation of 960 places, compared with fifteen schools and accommodation for 1,975 children in 1938. In addition, six residential special schools for delicate children needing a stay of about three months or more in seaside or country surroundings, were brought into commission, with a total accommodation of 474 places. Provision of meals The education officer has supplied the following information :— The numbers of children provided with school meals and milk in primary and secondary schools and junior technical institutes in London on a typical school day in June, 1945, were as follows:— Type of school No. in attendance on selected day Number who had dinner Number who had milk 1/3pint 2/3pint Free Paying Free Paying Free Paying Primary 173,008 3,734 57,000 981 29,260 5,359 87,811 Secondary 45,072 483 20,949 76 15,549 655 8,931 Junior technical schools 5,366 38 2,917 3 2,401 — 320 Total 223,446 4,255 80,866 1,060 47,210 6,014 97,062 85,121 151,346 In addition, 2,197 children attending day special schools and 246 in day continuation schools had school dinner, making a total of 87,564 pupils having school dinner on the selected day. Of these, only a few hundreds were supplied by independent canteens, the remainder being supplied by the Meals Services Department and the Rest Centre Service. The percentages of the number of children in attendance who had school meals and milk were:— Meals Milk Primary 31.52 71.33 Secondary 47.55 55.93 56 No separate figures of comparison can be made with the return previously prepared (February, 1945) as the return for June for secondary schools included the former elementary schools recognised, in pursuance of the Education Act, 1944, as secondary schools from 1st April, 1945. The percentage of the total number of children in both primary and secondary schools who received dinners in June was 37.66, compared with 35.19 in February, 1945. Similar figures for a typical day in October, 1945, were:— Type of school No. in attendance on selected day Number who had dinner Number who had milk 1/3pint 2/3pint Free Payinq Free Paying Free Paying Primary 182,319 4,497 65,156 443 24,687 6,903 102,796 Secondary 67,647 1,633 35,907 751 24,508 1,456 11,360 Totals 249,966 6,130 101,063 1,194 49,195 8,359 114,156 107,193 172,904 In addition, 2,800 children attending day special schools and 193 in day continuation schools had school dinner, making a total of 110,186 pupils having school dinner on the selected day. The percentages of the number of children having milk and meals to the total number of children in attendance were as follows, the comparable figures in June, 1945, being given in brackets:— Meals Milk Primary 38.2 (31.52) 73.9 (71.33) Secondary 55.5 (47.55) 56.3 (55.93) It will be seen from the figures that in both the primary and secondary schools there was a slight increase in both the percentage of children having milk, and in children taking their mid-day meal at school, resulting in some cases in kitchens and staff being strained beyond their capacity. Infectious diseases in schools As in the previous war-time years, the figures available on the incidence of infectious diseases during 1945 were 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 in the arrangements for carrying out in schools and centres immunisation against diphtheria, was continued. In 20 boroughs, the Council's school medical staff carried out the immunisation while in eight boroughs this work was done in the schools by the medical staff of the Borough Councils. In 1945 the number of children who received the full course from the Council's medical staff was 3,298, bringing up to 68,497 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. A survey by the school nurses in June, 1944, showed that about 68 per cent. of the children on the rolls of the elementary schools had been immunised. Every effort was made during the year under review to maintain and if possible to improve upon this figure. 57 Heavy work continued to be 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. During the year there was a marked increase in the number of cases of scalp ringworm. Throughout the war years the incidence of this disease in London had been small, but extensive outbreaks were reported from other parts of the country. With the cessation of hostilities the return of children from all over the country almost certainly resulted in the marked increase in the number of cases in London. Treatment by X-ray continued to be the method of choice; and, in addition to the arrangements made with certain voluntary hospitals, facilities were provided by the Council for out-patients at Hammersmith Hospital and for in-patients at Goldie Leigh Hospital. Ringworm Child guidance Reference was made in the report for 1943 to the decision of the Education Committee that, in order to ensure that "problem" children should at the earliest moment be given appropriate help, a conference of officers should be established as an experiment for one year in each of the nine educational divisions. The conferences began in June, 1944, and, except for disturbance by the flying bomb attack, have continued uninterruptedly since. They have been of particular assistance in the difficult task of ascertaining whether children are handicapped by reason of maladjustment—one of the new categories of handicapped children for whom special educational treatment has to be provided under the Education Act, 1944. All recommendations by these case conferences for child guidance treatment receive the formal concurrence of the school medical officer before the child is officially referred to a child guidance clinic. For each child so referred to voluntary child guidance clinics, a payment is made to the clinic at the rate of 15s. for the first visit, and 5s. for each subsequent visit. During 1945, the Council accepted financial liability on this basis for 452 children. At the end of the year there were arrangements for treatment at eight voluntary child guidance clinics, and in addition children were referred to the children's department of the Council's Maudsley Hospital. Teaching of mothercraft in schools It has been the practice, for many years, for instruction in mothercraft to be given in the Council's schools as part of the course in domestic science, stress being particularly laid upon the care of the toddler rather than the young baby. During the latter part of 1944, following discussion with the Education Officer's department, it was decided to give more specific instruction to older girls in the care and routine of the babe. A comprehensive syllabus was drawn up, talks were arranged ranging from the objects of mothercraft through the routine care and feeding of, to the physical and mental development of, the child, with a final talk on the social services available for the mother and child. The course comprised twelve lectures, each of about 40 minutes, with added time for practical demonstration and discussion. The lecturers were school nursing sisters with special experience. Courses were given in five secondary (former central) schools and were an unqualified success. By the middle of 1945 the arrangements were in operation at ten schools, and it is proposed to extend these courses to more schools when additional suitably qualified nursing staff become available. Nursery schools and classes, war-time nurseries, flay corners and play centres Before the war there were five nursery schools maintained by the Council and eighteen voluntary nursery schools in London which were aided by the Council. These schools closed on the outbreak of hostilities and the children were evacuated. Under the Education Act, 1944, the Council, as local education authority, is required to provide suitable accommodation for children from two to five years of age, although 58 attendance at school under five years of age is not compulsory. Accommodation for these children can be provided either in nursery schools or in nursery classes. During the war, four of the Council's nursery schools were used by certain Metropolitan Borough Councils as war-time day nurseries. By December, 1945, one of the Council's nursery schools had re-opened, and also one of the former 18 voluntary nursery schools in London. The number of children in London under five years of age increased rapidly during the year, and with a view to discharging the Council's duties under the Education Act, 1944, a survey was made of each school where more than 30 children under five years of age were in attendance, in order to provide more nursery classes. By the end of the year, 20 such classes had been provisionally approved. All the children attending nursery schools are provided with three meals daily (two light meals in the case of nursery classes), and in addition with mid-morning milk, cod-liver oil and orange juice. Each child is seen every three months by the school doctor, and a school nursing sister visits each school or class daily. War-time nursery classes and play centres were provided primarily for children whose mothers were at work. At the end of 1945, there were 16 war-time nursery classes, and one play corner providing for an average attendance of 460 children. All the children were supplied on the premises with mid-morning milk, cod-liver oil, orange juice, and dinners, and also in some cases with breakfast and tea. All facilities for medical inspection and treatment, cleansing and infectious disease control were provided on the fines usual in the Council's school health service. There were also at the end of the year, 107 evening play centres attended each evening by some 14,500 school children. Tea was provided at 74 of these centres and in addition 5 play centres open before morning school, provided breakfasts for 45 children a day. Statistics 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 1945:— Lunacy and Mental Treatment Acts Uncertified senile patients M.D. Acts Total Certified Voluntary Temporary Lunacy Acts Sections 24 &25 Patients at 1st Jan., 1945 17,544 1,452 11 2,874 1,087 7,404 30,372 Admissions in 1945— 419 4,897 Direct 1,622 1,135 29 59 519 Indirect 1,043 57 — 14 — Exits in 1945— Discharged recovered 586 365 3 — — 264 3,614 Discharged otherwise 1,443 754 22 106 71 Deaths 907 83 7 243 408 154 1,802 Total patients 31st Dec., 1945 17,273 1,442 8 2,598 1,127 7,405 29,853 In addition there were 3,770 mental defectives under statutory supervision in their own homes and 343 under statutory guardianship. The decline in the number of mental patients requiring institutional treatment, which persisted throughout the war, has continued during 1945, and at the end of the year there were nearly 4,500 fewer patients in London County mental hospitals and institutions for the mentally defective than at the outbreak of war. At the end of 1945, there were 446 patients on licence from the Council's certified 59 institutions for the mentally defective in outside paid employment found for them by the institutions and, in addition, there were 53 patients on licence in employment found by the women inspectors on the central staff. The number of patients under treatment in the Emergency Medical Services hospitals attached to the Mental Health Services during 1945 on the undermentioned dates were:— 1st January 2,336 1st April 2,473 1st July 2,259 1st September 1,953 31st December 1,227 In all, 21,343 patients passed through these E.M.S. hospitals during 1945. During the year, Friern and Mill Hill Hospitals were withdrawn from the Emergency Medical Services scheme, leaving only Claybury, Horton and Sutton Hospitals still in the scheme at the end of the year. A part of Banstead Hospital continues to function as a military hospital. In January, 1945, the state of the war was such that the Ministry of Health, Emergency Medical Service, was forced to consider three interrelated problems, intimately concerned with the psychiatric services provided on the Ministry's behalf by the Council at Mill Hill Emergency Hospital. The three problems were:— Mill Hill emergency hospital (1) The provision of in-patient treatment for repatriated prisoners of war suffering from neurotic illness; (2) The closure of the Mill Hill Emergency Hospital to allow the return of Mill Hill School to its premises; (3) The re-opening of the Maudsley Hospital, particularly to reinstate the post-graduate medical school there for the training of demobilised doctors in the psychiatric specialty. (1) The work at Mill Hill continued in full function until May, 1945. From that date medical, nursing and ancillary staff were transferred to the Southern Hospital, Dartford, to build up a neurosis centre for repatriated prisoners of war. By July, 1945, the centre was fully staffed for 350 beds, and in full function. The work of the centre is dealt with more fully later in this report. (2) From May, 1945, in inverse relationship to the building up of Dartford the work at Mill Hill decreased. No further admissions were accepted after the end of July; the final disposal of all cases had been made by the end of August and the hospital was closed on 3rd September, 1945, six years after its opening. The Governors and Head Master of Mill Hill School were, throughout the occupation of the school, most generous in their co-operation and warm thanks are due to them. (3) Transfer of medical, nursing and ancillary staff to the Maudsley hospital was effected on 3rd September. Beds were opened in October, and the training scheme for demobilised doctors started in December. At Mill Hill, in 1945, the total numbers of patients treated were:— In-Patients Male Female Children Total Neurosis Forces cases 947 708 - 1,655 Civilian cases 184 188 55 427 Surgical cases 53 78 105 236 Total 1,184 974 160 2,318 Comparable figures in other years were:— 1940 2,132 380 66 2,578 1941 2,231 209 25 2,465* 1942 2,841 516 290 3,647 1943 2,516 1,203 413 4,132 1944 2,322 1,310 199 3,831 Totals for 6 years, including surgical cases 13,226 4,592 1,153 18,971 Total neurosis cases for 6 years 12,432 3,982 259 16,673 * Period of bomb damage. 60 Out-Patients Work was carried on up to the closure both at Mill Hill and at the associated northern clinics. Attendances in 1945 (half-year) were:— New patients Attendances 460 1,555 Comparable figures for the other war years were:— 1940 1,252 4,381 1941 955 2,522 1942 1,149 4,182 1943 979 3,268 1944 918 3,148 Total of war time out-patient work 5,713 19,056 Apart from treatment, teaching and research were carried on up to the closure. Teaching included post-graduate and under-graduate medical courses, the training of psychiatric social workers, training of nurses, sick berth attendants, physical training instructors and other ancillaries. Research was mainly in the psychological and social fields: the work done has been taken up widely in its practical implications. Neurosis Centre, Southern hospital, Dartford In May, 1945, medical, nursing and ancillary staff were sent from Mill Hill Emergency hospital to the Southern hospital, Dartford, to prepare for the admission of neurotic prisoners of war requiring hospital treatment. Seven separate blocks, each containing fifty beds, were used for the purpose. Treatment measures developed at Mill Hill during the five years of war were continued, and several trends of treatment were developed further. Most of the men received at the Centre had been segregated in prison camps for up to five years and lacked confidence in their ability to mix socially and to succeed in some job in civilian life. To help counter this it was decided to try to enlist the help of the industrial concerns in Dartford. The response was remarkable, and eventually over fifty employers were actively helping. Three buses conveyed the men to work morning and afternoon for two-hour periods. The men were not paid and were employed on skilled work only if they were tradesmen; generally they helped in an unskilled capacity. They did, however, get some experience of the nature and conditions of work in a particular trade and were in contact with healthy workmen, who welcomed them and made them feel that they "belonged." The occupations ranged from big engineering firms to small shops, and were a good crosssection of the employments in a small industrial town. Change of occupation, if desired, was allowed once a week, and the patients were visited at work frequently by both the vocational psychologist and a nurse, who was employed full-time as a liaison between psychiatrist and employer. It was of enormous importance to ensure that the patients on return to civil life should have suitable work available for them and to avoid as far as possible any danger of failure, which in these cases might have led to a chronic neurosis. If the patient had a trade or occupation to which he intended to return after release from the Army, he was placed, so far as this was possible, in a similar occupation. If he did not wish to continue his pre-war occupation, or had no definite trade or occupation to return to, he was referred to the vocational psychologist, who applied appropriate tests and recommended work-therapy on the basis of the man's own preference, aptitude and intelligence. The psychologist took a close interest in the various employments available to the patients, and the limited use of vocational tests was greatly enhanced by his frequent visits to the men while they were actually at work ; frequent change of employment was recommended if this seemed to be indicated. The Centre was very fortunate in having the full-time services of a disablement rehabilitation officer of the Ministry of Labour. Patients who were likely to be 61 recommended for discharge from the Army saw him during their first two weeks in hospital. At this "assessment interview," the disablement rehabilitation officer investigated fully the man's past work record and discussed his future plans; if necessary he would write to the local office of the Ministry of Labour in the man's home town for information regarding local conditions, etc., e.g., if the man's pre-war place of employment had been bombed, it was important to know what were the prospects for the firm's old employees. There was a second interview (" placement interview") during the patient's last week in hospital; on this occasion all relevant information was made available for the disablement rehabilitation officer. He had replies to his own enquiries from local offices of the Ministry of Labour, and might have obtained aid from other Ministry of Labour sources by using the Resettlement Advice Service (the local resettlement advisory officer helped in many ways on general questions outside the scope of the disablement rehabilitation officer's work), or by referring patients to the Advisory Careers Section of Appointments Offices, where higher education or training was sought. At the " placement interview " the disablement rehabilitation officer also had available the psychiatrist's opinion of the man's value in the open labour market expressed in non-medical terms, information obtained by the vocational psychologist, and the report on the patient's progress at his occupation. So far as was possible, the patient's future occupation was made secure before he left the hospital. Routine treatment for neuroses was carried on as at any neurosis centre. Group treatment, psychodrama, discussions and educational films were used freely. A highly successful newspaper appeared weekly from the third week of the Centre's inception. Variety shows and one-act plays were produced by patients and nurses for the whole hospital on an average of one every three weeks. The nurses continued their remarkably fine work which had started at Mill Hill and showed how much they could contribute to treatment in psychiatry. The Centre was in existence for eleven months, during which time 1,202 patients were treated. Practically all patients were discharged from the Army at the end of their stay in hospital. The men as a whole were excellent material with good previous personalities exposed to excessive war stress. The results of treatment were probably better than seen elsewhere, partly because the material was better than that reaching other neurosis centres, and partly because all treatment facilities were readily available —a selected and enthusiastic group of doctors and nurses, a sympathetic and actively helpful public and local employers, a full-time disablement rehabilitation officer from the Ministry of Labour, adequate psychiatric social work, a vocational psychologist, transport, pleasant environment, etc. The Ministry of Labour did a follow-up through their employment exchanges. In May, 1946, they reported that, out of 711 discharged more than 3 months before, 623 were at work or in training, 9 were unfit, 35 were not yet at work, 18 had not replied to labour office enquiries, 26 replies were still outstanding from local employment exchanges. In brief, of those ex-patients who had been back in civil life for three months or more, and about whom information had been received, only about 7 per cent, were definitely not working, and the others had started work although no information was available regarding their adjustment, time off work, etc. A much more detailed study was made by the psychiatric social worker at the Centre on 100 ex-patients resident in London three months after discharge from hospital. Of these, 46 had had no time off work, 34 had had less than fourteen days off work, 12 more than fourteen days off work and 8 had not yet started work. Compared with their pre-army work status, 64 showed no change, 20 had improved their status, 12 had deteriorated and 4 were not in the labour market pre-war. Enquiry into their pre-enlistment work records showed that 80 were satisfactory, 16 unsatisfactory, and 4 had never been in the labour market. In conclusion, it is felt that increasing difficulties in finding employment, as the labour market becomes more stable, will lead to an increasing number of persons with 62 neurotic problems requiring not only psychiatric treatment but also vocational assessment and placement. There would appear to be a real need for a neurosis centre working in close collaboration with the Ministry of Labour where these casescan be studied. Such a centre could separate out-patients fit only for sheltered employment from those who might be capable of rehabilitation. The exact organisation of such a centre could best be decided when the nature of the case material referred was known, and the extent of the problem became clear. Maudsley hospital re-opening The Maudsley hospital, closed at the outbreak of the war, was re-opened for the reception of in-patients on 8th October, 1945. The pre-war arrangements whereby the bulk of the accommodation was reserved for Londoners and admission was restricted to voluntary patients under the Mental Treatment Act, 1930, were continued, but the definition of a London patient was widened to include not only persons " settled " in or " irremovable " from London under the rules relating to settlement and chargeability, but also bona-fide residents in the County of London who have not acquired a status of irremovability by twelve months' continuous residence in the county, thus bringing the conditions governing admission into line with those operating in respect of the admission of voluntary patients to the other London County mental hospitals. In view of the special nature of the hospital and the desirability of drawing upon as wide a field as possible for patients, a discretionary power was given to enable not more than 10 per cent, of the total available beds to be used for outcounty patients. This discretion was not limited, as before the war, to those outcounty patients who could pay the full cost of maintenance, but was based on the needs of the patient, irrespective of means, and the interests of the hospital as a centre for teaching and research. A change was also made in the method of assessment and collection of contributions from rate-aided patients. Instead of being done within the Mental Health Services, this work was transferred to the Social Welfare department, and dealt with in the same way as other cases in the hospitals service. Recovery of the full cost of maintenance of out-county cases is made under No. 17 of the Mental Treatment Rules from the appropriate out-county authority, and that authority makes its own arrangements for re-imbursement from the patient or liable relatives. The cost of maintenance was fixed at £6 13s. a head a week for London cases, and £7 a head a week for out-county cases. The administrative arrangements referred to above were designed to facilitate the execution by the hospital of its special functions. As a psychiatric teaching centre the Maudsley hospital attracts an exceptional range of clinical cases from many sources for investigation and treatment. A reorganisation of the medical staffing has been carried out and the appointment of physicians, senior physicians in psychotherapy, pediatric physicians supported by assistant physicians, senior and junior registrars and house physicians, makes up a competent staff for teaching, research and treatment purposes. Direction of this work is by the professor of psychiatry in the University of London; the medical superintendent is responsible for the general administration of the hospital. A similar reorganisation of the Central Pathological Laboratory has taken place under the direction of the professor in mental pathology. Appointments are being made to senior posts in the departments of neuropathology, biochemistry and neurophysiology. Together the hospital and laboratory form the Maudsley Postgraduate Medical School. The reconstitution of the School on a peacetime basis anticipates an effective role in post-graduate medical education along the fines of the Goodenough report. Pre-frontal leucotomy During the year, a review was made of the patients in the Council s mental hospitals on whom the operation known as pre-frontal leucotomy had been performed. The first leucotomy in the Council's mental health services was performed at Bexley hospital on 13th December, 1941. This method of treatment was extended to other hospitals, and up to 20th July, 1945, 102 patients had been dealt with in this way. 63 Of these, 15 benefited to the extent of being discharged recovered, while the mental condition of 50 others was considered to have improved subsequent to the operation. Having regard to the fact that other forms of treatment had failed to bring any relief of symptoms, and that consequently the prognosis before operation was uniformly bad, if not entirely hopeless, the results achieved by leucotomy in the Council's mental hospitals must be considered distinctly encouraging. Without a careful and systematic follow-up over a long period, it is impossible to say whether the recoveries will be permanent; but, even if there were no discharges, it is obvious that pre-frontal leucotomy has something to offer. The change from noisy, violent and destructive behaviour to that of orderly habits and of cheerful compliance with hospital routine is an indication of a peace of mind that brings relief not only to the patients themselves, but also to their friends and to the nurses who have to minister to these distressing manifestations of mental disorder. A further inquiry will be made as to the progress of the patients treated in this way. The experimental scheme authorised at the end of 1943 whereby, subject to necessary safeguards, patients at St. Bernards' and St. Ebba's hospitals were allowed, as preparation for discharge to take local paid employment on a daily basis, returning each night to the hospital, was commenced in the spring of 1944, but in June, 1944, the former hospital was heavily damaged by enemy action, with the result that it was necessary to evacuate about 1,900 patients to other hospitals, of whom some 200 patients were sent to St. Ebba's, and the consequent disorganisation made it impossible to develop the scheme at either hospital to the extent anticipated. Nevertheless, by the end of April, 1945,12 patients at St. Bernard's hospital and 14 patients at St. Ebba's hospital had been dealt with under the scheme with such success that the scheme was continued as a permanent arrangement at those hospitals, and authority was given for the scheme to be operated on the same conditions at any other London County mental hospital where the medical superintendent considered it would be in the interests of the patients for it to be introduced. Rehabilitation of patients Owing to the increased cost of living, the maximum maintenance allowances which may normally be granted by hospital sub-committees at their discretion were increased from 15s. to 20s. a week (a) for limited or prolonged periods to patients who are permitted to be absent on trial in the care of relatives or friends from London County mental hospitals, and (b) during a period of convalescence not normally longer than four weeks, to patients who are discharged from Tooting Bee Hospital to the care of relatives or friends, or who have undergone voluntary or temporary treatment in a London County mental hospital and are returning to their normal environment. After-care allowances The purpose of these allowances is to provide patients with the means to secure necessary comforts during convalescence, and to relieve them of financial worry during their trial period. The amount payable in individual cases is authorised by the hospital sub-committee after considering a report on the patient's financial circumstances, and in special cases the amount of the allowance may be increased up to the current cost of maintenance of patients in the hospital, with the proviso that every instance in which more than £1 a week is allowed is reported to the Mental Hospitals Committee. The maximum allowance for the maintenance of mental defectives placed under the statutory guardianship of relatives was also increased from 17s. 6d. to £1 a week. During the year 1945, the area of land farmed by the Mental Health Services decreased by 16 acres, the total acreage on 30th September, 1945, being 6,543 acres Farming operations (3,777 arable and 2,766 grass). Figures for previous years were:— 30th September, 1944—6,559 acres (3,793 arable and 2,766 grass) 1943—6,324 „ (3,574 „ 2,750 „ ) 1942—5,983 „ (3,169 „ 2,814 „ ) 1941—5,144 „ (2,239 „ 2,905 „ ) At outbreak of war—2,789 „ (1,041 „ 1,748 „ ) 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. Index PAGE Admissions to hospitals 36 After-care of mental patients. 63 Anthrax 8 Artificial limbs 39 Births 3 Blind persons 24 British Standards Institution 24 Bronchitis 6 Cancer 6 Chemical branch 31 Child guidance 57 Children's hospitals 35 Chronic sick hospitals 35 Civil Defence personnel 30, 37 Cleanliness of school children 53, 54 Clinical Research Committee 41 Clinical rounds 41 Convalescence 36 Deaths 3 Demobilised doctors 44, 59 Dental condition of school children ... 53 Diabetes 6 Diarrhoea 9 Diphtheria 56 District medical service 39 District nursing service 39 Domiciliary midwifery service 29 Dysentery 9 Ear, nose and throat treatment of school children 54 Education Act, 1944 50 Enteric fevers 9 Enteritis 9 Epileptics, Hospitals for 36 Evacuation 33, 51 Farming 63 General hospitals 34,35 Handicapped children 55 Heart disease 6, 53 Hospital organisation 45 Hospitals and ancillary services 33 Housing 20 Illegitimacy 4 Immunisation against diphtheria 56 Infant mortality 6 Infectious diseases-8, 56 Infectious hospitals 35 Influenza 9 Insulin 39 Legacies to hospitals 40 London Ambulance Service 47 Londoners' Meals Service 24 Marriages 3 Maternal mortality 8 Maternity and child welfare 30 Maternity patients 34 PAGE Maudsley Hospital 62 Meals at hospitals 41 Meals for school children 55 Measles 10, 46 Medical education 41, 62 Medical examination of staff 30 Medical inspection of school children 51 Medical Society of the L.C.C. Service 43 Medical treatment of school children 53 Mental Health Services 58 Midwives Acts 28 Mill Hill Emergency Hospital 59 Miniature mass radiography 27 Mortality 4, 6, 8 Mothercraft in schools 57 Neonatal mortality 8 Neurosis centre 60 Nursery schools and nurseries 37, 57 Nursing homes 30 Nutrition of school children 53 Open-air schools 26 Out-patients 38, 60 Pathological Laboratory Service 45 Penicillin 22, 46 Pharmaceutical supplies 39 Play corners and play centres 57 Pneumonia 6 Population 3 Pre-frontal leucotomy 62 Puerperal fever and pyrexia 8 Rehabilitation 26, 38, 45, 60, 63 Residential accommodation for young children 37, 51 Respiratory diseases 6 Rheumatic fever 10 Rheumatism 54 Ringworm 57 Road accidents 6 Scabies 10 Scarlet fever 10 School Health Service 50 Sewage disposal 32 Smallpox 10, 35 Speech defects in school children 54 Staff 30, 44 Still births 4 Tuberculosis 6, 11, 25, 35 Tuberculous milk 20 Typhus 11, 35 Venereal diseases 21, 36 Vermin infestation 24 Visits to hospitals 40 Vital statistics 3 Voluntary hospitals 38 War work by patients 40 Whooping-cough 11 Works at hospitals 40