- Email: [email protected]
Public health problems in the A.T.S.
232
PUBLIC HEALTH, September, 1947
P U B L I C H E A L T H P R O B L E M S IN T H E A.T.S. * By ALBERTINE I., WI1WNER, O.B.E., M.D., M.R.C.P.,
Late Lieut.-Colonel, R.A.M.C., Honorary Medical Consultant for Women's Services in the Army I must confess that w h e n your G r o u p first invited me to address you, I feared that m y war-time work had lain so far from the paths of maternity and child welfare that I should have nothing to offer that would interest you. But when I really got down to a consideration of m y material I began to feel that perhaps our fields had not lain so far apart after all and that the public health problems of a large body of women might indeed be of interest to you ; in fact I realised that if, as at first I feared, m y paper fails to interest you, the fault will be mine rather than m y subject's. Because it is a remarkable subject. As some of you may know I was fortunate enough to be given the post, in succession to Dr. Letitia Fairfield, of senior w o m a n doctor at the War Office with responsibility for advising the Director-General and the Director of Hygiene on all matters affecting the health of w o m e n in the Army, including A.T.S., A r m y nurses, V.A.D.s and w o m e n doctors. At our peak we were responsible for some 220,000 w o m e n of all ages from 17½ to 55 or even, in the case of nurses, 60, whose work ranged from clerical and sedentary to operational duties of the most exacting types, mentally and physically. W e had every social stratum, from the aristocracy to the slums, and every intelligence level from the honours graduate to the high-grade mental defective. Moreover, these w o m e n were for the most part living under what for t h e m were highly abnormal conditions : away from their homes, in large communities, without privacy, with strange food, strange work, strange ways of eating, washing, working, playing. T h a t {hese conditions, as I hope to show you, were on the whole excellent does not detract from their strangeness, nor from our responsibility to educate and adjust the women to c o m m u n i t y life. T h e marvel is, not that we had complaints, but that we had not more ; not that we had some breakdowns but that so few failed to make the adjustments. And here I must pay tribute to the officers of the R.A.M.C., m e n and w o m e n alike, who contributed greatly to this adjustment, and especially to m y predecessor, Colonel Fairfield, who laid such a sound foundation of good public health administration that it stood up to the enormous superstructure that our later expansion built on it.
Living Conditions Living conditions varied enormously through the Service. A small proportion lived in their own homes throughout their A r m y career and worked at nearby Pay and Record Offices. T h e i r health was a constant problem to us as we had no control over their living conditions and very little if they were " sick at h o m e . " T h e r e was, too, the conflict between home interests and responsibilities and Service duties, and the sickness rate in these girls was always high. O f the remainder a large proportion, especially in towns, lived in requisitioned houses, of every size and type from little bungalows to large mansions. Always the p l u m b i n g was a problem, as we tended to have far more people in the house than it had had in private occupation ; we always had to add baths, showers, lavatories, wash basins, and always we had to do something to supplement the hot water supply. Incidentally I would lay it down as an axiom in dealing with w o m e n that so long as you give t h e m an adequate and ample supply of really hot water they will stand up to almost any hardships. It is their requirement No. 1 - - t h e y must be able to wash their " smalls," if possible have a hot bath and (very important) shampoo their hair, if they are to be kept good and happy. Apart from a certain n u m b e r in permanent barracks and married quarters and a few from time to time under canvas, the great majority of the w o m e n were in hutted camps. T h e huts were of various types--Nissen, Tarran, Jane, Ministry of Works, etc., and the only point about t h e m was the difficulty in keeping them really weatherproof and in dealing with extremes of temperature, neither of which were specifically * A paper read to the Maternity and Child Welfare Group, Society of M.O.H., London, March 7th, 1947.
feminine problems. T h e w o m e n had rather more floor space than the m e n - - 4 5 sq. ft. as compared with 3 0 - - b u t their doublebunking allowance was the same, 345 cu. ft. T h e y disliked double b u n k i n g - - a woman wants to sit on her bed and do her bits of mending and she cannot do that on a double b u n k - but we were so short of huts and beds that we had to allow it. T h e spacing seems to have been adequate ; we had no serious epidemics of droplet infection of any kind. T h e r e were various ways of dealing with sanitary annexes. T h e ideal was to have t h e m connected up with the huts by enclosed passages, and various lay-outs were devised with central ablutions serving a n u m b e r of huts ; they were picturesquely known as " spider huts " (the spider could have any n u m b e r of legs up to eight) or, if there were only two end to end, as " cracker huts." T h e y were, however, very expensive to build and in m a n y cases we had to be content with sleeping huts and separate huts for latrines, wash basins, baths and showers. T h e scale was originally (for other ranks) 15% each of wash basins and latrines, afterwards reduced to 12%; and 4% baths and showers:with, if possible, at least one slipper bath. N i g h t latrines were provided in each hut. T h e w o m e n did not take at all kindly to showers and were most reluctant to use them. T h i s was partly because they were strange and the girls did not know how to wash under them, but chiefly because they hated getting their hair wet. Bathing caps were unobtainable and though the steel helmet found an unexpected domestic function under the shower, we did not break down the objections even partially until we devised methods of overcoming this. O u r first expedient consisted in attaching the " rose " of the shower to a piece of hose long enough to reach below the shoulder ; later we fixed the rose at the side of the cubicle, shoulder height and pointing downwards. But the girls never really liked the showers and if we could have avoided t h e m we would. Unfortunately the saving in water, fuel and space was so great that we had to accept t h e m during the emergency. Incidentally an important public health problem in dealing with w o m e n is their m u c h greater consumption of water. T h e i r fondness for washing clothes, for having baths rather than showers and the need for providing all W.C.s instead of some urinals, all makes their water consumption quite a p r o b l e m for the camp engineers. A very large proportion of our girls were t o w n - b r e d (as also were many of their officers), and where water-borne sanitation was impracticable, as on some of the gun-sites and tented camps, we had some difficulty in overcoming their mistrust of bucket or chemical latrines, and indeed of anything but plugs that pulled. Actually these simpler latrines were perfectly satisfactory when properly cared for but we had a good deal of educating to do. W e fought shy of the types using strong disintegrating chemicals like caustic soda as we feared possible accidents to the sanitary orderlies, who were not always chosen from among the most intelligent auxiliaries. I can only remember one quite small epidemic of dysentery that was thought to be due to defective sanitation.
Gynaeeological Problems I now turn to some of the more specifically feminine problems we had to meet. One of our more unexpected discoveries (though we might well have foreseen it), was that our gynaecological problems were almost entirely non-surgical and on the face of it trivial. T h o u g h we had some women over 40, the great mass of the A . T . S . were between 18 and 25 years old and that is an age-group that does not figure m u c h at the gynaecological out-patient department. W e had of course a certain n u m b e r of hysterectomies and myomectomies for fibroids or menorrhagia, a few ovarian cysts, a very few carcinomas and some severe prolapses; but on the whole our gynaecological specialists had very little operating to do and were mainly concerned with menstrual disorders, the differential diagnosis of leucorrhoea and the early diagnosis of pregnancy. Menstruation T h e main disorder of menstruation was amenorrhoea, especially soon after joining. T h i s is, of course, a well-recognised phenomenon, but as there seemed little o r n o information
PUBLIC HEAI.TH, September, 1947 available as to its incidence and prognosis a survey was carried out which has recently been published.* It was found that something like 25% of all recruits missed one or more periods on joining the Service, but that 95% of these had returned to normal within eight months without treatment. O f the remainder all recovered normal rhythm within 15 months and only a very few needed endocrine treatment. T h i s is interesting as showing that the condition is essentially self-limiting though common and (to the recruit) worrying. All efforts to correlate the incidence with any specific factors such as intelligence, occupation, general health, anaemia, etc., failed except for a very odd and unexplained finding that hardly any of the recruits who afterwards became officers suffered from amenorrhoea. T h e r e may possibly be a temperamental factor involved. Dysmenorrhoea was never a service problem, though we have no support for the commonly held view that an active, healthy life improves i t ; in our experience it seemed to have no effect either way. We did not take recruits who admitted to having incapacitating dysmenorrhoea, so to that extent our sample is selected. It was a little disconcerting, however, to find in the survey quoted above, that some 25% of the w o m e n had some symptoms at the period, 5% having quite severe pain, but that only a tiny proportion had ever consulted a doctor about i t - - a depressing, but just, commentary on the ability of our profession to deal with this real feminine affliction. T w o occupational problems of menstruation deserve mention. W e had to prohibit women from driving Bren-gun carriers and other tracked vehicles, as the vibration definitely caused menorrhagia. T h i s finks up with the finding in the 1914-18 war that w o m e n motor-cyclists suffered from the same cond i t i o n ; in World W a r II the design of motor cycles had improved so m u c h that this time we had no trouble with our women despatch-riders. O u r second problem was m o r e one of propaganda than medicine. Cathode ray tubes are m u c h used in radar and a and a r u m o u r got round that w o m e n working with some radar sets might have their ovaries damaged and become sterile in consequence. We had the problem at once looked into by the Medical Research Council, who reported that no harmful rays or particles could reach the operator, but in spite of intensive propaganda among medical officers and A.A. officers we never really managed to kill the rumour. It cropped up again at intervals right through the war, and was also encountered by the other services. T h e proof of the pudding finally is in the eating : so far as I am aware no woman has ever put in a claim for pension on the grounds that she has been rendered sterile by a radar set. While I am on the subject of menstruation I would like to mention the intimate, but by no means unimportant problem of sanitary towels. T h e main difficulty lay in their disposal; they were the ordinary insoluble pads and in every unit arrangements were made for the wrapped soiled towels to be placed in a bin whence they could be collected and burnt. W h a t came as a surprise to all of us (though I gather the industrial and school M . O . s could have warned us) was the extreme reluctance of many women to use either the wrapping paper or the bins provided. Apart from the frequent blocking of the drains caused by ill-advised attempts to put t h e m down the lavatory, the soiled towels, wrapped and unwrapped were found in the most unexpected places--stuffed behind pipes, in the backs of cupboards and drawers, in desks, anywhere but in the right place. T h e astonishing thing was that these habits were not confined to slum-bred privates but were found among officers, even quite high ranking ones. O u r psychiatric colleagues had profound Freudian explanations for this curiously unhygienic behaviour but these never seemed very convincing ; whatever the cause, the only remedy was constant propaganda, with threats of disciplinary action, together with bins and wrapping paper in every W.C. so that everything was made as easy as possible, and by the end of the war some impression certainly had been made. As a rule soiled towels were burnt in boiler furnaces, incinerators or slow combustion stoves, b u t we did try out the small electric incinerators used in nurses' * DalLLIEN, C.
(1946.) y. Obst. & Gyn., June.
233 homes and schools in civil life ; they were very satisfactory for small units, b u t in larger ones, where they were constantly in use, they tended to become choked and break down.
Vaginal Discharges O u r second main group of gynaecological cases was the leucorrhoeas, and here there were three problems. First the differential diagnosis of the discharges proved to require an unexpectedly high standard of skill. W e thought at first that any reasonably experienced doctor, especially a woman doctor whose practice inevitably lies so m u c h in this field, could expose the cervix and take a smear for examination, but this hope proved m u c h too optimistic ; not only had they neither the equipment nor training to diagnose the trichomonas infections, but a surprisingly high proportion proved incapable of taking a satisfactory smear for gonococci, m u c h less a swab for culture. W e were forced in the end to concentrate all diagnosis in the hands of specialist gynaecologists and venereologists. O u r second problem was treatment ; the gonococcal discharge was e a s y - - w e concentrated all V.D. treatment of women in three military hospitals, staffed with experienced w o m e n venereologists, and the results of treatment were first xate--an outstanding advertisement for the policy of treating all V.D. cases as inpatients under the best conditions. But the non-venereal discharges were a m u c h more difficult problem, especially those attributed to the trichomonas. T h e y were extremely common, they gave rise to complaints from barrack r o o m mates and they were difficult to treat as outpatients under A r m y conditions owing to lack of privacy and facilities for douching, introduction of pessaries, etc. Finally, we were driven here too to provide in-patient facilities, in camp reception stations close to large u n i t s ; in these we provided a nursing officer and V.A.D.s who had had a brief training in the methods of treatment advocated by the prescribing specialists (these methods were to some extent standardised to facilitate supply) and the auxiliaries were admitted for a week or so for intensive treatment. T h i s arrangement worked admirably and the problem ceased to be troublesome. Follow-up was carried out by the specialist in charge of the case." F r o m the public health standpoint I confess I am not satisfied with current views as to the causation and transmission of the vaginitis associated with the trichomonas. It seems to me that the pathogenicity of the trichomonas is by no means conclusively proven and I am not convinced of the theory that its transmission is venereal as many seem to think. Some of our gynaecologists thought it was more prevalent where baths were replaced by showers, others thought baths were more conducive to its appearance. I do not think anyone who has not dealt with large numbers of women under Service conditions can realise what a public health problem the trichomonas can become and m u c h careful research is obviously needed into this trivial but troublesome complaint. W e had a unique opportunity to find out something about it but unfortunately shortage of medical manpower at a critical time prevented the concerted study from the pathological, gynaecological, venereological and hygiene angles that alone can throw light on the problem.
Pregnancy You will, I think, wish to hear something about our experience in connection with pregnancy. First I must assert firmly, in the face of m u c h cruel gossip, that from two-thirds to threequarters of our pregnancies were in married women though these formed only 10 to 15% of the Service. T h e illegitimate pregnancy rates remained low throughout the war, lower considerably than any comparable civilian rate we were able to calculate. It is almost impossible to convince the general public of this, even to convince the social workers who point to the large numbers they had to deal with, but in a service of 200,000 even a small percentage will produce a larger n u m b e r and the unmarried mothers certainly gave us m a n y headaches. T h e general policy was that all pregnant women were discharged from the Service as early as it was administratively possible to do so. It was felt that the A r m y was no place for a pregnant woman with its communal living, frequent changes of station and arduous jobs that had to be done ; moreover, it
PUBLIC HEALTH, September, 1947
234 was felt that the sooner she was a civilian the sooner could she start making arrangements for her confinement and readjusting herself to civil life ; also if she were unmarried, it gave a chance to deal with her often difficult disposal. W e should have liked to get most of them out by the twelfth week and in the early stages, when Zondek Aschheim tests could be performed in large numbers, we did achieve this with the married women (the single ones are always m u c h later in reporting and their average time of discharge was about the 20th week). But the blitz destroyed most of the mice required for the test, and feeding stuffs for the remainder were short, and in 1941 we were forced to resWict the use of the test to gynaecologists, for exceptional cases only. W e then found, by sad experience, that the average M.O. is prepared lightheartedly to diagnose a suspected pregnancy without a Z.A. at any time from the sixth week onwards, and in this way we lost not a few perfectly normal young women who mistakenly thought (or perhaps hoped) they were pregnant and communicated that belief to a doctor. So we were forced to say that we would not accepffa pregnancy certificate of less than twelve weeks unless countersigned by a gynaecologist (in our experience gynaecologists were m u c h more cautious in committing themselves to early diagnosis than were the less skilled). This, of course, delayed diagnosis in the normal case, though earlier discharge could always be obtained through a specialist if for any reason desirable, but even so the average time of discharge of married w o m e n was about 14 weeks. I am quite sure that the administrative ideal is to have biological tests available for all early cases as soon as suspected, and experience of the Canadian W o m e n ' s A r m y Corps seems to show that the H o g b e n Xenopus test is the best available at present, but for various reasons we could not adopt it during the war. O f course, many pregnancies were missed, an astonishing n u m b e r in spite of monthly routine health inspection in which the girls were seen in brassiere and knickers only. It seems impossible to spot the girl who is deliberately out to conceal her condition and the tunic and skirt curiously enough hide an enlarged abdomen to a remarkable extent, as also does the leather jerkin and other operational clothing. I was constantly in the embarrassing position of having to explain to pained A . T . S . Officers how a careful M.O. could come to miss a fulltime pregnancy. Several cases of " rheumatism," " gastritis," even " chilblains," in bed and u n d e r treatment, turned out to be in labour, and there was one astonishing girl who produced a full-time child in a Camp Reception Station under the eyes of an M.O., medical orderly, and ward mate without anyone suspecting what was going on I It was born (dead, fortunately) in the latrine and she buried it under the floorboards, where some days later it gave unequivocal warning of its presence and the whole pitiful case was uncovered. W e had no evidence that Service life conduces to abortion, except in the predisposed who would probably miscarry anyway. Indeed, the auxiliaries in A.A. C o m m a n d and with M o t o r Transport Companies appeared to have a rather lower miscarriage rate than the rest of the Service, which seems to dispose of m a n y popular superstitions as to what causes abortion. W e tried to relate our miscarriage rate to all the known pregnancies, but there were many snags, not the least of which was that we almost certainly never knew of miscarriages at less than eight weeks, and it was doubtful whether all the others found their way to hospital, and our figures were not regarded as accurate enough to publish. T h e y did, however, show conclusively that liability to miscarry increases with age, being lowest at 18 to 20 and rising surprisingly steeply after this. W e took very great care over the disposal of the single girl (and of such married ones as needed help). T h i s was primarily the responsibility of the A . T . S . Officer and her instructions were that no girl was to be discharged unless she had somewhere to go. I f possible she was persuaded to go back to her family : if she refused or they would not have her every effort was made to hand her over to a social worker. A few cases, however, proved too difficult for the ordinary officer untrained in social work, and for those we established a special Discharge Depot, under the command of a very experienced" officer, which had special liaison with the various social agencies and which took
these problem cases and kept them until satisfactory arrangements could be made. T h i s unit of 30 beds was very successful and, indeed, proved quite indispensable. It was not a maternity home and was not supposed to keep cases after 28 weeks. As the blitz and evacuation reduced more and more the already inadequate n u m b e r of beds in mother and baby homes, the difficulty in finding accommodation for those girls who could not or would not return to their families became extreme, and in 1943 urgent representations induced the Ministry of Health to start a scheme whereby pregnant ex-Service girls were taken into an evacuation ante- and post-natal home, and confined in an E m e r g e n c y Maternity Home. T h e scheme was centrally controlled by the Ministry, and the results were outstandingly good. Indeed, some of these homes, especially the one at Panshanger in Hertfordshire, set a new standard in methods of handling unmarried mothers. Infeetlous Diseases
T o turn now tO some of our other public health problems. T h e acute infectious fevers caused us no headaches. We shared in any epide/nics that were occurring in the c o u n t r y - we had influenza and G e r m a n measles in the spring of 1940, influenza in the early winter 1944-45, a mild measles epidemic in 1944, but that was all. O u r T B . rate never gave us any anxiety, though we should have been happier if the facilities for mass radiography had been more plentiful. However, from about 1943 all auxiliaries going overseas were radiographed, and a considerable proportion of the new recruits. I have already discussed the diagnosis and treatment of V.D. but it should be said that the rate throughout the war was extraordinarily low ; the m a x i m u m in 1942 was about 3.0 per thousand per annum, but the next year it dropped to 1"5 and remained round about 1 "0 for the rest of the war. O f course, V.D. in w o m e n is m u c h more difficult to detect than in men, and we shall never know how many cases we missed, but we are convinced that the proportion detected and treated was m u c h higher than in civil life. Scabies was rather high in 1942 but after that dropped and finally settled at a very satisfactory level. But our nightmare was the infestation of recruits with headlice. Just as the evacuation revealed an unsuspected prevalence in children, so the Service recruits proved to have a truly horrifying infestation rate that throws a disquieting light on the hygienic levels in our great cities. T h e variations in the rate are interesting; we have no accurate figures for the first 18 months of the war, but the rate seems to have been about 1O to 15%, rising during 1941 with increased recruiting to about 25 to 28%. In 1942 the least intelligent 10% were eliminated by the Raven Matrix test and at once the rate fell to between 18 and 20% where it stayed until 1944 when for no very good reason, except perhaps that we were recruiting the very young that year (the under 19s only), it rose to between 32 and 33%, settling later in the year to about 28% where it stayed for the rest of the war. But the overall infestation rate reveals only part of the story. It is quite bad enough that such a proportion of our healthy young women, ranging from a fifth to a third, should carry the head louse, but the rate varied enormously in recruits from different parts of the country. Girls from rural areas showed a very low rate indeed, and L o n d o n was m u c h the lowest of the great towns, seldom having more than 5 to 7~o. But as one travelled further north the picture blackened; the great industrial cities of Lancashire, Yorkshire and Tyneside gave rates of 30 to 50%. Clydeside often reached 65% and N o r t h e r n Ireland, via which came a n u m b e r of recruits from Eire as well as its own, was consistently above 70% and once averaged 92% over a whole m o n t h ' s intakes 1 You who come from all over the country and may feel patriotically insulted by these facts, take t h e m to heart and go back and tell your chiefs I It was only the recruit intake that gave trouble---the girl fresh from civilian life. T h e incidence of head infestation among serving auxiliaries seldom exceeded 0.5% per month, a very manageable figure. But the recruit intakes were a considerable administrative problem, as 200 might arrive at one training centre in one day, of w h o m 80 to 100 might require disinfestation. Methods of treatment, too, were far from satisfactory: at the very beginning there was no standardised method and
235
PUBLIC HEALTH, September, 1947 all the traditional ones--paraffin, sassafras, vinegar, quassia, etc., were in use,c By 1941 the L.C.C. routine was introduced, i.e., soaking in a mixture of tar, paraffin and cotton seed oil, followed by careful combing with a square-toothed metal comb and finally by shampooing ; when some of the ingredients of the tar oil became scarce, the alternative was 1 : 40 carbolic. These treatments were given by V.A.D.s and by trained A.T.S. medical orderlies and N.C.O.s, who became extremely good at ther~a, and in the light of later findings it seems likely that the excellent results we had at this time were due to their skilled and meticulous combing, rather than to the application used. During 1942 trials were carried out, in conjunction with the Ministry of Health, of various new insecticides whose efficacy, as judged by laboratory tests, was much greater than the older remedies. These new drugs included derris powder, cub6 powder and emulsion, laurylthiocyanate and another thiocyanate known as " lethane 384 special," which was used as a hair oil. This last proved the most satisfactory and had the great advantage that hair impregnated with it remained lethal for up to a week after application, thus destroying any lice hatched from nits that had been missed. T h e " drill " finally evolved consisted of a preliminary application for an hour or two, followed by combing and shampooing, then reapplication of lethane which was left on for a week. After this there was a further combing and washing and a third application with a final check at the end of a fortnight. The inventors of the method claimed that combing was unnecessary as any nits undestroyed would be killed on hatching, but we felt that it was had health education to encourage the belief that any nits were a good thing in one's head, even dead ones. This method proved extremely effective and administratively was far easier than the older ones, and its only drawbacks were its transient but unpleasant smell (which seemed to he aggravated by added perfumes) and its greasiness. This last was usually due to the application of too much lethane, the correct amount (less than 2 drachms) merely giving the hair a pleasant gloss, but where the hair was sticky it was difficult to prevent the girls from shamlbooing it themselves and thus removing the drug. Just before I left the Army, experiments were in progress with a D D T emulsion which was showing signs of being much more effective even than lethane, and free from its drawbacks. I understand that this has indeed proved to be so, but that the ideal emulsion or suspension has not yet been found. Meanwhile lethane is still being used. It is interesting to speculate on the cause of this high infestation rate ; general hygiene was probably not the main fanlt-in the same recruits the scabies rate was about 2%, and infestation with P. corposis and Ph. pubis almost non-existent. We ourselves blamed the fashionable hair styles which involved elaborate curls which their owners seldom or never brushed out. Visits to the hairdresser were usually every three or four weeks, so a single louse picked up accidentally would have ample time to reproduce undisturbed. All efforts to change the fashion failed, including a determined campaign, supported by the hairdressers, to sponsor the " liberty cut," a much shorter style. We were told that our only hope would have been to persuade a famous Hollywood film star to introduce a new style and that would probably have succeeded. There was no question hut that head infestation and intelligence rating were related--the lower [grades had significantly more dirty heads. What is also amusing is that we found some support for the old wives' tale that lice only stay on healthy people. T h e incidence among those whose medical category was A1 was slightly but significantly higher than those in lower categories. I have only touched the fringe of our public health activities which covered every aspect of the women's life; we dealt with their working and living conditions, suitability of employment, clothing, food, morale, medical arrangements, hospital and everything which could possibly affect their health. It was a wonderful experience. I believe the fine upstanding young women who wore our uniform are testimony that our work was not altogether in vain. Certainly I for one, would not have missed the opportunity of learning so many salutary, and often painful, lessons in a branch of medicine which, when I went into the Army, was entirely outside my field of vision. With great diffidence I offer to you, as experts, these fruits of experience of an amateur.
THE WORK OF T H E HEALTH DIVISION OF THE U N R R A ITALIAN MISSION, 1944-47" By E. C. BENN, M.B., CH.B., D.P.H., Medical Superintendent, Seacroft Hospital, Leeds ; late Director of Health, U N R R A ltalian Mission T h e responsibilities of the U N R R A Italian Mission until the end of 1945 were limited, by resolution of the U N R R A Council, to measures designed to give immediate, relief to certain sections of the Italian population and particularly to nursing and expectant mothers and to children. In addition to giving medical relief, the Health Division was responsible for epidemic control, for the medical care of non-Italian displaced persons and for the U N R R A staff medical services. In 1945 the overall expenditure of the Mission was limited to 50 million dollars of which the health services were allocated nine million. T h e bulk of this went to provide medical relief supplies. T h e 1945 programme was supplementary to that carried out by the Allied Commission which was based on the provision of supplies and services sufficient to prevent disease and civil unrest. At that time the Mission was dependent upon the Allied Armies for all facilities such as office and living accommodation, rations and transport and movement was impossible except by military transport and with military travel orders. When the war ended, U N R R A gradually took over increasing responsibilities from the military and provided its own services as its operations extended. In 1946 the Mission was responsible for almost all the essential imported supplies which were required by the country, grain, coal, oil, metals, fertilisers and many others, and the Mission budget for that year was in the neighbourhood of 400 million dollars, of which seven million was used for the health services.
Medical Supplies After consultation with the Italian Government and Allied Commission, and after surveys in several parts of Southern Italy by the staff of the Health Division, lists of requirements were drawn up and sent to Headquarters early in 1945. These contained requests for large quantities of finished products such as drugs, dressings, medical and surgical equipment, hospital supplies and sanitation equipment to meet immediate needs. Among the larger items requested were ambulances, 40-bed and 200-bed hospital units, laboratory units and a few X-ray units. These were enthusiastically received some months later by communities which, owing to war damage, had been without such facilities for considerable periods. T h e reception, assembly and distribution of medical supplies was carried out by the Italian Government with U N R R A assistance, and no supplies were distributed unless need was proved by the recipient and approval given by the Health Division as the representative of the Mission. This was a large-scale supply operation and was not without its difficulties. Deliveries were delayed and component parts did not always arrive together. T h e greatest setback took place when a ship carrying surgical instruments and hospital and laboratory equipment hit a mine off the coast of Italy. T h e supplies were lost and procurement from overseas had to start over again. Cotton fabrics proved to be unobtainable from overseas and it was necessary to import raw cotton and to manufacture cloth for hospital linen and surgical dressings in Italy. In all about four and a half million metres of cotton cloth were made in Italy for the medical supply programme. T h e urgent need for medical supplies was obvious. Many hospitals in 1945 were without such essential drugs as morphia and ether, surgical dressings were almost unobtainable, many hospitals had been totally destroyed and large communities were without hospital accommodation, X-ray film did not exist and X-ray tubes could not be repaired or replaced so even screening was impossible. T h e general requisitioning of transport had almost stripped the country of ambulances which had departed with the retreating enemy. T h e need was therefore great, and distribution was carried through as rapidly as * Paper read to the Yorkshire Branch of the Society of Medical Officers of Health, Leeds, May 30th, 1947.
PUBLIC HEALTH, September, 1947
P U B L I C H E A L T H P R O B L E M S IN T H E A.T.S. * By ALBERTINE I., WI1WNER, O.B.E., M.D., M.R.C.P.,
Late Lieut.-Colonel, R.A.M.C., Honorary Medical Consultant for Women's Services in the Army I must confess that w h e n your G r o u p first invited me to address you, I feared that m y war-time work had lain so far from the paths of maternity and child welfare that I should have nothing to offer that would interest you. But when I really got down to a consideration of m y material I began to feel that perhaps our fields had not lain so far apart after all and that the public health problems of a large body of women might indeed be of interest to you ; in fact I realised that if, as at first I feared, m y paper fails to interest you, the fault will be mine rather than m y subject's. Because it is a remarkable subject. As some of you may know I was fortunate enough to be given the post, in succession to Dr. Letitia Fairfield, of senior w o m a n doctor at the War Office with responsibility for advising the Director-General and the Director of Hygiene on all matters affecting the health of w o m e n in the Army, including A.T.S., A r m y nurses, V.A.D.s and w o m e n doctors. At our peak we were responsible for some 220,000 w o m e n of all ages from 17½ to 55 or even, in the case of nurses, 60, whose work ranged from clerical and sedentary to operational duties of the most exacting types, mentally and physically. W e had every social stratum, from the aristocracy to the slums, and every intelligence level from the honours graduate to the high-grade mental defective. Moreover, these w o m e n were for the most part living under what for t h e m were highly abnormal conditions : away from their homes, in large communities, without privacy, with strange food, strange work, strange ways of eating, washing, working, playing. T h a t {hese conditions, as I hope to show you, were on the whole excellent does not detract from their strangeness, nor from our responsibility to educate and adjust the women to c o m m u n i t y life. T h e marvel is, not that we had complaints, but that we had not more ; not that we had some breakdowns but that so few failed to make the adjustments. And here I must pay tribute to the officers of the R.A.M.C., m e n and w o m e n alike, who contributed greatly to this adjustment, and especially to m y predecessor, Colonel Fairfield, who laid such a sound foundation of good public health administration that it stood up to the enormous superstructure that our later expansion built on it.
Living Conditions Living conditions varied enormously through the Service. A small proportion lived in their own homes throughout their A r m y career and worked at nearby Pay and Record Offices. T h e i r health was a constant problem to us as we had no control over their living conditions and very little if they were " sick at h o m e . " T h e r e was, too, the conflict between home interests and responsibilities and Service duties, and the sickness rate in these girls was always high. O f the remainder a large proportion, especially in towns, lived in requisitioned houses, of every size and type from little bungalows to large mansions. Always the p l u m b i n g was a problem, as we tended to have far more people in the house than it had had in private occupation ; we always had to add baths, showers, lavatories, wash basins, and always we had to do something to supplement the hot water supply. Incidentally I would lay it down as an axiom in dealing with w o m e n that so long as you give t h e m an adequate and ample supply of really hot water they will stand up to almost any hardships. It is their requirement No. 1 - - t h e y must be able to wash their " smalls," if possible have a hot bath and (very important) shampoo their hair, if they are to be kept good and happy. Apart from a certain n u m b e r in permanent barracks and married quarters and a few from time to time under canvas, the great majority of the w o m e n were in hutted camps. T h e huts were of various types--Nissen, Tarran, Jane, Ministry of Works, etc., and the only point about t h e m was the difficulty in keeping them really weatherproof and in dealing with extremes of temperature, neither of which were specifically * A paper read to the Maternity and Child Welfare Group, Society of M.O.H., London, March 7th, 1947.
feminine problems. T h e w o m e n had rather more floor space than the m e n - - 4 5 sq. ft. as compared with 3 0 - - b u t their doublebunking allowance was the same, 345 cu. ft. T h e y disliked double b u n k i n g - - a woman wants to sit on her bed and do her bits of mending and she cannot do that on a double b u n k - but we were so short of huts and beds that we had to allow it. T h e spacing seems to have been adequate ; we had no serious epidemics of droplet infection of any kind. T h e r e were various ways of dealing with sanitary annexes. T h e ideal was to have t h e m connected up with the huts by enclosed passages, and various lay-outs were devised with central ablutions serving a n u m b e r of huts ; they were picturesquely known as " spider huts " (the spider could have any n u m b e r of legs up to eight) or, if there were only two end to end, as " cracker huts." T h e y were, however, very expensive to build and in m a n y cases we had to be content with sleeping huts and separate huts for latrines, wash basins, baths and showers. T h e scale was originally (for other ranks) 15% each of wash basins and latrines, afterwards reduced to 12%; and 4% baths and showers:with, if possible, at least one slipper bath. N i g h t latrines were provided in each hut. T h e w o m e n did not take at all kindly to showers and were most reluctant to use them. T h i s was partly because they were strange and the girls did not know how to wash under them, but chiefly because they hated getting their hair wet. Bathing caps were unobtainable and though the steel helmet found an unexpected domestic function under the shower, we did not break down the objections even partially until we devised methods of overcoming this. O u r first expedient consisted in attaching the " rose " of the shower to a piece of hose long enough to reach below the shoulder ; later we fixed the rose at the side of the cubicle, shoulder height and pointing downwards. But the girls never really liked the showers and if we could have avoided t h e m we would. Unfortunately the saving in water, fuel and space was so great that we had to accept t h e m during the emergency. Incidentally an important public health problem in dealing with w o m e n is their m u c h greater consumption of water. T h e i r fondness for washing clothes, for having baths rather than showers and the need for providing all W.C.s instead of some urinals, all makes their water consumption quite a p r o b l e m for the camp engineers. A very large proportion of our girls were t o w n - b r e d (as also were many of their officers), and where water-borne sanitation was impracticable, as on some of the gun-sites and tented camps, we had some difficulty in overcoming their mistrust of bucket or chemical latrines, and indeed of anything but plugs that pulled. Actually these simpler latrines were perfectly satisfactory when properly cared for but we had a good deal of educating to do. W e fought shy of the types using strong disintegrating chemicals like caustic soda as we feared possible accidents to the sanitary orderlies, who were not always chosen from among the most intelligent auxiliaries. I can only remember one quite small epidemic of dysentery that was thought to be due to defective sanitation.
Gynaeeological Problems I now turn to some of the more specifically feminine problems we had to meet. One of our more unexpected discoveries (though we might well have foreseen it), was that our gynaecological problems were almost entirely non-surgical and on the face of it trivial. T h o u g h we had some women over 40, the great mass of the A . T . S . were between 18 and 25 years old and that is an age-group that does not figure m u c h at the gynaecological out-patient department. W e had of course a certain n u m b e r of hysterectomies and myomectomies for fibroids or menorrhagia, a few ovarian cysts, a very few carcinomas and some severe prolapses; but on the whole our gynaecological specialists had very little operating to do and were mainly concerned with menstrual disorders, the differential diagnosis of leucorrhoea and the early diagnosis of pregnancy. Menstruation T h e main disorder of menstruation was amenorrhoea, especially soon after joining. T h i s is, of course, a well-recognised phenomenon, but as there seemed little o r n o information
PUBLIC HEAI.TH, September, 1947 available as to its incidence and prognosis a survey was carried out which has recently been published.* It was found that something like 25% of all recruits missed one or more periods on joining the Service, but that 95% of these had returned to normal within eight months without treatment. O f the remainder all recovered normal rhythm within 15 months and only a very few needed endocrine treatment. T h i s is interesting as showing that the condition is essentially self-limiting though common and (to the recruit) worrying. All efforts to correlate the incidence with any specific factors such as intelligence, occupation, general health, anaemia, etc., failed except for a very odd and unexplained finding that hardly any of the recruits who afterwards became officers suffered from amenorrhoea. T h e r e may possibly be a temperamental factor involved. Dysmenorrhoea was never a service problem, though we have no support for the commonly held view that an active, healthy life improves i t ; in our experience it seemed to have no effect either way. We did not take recruits who admitted to having incapacitating dysmenorrhoea, so to that extent our sample is selected. It was a little disconcerting, however, to find in the survey quoted above, that some 25% of the w o m e n had some symptoms at the period, 5% having quite severe pain, but that only a tiny proportion had ever consulted a doctor about i t - - a depressing, but just, commentary on the ability of our profession to deal with this real feminine affliction. T w o occupational problems of menstruation deserve mention. W e had to prohibit women from driving Bren-gun carriers and other tracked vehicles, as the vibration definitely caused menorrhagia. T h i s finks up with the finding in the 1914-18 war that w o m e n motor-cyclists suffered from the same cond i t i o n ; in World W a r II the design of motor cycles had improved so m u c h that this time we had no trouble with our women despatch-riders. O u r second problem was m o r e one of propaganda than medicine. Cathode ray tubes are m u c h used in radar and a and a r u m o u r got round that w o m e n working with some radar sets might have their ovaries damaged and become sterile in consequence. We had the problem at once looked into by the Medical Research Council, who reported that no harmful rays or particles could reach the operator, but in spite of intensive propaganda among medical officers and A.A. officers we never really managed to kill the rumour. It cropped up again at intervals right through the war, and was also encountered by the other services. T h e proof of the pudding finally is in the eating : so far as I am aware no woman has ever put in a claim for pension on the grounds that she has been rendered sterile by a radar set. While I am on the subject of menstruation I would like to mention the intimate, but by no means unimportant problem of sanitary towels. T h e main difficulty lay in their disposal; they were the ordinary insoluble pads and in every unit arrangements were made for the wrapped soiled towels to be placed in a bin whence they could be collected and burnt. W h a t came as a surprise to all of us (though I gather the industrial and school M . O . s could have warned us) was the extreme reluctance of many women to use either the wrapping paper or the bins provided. Apart from the frequent blocking of the drains caused by ill-advised attempts to put t h e m down the lavatory, the soiled towels, wrapped and unwrapped were found in the most unexpected places--stuffed behind pipes, in the backs of cupboards and drawers, in desks, anywhere but in the right place. T h e astonishing thing was that these habits were not confined to slum-bred privates but were found among officers, even quite high ranking ones. O u r psychiatric colleagues had profound Freudian explanations for this curiously unhygienic behaviour but these never seemed very convincing ; whatever the cause, the only remedy was constant propaganda, with threats of disciplinary action, together with bins and wrapping paper in every W.C. so that everything was made as easy as possible, and by the end of the war some impression certainly had been made. As a rule soiled towels were burnt in boiler furnaces, incinerators or slow combustion stoves, b u t we did try out the small electric incinerators used in nurses' * DalLLIEN, C.
(1946.) y. Obst. & Gyn., June.
233 homes and schools in civil life ; they were very satisfactory for small units, b u t in larger ones, where they were constantly in use, they tended to become choked and break down.
Vaginal Discharges O u r second main group of gynaecological cases was the leucorrhoeas, and here there were three problems. First the differential diagnosis of the discharges proved to require an unexpectedly high standard of skill. W e thought at first that any reasonably experienced doctor, especially a woman doctor whose practice inevitably lies so m u c h in this field, could expose the cervix and take a smear for examination, but this hope proved m u c h too optimistic ; not only had they neither the equipment nor training to diagnose the trichomonas infections, but a surprisingly high proportion proved incapable of taking a satisfactory smear for gonococci, m u c h less a swab for culture. W e were forced in the end to concentrate all diagnosis in the hands of specialist gynaecologists and venereologists. O u r second problem was treatment ; the gonococcal discharge was e a s y - - w e concentrated all V.D. treatment of women in three military hospitals, staffed with experienced w o m e n venereologists, and the results of treatment were first xate--an outstanding advertisement for the policy of treating all V.D. cases as inpatients under the best conditions. But the non-venereal discharges were a m u c h more difficult problem, especially those attributed to the trichomonas. T h e y were extremely common, they gave rise to complaints from barrack r o o m mates and they were difficult to treat as outpatients under A r m y conditions owing to lack of privacy and facilities for douching, introduction of pessaries, etc. Finally, we were driven here too to provide in-patient facilities, in camp reception stations close to large u n i t s ; in these we provided a nursing officer and V.A.D.s who had had a brief training in the methods of treatment advocated by the prescribing specialists (these methods were to some extent standardised to facilitate supply) and the auxiliaries were admitted for a week or so for intensive treatment. T h i s arrangement worked admirably and the problem ceased to be troublesome. Follow-up was carried out by the specialist in charge of the case." F r o m the public health standpoint I confess I am not satisfied with current views as to the causation and transmission of the vaginitis associated with the trichomonas. It seems to me that the pathogenicity of the trichomonas is by no means conclusively proven and I am not convinced of the theory that its transmission is venereal as many seem to think. Some of our gynaecologists thought it was more prevalent where baths were replaced by showers, others thought baths were more conducive to its appearance. I do not think anyone who has not dealt with large numbers of women under Service conditions can realise what a public health problem the trichomonas can become and m u c h careful research is obviously needed into this trivial but troublesome complaint. W e had a unique opportunity to find out something about it but unfortunately shortage of medical manpower at a critical time prevented the concerted study from the pathological, gynaecological, venereological and hygiene angles that alone can throw light on the problem.
Pregnancy You will, I think, wish to hear something about our experience in connection with pregnancy. First I must assert firmly, in the face of m u c h cruel gossip, that from two-thirds to threequarters of our pregnancies were in married women though these formed only 10 to 15% of the Service. T h e illegitimate pregnancy rates remained low throughout the war, lower considerably than any comparable civilian rate we were able to calculate. It is almost impossible to convince the general public of this, even to convince the social workers who point to the large numbers they had to deal with, but in a service of 200,000 even a small percentage will produce a larger n u m b e r and the unmarried mothers certainly gave us m a n y headaches. T h e general policy was that all pregnant women were discharged from the Service as early as it was administratively possible to do so. It was felt that the A r m y was no place for a pregnant woman with its communal living, frequent changes of station and arduous jobs that had to be done ; moreover, it
PUBLIC HEALTH, September, 1947
234 was felt that the sooner she was a civilian the sooner could she start making arrangements for her confinement and readjusting herself to civil life ; also if she were unmarried, it gave a chance to deal with her often difficult disposal. W e should have liked to get most of them out by the twelfth week and in the early stages, when Zondek Aschheim tests could be performed in large numbers, we did achieve this with the married women (the single ones are always m u c h later in reporting and their average time of discharge was about the 20th week). But the blitz destroyed most of the mice required for the test, and feeding stuffs for the remainder were short, and in 1941 we were forced to resWict the use of the test to gynaecologists, for exceptional cases only. W e then found, by sad experience, that the average M.O. is prepared lightheartedly to diagnose a suspected pregnancy without a Z.A. at any time from the sixth week onwards, and in this way we lost not a few perfectly normal young women who mistakenly thought (or perhaps hoped) they were pregnant and communicated that belief to a doctor. So we were forced to say that we would not accepffa pregnancy certificate of less than twelve weeks unless countersigned by a gynaecologist (in our experience gynaecologists were m u c h more cautious in committing themselves to early diagnosis than were the less skilled). This, of course, delayed diagnosis in the normal case, though earlier discharge could always be obtained through a specialist if for any reason desirable, but even so the average time of discharge of married w o m e n was about 14 weeks. I am quite sure that the administrative ideal is to have biological tests available for all early cases as soon as suspected, and experience of the Canadian W o m e n ' s A r m y Corps seems to show that the H o g b e n Xenopus test is the best available at present, but for various reasons we could not adopt it during the war. O f course, many pregnancies were missed, an astonishing n u m b e r in spite of monthly routine health inspection in which the girls were seen in brassiere and knickers only. It seems impossible to spot the girl who is deliberately out to conceal her condition and the tunic and skirt curiously enough hide an enlarged abdomen to a remarkable extent, as also does the leather jerkin and other operational clothing. I was constantly in the embarrassing position of having to explain to pained A . T . S . Officers how a careful M.O. could come to miss a fulltime pregnancy. Several cases of " rheumatism," " gastritis," even " chilblains," in bed and u n d e r treatment, turned out to be in labour, and there was one astonishing girl who produced a full-time child in a Camp Reception Station under the eyes of an M.O., medical orderly, and ward mate without anyone suspecting what was going on I It was born (dead, fortunately) in the latrine and she buried it under the floorboards, where some days later it gave unequivocal warning of its presence and the whole pitiful case was uncovered. W e had no evidence that Service life conduces to abortion, except in the predisposed who would probably miscarry anyway. Indeed, the auxiliaries in A.A. C o m m a n d and with M o t o r Transport Companies appeared to have a rather lower miscarriage rate than the rest of the Service, which seems to dispose of m a n y popular superstitions as to what causes abortion. W e tried to relate our miscarriage rate to all the known pregnancies, but there were many snags, not the least of which was that we almost certainly never knew of miscarriages at less than eight weeks, and it was doubtful whether all the others found their way to hospital, and our figures were not regarded as accurate enough to publish. T h e y did, however, show conclusively that liability to miscarry increases with age, being lowest at 18 to 20 and rising surprisingly steeply after this. W e took very great care over the disposal of the single girl (and of such married ones as needed help). T h i s was primarily the responsibility of the A . T . S . Officer and her instructions were that no girl was to be discharged unless she had somewhere to go. I f possible she was persuaded to go back to her family : if she refused or they would not have her every effort was made to hand her over to a social worker. A few cases, however, proved too difficult for the ordinary officer untrained in social work, and for those we established a special Discharge Depot, under the command of a very experienced" officer, which had special liaison with the various social agencies and which took
these problem cases and kept them until satisfactory arrangements could be made. T h i s unit of 30 beds was very successful and, indeed, proved quite indispensable. It was not a maternity home and was not supposed to keep cases after 28 weeks. As the blitz and evacuation reduced more and more the already inadequate n u m b e r of beds in mother and baby homes, the difficulty in finding accommodation for those girls who could not or would not return to their families became extreme, and in 1943 urgent representations induced the Ministry of Health to start a scheme whereby pregnant ex-Service girls were taken into an evacuation ante- and post-natal home, and confined in an E m e r g e n c y Maternity Home. T h e scheme was centrally controlled by the Ministry, and the results were outstandingly good. Indeed, some of these homes, especially the one at Panshanger in Hertfordshire, set a new standard in methods of handling unmarried mothers. Infeetlous Diseases
T o turn now tO some of our other public health problems. T h e acute infectious fevers caused us no headaches. We shared in any epide/nics that were occurring in the c o u n t r y - we had influenza and G e r m a n measles in the spring of 1940, influenza in the early winter 1944-45, a mild measles epidemic in 1944, but that was all. O u r T B . rate never gave us any anxiety, though we should have been happier if the facilities for mass radiography had been more plentiful. However, from about 1943 all auxiliaries going overseas were radiographed, and a considerable proportion of the new recruits. I have already discussed the diagnosis and treatment of V.D. but it should be said that the rate throughout the war was extraordinarily low ; the m a x i m u m in 1942 was about 3.0 per thousand per annum, but the next year it dropped to 1"5 and remained round about 1 "0 for the rest of the war. O f course, V.D. in w o m e n is m u c h more difficult to detect than in men, and we shall never know how many cases we missed, but we are convinced that the proportion detected and treated was m u c h higher than in civil life. Scabies was rather high in 1942 but after that dropped and finally settled at a very satisfactory level. But our nightmare was the infestation of recruits with headlice. Just as the evacuation revealed an unsuspected prevalence in children, so the Service recruits proved to have a truly horrifying infestation rate that throws a disquieting light on the hygienic levels in our great cities. T h e variations in the rate are interesting; we have no accurate figures for the first 18 months of the war, but the rate seems to have been about 1O to 15%, rising during 1941 with increased recruiting to about 25 to 28%. In 1942 the least intelligent 10% were eliminated by the Raven Matrix test and at once the rate fell to between 18 and 20% where it stayed until 1944 when for no very good reason, except perhaps that we were recruiting the very young that year (the under 19s only), it rose to between 32 and 33%, settling later in the year to about 28% where it stayed for the rest of the war. But the overall infestation rate reveals only part of the story. It is quite bad enough that such a proportion of our healthy young women, ranging from a fifth to a third, should carry the head louse, but the rate varied enormously in recruits from different parts of the country. Girls from rural areas showed a very low rate indeed, and L o n d o n was m u c h the lowest of the great towns, seldom having more than 5 to 7~o. But as one travelled further north the picture blackened; the great industrial cities of Lancashire, Yorkshire and Tyneside gave rates of 30 to 50%. Clydeside often reached 65% and N o r t h e r n Ireland, via which came a n u m b e r of recruits from Eire as well as its own, was consistently above 70% and once averaged 92% over a whole m o n t h ' s intakes 1 You who come from all over the country and may feel patriotically insulted by these facts, take t h e m to heart and go back and tell your chiefs I It was only the recruit intake that gave trouble---the girl fresh from civilian life. T h e incidence of head infestation among serving auxiliaries seldom exceeded 0.5% per month, a very manageable figure. But the recruit intakes were a considerable administrative problem, as 200 might arrive at one training centre in one day, of w h o m 80 to 100 might require disinfestation. Methods of treatment, too, were far from satisfactory: at the very beginning there was no standardised method and
235
PUBLIC HEALTH, September, 1947 all the traditional ones--paraffin, sassafras, vinegar, quassia, etc., were in use,c By 1941 the L.C.C. routine was introduced, i.e., soaking in a mixture of tar, paraffin and cotton seed oil, followed by careful combing with a square-toothed metal comb and finally by shampooing ; when some of the ingredients of the tar oil became scarce, the alternative was 1 : 40 carbolic. These treatments were given by V.A.D.s and by trained A.T.S. medical orderlies and N.C.O.s, who became extremely good at ther~a, and in the light of later findings it seems likely that the excellent results we had at this time were due to their skilled and meticulous combing, rather than to the application used. During 1942 trials were carried out, in conjunction with the Ministry of Health, of various new insecticides whose efficacy, as judged by laboratory tests, was much greater than the older remedies. These new drugs included derris powder, cub6 powder and emulsion, laurylthiocyanate and another thiocyanate known as " lethane 384 special," which was used as a hair oil. This last proved the most satisfactory and had the great advantage that hair impregnated with it remained lethal for up to a week after application, thus destroying any lice hatched from nits that had been missed. T h e " drill " finally evolved consisted of a preliminary application for an hour or two, followed by combing and shampooing, then reapplication of lethane which was left on for a week. After this there was a further combing and washing and a third application with a final check at the end of a fortnight. The inventors of the method claimed that combing was unnecessary as any nits undestroyed would be killed on hatching, but we felt that it was had health education to encourage the belief that any nits were a good thing in one's head, even dead ones. This method proved extremely effective and administratively was far easier than the older ones, and its only drawbacks were its transient but unpleasant smell (which seemed to he aggravated by added perfumes) and its greasiness. This last was usually due to the application of too much lethane, the correct amount (less than 2 drachms) merely giving the hair a pleasant gloss, but where the hair was sticky it was difficult to prevent the girls from shamlbooing it themselves and thus removing the drug. Just before I left the Army, experiments were in progress with a D D T emulsion which was showing signs of being much more effective even than lethane, and free from its drawbacks. I understand that this has indeed proved to be so, but that the ideal emulsion or suspension has not yet been found. Meanwhile lethane is still being used. It is interesting to speculate on the cause of this high infestation rate ; general hygiene was probably not the main fanlt-in the same recruits the scabies rate was about 2%, and infestation with P. corposis and Ph. pubis almost non-existent. We ourselves blamed the fashionable hair styles which involved elaborate curls which their owners seldom or never brushed out. Visits to the hairdresser were usually every three or four weeks, so a single louse picked up accidentally would have ample time to reproduce undisturbed. All efforts to change the fashion failed, including a determined campaign, supported by the hairdressers, to sponsor the " liberty cut," a much shorter style. We were told that our only hope would have been to persuade a famous Hollywood film star to introduce a new style and that would probably have succeeded. There was no question hut that head infestation and intelligence rating were related--the lower [grades had significantly more dirty heads. What is also amusing is that we found some support for the old wives' tale that lice only stay on healthy people. T h e incidence among those whose medical category was A1 was slightly but significantly higher than those in lower categories. I have only touched the fringe of our public health activities which covered every aspect of the women's life; we dealt with their working and living conditions, suitability of employment, clothing, food, morale, medical arrangements, hospital and everything which could possibly affect their health. It was a wonderful experience. I believe the fine upstanding young women who wore our uniform are testimony that our work was not altogether in vain. Certainly I for one, would not have missed the opportunity of learning so many salutary, and often painful, lessons in a branch of medicine which, when I went into the Army, was entirely outside my field of vision. With great diffidence I offer to you, as experts, these fruits of experience of an amateur.
THE WORK OF T H E HEALTH DIVISION OF THE U N R R A ITALIAN MISSION, 1944-47" By E. C. BENN, M.B., CH.B., D.P.H., Medical Superintendent, Seacroft Hospital, Leeds ; late Director of Health, U N R R A ltalian Mission T h e responsibilities of the U N R R A Italian Mission until the end of 1945 were limited, by resolution of the U N R R A Council, to measures designed to give immediate, relief to certain sections of the Italian population and particularly to nursing and expectant mothers and to children. In addition to giving medical relief, the Health Division was responsible for epidemic control, for the medical care of non-Italian displaced persons and for the U N R R A staff medical services. In 1945 the overall expenditure of the Mission was limited to 50 million dollars of which the health services were allocated nine million. T h e bulk of this went to provide medical relief supplies. T h e 1945 programme was supplementary to that carried out by the Allied Commission which was based on the provision of supplies and services sufficient to prevent disease and civil unrest. At that time the Mission was dependent upon the Allied Armies for all facilities such as office and living accommodation, rations and transport and movement was impossible except by military transport and with military travel orders. When the war ended, U N R R A gradually took over increasing responsibilities from the military and provided its own services as its operations extended. In 1946 the Mission was responsible for almost all the essential imported supplies which were required by the country, grain, coal, oil, metals, fertilisers and many others, and the Mission budget for that year was in the neighbourhood of 400 million dollars, of which seven million was used for the health services.
Medical Supplies After consultation with the Italian Government and Allied Commission, and after surveys in several parts of Southern Italy by the staff of the Health Division, lists of requirements were drawn up and sent to Headquarters early in 1945. These contained requests for large quantities of finished products such as drugs, dressings, medical and surgical equipment, hospital supplies and sanitation equipment to meet immediate needs. Among the larger items requested were ambulances, 40-bed and 200-bed hospital units, laboratory units and a few X-ray units. These were enthusiastically received some months later by communities which, owing to war damage, had been without such facilities for considerable periods. T h e reception, assembly and distribution of medical supplies was carried out by the Italian Government with U N R R A assistance, and no supplies were distributed unless need was proved by the recipient and approval given by the Health Division as the representative of the Mission. This was a large-scale supply operation and was not without its difficulties. Deliveries were delayed and component parts did not always arrive together. T h e greatest setback took place when a ship carrying surgical instruments and hospital and laboratory equipment hit a mine off the coast of Italy. T h e supplies were lost and procurement from overseas had to start over again. Cotton fabrics proved to be unobtainable from overseas and it was necessary to import raw cotton and to manufacture cloth for hospital linen and surgical dressings in Italy. In all about four and a half million metres of cotton cloth were made in Italy for the medical supply programme. T h e urgent need for medical supplies was obvious. Many hospitals in 1945 were without such essential drugs as morphia and ether, surgical dressings were almost unobtainable, many hospitals had been totally destroyed and large communities were without hospital accommodation, X-ray film did not exist and X-ray tubes could not be repaired or replaced so even screening was impossible. T h e general requisitioning of transport had almost stripped the country of ambulances which had departed with the retreating enemy. T h e need was therefore great, and distribution was carried through as rapidly as * Paper read to the Yorkshire Branch of the Society of Medical Officers of Health, Leeds, May 30th, 1947.