690

,order of tnagnitude of the problems studied as theyobtain today in the mass of industrialised communitiesin England. -

"

Throughout the war of 1939-45 Luton’s birth-rate-e.g., total live births related to total resident populationof all ages-was higher than that in the country as awhole. Yet in 1945, when Luton’s rate stood at 18-9

per 1000 population (as compared with 16-1 for Englandand Wales), the number of live births to 1000 marriedwomen aged 15-49 was only 88 in contrast to a figureof 92 for England and Wales in 1938. On the other handthe net reproduction-rate in Luton was above unity-namely, 1-03 for 1944-45-while this index stood at0.95 for England and Wales. As Luton’8 birth-rate in1938 was higher than the national rate in the same year,it seems, from a comparison with the figures for 1944-45,that the relatively large number of births in the townduring the war years has not meant any increase in

fertility within marriage. There were many more

marriages, especially youthful ones, and a rise in theproportion of first-born children. It is highly probablethat a corresponding development took place in the restof the country, but until comprehensive national datahave been published we cannot be sure.The more notable biological facts reported in this

paper may be summarised as follows :

(1) There is no evidence of any increase in the proportionof childless marriages over three generations, and(given the same age at marriage) no marked socialclass differences.

(2) The degree of control over childbearing withinmarriage, hitherto exercised by women marrying inthe late twenties and early thirties, is now in processof being adopted by those marrying at earlier ages.

(3) For many wives there is now a long interval of time" between marriage and the first pregnancy, and

between first and subsequent pregnancies.(4) Only a small proportion-less than 2 %-of all wives

can now be described as continuously childbearing.5) A large increase has been noted in the proportion

of one-child and two-child families in recent years,and a dramatic fall in the proportion of familiescontaining five or more children.

{6) The trend towards a smaller family size continuedduring the war-despite a rise in - the birth- andreproduction-rates.

"

OUR MENTAL HOSPITALS

REPORT OF THE BOARD OF CONTROL FOR 1945

DURING the war the Board of Control ceased to

publish their annual reports ; so the report for theyear 1945, the first to appear since 1939, has muchto tell-and, surprisingly, much that is cheering.Mental hospitals and mental-deficiency institutions

evacuated 25,000 beds at the outbreak of war, thus

putting space for some 42,000 beds at the disposal of theForces and the Emergency Medical Service. In the

hospitals to which the displaced mental patients wereremoved this meant overcrowding amounting at one timeto 16% ; and those who were then working in mentalhospitals well remember the gloomy prognoses the

sight of the close-packed beds invited. Yet few of thefears were fulfilled : certainly the death-rate increasedduring the early years, reaching in 1941 a point 33%higher than the pre-war average ; but thereafter it

slowly.fell, until in 1945 it was just below the rate for1935-39-68.4 per 1000 patients compared with 68-5.The death-rate for women in 1943 was 64 per 1000,among the lowest ever recorded ; and it is curious tonote that this happened when the shortage of nurses wasgreater than at any time during the century. Thisrecord may be compared with that of the previous war,when by 1918 the death-rate had risen to a maximumof 203 per 1000, or 111% over the pre-war quinquennialrate. -

Nor was the increase of tuberculosis as devastatingas had been expected. The incidence of fresh cases

rose from 5-6 per 1000 in 1939 to 11-3 in 1941, but thenbega,n to fall, reaching 7-2 in 1945. The death-rate fromtuberculosis, which was 3-8 in 1938 and 4-1 in 1939, roseto 9 per 1000 in 1942, but had fallen to 5 in 1945.

Similarly the death-rate from dysentery showed a

temporary rise, reaching a peak in 1941, then quicklyreturning to the 1938 level; by 1945 it was only 0.2per 1000 patients.

THE RULING FACTOR

What was the cause of this gradual change for thebetter, starting in mid-war ? Evidently it cannot be putdown to any improvement in living conditions, for thesewere throughout worse than in the 1914-18 war, whenthe death-rate -in mental hospitals steadily rose. Over-

crowding was greater in the recent war, blackout morestrict, ventilation poorer, staff shortage more acute,enemy action more violent. Certainly the diagnosis oftuberculosis was made earlier, thanks to. the intensive

’

use of X rays ; and the treatment of dysentery is nowa.days more successful; but these measures alone couldnot have changed a main trend.

After the 1914-18 war the board concluded thatreduction in quantity and deterioration in quality offood supplied to the patients was the chief factor inducingthe increased sickness- and death-rates in mental hos-

pitals. This time the board were on their guard. Mentalpatients customarily lose weight in the first two yearsof their illness, but in 1941 the board initiated studiesto decide whether the losses were greater than in the pre-war years, and also whether overcrowding was havingan effect on weight-loss. The degree of overcrowdingexisting at that time was found to make no differenceto the proportion of patients losing weight ; and from1941 onwards the situation righted itself, weight-lossesreverting to the pre-war range.

" The recovery was due, we believe," the board write," to the changes induced in the latter half of 1941 as a resultof which the food situation improved, and also becausewe became food-conscious and much was done to improvethe quantity and balance of the diet."

Dietaries were investigated not in the rosy light ofthe official diet sheet but by studies of the bulk issuesof food over a period of four weeks. The mean valuewas found to be 2360 calories daily, ranging from 1951to 2731, whereas, since 1941, the level in the generalpopulation has been 2800 calories. In about half the

hospitals the amounts of vitamins included in the foodwas below the League of Nations level. The analysisenabled a large number of hospitals to change theirdiets and particularly to improve the supply of vitaminsC and A ; on the whole the board feel that from 1942onwards the diet was satisfactory, and they attribute thebetter health and welfare of the patients largely to thischange.

In the early days, however, nobody could foresee thiscomparatively happy outcome, and many mental-hos-pital doctors and nurses felt indignant at what seemeda cynical disregard of their patients’ welfare. It is worthnoting in passing that their discontent could have beenchanged to willing support if a member of the board, ora Government official, however minor, had visited thehospitals and explained to the assembled staff in tenminutes what the relinquished space meant to the nationat large. It is imaginative dealing with the peopleon -the spot which makes the difference between a happyand a disgruntled service-a point worth bearing in mindwhen the National Health Service is established.

WAR AND MENTAL HEALTH

The effect of the war on the mental health of the

community has been impossible to estimate. The

691

strain imposed by air attacks and family anxieties waspartly offset by opportunities for full employment, abetter standard of living, and the stimulus to the spiritof team-work in an important cause. Admissions tomental hospitals in 1940, 1941, and 1942 were lower,the board report, than the average for the five yearsbefore the war. By 1943 they had exceeded this aver-age, and continued to rise in the next two years, reaching33,961 in 1945, the highest number on record. But nofewer than 50-7% of these admissions were voluntary,and the patients discharged that year amounted to

71’7% of the direct admissions-also the highest figureon record. The percentage of patients, calculated ondirect admissions during the year, who left mental

hospitals recovered or relieved was 63 ; and forrecoveries alone the figure was 33-2. The percentageof absolute discharges (including those who were notimproved and 150 who absconded) was 71-7, comparedwith 66’8 for the preceding five years. The averageannual percentage for the five years before the opera-tion of the Mental Treatment Act, 1930, was 48-3.

DEMAND AND SUPPLY

The hospitals, in fact, are being used earlier and will-ingly by people with incipient mental illness, and acontinued rise in admissions is therefore possible. Tomeet it we have old buildings, too few beds, and a staffshortage. At the end of 1945, bed-space for 17,020mental patients still remained in the hands of the Servicesand the EJBLS., and a further 847 beds were not in usebecause they could not be staffed. For mental defectives,especially, it is often difficult to find institutionalvacancies even when their need is urgent. The boarddraw fresh attention to the report of the Athlone Com-mittee’s subcommittee on the mental-nursing service,in which better conditions of service for the mentalnurses were advocated.

SERVICES AFTERCARE SCHEME

In 1943, at the request of the War Office, the boardfounded a scheme for aftercare of ex-Service patientsdischarged from hospitals and E.M.S. centres on accountof psychiatric disability, and in 1944 merchant seamenwere included. The Ministries of Pensions, Labour,and Health, the Provisional National Council for MentalHealth, and the Mental After Care Association all gavetheir help in this specialised form of reablement, andup to September, 1945, some 7800 patients had beenreferred to the board for help. The Provisional NationalCouncil arranged for patients to be visited in hospitalby a trained social worker ; and regional aftercareofficers look after them in the areas to which they aredischarged. No patient is referred unless in the opinionof the commanding officer he or she needs aftercare andhas expressed willingness to receive it. As new casesare referred those whose needs have been met are closeddown, but in 1945 new cases were still outrunning thenumbers requiring no further help. The board notethat the scheme could be extended and help given toother members of the Forces were it not for the shortageof trained psychiatric social workers.They have been closely concerned with plans for

integrating the mental-health service with the NationalHealth Service. One aspect of this calls for the rewrit-ing of the Lunacy Code, a task which would already havebeen undertaken but for the war. In 1926 the RoyalCommission advised that the code should be recast andsimplified, and the need is now urgent since the NationalHealth Service Act will modify the Mental Treatment andMental Deficiency Acts.The report as a whole gives a picture of a promising

and improving service badly hampered by lack of nursingstan and proper buildings. The staffing of mental

hospitals is a part of the whole nursing problem, whichis still not being faced realistically.

In England NowA Running Commentary by Peripatetic CorrespondentsI THOUGHT that I had attained to that sublime pose

for which the tag of Horace serves as slogan-niladmirari-but my self-esteem has received a rude shock,for I am full of wonder. I have just returned from abrief visit to our hospitals in the Middle East, whereI found the hygienic conditions contrasted so favourablywith those of the last war that it seemed as if a miraclehad been performed.

Thirty years ago I landed with a large medical unitat Basra, and within a fortnight half the officers weresick and in hospital. At that time flies and mosquitoesswarmed round the camps, dysentery was rife andmalaria dangerously common, while the river steamerswere crowded with sick on their way to India. Heavychlorination gave the drinking-water a strong anti-septic flavour. For more than two years my daily rationfor a bath was a petrol tin filled with water, which wascarefully poured into the shallow canvas bath whicheach officer carried in his kit. The thought of animmersion-bath was a dream of Paradise. Latrines were-primitive and the incinerator a prominent feature of the-landscape. A commission which was sent out fromEngland to inquire into hygienic conditions soon

demonstrated the need for improvement since three outof the four members soon fell sick and it fell to my lotto treat them.But their work and that of their successors has borne

fruit. Today, hygienic conditions are immeasurably-better. Malaria control has worked wonders. Duringa three weeks’ visit I saw fewer mosquitoes than I doin a London garden in one day. The regular use ofD.D.T. has almost banished flies; the water is pure andtasteless. The sickness-rate among the troops is but aquarter that of the last war. In the various hospitalcamps one can always have the luxury of a cold shower-bath, and sometimes even hot water is laid on. It only-added to the interest to find that in one camp a toadappreciated the same amenities as the members of themess. We thought the acme of luxury was the flushing-water-closet far away in the desert.The only sad and deeply felt regret came when one

saw the huge cemeteries filled with those who wouldalmost certainly have been saved if similar conditionsand precautions had existed thirty years ago.

* * *

My wife says it’s her turn,. so over to her.At 3.45 A.M. the phone rings. " Poor old boy, you’ll

have to get up," I mutter thickly into the darkness.An awful blast of cold air and even colder invectivemakes me curl up and pull my nightdress around mytoes. He gets up, his super renal whatnots working athigh pressure. From a long distance I hear that there-has been an accident, so I roll over to keep his side of thebed warm.How I envy those efficient wives who, when their

husbands are called out, turn over and go to sleep in aninstant! My imagination is too much for me (I oftenwish he would share some of it with me, but he is usuallytoo busy), or perhaps my renals are super super ones ;anyway, I call out fit to wake the children, " Don’tforget you took the bag out of the car, darling." He-hisses back in the manner of Gielgud, " Sweetheart,I have remembered." Why do they get so angry with us,as we try to help ? Poor chap, it’s not my fault youget called out. It’s something to do with his glands thathe gets bet up. He says he’s a Kretchmer’s picnic...the real trouble is that they all like to appear so efficientany suggestion, any hint from us....The bed is warm now ; how nasty to be lying on a

roadside cut by glass ... cold ... shivering... surgicalshock supervened.... " At the inquest Dr. Prem saidthat death was due to shock consequent upon theinjuries." How nice he looks in his dark suit; the Coronersmiles faintly,

" Thank you, doctor." Dr. Prem left thewitness stand, his monumental calm, the air of faintresignation ... so certain ... so impregnable. I roll overin bed. " Phooey " I say aloud into the darkness.

I hear a train come into the station and the sound ofboxes being dumped on the platform. Fish. I must