CRO 33 1 COUNTY BOROUGH OF CROYDON ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER For the Year 1931 OSCAR M. HOLDEN, M.D., D.P.H. CROYDON: Printed by the Croydon Times Ltd., 104, High Street. 3 PUBLIC HEALTH COMMITTEE. NOVEMBER, 1930—1931. The Worshipful the Mayor (Mr. Alderman T. Arthur Lewis, J.P.) Mr. Alderman H. J. Mori.and, M.A. J.P. (Chairman). Councillor Mrs. Roberts (Vice-Chairman). Mr. Alderman W. B. Southwell, J.P. Mr. Councillor E. E. L. Arkell. Mr. Councillor A. L. Boddington. Councillor Miss M. H. Glazier. Mr. Councillor W. J. Gibbins. Councillor Mrs. Heighton, J.P. Mr. Councillor B. Holden. Mr. Councillor S. Roden. Councillor Dr. A. Sandison, O.B.E. Councillor Mrs. Squire. Mr. Councillor A. J. Stubbs, M.I.C.E. For purposes of Maternity and Child Welfare: — Mesdames Hicks, Horn, Lewis, Southwell, and West. 3 COUNTY BOROUGH OF CROYDON ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER For the Year 1931. To the Chairman and Members of the Public Health Committee. Ladies and Gentlemen, I have the honour to present herewith my fourth Annual Report as Medical Officer of Health. The arrangement follows that of last year's report, but a new section dealing with the activities of the Obstetric unit, which commenced at the end of 1930, has been included. The contents of the report have been compiled to accord with the requirements of Circular 1206 of the Ministry of Health. Yital Statistics.—The Census has shown that the population has risen from 191,375 in 1921 to 233,115 ; an increase of 21.8%. The statistics for the year are, in consequence of the more accurate basic figure of population. nearer the truth than in 1930 when the population was an estimated one; and with a period of nine years since the previous census, the estimation was bound to be a little wide of the true figure. Nineteen thirty one did not maintain the high level of health of the previous year. The general death rate rose 0.9 per 1,000, and the Infantile Mortality 10 per 1,000 births. The Birth Rate again dropped and reached the low rate of 14.9 per 1,000 population. It is obvious that the large increase in population is mostly caused by immigration. Sanitary Circumstances.—Housing has occupied much attention. In addition to the routine inspections of houses, and the 4 investigation of complaints, a detailed survey has been made of the Old Town Area and four areas have been scheduled under Section I. of the Housing Act as Clearance Areas. A Local Enquiry was held by the Ministry of Health early in 1932, the result being that the majority of the properties scheduled were found to be such as to come under a Clearance Order. One of the most difficult problems to be dealt with in Croydon is the practice of subletting. It has quite frequently been found that overcrowding is caused by the tenant subletting a portion of the house. At present there appears to be no effective way of dealing with this practice. Five thousand one hundred and forty houses were inspected under the Public Health or Housing Acts and 3,094 were inspected under the Housing Consolidated Regulations 1925. Both of these figures ate a substantial increase on last year's showing. 3,381 houses were found not to be in all respects reasonably fit for human habitation. 1,206 houses were built in the Borough during the year of which 376 were erected by the Local Authority. Notices were served on owners to remedy housing defects in 3,381 cases, and 3,480 houses had been rendered fit by the end of the year. In a total of 5,140 houses inspected 2.4% were found to be overcrowded As there is no legal definition of overcrowding the basis used was that laid down in the local byelaws for Common Lodging Houses, and Houses Let in Lodgings. New byelaws came into force during the year, the standard of accommodation being altered: it is now based on floor area, and not as formerly on cubic space. The new standard is 40 square feet for persons over 5 years and 30 square feet for persons under 5 years. Continued and close supervision has been maintained by the Sanitary In spectore over Factories, Workshops and Workplaces, Common Lodging Houses, Houses let in lodgings, and Offensive Trades. The large amount of building taking place has led to difficulties inasmuch as houses may be built in proximity to an established trade, and later when the houses are occupied complaints arise about the trade. The same also occurs, when in a non Town planned area, a factory or similar building is erected in the midst of housing property. The only remedy for this would seem to be widespread Town-planning and grouping of industries as far as possible in one area of the town. 5 Food Supply.—There is manifest a general improvement in standard of cleanliness, it rests with purchasers to insist on being supplied with a clean, wholesome article, prepared or stored under hygienic conditions. Strict supervision has been maintained on the milk supplies. The chemical standard was, on the whole, satisfactory. 13 samples out of 425 or 3.05% did not come up to statutory requirements. It was, however, on the bacteriological side that most concern was felt. Although clean and dirty milk are not legally recognised, there being only one fluid, namely milk, as produced by the cow; from the health standpoint the bacteriological content is of greater moment than chemical composition. The era of a clean raw milk is apparently a long way off, and consequently it is necessary to advocate the second best, namely pasteurisation. Efficient pasteurisation is a safeguard against milk infections but it should not take the place of careful and cleanly production and collection of milk. The large milk companies recognised the importance of this and have in operation systems of checking the cleanliness of milk received by them from farms, before it is objected to pasteurisation. Farms sending in dirty milk are warned and if no improvement results, the supply is stopped. Out of a total of 302 samples of milk taken by the inspectors 60 fell below the very moderate standard of Grade A milk. Eleven samples were found to contain tubercle bacilli. These samples were derived from seven farms. The Milk Control Committee have considered the present confusing nomenclature of graded milks, and have drawn up and submitted a simplified classification to the Ministry of Health. Over 90% of the milk sold in Croydon is bottled milk; the days of the can and jug seem to be passing. This his is all to the good if it is remembered that bottling only keeps milk from external contamination in transit; it will not clean dirty milk, and dirty bottles will make a clean milk dirty. The consumer also cannot complain of the milk going sour if it is kept under unsuitable conditions in the home. An innovation, which promises to expand, is the retailing of milk in sealed cartons. This milk is put into the cartons at the farm and the process eliminates all human contact with the milk. Provided the milk at its source is satisfactory, this is an excellent method of distribution. Constant supervision has been maintained over bakehouses, ice-cream factories and other food preparing premises, also over eating houses, restaurants, and similar establishments. Infringements of the Shop Hours' Act have been 59 less than in 1930. 6 Cancer.—There is no notable increase in the mortality from this disease. As cancer is essentially an ailment of older people, its true incidence cannot be accurately estimated without a recent age-grouping of the population. These details are not yet available from the 1931 Census returns. Once more it is emphasised that cancer is a curable disease if diagnosed early and treated skilfully. Any unusual and persisting symptoms in persons over 40 years of age should be medically investigated. Hospital Accommodation.—Although the appropriation of Mayday Hospital by the Public Health Committee had not taken place when the year ended, the whole matter of hospital accommodation has been thoroughly explored and schemes for considerable extensions to the Mayday Hospital have been before the Council. There is a serious dearth of hospital beds in the town, which is not met by its proximity to the big London hospitals, as the demands on the latter from the areas served by them are greater than they can meet. The modern practise of living in flats or apartments has something to do with this increased demand on hospital beds. Also the increasing complexity and expense of modern treatment are leading people to be nursed away from home. The proposed extensions to Mayday Hospital will increase the total number of beds in the hospital from 465 to 564. When it is remembered that already, in times of widespread illness, the number of patients in the hospital at one time has exceeded this latter number, the present condition of overcrowding can be appreciated. The proposed extension only meets normal requirements, in times of extraordinary demands there still will be overcrowding. For forty years the bed accommodation in Mayday has remained the same, with the exception of 40 beds in two pavilions for children. In this time the population has increased by 131,103. Infectious Diseases.—Neither Diphtheria nor Scarlet Fever have been prevalent, and all the notifiable infectious diseases show a decreased incidence with the exception of Small-Pox and Pneumonia. There was a short, sharp but circumscribed outbreak of the former, originating in the Council's Common Lodging House. Prompt and energetic action, however, limited its spread to a small area of the town. The increase of Pneumonia was due to a moderately severe incidence of Influenza during the first quarter of the year. Influenza was the chief cause for the less favourable vital statistics of the year. Tuberculosis.—There is a steady decline in the incidence of and mortality from this widespread infection. Certain age groups 7 of the population, however, are showing a greater decline than others; among the 15-30 age period in females the decline has apparently ceased. The causes for the behaviour of Tuberculosis are imperfectly understood, in spite of the great amount of research which has been and is being carried out. Whether the Tuberculosis Schemes of local authorities have exerted an influence in bringing about the decline, or whether it is merely a variation in the cyclic course of a disease in which the cycle covers a very long period of years, is impossible with our present knowledge, to ascertain with any degree of certainty. There is, however, very little doubt, that the activities of sanitary authorities, in connection with the milk supply, has lessened the amount of non-pulmonary Tuberculosis. One of the most difficult aspects of Tuberculosis is its chronicity. This is more a social problem than a medical. The rehabilitation of a Tuberculous patient after a long period of sanatorium treatment is a difficult matter. In many instances the patient, although fit for productive work if the work can be done on free and easy lines, breaks down when thrown into the competitive work of every day business. In others the patient returns with the disease quiescent from the Sanatorium back to the same condition which brought about his initial breakdown ; naturally before very long another breakdown happens. It is not the early Sanatorium case nor the advanced bed-ridden hospital case who cause the difficulties, but the case in between who is unfit for full work under industrial conditions, but fit for sheltered work; who is capable of mixing freely with his fellowmen, but unable to compete with them on level terms. Until some widespread scheme is adopted, possibly extensions or modification of the present, very limited colony system, throughout the country, there will be little hope of the final eradication of Tuberculosis. Such schemes would perforce, be expensive, but Tuberculosis is a costly disease and its eradication would be an ultimate saving; unfortunately perhaps the visible saving effected would be a deferred one and would not, to any great degree, benefit the present generation. The Occupation work organised in the Cheam Sanatorium and also for patients in their homes on returning from the Sanatorium has had a busy and successful year. The object of this scheme is primarily therapeutic. There is perhaps nothing more demoralising mentally and bodily, than months of enforced idleness. If a patient can occupy the time in making useful and artistic articles it is of distinct benefit in the treatment. All the home workers are kept under supervision and visited from time to time by the 8 Instructress. A ready market has been found for the goods, as they are of a high quality, in most cases being very beautifully conceived and skilfully executed. Venereal Diseases.—The year showed no signs of any distinct increase in the incidence of venereal disease. The number of attendances for treatment dropped. This is unfortunate. The weakest point in the control of venereal disease is the cessation of attendances for treatment before the disease is properly cured. Some patients think as soon as the acute symptoms have passed there is no need for further treatment. This attitude is a very mistaken one and a patient who ceases treatment before being pronounced cured by the doctor is doing a grievous disservice to the community and to himself. Maternity and Child Welfare.—The section of my report dealing with this subject contains a full account of the work carried out in the new Obstetrical Unit. Though much of the information is naturally of a purely medical character, there is furnished abundant proofs of the utility and essentially preventive aims of the work, and, of the increasing willingness of women to avail themselves of the facilities placed at their disposal. More especially has the new Post-Natal Clinic filled a former blank and through its agency many women have been spared unnecessary ill-health. The Infant Welfare Centres show a new peak of attendances, namely 67,783, an increase of 3,832 on last year's total. Some of the Centres are badly overcrowded. The Croydon Mothers' and Infants' Welfare Association will open a new Centre shortly in Thornton Road which should help to relieve two other centres, but there is need for further Centres in various parts of the town. The Children's Convalescent Home at Coombe Cliff has proved of great value and has been fully occupied throughout the year. The results obtained have shown that given careful management, proper dieting and hygienic surroundings children will improve in health just as rapidly and completely as they do at the seaside. The Observation Nursery has also had a busy year and although only a small and consequently a rather expensive institution, it is doing useful public health work. When additional accommodation for young children is available at the Mayday Hospital there will be no reason for a separate Observation Nursery, as both institutions will be administered by the same Committee. The School Clinics 9 and the Ante-Natal Clinics which are housed on the ground floor of the Nursery buildings, are seriously cramped. The release of the upper floor from its present functions would give a welcome opportunity to house the Clinics in more spacious quarters. Although the infantile Mortality rose a little, due to an unfavourable frist quarter of the year, the rate is maintained at a low figure. That the rate can be further reduced is not disputed, and the energies of the department are being continually directed towards this aim; but, on the other hand the population of the town and its character are changing. Increasing industrialisation of the area is bringing new difficulties to overcome. The Health Visitors are now responsible for all home visiting, with the exception of visits to Tuberculosis patients. The nature of their work is varied, embracing as it does, visits for the School Medical Service; for Maternity and Child Welfare; Blind Persons, and Foster Children, it is considered advantageous that these different kinds of visiting should be done by one person only. The town has been divided into districts and each health visitor is responsible for all visits in her district. By this means, a succession of different visitors to a house is avoided ; time is saved; and the visitors have a higher prestige with their clientele, as they can advise and help officially on a variety of Public Health matters affecting family life. Mental Deficiency.—The Surrey County Council, during the year completed their preliminary arrangements for founding a Colony at Chertsey and the Botley's Park Institution was opened on the 30th January, 1932. A former Poor Law institution at Bletchingley and another at Ottershaw have been adapted for the accommodation of adult mentally defective persons. This has relieved the situation to some extent, as Croydon is participating in these provisions. There is still, however, a dearth of institution beds for our cases. The Council's small home for low-grade mentally deficient boys, at 6, Morland Road, has been continued and its accommodation has been fully occupied. Orthopaedics.—This department continues to grow. Although gross deformities are not seen so frequently as in years past there is still an amount of avoidable crippling brought about in various ways, sometimes due to disease, sometimes to accident. Slight deformities may be neglected so that from being curable they 10 become fixed and incurable. The Remedial Exercises Clinic at Pump Pail and the Massage Clinic at Lodge Road have done useful work in their endeavours to cure and to prevent cripples. Propaganda.—No spectacular efforts have been made. It is felt that the best propaganda is steady work, for the basis of all Public Health work is education. The time of the medical and nursing staff is not so much spent in mending damaged goods as in advising and teaching how damage may be prevented. The localised edition of "Better Health" has been continued; 4,000 copies being distributed monthly. Addresses have been given, on request, to several of the Ratepayers Associations in the town. The audiences have not always been large, but their smallness has been compensated for by the interest displayed. There is, however, still widespread ignorance of the scope and aims of Public Health services. It is to the advantage of the work for its extent to be widely known and to this end a small handbook has been drawn up and circulated in the town. Ignorance of its objects or lack of interest in its activities are the greatest obstacles to a proper valuation of the Public Health Services in force throughout the country. In a time of financial stringency illness is extravagance. Schemes which have as their object the betterment of health, and the reduction of avoidable ill-health, are economies, not luxuries. In conclusion I wish to tender my thanks to the Chairman and Members of the Public Health Committee, the Menal Deficiency Committee, the Housing Committee and the various Sub-Committees for the sympathetic consideration they have given to proposals I have submitted to them, and for the interest they have taken in the work of the department. The staff have carried out their duties in a satisfactory manner, and especially I wish to mention the large and increasing amount of work carried through by the clerical staff. The Local Government Act, 1929, brought additional responsibilities which they have undertaken without any augmentation in their personnel. Dr. W. B. Watson, the Deputy Medical Officer of Health has continued his unfailing and unstinted help at all times. I am , Yours faithfully, OSCAR M. HOLDEN. Medical Officer of Health. 11 CONTENTS. A.-PUBLIC HEALTH REPORT. PAGE Acts, Adoptive 41 Ambulance Service 21 Amusement Houses 56 Animals, Keeping of 56 Ante-natal Clinic 161 Aerodrome 226 Bacteriological Examination 110 Bakehouses 52 Births 30 Blind Persons 210 Borough Hospital 95 Bye-laws and Regulations 42 Cancer 80 Contacts, Tuberculosis 124 Cowkeepers 68 Croydon Nursing Service 143 Children's Act 209 Convalescence 207, 208 Dairies, Cowsheds and Milkshops 68 Deaths 36 Dental Treatment—M. & C.W. 204 Diphtheria 89 Disinfection 57 Dispensary, Tuberculosis 130 Dried Milk 200 Enteric Fever 105 Expectant Mothers 205 Factories & Workshops Acts 50 Fertilisers & Feeding Stuffs Act 57 Foods, Inspection of 64 Foods & Drugs Acts, Sale of 75 Foster-Mothers 209 Foster-Children 209 Grangewood, Special School 215 Health Visitors, Work of 199 Home Nursing 143 Homework 52 Hospitals 18 Hospital, St. Mary's (Maternity) 179 Housing 48 Illegitimacy 15 Infant Welfare Clinics, Municipal 157 „ „ „ Voluntary 157 Infant Mortality 182 Infectious Diseases 83 Laboratory Work 110 Local Acts 41 Local Government Act 22 Lodging Houses, Common 53 Massage Clinic 202 Maternity Homes 192 Maternity Homes, Registration 192 Mayday Road Hospital 23 Measles 85 Meat Inspection 62 Medical Help Records 190 Meteorology 27 Mental Deficiency 212 Midwives 189 Midwives Act, Section 14 192 Milk, Provision of 200 Milk, Tuberculous 73 Milkshops 68 Mortality in Child-birth 158 Mothers' and Infants' Welfare Association 193 Neo-natal Deaths 186 Notification of Births Acts 158 Nuisances 42 Nursing Arrangements 143 „ Homes 192 Obstetrical Unit 160 Occupation Centres 217 Offensive Trades 55 Ophthalmia Neonatorum 182 Orthopaedic Department 219 Overcrowding 50 Poisons & Pharmacy Act 56 Poor Law Relief 21 Population 40 Prosecutions 76 Public Laboratory 110 Puerperal Sepsis and Pyrexia 159 Rag Flock Act 55 Rats & Mice (Destruction) Act 58 Rent Restriction Acts 48 Sanatorium, Cheam 148 Sanatoria, Treatment in 141 Sanitary Administration 41 Sanitary Inspectors, Work of 42 Scarlet Fever 88 Shop Hours Acts 53 Sick Nursery 201 12 PAGE Slaughterhouses 61 Social Conditions 16 Smallpox 90 Smoke Observations 55 Sputum, Examination 125 Staff 13 Still-births 180 Tuberculosis—Contacts 124 „ Deaths 115 „ Notifications 117 „ Home Nursing 143 „ Home Visits 143 „ Tables 130 PAGE Unmarried Mothers 207 Ultra-Violet Light 223 Vaccination 111 Venereal Diseases 151 Verminous Persons 57 Veterinary Inspection 225 Vital Statistics 16,30 Water Supply 17 Winds, Prevailing 28 Workplaces 51 Workshops 51 X-ray Examination 129 B.—SCHOOL MEDICAL REPORT. PAGE Accommodatio 240 Adenoids 252 Blind Children 297 Cleansing of Children 244 Clinics 268 Clothing and Footgear 244 Cost 240 Crippling Defects 272 Deaths 262 Deaf Children 254 Defective Children 298 Deformities 272 Dental Disease 273 Dental Treatment 273 Domestic Subjects 303 Ear Disease 286 Epileptic Children 298 Exclusions 261 Eye Clinic 271 Eye Disease 256 Following up 267 Health Visitors, Work of 267 Heights and Weights 247 Hygiene of Schools 236 Infectious Diseases 263 Inspection Clinic 271 Inspections, Routine 244 Inspections, Special 242 Ionization Treatment 286 Juvenile Employment 299 PAGE Lungs, Diseases of 250 Malnutrition 244 Massage Clinic 272 Meals, Provision of 299 Mentally Defective Children 298 Milk, etc., Provision of 299 Minor Ailments 269 Open-air Classes 297 Orthopaedic Work 272 Orthodontic Service 279 Parents, Attendance of 239 Physical Training 302 Physically Defective Children 298 Remedial Exercises 272 Rheumatism clinic 291 Sanitary Accommodation 238 Schick Test 265 School Camps 298 Schools, Special 298 Secondary Schools 304 Skin Affections 255 Speech 254 Staff 228 Statistical Tables 306 Surveys, Uncleanliness Tonsils, Enlarged 252 Treatment 268 Tuberculosis 250 Uncleanliness 244 Vision Defective 256 13 STAFF OF THE HEALTH DEPARTMENT. The staff of the Public Health Department on the 31st December, 1931, was as follows:— Medical Staff.— (a) whole-time:— Oscar M. Holden. M.D., D.P.H., Medical Officer of Health, School Medical Officer, and Medical Officer under the Mental Deficiency Acts, etc. Wm. B. Watson, L.R.C.P., L.B.C.S., D.P.H., Deputy Medical Officer of Health, Deputy School Medical Officer and Medical Officer under the Mental Deficiency Acts. J. C. McMillan, M.B., Ch.B., B.A.O., B.Sc., D.P.H., Assistant Medical Officer of Health for Tuberculosis. Douglas M. Lindsay, M.D., F.R.F.P. & 8., Assistant Medical Officer of Health for Obstetrics. F. W. Gavin, M.D., Ch.B., D.P.H., Assistant Medical Officer of Health and Assistant School Medical Officer. P. J. O'Connell, M.D., B.S., D.P.H., Assistant Medical Officer of Health and Assistant School Medical Officer. Olive B. Falk, M.B., B.S., Assistant Medical Officer, Maternity and Child Welfare, and School Medical Service. Iris A. Jenkin-Lloyd, M.R.C.S., L.R.C.P., D.P.H., Assistant Medical Officer, Maternity and Child Welfare, and School Medical Service. J. Todesco, M.D., M.R.C.S., L.R.C.P., D.P.H., Resident Medical Superintendent, Borough (Fever) Hospital. R C. Poyser, M.R.C.S., L.R.C.P., Resident Medical Superintendent, Croydon Borough Sanatorium. (6) Part-time:— J. R. Draper, B.A., M.B., Medical Inspector of Aliens. Mary McDougall, M.B., C.M., Assistant Medical Officer, Maternity and Child Welfare. L. Ruth Duffy, M.B., Ch.B., Assistant Medical Officer, Maternity and Child Welfare. J. S. Bookless, B.A., M.B., F.R.C.S.—Opthalmic Surgeon (School Medical Service). J. D. McLaggan, M.A., M.B., Ch.B., F.R.C.S.—Ionization Clinic Specialist. Rota of 8 local medical practitioners for surgical treatment of tonsils and adenoids. Dental Staff.— Senior Dental Surgeon: J. F. Pilbcam, L.D.S. Assistant Dental Surgeons: J. K. R. Bryce, L.D.S., K. C. B. Webster, L.D.S. Inspectors.— R. J. Jackson, M.R.S.I., A.M.I.S.E., M.S.I.A., Chief Sauitary Inspector, F. F. Fulker, A.R.S.I., A.I.S.E., M.S.I.A., Deputy Chief Inspector. 14 District Sanitary Inspectors. In addition, there are 5 disinfectors, 1 rat-catcher, and 4 assistants to the Sanitary Inspectors. Health Yislting Staff— 19 District Health Visitors; 2 Special Visitors; 2 Tuberculosis Nurses; 2 Clinic Nurses; 1 Almoner and 2 Dental Assistants. Also 2 whole-time Masseuses and Remedial Gymnasts. Croydon Borough Hospital, Croydon Borough Sanatorium, Sick Nursery, Coombe Cliff Convalescent Home and 6, Morland Road. Nursing and Domestic Staffs. Clerical staff— Twenty-three full-time clerks, 14 SUMMARY OF VITAL STATISTICS FOR 1931. Area 12,617 acres. Population (Census 1931), 233,115. Population (estimated middle of 1931), 233,800 Number of Inhabited Houses (1931 Census), 56,429. Rateable Value (1st April, 1931), £1,961,171. Product of a Penny Rate (1930-31), £7,668. Rate in the £ (1930-31), 9s. 8d. (Addington Ward only, 9s. 5d.). Gross expenditure on Health Services (administered by Medical Officer of Health) £88,535 4 4 Income on Health Services 5,802 13 1 Net expenditure on Health Services £82,732 11 3 The changes caused by the Local Government Act, 1929, prevent any true comparison of the financial figures for 1929-30 and 1930-31. The net expenditure of the Public Health Department for 1929-30 was £52,721. The excess of £30,011 in 1930-31 is largely accounted for by the discontinuation of Government grants and the payment by the local authority to voluntary associations, of grants formerly paid directly by the Government. Live Births— M. F. Total. Legitimate 1,711 1,525 3,236 Illegitimate 100 64 164 Birth-rate per 1,000 of the estimated resident population, 14.6. Still Births—101. Rate per 1,000 total (live and still) births, 14.9. Deaths—2,674. Death-rate per 1,000 of the estimated resident population, 11.4. Deaths from diseases and accidents of pregnancy and childbirth: From sepsis, 11; other causes, 12. 15 Death-rate of Infants under one year of age:— All infants per 1,000 live births 58 Legitimate infants per 1,000 legitimate live births 48 Illegitimate infants per 1,000 illegitimate live births 134 Deaths from Measles (all ages) 0 ,, ,, Whooping Cough (all ages) 9 ,, ,, Diarrhoea (under 2 years of age) 15 „ ,, Diphtheria (all ages) 5 Per 1,000 of the population. Deaths from Diseases of the Respiratory System (including Tuberculosis) 2.39 ,, ,, Cardiac and Circulatory System (including Cerebral Hæmorrhage) 4.06 „ ,, Renal System 0.33 „ ,, Digestive System 0.37 ,, ,, Suicide or Accidents 0.53 ,, Old Age 0.12 16 SECTION I. SOCIAL CONDITIONS AND VITAL STATISTICS. Croydon is largely a. dormitory town, but there are a number of industries in the area. The industrial side of the town shows progressive development. The chief industr.es are iron foundries (bell casting) and engineering. The London Terminal Aerodrome is within the County Borough Boundary. The population is growing rapidly. The increase of population revealed in the 1931 census was 21.8% on that for 1921. This is the highest rate of increase for any town having a population of over 100,000 at the 1921 census; and is the fourteenth for all towns in England and Wales. Bearing on this great increase it is noteworthy that 15 of the 28 increases of over 10% are in areas wholly or partially within Greater London. There is a definite drift of the population southwards. Towns showing decreases in population are nearly all northern towns. This drift brings with it public health problems which must be met as they arise. Croydon is an aggregation of townships, each of which shows its own characteristics. Bad structural housing conditions are met with in the central part of the town, particularly in Whitehorse and Central Wards, though there are individual streets in nearly every ward in the town in which the standard of house property is low, when compared with the other residential streets. Various miscellaneous industrial undertakings are scattered throughout the Borough. This is a matter of some moment. There is at present no power to prohibit factories being placed anywhere in areas which are not scheduled under Town Planning. As Town Planning deals with immediate and future development, it does not affect oldestablished areas, and the proximity of factories to residential areas has caused complaints from time to time. The 1931 Census gave a total enumerated population of 233,115, details regarding the number of the sexes, occupations and housing have not yet been published by the Registrar General. In the 1921 Census returns 5.75 was the average number of rooms per dwelling and 1.14 the average number of families in each dwelling, which gives 1.25 rooms per person. In 1921, 4.7% of the population was living more than two persons per room, a slight increase in density over 1911 (4.3%), 17 Water. The water supply is drawn from deep wells in the chalk. These wells are situated at Surrey Street, Stroud Green, Waddon, Selhurst, and Addington. A portion of the northern side of the Borough obtains water supplies from the Metropolitan Water Board. I am indebted to the Borough Engineer, Mr. G. F. Carter, for the following information:— A constant supply of water was maintained throughout the year, and has been satisfactory both in quality and quantity. Monthly analyses of the water were made at the five pumping stations, and in many cases at more frequent intervals. The Corporation's wells are all in the chalk, and a sample analysis is as follows:— Clear and bright. Hardness—Temporary, 16.3 deg. „ Permanent, 3.7 deg. No B. Coli in 100 c.c. No Streptococci. No acid in 100 c.c. The supply during the year was from the Corporation's Wells 2,179,205,749 Metropolitan Water Board in bulk 489,587,000 2,668,792,749 gallons. This works out, on a population basis of 235,000, at a consumption of 31.114 gallons per diem per head. Risers and Streams. There are only small streams or ditches. These have been kept in a good state. Drainage and Sewage. Extensions of the sewerage system have been made to keep pace with the growth of the Borough, in particular in the new area of Addington which was added to the Borough in 1928. Over £36,000 has been expended in main sewers and surface water 18 drains. At the sewage disposal works at Beddington, three Activated Sludge plants are in operation dealing with 3½ to 5 million gallons per day. Closet Accommodation. All the buildings are provided with water closets connected to a proper sewerage system excepting a few cases of houses and bungalows situate in remote positions, in which the sewage goes to cesspits. Owing to topographical reasons, certain large houses in Upper Norwood have their own sewage purification plants. Scavenging- Complete and up-to-date methods are in operation for scavenging and refuse disposal. There are two Refuse Destructors, and at one of these a new Salvage Plant has been constructed for separating paper, tins, etc., before passing to the furnaces. Hospitals Provided or Subsidised by the Local Authority. (1) Tuberculosis. Borough Sanatorium, North Cheam. 93 beds are provided for the treatment of early, intermediate and advanced cases. Five beds are reserved by the Kent County Council for cases sent by them. (2) Maternity. St. Mary's Hospital, St. James' Road, Croydon. This Hospital is conducted under the auspices of the Croydon Mothers' and Infants' Welfare Association. Thirty-two beds (with cots attached) are provided. The Hospital receives an annual subsidy of £3,600 from the Local Authority as 30 of the beds are reserved for cases referred through the Local Authority. (3) Children. (a) Sick Nursery, Lodge Road. These premises occupy the upper storey of the buildings erected by the Council. Accommodation is provided for 14 sick children under 5 years of age, and a ward for the reception of two nursing mothers, 19 (b) 6, Morland Road. This is a small house for low grade mentally defective boys. It contains 20 beds which have been fully occupied throughout the year. (c) Coombe Cliff Convalescent Hospital. This Home was opened in November, 1930, for the reception of infants and children convalescing from acute illnesses. It is available for any child resident in the Borough and approved as suitable. The majority of the cases are referred from the Public Health and School Medical Departments, but cases have also been admitted from Mayday Road Hospital and at the request of private medical practitioners. (4) Fever. The Borough Hospital, Purley Way. The nominal accommodation is for 220 patients. Cases of all the notifiable infectious diseases are admitted other than tuberculosis. (5) Small Pox. The Croydon and District Joint Small Pox Hospital Board's Hospital is now used as the Borough Sanatorium. Arrangements have been made with the Surrey County Council to receive into their Clandon Hospital cases of small pox arising in Croydon. Wher Hospitals. Croydon General Hospital. A voluntary institution at which the Council holds four clinics conducted mainly by members of the staff of the Hospital. These (a) Tonsils and Adenoids Clinic; (b) Orthopaedic Clinic; (c) Venereal Diseases Clinic; (d) Ultra-Violet Ray Clinic. The Council's Pathological and Bacteriological Laboratory is also within 'he curtilage of the Hospital; the buildings being provided by the Hospital; the staff, equipment, etc., by the Corporation. I am indebted to the Secretary, Mr. G. H. Dams, for the following information:— Male Beds 36 surgical 19 medical Female Beds 34 surgical 19 medical Children's Beds 22 A total of 130 beds. 20 The number of in-patients treated during 1931 was 1,947 the average stay of each in hospital being 20.1 days. The number of out-patient attendances was 126,655. The bed accommodation remained unchanged, but plans are in hand for the addition of 61 beds. Mayday Hospital. The institution provides the following accommodation:— Male Beds urgical 32 Medical 64 Tuberculosis 32 Mental 32 Female Beds Surgical 32 Medical 128 Tuberculosis 32 Mental 32 Children's Beds 70 Maternity Beds 22 with 14 cots additionally. Total 476 beds. The Purley and District War Memorial Hospital. This is situated on the Brighton Road close to the boundary between Croydon and Purley. It is supported entirely by voluntary aid and offers the following provision:— Males (surgical and medical) 10 beds; Female (surgical and medical) 10 beds; Children 8 beds; Maternity 6 beds; together with 6 private wards; a total of 40 beds. The Norwood and District Cottage Hospital. Males (surgical and medical) 15 beds; Female (surgical and medical) 15 beds. In addition there are two private wards; a total of 32 beds. Provision for Unmarried Mothers, Illegitimate Infants and Homeless Children. Provision is made at Mayday Road Hospital and at various Children's Homes. Unmarried mothers are admitted to Mayday Road Hospital, and to St. Mary's Hospital for the first confinement only, as well as to a large maternity home at Norwood, established by the Free Church Council. Two other Voluntary Institutions also 21 offer facilities for unmarried mothers, namely, The Mission of Hope, Birdhursr, Lodge, and the Rescue and Preventive Home, 34, Morland Road, Croydon. The Mission of Hope also receives illegitimate children from various districts, as a preliminary to establishing them with foster mothers or adopting parents. The Babies Help Committee of the Croydon Mothers' and Infants' Welfare Association is especially concerned with individual cases of unmarried mothers and their children. The National Society for the Prevention of Cruelty to Children. This Society, through their Inspector, Mr. Brown, has helped the department in various ways. During the year 14 cases were referred. The reasons for reference were: neglect to obtain treatment for adenoids and enlarged tonsils, 9 ; neglect to obtain other medical or dental attention, 1; for miscellaneous reasons, 4. In connection with these references; the Society's Inspector paid 52 supervisory visits additional to the preliminary investigation. AMBULANCE FACILITIES (1) Two Motor Ambulances are provided by the Council for the removal of infectious cases from the Borough and Penge. (2) For non-infectious, surgical or medical cases— (a) Three motor ambulance provided by the Council operating from the Chief Fire Station, Park Lane. (b) Three motor ambulances operating from the Addiscombe Division of the St. John's Ambulance Brigade. POOR LAW RELIEF. No. of residents in Croydon County Borough Area in receipt of outdoor poor relief on the 1st January, 1931 1,546 persons; 669 cases (including able1st July. 1931 1,531 „ 649 „ „ bodied). 1st January, 1932 2,057 ,, 861 ,, „ Number of Croydon persons relieved in the Mayday Road Hospital on 1st January, 1932, and in the Queen's Road Homes on the same date— Mayday Road Hospital 436 Queen's Road Homes 474 22 Expenditure on Out-relief to Croydon cases during the 12 months ended 30th September, 1931— Half-year ended 31st March, 1931 £12,055 9 7 Half-year ended 30th Sept., 1931 £11,941 0 7 Mayday Road Hospital. The total number of sick children on 1st January, 1931: 98. Admitted during the year 1931 895 Discharged or died 908 No. remaining on 1st January, 1932 85 On 1st January, 1932, the total number of beds at the Mayday Road Hospital was 465 and the total number of inmates 479.* *It will be noticed this number is in excess of the certified accommodation. Extra beds are introduced as and when required, to take the excess cases. THE LOCAL GOVERNMENT AGT, 1929 This Act came into force on April 1st, 1930. Among other provisions not immediately related to public health, this Act abolished the Boards of Guardians, whose duties passed to the Councils of Counties and County Boroughs. In order to meet the new obligations the Councils formed Public Assistance Committees, who undertook all those duties of the Guardians which were not delegated to Special Committees of the Councils. In Croydon the delegated duties comprise the carrying out of the Children Act, 1908, Part I., which is now done by the Public Health Committee, as is also the carrying out of the Vaccination Acts. In addition modified arrangements were made in connection with Maternity, Tuberculosis, and Mentally Deficient patients. Tne Council is now responsible directly through its Public Health and Mental Deficiency Committees for the care of these classes. The Mayday Road Hospital has not yet been appropriated by the Public Health Committee under Section 137 of the Public Health Act, 1875. The cessation of the percentage grants from the Ministry of Health and the substitution of block grants affected the social services far more than any other sphere of the Council's work. As indicated in the various relevant portions of this report, the voluntary agencies carrying out work of public health interest now 23 receive their assistance direct from the Council in the form of annual grants. These grants have been fixed for a three-year period, at the end of which term they will be open to revision. The valuable work which the Voluntary Societies are doing is now closely linked up with official public health work, to the mutual benefit of both parties, and especially of the persons to aid whom the Societies have been founded. Details were given in my Annual Report for 1930, of various reports that had been compiled in ascertaining the hospital bed accommodation at present available, and the estimations of what was thought to be required. No material change has taken place during 1931. MAYDAY ROAD HOSPITAL. Area and Population served by the Institution— (a) Oroydon County Borough: Acreage, 12,617 acres. Population (estimated 1931), 233,800. (b) Surrey Parish of late Croydon Union (Beddington, Coulsdon, Merton, Morden, Mitcham, Sanderstead, Walliugton and Woodmansteme). Acreage, 19,176. Population (1931 Census), 163,300. (c) Penge Parish (Portion of former Croydon Union"). Acreage, 770. Population (1931 Census), 27,762. The medical staffing of the hospital comprises a medical superintendent, four resident medical officers and five visiting medical staff. The specialist services supplied are Ophthalmic, Dental, Radiological, Orthopaedic, Ear, Nose and Throat and Tuberculosis. The nursing staff consists of matron, 18 sisters, 11 trained stall nurse, 5 assistant nurses, 57 probationers and 9 male attendants. Beds available for Sick, Maternity and Mental Cases— (a) For Men 160 (b) For Women 246 (c) For Children under 16 70 476 24 Table I. Table shewing the Classification of the accommodation for the sick and the number of beds occupied on the 31st December, 1931— ALL CASES. Classification of Wards. (1) Number of Wards. (2) BEDS MEN WOMEN CHILDREN under 16 years of age) Total Provided. (3) Occupied (4) Provided (5) Occupied (6) Provided (7) Occupied (8) Provided (9) Occupied (10) 1. Medical 21 32 34 48 49 ... ... 80 83 2. Surgical 2½ 32 27 48 45 ... ... 80 72 3. Children 4 ... ... ... ... 70 50 70 50 4. Ohronic sick 3 32 33 64 67 ... ... 96 100 5. Venereal ... ... ... ... ... ... ... ... ... 6. Tuberculosis 2 32 34 32 38 ... ... 64 72 7. Isolation ... ... ... ... ... ... ... ... ... 8. Maternity 1 ... ... 22 19 ... ... 32 19 9. Mental 2 32 35 32 29 ... ... 64 64 Total 17 160 163 246 247 70 50 476 460 Table II Statistics relating to the Year ended 31st December, 1931. IN-PATIENTS. Croydon. Surrey. Kent. 1.—Total number of admissions (including infants born in hospital) 3289 390 3 2.—No. of Maternity cases admitted. 347 26 1 3.—No. of live births 326 24 1 4.—No. of still births 22 2 0 5.—No. of deaths among the newlyborn (i.e., under 4 weeks of age) 19 2 0 6.—Total number of deaths of children under one year 61 2 0 7.—Total number of maternal deaths. 3 1 0 8.—Total number of deaths 671 78 1 9.—No. of patients discharged 2719 265 5 10.—Duration of stay of patients included in 8 and 9 above: (a) Four weeks or less 2347 240 6 (b) Exceeding 4 weeks, but under 13 weeks 762 72 0 (c) Exceeding 13 weeks 281 31 0 11.—No. of beds occupied: (a) Average during the year 402 84 4 (b) Highest (on 23-4-31) 455 113 6 (c) Lowest (on 26-9-31) 307 37 3 12.—No. of surgical operations under general anæsthetic (excluding dental operations) 564 34 0 13.—No. of abdominal sections 219 24 0 OUT-PATIENTS: Nil. 35 Table III. Classification of In-Patients who were Discharged from, or who Died in the Institution during the year ended 31st December, 1931. Disease Groups. Children (under 16 years of age). Men and Women. Discharged Died Discharged Died C. S. K. C. S. K. C. S. K. C. S. K. A.—Acute infectious disease. 18 3 - - - - 23 1 - - - - B.—Influenza 2 - - - - - 23 3 - 4 - - C.—Tuberculosis: Pulmonary Non-pulmonary 2 - - 3 - - 54 8 - 46 2 - D.—Malignant disease 4 - - - - - 4 1 - 4 - - E.—Rheumatism— - - - - - - 46 7 — 84 8 - (1) Acute rheumatism (rheumatic fever) together with subacute rheumatism and chorea) 6 1 - - - - 10 6 - 8 2 - (2) Non-articular manifestations of socalled “rheumatism” (muscular rheumatism, fibrositis, lumbago and sciatica) 2 - - - - - 16 4 - 4 - - (3) Chronic arthritis - - - - - - 21 - - 3 - - F.—Venereal disease 1 - - - - - 17 1 - 1 - - G.—.Puerperal pyrexia - - - - - - 15 - - - - - H.—Puerperal fever— (a) Women confined in the hospital - - - - - - - - - - - - (b) Admitted from outside - - - - - - - - - - - - I.—Other diseases and accidents connected with pregnancy and childbirth - - - - - - 103 9 8 - - J.—Mental diseases— (a) Senile dementia 4 - - 1 - - 276 43 2 14 8 - (b) Other - - - - - - - - - - - - K-—Senile decay - - - - - - 27 1 - 86 7 - L.—Accidental injury and violence 24 1 - 2 - - 123 12 - 6 2 - In respect of cases not included above: M.—Disease of the Nervous System & Sense Organs. 58 2 - 9 1 - 83 14 - 29 5 - ,, Respiratory ,, 71 6 - 15 2 - 166 20 - 106 14 - O. Circulatory „ 25 - - 6 - - 96 8 - 106 9 - P. „ Digestive ,, 126 12 - 19 - 1 234 19 - 47 8 - Q. „ Genito-urinary 3 1 - - - - 162 12 1 19 2 - R. Disease of the Skin 61 2 - 3 - - 96 17 - 5 6 - S.—Other diseases Children admitted “with Mother” 21 - - 4 - - 36 - - 7 - - T.—Mothers and infants discharged from Maternity Wards and not included in above figures— 38 - - - - - - - - - - - Mothers 1 - - - - - 347 25 1 3 1 - Infants 324 24 1 19 2 - - - - - - Totals 791 52 1 81 5 1 1978 213 4 590 73 - “C”: Croydon “S”: Surrey Cases. “K”: Kent (Penge) 26 QUEEN'S ROAD HOMES. Area and Population served by the Institution— The same as for Mayday Road Hospital. Beds available for Sick, Maternity and Mental Cases— (a) For Men 50 (b) For Women 50 100 Table shewing the classification of the accommodation for the sick and the number of beds occupied on the 31st December, 1931— Classification Beds. Men. Women. Total. Provided Occupied. Provided. Occupied. Provided Occupied. Chronic Sick 50 48 50 52 100 100 Statistics relating to the year ended 31st December, 1931. IN-PATIENTS. Total number of admissions (including infants born in hospital) : 67. Total number of deaths: 45 (15 Surrey). Total number of discharges (including infants born in hospital) : 12. Duration of stay of patients— (a) Four weeks or less: 4. (b) Exceeding four weeks but under thirteen weeks: 4. (c) Exceeding thirteen weeks: 49 (15 Surrey). Number of beds occupied— (a) Average during the vear, 100; (b) highest, 100; (c) lowest, 99 Classification of In-Patients who were discharged from or who died in the Institution during the year ended 31st December, 1931. Men and Women. Disease Groups. Discharged. Died. Rheumatism—Chronic arthritis 2 — Senile decay 6 19 (5 Surrey) Disease of the Nervous System & Sense Organs — 5(1 „ ) „ „ Respiratory System — 11(2 „) „ „ Circulatory System 3 9 (4 „ ) „ „ Digestive System — 1 Other diseases 1 — Totals 12 45 (including 15 Surrey) 27 Table IV. METEOROLOGY. I am indebted to Mr. H. W. Corden for the information contained in the tables below. METEOROLOGICAL. RECORD—YEAR 1931. Rain Gauge 5-in. in diameter, 1-ft. above ground, 146-ft. above sea level Temperature taken in the shade ot a Stevenson's Screen, 4-ft. from the ground. The Ground Thermometer is suspended in an iron tube, the bulb being 4-ft. below the level of the ground. Months 1031. Temperature of Air during Month Mean Temperature of Air. Difference from average 50 years at Greenwich. Mean Temperature of Ground at 4-ft. Mean Temperature of the Dew Point. Mean Tensional Difference between Ground and Dew Point at 9 a m. and 3 p.m. Rainfall. Highest. Lowest. Mean of No. of Days on which Rain fell. Amount collected in Inches. Difference from average 50 years at Greenwich All Highest. All Lowest. in. in. in. January 52° 24° 42°.7 34°.1 38°.4 — 0°.1 43°.9 37°.0 —.062 21 1.63 —0.16 February 54° 28° 44°.6 34°.3 39°.4 — 0°.1 42°.3 36°.8 —.049 17 1.50 — 0.03 March 69° 20° 48°.8 34°.0 41°.4 — 0°.3 41°.6 36°.6 —.040 6 0.37 — 1.14 April 67° 33° 54°.4 40°.4 47°.4 + 0°.2 45°.5 42°.9 —.027 16 4.52 + 2.92 May 77° 39° 62°.9 46°.4 54°.6 + 1°.5 49°.0 49°.8 —.012 13 2.57 + 0.69 June 81° 43° 70°.0 52° 61°.0 + 1°.6 53°.9 54°.5 +.008 10 1.91 — 0.12 July 77° 45° 69°.4 59°.9 64°.0 + 2°.1 57°.4 56°.6 —.012 16 2.47 + 0.06 August 78° 40° 67°.1 51°.6 59°.3 — 2°.3 58°.0 55°.3 —.040 19 4.37 + 1.99 September 70° 36° 60°.8 46°.2 53°.5 — 3°.7 55°.9 50°.1 —.080 11 1.60 —0.60 October 67° 24° 56°.6 41°.5 49°.0 — 1°.0 54°.1 46°.3 —.096 5 0.69 — 2.04 November 61° 31° 51°.4 41°.8 46°.6 + 3°.4 50°.0 44°.1 —.068 11 3.03 + 0.74 December 59° 23° 45°.6 37°.8 41°.7 + 2°.0 47°.2 39°.0 —.082 9 0.49 1.45 Means and Totals for Year. 81° 20° 56°.1 43°.3 49°.7 + 0°.3 49°.9 45°.7 —.046 154 25.15 + 0.86 28 Table V. Prevailing direction of the Wind at Croydon in 1931. Number of Days each Month. 1930. N.E. e. s.E. S. S.W. W. n.W. N. January 1 1 ... ... 6 12 5 6 February 4 ... 3 ... 8 9 3 1 March 4 10 6 ... 2 3 3 4 April ... 2 4 3 5 8 6 2 May 4 2 3 6 10 3 1 2 June 2 2 1 ... 17 5 2 1 July 1 ... ... 1 22 5 2 ... August 6 6 ... ... 8 4 2 5 September 4 ... ... 4 6 1 4 11 October 4 4 ... ... 11 4 1 7 November 4 1 3 9 8 4 1 ... December 2 ... ... 1 8 10 7 3 Totals 36 28 19 24 111 08 37 42 64 43 179 79 Summary of Meteorological Conditions During 1931. (Compiled from the Registrar General's quarterly returns). This precis is included as, undoubtedly weather conditions exert an influence on death rates and sickness incidence. This influence may be detected by a comparison of the monthly vital statistics. January.—The first half was cold and foggy ; the second half mild, windy and wet. Snow and sleet occurred on a few days in the middle of the month, but bright periods were frequent and there was a pronounced excess of sunshine recorded in most districts. 29 February.—Squally westerly or north westerly winds with snowfalls were the chief features of the weather during this month. The mean temperatures were slightly below normal in the S.E. A slight excess of sunshine was recorded on the south coast of England. March was on the whole cold, dry and sunny, though there were remarkable ranges of temperature, the 6th to the 10th being unusually cold, the 16th to the 22nd unusually warm. Sunshine aggregates were well above the normal. April was unsettled, dull and very wet; north westerly and northerly winds predominated with general deficiency of sunshine. Day maximum temperatures were mostly below the normal, though from the 8th to the 12th there was a spell of warm weather. Rainfall was very excessive, London having 274% of the normal April rainfall. May.—The weather was mostly unsettled, wet and cloudy with southerly winds predominating. Associated with the wet and cloudy weather was a lack of warm spells, though the temperature rose considerably during Whitsuntide week. Thunderstorms occurred in various districts. June.—For the first three weeks unsettled dull and wet weather prevailed, after which there was a gradual change to fine and warm weather. Thunderstorms were general and floods occurred in some districts. A remarkable phenomenon was recorded in Birmingham where a tornado accompanied a thunderstorm during the afternoon of the 14th causing much damage along a path about 10 miles long and from 800 to 200 yards wide. Rainfall exceeded the normal over most of England but in the South East, including Croydon, less than half the normal was recorded. July was wet and dull with frequent thunderstorms and heavy rain Sunshine aggregates for the month were subnormal. August was wet, cool and dull. Following a wet June and July the month completed one of the wettest summers since recording was begun. Mean temperatures were below the normal, thunderstorms occurred during the first 3 weeks and at the end of the month gales occurred on the south coast. 30 September was dull, rather cold and relatively dry. North west and north east winds predominated. During the first four days of the month rainfall was abnormally heavy. Sunshine aggregates were, for the sixth consecutive month, less than the average. October was dry and sunny; during the first half of the month maximum temperatures were mostly above normal but there were during the last week some abnormally low temperatures, especially at night. Sunshine aggregates exceeded the normal. November.—The month was mild and wet with an abnormal prevalence of southerly winds. Sunshine in the London area was about the average. Fog occurred during the last two days of the month. December.—The weather was unusually mild with much cloudiness but not much rain. In London no sunshine was recorded from the 11th to the 26th inclusive. Dense fog occurred in the London area on the 18th, 19th and 20th. VITAL STATISTICS. Marriages.—The number of marriages solemnised was 2,21-, compared with 2,112 in 1930, 1,982 in 1929; 1,874 in 1928; 1,847 in 1927; and 1,764 in 1926. The marriage rate was 9.5 per 1,000 of the population; 976 were solemnised in Established Churches, 256 in other places of worship, 974 in the Register Office, 2 ceremonies were performed under Jewish ritual, and 4 under ritual of Society of Friends. Births.—The births registered were 3,236 legitimate and 164 illegitimate. The birth-rate consequently was 14.6. For England and Wales the rate was 15.8, and in the 107 Great Towns it was 16.0. The illegitimate births in Croydon were 4.8% of the total, compared with 5.1% in 1930, 4.80% in 1929, 4.36% in 1928, 4.79% in 1927, and 4.26% in 1926. The total male births numbered 1,811, the female 1,589, being a proportion of 1,139 males to 1,000 females. 31 The subjoined table (VI.) gives the vital statistics for the Wards in the Town. It is seen that the Wards with the highest birth-rates were Whitehorse Manor (20.8), South Norwood (19.4), Broad Green (18.9), and Thornton Heath (18.0). Those with the lowest were: Upper Norwood (8.5), Norbury 110.0), and South (10.9). Deaths.—The deaths numbered 2,674, compared with 2,337 last year. For 1931 the death-rate was 11.4. The death-rate for England and Wales was 12.3, and for the 107 Great Towns 12.3. For London the death-rate was 12.4. The male death-rate was 11.8, the female 11.2 for the Borough. There were 198 inquests held by Coroners in respect of Croydon residents during 1931, and 121 findings by Coroners after postmortem examination without inquest. Wards with the highest death-rates were: Cental (14.9), Whitehorse Manor (14.0), and Broad Green (13.9). Those with the lowest were' Norbury (8.3), Thornton Heath (10.0), West Thornton (10.1), and Upper Norwood (10.2). Natural Increase.—The excess of birth over deaths was 726 or 3.1 per 1,000 of the population. A comparison with previous years is given below. Immigration is apparently playing a larger part than emigration and is leading to a rapid population increase. In the nature of things this is a difficult factor to estimate with any accuracy and in time leads to deductions based on total population being only approximate. In a town like Croydon standardisation of rates upon group ages of population is a valuable method of arriving at more accurate results, but this cannot be done without a census. The longer the period from the last Census the more problematical do statistics become. 32 Table VI. WARDS. Population (Census 1931). Births. Deaths. Birth Rate. Death Rate. Deaths under 1 year per 1,000 Births. Death Rate from Six Zymotic Diseases (excluding Diarrhoea) Death Rate from Diarrhoea. Death Rate from Bronchitis and Pneumonia. Death Rate from Pulmonary Tuberculosis. Death Rate from Non-Pulmonary Tuberculosis. Death Rate from Heart and Circulation Diseases. Death Rate from Nervous Diseases. Death Rate from Cancer. Estimated persons per acre (1931). Upper Norwood 21742 186 221 8.5 10.2 80 ... ... 1.24 0.78 0.08 2.58 0.37 1.65 19.5 Norbury 15536 155 130 10.0 8.3 39 ... ... 1.41 0.64 0.06 2.19 0.19 0.48 28.4 West Thornton 19493 256 196 13.1 10.1 66 0.20 0.05 1.90 0.46 0.10 3.18 0.30 1.03 41.0 Bensham Manor 15625 221 173 14.1 11.1 72 0.06 ... 1.60 0.38 0.06 3.20 0.58 1.15 48.4 Thornton Heath 15175 274 159 18 .0 10.0 66 0.13 ... 2.37 0.59 0.13 2.11 0.19 1.51 49.1 South Norwood 17211 334 216 19.4 12.5 48 0.12 0.12 2.15 0.64 ... 3.95 0.29 1.51 28.0 Woodside 15213 190 175 12.5 11.5 37 0 .13 ... 2.23 0.99 0.06 3.61 0.33 1.84 35.6 East 17529 197 191 11.2 10.9 30 0 .06 ... 1.71 0.63 ... 3.99 0.40 1.25 9.3 Addiscombe 14047 190 170 13.5 12.5 47 0.14 0.21 2.35 0.64 0.07 3.13 0.35 1.85 47.6 Whitehorse Manor 16276 339 228 20. 8 14 .0 74 0 .06 0.12 2.70 0.92 0.25 3.69 0.55 1.23 61.2 Broad Green 14932 283 207 18.9 13.9 46 ... ... 2.48 0.94 ... 4.96 0.20 1.41 67.0 Central 11858 186 176 15.7 14.9 91 ... 0.17 1.77 0.68 0.17 4.05 0.59 2.20 32.4 Waddon 21216 340 222 16.0 * 10.5 53 0.09 0.14 1.65 0.57 0.14 3.35 0.24 1.08 21.6 South 14471 158 171 10.9 11.8 63 ... 0.07 2.35 0.41 ... 2.97 0.48 1.73 12.2 Addington 2791 39 21 13.0 7.6 51 ... ... 0.71 0.71 ... 1.79 0.71 1.43 7.8 Borough 233115 3400* 2674* 14.5 11.4 58 0.07 0.6 1.05 0.67 0.08 3.31 0.36 1.48 ... * These are the corrected figures. 33 Table VII. Year. Birth Rate. Death Rate. Nat. Increase 1000 population. Natural Increase 1891 2832 27.4 1553 15.0 103,300 12.4 1279 1901 3578 26.6* 1748 12.9 134,665 13.6 1830 1904 3769 26.1* 1998 13.8 144,419 12.2 1771 1914 4007 22.0 1084 10.9 181.956 11.1 2023 1921 3631 18.9 2054 10.7 191,500 8.2 1577 1922 3505 18.2 2387 12.4 192,300 5.8 1118 1923 3370 17.4 2007 10.4 193,400 7.0 1363 1924 3456 17.6 2280 11.6 196,000 6.0 1176 1925 3406 17.1 2169 10.9 199,300 6.2 1237 1926 3477 16.9 2269 11.0 205,900 5.4 1208 1927 3174 15.0 2452 11.6 211,700 3.4 722 1928 3374 15.7 2351 10.9 214,800 4.8 1023 1929 3399 15.3 2792 12.5 222,300 2.7 607 1930 3514 15.8 2337 10.5 222,300 5.7 1177 1931 3460 14.6 2674 11.4 233,800 3.1 726 * Uncorrected or gross figure. 34 Table VIII. WARD. Census population 1931. Person* per acre. Births. Birth Rite. Infant Mortality Deaths. Death Rate. Natural increase of population. Upper Norwood 21,724 19.5 186 8.5 80 221 10.2 -35 Norbury 15,536 28.4 155 10.0 39 130 8.3 +25 West Thornton 19,493 41.0 256 13.1 66 196 10.1 + 60 Bensham Manor 15,625 48.4 221 14.1 72 173 11.1 +48 Thornton Heath 15,175 49.1 274 18.0 66 159 10.0 + 115 South Norwood 17,211 28.0 334 19.4 48 216 12.5 + 118 Woodside 15,213 35.7 190 12.5 37 175 11.5 +15 East 17,529 9.3 197 11.2 30 191 10.9 +6 Addiscombe 14,047 47.4 190 13.5 47 176 12.5 +14 Whitehorse Manor 16,276 61.2 339 20.8 74 228 14.0 + 111 Broad Green 14,932 67.0 283 18.9 46 207 13.9 +76 Central 11,858 32.4 186 15.7 91 176 14.9 + 10 Waddon 21,216 11.6 340 16.0 53 222 10.5 + 118 South 14,471 12.2 158 10.9 63 171 11.8 -13 Addington 2,791 0,8 39 14.0 51 21 7.5 + 18 233,115 18,5 3400* 14.6 58 2674 11.4 +726 35 Most persons to acre in Broad Green, Whitehorse Manor, and Bensham Manor; least in East, Waddon and South. Addington, owing to its relatively scanty population, has not been included for purposes of comparison. The birth-rate is the lowest recorded with the exception of 1918. Table IX. Year. Population estimated to Middle of each Year. Births. Total Deaths Reg. in the District. Transferable Deaths Nett deaths belonging to the District. of Non-residents registered in the District. of Residents not registered in the District. Under 1 Year of Age. At all Ages. Uncorrected Number. Nett. Number. Rate. Number. Kate per 1,000 Nett Births. Number. Rate. Number. Rate. 1918 188,755 2632 2626 13.9 2687 15.9 388 245 202 76 2544 15.1 1919 191,922 3008 2965 15.4 2287 12.4 312 197 219 73 2172 11.7 1920 191,820 4434 4351 22.6 2225 11.6 299 209 275 63 2134 11.1 1921 191,500 3713 3631 18.9 2115 11.0 283 222 269 74 2054 10.7 1923 192,S00 3616 3505 18.2 2469 12.8 337 255 224 64 2387 12.4 1923 193,400 3446 3370 17.4 2082 12.5 284 209 176 52 2007 10.4 1924 196,000 3536 3456 17.6 2384 12.1 317 213 195 56 2280 11.6 1935 199,300 3521 3406 17.1 2262 11.4 336 243 187 55 2169 10.9 1936 205,900 3569 3477 16.9 2340 11.4 318 247 211 61 2269 11.0 1927 211,700 3329 3174 15.0 2542 12.1 384 294 176 55 2452 11.6 1928 214,800 3501 3374 15.7 2439 11.4 389 301 178 53 2354 11.0 1929 222,300 3553 3399 15.3 2954 13.3 463 301 221 65 2792 12.5 1930 222,300 3703 3514 15.8 2407 10.8 364 294 171 48 2337 10.5 1931 233,800 3601 3400 14.5 2719 11.6 331 300 196 58 2674 11.4 Comments on Table IX. The birth-rate showed a decrease over 1930 and the deathrate an increase. The year was not such a satisfactory one as 1930. 36 Table X. DEATHS REGISTERED DURING THE CALENDAR YEAR 1931 CLASSIFIED BY AGE AND CAUSE. CAUSES OF DEATH. Nett Deaths at the subjoined ages of "Residents," whether occurring within or without the District. Total Deaths whether of "Residents of "non- Residents" in institutions in the districts. All ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 15 years. 15 and under 25 years. 25 and under 35 years. 35 and under 45 years. 45 and under 55 years. 55 and under 65 years. 65 years and upwards. 1 2 3 4 5 6 7 8 9 10 11 12 13 All Causes Certified 2672 196 34 29 39 104 109 144 261 413 1341 1391 Uncertified 2 ... ... ... ... ... ... ... ... 1 1 ... Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... Small Fox ... ... ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever 3 ... ... ... 2 ... ... 1 ... ... ... 3 Whooping Cough 9 6 2 ... ... ... ... ... ... 1 ... 2 Diphtheria and Croup 5 ... 1 1 3 ... ... ... ... ... ... 5 Influenza 79 ... 4 ... ... 1 1 4 9 10 50 6 Erysipelas 4 ... 1 ... ... ... ... ... 1 ... 2 4 Tetanus ... ... ... ... ... ... ... ... ... ... ... ... Pulmonary Tuberculosis 155 3 2 2 1 34 31 33 24 17 8 79 Tuberculous Meningitis 11 ... 1 2 3 2 ... 1 ... 2 ... 15 Other Tuberculous Disease 11 3 ... 1 ... ... 5 1 ... 1 ... 8 Cancer, Malignant Disease 342 1 ... ... ... ... 3 18 52 89 179 202 Acute Rheumatism and Rheumatic Fever 7 ... ... ... 1 2 1 2 ... 1 ... 6 Cerebro-Spinal Meningitis 3 ... ... 2 ... ... 1 ... ... ... ... 3 Encephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... 3 Other Forms of Meningitis (not T.B.) 16 3 3 1 2 2 ... 1 2 ... 1 13 Poliomyelitis ... ... ... ... ... ... ... ... ... ... ... ... Locomotor Ataxy 3 ... ... ... ... ... ... ... 1 2 ... 4 General Paralysis ot the Insane 3 ... ... ... ... ... ... 1 1 1 ... 3 Cerebral Hæmorrhage 151 ... ... ... ... 1 1 2 17 23 107 89 Other Diseases of the Nervous Sys'm 72 ... 1 4 3 4 4 6 8 8 34 32 Senile Decay 118 ... ... ... ... ... ... ... ... ... 118 63 Diabetes 37 ... ... ... ... ... ... ... 7 7 23 27 Organic Heart Disease 490 ... ... ... 3 8 6 17 34 86 336 193 Arterio-Sclerosis 124 ... ... ... ... ... ... 1 8 19 96 65 Aneurism 2 ... ... ... ... ... ... ... 1 1 ... 1 Other Diseases of the Circulatory System 10 ... ... ... ... ... ... 2 1 4 3 1 Bronchitis, Acute 51 5 ... ... ... 1 ... ... 4 7 34 6 Bronchitis, Chronic 147 ... ... ... ... ... ... ... 8 17 122 72 Influenzal Pneumonia 5 ... ... ... ... ... 1 ... 2 ... 2 1 Pneumonia (other forms) 258 31 14 9 4 9 12 20 24 48 87 171 Other Diseases of the Respiratory System 20 ... ... 1 ... ... 2 2 2 6 7 3 Diarrhœa and Enteritis 15 12 ... ... ... ... ... ... ... 1 1 12 Appendicitis, Typhlitis, and Peritonitis 23 ... ... 1 3 3 5 1 2 5 3 30 Cirrhosis of the Liver 5 ... ... ... ... ... ... ... ... 1 4 2 Alcoholism 1 ... ... ... ... ... ... ... ... 1 ... ... Other Diseases of the Digestive Sy'm 61 ... 1 ... 1 2 2 3 13 11 28 45 Nephritis and Blight's Disease 60 ... ... ... ... 2 3 1 11 12 31 33 Other Diseases of the Urinary Sys'm 37 ... ... ... ... 1 ... 2 4 4 26 25 Puerperal Fever 8 ... ... ... ... 3 5 ... ... ... ... 8 Puerperal Pyrexia ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases and Accidents of Pregnancy and Parturition 14 ... ... ... ... 4 7 3 ... ... ... 10 Congenital Debility and Malforma'n 49 46 1 ... ... 2 ... ... ... ... ... 30 Premature Birth 49 49 ... ... ... ... ... ... ... ... ... 30 Venereal Diseases 6 4 ... ... ... ... ... ... 2 ... ... 6 Other Diseases of the Reproductive System (Non-Malignant) 6 ... ... ... ... ... ... 2 ... ... 4 4 Violent Deaths (excluding Suicide) 92 ... 2 2 8 15 9 7 7 15 27 81 Suicide 33 ... ... ... ... 3 5 2 9 8 6 6 All other Defined Diseases 79 33 1 3 5 5 4 11 6 6 5 51 Diseases Ill-defined or unknown 1 ... ... ... ... ... 1 ... ... ... ... 1 All Causes 2674 196 34 29 39 104 109 144 261 414 1344 1440 The deaths entered in the last column include deaths of non-residents of the borough. 37 Comparisons with 1930. (i) No deaths from measles as compared with 22 in 1930. (ii) Whooping Cough showed a slightly increased fatality in the first five years of life, (iii) Continued decrease in the number of deaths from diphtheria, (iv) Increase in deaths from influenza, chiefly affecting those over 65. (v) Deaths from pulmonary tuberculosis, which are largely concentrated between 15 and 45 years years of age, remained the same, (vi) Cancer deaths remained practically the same with a preponderance of deaths over 45 years of age, as in 1930. (vii) Deaths attributed to senile decay remained much the same, (viii) A further increase in deaths from organic tieart disease and arterio-sclerosis. (ix) An increase in deaths from acute and chronic bronchitis, probably due to the increased prevalence of influenza during the year, (x) A decrease in infantile deaths from diarrhœa. (xi) An increase in deaths from nephritis, (xii) An increase in the number of suicides. Deaths from violence now loom conspicuously in the causes of death and assume importance from Public Health aspects. The majority of these are caused through the agency of mechanically propelled vehicles. Comments on Table X. (i) Cancer remains the chief cause of death between the ages, of 55 and 65 years closely followed by heart disease, (ii) Heart disease is the main cause of death over 65, closely followed by cancer. (iii) Cancer remained, as in 1929 and 1930, the chief cause of death of persons dying in institutions, (iv) The main causes of death in persons over 65—excluding senile decay—were: Heart Disease (336), Cancer (179), Chronic Bronchitis (122), Cerebral Haemorrhage (107), Pneumonia (87), Influenza (50). (v) Pneumonia still showed its maxima at both extremes of life as in 1930 and 1929. (vi) The dangers run by an infant during the first year of life. This is the most dangerous time until the 15—55 age group is reached, (vii) Violent death overtakes the older groups of the population more often than the younger groups, though both in 1930 and the year under review the age-group 15-25 an unduly large number of fatalities from this cause. Suicide commonest between 45 and 65. There are a few points of difference between Table VII. and the short list of causes of death supplied by the Registrar-General. The causes of the differences are due to the different methods of classification when more than one cause of death is given on the 38 death certificate. For example, in the abbreviated table of the Registrar-General there are 700 deaths from Heart Disease, whilst Table VII. gives only 490. There are, however, given in the latter table 118 deaths from Senile Decay as against 28 in the RegistrarGeneral's table, and 92 more deaths from Bronchitis. A number of certificates state the deceased died from Myocarditis and Senility, or Myocarditis and Chronic Bronchitis; in the local classification the latter cause has been taken as the cause of death. The percentage of deaths under 1 year of age to total deaths was 7.3. Deaths under 15 years, 11.1%; deaths under 65 years, 49.7%; deaths over 65 years, 50.3%. Table XI. CLASSIFICATION OF DEATHS ACCORDING TO DISEASE OVER A PERIOD OF 12 YEARS Cause of Death. 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 Total Deaths Total Deaths Total Deaths. Total Deaths. Total Deaths. Total Deaths. Total Deaths Total Deaths. Total Deaths. Total Deaths Total Deaths Death Rate. Total Deaths. Enteric Fever 4 1 1 ... 2 ... 1 2 ... 1 ... ... ... Malaria ... ... 1 ... ... 1 1 ... ... ... ... ... ... Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... Measles 22 6 19 9 4 7 13 6 30 1 22 ... ... Scarlet Fever 7 4 6 2 2 1 ... 3 5 4 2 3 0.013 Whooping Cough 2 22 11 11 11 9 9 21 14 24 3 9 0.038 Diphtheria and Croup 26 23 27 21 8 8 32 10 32 23 14 5 0.021 Influenza (including Influenzal pneumonia) 43 39 101 20 89 63 44 118 38 199 32 84 0.359 Dysentery 2 1 ... ... ... ... ... ... ... ... 1 1 0.004 Erysipelas 3 4 2 2 4 5 5 5 3 8 7 4 0.016 Cerebro-Spinal Fever ... ... 2 ... 2 ... ... ... 2 ... 2 3 0.013 Pulmonary Tuberculosis 156 156 183 153 157 151 171 165 167 170 154 155 0.663 Tuberculous Meningitis 16 12 14 22 12 17 17 10 13 10 7 11 0.470 Other Tuberculous Disease 23 16 12 15 19 13 20 28 26 19 14 11 0.470 Cancer, Malignant Disease 218 218 252 259 293 319 330 344 327 330 339 342 1.463 Rheumatic Fever 5 12 7 5 9 8 11 6 6 5 4 7 0.030 Meningitis 13 11 12 8 6 6 2 9 11 17 14 15 0.064 Organic Heart Disease 258 229 324 254 305 273 281 346 405 308 375 490 2.058 Bronchitis 163 143 194 139 142 130 100 92 92 226 125 200 0.855 Pneumonia* 160 138 183 144 182 140 138 200 158 272 199 258 1.104 Other Diseases of the Respiratory Organs 40 34 40 36 33 32 34 33 .33 21 16 10 0.086 Diarrhœa and Enteritis 40 62 37 36 32 36 34 24 28 45 32 15 0.064 Appendicitis and Typhlitis 14 9 15 21 28 20 14 17 16 27 23 23 0.098 Cirrhosis of Liver 10 10 14 11 7 12 3 9 11 10 5 5 0.021 Alcoholism 2 2 1 3 3 1 2 3 3 4 3 1 0.004 Nephritis and Bright's Disease 55 59 47 59 70 65 81 77 79 117 45 60 0.257 Puerperal Fever 6 4 6 4 2 5 11 4 2 6 1 8 0.034 Other Diseases and Accidents of Pregnancy & Parturition 12 10 10 6 8 8 13 5 11 5 6 14 0.060 Congenital Debility and Malformation 62 48 52 32 37 36 52 30 26 42 42 49 0.209 Premature Birth 61 47 38 39 54 42 40 48 32 47 40 49 0.209 Violent deaths (excluding Suicide) 33 26 48 49 66 65 71 83 75 64 74 92 0.393 Suicide 17 30 19 23 23 23 33 30 35 29 19 33 0.141 Other Defined Diseases 642 665 687 624 670 672 703 720 664 748 713 706 3.020 Diseases Ill-defined or unknown 19 13 22 ... ... 1 3 4 10 10 4 1 0.004 Total 2134 2054 2387 2007 2280 2169 2269 2452 2354 2792 2337 2674 11.4 39 Comments on Table XI. The main features for 1931, as compared with last year, are: (1) The increase in the death rate from Influenza. (2) The increase in the deaths attributed to Heart Disease which, of late years, has shown a steady rise. It is difficult to ascertain the relative importance of some change in certification of deaths, with the possibility of an actual increase in the number of damaged hearts. Probably both factors enter into the calculations. (3) The increase in the death rate from Bronchitis and Pneumonia. This is probably a result of the epidemic of influenza which occurred in the first quarter of the year. 1931 was not such a healthy year as 1930. Causes of Death. The chief causes of death during 1931 were:—Organic heart disease, 190 deaths, death-rate 2.06; Cancer, 342 deaths, deathrate 1.48; All forms of Tuberculosis, 177 deaths, death-rate 0.76; Pneumonia (including influenzal pneumonia), 263 deaths, deathrate 1.12; Arterio-sclerosis and Cerebral Hæmorrhage, 275 deaths, death-rate 1.18. Taking diseases of bodily systems and group diseases to which death was definitely assigned we find:— Circulatory System (including Atheroma and Cerebral Hæmorrhage) 777 3.33 Cancer 342 1.46 Respiratory System (not Tubercular) 476 2.04 Tuberculosis (all forms) 177 0.76 Infectious Diseases (excluding Tuberculosis but including Enteritis and Influenza) 120 0.51 Diseases of the Nervous System (not Tubercular) 93 0.40 Diseases of the Digestive System (excluding Cancer and Tuberculosis) 105 0.45 Diseases of Renal System 97 0.41 Suicides and Violent Deaths 125 0.53 Conditions at Birth 98 0.42 Old Age 118 0.50 The greatest single group of causes of death as in 1930 was diseases of the Circulatory system, and of this group Organic Heart 40 Disease was the most prominent member (490 deaths): the majority of deaths in this group occurred over 65 years of age. Rheumatism in childhood is indubitably a cause of cardiac breakdown later on in life, more particularly if the original attack of rheumatism has been missed or disregarded. Arterio-sclerosis (124 deaths) is the second big cause of death in this group. This is a thickening, and diminution in the elasticity, of the walls of the arteries and is an expression either of prolonged stress or unwise living which, if continued, leads to a final rupture of the walls of the vessel—most often in the brain—leading to Cerebral Haemorrhage, which caused, incidentally, 151 deaths. Arterio-sclerosis and Cerebral Haemorrhage between them caused 275 deaths. Influenza was the most fatal infectious disease; the majority of deaths occuring over 65 years of age. Whooping Cough came second. All the deaths except one being in children under 15 years of age. POPULATION. Explanation of Graphs. The estimated population is shown by a continuous black line from 1860 onwards, the letter C denoting a census year. In 1860 Croydon's population was a little over 30,000; in 1931 the census showed it to have risen to 233,115. The growth of Croydon has been rapid and continuous; even during the war years the increase was not arrested, whilst since the war its growth has been even more rapid. Such an increase of population gives rise to problems of its own from Public Health aspects; additionally inhabitants do not always appreciate that within a space of 60 years their town has grown from a village to one of the great and important centres of England. With the extension of civil aviation, Croydon's importance is likely to become greater each year. The trend of industrialism to the south is also exerting a prominent influence. 41 SECTION II. SANITARY CIRCUMSTANCES. To the Medical Officer of Health. I beg to submit in accordance with the Sanitary Officers' Order, 1922, a report for the year ending December 31st, 1931, of the work carried out by the Sanitary Inspectors and other officers under my supervision. ROBERT J. JACKSON, Chief Sanitary Inspector. List of Adoptive Acts and Local Acts and Regulations Relating to Public Health. Local Acts. 1884. Croydon Corporation Act. 1895. „ „ 1900. „ „ 1905. „ „ 1920. „ „ 1921. Croydon Corporation Water Act. 1924. Croydon Corporation Act. 1927. „ „ 1930. „ „ General Adoptive Acts. Baths and Washhouses Act, 1846-1899. Public Health Acts Amendment Act, 1890, Part 3 (sections 16-50). Section 19 repealed by Croydon Corporation Act, 3905, Section 34. Infectious Diseases (Prevention) Act, 1890. Public Health Acts Amendment Act, 1907, Sections 19, 20, 21, 24, 25, 28, 33, 35, 36, 51, 55 and Part V. Public Health Act, 1925. Sections 14, 17, 18, 19, 23, to 26 (inclusive) 28, 30, 31, 33, 35, 41, 42, 43, 45 and 47 to 55 (inclusive). Regulations. Regulations as to connections with sewers, 1911. 45 Byelaws. With respect to Common Lodging Houses, 1931. ,, Tents, Vans, Sheds and similar structures used for human habitation, 1931. ,, Slaughterhouses, 1914. ,, New Streets and Buildings, 1929. ,, Offensive Trades, 1925. ,, Conduct of Persons using Public ences, 1926. ,, Street Trading, 1927. ,, Slaughterhouses. Amending 1914 Byelaws. ,, Cleanliness of Food, 1929. ,, Smoke. Public Health (Smoke Abatement) Act, 1926. ,, Houses Let in Lodgings, 1931. ,, The Prevention of Nuisances arising from Snow, Rubbish, etc., and for the Prevention of Keeping of Animals so as to be Injurious to Health, 1931. ,, The Good Rule and Government of the County Borough of Croydon and for the Prevention of Nuisances. Summary of Inspections made by the Sanitary Inspectors and other Departmental Work. Total No. of Houses inspected for housing defects (under Public Health or Housing Acts) 5140 No. oif houses inspected under the Housing (Consolidated Rrgulalations) 1925 3094 No. of Houses inspected under the Rent Restrictions Act, 1920 47 No. of Houses inspected where zymotic diseases have occurred 591 House drains tested with smoke (primary) 1210 House drains tested with smoke (on application) 71 No. of smoke tests during repair 540 Inspection of drainage work during construction 3295 No. of water tests during repair 457 Final tests of drains after repair 89 Final tests of drains when completely relaid 57 Length of new drains tested with water yards 2759 Inspections of yards, stables and manure pits 595 ,, Passages 55 ,, Public Conveniences 718 „ Pigstyes 33 ,, Tents, Vans, and similar structures 21 ,, Theatres, Cinemas, Halls, etc. 153 „ Ponds and Ditches 32 „ . School Lavatories 54 ,, Common Lodging Houses (including night visits) 85 ,, Houses let in lodgings 95 ,, Premises where offensive trades are conducted 240 Smoke Observations 27 43 No. of Visits re Infectious Diseases 4194 Inspections of Shops (under Shops Acts) 1368 Special Early Closing Patrols 100 Special Evening Inspections under Shop Hours' Act 40 Inspections under Fertilisers and Feeding Stuffs Act 8 „ under Poisons and Pharmacy Act 13 „ Dairies 279 „ Farms and Cowsheds 336 „ Milkshops 342 ,, Premises where food is prepared or sold 6321 „ Slaughterhouses 1252 „ Factories 435 „ Factory Laundries 21 „ Workshops 560 „ Workshop Laundries 16 ,, Workplaces 148 „ Factory Bakehouses 204 „ Workshop Bakehouses 99 „ Outworkers Premises 78 Visits to Employers of Outworkers 20 Reinspections of Work in Progress 25691 Sundry Inspections and Visits 16901 Appointments kept with Owners, Builders, etc. 1770 Complaints from public investigated (for purposes other than inspection of House) 3181 Examination of Building Plans 1016 Informal Notices outstanding 31/12/30 2573 „ „ served 10557 „ „ complied 9994 No. of Informal Notices referred for Statutory Orders 834 Informal Notices outstanding (including 423 overcrowding) 2302 Statutory Notices outstanding 31/12/30 256 „ „ served 793 „ „ complied 825 Total number of complaints received 3455 Interviews with callers 4977 Letters received 4757 Letters and other intimations, etc. sent (not including notices) 9438 Nuisances, Infringements of Acts, Byelaws, Regulations or Orders, ascertained by the Sanitary Inspectors during the year 1931 and for which action was taken to enforce compliance:— (1) NUISANCES AND HOUSING DEFECTS AT HOUSES, &c. Insufficient means of ventilation— Defective sashcords 1591 ,, windows 875 Want of windows or ventilators 35 Conditions causing dampness— Defective roofs 1442 „ gutters 832 „ downspouts 336 „ walls, etc. 1425 Deposits of refuse causing dampness 16 Want of proper damp proof course 75 Other internal defects and nuisances— Defective plaster 1582 Cleansing and limewashing required 2211 44 Defective floors 693 Insufficient ventilation under floor 25 Defective stoves and fireplaces 706 Defective sanitary fittings— Defective sinks 281 „ waste pipes 326 Abolition of drinking water cisterns 131 Defective w.c.'s 955 „ drainage 619 Stoppage in drains 287 Domestic nuisances— Want of cleanliness 64 Dirty w.c. pans 41 Other nuisances— Bad smells 2 Offensive accumulations 185 Insufficient accommodation for sub-tenants 2 Defective manure receptacles 6 Want of manure receptacles 4 Defective sanitary conveniences 16 Dirty sanitary conveniences 8 Smoke nuisances 23 Sundry nuisances or defects 886 Limewashing of stables 2 Discontinue use of stable 1 (2) FACTORIES, WORKSHOPS & WORKPLACES— Cleansing and whitewashing required 226 Additional ventilation 11 Dustbins required 73 Drainage of floors 8 Repairs to floors 18 Repairs to paving 23 Overcrowding 1 Ventilation of stoves 2 Infringements of drinking water supply regulations 15 Sundry other nuisances or defects 63 Outworkers lists not in accordance with Act 1 Abstract not exhibited 9 W.c.'s— Insufficiently screened 8 Insufficient 3 Defective 113 Not kept clean 69 Not separate for sexes 6 Want of intervening ventilated space 14 (3) INFRINGEMENTS OF CROYDON CORPORATION ACT, 1924— Food cupboards defective or required 428 Dustbins required 1662 Verminous conditions 57 (4) INFRINGEMENTS OF PUBLIC HEALTH ACT, 1925 (S.72—75) AND INFRINGEMENTS OF FOOD BYELAWS— Cleansing of walls and ceilings 147 „ „ floors 25 „ „ utensils 12 „ „ counters, shelves, fixtures, &c. 28 „ „ w.c.'s 10 45 Dirty yards 4 Accumulation in food store 21 Refuse bins left uncovered 13 Food in uncovered vehicles 6 Food not kept covered 6 Renewal of swill bins 1 Food improperly kept or manufactured 32 Premises not suitable for food stored 5 Want of provision of towels 20 Provision of cloak rooms 32 Overalls required 10 Illegal wrapping of food 16 Washing in food store 5 Want of ventilation in food store 4 „ intervening ventilated space between w.c. and food store 9 Defective floors 5 „ sink waste pipes 1 „ sanitary fittings 9 Removal of defective fittings 4 Want of proper water supply 3 „ sink accommodation 3 (5) INFRINGEMENTS OF PUBLIC HEALTH ACTS (AMENDMENT) ACT, 1907— Defective yard paving 643 Rainwater pipes used as ventilation pipes 2 (6) INFRINGEMENTS OF SHOPS ACTS— Mixed shop notices required 115 Assistants Weekly Half-Holiday notices required 183 Employment of Young Persons notices required 65 Infringements of Weekly Half-holiday Closing Order 4 Infringements of evening closure ... ... • 14 (7) INFRINGEMENTS OF COMMON LODGING HOUSE BYELAWS Defective walls 1 ,, floors o ,, windows ... .. ... ... 1 „ sashcords 1 ,, sanitary fittings 1 .. yard 1 ,, gutters 1 Additional dustbin required 1 Offensive accumulation 1 Verminous conditions 2 (8) INFRINGEMENTS OF HOUSES LET IN LODGINGS BYELAWS— Additional cooking and sink accommodation 6 Want of food storage accommodation 3 Provision of washing accommodation 1 Want of balusters 2 „ artificial lighting to common staircase 2 Cleansing and limewashing required 5 Defective roofs 8 „ plaster 3 „ w.c.'s 3 „ downspouts 1 „ sashcords 2 Dampness 2 Drains stopped 1 46 (9) INFRINGEMENTS OF OFFENSIVE TRADE BYELAWS. Fishfrying premises— Dirty conditions 2 Want of proper hood 1 Cleanliness of premises 2 Gutting shed dirty 1 Other premises— Marine store dealers yard dirty 1 Dirty yard 1 Dustbins required 1 Premises requiring repair 1 Manure pit to be emptied 1 Cleansing and whitewashing required 1 (10) INSPECTION OF AMUSEMENT HOUSES— Defective w.c. seat 1 „ „ cistern 1 „ „ flushpipe 1 ,, wastepipe 1 „ ventilation pipe 1 Lighting to w.c. required 2 W.c.'s require cleansing 4 Affix notices to lavatory 1 (11) KEEPING OF ANIMALS— Pigstyes within 100 feet of dwellings 2 Other nuisances in connection with the keeping of pigs 8 Nuisances arising from the keeping of other animals 35 (12) INSPECTION OF WATERCOURSES, etc.— Pond sprayed with formalin owing to prevalence of mosquitoes 1 (13) INFRINGEMENTS OF POISONS & PHARMACY ACT— Article not labelled in accordance with the Act 1 (14) INFRINGEMENTS OF FERTILISERS & FEEDING STUFFS ACT 7 (15) INFRINGEMENTS OF RATS & MICE DESTRUCTION ACT— Rat runs require sealing up 3 Accumulations harbouring rats 3 Defective food bins 2 ,, floors at food premises 1 „ ventilation pipe 1 (16) INFRINGEMENTS OF MERCHANDISE MARKS ACT & AGRICULTURAL PRODUCE & MARKING ACT— Apples not marked 83 Tomatoes not marked 64 Eggs not marked 10 (17) INSPECTION OF SCHOOL LAVATORIES— Drains stopped 1 Defective Sanitary fittings 4 (18) INFRINGEMENTS OF OTHER BYELAWS— Noisy loud speakers 1 Noisy animals 12 Refuse deposited in streets 3 Washing down shop fronts 3 Offensive washing up water thrown over footpath 4 47 (19) CORN PRODUCTION ACTS (REPEAL) ACT, 1921, WITH REGARD TO CERTAIN WEEDS— Infringements 6 (20) INFRINGEMENTS OF PUBLIC HEALTH (MEAT) REGULATIONS— Want of receptacles for the storage of scraps 8 Scraps not kept in receptacles 1 Food not protected 2 (21) INFRINGEMENTS OF FOOD AND DRUGS (ADULTERATION) ACT, 1928— Margarine not marked 16 (22) SALE OF FOOD ORDER, 1921— Meat not marked 9 (23) INFRINGEMENTS OF MILK & DAIRIES REGULATIONS, &c.— Unregistered Dairies 3 Defective dairy floors 1 „ „ walls 1 Dirty dairies 2 „ utensils in dairies 5 „ wash-ups 2 Want of sink accommodation 1 „ staff ablution accommodation 1 Washing dried on premises 1 Milk left uncovered 3 Counter pans to be cleansed and kept covered 6 Illegal bottling of milk 1 Defective yard paving at dairies 2 Vehicles not labelled 2 Defective cowshed roof 1 „ „ paving 1 „ „ lighting 1 Dirty milking stools 1 Cows require grooming 1 Cowshed required limewashing 1 Drains stopped 2 SANITARY CERTIFICATES. On application, an intending or actual occupier or owner, may have a sanitary survey made of the house, to ascertain whether there are conditions existing which may be injurious to health or requiring attention. In each case an examination is made of the premises and the drains are tested. During 1931 requests were made in connection with 67 houses. 4 schools. Total 71. 48 The following defects were ascertained in consequence of these inspections:— Defective gutters 1 „ downspouts 5 „ drains 26 „ sanitary fittings 15 „ walls 2 ,, sink waste pipe 1 RENT RESTRICTION ACTS. A number of applications were received for certificates as to the sanitary condition of the houses concerned. In 41 instances where the Acts applied certificates were granted. In four instances the applications were withdrawn and in five instances certificates were given to owners stating that the work had been carried out. LEGAL PROCEEDINGS TAKEN REGARDING NUISANCES, ETC. Offence. Result Total. Fines. Costs. £ s. d. £ s. d £ s. d. Failing to abate a nuisance — 1 1 0 1 1 0 Do. Do. Order made. — HOUSING. The following table gives particulars as to Housing during 1931 under the headings prescribed by the Ministry of Health:— Table XII. Housing Statistics, 1931. 1.—Inspection of Dwelling-houses during the year:— (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 5140 (b) Number of inspections made for the purpose 5140 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 3094 (b) Number of inspections made for the purpose 3094 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 6 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 3381 49 2.—Remedy of Defects during the year without service of Formal Notices:— Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority or their officers ... 3110 3.—Action under Statutory Powers during the Year :— A. Proceedings under sections 17, 18 and 23 of the Housing Act, 1930 (1) Number of dwelling houses in respect of which notices were served requiring repairs 24 (2) Number of dwelling houses which were rendered fit after service of formal notices:— (a) By owners 6 (b) By local authority in default of owners Nil B. Proceedings under Public Health Acts:— (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 478 (2) Number of dwelling houses in which defects were remedied after service of formal notices:— (a) By owners 358 (b) By local authority in default of owners Nil C. Proceedings under sections 19 and 21 of the Housing Act, 1930:— (1) Number of dwelling houses in respect of which Demolition Orders were made Nil (2) Number of dwelling houses demolished in pursuance of Demolition Orders Nil D. Proceedings under section 20 of the Housing Act, 1930: — (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made Nil (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit Nil E. Proceedings under section 3 of the Housing Act, 1925:— (1) Number of dwelling houses in respect of which notices were served requiring repairs Nil (2) Number of dwelling houses which were rendered fit after service of formal notices:— (a) By owners Nil (&) By local authority in default of owners Nil (3) Number of dwelling houses in respect of which Closing Orders became operative in pursuance of declarations by owners of intention to close Nil F. Proceedings under sections 11, 14 and 15 of the Housing Act, 1925:— (1) Number of dwelling houses in respect of which Closing Orders were made Nil (2) Number of dwelling houses in respect of which Closing Orders were determined, the dwelling houses having been rendered fit 1 (3) Number of dwelling houses in rcspect of which Demolition Orders were made Nil (4) Number of dwelling houses demolished in pursuance of Demolition Orders Nil Number of dwelling houses demolished voluntarily 12 This number does not include 181 houses where notices were served in the latter part of 1930 and complied with in 1931. 50 OVERCROWDING. During the course of a systematic inspection of 5,140 houses between 1st January and 31st December, 1931, 124 or 2.4 per cent. were found to contain one or more overcrowded rooms. The standard of overcrowding was on the basis of a minimum of 360 cubic feet air space in sleeping rooms for persons over 10 years or 400 cubic feet where the room is both a living and sleeping room; and 250 cubic feet per person under 10—this being the standard fixed in the local byelaws for houses let in lodgings. During the year a new standard of overcrowding came into operation, so that a family is now considered to be overcrowded if the total accommodation, after allowing one room as a living room, in addition to the necessary bedroom accommodation, does not provide floor area for each member of the family of 40 square feet for persons over 5 years and 30 square feet for persons under 5 years, or the accommodation does not permit of the sexes being properly divided. 212 families occupied these 124 houses and 141 or 66.5 per cent. of these families were found to be overcrowded. In 76 houses of the 124 houses it was found possible to abate overcrowding without producing corresponding overcrowding elsewhere. 141 notices were served to abate overcrowding. Table XIII. FACTORIES, WORKSHOPS, AND WORKPLACES. 1. Inspection. Premises. Inspections. Number ot Written Notices. Prosecutions FACTORIES. (including Factory Laundries) 456 213 ... WORKSHOPS. (including Workshop Laundries) 576 163 ... WORK PLACES. (other than Outworkers premises) 148 95 ... Total 1180 471 61 Table XIV. 2. Defects Found in Factories, Workshops, and Workplaces. Particulars. No of Defects. Referred to H.M. Inspector. Prosecutions. Found. Remedied. Nuisances under the Public Health Acts— Want of Cleanliness 226 209 ... ... Want of Ventilation 11 11 ... ... Overcrowding 1 1 ... ... Want of Drainage of Floors 8 8 ... ... Other Nuisances 204 165 ... ... Sanitary Accommodation— Insufficient 3 3 ... Unsuitable or Defective 204 163 ... ... Not separate for sexes 6 3 ... ... Offences under the Factory and Workshops Acts— Illegal occupation of underground bakehouses ... ... ... ... Other offences— (excluding offences relating to outwork and offences under the Sections mentioned in the Schedule to the Ministry of Health (Factories and Workshops Transfer of Powers Order, 1921) ... ... ... ... Reports to H. M. Inspector ... ... 13 ... Total 663 563 13 ... 3. List of Registered Workshops. Trades. Totals. Bakers and Confectioners 65 Tailors 90 Dressmakers 68 Building Trades 77 Milliners 27 Upholsterers 43 Laundries 18 Cycle Works 26 Blacksmiths 18 Bootmakers 68 Watchmakers 20 Motor Engineers 63 Coachbuilders 13 Photographers 8 Picture Framers 6 Umbrella Makers and Repairers 3 Saddlers 7 Ladder and Barrow Makers 4 52 Wig Makers 2 Scale Makers 2 Blind Makers 4 Furriers 2 Marine Stores 8 Cabinet Makers 14 French Polishers 5 Embroidery 2 Sign Writers 8 Miscellaneous Trades 145 4. Bakehouses. The control of Bakehouses is dealt with under the Factory and Workshops Act, the Public Health Acts, Croydon Corporation Act. 1924. and Cleanliness of Food Bvelaws. For details of Croydon Corporation Act, see under Food Inspection. Number of bakehouses on Register, 31st December, 1931 106 Number of underground bakehouses (included in above) 7 Visits made to bakehouses during the year 303 Defects found 167 Notices issued 124 Notices complied 112 5. Home Work. Lists of homeworkers are sent in twice yearly, and last year contained the names of 294 outworkers residing within the Borough. 78 visits were paid to outworkers and 20 visits were paid to premises of employers of outworkers to examine lists and for other purposes. Table XV. NATURE OF EMPLOYMENT OF WORKERS ON THE REGISTER, 31st DECEMBER, 1931. Nature of Work. Number employed. Outwork in infected premises. Outwork in unsatisfactory premises. Remarks. Making, cleaning, altering and repairing wearing apparel 147 ... ... ... Upholstery work 4 ... ... ... Blind Repairs 1 ... ... ... Table Linen 2 ... ... ... Lace goods 2 ... ... ... Other classes of work 5 ... ... ... 161 ... ... ... 53 REGISTERED AND LICENSED PREMISES IN THE BOROUGH, 31st DECEMBER, 1931. Slaughterhouses (not including Public) 4 Bakehouses 106 Common Lodging Houses 13 Houses Let in Lodgings 87 Dairies and Milkshops 263 Cowsheds 26 Offensive Trades 122 Wholesale Dealers in Margarine, etc. 36 Registered Workshops 816 Premises registered under Artificial Cream Act, 1929 0 Premises registered for preparation or manufacture of potted, pressed, pickled or preserved meat, fish, or other food intended for the purpose of sale 251 SHOP HOURS ACTS. 1,508 visits and patrols were made during the year, including week-day and evening patrols and Sunday evening patrols. Infringements of the Acts ascertained as the result of these inspections are set out in the summary of infringements (paragraph 6). COMMON LODGING HOUSES. 1. Municipal Lodging House. The Municipal Lodging House (built by the Corporation owing to displacement of private common lodging houses due to improvement scheme) is situate at Pitlake, and contains 101 cubicle beds for nightly letting to lodgers. In addition there are three cubicles allotted to members of the Municipal Lodging House Staff, making a total of 104 cubicles on the premises. The charge per night to lodgers is 1s., the cost of a weekly ticket is 6s. for seven nights. The receipts and expenditure for the last ten years are as follows: — Receipts. Expenditure. £ s. d. £ s. d. 1922 1027 17 10 1279 13 4 1923 1081 4 2 1288 1 3 1924 1182 11 2 1350 10 7 1925 1346 16 6 1485 0 1 1926 1338 8 7 1639 2 8 1927 1362 14 7 1591 17 0 1928 1346 2 8 1516 7 11 1929 1329 5 1 1483 1 5 1930 1324 10 8 1477 13 6 1931 1385 6 4 1711 19 6 The number of men accommodated during the year was 32,519. The number of men lodgers exceeded 89 per night throughout the year. 54 2. Private Common Lodging Houses. There are 13 common lodging houses on the register. During 1931, 59 day and 26 night inspections were made. Notices were served for the conditions and defects as set out in the summary of defects found (paragraph 7). Table XVI. The following table gives the situation of and the accommodation in the common lodging houses: - Premises No. of Rooms. Accommodation 9, Prospect Place 3 17 men 52 and 53, Union Street 17 41 men 19, 20, 21, 22, 23 and 24, Lahore Road 3o 75 men and women 11 and 12, Princess Road 10 39 men and women ia and 2, Tamworth Road 11 44 men 13 71 216 men and women HOUSES LET IN LODGINGS. There are 87 houses registered under the Byelaws. 95 visits were made for inspection purposes. 26 notices were served for various amendments. 21 notices were complied with. Table XVII. The following table gives the situation of these premises Road. No. of Houses Let in Lodgings. Beulah Grove 1 Princess Road 1 Queen's Road (Croydon) 1 Ely Road 7 Forster Road 13 Holmesdale Road 4 Wilford Road 31 Donald Road 1 Canterbury Road 3 London Road 1 Whitehorse Lane 1 Nursery Road 1 Mayday Road 1 55 Tamworth Road 2 Bert Road 1 Croydon Grove 1 Derby Road 3 Belgrave Road 2 Cecil Road 1 Windmill Road 2 Auckland Road 1 Harrington Road 1 Portland Road 1 St. Peter's Road 2 Alexandra Road 1 Whitehorse Road 2 Grange Road 1 Notices were served for the conditions and defects as set out in the summary of defects found (paragraph 8). OFFENSIVE TRADES. Bye-laws relating to Offensive Trades were adopted during the latter part of the year 1925. 240 inspections were made of premises where such trades were carried on and notices issued requiring amendments in accordance with the byelaws. The following are on the register: — Rag and Bone Dealers 47 Gut Scrapers 2 Fish Friers 71 Rabbit Skin Drier 1 Fellmonger 1 122 RAG FLOCK ACTS, 1911 AND 1928. Two samples were obtained and subjected to analysis, the results being as follows: — No. 1 contained 6 parts of Chlorine per 100,000 ,, 2 ,, 3 ,, ,, ,, The samples conformed to the standard of cleanliness prescribed under the Rag Flock Regulations, 1912, made under the Rag Flock Act, 1911. The legal maximum of chlorine allowed is 30 parts per 100,000. SMOKE OBSERVATIONS. During the year 27 observations were made of factory chimneys for the purpose of detecting offences under the Act. 23 notices were sent and amendments carried out to stop the nuisance. 56 AMUSEMENT HOUSES. 153 visits were made to theatres, music halls, cinemas, and premises where stage plays are given. Attention was given to the ventilation of the halls, sanitary conveniences, structure and cleanliness of the dressing rooms. A report is submitted to the Licensing Authorities annually. Notices were issued for the conditions and defects as set out in the summary of defects found (paragraph 10). KEEPING OF ANIMALS. 68 inspections were made in connection with the keeping of animals. There were 35 premises, including institutions, where pigs were known to be kept in the Borough. 10 notices were served to abate nuisances arising from various causes in connection with the keeping of pigs and 35 notices were served to abate nuisances arising from the keeping of other animals. SCHOOLS. 54 inspections of school lavatories were made during 1931. In one instance the drains were found stopped and there were four instances of defective sanitary fittings. The water supply in all cases is from the mains. INSPECTION OF WATERCOURSES, ETC. During the year 32 visits were made to ditches, watercourses, etc., in order to see whether there were any infringements of the several Acts, etc. In a number of instances action was taken and notices served to disconnect surface water and other drains from ditches, watercourses, etc., and for other defects. POISONS AND PHARMACY ACT, 1908. The Poisons and Pharmacy Act, 1908, came into operation on April 1st, 1909. The object is to regulate the sale of certain poisonous substances and to amend the Pharmacy Act. The number of licences renewed under the Act during 1931 was seven, and in addition five licences were renewed and two additional licences were granted under the Order-in-Council dated November 10th, 1911, to assistants in the employ of persons already holding licences. Inspections of the premises were carried out periodically, when no infringements of the Act were found. 67 FERTILISERS AND FEEDING STUFFS Ad, 1926. During the year one sample was submitted for analysis under this Act and was found to be satisfactory. Six inspections of premises where fertilisers and feeding stuffs were sold by retail and one inspection of the premises of a wholesale dealer were carried out during the year. Infringements of Section 1 of the Act were found in each case. Reinspections were made at a later date and the infringements found to have been rectified. DISINFECTION. The Borough Disinfecting Station is situate in Factory Lane. Two steam disinfectors are in use and are supplied with steam from the refuse destructor. A Cleansing Station, consisting of reception room, four baths and discharge room, is attached to the Disinfecting Station, and is used for dealing with verminous conditions in children and adults. The following articles were disinfected at the Disinfecting Station during the year:— No. of Articles. By Steam 33,719 By Formalin gas 2,356 By Formalin spray „. 269 By Izal fluid 1 36,345 In addition 1,151 articles were destroyed on request. Disinfection after infectious or contagious disease was carried out in 2,496 rooms at 1,618 houses. 2 school departments and 22 class rooms. 53 hospital wards. 7 vehicles. 1 hut. 1 aeroplane. CLEANSING OF VERMINOUS PERSONS, ETC. During the year 10 adults and 15 children were cleansed for verminous conditions, and one adult and 10 children for scabies. 58 RATS AND MICE DESTRUCTION. The rat-catcher is a permanent member of the staff, and no charge is made for his services. Rats are destroyed by the following methods:—Dogs, poison baits, traps, and rat varnish smeared on cardboard. Close co-operation is carried out between the rat-catcher and he District Sanitary Inspectors. The following is a summary of the visits paid during 1931 under the Rats and Mice (Destruction) Act, 1919. Table XVIII. Premises. No. of Visits made. No. of Poison and other baits laid. No. of Rats Killed. Private Houses 1604 3941 977 Butchers 28 Other premises where food is prepared or sold 132 Other premises 217 Total 1981 3941 977 In addition to the above, 1,487 rats were killed at Corporation refuse tips by employees of another department. 59 SECTION III.—FOOD SUPPLY. The supervision and inspection of the food supplies is carried out by twelve of the district inspectors, who are qualified in food inspection. The work is supervised by the Chief Sanitary Inspector and the Deputy Chief Inspector, who also hold the necessary qualifications. Each district inspector is responsible for the examination of all foodstuffs, exposed or deposited, or in preparation for sale in shops, wholesale and retail markets, hotel and cafe kitchens, etc. together with the methods used in the preparation of the foodstuffs, the storage places and premises. This method of inspection, along with frequent sampling of all articles of food, is intended to procure for the public a wholesome supply of pure, unadulterated food. This desirable condition entails an enormous amount of detail work at all times of the year, especially intensified during the hot months, and it is only by eternal vigilance, screwed up to the highest pitch, that this can be maintained. The traders of the town have by their co-operation helped in the task, and I am sure desire to supply pure, wholesome food to the public. On the other hand the householder can help considerably in attaining the best standard by purchasing clean food, at the same time insisting that it has not been handled by unauthorised persons or exposed to injurious contamination such as flies and dust. It is, moreover, of great importance that householders should take equal precautions in the home. Foodstuffs should be bought in small quantities and kept in a clean, well-ventilated food pantry, screened from flies. Refrigeration, as a method of storage, gains further ground, not only in the shops but in the home. This method of low temperature storage ensures a fresher article with practically no waste. A larger number of articles are packed in hygienic containers and this method facilitates handling and prevents contamination. 60 The wrapping of bread and cakes, as delivered to houses in the borough, has not kept pace with other hygienic measures. This desirable method would soon materialise if the public were to demand it. Additional legislation continues to impose new tasks on the inspectorate. In addition to the actual examination of all foodstuffs the inspectors also observe if the marking of the foodstuffs, required by the various acts and orders, is being complied with. The Merchandise Marks Act requires an indication of the origin of certain imported goods. Orders under the Act have been made dealing with imported apples, honey, raw tomatoes, oat products, currants, sultanas, raisins, eggs, salmon, butter, etc. In addition Regulations regarding condensed and dried milk have been adopted, while other foodstuffs require marking under the Milk (Special Designations) Order, Food and Drugs Acts, Artificial Cream Act, Public Health (Preservatives) Regulations, Sale of Food Orders, etc. The necessity for a wholesome meat supply necessitates the examination of meat, not only in the shops, but also in the wholesale markets. Carcases coming into the borough, but dressed elsewhere, are subjected to minute examination. The private slaughterhouses are visited and the dressed meat is inspected before being passed out for human consumption, either in the borough or elsewhere. In order that a proper supervision of the food supplies in the borough be maintained it is necessary for the inspectors to be on duty long after ordinary hours of working. The Public Slaughterhouses are under the control of the Superintendent, who also acts under the supervision of the Chief Sanitary Inspector. During the year there were 40,974 animals slaughtered for human consumption, these figures being an increase of 641 on those for the year 1930. The following table shows the premises in the Borough at which foodstuffs are known to be sold, manufactured or stored:- General Shops 168 Grocers and Provision Shops 554 Greengrocers and Fruiterers 388 Confectioners, Bakers, and Ple Makers 496 Ice-Cream Shops 250 61 Hotel and Restaurant Kitchens and Dining Rooms 225 Butchers 205 Fishmongers (including Fried Fish Shops) 135 Ham and Beef Shops 58 Sweet Manufacturers 7 Other Food Premises 27 2,513 In addition to the premises in the above table, there are the following food premises, referred to in other paragraphs of this report:—Slaughterhouses and dairies, cowsheds and milkshops on the registers. Further, there are a large number of stalls and barrows used for food purposes in different areas in the Borough and forming street markets. There are also barrows and other vehicles which are used by hawkers, etc., for the selling of foodstuffs, but it is difficult to estimate the actual number in use, as this varies daily. All these barrows and vehicles, wherever found, are inspected by the food inspectors. PUBLIC SLAUGHTERHOUSES, PITLAKE, AND MEAT INSPECTION. These slaughterhouses, although the buildings were not originally intended for such, comprise twelve slaughterhouses with lairage attached. In addition a gut cleaning firm utilises one building on the premises. Of the twelve slaughterhouses nine with lairage attached, are let on agreement to tenant butchers, and the remainder are used for public slaughtering, for which head rate tolls are charged. Table XIX. The following animals were slaughtered at the Public Slaugterhouses during 1931:— Pitlake. Public Slanghterhonaes- Cattle. Shrep- pigs. Calves. Total. Public section 73 51 1755 81 1960 Private section 763 6810 19275 2892 29740 Total 836 6861 21030 2973 31700 The whole of the meat and offal is examined before it leaves the premises. 62 The following meat and offal from the Public Slaughterhouses was surrendered and destroyed during the year 1931:— Description. Cause. 7 beef carcases and offal General tuberculosis. 6 ,, forequarters Localised tuberculosis. 8 ,, parts ,, ,, 32 sets beef lungs ,, ,, 17 beef heads ,, ,, 24 ,, various offals ,, ,, 4 „ carcases and offals Emaciated, dropsical. 2 „ heads and tongues Actinomycosis. 2 ,, quarters Inflammatory conditions, etc. 108 ,, various offals ,, ,, 1 veal carcase and offal General tuberculosis. 9 „ plucks Tubercular. 4 „ heads ,, 3 ,, various offals Localised tuberculosis. 4 ,, carcases and offals Inflammatory, etc. 7 „ parts Various causes. 11 „ various offals ,, ,, 15 pig carcases and offals General tuberculosis. 7 ,, quarters Localised tuberculosis. 23 ,, various parts ,, ,, 380 „ heads ,, ,, 198 „ plucks ,, ,, 78 „ various offals ,, 18 ,, carcases and offals Inflammatory conditions, etc. 278 „ plucks ,, ,, 296 ,, various offals and 62 parts ,, ,, 6 sheep carcases and offals Emaciation, Inflammatory, etc. 1 ,, forequarter Traumatism. 9 ,, plucks Parasitical, etc. 34 ,, various offals Total weight destroyed: 26,660 lbs. PRIVATE SLAUGHTERHOUSES AND MEAT INSPECTION At the end of 1931 there were 4 registered slaughterhouses in the Borough. Of these 3 are in use. The number of visits paid to the private slaughterhouses for the purpose of inspecting the meat during 1931 was 1,2-52. Table XX. The number of animals slaughtered in the private slaughter houses during the year was:— Cattle. Sheep. Pigs. Calves. Total. 87 2290 4347 2550 9,274 63 The following meat and offal from private slaughterhouses was surrendered and destroyed during 1931:— Description. Cause. 1 beef carcase and offal. General tuberculosis. 4 „ heads. Localised tuberculosis. 1 set beef lungs. ,, ,, 4 beerf offals (various). ,, ,, 11 „ various offals. Inflammatory conditions, etc. 1 ,, pluck. Localised tuberculosis. 1 „ offal. Inflammatory conditions. 1 pig carcase and offal. General tuberculosis. 33 ,, heads and 2 parts. Localised tuberculosis. 13 „ plucks. ,, ,, 5 „ sundry offals. „ ,, 4 „ carcases and offals. Inflammatory, etc. 2 „ parts. „ ,, 17 „ plucks. „ „ 20 ,, offals (various). „ ,, 1 sheep carcase. Emaciated, etc. 2 „ plucks. Inflammatory. 5 „ offals (various). ,, Total weight destroyed 2,291 lbs. Table XXI. Total number of animals slaughtered for human consumption in the Borough during 1931:— Cattle. Sheep. Pigs. Calves. Total. 923 9,151 25,377 5,523 40,974 Table XXII. Summary of whole carcases destroyed with the reasons for such destruction. Class of Animal. Tuberculosis. Emaciated and Dropsical. Pyaemia. Inflammatory Conditions. Apoplexy. Traumatism. Jaundice. Swine Erysipelas. Asphyxiation. Total carcases. Cattle 8 3 ... ... ... 1 ... ... ... 12 Calves 1 1 1 1 ... ... 1 ... ... 5 Sheep ... 4 ... 1 ... 1 ... ... 1 7 pigs 16 ... ... 16 1 1 ... 1 3 38 Total* 25 8 1 18 1 3 1 1 4 62 64 Table XXIII. Summary of carcases in which tuberculosis was found in the course of inspection, and method of disposal. Animals affected. Carcase and all internal organs destroyed, Quarters or parts of carcase destroyed (including heads) All or parts of organs destroyed. Total. Cattle (including calves) 9 31 52 92 Pigs 16 413 222 651 Total 25 444 274 743 General food Inspection. The following table gives a summary of the inspections made during the year (not including visits made to slaughterhouses or dairies, cowsheds and milkshops):— Butchers 1877 Fishmongers 183 Fried Fish Shops 141 Grocers 737 Greengrocers 438 Poultry and Game Dealers 33 Cooked and Prepared Meat Shops 152 Bakers' Premises 229 Confectioners' Premises 527 Markets 726 Hawkers' Carts and Barrows 93 Hotel and other Kitchens, etc. 433 Ice Cream Manufacturers and Vendors 278 General Shops 404 Other premises 70 6,321 The following articles of food were surrendered and destroyed during 1931:— 3 beef forequarters (Imported) Unsound 17 ,, hindquarters „ do. 100 ,, parts and trimmings ,, do. 38 „ kidneys or parts „ do. 6 „ livers „ do. 4 cases beef fillets „ do. 10 mutton parts „ do. 11 lbs. lambs' liver ,, do. 8 pork parts „ do. 52 lbs. pig plucks, etc. ,, do. 366 lbs. sweetbreads ,, do. 21 lbs. rabbit do, 65 61 lbs. bacon Unsound 16 tins beef do. 1019 lbs. cod, haddock, etc. do. 29 boxes fish fillets do. 126 lbs. kippers do. 56 lbs. dogfish do. 84 lbs. whiting do. 42 lbs. witches do. 1 bag winkles do. 13 tins salmon do. 146 tins sardines do. 13 turkeys do. 287 tins cherries, loganberries, plums, etc. do. 417 lbs. pears do. 9 lbs. bananas do. 36 lbs. apples do. 9 lbs. oranges do. 20 lbs. tomatoes do. 30 lbs. prunes, etc. do. 30 lbs. dates do. 18 lbs. carrots, turnips, etc. do. 4376 lbs. potatoes do. 15 packets raisins do. 5 lbs. sprouts do. 6 lbs. cabbages do. 2 tins mushrooms do. 26 tins vegetables do. 12 tins tomatoes do. 64 tins milk do. 30 lbs. boiling sugar do. 7 jars jam, syrup, etc. do. 30 lbs. sweets do. 28 jars pickles do. 1 case eggs do. 24 lbs. butter margarine, etc. do. 4 tins soup do. 4 jars paste do. 2 lbs. cake do. 3 lbs. brawn, etc. do. 16 lbs. flour, etc. do. Total weight destroyed: 13,865 lbs. 66 Table XXIV. General Summary of Meat and other articles destroyed during the year 1931. ARTICLES. Weight in lbs. Remarks. Diseased. Unsound. Total. Beef 6,863 6,175 13,038 Including 12 carcases. Veal 355 61 416 ,, 5 „ Mutton 203 178 381 ,, 7 ,, Pork 12,301 822 13,123 „ 3S „ Offal 7,139¾ 892¾ 8,031¾ ,, imported offal. Fish ... 1,813 . 1813 Cod, Haddocks, Whining, etc. Fruit & Vegetables ... 4,950 4,960 Potatoes, Pears, Apples, Dates, etc. Tinned Goods ... 744 744 561 tins, 40 jars. Sundries ... 329½ 329¾ Bacon, Rabbits, Sweets, etc. 26,861¾ 15,964½ 42,825¾ MILK. The milk supply of the Borough is derived, principally from the south, south-east and south-west counties and arrives either by rail or road. Only a small proportion is produced in the borough, due largely to the absorption of land for building purposes and the decreasing amount of available pasture land. The Milk and Dairies (Consolidation) Act, 1915, and the Milk and Dairies Orders gave additional powers to deal with milk premises. Dairies, milkshops and cowsheds have received continuous inspection. In the case of dairies separate premises are required for the storage of milk and also for the washing of utensils. Alterations have been carried out to existing dairies in conformity with modern practice. Further, a large additional distribution depot with the most up-to-date equipment has been erected to facilitate the handling of milk in the best possible manner. 67 Mechanical refrigeration and cooling is used by increasing numbers of dairymen in the Borough as part of their equipment. Enquiries show that approximately 18,332 gallons of milk are sold daily in the Borough. Of this amount 92% is bottled, 5.5% is retailed as loose milk, the remaining 2.5% being sold wholesale to large consumers. These figures are interesting in view of the fact that eight years ago the whole of the milk sold was distributed loose. The sale of this type of milk, whether in shops or on the rounds, is discouraged. Of the total milk sold daily in the Borough, 13,380 gallons is graded milk, this being an increase of 3,395 gallons daily, as compared with the figures for 1930. This latter figure is extremely gratifying and draws attention to the remarkable changes which have taken place in the treatment and distribution of our milk supplies. Sterilised milk continues to be sold in the Borough. A recent innovation is the introduction of milk sold in waxed cartons, this method ensures that by ingenious machinery the carton is made and filled with milk and delivered ready sealed. During this operation it is untouched by hand. This method entirely eliminates the costly bottle and it will be interesting to watch the progress of this new method of distribution. Large numbers of samples have been obtained both for chemical and bacteriological analysis during the year. When a sample of milk is not up to a reasonable standard of bacterial purity the supplier, whether retailer or producer, is notified. At the same time he is invited to interview the Chief Sanitary Inspector. The methods of production and distribution are discussed and suggestions made, these when adopted have produced excellent results. Whilst the milk distributed in the borough is uniformly of excellent quality there remains the fact that a very large amount of the milk as produced on the farms shows contamination which is entirely unnecessary. This low standard makes it necessary for the vendors to provide and maintain elaborate and expensive plant to elininate something which should be kept out at the source. 68 MILK AND DAIRIES (CONSOLIDATION) ACT, 1915, THE MILK AND DAIRIES AMENDMENT ACT, 1922, AND THE MILK AND DAIRIES ORDERS, 1926. Cowkeepers, Dairymen and Purveyors of Milk. The following statement shows the number of Cowkeepers, Cowsheds, Dairies and Purveyor of Milk Premises on the register:— Cowkeepers on register (1930) 9 ,, added to the register (1931) 2 ,, discontinued (1931) 1 Net 10 Cowsheds on register (1930) 26 ,, added to the register (1931) 2 ,, discontinued (1931) 1 Net 27 Number of cows provided for 297 Average number of cows in sheds (1931) 215 No. of dairies and purveyors of milk on register (1930) 254 No. of dairies and purveyors of milk added to register (1931) 34 No. of dairies and purvevors of milk tinued during 1931 25 Net 263 Grand total of cowsheds, dairies and purveyors of milk on register, 31st December, 1931 290 During- the year 957 inspections were made of dairies, cowsheds and milkshops. Milk (Special Designations) Order, 1923. The following licences were granted during the year under this Order and were in force on the 31st December, 1931: — Description of Licences. No. (1) Producers' Licences to use the designation , "Grade A" — 69 (2) Dealers' Licences to use the designation "Certified" 19 (3) Dealers' Licences to use the designation "Grade A" (Tuberculin tested)— (a) Bottling establishments 1 (b) Shops 15 (4) Dealers' Licences to use the designation "Grade A"— (a) Bottling establishments — (b) Shops 7 (5) Dealers' Licences to use the designation "Grade A Pasteurised"— (a) Shops — (6) Dealers' Licences to use the designation "Pasteurised"— (a) Pasteurising establishments 1 (b) Shops 52 (7) Dealers' Supplementary Licences to use the designation (a) Certified 2 (b) Grade A 2 (c) Pasteurised 1 Inspection of these licensed premises has been carried out regularly during the year to see that the conditions of the licences were observed. During the year the following samples of milk were examined under the Milk (Special Designations) Order, 1923: — Certified Milk. Licensed country producers supplying milk to licensed local dairymen 3 Grade A (Tuberculin Tested) and Grade A Milks. Licensed country producers of Grade A (Tuberculin Tested) milk supplying milk to licensed local dairymen 6 Licensed country producer of Grade A milk supplying milk to a licensed local dairyman — 70 Pasteurised Milk. Samples from licensed dealers 106 The following tables summarise the result of the bacteriological examinations of Certified, Grade A (Tuberculin Tested), Grade A and Pasteurised samples, from 1st January to 31st December, 1931:— Table XXV. CERTIFIED MILK. Present. Absent. Over 30,000 per c.c. Under 30,000 per c.c. Present in 1/10 c.c. Not present in 1/10 c.c. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding a trace. Tubercle bacillus ... 3 Total number of bacteria ... 3 Bacillus Coli 1 2 Blood ... 3 Pus .. 3 Detritus ... 3 ... 3 ... 3 1 2 ... 3 ... 3 ... 3 The above 3 Certified Milk samples contained total bacteria per c.c. as follows:— 0—1,000 1 1,000—5,000 1 5,000—10,000 1 10,000—20,000 — 20,000—30,000 — Over 30,000 — 3 Under the Regulations Certified Milk must not contain more than 30,000 bacteria per c.c. 71 Table XXVI. GRADE A (TUBERCULIN TESTED) AND GRADE A MILKS. Present. Absent. Over 200,000 per c.c. Under 200.000 per c.c. Present in 1/100 c.c. Not present in 1/100 c.c. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding a trace. Tubercle bacillus ... 6 Total number of bacteria ... 6 Bacillus coli ... 6 Blood ... 6 Pus ... 6 Detritus ... 6 ... 6 ... 6 ... 6 ... 6 ... 6 ... 6 The 6 Grade A (Tuberculin Tested) and Grade A milks contained bacteria per c.c. as follows:— 0—1,000 4 1,000—5,000 2 6 Under the Regulations Grade A (Tuberculin Tested) or Grade A inilk must not contain more than 200,000 bacteria per c.c. The following table sumarise the results of the bacteriological examinations of Pasteurised milk samples from 1st January to 31st December, 1931:— Table XXVII. PASTEURISED MILK, (licences granted under the Milk (Special Designations) Order, 1923). Present. Absent. Over 100,000 per c.c. Under 100,000 per c.c. Present. Absent. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding a trace. Tubercle bacillus ... 106 Total number of bacteria 4 102 Bacillus coli 37 69 Blood ... 106 Pus ... 106 Detritus ... 106 ... 106 4 102 37 69 ... 106 ... 106 ... 106 72 The above 106 Pasteurised Milk samples contained bacteria per c.c. as follows:— 1,000—5,000 22 5,000—10,000 24 10,000—20,000 22 20,000—30,000 15 30,000—50,000 10 50,000—100,000 8 Over 100,000 5 106 Under the Regulations Pasteurised Milk must not contain more than 100,000 bacteria per c.c. There were 2 samples of Sterilized Milk taken during 1931. Bacillus Coli was absent in each case, and the bacterial content was as follows:— 1 sample contained Nil bacteria per c.c. 1 sample contained 10 bacteria per c.c. MILK AND DAIRIES ORDERS 1926. There were four offences discovered under the above Orders, namely:— Bottling milk on other than the Registered premises. In each case the roundsman was prosecuted and fines and costs amounting to £13 4s. were incurred. PROVISION AS TO MILK SUPPLY. During the year 302 samples of ordinary milk were procured and submitted to examination for tuberculosis in accordance with the Milk and Dairies (Consolidation) Act, 1915. These samples were taken as follows:— Samples taken at cowsheds in the Borough 18 Samples in course of delivery from country cowsheds to local dairymen and purveyors of milk in the Borough 53 Samples taken at dairymen's premises in the Borough 61 73 Samples taken in course of delivery by local dairymen or milk sellers on then rounds in different parts of the Borough 168 Other samples taken 2 302 Eleven samples proved to be tuberculous, but oi these four were from supplies from which previous tuberculous samples had been taken and which were at the time the subject of action by the Authorities concerned, and therefore could be taken to be duplicate samples. The milk came from farms in East Sussex, Surrey, and a farm in the borough. The Authorities concerned were notified that samples of milk taken had been shown to contain tubercle bacilli and enquiries were made with a view of tracing the cows involved. A considerable number of cows were examined by the Authorities' Veterinary Officers, suspected animals isolated and samples taken and as the result of their investigations five animals were dealt with under the Tuberculosis Order, 1925. In two cases it was ascertained that the milk was a mixed supply coming from a considerable number of farms, and much difficulty is met with in these cases in locating affected animals. The following table summarises the results of the bacteriological examination of ordinary milk samples, taken under the Milk and Dairies (Consolidation) Act, 1915, from 1st January to 31st December, 1931:— Table XXVIII. ORDINARY MILK. Present. Absent. Over 200,000 per c.c. Under 200,000 per c.c. Present in 1/100 c.c. Absent from 1/100 c.c. Present. Absent. Present. Absent. Exceeding a trace. Not exceeding a trace. Tubercle bacillus 11 291 Total No. of bacteria 60 242 Bacillus Coli 198 104 Blood ... 302 Pus ... 302 Detritus ... 302 11 291 60 242 198 104 ... 302 ... 302 ... 302 74 The 302 samples of ordinary milk contained total bacteria per c.c. as follows:— 0—1,000 4 1,000—5,000 24 5,000—10,000 25 10,000—20,000 30 20,000—30,000 33 30,000—40,000 22 40,000—50,000 20 50,000—100,000 57 100,000—150,000 18 150,000—200,000 9 200,000—250,000 8 250,000—500,000 16 500,000—750,000 12 750,000—1,000,000 5 1,000,000—2,000,000 6 Over 2,000,000 13 302 There is no standard fixed for total bacteria per c.c. in ordinary commercial milk, but comparing the results with the Grade A standard, i.e., 200,000 per c.c., it will be seen that 242 of the samples contained total bacteria in accordance with that standard. It has to be remembered that a proportion of this milk has been subjected to commercial pasteurisation. The 302 samples taken under the Milk and Dairies (Consolidation) Act, 1915, were samples of milk which had been produced in the following areas:— 75 Table XXIX. Areas. No. obtained. No. Tuberculous. Croydon 18 2 Kent 12 Surrey 14 4 Sussex 27 5 Wiltshire 1 *Unclassified 230 Totals 302 11 *These samples could not be classified owing to the fact that it was mixed milk of large dairy firms or wholesale purveyors of milk, who obtain their milk from practically all the areas mentioned in the above table. FOOD AND DRUGS (ADULTERATION) ACT, 1928. During the year 429 samples of milk (425 new, 2 separated, 2 condensed) and 458 other samples were taken. In 1 instance the vendor was prosecuted and 11 were warned. 17 samples of Ice Cream were taken during the year. The Public Analyst reports that 4 of these samples contained fat in amounts varying from 1.9% to 6.3%. The remaining thirteen contained fat in amounts varying from 10.0% to 13.3%. There is no legal standard for fat in Ice Cream. 10 per cent. is suggested as a reasonable minimum amount. Bearing in mind this figure, it will be seen that the majority of the samples of Ice Cream were well above this suggested standard. 1. Summary of Samples. During 1931 samples were obtained and submitted to the Public Analyst as follows:— 76 Table XXX. Samples of Total Samples. Genuine. Not Genuine. Prosecutions. Convictions. Cautions. Milk 425 412 13 1 1 3 „ Separated 2 2 — — — — Condensed milk 2 2 — — — — Tinned Cream 1 1 — — — — Arrowroot 8 8 — — — — Aspirin tablets 8 6 — — — 1 Bacon 8 8 — — — — Baking Powder 9 9 — — — — Baked Beans 1 1 — — — — Boracic Ointment 2 2 — — — — boric Ointment 1 — 1 — — 1 Brawn 10 10 — — — — Bread 7 7 — — — — Bun Flour 6 6 — — — Butter 12 12 — — — — Camphorated Oil 3 3 — — — — Castor Oil 5 5 — — — — Cheese, Cheddar 1 1 — — — — Cheese, Cream 2 1 1 — — 1 Cocoa 10 10 — — — — Cod Liver Oil 7 7 — — — — Coffee 6 6 — — — — ,, and Chicory 2 2 — — — ,, Essence 1 1 — — — — ,, with Chicory 2 2 — — — — Confection of Senna 5 0 — — — — Corned Beef 1 1 — — — — Corn Flour 6 6 — — — — Cream Buns 1 — 1 — — — ,, Doughnuts 3 — 3 — — — Cream of Tartar 6 6 — — — — Custard Powder 3 3 — — — — Dripping 6 6 — — — — Faggots 7 6 1 — — 1 Fish Paste 9 9 — — — Flour (includ. Self-raising) 8 8 — — — — Ginger Ale 4 4 — — — — Ginger Beer 5 5 — — — Gammon 1 1 — — — Glycerine 5 5 — — — — Golden Syrup 7 7 — — — Ground Almonds 6 6 — — — — Ground Ginger 6 5 1 — — 1 Ground Rice 7 7 — — — — Ham 2 2 — — — — Honey 7 7 — — — — Ice Cream 17 17 — — — Jam 10 10 — — — — Lard 7 7 — — — — Lemon Cheese 5 5 — — — — Lemonade Powder 6 6 — — — — Lemon Squash 2 2 — — — — Light Calcined Magnesia 3 3 — — — — Liquorice Powder Compd. 5 5 — — — — Margarine 9 8 1 — — 1 Meat Paste 11 11 — — — — Mincemeat 4 4 — — — — Minced Beef 1 1 — — — — Carried forward 726 702 24 1 1 9 77 Samples of Total Samples. Genuine. Not Genuine. Prosecutions. Convictions. Cautions. Brought forward 726 702 24 1 1 9 Mixed Pickles 13 13 — — — — Olive Oil 4 4 — — — — Peaches, Sliced 1 1 — — — — Pearl Barley 5 5 — — — — Pate de Fois Gras 1 1 — — — — Pepper 7 7 — — — — Pickled Onions 2 2 — — — — Pressed Brisket 1 1 — — — — Rissoles 3 3 — — — — Rochelle Salt 6 6 — — — — Sausage, Beef 20 20 — — — — „ Breakfast 7 6 1 — — 1 „ Liver 1 1 — — — — ,, Lunch 4 4 — — — — ,, Metz 1 1 — — — ,, Pork 14 13 1 — — 1 Saveloys 2 2 — — — — Shredded or Chopped Beef Suet 4 4 — — — — Sweets 20 20 — — — — Syrup of Figs 4 4 — — — — Syrup of Rhubarb 3 3 — — — Sponge Mixture e 2 — — — — Tea 8 8 — — — — Tinned Asparagus 2 2 — — — Tinned Beans 1 2 — — — — Tinned Peas 6 6 — — — — Tomato Soup 1 1 — — — — Treacle 5 5 — — — — Vinegar, Malt 7 7 — — — Veal and Ham Cutlets 1 1 — — — — Barley, Scotch 1 1 — — — — Whiskey 3 3 — — — Tutals 887 861 26 1 1 11 2. Result of Analysis of New Milk Samples. SOLIDS NOT FAT.* (Legal standard is 8.5%). 8.1 8.3 8.4 8.5* 8.6 8.7 8.8 8.9 9.0 9.1 9.2 9.3 9.4 Total 425 1 1 2 3 36 91 120 106 41 10 3 2 1 MILK FAT.* (Legal standard is 3%). 19 2.7 2.8 2.9 3.0* 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 1 2 2 4 8 11 16 36 79 58 61 34 38 16 2672653332111 Total 425 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.9 5.1 5.2 5.5 Total Samples of New Milk ,, ,, Separated Milk ,, ,, (Informal) 425 2 — 427 78 The Samples of Milk (including Separated Milk) for analysis were obtained as follows: — Country Milk in course of delivery at Railway Stations 7 Country Milk in course of delivery by Motor Lorry to Local Dairymen 7 On Milk Rounds (Sundays) 15 ,, „ (Week-days) 285 Cowsheds — At shops 106 Taken at Institutions 2 "Appeal to Cow" Samples taken at farms outside Borough 5 427 AVERAGE COMPOSITION OF NEW MILK SAMPLES. 9olids not Fat 8.8% Milk Fat 3.6% Percentage of New Milk Samples below legal standard : 3.05% Adulterated Samples. The following is a detailed statement of the adulterated samples and action taken : — No. Sample. Adulteration or Deficiency. Remarks. 1594. Pork Sausage Contained sulphur dioxide 0.016 per cent. Vendor warned. 1613. Cream Doughnuts (informal). Cream used was not prepared from milk. See samples 1701 and 1702. 1622. Faggots Contained boric acid 0.01 per cent. Vendor warned. Further sample proved genuine. 1640. Cream Buns Cream used was not prepared from milk. See samples 1701 and 1702. 1676. Cream Cheese Cheese not prepared from cream. Exiplanation accented. Vendor warned. 1677. Aspirin Tablets Deficiency of acetylsalicylic acid, 0.7 grain per tablet. Explanation from manuifacturei accepted. 1683. New Milk 1 per cent. added water. Further sample genuine. Vendor warned. 1701. Cream Doughnuts Cream used was not prepared from milk. No action. 1702. Cream Doughnuts Cream used was not prepared from milk. No action. 1737. New Milk 3 per cent. added water. Explanation accented. Vendor warned. 1835. Aspirin Tablets Deficiency of acetvlsalicylic acid, 0.25 grains per tablet. Vendor warned. 79 1868. New Milk 2 per cent. deficient in fat. Explanation accepted. Vendor warned. 1890. New Milk 37 per cent. deficient in fat. Vendor and employee prosecuted and convicted. Vendor fined £2 and £3 18s. 6d. costs. Employee fined £5 and 15s. costs. 2107. New Milk 4 per cent. deficient in fat. See sample 2162. 2096. Breakfast Sausage Contained sulphur dioxide 0.0025 per cent. Vendor warned. 2152. Grade "A" T.T. Milk 10 per cent. deficient in fat. See sample 2185. 2154. New Milk 7 per cent. deficient in fat. See sample 2162. 2160. Grade "A" T.T. Milk 12 per cent. deficient in fat. See sample 2185. 2162. New Milk 8 per cent. deficient in fat. Further samples proved genuine. Ca.se referred to Director of Agriculture for county. 2141. Boric Ointment N'ot according to British Pharmacopoeia. Explanation accepted. Vendor warned. C1. New Milk 2 per cent. deficient in fat. " Appeal to cow " samples. C2. New Milk 1 per cent. deficient in fat. See sample 2185. Steps were taken C3. New Milk 2 per cent. deficient in fat. regarding the herd to raise the fatty solids 2185. Grade "A" T.T. Milk 4 per cent deficient in fat. Further sample proved genuine. 2226. Ground Ginger Contained sulphur dioxide 0.026 Vendor warned. 2288. Margarine per cent. Contained 17 per cent. of water. Vendor warned. 80 SECTION IV. CANCER. Deaths from Cancer numbered 342 as compared with 339 in 1930; 330 in 1929 ; 327 in 1928; 344 in 1927 ; 330 in 1926; 319 in 1925 ; 293 in 1924. Death-rates per 1,000 of the population for the past 10 years are as follows:— 1921—1.14 (218) 1926—1.60 (330) 1922—1.31 (252) 1927—1.62 (344) 1923—1.34 (259) 1928—1.54 (327) 1924—1.50 (293) 1929—1.48 (330) 1925—1.60 (319) 1930—1.52 (339) For 1931 the rate is 1.46 (342). Deaths From Cancer in Municipal Wards. Table XXXI. Ward. M ale. Female. Total. Death-rate Population Census 1931. Male. Female Upper Norwood 16 20 36 1.65 9835 11907 Norbury 12 11 23 1.48 7034 8502 West Thornton 12 8 20 1.00 91315 10358 Bensham Manor 7 11 18 1.15 7301 8324 Thornton Heath 7 16 23 1.51 7240 7935 South Norwood 10 16 26 1.51 7849 9362 Woodside 10 18 28 1.84 7223 7990 East 8 14 22 1.25 7706 9823 Addiscombe 9 17 26 1.85 6498 7519 Whitehorse Mnr 5 15 20 1.23 7768 8508 Broad Green 11 10 21 1.41 7093 7839 Central 15 11 26 2.20 5276 6582 Waddon 8 15 23 1.08 10090 11126 South 8 17 25 1.73 6150 8321 No fixed abode 1 1 — — Addington 3 1 4 1.43 1384 1407 Total 142 200 342 1.46 107,582 125,533 81 Table XXXII. Based on 1931 Census figures. Deaths 'from Cancer occurred at the following ages:— Age period. Male. Female. Total. Calculated population at this age period. Incidence per 1,000 persons living. Under 25 years 1 — 1 97907 .001 25 and under 35 years — 3 3 34970 .009 35 and under 45 years 6 12 18 37296 .048 45 and under 65 years 60 79 141 46623 .302 65 years and over 73 106 179 16318 1.097 142 200 343 233,113 1.46 Table XXXIII. Sites of Fatal Cancer. Site. Male. Female. Total. Percentage of Total. Brain 1 — 1 0.29 Skin 6 2 7 2.06 Tongue and Mouth 6 1 7 2.05 Tonsils 1 — 1 0.29 Oesophagus 3 2 5 1.46 Stomach 41 27 68 19.88 Liver 7 12 19 5.56 Bowel 17 40 57 16.67 Rectum 15 14 29 8.48 Bladder 1 3 4 1.17 Prostate 15 — 15 4.39 Larynx 4 — 4 1.17 Uterus — 21 21 6.14 Breast — 41 41 11.99 Ovary — 11 11 3.21 Pancreas 2 2 4 1.17 Gall Bladder 1 6 7 2.06 Abdominal 1 3 4 1.17 Bones 1 2 3 0.88 Mediastinum 2 1 3 0.88 Lungs 7 4 11 3.21 Kidneys 4 1 5 1.46 Glands 4 3 7 2.06 Not stated 1 — 1 0.29 Reproductive — 3 3 0.88 Pharynx 2 — 2 0.58 Penis 1 — 1 0.29 Ureter — 1 1 0.29 142 200 342 82 (1) The Cancer mortality rises as age rises ; this is in accordance with established facts. (2) Mortality is about evenly distributed between the two sexes at all ages, making allowance for the preponderance of females in the general population. (3) The two main groups of organs attacked in both sexes are the alimentary system and the reproductive system. In males 77.4% of the total deaths fall within these groups and in females 91.5%. In both sexes Cancer of the digestive system is the commonest situation, amounting to 66.2% in males and 53.5% in females. Oancer of the reproductive system caused 38.0% of the total deaths in females. Cancer of the larynx, tongue and mouth is much commoner in males than females, 13 deaths occurring in males as compared with 1 in females. The organs most often attacked in descending order of incidence are, in males—the Stomach (28.8%), Rectum and Bowels (22.5%), Tongue and Mouth (9.2%) ; in females—Bowels and Rectum (27.0%), the Breast (20.5), Stomach (13.5%), and Uterus (10.5%). This is slightly different from the incidence in 1930. The main incidence of Cancer is, in both sexes, on two groups of organs, both having a common characteristic, namely, periods of active cell degeneration and regeneration. 83 SECTION Y. PREVALENCE AND CONTROL OF INFECTIOUS DISEASE. Table XXXIV. gives the figures for ages and wards. Scarlet Fever was not so prevalent as in 1930; the largest incidence has been in Waddon, West Thornton, Woodside, Thornton Heath, Norbury and Broad Green Wards. Based on the estimated ward populations, the case rate for these wards was respectively, 372 ; 359 ; 309 ; 250; 212 ; and 221 per 100,000 of the population. The age group 5-15 years, as usual, suffered most; cases in this group comprising 58.4% of the total. Diphtheria was not so prevalent as in 1930, most cases, as in 1930, occurred in Upper Norwood (case rate 262) ; West Thornton (108) ; Waddon (170) ; Norbury (103) ; and Broad Green (107). Once again the age group 5-15 years gave the highest figures. Fifty-one cases of Small Pox occurred, all were of the modified type, 19 in Waddon, 13 in Broad Green and 7 in West Thornton. The outbreak is dealt with in detail later in this section. There were 23 cases of Puerperal Fever and 50 of Puerperal Pyrexia; 26 occurred in the age group 16-25 years and 47 in the age group 26-45 years. A majority of the cases occurred in women having their first confinement. All the notifiable infectious diseases showed a decreased incidence with the exception of Small Pox and Acute Primary Pneumonia and the Puerperal conditions. There was a notable increase to the notification of both Puerperal Fever and Puerperal Pyrexia. The probable reason for this given in the obstetrical section of the report (page 161). The following streets or districts showed the highest incidence Scarlet Fever, namely, the Corporation Housing Estate, MitMitcham Road ; Mayday Road Hospital. Otherwise the cases were Widely scattered over the whole borough area. Diphtheria showed the highest area incidence in Hermitage Road owing to an outbreak to the Convent, and on the Waddon Housing Estate, cases otherwise were widely scattered. The incidence of the commoner infectious diseases in Croydon during the past eight years is of interest. 84 Scarlet Fever has shown a succession of shallow waves of incidence with a distinct trend towards an aggregate increase. The periods of maximum intensity have been in 1924, June and July; 1925, March, April and May; 1926, May, June and July; 1927, April, May and June; 1928, January and February, with another in November and December. 1929, a gradual increase throughout the year without any intermissions. 1930, the incidence was relatively constant, with a slight decline in the number of cases in August and September. During 1931, the incidence was fairly constant, the highest number of cases occurring in January with a gradual decline as a whole to the end of the year. The weekly average of cases was 10.5. Diphtheria.—During 1924 there was a small but steady incidence throughout the year; in 1925 a trough occurred in the curve and very few cases were notified, but towards the end of the year the notifications began to increase steadily, the curve reaching its apex in November and December, 1926; the curve then declined through 1927 until the last quarter, when the tend became upwards once more, reaching its apex in January, 1928, this was followed by a slight fall, followed by a slight rise until December, 1928, when another fall commenced, reaching its minimum in July, 1929, from when the curve rose steadily to its maximum in November. In 1930 Diphtheria was not troublesome, though there was a small rise in the number of cases in October, reaching a maximum of 22 during the week ending October 18th. In 1931 the highest number of cases arose in February and the last two weeks of March. The highest number of cases in one week was during the week ending February 14th, when 13 cases were notified. The weekly average was 4.2. Whooping Cough, from being inconspicuous in 1924, the curve rose gradually to a maximum in May, June and July, 1925, then fell rapidly to a minimum in November and December, then rose very gradually to a lower maximum in September, 1926; once again the curve fell abruptly to a minimum in January, 1927, rose in June and July, and fell again gradually to a minimum in November and December, then rose steadily to the highest level of the period under review in January, 1929, from when it fell steadily to the end of the year. Throughout 1930 it remained quite inconspicuous, until December when there were indications of the commencement of a wave of increased incidence which persisted in 1931 until the end of July, after which the number of cases dropped considerably. December showed a small rise in cases. The average number of cases brought to our knowledge was two weekly. 85 Measles was very prevalent in April and May, 1924, then dropped suddenly, but showed a small rebound during September, October and November, after when it died away until a sudden rise in May, June and July, 1925, was followed, after a fall, by a further and more prolonged rise from October, 1925, to May, 1926. During 1927 there was very little Measles in Croydon ; a small rise in October, November and December, however, heralded a very big incidence of cases—the highest during the period under review —during the first six months of 1928. Practically no cases occurred after this exacerbation, until March, 1929, but during this month, and April, May and June, 1929, a number of cases occurred from when the incidence dropped away until the end of the year. Another wave of considerable intensity commenced abruptly during the last week of February, 1930, reaching its maximum in the second week of March and dying away gradually until terminating at the end of June. During 1931, Measles was quite inconspicuous ; the highest number of cases coming to our notice being in the middle of May and the end of April. The measles waves therefore were as follows: the first half of 1924, the second half of 1925, and first quarter of 1926 ; first half of 1928, the first half of 1929 and the first half of 1930. The characteristics of the Measles curves were their abrupt rises and rather less abrupt falls. Chicken Pox.—A small wave of cases occurred during the first half of 1924, followed by a higher wave covering the last quarter nf 1924 and the first half of 1925 ; another irregular wave was experienced during the first half of 1926, followed by a secondary in the last quarter. During 1927 and 1928 there was a fairly high and steady incidence with a peak in October and November, 1927. Another wave came during the latter half of 1929 with its maximum in December ; this wave continued into 1930, gradually declining to a minimum at the end of July. Another wave commenced in November and continued until the end of the year. During 1931 Chicken Pox was prevalent until the end of June, when the number of cases declined and remained low until November when the rases again rose. Mumps occurred in a series of waves from 1924 to 1928 inclusive, but was not at all prevalent in 1929. In 1930, however, a rather severe incidence was noted throughout the first half of the year. In 1931, there was an irregular and gradual decline throughout the year from a maximum in January and February. The waves showed their maxima in March, 1924; May, 1925; March, 926, May, 1927 ; March, 1928 and May, 1930, and their minima in September, 1924; September, 1925; September, 1926; and September, 1927. 86 Table XXXIV. CASES OF NOTIFIED INFECTIOUS DISEASE, 1931 Notifiable Disease. Cases notified in the whole District. Total cases notified in each Ward. Total cases removed to Borough Hospital. Total Deaths in the Borough. 1930. At all Ages. At ages—years. Upper Norwood. Norbury West Thornton. Bensham Manor. Thornton Heath. South Norwood. Woodside. East. Addiscombe. Whitehorse Manor. Broad Green. Central. Waddon. South. Addington. Under 1 year. 1-5 6—15 16—25 26—45 46—65 66 and up. M F Small Pox 51 1 6 14 8 7 11 4 ... ... 7 1 1 ... ... 2 1 6 13 1 19 ... ... 2 ... 12 12 Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria (inc. Membranous Croup) 221 3 64 109 28 14 3 ... 57 16 21 4 14 8 12 6 3 8 16 10 36 9 1 269 5 194 200 Erysipelas 68 1 ... 1 7 21 25 13 4 1 20 6 3 5 6 2 4 6 3 2 6 ... ... 29 4 31 33 Scarlet Fever 527 3 117 308 55 38 6 ... 31 33 70 25 38 32 47 32 29 21 33 22 79 28 7 531 3 349 332 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever (including Paratyphoid) 6 ... 1 1 1 3 ... ... 1 1 ... ... ... ... ... 1 ... ... 3 ... ... ... ... 8 ... 9 6 Puerperal Fever 23 ... ... ... 3 20 ... ... 2 ... 7 2 1 ... 1 1 1 2 2 3 1 ... ... 23 8 ... 13 Puerperal Pyrexia 50 ... ... ... 23 27 ... ... 3 2 28 1 ... ... 1 1 ... ... 9 1 1 3 ... 2 ... ... 24 Cerebro-Spinal Meningitis 3 ... 1 1 1 ... ... ... ... 1 1 ... ... ... ... ... ... 1 ... ... ... ... ... 5 3 1 ... Ophthalmia Neonatorum 14 14 ... ... ... ... ... ... 1 ... 3 1 1 ... ... ... ... 4 2 2 ... ... ... 3 ... 13 6 Poliomyelitis 4 ... 3 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3 ... ... 1 3 1 ... Encephalitis Lethargica 2 ... ... 1 ... 1 ... ... 1 ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3 ... Dysentery 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ac. Primary or Ac. Inf. Pneumonia 80 1 2 9 14 26 21 7 8 3 8 5 3 8 10 8 7 5 3 3 2 6 1 ... 5* 41 32 *Influenzal Pneumonia only. 87 Table XXXV. Notified Disease. Incidence Rate per 1,000 population. Housing Conditions. Case occurring in Institutions in the Borough. Total cases notified. 1-3 rooms. 4-5 rooms. Over 5 rooms. 1931 1930 Small Fox 0.22 0.103 — 24 4 23 51 Diphtheria 0.95 1.77 3 156 29 33 221 Erysipelas 0.29 0.24 — 45 4 19 68 Scarlet Fever 2.26 3.06 5 396 97 29 527 Enteric Fever (inc. Paratyphoid) 0.026 0.067 — 4 1 1 6 Puerperal Fever 0.099 0.05 — 13 1 9 23 Puerperal Pyrexia 0.214 0.10 — 12 4 34 50 Cerebro-Spinal Meningitis 0.013 0.004 — 2 — 1 3 Ophthalmia Neonatorum 0.06 0.085 1 6 1 6 14 Poliomyelitis 0.017 0.004 — 3 1 — 4 Encephalitis Lethargica 0.008 0.013 — 1 1 2 Acute Primary or Acute Influenzal Pneumonia 0.34 0.32 1 60 18 1 80 Dysentery 0.004 — — — — — 1 The highest incidence of notifiable infectious diseases was in houses of 4-5 roomis. Houses of this size preponderate in the borough, but as the actual number are not yet available from the Census returns the comparative incidences in the various sizes of bouse cannot be given. 88 Table XXXVI. SCARLET FEVER. YEAR. Cases notified in Croydon. Attack Rate Per 100,000 of Population. No. of Deaths. Percentage of Deaths to Cases notified. All Cases Admitted to Hospital with a Diagnosis of Scarlet Fever. No. Admitted. No. of Deaths. Percentage of Deaths to caaes Treated* 1 2 3 4 5 6 7 8 1908 534 338 5 9 497 8 1.6 1909 727 451 9 1.2 608 11 1.8 1910 759 454 7 .9 624 7 1.1 1911 468 274 7 1.5 377 5 1.3 1912 476 273 2 .4 365 4 1.09 1913 470 263 3 .6 411 4 .9 1914 748 411 5 .6 638 5 .7 1915 414 233 5 1.2 391 4 1.02 1916 297 169 4 1.3 283 6 2.1 1917 191 102 2 1.05 196 2 1.02 1918 414 219 6 1.4 376 8 2.1 1919 603 314 11 1.8 522 11 2.1 1920 638 332 7 1.09 535 8 1.4 1921 855 446 4 .4 720 4 .5 1922 800 416 6 .7 691 6 .8 1923 379 195 2 .5 340 ... ... 1924 289 147 2 .6 237 2 .8 1925 347 174 1 .2 248 2 .8 1926 525 254 ... ... 409 ... ... 1927 717 338 3 .4 686 3 .4 1928 552 259 4 .7 574 8 1.3 1929 769 335 4 0.54 714 3 0.42 1930 681 306 2 0.29 679 2 0.29 1931 527 225 3 0.57 528 2 0.38 *Cases admitted to the Borough Hospital from Penge are included in arriving at the figures in Cols. 6 to 8. There was a decrease in the number of cases notified and admitted to Hospital in 1931 as compared with 1930. The type was relatively mild though not so mild as in 1930. Waves of 89 severity in this complaint are usual and, in the comparatively short period coveted by the above table, make themselves noticeable. The case rate (Col. 3) for England and Wales was 205. Croydon's figure shows an excess. Table XXXVII. DIPHTHERIA, YEAR. Cases notified in Croydon. Attack Rate Per 100,000 of Population. No. of Deaths. Percentage of Deaths to Cases notified. All Cases Admitted to Hospital with a diagnosis of Diphtheria. No.Admitted. No. of Deaths. Percentage of Deaths to cases Treated* 1 2 3 4 5 6 7 8 1908 405 256 37 9.1 354 29 8.18 1909 356 220 24 6.7 292 24 8.2 1910 267 159 21 7.8 222 15 6.7 1911 514 301 37 7.2 430 35 8.1 1912 767 440 25 3.2 600 22 3.6 1913 451 253 16 3.5 389 13 3.3 1914 226 124 18 7.9 186 19 10.2 1915 195 109 14 7.1 188 8 4.2 1916 312 177 4 1.2 303 15 4.9 1917 191 102 9 4.7 194 8 4.1 1918 179 94 2 1.1 158 21 1.3 1919 429 223 36 8.3 388 38 9.7 1920 558 290 26 4.6 529 21 3.9 1921 483 252 23 4.7 451 24 5.3 1922 358 186 27 7.5 329 21 6.3 1923 196 101 21 10.7 202 18 8.9 1924 222 113 8 3.6 196 7 3.5 1925 104 52 8 7.6 114 11 9.6 1926 321 155 32 9.9 321 28 8.7 1927 262 123 10 3.8 300 8 2.6 1928 476 224 32 6.7 493 31 6.2 1929 435 194 23 5.3 470 23 4.9 1930 394 177 14 5.3 462 12 2.6 1931 221 94 5 2.2 219 7 3.2 *Cases from Penge are included in Cols. 6 to 8. 90 The incidence of diphtheria showed a considerable decrease in 1931. The mortality was 3.2% in the Hospital cases. The type was decidedly more severe than in 1930. Forty-one cases of bacteriological Diphtheria were admitted, but these are not included as diphtheria as they exhibited no clinical symptoms. The Case rate (Col. 3) for England and Wales was 127. Croydon's rate is therefore considerably lower than for the whole country. SMALL POX An outbreak occurred in Croydon, lasting from February 23rd until May 9th. A total of 49 cases were diagnosed and investigated. The disease was of the prevalent mild type and indeed its most disturbing feature was its name. As a clinical entity, the majority of the cases have been less severe than ordinary cases of Chicken-Pox. The results of vaccination in the contacts have also, in a few instances, been more severe in their effects than the actual disease. There is, however, no means of knowing if or when the more serious type may arise consequently a trivial complaint must be handled as if it was a matter of much greater consequence. Its infectivity varied, in some cases it appeared more liable to attack contacts than in others, but as a whole it was not very infections, when the unvaccinated condition of the community is remembered. The present modified form is most decidedly less infectious than the old type of the disease. The same characteristic was observed in outbreaks with which I had to deal in Lancashire and Yorkshire. The history of Small Pox in England during the past few years shows that it broke out in the extreme North of England and has gradually passed southwards. The North is now practically free, but for the past 2½ years it has been very prevalent in London and neighbourhood. Until the visitation under review only a few odd unconnected cases occurred in Croydon, viz., 2 in 1929 and 24 in 1930. The usual procedure was carried out. Among other details this comprised, (a) Recommendation of vaccination to all contacts. 91 (b) Daily visitation of all known contacts by Sanitary Inspectors who report any deviation from normal health. (c) Visitation by a medical officer to cases referred by a Sanitary Inspector. (d) Notification of Employers. (e) Notification of M.O.H.'s of surrounding districts. (f) Removal of cases and disinfection of premises, bedding, etc. (g) Distribution of leaflets. (h) Circular letter to all medical practitioners. History of Outbreak. On the 23rd February, 1931, 1 was asked to see a patient in a doctor's surgery in South Croydon, and on the same evening a similar request was made by a doctor in Addiscombe. Both patients were inmates of the Municipal Lodging House and were found to be suffering from Small Pox. The same evening my deputy and myself visited the Municipal Lodging House and inspected all the men then resident. As a result two were discovered suffering from Small Pox in a rather later stage than the two seen at the doctors' surgeries. The cases were removed to Clandon Isolation Hospital and vaccination advised to the contacts. Very few, however, took this advice. No further cases arose until March 5th when I was requested to see a case in the Mayday Road Hospital, sent there, suffering from Chronic Bronchitis by his private doctor. This case had mild Small Pox and was removed. His ordinary place of residence was the Municipal Lodging House and his connection with the four previous cases undoubted. The diurnal inspection of lodgers at the Municipal Lodging House enabled us to detect another case on the 9th March ; on the 11th a case was seen in Mayday Road Hospital, having been sent there by his private doctor for another complaint. This man also lived in the Municipal Lodging House. On the next day's Municipal Lodging House inspection a further case was discovered and two more cases removed from Mayday Road, in the persons of men sent for other complaints but who resided at the Municipal Lodging House. On the 13th two more cases were found at the Municipal Lodging House. The outbreak in the Municipal Lodging House and the Mayday Road Hospital was now controlled, only two more cases occurred among inmates of the Lodging House, viz., on the 15th and 16th and two cases at Mayday Road, viz. on the 26th and It is a commentary on the relatively low infectivity that so 92 few cases arose when the number of unvaccinated contacts was large. In both these institutions, however, a close supervision could be exerted, and the clinical inspections enabled any incipient case to be dealt with immediately. On the 13th a case occurred in Coniston Road. This was a woman and no history of any contact with a previous case could be elicited, though there was probably some relation to the Municipal Lodging House cases. On the 16th a case occurred in Old Town in a male who had recently stayed at the Lodging House and who was under supervision as a contact. By the use of the method of daily supervision of contacts, 3 cases were found in a family in Albion Street on the 21st; one of these worked in the Public Laundry, and a case in Leighton Street East on the 24th. A further case arose in Priory Road the next day, in a girl aged 13 years who attended Rectory Manor School and whose sister worked at the same laundry as the Albion Street case. Examination of the children at this school by a Medical Officer did not unearth any other cases in the school. On the 1st April, as was expected, 3 more cases arose in the family in Old Town. None had been recently vaccinated. Another case arose in Priory Road (different house) on April 2nd. This case was said to attend the same Mission as the Old Town case but no definite contact was elicited. On April 4th a case was seen at an address in London Road. This was a young lady working in a popular photographer's in Church Street and no history of contact could be discovered, though the inference that there was some relationship between the previous cases in the Pitlake area was strong in view of the situation and the nature of her work. The diagnosis in this case was difficult and she was removed for observation to the Borough Hospital on 4th April, being placed in a cubicle ward and all precautions being taken in view of the possibilities. The diagnosis was ultimately decided as Small Pox and she was removed to Clandon on 8th April, 1931. Two further cases arose on April 7th in Leighton Street East in unvaccinated children of the same family as the primary case, and a school contact of one of these children living in Onslow Road, was removed on 9th April. On April 11th I was asked by the doctor concerned to see a lady in Park Lane who had visited one of the cases removed from Old Town, the day before her removal. This lady had been vaccinated two days later. She exhibited 3 very slight rash. I did not consider her a true case, but removed her to the Borough Hospital for observation. The subsequent history of this case seemed to prove that the condition was that of Vaccinia. 93 On April 11th a case occurred in Albion Street next door to the cases removed on March 21st. This patient had been ill a week before advice was sought. On April 14th a school contact of the case in Onslow Road was found at Wentworth Road. On April 23rd I was requested by the lady who had nursed the case in London Road to call and see her. I did so and found her to be suffering from the complaint. This person lived in Ashling Road, Addiscombe. On April 22nd three cases were found in a house in Pawson's Road through the agency of the following up plan and the co-operation of the medical practitioner concerned, and the next clay 3 more cases were removed from the same family. Another case arose in Onslow Road on the 22nd in a member of the same family as the case removed on April 9th. On April 24th two children in the Leighton Street East family who had recently been vaccinated, developed spots. The vaccination had taken. I had them removed for observation to the Borough Hospital. One of these children was the next day removed to Clandon as the rash had increased but I am not of the opinion that these children had Small Pox, but rather the modification thereof, known as Vaccinia. On April 24th I was asked by the district Medical Officer to see a case in Foss Avenue. This I diagnosed as Small Pox and had her removed the same day. This patient was in a cubicle ward at the Borough Hospital at the time when the ca-se from London Road was admitted. She was then suffering from Erysipelas and was discharged the morning after the admission of the latter case. Although it is not possible entirely to discountenance the chance of infection of this case whilst in the Borough Hospital the following facts are against it:— (a) The block in question is a "cubicle" Block, each cubicle being entirely cut off from its neighbour. (b) This block is intended to be used and is so used, for the isolation of various forms of infectious illness, including Measles, Mumps, Chicken Pox, Sleeping Sickness, Cerebro-Spinal Fever, etc. (c) The staff is specially skilled in the maintenance of strict quarantine measures. (d) The suspicious Small Pox case had her own nurse who did not leave the cubicle in which she was, except to go off duty. (e) The strongest point against the infection being contracted at the Hospital is that the interval between the possible contact and the onset of symptoms in the Foss Avenue 94 case was 20 days. This period, known as the quarantine period, is stated to be from 8-16 days with a maximum between 12 and 14 days. If this is so it rules out the possibility of infection at the Hospital. A child was removed on April 28th from Longley Road ; another from Pawsons Road on May 8th and a case from Whitehorse Lane on May 9th. The measures adopted now caused the epidemic to cease and no more cases arose. Yaccination History of Cases. Not Vaccinated: 28. Vaccinated in Infancy: 7. Twice Vaccinated, last time 35 years ago: 1. Recently Vaccinated 3. One 7 days previously. Two 17 days previously. In my opinion these cases were instances of Vaccinia and were not Small Pox. Age Grouping. Under 5 years 5 cases 20-29 years 4 cases 5-9 years 7 cases 30-39 years 3 cases 10-20 years 13 cases 40-59 years 5 cases Age not stated 1 case 60 years or over 11 cases Comments. Sex: Males, 30. Females, 19. (1) The outbreak consisted of 49 cases. There were no deaths. One patient, aged 67 years, died from Pneumonia at Clandon. His death was not attributed by the doctor there as in any way due to Small Pox. (2) The type was of the prevalent mild form. No instances of confluency and in many, the rash was very scanty. Constitutional symptoms were slight. The early cases, among inmates of the Municipal Lodging House, commenced with symptoms similar to those of Influenza and were in fact diagnosed as such in the first instance. (3) Vaccination proved to be a safeguard against attack. 95 The table gives a summary of all cases treated in hospital in 1931. 879 patients were admitted and discharged during the year, whilst including the patients in at the commencement of 1931 Complaint for which Admitted. Patients remaining in Hospital on Jan. 1st, 1931. Patients admitted and discharged in 1931. Patients remaining in Hospital on Jan. 1st, 1932. Analysis of all Cases admitted in 1931 whether discharged or not during the year. Average No. of bed* occupied during 1931. BOROUGH HOSPITAL. Table XXXVIII. Total. Recovered Died. Total. Recovered Died. Total. Recovered Died. Total. Recovered Died. Case Mortality. Average No. of days in Hospital. Scarlet Fever 84 84 ... 531 483 2 46 48 ... 531 529 2 0.3 40.2 57.7 Diphtheria 52 51 1 269 234 6 29 29 ... 269 263 6 2.2 38.8 30.3 Typhoid Fever ... ... ... 5 4 1 1 ... 5 5 ... ... 30.6 0.6 Paratyphoid Fever ... ... ... 3 2 1 1 ... 3 3 ... ... 60 0.4 Erysipelas 2 2 ... 29 25 I 3 3 ... 29 28 1 3.4 25.0 3.3 Measles ... ... ... 10 10 ... ... ... 10 10 ... ... 18 1.0 Puerperal Fever ... ... ... 23 15 8 ... ... ... 23 15 8 3.7 27.2 3.1 Puerperal Pyrexia ... ... ... 2 2 ... ... ... 2 2 ... ... 22 0.2 Encephalitis Lethargica ... ... ... 1 ... i ... ... ... 1 ... 1 100 2 0.2 Whooping Cough 1 1 ... 47 44 2 1 1 ... 47 45 2 4.2 40.7 4.9 Cerebro-Spinal Meningitis ... ... ... 5 2 3 ... ... ... 5 2 3 60 29 0.8 Chicken Pox ... ... ... 11 10 1 1 ... 11 11 ...... ... 258 1.2 Mumps ... ... ... 6 6 ... ... ... 6 6 ... ... 16 0.6 Ophthalmia Neonatorum ... ... ... 3 3 ... ... 3 3 ... ... 10 0.3 T.B. Meningitis ... ... ... 3 ... 3 ... ... ... 3 ... 3 100. 4 0.6 Infantile Palsy ... ... ... 4 4 ... ... ... ... 4 4 ... ... 36 0.4 Dermatitis ... ... ... 1 1 ... ... ... ... 1 1 ... ... 4 0.1 White Leg ... ... ... 1 1 ... ... ... ... 1 1 ... ... 50 0.1 Small Pox ... ... ... 2 2 ... ... ... ... 2 2 ... ... 3 0.2 Small Pox (Observation) ... ... ... 6 6 ... ... ... ... 6 6 ... ... 10 0.6 German Measles ... ... ... 1 1 ... ... ... ... I 1 ... ... 10 0.1 No Diseases 1 1 ... 24 24 ... ... ... ... 24 24 ... ... 13 2.4 Total 140 139 1 987 879 26 82 82 ... 987 961 26 ... ... 96 (140) a total of 1,127 cases were dealt with. 26 died, giving a case mortalitv for the whole hospital of 2.3%, an increase of .5% on 1930. The average number of days of each patient in hospital for all classes of patients was 37.7 days, the increase being probably explained by the longer fixed time of isolation of scarlet fever cases (5 weeks). Penge Urban District Council has an agreement with the Corporation to send their cases into the Hospital. During 1931 a total of 46 cases was admitted from this district. These cases are included in the above table. The Hospital is situated in Purley Way, Waddon Marshes, on a site of 22 acres and a height of 144 feet above sea level. There are provided 96 beds for scarlet fever, 62 beds for diphtheria and 26 beds for other infectious diseases. There are 2 glass cubicle blocks containing 12 cubicles each for the nursing of heterogenous cases in one ward. One ward for measles contains 16 beds. The Hospital is a recognised training school for Fever nurses and during the year 4 probationers passed the preliminary examination and 3 the final examination of the General Nursing Council. During the year a new "en-tout-cas" hard tennis court has been constructed, also an operating theatre has been built and equipped. SCARLET FEYER. The total number of cases admitted as Scarlet Fever during 1 lie year was -531. This was a decrease of 148 on last year's total. 495 cases were from the Borough and 36 from outside the Borough. There were 6 definite return cases. The type of Scarlet Fever in 1931 was of average severity, and once again there were a large number of cases occurring over the age of 15 years (as shewn by Table XXXIX.). One hundred and one cases were recorded in the age groups 15-20, 20-30. 30 or over as against 118 cases in 1930. There were 21 cases in the age group 30 or over. The highest number of admissions occurred in January and March whilst there was a considerable drop in the last quarter of the year, when as a role the incidence of Scarlet Fever rises, 97 The following complications and sequelae occurred amongst the 307 cases of Scarlet Fever (excluding the serum-treated cases 224). Adenitis 19 Relapses 4 Otorrhoea 22 Secondary Sore Throat 2 Rhinorrhoea 22 Albuminuria 5 Abscesses and Boils 7 Nephritis 4 Septicaemia 1 Rheumatism 6 Three cases sent in as Scarlet Fever were found not to be suffering from the disease. Two deaths occurred amongst the cases of Scarlet Fever, one being a case of toxic Scarlet Fever with heart failure and the other being a case of Scarle! Fever septicaemia. The number of complicated cases represented 29.9% of the total. Ages and Sexes of Scarlet Fever Patients Admitted. The following Table shows the ages and sexes of Scarlet Feve. patients admitted:— Table XXXIX. Age. Males. Females. Totals. Deaths. 1—2 10 9 19 - 2—3 14 15 29 - 3—4 15 11 26 - 4—5 33 37 70 - 5—10 106 98 204 1 10—15 41 41 82 - 15—20 13 20 33 - 20—30 12 35 47 - 30 or over 8 13 21 1 Total 1931 252 279 531 2 Total 1930 333 346 679 2 The total deaths amongst true Scarlet Fever patients was 2. The death rate was 0.37% of the cases admitted. 98 Monthly Admissions of Scarlet Fever Patients to the Hospital. Table XL. Month. Cases ad mitted. Cases notified. 1930. 1931. January 75 78 80 February 54 45 50 March 59 57 51 April 56 52 35 May 62 40 54 June 51 43 35 July 54 42 38 August 33 27 41 September 34 34 28 October 63 39 46 November 60 41 40 December 73 33 29 Total *679 †531 527 * Including 56 cases from Penge. † Including 36 cases from Penge. The percentage of Croydon (495) cases removed was 93.9. There were 7 cases shewing relapses with repitition of the original symptoms as compared with 10 cases in 1930. Four were boys and 3 girls. Three of the cases had 10 c.c. Scarlet Fever serum on admission. The following table gives the age groups and incidence of the cases shewing relapses:— Table XL I. Age. Male. Female. Date of Disease when admitted. Day of Relapse. 4—5 M 3rd 25th 5—10 F 4th 34th ,, F 2nd 39th ,, M — 3rd 24 th ,, M — 3rd 26th ,, M — 5th 24th 10—15 F 2nd 41st 99 SCARLET FEVER SERUM CASES. Total cases treated 224 (118 males; 106 females). Total cases uncomplicated 73.2%. (1) Type of Case. The serum was given in cases which on admission had some or all of the following symtoms:— (1) Marked general erythema. (2) Marked infection of throat with dirty tonsils. (3) Enlarged sub-maxillary glands. (4) Rhinorrhoea. (5) Abnormally high temperature. (2) Method of Administration. The serum was given intra-muscularly in the thigh. The quantity of serum given in a single dose was 10 c.c.; in some cases this was repeated in 24 hours. (3) Rashes. Fifty-four cases developed serum rashes which were either urticarial or morbilliform, often limited to the area around the site of injection and lasting 2-3 days without leaving any staining: this equals 24.1%. Rashes were more numerous with some batches of serum than with others. No case of serum illness developed as a result of serum injections, though headache, slight oedema, slight joint pains and a slight rise of temperature occurred in some, which lasted from 24-48 hours. (4) Influence of Serum on course of disease. This might be considered under the following:— (a) Effect of Temperature. The temperature came down rapidly after serum administration but in some cases the fall was more gradual taking 2-6 days to reach normal. With the fall of temperature the patients stated they felt much better and the throat condition improved. (b) Length of Stay in Hospital. Serum treated cases. 40.6 days. Non-serum treated cases, 40.8 days. 100 The slight shortening of period of isolation in hospital which was noted in the previous report was not observed in the present series. (c) Reduction of Complications. The following table contrasts the complications in the two types. Nature of Complaint. Serum Treated (224 cases). Non-Serum Treated (307 oases). Adenitis 9 19 Otorrhoea 16 22 Rhinorrhoea 13 22 Albuminuria 4 5 Nephritis — 4 Rheumatism 5 6 Relapses 3 4 Secondary Throat 2 2 Abscesses and Boils 5 7 Endocarditis 2 — Septicaemia 1 1 Total 60 (26.7%) 92 (30%) It would appear, therefore, that the giving of Scarlet Fever serum had little effect in diminishing the incidence of complications, though no cases of nephritis occurred in the serum1 treated cases, and this was also noted in the previous report. The relapses occurred on the 24th, 26th and 29th day of disease respectively. (d) Desquamation. Desquamation occurred in 114 out of the 224 cases treated with serum. In many cases treated with serum the peeling was very fine generally. The cases which had a relapse peeled a second time. 101 (e) Day of disease when Serum given and Nutnber and Sex of Cases and Complications. Reputed day of disease. No. of Males. Cases. Females Complications. 1 4 6 2 48 37 25 3 38 31 13 4 17 21 13 5 6 10 7 6 2 — 1 7 1 — — 9 1 — — 19 — — 1 26 1 1 — Totals 118 106 60 It will be seen that no complications occurred among those cases who had serum on the first day of disease, and that the proportion of complications in those who received treatment on the 4th and 5th day of disease was higher relatively than the cases who received serum earlier. The cases that received serum late were those who had a relapse but had not received serum at the onset of the disease. Table shewing the age groups and sex of Scarlet Fever Serum cases:— Age. Males. Females. Totals. 1—2 2 4 6 2—3 5 2 7 3—4 7 3 10 4—5 12 9 21 5—10 53 40 93 10—15 22 15 37 15—20 6 10 16 20—30 6 17 23 30 and over 5 6 11 Totals 118 106 224 Diphtheria. 269 cases were admitted with a diagnosis of diphtheria a decrease of 193 cases on 1930. Of these 9 were found not to be 102 diphtheria and 41 cases were positive swabs without clinical symptoms, leaving 219 cases of true diphtheria. The negative cases were:— 4 cases of follicular tonsillitis. 5 cases sent in for observation in whom the diagnosis was not confirmed. There were 9 cases admitted from outside the Borough, a decrease of 38 on 1930: two deaths occurred amongst them. Of the 219 cases 6 had the larynx implicated, tracheotomy was necessary in two cases, one died being moribund on admission. The following complications and sequelae arose amongst diphtheria patients. Adenitis 8 Otorrhoea 8 Rhinorrhoea 5 Albuminuria 1 Secondary Sore Throat 9 Laryngeal Involvement and Heart Failure 12 Irregularity 1 Tachycardia 2 Influenza 1 Rheumatism 1 Paralysis:— Facial 1 Palatal 6 Ocular 3 Of Legs 1 Table XLII. shews the ages and sexes of the diphtheria patients. The greatest number of cases occurred in the 5-10 years group which also shewed the highest mortality. In 1930 the 4 to 5 years age group gave the worst figures. Ages and Sexes of Diphtheria Cases Admitted. Table XLII. Age. Males. . Females. Totals. Deaths. Death-rate 100 cases. 1—2 . 10 9 19 1 5.2 2—3 6 6 12 1 8.3 3—4 8 18 26 — — 4—5 12 20 32 1 3.1 5—10 43 59 102 3 2.9 10—15 10 19 29 1 3.4 15—20 8 11 19 — — 20—30 7 13 20 — — 30 & over 3 7 10 — — Total 1931 107 162 269 7 8.1 Total 1930 235 227 462 12 2.5 103 Admissions of Diphtheria cases to Borough Hospital in 1931. Table XLIII Month. Cases notified. Cases 1931. admitted. 1930. January 30 42 50 February 31 33 29 March 30 44 34 April 20 21 47 May 15 16 34 June 10 14 37 July 14 14 30 August 17 20 20 September 7 11 25 October 14 14 64 November 11 17 62 December 22 23 30 Total 221 269* 462† *Including 9 cases from Penge. +lncluding 47 cases from Penge. 104 Particulars of Fatal Cases Table XLIV. Name. Day of Disease. Condition on Admission. Subsequent progress. Date o] Death Days after Admission. (1) R.V. (M.) 4 years. 9 Moribund; extreme cyanosis; extensive bilateral membrane; recession. Died 1 hour after admission. 1 hour. (2) R.C. (M.) 3 years. 3 Extensive membrane; glands of neck + +; rhinorrhoea foetor. Cardiac irregularity after 9 days and palatal paralysis 12th day which persisted; 44 days after admission intercostal paralysis set in which proved rapidly fatal. 44 days. (3) J.P. (F.) 14 years. 5 Extensive membrane cyanosed and toxic; blood stained rhinorrhoea; bleeding from throat. Very restless on admission with tendency to bleeding and general bruising; weak heart action—"Heart" vomiting; palatal paresis VII paralysis; collapsed suddenly. 10 days. (4) R.K. (M.) 6 years. 2 Extensive membrane "bull neck" rhinorrhoea foetor. Showed signs of heart failure on admission which was progressive till death. 4 days. (5) D.D. (M.) 8 years. 4 Extensive membrane "bull neck" rhinorrhoea drowsy; pulse soft and rapid. Four days after admission started bleeding from nose and throat with general bruising, also had progressive heart failure from admission. 6 days. (6) G.G. (F.) 1 year. 4 Moribund; cyanosed extreme restlessness and recession. Tracheotomy on admission without relief. 1 hour. (7) I.G. (F.) 6 years. 7 Late case:toxic; sloughing membrane all over pharynx; cyanosis"bull neck" general bronchitis and signs of heart failure. The heart failure was progressive and rapidly fatal. 32 hours. 105 Analysis of 7 Fatal Cases. The cases were divided as follows:— 2 were moribund on admission, dying within one hour. 2 were hemorrhagic. 2 shewed early heart failure which was progressive. 1 shewed increasing late paralysis, the intercostal involvement causing death. There were 4 males and 3 females. Five cases were admitted late between 4th day and 9th day of disease respectively. They were all very severe cases with extensive membrane, glandular enlargement, cyanosis and foetor. Six of the cases had received no serum before admission, whilst 1 case only received 8,000 units. Intra-muscular doses of serum between 24,000 units and 56,000 units were given to all cases, one case receiving 16,000 units intravenously. Though large doses of serum are of great value in the treatment of diphtheria when given early in the disease, in those late cases the beneficial effect is less marked, as the patient has already absorbed a great amount of toxin into his system, which one cannot "fix," and is the cause of the subsequent rapid paralysis of heart. The total deaths amongst true diphtheria cases were 7 as compared with 12 in 1930: the death rate was 3.1%. Enteric Fever. 8 cases of Enteric, and Paratyphoid were admitted: 1 case was admitted from Penge. The following gives an analysis of these cases:— Sent in as enteric and confirmed 2 Sent in as para-typhoid and confirmed 3 Sent in as enteric and not confirmed 1 Sent in as enteric, really dvsenteiy 1 Sent in as enteric: really simple enteritis 1 The cases were clinically of moderate severity and there were no deaths. 106 Puerperal Fever and Puerperal Pyrexia. 23 cases were sent in as Puerperal Fever: of these:— 1 was a case of Influenza only. 2 were cases of Puerperal Pyrexia. 20 were cases of Puerperal Fever. Amongst the 20 cases 8 deaths occurred. The 8 fatal cases were all very severe septicaemia on admission and 3 shewed extensive lacerations of perineum and vaginal walls. The percentage of deaths of the Puerperal Fever cases (20) was 40. Erysipelas. There were 29 cases of true Erysipelas admitted in 1931 as against 7 cases in 1930, this large increase being due to the fact that all such cases are admitted to the Borough Hospital, whereas formerly some went to Mayday Hospital. One death occurred amongst them but the cause of death was carcinoma of the bowel, confirmed by pathological investigation. Measles. Only 10 admissions were made for measles, the disease being of a mild type. Three of the ten cases were not measles but suffered from the following:— 1 was a case of scalds of head with a septic rash. 1 was a case of septic lash. 1 was suffering from bronchitis only. Small Pox. There were 8 cases admited for observation for Small Pox but only in 2 cases was the diagnosis confirmed and 1 case was one of Cow Pox (Vaccinia) in a recently vaccinated person. Whooping Cough. 47 cases were admitted with a diagnosis of Whooping Cough but this was confirmed in 33 cases only. 2 cases of Whooping Cough proved fatal owing to ensuing Broncho-pneumonia. 107 Age Group 0-1 1-2 2-5 5-15 15-25 25-35 35-45 15 & up. Total Deaths. Table XLV. Other Diseases. Disease M F M F M F M F M F M F M F M F Enteric Fever ... ... ... ... ... ... ... ... 2 2 ... ... ... ... ... 1 5 ... Paratyphoid B. ... ... ... ... ... 1 ... ... ... ... ... 2 ... ... ... ... 3 ... Puerperal Fever ... ... ... ... ... ... ... ... ... 7 ... 13 ... 3 ... ... 23 8 Puerperal Pyrexia ... ... ... ... ... ... ... ... ... ... ... 2 ... ... ... ... 2 ... Erysipelas ... 1 ... ... ... ... ... ... 2 1 ... ... ... 5 10 5 29 1 Measles 1 2 ... 1 2 2 ... 1 ... 1 ... ... ... ... ... ... 10 ... German Measles ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... 1 ... Encephalitis Lethargica ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 1 Cerebro-Spinal Meningiti ... ... ... ... 2 1 ... 1 ... ... 1 ... ... ... ... 5 3 Whooping Cough 6 6 11 9 5 8 ... 2 ... ... ... ... ... ... ... ... 47 2 Chicken Pox ... ... 2 ... ... 4 4 ... ... 1 ... ... ... ... ... ... 11 ... *Ophthalmia Neonatorum ... 3 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3 ... †Mumps 1 ... ... 1 ... 2 1 ... ... ... ... ... ... ... ... ... 6 ... T. B. Meningitis ... ... ... ... 1 1 ... ... 1 ... ... ... ... ... ... ... 3 3 Small Pox ... ... 1 ... ... 1 1 ... 2 ... ... ... ... 1 2 ... 8 ... ‡Infantile Palsy ... ... ... 1 1 ... 1 ... 1 ... ... ... ... ... ... ... 4 ... Dermatitis 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... White Leg ... ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... 1 ... § No disease ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 24 ... Totals 9 12 14 12 9 21 8 3 10 13 3 19 3 9 12 6 187 18 *This includes 1 case of simple ophthalmia, †This includes i case of glandsof neck and 1 case where the diagnosis was not confirmed. ‡This includes 1 case where the diagnosis was not confirmed. § This includes 4 mothers in with babies and 20 babies in with mothers, 108 Table XLVI. Out of Borough Cases. Disease. Males. Females. Total. Deaths. Scarlet Fever 18 18 36 — Diphtheria 5 4 9 2 Enteric Fever 1 – 1 — Laboratory Report, 1931. Table XLVI I. DIPHTHERIA. Ward Swabs examined (including Nose and Throat). — Positives on Admission. Positives during Convalescence. Total. 4,120 66 1,59 4,345 ENTERIC (Widals). Negatives. Positives. Total. 9 1 10 Positive was case of Para-Typhoid B. FAECES (Enteric). Negatives. Positives. Total. 13 — 13 FAECES (Dysentry Group). Negatives. Positives. Total. 6 6 All positives were obtained from one case (2 during acute stage, 4 during convalescence). CEREBRO-SPINAL FLUIDS FOR MENINGOCOCCUS. Negatives. Positives. Total. — 5 5 Also Fluid from Knee Joint. Meningococcus seen in smear. 109 SPUTUMS AND PUS EXAMINED FOR T.B. Negatives. Positives. Total. Sputums 6 — 6 Pus 3 — 3 SPECIMENS OF BLOOD CULTURED FOR ORGANISMS. Negatives. Positives. Total. 12 4 16 Hemolytic Streptococcus isolated from cases reported positive. Miscellaneous Items. Urines for organisms 6 Pus for organisms 6 1 C.S.F. for organisms 1 Spec. Skin for organisms 1 Spec. Faeces for organisms 1 — + t Swabs for Gonococcus 8—1—9 Culture Media. Blood Serum : 294 doz. tubes at 5/- per doz. tubes : £73 10s. Od. Peptone Broth 2,800cc McConkey's Media l,150cc Peptone Water 700cc Agar Agar 2,500cc Litmus Milk 450cc Hiss' Serum Water 300cc 110 For private practitioners For Borough Hospital For Tab. Dispensary For School Medical Other Instants. of Corporation Other Institutions Total BACTERIOLOGICAL EXAMINATIONS. I am indebted to the Borough Pathologist, Dr. H. Southgate, for the figures given in the appended tables: — Table XLVII. I. At the Laboratory, Croydon General Hospital. Pos. Neg. Pos. Neg. Pos. Neg Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Swabs for Diphtheria 105 1038 1 1 2 16 138 3049 4 207 31 470 281 4781 Virulence tests for Diphtheria 3 ... 2 2 ... ... 2 4 ... 2 1 ... 8 8 Sputum for Tub Bac. 139 647 ... ... 304 492 ... ... 87 126 8 32 538 1297 Pus for Tub. Bac. ... ... ... 2 ... ... ... ... 4 197 ... ... 4 199 Pus for Gonococci 2 15 ... 4 ... ... ... ... 43 114 ... ... 45 133 Pus for other organisms ... 4 ... 25 ... ... ... ... ... 275 ... ... ... 304 Blood for Typhoid Groups 1 12 ... ... ... ... ... ... ... 2 1 4 2 18 Blood for Wasserrnann ... ... ... 4 ... ... ... ... 17 61 ... ... 17 65 Material for Spirochaetes ... ... ... ... ... ... ... ... ... ... ... ... ... ... Faeces for Typhoid Group ... 2 ... 1 ... ... ... ... ... 18 ... ... ... 21 Hair for Ringworm ... 1 ... ... ... ... ... ... 16 8 ... ... 16 9 Examination of Urine ... 1 ... ... ... 145 ... 146 Examination of Pleural Fluid ... ... ... ... ... 27 ... 27 Examination of C,S. Fluid ... 1 ... ... ... 15 ... 16 Other Examinations ... 9 ... ... ... 228 ... 237 Ill Examinations Done Under National Health Insurance Act. Table XLIX. Nature of Examination. Nature of Examination. Pus for Gonococci 15 (4 pos.) Blood for Sugar Est. 1 Pus for other organisms 8 Urine for Chemical Exam. 2 Pus for Tubercle B. 6 (1 pos.) Urine for Microscopical Exam. 2 Blood for Wassermann. 24 (4 pos.) Urine for Tubercle B. 2 Complete Blood counts. 5 Urine for Cultural Exam. 2 Blood for Culture 1 Other Examinations 4 Bacteriological Examination of Milk. Table L. Number of Samples submitted for Counts 419 Number under 10,000 per cc 110 No. over 10,000 but under 50,000 per cc 152 Over 50,000 but under 100,000 per cc 65 Over 100,000 but under 500,000 per cc 56 Over 500,000 but under 1,000,000 per cc 17 Over 1,000,000 per cc 19 Bacillus Coll Content— Not found in 0.1 cc 140 ,, ,, 0.01 cc 75 ,, ,, 0.001 cc 66 Present in 0.001 cc 138 Higher dilutions not made. Tubercle Bacilli— No. of samples of milk submitted 419 No. found positive by inoculation test 11 VACCINATION ACTS. I am indebted to Mr. Huggins, the Vaccination Officer, for the particulars in the returns in subjoined Table. Table LI. Registration Sub-Districts in V.O. District. Births Registered. Vaccinated. Unsusceptible Statutory Declarations Died Unvaccinated. P. P.O. Transferred tootherV.O Not traced Removals. In Default. Overage when Registered. South Sub-District 922 338 4 372 22 ... 56 5 123 2 West ,, 1818 549 802 84 ... 32 21 329 1 North ,, 877 343 7 359 26 ... 15 10 116 1 3617 1230 11 1533 132 ... 103 36 568 4 112 Return showing the Numbers of Persons vaccinated and revaccinated at the cost of the Rates by the Medical Officer of the Poor Law Institutions and the Public Vaccinators during the year ended 30th September, 1931:— Table LI I. Name of Poor Law Institution or Vaccination District. Numbers of successful Primary Vaccinations of persons. No. successful revaccinations, i.e., successful vaccinations of persons who had been successfully vaccinated at some previous time. Under 1 year of age. 1 year and upwards. Total. Crovdon No. 1 Area 106 45 151 63 No. 2 Area 177 25 202 37 No. 3 Area 61 17 78 9 No. 4 Area 118 130 248 134 No. 5 Area 259 85 344 103 Addington 3 — 3 — Queen's Road Homes — — — — Mayday Road Hospital 5 22 27 64 Children's Homes — — — — 729 324 1053 410 Table LIII. SOUTH CROYDON. Births Registered. Vaccinated. Insuscep tibility. Statutory declarations. Died Unvaccinated. P.P.O. Transferred to other V.O.s. Not traced removals. In default. Overage when registered. 1930. Oct. 83 22 — 46 2 — 5 1 6 1 Nov. 67 24 — 34 — — 3 1 5 – Dec. 75 24 — 29 4 — 8 2 8 – 1931. Jan. 80 33 — 34 3 — 1 1 8 – Feb. 54 23 — 17 — — 9 — 5 – March 81 36 — 27 4 — 7 — 7 — April 90 38 — 37 2 — 1 — 12 — May 79 31 — 30 2 — 1 — 15 — June 98 37 3 34 4 — 3 — 17 — July 68 25 — 31 1 — 3 — 8 — August 78 27 — 28 — — 7 — 15 1 Sept. 69 18 1 25 — — 8 — 17 – 922 338 4 372 22 — 56 5 123 2 113 Table LIV. WEST CROYDON. Births Registered. Vaccinated. Insuscep tibility. Statutory declarations. Died Unvaccinated. P.P.O. Transferred to other V.O.s. Not traced removals. In default. Overage when registered. 1930. Oct. 155 51 — 77 6 — 4 6 11 – Nov. 135 41 — 59 7 — 7 7 14 — Dec. 155 47 — 79 11 — 3 6 9 — 1831. Jan. 149 50 — 68 10 21 _ Feb. 123 46 — 46 12 — 4 1 14 – March 154 58 — 57 8 — 2 1 27 1 April 131 41 — 73 5 — — — 12 – May 143 59 — 54 2 — — — 28 – June 171 44 — 78 5 — 1 — 43 – July 178 53 — 73 12 — 2 — 38 – August 160 35 — 77 1 . — 2 — 45 – Sept. 164 24 — 61 5 — 7 — 67 — 1818 549 — 802 84 — 32 21 329 1 114 LV. NORTH CROYDON, Births Registered. Vaccinated. Insuscep tibility. Statutory declarations. Died Unvaccinated. P.P.O. Tin. fenul to other V.O.s. Not traced removals. In default. Overage when registered. 1930. Oct. 72 31 — 29 4 — 3 5 Nov. 75 26 — 39 — — — 3 7 — Dec. 56 28 — 19 1 — 1 2 4 1 1931. Jan. 72 33 — 29 4 – 6 _ Feb. 56 24 — 26 — — – 3 3 – March 69 32 1 25 2 — 1 2 6 – April 87 42 2 31 2 — — — 10 – May 70 27 3 29 2 – 2 — 7 – June 90 32 — 34 4 — — — 20 - – July 95 31 — 43 3 — 4 — 14 – August 60 21 — 25 2 — 1 — 11 – Sept. 75 16 1 30 2 — 3 — 23 - 877 343 7 359 26 — 15 10 116 1 115 SECTION YI. PREVENTION AND CONTROL OF TUBERCULOSIS. The Tuberculosis Clinic is situated at 13, Katharine Street. The premises are not ideal, being cramped and noisy, though measures have been taken to reduce noise getting into the consulting room. The erection of three dressing cubicles has added to the comfort of the patients. Sessions are held daily in the mornings and afternoons except on Monday mornings and Friday afternoons. An evening session is held on Tuesdays. The Dispensary is a sorting house for cases. To it come patients sent by doctors, cases under observation and cases under treatment at home. From it patients are drafted to various Sanatoria and Hospitals or back to their private practitioner. It is essentially a consultative and not a treatment centre. A tuberculosis scheme, however complete, will break down unless the co-operation of the public and of the general medical practitioners, is obtained. The public can help by availing themselves, without delay, of the facilities afforded. The assistance practitioners can render from the preventive aspect is in three main ways:— (a) To secure the proper disposal of the sputum. (b) To see that an infective patient has a bedroom to himself, or, if this is impossible, at least a bed to himself, and to emphasise the need for free ventilation. (c) To advise an infective patient not to handle milk or other foodstuffs or to have the intimate care of young children. I am indebted to Dr. J. C. McMillan, the Assistant M.O.H. for Tuberculosis, for the greater part of this section. OBSERVATIONS ON TUBERCULOSIS MORTALITY. The decline in the mortality from tuberculosis which appears to be taking place in England occurs at different ages, some ages shewing it more than others. Different forms of tuberculosis are responsible at different ages for the decline, and amongst young women, in the 15-30 age period the decline has apparently ceased. Fhe curve of tuberculosis mortality for males and females at different ages shew three definite peaks of mortality and indication of a fourth. The first peak occurs in the second year of life, the second in young adult life, the third in middle age and the fourth 116 in old age. The first peak is due to respiratory tuberculosis of the infantile type to some extent, but chiefly non-respiratory tuberculosis. There is reason to believe that this peak is due to primary infection. The last three peaks are entirely due to respiratory tuberculosis. The second peak occurs in the 20-25 age-period in females and in the 25-30 age-period in males. This peak is well marked in females and is now in fact the principal peak. The third peak occurs in males in the 45-50 age-period, and somewhat earlier in females. This is at present the peak of highest mortality in males. The fourth peak occurs in the 60-65 age-period in both sexes. These peaks are not peculiar to the mortality graph of this country. In some countries one peak predominates, in others, another. If the causation of these peaks was thoroughly understood, we might possess information of the greatest value in directing our efforts for the prevention of tuberculosis. BOVINE TUBERCULOSIS A certain proportion of human tuberculosis is caused by the bovine tubercle bacillus, and Dr. A. Stanley Griffith, from the work which he has done on this subject for the Medical Research Council, estimates that at least 5% is due to this type of tubercle bacillus. During the past ten years there has been a marked fall in the number of deaths from non-pulmonary tuberculosis. Part of the improvement must be attributed to a safer milk supply. The inspection of herds, farms, dairies and milk distributing centres, the bacteriological testing of samples of milk for tubercle bacillus and the increasing attention paid to the pasteurisation of milk, are all measures which must materially contribute to this improvement FAMILY INFECTION. The influence of family infection has been shewn by an investigation made in the County of Lancashire into the death-rate from non-pulmonary tuberculosis in children under five years expose 117 to risk in tuberculous households from an adult with positive sputum. It was found that the death rate was greatly in excess of the rate from the same cause in the County serving as a "control" the rate being:— Nine times greater in the age group 0-1. Fourteen times greater in the age group 1-2. Nineteen times greater in the age group 2-5. The great excess was mainly due to deaths from tuberculous meningitis, which accounted for two-thirds of the mortality. The rate was greater amongst the children of tuberculous mothers with positive sputum than amongst children whose fathers had positive sputum. It was also found that those children in the group ages 0-5 who were in contact at home with an adult person suffering from pulmonary tuberculosis (whether sputum positive or negative) did not have a higher mortality from all causes, when compared with the expectation of life of children in England and Wales. NOTIFICATION OF TUBERCULOSIS. Two hundred and eighty-two cases of Pulmonary tuberculosis and 48 of Non-Pulmonary tuberculosis were notified on Form A (primary notifications) ; of these 158 males and 124 females were pulmonary cases, 24 males and 24 females non pulmonary. In addition 59 pulmonary cases and 23 non-pulmonary came to our notice as new cases otherwise than by notification. Table lvi. Notification in Previous Years. Pulmonary NonPulmonary 1926 244 140 1927 231 97 1928 314 75 1929 250 68 1930 262 54 1931 282 48 118 The total number of new cases of tuberculosis coming to the knowledge of the Medical Officer of Health during 1931 by notification or otherwise, was 412, as compared with 387 in 1930 , 390 in 1929 and 449 in 1928. 341 of these cases were Pulmonary Tuberculosis, 186 in males and 155 in females. There were 17 more cases of Pulmonary Tuberculosis in males, and 12 more in females than in 1930. Tliere were 5 fewer cases of Non-Pulmonary Tuberculosis among children under 15 years than in 1930. One more case, however, occurred in adults, 8 fewer in boys and 3 more in girls. Of the cases notified in 1931 30 males and 20 females died from the pulmonary form of the disease during the year, equal to 17.7% of those notified, and 2 males and 3 females from the non-pulmonary. The incidence rate of Tuberculosis of all forms was 1.76 per 1,000 of the population ; for Pulmonary Tuberculosis 1.46 and for Non-Pulmonary 0.3 per 1,000 population. The Notification rate was 1.41 per 1,000. Public Health (Tuberculosis) Regulations 1930. Table LVII. Summary of Notifications during the period from the 28th December, 1930, to the 2nd January, 1932, in the area of the County Borough of Croydon:— Age periods Notifications on Form A. No. of Piimary Notifications of new cases of tuberculosis. Total Notifications on Form A. 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 35 35 to 45 45 to 55 55 to 65 65 and upwards Total (all ages) Pulmonary Males ... ... 4 3 17 28 40 31 15 16 6 153 203 ,, Females ... ... 1 4 21 21 38 16 8 10 5 124 180 Non-pulmonary Males ... 4 7 1 3 2 1 2 2 1 1 24 28 ,, ,, Females 1 2 4 3 3 3 4 1 2 ... 1 24 24 119 Table LVIII. New cases of Tuberculosis coming to the knowledge of the Medical Officer of Health during the period from the 28th December, 1930, to the 2nd Januarys 1932, otherwise than by notification on Form A under the Public Health (Tuberculosis) Regulations, 1930:— Age periods 0 to 1 1 to 5 5 to 10 10 to 15 15 to 20 20 to 25 25 to 36 35 to 45 45 to 55 55 to 65 65 and upwards Total Cases Pulmonary Males 1 1 ... ... 2 4 9 8 1 2 ... 28 „ Females 1 ... ... 1 2 4 12 8 1 2 ... 31 Non-Pulmonary Males ... 2 ... 1 1 ... 2 1 ... 1 ... 8 „ „ Females ... 1 1 2 5 ... 2 2 ... 2 ... 15 The source or sources from which information as to the abovementioned cases was obtained are shown below.— Source of Information. No. of Cases. Pulmonary. NonPulmonary. Death Returns (i.e., from local Registrars, or transferable deaths from Registrar General) 14 10 "Transfers " from other areas (other than transferable deaths) 43 11 Posthumous notifications 1 2 Other Sources (form "C") 1 ... The Mortality from Tuberculosis. The following Table shows the intervals of time elapsing between the date of notification of a patient as suffering from Pulmonary Tuberculosis and the date of his death from that complaint. In the total of 155 deaths during 1931, 41 (26.4%) were either not notified at all or only notified within a month prior to death. In 1930 this figure was 30 or 19.4%. 18 of these were not notified during life. Of these 18, 6 were certified by the Coroner or discovered after a post-mortem examination had been held; 2 died outside the Borough; 7 were cases of fulminating or complicated cases of Tuberculosis; 3 cases were not notified owing to a misunderstanding. 120 Pulmonary Tuberculosis in the vast majority of sufferers is a relatively chronic disease and it rarely kills so rapidly that its entire course is only of a month's duration. It must be inferred either, that the victims omitted to seek advice until absolutely compelled to do so, or the medical men in attendance did not diagnose the condition until it was far advanced. Early notification is of great importance from both the preventive and the curative aspects of this malady. In 32.2% notification preceded death by less than six months. For Non-pulmonary Tuberculosis the proportion of non-notified fatal cases to the total deaths from this form of the disease was 57.9%. In other words, out of a total of 19 deaths, 11 were not notified during life; only 3 of these 11 cases died at home. Of the total deaths from Tuberculosis of all forms, 29 or 16.6%, were not notified prior to death, compared with 16.5% in 1930. Interval Between Notification and Death From Pulmonary Tuberculosis in Cases Dying in 1931. Table LIX. Not Notified Under 1 week 1-2 weeks 2-4 weeks 1-2 months 2 3 months 8-6 months 6-12 months 18 9 5 9 10 2 15 20 One Year Two Years Three Years Four Years Five Years Six Years Seven Years Eight years and ovtr 16 15 7 9 3 5 3 9 Table LX. shows the incidence rate and death rate of all forms of Tuberculosis for the various wards of the Borough, based on ward populations calculated from a total population of 233,115. The death rate for the whole Borough was 0.746. 121 Table LX. The following were the Wards from which new patients came:— Ward. Density of Population persons per acre 1931 census Pulmonary Non-Pulmonary Total Incidence Rate pe 1000 Death Kate per 1000 Upper Norwood 19.5 32 6 38 1.7 0.74 Norbury 28.4 25 1 26 1.7 0.77 West Thornton 41.0 37 8 45 2.4 0.56 Bensham Manor 48.4 26 6 32 2.0 0.51 Thornton Heath 49.1 22 6 28 1.1 0.66 South Norwood 28.0 17 4 21 1.2 0.64 Weodside 35.6 19 2 21 1.4 1.05 East 9.3 27 4 31 1.9 0.63 Addiscombe 47.4 21 2 23 1.7 0.78 Whitehorse Manor 61.2 32 6 38 2.3 1.17 Broad Green 67.0 17 6 23 1.5 0.94 Central 32.4 15 4 19 1.6 0.84 Waddon 21.6 28 8 35 1.7 1.71 Sooth 12.2 14 5 19 1.3 0,41 Addington 0.8 4 1 5 1.8 0.36 No fixed abode ... 5 2 7 ... ... 341 71 412 1.8 0.746 The Wards showing the highest incidence of new patients in '931 were- West Thornton (2.4), Whitehorse Manor (2.3), and Bensham Manor (2.0). The highest death-rates were in Whitehorse Manor (1.17), and Woodside (1.05). With the relatively small figures available, these rates are subject to wide annual variations. 122 Table LXI. TUBERCULOSIS. Age periods. 1931 Population at age period, (estimated) Pulmonary, Non-Pulmonary. New Cases. All Cases. New Cases. All Cases. Number. Incidence Rate. Deaths. Death Rate (based on 1931 figures). Number. Incidence Kate. Deaths. Death Kate (based on 1931 est. figs.) M F M F M F M F M F M F M F M F M F Under one year 2064 1896 1 1 0 48 0.53 1 2 0.48 1.06 ... 1 ... 0.53 ... ... ... ... 1— 5 years 6686 7035 1 ... 0.15 ... 3 0.45 ... 6 3 0.90 0 42 1 3 , 0.15 0.42 5—10 ,, 10908 10052 4 1 0 37 0.10 ... ... ... ... 7 5 0.64 0.50 1 1 0.09 0.10 10—15 11561 11003 3 5 0 26 0.45 ... 1 ... 0.09 2 5 0.18 0.45 ... 1 ... 0.09 15—20 ,, 9511 10261 19 23 2 0 2.24 4 9 0.42 0.87 4 8 0.42 0.78 ... 2 ... 0 19 20—25 „ 7381 9551 30 25 4.06 2.62 8 12 1.08 1.26 2 3 0.27 0 31 ... ... ... ... 25—35 „ 15097 19873 49 50 3.25 2.52 18 15 1.19 0.76 3 6 0.20 0 30 5 0.25 35-45 , 16812 20483 39 24 2.32 1. 17 22 10 1.81 0.49 3 3 0.18 0 15 2 ... 0.12 ... 45—55 13424 15409 16 9 1.19 0 58 15 9 1.12 0.59 2 2 0.15 0.13 ... ... ... ... 55—65 ,, 8016 9774 18 12 2.24 1.23 10 7 1.25 0.72 2 2 0.2,5 0.20 1 2 012 0.20 65 and upwards 6122 10196 6 5 0.98 0.49 6 3 0.98 0.29 1 1 0.16 0.10 ... ... ... ... Totals 107582 125533 186 155 1.73 1.21 87 68 0.81 0.54 32 39 0.30 0.31 5 14 0.05 0.11 In the above table the death rate is based upon the total deaths in 1931,and not on deaths in New Cases only. 123 In 1931 the deaths from Pulmonary Tuberculosis in the age groups 10 to 20 years and over 55 years were fewer than in 1930, but between the age of 35 and 55 years there were more deaths. The greatest number of deaths in women occurred between the ages of 20 and 30 years, and to a less extent between 35 and 40 years, after which there was a gradual fall, whereas among men the maximum number occurred in the 35 to 40 age group. From 30 years onwards the deaths among males exceeded those in females. The greater proportion of new cases of Pulmonary Tuberculosis were in the age groups comprising 20 to 35 years. In the age groups 15 to 25 years there was a greater number of new cases among women but after 25 years there was a greater number in men. There is a close similarity between the age distribution of new cases and of deaths from Pulmonary Tuberculosis. The figures indicate that Pulmonary Tuberculosis is a rare disease in the first 10 years of life. Non-pulmonary Tuberculosis shows its highest incidence in the 1-5 year group ; the death rate also being highest at this age. Tables LXVIII.—IX. summarise the condition of all patients whose records are at the Dispensary at the end of 1931. These tables show that of patients who came under treatment for Pulmonary Tuberculosis before 1926, 337 adults and 94 children have been discharged as recovered. Of these all but 8 were early cases. Of 1926 cases 11 adults have recovered. Of patients who first attended in 1931, 20 have been lost sight or otherwise removed from the Dispensary Register. Of the 1930 cases 43 were lost sight of. Of patients who attended prior to 1926, 222 adults and 13 children are known to have died; since 1926, 451 adults and 10 children are known to have died. Of patients attending for the first time in 1931 44 have died. In sufferers from Non-pulmonary Tuberculosis who first attended prior to 1926, 39 adults and 506 children have been discharged as recovered, and of those first attending in 1926 and following years, 14 adults and 51 children. 10 adults and 9 children died in the Pre-1926 class; 19 adults and 13 children died in the 1926 and foowing years group. One adult attending for the first time in 1931 died during the year. 124 The contrast in the numbers recovered, arrested and died, as also the different incidence in adults and children, as between the Pulmonary and Non-pulmonary types of the disease, is most marked. This Table also emphasises the essential chronicity of the illness, more particularly in the direction of recovery. Co-ordination with Medical Practitioner:, and Other Branches of the Health Department. During the year 276 cases of suspected Tuberculosis were referred by private medical practitioners for the Tuberculosis Officer's opinion ; 124 were diagnosed as suffering from Pulmonary Tuberculosis and were subsequently notified. 81.2% of all notified cases were sent for examination to the Dispensary or were seen at the request of the medical attendant at the patient's home, as compared with 72.7% in 1930. Table LXV., 534 new cases were examined during the year. This is equal to 307 for each 100 deaths from the disease. 268 or 50% were found to be definitely tuberculous. The contacts of definite cases are urged to attend the Dispensary for examination (and subsequent supervision). A small proportion avail themselves of this prophylactic facility. In 1931, 593 contacts were examined, equal to 340 for each 100 deaths, compared with 465 in 1930 or 265 per 100 deaths, and of these 15 were considered to be tuberculous. This is equal to a Tuberculosis rate per 1,000 contacts of 25.3, compared with 1.76 per 1,000 of the general population. In 333 adult contacts examined the Tuberculosis rate per 1,000 contacts was 36. 4 of these who had been under observation from previous years were found to be suffering from Tuberculosis. The number of reports sent in by Insurance medical practitioners on their domiciliary cases (Form G.P. 36) was 487. This is a duty laid on all Medical men accepting service under the "National Health Insurance Act. Public Health (Tuberculosis) Regulations, 1930. Number of cases of Tuberculosis remaining on the registers of Notifications kept by the Medical Officer of Health of the County Borough on the 31st December, 1931:— Table LXII. PULMONARY NON-PULMONARY Total Cases Males Females Tot*l Males Females Total 680 577 1,257 235 276 511 1,768 125 These figures are fewer than last year, due to a further revision of the Register. The figures are now a correct reflection of the number of "live" cases. This revision has entailed much work, but, unless done periodically the Registers become overburdened with cases, and though the figures are obviously more impressive, the picture is out of perspective. The figures include all the notified cases in mental hospitals, poor law infirmaries and other institutions, and also cases not suitable for treatment under the Council's scheme. A summary of the work of the Dispensary during the year 1931 will be found in Tables LXV. and LXXIV. The Dispensary Register of Cases. The number of cases of Tuberculosis under the supervision of the Dispensary at the end of the year was 1,037. This is equivalent to 4.44 persons per 1,000 of the population. The Dispensary Register has been revised yearly during the past four years, so as to make it a correct record of the cases in the Borough who are under the supervision of the Dispensary. This has necessitated a lot of patient work in following up old cases, some of whom had not been seen for a number of years. A considerable proportion of the cases marked off had left the Borough or bad recovered to such an extent that they could be considered as cured. The names of those who did not desire or require public medical treatment were also removed. By these means the number of persons on this Register has been reduced from 1,965 on 1st January, 1928, to 1,066 on 31st December, 1931. During the year 130 Dispensary cases died ; of this number, 45 or 34.6% were seen for the first time in 1931. The Medical Officer of Health and the Tuberculosis Officer visited a number of the institutions in which Croydon patients were being treated (in addition to frequent visits to the Borough Sanatorium at Cheam by the Medical Officer of Health). Examination of Sputum. This is done by the Council's Bacteriologist in the Laboratory at the Croydon General Hospital. 126 The results of examinations made in 1931 are as follows:— For Dispensary. For General Practitioners. For Mayday Road Hospital. Totals. Positive (i.e., tubercle bacilli present) 400 131 86 617 Negative (i.e., tubercle bacilli absent 534 675 123 1332 Total 934 806 209 1949 For each 100 new cases and contacts examined at the Dispensary 82.8 specimens of sputum were examined. The 806 examinations include a considerable number from the Croydon General Hospital, in addition to those sent in by General Practitioners. Only a small proportion of the total number of patients sent to the Dispensary have had their sputum examined before arrival, although many have had both sputum and symptoms for months. It is difficult to understand why this simple test is not universally applied and so avoid delay in diagnosis. 1931, however, shows an increase in the number of examinations of sputa made for General Pactitioners. To much reliance is placed upon one negative sputum examination. In any case in which it is considered advisable to have the sputum examined, at least three specimens should be submitted if the result is returned as negative. 137 HOUSING STATISTICS OF PATIENTS. Table LXIII. Patients occupying a separate bedroom. Patients occupying a separate bed but not a separate bedroom. Patients not occupying a separate bed. Totals. Number of Pulmonary cases: Under 15 years 13 6 4 23 15 years and over 422 86 386 894 435 92 390 917 Number of Non-Pulmonary cases: Under 15 years 53 48 73 174 15 years and over 44 25 55 124 97 73 128 298 Totals 532 165 518 1215 The above table gives a summary of the housing conditions found in notified cases. It is seen that 47.4% of the pulmonary cases and 32.5% of the non-pulmonary cases were occupying a separate bedroom. In 42.5% of the pulmonary and 42.9% of the non-pulmonary the sleeping arrangements were not satisfactory inasmuch as the patient did not have a separate bed. 45 patients, who are definite cases of pulmonary tuberculosis on the Dispensary Register at the end of 1931 resided in houses built by the Corporation and let at a rental. CLASSIFICATION OF NEW PATIENTS. Pulmonary Tuberculosis. During 1931, 255 new patients were examined at the Dispensary and were found to be in the undermentioned stages of the disease on the first examination:— T.B. minus (sputum negative or absent) 72 or 28.2% T.B. plus 1 (early cases, sputum positive 8 or 3.1% T.B. plus 2 (intermediate cases, sputum positive) 113 or 44.3% T.B. plus 3 (advanced cases, sputum positive 62 or 24.3% 255 or 100.0% I 128 It is well known that Tuberculosis officers do not see many of the new cases in the early stages of the disease. This, as Sir George Newman remarks, "is not invariably due to neglect by medical practitioners under the regulations. Far too frequently there has been delay on the part of the patient in obtaining medical advice, or delay on the part of the practitioner in seeking the assistance of the Tuberculosis officer in regard to patients suffering from chest trouble which may have a tuberculous basis." The initiative to seek treatment when ill rests with the patient himself, and the remedy lies in the education of the public as to symptoms and common dangers of Tuberculosis and the need for securing early treatment. In 1931 there was a decrease in the number of early cases and a corresponding increase in the advanced cases. It is unfortunate that 68.6% of the new cases were more or less advanced in the disease. Non-Pulmonary Tuberculosis. There were 28 cases examined at the Dispensary and found to have Non-pulmonary Tuberculosis in the following forms:— Bones and Joints 10 Abdominal 6 Other Organs 3 Peripheral Glands 9 28 Table LXIV. TUBERCULOSIS DENTAL REPORT Men. Women. Total. Referred Treatment 12 7 19 Treated 11 5 16 Extractions 63 35 98 Fillings 6 2 8 Dressings 7 1 8 Denture Dressings 9 — 9 Dentures Fitted 2 — 2 Attendances 43 23 66 The above Table shows the number of Tuberculosis patients dealt with by the Dentist at the Lodge Road Clinic. 129 X-ray Work. A greater number of doubtful and difficult cases were sent for radiological examination than in previous years. By this means the number of beds necessary for the observation of such cases has been reduced and cases of Bronchiectasis, Pulmonary tumour, etc., were discovered which otherwise would have been classed as suffering from Pulmonary Tuberculosis. The Radiological technique for the examination of chest cases has been very much improved in the past few years, and this has led to the detection of the disease in some patients in a very early stage who formerly would not have been diagnosed until a later date, thus enhancing their chance of complete recovery. X-ray examinations are also a great help in determining the most suitable form of treatment and in controlling such treatment. It, will thus be seen that X-ray examination forms an indispensable part of the routine examination of the doubtful cases. 244 X-ray examinations were made during the year. This is equivalent to 21.4 for every 100 new cases and contacts seen, and compares with a rate of 19 per 100 new cases and contacts seen in 1930. Extra Nourishment. Provision of special nourishment in the form of milk was granted to a number of selected cases for varying periods. Sleeping Shelters. The loan of such shelters is made to suitable cases. That is, to patients in an infectious condition or on account of overcrowding, but frequently one finds there is no available space for a shelter in the garden or yard attached to the patient's house. Lack of privacy sometimes is also an obstacle. 130 Table LXV. (A) Return showing the work of the Dispensary. Diagnosis. Pulmonary. Non-Pulmonary. Total. Gran TotaL. Adults. Children. Adults. Children. Adults. Children. m. F. M. F- m. F. m. F. M. F. m. F. A.—New Cases examined during the year (excluding contacts) : (a) Definitely tuberculous. 141 96 3 1 10 5 6 6 151 101 9 7 268 (6) Diagnosis not completed - - - - - - - - 5 10 2 1 18 (c) Non-tuberculous - - - - - - - - 63 90 46 49 248 B.—Contacts examined during year :— (a) Definitely tuberculous 5 7 1 1 - - 1 - 5 7 2 1 15 (ft) Diagnosis not completed - - - - - - - - 1 7 2 1 II (c) Non-tuberculous - - - - - - - — 81 232 128 126 567 C.—Cases written off the Dispensary Register as:— (a) Recovered 49 25 6 1 3 6 46 30 52 31 52 31 166 (ft) Non-tuberculous (including any such cases previously diagnosed and entered on the Dispensary Register as tuberculous)... - - - - - - - - 155 335 180 185 855 D.—Number of Cases on Dispensary Register on December 31st («) Definitely tuberculous... 401 3I9 17 23 34 43 108 92 435 362 125 115 1037 (ft) Diagnosis not completed - - - - - - - - 6 17 4 2 29 1. Number of cases on Dispensary Register on January 1st 1,227 2. Number of cases transferred from other areas and cases returned after discharge under Head 3 in previous years 56 3. Number of cases transferred to other areas, cases not desiring further assistance under the scheme, and cases" lost sight of " 193 4. Cases written off during the year as Dead (all causes) 130 5. Number of attendances at the Dispensary (including Contacts) 5,520 6. Number of Insured Persons under Domiciliary Treatment on the 31st December 194 7. Number of consultations with medical practitioners :— (a) Personal 57 (b) Other 593 8. Number of visits by Tuberculosis Officers to homes (including personal consultations) 308 9. Number of visits by Nurses or Health Visitors to homes for Dispensary purposes 4,876 11. Number of "Recovered" cases restored to Dispensary Register, and included in A (a) and A(b) above Nil 10. Number of (a) Specimens of sputum, etc., examined 934 (ft) X-ray examinations made in connection with Dispensary work 242 12. Number of "T.B. plus" cases on Dispensary Register on 31st December 483 (B) Number of Dispensaries for the treatment of Tuberculosis (excluding centres used only for special forms of treatment Provided by the Council 1 Provided by Voluntary Bodies Nil 131 Table LXVI. Return showing the immediate results of treatment of definitely tuberculous patients discharged during the year from Institutions approved for the treatment of Tuberculosis. Pulmonary Tuberculosis. Cassification on admission to the Institution. Condition at time of discharge. Duration of Residential Treatment in the Institution. Grand Totals Under 3 months. 3-6 months. 6-12 months. More than 12 months. Totals. m. f. Ch. m. f. Ch. m. f. Ch. M. f. Ch. M. f. Ch Class T.B. minus. Quiescent 1 4 1 8 8 1 6 6 — — — 4 15 18 6 39 Not quiescent Died in Institution — 3 — 1 2 — — 1 — — — — 1 6 — 7 - - - 1 - - - - - - - - 1 - - 1 Class T.B. plus Group 1. Quiescent — — 3 — — 3 — — — — — 6 — — 6 Not quiescent Died in Institution 1 — — 2 — — 1 — 1 6 — — 10 — 1 11 - - - - - - - - - - - - - - - - Class T.B. plus Group, II. Quiescent 2 — — 4 3 — 4 7 — — 1 — 10 11 — 21 Not quiescent Died in Institution 6 5 — 20 12 — 17 9 — — 1 43 27 — 70 1 — — 1 — — 2 4 — — — - 4 4 — 8 Class T.B. plus Group III Quiescent - - - - - - - 1 - - - - - 1 — 1 Not quiescent Died in Institution 4 5 — 8 2 1 5 2 — — 1 — 17 10 1 28 2 2 — 2 1 — 1 2 — — — — 5 5 — 10 Non-Pulmonary Tuberculosis. Classification on admission to the institution. Condition at time of discharge. Duration of Residential Treatment in the Institution. Grand Totals Under 3 months. 3-6 months. 6-12 months. More than 12 months. Totals. M. f. Ch. M. f. Ch. M. f. Ch. M. f. Ch. M. f. Ch. Bones and Joints. Quiescent — — 2 — — 1 — 1 1 2 — 4 2 1 8 11 Not quiescent Died in Institution — 3 - - 1 - - 1 - - 1 - - 6 — 6 — 1 — — — — 1 — — — 1 — 1 2 — 3 Abdominal. Quiescent - - - - - - 1 - - - - 1 1 — 1 2 Not quiescent Died in Institution - - - - - - - - - - - - - - - - — - - - - - - - - - - - - - - - Other organs. Quiescent - - - - - - - - - - - - - - - - Not quiescent Died in Institution - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Peripheral gland Quiescent — — — — 1 — — I — — 6 — — 8 8 Not quiescent Died in Institution — 3 - - - - - - - - - - - 3 — 3 - - - - - - - - - - - - - - - - 132 Table LXVII. Return showing the results of doubtfully tuberculous cases discharged during the year from Institutions approved for the treatment of Tuberculosis. Diagnosis on discharge from observation. For Pulmonary Tuberculosis. For Non-Pulmonary Tuberculosis. Totals. Stay under 4 weeks. Stay over 4 weeks. Stay under 4 weeks. Stay over 4 weeks. M. F. Ch. M. F. ; Ch. M. F. Ch. M. F. Ch. M. F. Ch. Tuberculous — — — 2 — — - - — — — 2 — - Non-tuberculous 1 — — 3 1 — - - — — — — 4 1 - Doubtful - - - - - - - - - - - - - - - Totals 1 — — 5 1 - - - - - - - 6 1 - 134 135 T ABLE LXVIII. PULMONARY TUBERCULOSIS. Condition at the time of the last record made during the year to which the return relates. Previous to 1926 1926 1927 1928 1929 1930 1931 Class T.B. plus Class T.B. plus i Class T.B. plus Class T.B. plus Class T.B. plus Class T.B. plus Class T.B. plus Class 1 T.B. minus Group 1 Group 2 Group 3 Total (Class T.B. plus) Class T.B. minus Group 1 Group 2 Group 3 Total (ClassT.B. plus) Class T.B. minus Group 1 Group 2 Group 3 Total (Class T.B. plus) | Class T.B. minus | Group 1 Group 2 Group 3 Total (Class T.B. plus) Class T.B. minus Group 1 Group 2 Group 3 Total (Class T.B. plus) Class T.B. minus Group 1 Group 2 Group 3 Total (Class T.B. plus) Class T.B. minus Group 1 Group 2 Group 3 Total (Class T.B. plus) (a) Remaining on Dispensary Register on December 31st. Disease Arrested Adults M 14 14 4 2 20 2 6 3 - 9 8 9 - - 9 4 2 - - 2 2 - - - - - - - - - - - - - - F 18 6 5 2 13 3 1 1 — 2 7 2 - - 2 20 2 2 — 4 3 1 - - 1 - - - - - - - - 1 - Children 10 1 - - 1 - 1 - - 1 2 - - - - - - - - - 2 - - - - - - - - - - - - - - Disease not Arrested Adults M 1 17 23 5 45 - 4 5 1 10 1 11 6 - 17 2 4 23 1 28 10 7 18 - 25 23 10 40 3 53 29 7 47 21 75 F 5 7 17 4 28 4 1 6 1 8 2 1 8 - 9 7 3 6 1 10 13 3 13 — 16 23 1 24 3 28 29 — 45 9 54 Children 1 — 2 — 2 — — — — — — — 1 - 1 1 - - - — 4 — 1 — 1 7 1 — — 1 5 — — — — Condition not ascertained during the year 5 2 - — 2 — — — — — 2 — - - - 1 - 1 — 1 4 — 2 — 2 3 1 2 — 3 - - - - - Total on Dispensary Register at 31st December 54 47 51 13 111 9 13 15 2 30 22 23 15 - 38 35 11 32 2 45 38 11 34 — 45 56 13 66 6 85 63 7 92 30 129 (b) Not now on Dispensary Register and reasons for removal therefrom. Discharged as Recovered Adults M 165 13 4 1 18 5 2 - - 2 - - - - - - — - - - - - - - - - - - - - - - - - - F 143 8 3 — 11 3 1 — — 1 — — - - - - - - - - - - - - - - - - - - - - - - — Children 94 - - - - - - - - - - - - - - - - - - - - - — Lost sight of, or otherwise removed from Dispensary Register 222 43 37 7 87 31 " 26 6 48 17 18 12 1 31 25 13 11 - 24 21 5 26 — 31 12 7 15 2 24 j 6 1 10 2 13 Dead Adults M 18 23 40 47 110 4 20 24 11 55 2 5 29 8 42 1 3 21 7 31 3 2 33 16 51 i 3 14 11 25 3 9 18 27 F 14 5 21 54 80 9 15 18 14 47 2 3 21 14 38 3 1 26 7 34 2 2 22 8 32 4 — 12 8 20 — — 1 12 13 Children 3 1 3 6 10 - - 1 - 1 - - 1 2 3 1 — - - — 1 - 1 - 1 — — — 2 2 — — 1 -— 1 Total written off Dispensary Register 659 93 108 115 316 52 54 69 31 154 21 26 63 25 114 30 17 58 14 89 27 9 82 24 115 19 7 41 23 71 9 1 21 32 54 Grand Totals 713 140 159 128 427 61 67 84 33 184 43 49 78 25 152 65 28 90 16 134 65 20 116 24 160 75 20 107 29 156 72 8 113 62 183 136 137 TABLE LXIX. NON-PULMONARY TUBERCULOSIS. Condition at the time of the last record made during the year to which the return relates. Previous to 1926 1926 1927 1928 1929 1930 1931 Bones and Joints Abdominal Other Organs Peripheral Glands Total Bones and Joints Abdominal Other Organs Peripheral Glands Total Bones and Joints Abdominal Other Organs Peripheral Glands Total I Joints J Abdominal j Other Organs Peripheral Glands Total Bones and Joints Abdominal Other Organs Peripheral Glands Total Bones and Joints Abdominal Other Organs Peripheral Glands Total Bones and Joints Abdominal Other Organs Peripheral Glands Total (a) Remaining on Dispensary Register on December 31st. Disease Arrested Adults M 4 - - - 4 1 - - - 1 3 - 1 - 4 - - - 1 1 1 - - 2 1 1 - 2 1 1 - - 2 F 3 1 4 1 1 3 3 — — — — 1 1 — 1 3 - 2 - 1 3 - 1 - - 1 Children 9 — — 40 49 3 2 - 23 28 4 — — 19 23 7 - 16 23 3 1 — 4 8 — 1 — 8 9 — — — 2 2 Disease not Arrested Adults M - - 2 - 2 - - - - - 1 1 1 - 3 - — — - - - 1 - 1 1 1 - - 2 3 - 3 2 8 F 3 — 5 1 9 — — — 1 1 — — - - - I - - - — — — — 5 — 5 2 — 1 4 7 1 — — 1 2 Children 3 — — — 3 — — — 1 1 — — - - - I 3 - - 2 5 3 — — — 3 4 — — 2 6 5 2 — 4 11 Condition not ascertained during the year 3 — 1 12 16 1 — — 5 6 — — - 5 5 - - 2 3 — — — 4 4 1 — — — 1 — — — — — Total on Dispensary Register at 31st December 22 — 11 54 87 6 * a — 30 38 11 i 2 24 38 2 - 20 32 8 3 6 9 26 9 4 2 15 30 10 4 3 9 26 Transferred to Pulmonary 1 — — — 1 —. — — 1 1 — — - - - - - - - - - - - - - - - - - - - (ft) Not now on Dispensary Register and reasons for removal therefrom. Discharged as Recovered Adults M 6 - 2 2 10 2 - - - 2 - - - 1 1 - - - 1 - - - - - - - - - - - - - - - F 14 5 3 7 29 1 — 2 3 1 1 - 3 5 1 ~ - - 2 2 - - - - - - - - - - - - - - - Children 30 4 5 467 506 3 1 2 28 34 1 1 — 11 1 — 4 4 - - - - - - - - - - - - - - - Lost sight of, or otherwise removed from Dispensary Register 19 10 8 129 166 4 6 4 23 37 5 3 2 18 28 1 - 4 7 4 — 2 1 7 3 1 1 2 7 — 1 — — 1 Dead Adults M 2 1 2 1 6 2 - 1 1 4 - - - - - 1 1 — 4 1 - - - 1 - - - - - - - - - - F 2 - 1 1 4 1 - — 1 2 — 1 - - 1 |i _ 2 - 3 — 1 — — 1 1 — 1 — 2 — 1 — — 1 Children 5 1 1 2 9 — 2 1 3 6 — — 1 — 1 2 1 1 5 - - - - - - - - - 1 - - - - - Total written off Dispensary Register 78 21 22 609 730 13 9 8 58 88 7 6 3 33 49 |4 4 11 26 5 1 2 1 9 4 2 2 2 10 — 2 — — 2 Grand Totals of (a) and (ft) (excluding those transferred to Pulmonary). 100 21 33 663 817 19 11 8 88 126 18 7 5 57 87 4 4 31 58 13 4 8 10 35 13 6 4 17 40 10 6 3 9 28 138 Table LXX. Return showing the extent of Residential Treatment and Observation during the year In Institutions (other than Poor Law Institutions) approved for the treatment of Tuberculosis. In Institutions on Jan. 1st. (1) Admitted during the year (2) Discharged during the year. (3) Died in the Institutions. (4) In Institutions on Dec. 31st. (5) Number of doubtfully tuberculous cases admitted for observation : Adult males - 6 6 - - Adult females — 2 1 — 1 Children — — — — — Total - 8 7 — 1 Number of definitely tuberculous patients admitted for treatment : Adult males 60 123 105 11 67 Adult females 52 97 83 11 55 Children 31 21 25 — 27 Total 143 241 213 22 149 Grand Total 143 249 220 22 150 139 Table LXXI. Return showing the extent of Residential Treatment provided during the year in Poor Law Institutions for persons chargeable to the Council under their Tuberculosis Scheme. In Institutions on Jan. 1st. (1) Admitted during the year (2) Discharged during the year. (3) Died in the Institutions. (4) In Institutions on Dec. 31st. (5) Number of patients suffering from pulmonary tuberculosis admitted for treatment: Adult males 4 54 25 20 13 Adult females 6 40 20 14 12 Children — 2 2 — — Total 10 96 47 34 25 Number of patients suffering from non-pulmonary tuberculosis admitted for treatment: Adult males - 1 1 - - Adult females — 2 1 1 - Children — 1 - —- 1 Total — 4 2 1 1 Grand Total 10 100 49 35 26 140 Table LXXII. The following Table refers to the whole of the cases of tuberculosis treated at the Mayday Road Hospital whether under the Tuberculosis Scheme of the Public Health Committee, or otherwise. In Institu tions on Jan. 1st Admitted during the year Discharged during the year Died in the Institutions In Institu tions on Dec. 31st Number of patients suffering from pulmonary tuberculosis admitted for treatment. Adult Males 18 64 31 26 25 Adult Females 15 44 24 19 16 Children 0 3 2 1 0 Total 33 111 57 46 41 Number of patients suffering from nonpulmonary tuberculosis admitted for treatment. Adult Males 0 6 3 3 0 Adult Females 0 4 2 1 1 Children 3 1 0 1 3 Total 3 11 5 5 4 Grand Total 36 122 62 51 45 141 The Immediate Results of Sanatorium Treatment. Table LXXIII. Cases of Pulmonary Tuberculosis Treated in Sanatoria, 1931. In at beginning of 1931 Admitted during 1931 Discharged during 1931 Died during 1931 In at end of 1931 Adults Adults Adults Adults Adults m f c m f c m f c m f c m f c Croy. Boro' San., Cheam 38 31 ... 101 67 2 79 52 2 10 9 ... 50 37 ... Grosvenor 11 9 ... 10 13 ... 16 14 ... ... ... ... 5 8 ... Burrow Hill Colony ... ... 2 ... ... 2 ... ... 1 ... ... ... ... ... ... Brampton 3 3 1 8 9 ... 9 7 1 ... ... ... 2 5 ... Pap worth 2 ... ... 1 ... ... ... ... ... ... ... 3 ... ... King George's San. ... ... ... 1 ... ... ... ... ... ... ... 1 ... ... Benenden National San. 1 ..1 ... ... ... ... 1 1 ... ... ... ... ... ... East Anglian San. ... ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... Harpenden ... ... 1 ... ... 4 ... ... 1 ... ... ... ... ... 4 Victoria Park Hospital ... ... ... 1 1 ... ... ... ... ... ... ... 1 1 ... University College Hosp. ... ... ... ... 1 ... ... 1 ... ... ... ... ... ... ... Mid hurst ... ... ... 3 1 ... 3 1 ... ... ... ... ... ... ... Heritage Craft School ... ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... 55 44 6 125 92 8 108 76 7 10 9 ... 62 51 ..7 Types of Cases Treated. Table LXVI., Form T. 145 (G) of the Ministry of Health summarises the results of treatment. From this table it is seen that among the Pulmonary cases 31.6% were classified as early cases; the percentage of early cases receiving treatment in institutions was in women, '11.8%, in men, 16.3%. 49% of the total cases were intermediate cases, the males also showing an excess in this group—28.2% males to 20.7% females—and 19.3% were definitely advanced. Of the total Pulmonary cases treated in Sanatoria 76.7% were potentially infectious. 112 males and 82 females were discharged from or died in Sanatoria in connection with the Croydon Scheme during 1931. 142 In Class T.B. Minus, 15 males and 18 females were discharged with the disease in a quiescent condition, i.e., 70.2% of the total cases in this class; 1 male and 6 females were not in a quiescent condition, 14.8% ; 1 male died, 2.1%. In Class T.B. Plus, Croup I., the corresponding figures were 6 males quiescent, 35.3% ; 10 males were not quiescent, 58.8% ; there were no deaths in this group. In Class T.B. Plus, Group II., 10 males and 11 females quiescent, 21.2% ; 48 males and 27 females not quiescent, 70.7%; and 4 males and 4 females died, 8.0%. In Class T.B. Plus, Group III., or advanced group, 1 female was discharged quiescent, 2.5% ; 17 males and 10 females not quiescent, 69.2% ; and 5 males and 5 females died, 25.6%. Taking all groups together, 33.1% of cases were discharged as quiescent; 57.4% as not quiescent; and 9.4% died. These figures prove, what has been so often proved before, that if tuberculosis is to be cured and eradicated the first essential is to educate the patients themselves and the medical profession in the paramount necessity for early and thorough treatment. General Observations on the Results of Treatment. The onset of Pulmonary Tuberculosis is insidious and considerable bodily damage has been caused before the majority of cases seek advice. The process of arrest is slow; once damaged, lung tissue does not regenerate, and the most that can be aimed at is prevention of an extension of the damage, and healing of the tissue affected, by the formation of scars. The greatest factors making for success are patience on the part of the sufferer and helpful optimism on the part of his medical adviser. All who are unfortunately attacked sufficiently severely to cause symptoms should reconcile themselves to the fact that for the rest of their lives they will have to be circumspect, and that errors of judgment or carelessness will be visited by a retribution more severe than in the case of healthy people. No Tuberculous person, able to work, should lead a life of idleness. Occupation suited to their medical needs is far more beneficial than any medicine known to medical science, but the 143 majority are not in a position to compete with healthy labour, and in order to make their work self-sufficient some form of endowment or protection is necessary. Sickness benefit under the National Health Insurance Act for Tubercular persons could serve as a form of subsidy and, in those medically certified as fit to do work of some kind, should be given conditionally on the patient endeavouring to do suitable work. A modification on these lines would act as an encouragement towards the formation of after-care occupation schemes such as is being carried out, to a limited extent, in Croydon. It is gradually becoming recognised that Sanatorium treatment of Pulmonary Tuberculosis requires to be supplemented by other methods of treatment. These include artificial pneumo-thorax treatment, i.e., the collapse of the diseased lung or the part of the lung that is diseased, cauterisation of adhesions, phrenic avulsion and thoraco-plasty, either partial or complete. Eventually it will probably be necessary to have a Surgeon who has specialised in thoracic surgery as a Consultant on the staff of every sanatorium. The Tuberculosis Dispensary and Home Visiting. Tables LXY. and LXXIY. give a summary of the work done in connection with the dispensary. Ninety-five notified cases were examined for the first time and 276 were sent for an opinion. Five hundred and ninety-three contacts were examined, of whom 15 were pronounced tubercular. This is an important preventive measure, and it is regretable that so few contacts avail themselves of the facility. Patients attending the Dispensary made 5,520 visits during the year. One hundred and ninety-four were on Domiciliary treatment. The Tuberculosis Officer paid 308 home visits, and the health visitors or nurses 4,170 visits for Dispensary purposes. In addition the district health visitors made 1,069 visits for the purpose °f the Notification register. Patients requiring home nursing or surgical dressings are attended T» by nurses from the Croydon Nursing Service, by arrangement with that organisation. The number of contacts examined and the number of patients visited in their homes by the Tuberculosis Officer shew a decided nicrene over those for 1930. Next year will shew a considerable falling of in both these branches of the Dispensary's activities owing to the absence of any help from other members of the medical staff in consequence of the reduction in the medical staff under the economy measures it has been found necessary to introduce. As mentioned previously contact examinations are held to be essentially inventive and play an important role in any Tuberculosis scheme. 144 Table LXXIV. SUMMARY OF DISPENSARY STATISTICS AND OF HOME VISITING FOR 1931. No. of Insured persons on Dispensary Register, January 1st, 1931 562 „ Notified Cases examined for the first time 95 ,, Cases sent for an opinion 276 ,, First attendances including 36 transfers in 1163 ,, Consultations of T.O. with private practitioners 57 ,, Visits paid by T.O. to homes of patients 308 „ Visits paid to homes of patients by Tuberculosis Health Visitor 3970 ,, Attendances of patients at the Dispensary— Men 1620 Women 2124 Children 1776 Total 5520 No. of patients under Domiciliary Treatment— Pulmonary 187 Non-pulmonary Total 194 No. of reports received from Panel Practitioners (G.P.36) 487 ,, report forms sent to Panel Practitioners (G.P.36) 629 ,, reports received from Panel Practitioners on forms G.P.17 and 35 ,, X-rays taken 244 ,, reports made to Ministry of Pensions by the T.O. on general progress of Tuberculous Discharged Ex-service men 14 ,, cases referred for "Light" Treatment 8 ,, cases referred to Orthopaedic Clinic 16 ,, cases receiving extra nourishment at end of year 40 Ages at Death from Pulmonary Tuberculosis. TABLE LXXV. Year. 0—5 5—15 15—25 25—45 45—65 Over 65 Total 1922 2 6 35 85 44 7 170 1923 1 3 51 55 30 10 150 1924 ... 2 40 66 36 5 149 1925 ... 4 30 60 44 10 148 1926 ... ... 34 81 45 9 169 1927 1 1 39 76 41 7 165 1928 2 1 38 79 37 10 167 1929 3 2 41 76 41 7 170 1930 1 3 40 57 45 8 154 1931 6 1 33 65 41 9 155 145 The most fatal period is between 25 and 35 years; under 15 Pulmonary Tuberculosis is not a prominent cause of death, its fatality is greatest during the most productive and active periods of life, and herein lies much of its social and economic importance. The total deaths from Pulmonary Tuberculosis remain very steady, but as the population is steadily increasing the death-rate is consequently slowly decreasing. In 1931 the death-rate from all forms of Tuberculosis was 0.746 per 1,000 population ,, ,, Pulmonary Tuberculosis 0.66 ,, ,, ,, Non-pulmonary Tuberculosis 0-081 ,, The difference between death rates in 1931 and 1930 is partly accounted for by the fact that this year the rate is estimated from the actual population whereas last year it was obtained from an estimated population. Non-Pulmonary Tuberculosis. Table LXXVI. The diagnosis in the new cases were as follows:— Male. Female. Glands . 3 10 ,, and Peritoneum ... 1 Spine 8 3 General Miliary 1 1 Chest Wall ... 1 Caecnm and Peritoneum ... 1 Meninges 4 8 Peritoneum 2 5 Knee 1 1 Hip 4 3 Kidney 2 2 Left Carpal Bones ... 1 Dactylitis and Glands 1 ... Abdomen 3 1 Leg and Face ... 1 Elbow 1 ... Wrist 1 ... Genito Urinary Tb 1 ... 32 39 146 Deaths from Non-Pulmonary Tuberculosis. During 1931, 19 deaths were certified to be due to Non-pulmonary Tuberculosis, compared with 21 in 1930; 29 in 1929; 39 in 1928 , 38 in 1927; 39 in 1926; 33 in 1925; and 33 in 1924; The deaths were due to:— Males Females Total Meningitis 3 8 11 Tb. Peritonitis 0 2 2 Tb. Peritonitis and Kidney 0 1 1 Tb. Abdomen 0 1 1 Tb. Spine 0 2 2 Tb. Hip 2 0 2 5 14 19 Cases of Non-Pulmonary Tuberculosis Treated in Institutions, 1931. Table LXXVII. In on 1st Jan.,1931 Admitted during 1931 Discharged during 1931 Died during 1931 In on 31stDec.,1931 Adults Adults Adults Adults Adults M F C M F C M F C M F C M F C Royal Sea Bathing Hosp. 1 2 ... 1 1 ... ... 1 ... ... 1 ... 2 1 ... St. Anthony's Hosp. 2 2 2 ... ... ... 1 1 2 1 ... ... ... 1 ... St. Nicholas Hosp. ... ... 10 ... ... 4 ... ... 9 ... ... ... ... ... 5 Children's Hosp. Coldash ... ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... Tait Convalescent Home ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... Treloar Cripples' Hosp ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 King George's San. 1 ... ... 1 ... ... 1 ... ... ... ... ... 1 ... ... St. Peter's Memorial Hosp ... 1 ... ... 2 ... ... 2 ... ... ... ... ... 1 ... Croydon General Hosp ... 2 ... 2 3 1 ... 3 1 ... 1 ... 2 1 ... Pyrford ... ... 11 ... ... 7 ... ... 5 ... ... ... ... ... 13 Wing field 1 1 ... ... ... ... 1 ... ... ... ... ... ... ... ...... Heath End Sanatorium... ... ... ... ... ... ... ... ... ... ... ... ......... ... ... ... Heritage Craft School ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 5 8 25 4 7 13 3 8 18 1 2 ... 5 5 20 147 PULMONARY TUBERCULOSIS Table LXXVIII. Shewing the Condition at the end of 1931 of cases discharged from Sanatoria during the years indicated. 1927. 1928. 1929. 1930. 1931. Totals. T.B. T.B. + T.B. T.R. + T.B. T.B. + T.B. T.B. + T.B. T.B. + T.B. T.B. + Dead 8 79= 65.8% 7 89= 64% 1 58=53.2% 4 49= 44.9% 1 17=13% 21 292= 48% 60% 57.4% 46.1% 38.4% 10.7% 42.0% Working or Fit for Work 16 30 = 25% 19 27=19.3% 14 21 = 19.2% 22 24=22% 22 38=29% 93 140= 23% 31.7% 27.5 % 27.3 % 33.3% 35.9% 31.2% Not able to Work 1 11=9.1% 2 23=16.5% 4 30=27.5% 3 36=33% 13 76=58% 23 176= 28.9% 8.2% 15% 26.6% 28.2% 53.4% 26.7% Left district 9 19 11 20 3 22 6 17 7 8 36 86 34 139 39 159 22 131 35 126 43 139 173 694 148 Of the cases whose records are at the Dispensary, it will be seen that of the total number that received sanatorium treatment during the past five years only 31.2% are working or fit for work. The remainder are dead or too ill to work. In those oases with a positive sputum, i.e., those in whom tubercle bacilli have been found in the sputum, only 23% or less than ¼ are working or fit for work. 694, or 80% of the total cases discharged, were T.B.+ cases; 122, or 14% of the total cases discharged, have removed from the Borough, and as we have no information about their condition at the end of 1931 they have been ignored in working out the above percentages. CHEAM SANATORIUM. Table LXX1X. Authority, In-patients on Jan. Ist, 1931. Admitted during year 1931 Discharge, during year 1931. including deaths In on Jan. Ist 1932. Died during year 1931 m f M F M F M F M f Croydon C. b. 38 31 103 69 90 63 51 37 10 9 Kent C. C 3 2 5 3 6 3 2 2 ... 1 11 33 108 72 96 66 53 39 10 10 Immediate Results of Treatment. Group Total number of cases discharged 1931 Quiescent Imp owed No Material Improvement Died in institution Average duration 0' stay in days Discharged before completion of treatment M F M F M F M F M F M F Class T.B. Minus 21 14 12 ... 6 1 ... 1 1 ... 163 2 1 Class T.I!. Plus. Group 1 13 3 2 ... 11 ... ... ... ... ... 207 2 ,, ,, ,, Group II 27 29 ... ... 15 13 9 8 1 5 216 2 3 ,, ,, ,, Group III 31 16 ... ... 2 2 19 19 8 5 183 2 Observation 4 4 ... ... ... ... ... ... ... ... ... ... ... 96 66 14 12 34 16 28 28 10 10 ... 6 6 At the beginning of 1931 there were 74 patients in Cheam. During the year 180 were admitted and 142 discharged, whilst 20 died, thus leaving 92 patients in at the beginning of 1932, 149 Sir George Newman states in his Annual Report for 1929: "The Juration of treatment in the intermediate group should be limited to that necessary to restore general health and working capacity as fully as circumstances permit, to educate the patients in the mode of life they should endeavour to follow, and to teach them how to avoid spreading the disease to others. For these patients short periods of treatment repeated at intervals as required appear to meet the needs most effectively." In 45.5% of this group in 1931 the duration of residential treatment exceeded 6 months. 12 Croydon cases were discharged from Cheam at request of patients or parents, i.e., 6 males or 7.5 of males discharged and 6 females or 11.1 of females discharged. A modern X-ray plant has now been installed and is proving of very great utility both in noting the progress of patients and in controlling the operation of Artificial Pneumothorax. This latter procedure is now being carried out in suitable cases, a Wingfield instrument being used for the purpose. Owing to the expansion of the work of the Occupation Centre, an assistant was appointed to Miss Goodman, the instructress. This work continues to be of real value to the patients , whilst the high artistic quality of the work done has resulted in several important orders being received. The turnover of this department during the financial year amounted approximately to £390. Table LXXX. Cheam Sanatorium Dental Report. Males. Females. Total. No. Examined 53 23 76 Referred Treatment 50 21 71 Attendances 103 51 154 Extractions 97 46 143 Fillings 27 15 42 Scalings 13 4 17 Gum Treatment 2 2 4 Dressings 38 12 50 Dentures — 2 2 1 General anaesthetic to remove impacted wisdom. Sessions 22 150 All patients in Cheam Sanatorium with the exception of those in the acute wards were dentally examined during the year. Tuberculosis patients require more visits during treatment than is necessary with ordinary patients. Extractions must be limited to two or three at each sitting to prevent rapid absorption of toxins aud the "flaring" up of the patients general condition. Most of the patients suffer from dental diseases which are chiefly caused through lowered tissue resistance. There are times when these patients must of necessity live on a soft diet, and its very sticky nature is conductive to oral stagnation. In an effort to counteract this disability, facilities are provided for the brushing and cleaning of the teeth. 151 SECTION VII. VENEREAL DISEASES. The scheme in operation in the Borough consists of the Clinics held at the Croydon General Hospital. Males attend on Saturday afternoons and Thursday evenings, women and children on Wednesday afternoons. The Clinic is conducted by Dr. P. W. Hamond, who is not otherwise connected with the Health Department. Croydon is also one of the participating authorities in the London County Council's scheme, under which clinics for the treatment of venereal diseases are provided at a large number of London Hospitals, and at resident hostels; the cost being apportioned among the ten participating authorities in the scheme on a basis of user. Table LXXXI. Attendances at the Croydon Clinic. 1924. 1925. 1926. 1927. 1928. 1929 1930 1931. New male patients 101 116 141 145 121 101 196 263a New female patients 125 156 192 160 158 94 171 205 a Attendances, male patients 1774 27 3 2360 2643 3502 3581 5050 4923a Attendances, female patients 082 1230 1351 1417 1632 2127 3029 3271a a Includes 103 new cases from outside areas, who made 1799 attendances. Attendances of Croydon Patients at various London Hospitals under the General Scheme. 1924. 1925. 1926. 1927. 1928. 1929. 1930 1931 New patients 163 138 130 132 139 131 125 139 Total attendances 2890 2648 2767 3160 3080 3089 3150 2384 Of the 139 new patients in 1931, 24 had syphilis, 1 soft chancre, 28 gonorrhoea, and 86 were not suffering from venereal disease. 152 Pathological Examinations at London Hospitals for Croydon Patients. 1924. 1925. 1926. 1927. 1928. 1929. 1930. 1931. Texts for Clinics 551 642 542 540 716 924 715 829 Tests for practitioners 882 1069 799 667 570 932 2197 3198 Pour Croydon patients were admitted to approved hostels under the L.C.C. scheme, with an aggregate of 485 days in residence. Attendances of Patients at Venereal Diseases Clinic at the Croydon General Hospital. 1931 Out Patients 6395 1491 232 72 4 8194 inPatients (days) ... ... ... ... ... 1930 OutPatients 6159 1686 184 46 4 8079 Inpatients I (days) ... ... ... ... ... ... 1929 OutPatients 3998 1676 11 23 ... 5708 Inpatients (days) 132 46 ... ... ... 178 1928 Patients 3586 1451 77 2 ... 5116 Inpatients (days) 74 137 40 ... ... 251 1927 OutPatients 3003 977 80 ... ... 4060 Inpatients (days) 161 ...... ... ... ... 161 Authority Croydon Surrey C. C Kent C. C. London C.C. OtherAuthorities 153 Table LXXXII. Croydon Cases attending London Hospitals. Hospital Cases seen for the first time. Conditions other than Venereal Total No. of Attendances Aggregate No. ot InPatient Days No. of doses of N.A.B. compounds Syphilis Gonorrhoea Soft Chancre To Inpatients To OutPatients St. Thomas's ... 17 1 33 I 2 I 6 ... ... 22 Guy's 8 4 ... 21 572 76 ... 113 King's College 9 2 ... 1 186 22 ... 33 Great Ormond Street 4 1 ... 18 114 207 ... 42 Royal London Ophthalmic 2 ... ... 2 63 ... ... 19 S. London Hospital for Women ... 1 ... 1 13 ... ... ... Whitechapel Clinic (L.C.C.) ... I ... 2 20 ... ... 8 Metropolitan Hospital ... ... ... 1 45 4 ... ... Seamen's Hospital 1 1 ... ... 4 ... ... ... Table LXXXIII. Bacteriological Examinations carried out at London Hospitals for Croydon Patients. Hospital Detection of Spirochaetes Detection of Gonococci Wassermann Reaction Other Exams. For Clinic For Priv. Prac. For Clinic For Prac. For Clinic For Prac. For Clinic For Prac. Total St. Thomas's ... ... 113 1721 94 24 109 44 2105 Great Ormond Street ... ... 22 1 30 9 17 2 81 Met. Hospital ... ... 1 ... 1 ... ... ... 2 South London Hospital for Women ... ... 11 4 6 ... ... ... 21 Royal London Ophthalmic ... ... 2 ... 2 ... 2 ... 6 Whitechapel Clinic, L.C.C. ... ... ... ... 4 ... 5 ... 9 Seamen,s Hospital ... ... ... ... 1 ... ... ... 1 Guys Hospital 5 ... 182 853 75 290 83 242 1730 154 Table LXXXIV. Return relating to all persons who were treated at the Treatment Centre at Croydon General Hospital during the year ended the 31st December, 1931. Syphilis Soft Chancre Gonorrhoea Conditions other than venereal Totals m f m f m f m f m f Ttls 1. Number of cases on 1st January under treatment or observation 90 95 ... ... 208 111 ... ... 298 206 504 2. Number of cases removed from the register during any previous year which returned during the year under report for treatment or observation of the same infection 3 ... ... ... 16 7 2 ... 21 7 28 3. Number of cases dealt with for the first time during the year under report (exclusive of cases under Item 4) suffering from :— Syphilis, primary 6 2 ... ... ... ... ... ... 6 2 8 „ secondary 9 12 ... ... ... ... ... ... 9 12 21 „ latent in 1st year of infection ... ... ... ... ... ... ... ... ... ... ... „ all later stages 14 11 ... ... ... ... ... ... 14 11 25 „ congenital 3 7 ... ... ... ... ... ... 3 10 Soft Chancre ... ... ... ... ... ... ... ... ... ... ... Gonorrhoea, 1st year of infection ... ... ... ... 109 39 ... ... 109 39 148 „ later ... ... ... ... 33 40 ... ... 33 40 73 Conditions other than venereal ... ... ... ... ... ... 54 79 54 79 133 4. Number of cases dealt with for the first time during the year under report known to have received treatment at other Centres for the same infection 9 12 ... ... 26 3 ... ... 35 15 50 Totals of Items 1, 2, 3 and 4 134 139 ... ... 392 200 56 79 582 418 1000 5. Number of cases discharged after completion of treatment and final tests of cure (see Item 15) ... 2 ... ... 31 11 56 79 87 92 179 6. Number of cases which ceased to attend before completion of treatment and were, on first attendance suffering from :— Syphilis, primary ... ... ... ... ... ... ... ... ... ... ... „ secondary ... 2 ... ... ... ... ... ... ... 2 2 „ latent in 1st year of infection ... ... ... ... ... ... ... ... ... ... ... „ all later stages 14 9 ... ... ... ... ... ... 14 9 23 „ congenital ... ... ... ... ... ... ... ... ... ... ... Soft Chancre ... ... ... ... ... ... ... ... ... ... ... Gonorrhoea, 1st year of infection ... ... ... ... 83 53 ... ... 83 53 136 „ later ... ... ... ... 37 27 ... ... 37 27 64 7. Number of cases which ceased to attend after completion of treatment but before final tests of cure (see Item 15) ... ... ... ... ... ... ... ... ... ... ... 8. Number of cases transferred to other centres or to institutions, or to care of private practitioners 2 5 ... ... 32 14 ... ... 34 19 53 9. Number of cases remaining under treatment or observation on 31st December 118 121 ... ... 209 95 ... ... 327 216 543 Totals of Items 5, 6, 7, 8 and 9 (These totals should agree with those of Items 1, 2, 3 and 4) 134 139 ... ... 392 200 56 79 582 418 1000 10. Number of cases in the following stages of syphilis included in Item 6 which failed to complete one course of treatment:— Syphilis, primary ... ... ... ... ... ... ... ... ... ... ... „ secondary ... ... ... ... ... ... ... ... ... ... ... „ latent in 1st year of infection ... ... ... ... ... ... ... ... ... ... ... „ all later stages 1 2 ... ... ... ... ... ... 1 2 3 „ congenital ... ... ... ... ... ... ... ... ... ... ... 11. Number of attendances:— (a) for individual attention of the medical officers 1092 868 ... ... 1151 522 94 110 2337 1500 3837 (b) for intermediate treatment, e.g., irrigation, dressing 75 39 ... ... 2479 1711 32 21 2586 1771 4357 Total Attendances 1167 907 ... ... 3630 2233 126 131 4923 3271 8194 155 Syphilis Soft Chancre Gonorrhoea Conditions other than venereal Totals M F M F M F M F M F Ttls 1. In-patients:— (a) Total number of persons admitted for treatment during the year (i) Aggregate number of " in-patient days " of treatment given Nil Nil Under 1 year 1 and under 5 years 5 and under 15 years 15 years and over Totals M F M F M F M F | M F 13. Number of cases of congenital syphilis in Item 3 above classified according to age periods ... ... ... ... 3 4 ... 3 3 7 Arsenobenzene Compounds Mercury Bismuth 14. Chief preparations used in treatment of Syphilis : (a) Names of preparations Novarsenobenzene Stabilarsan Sulpharsenobenzene Pil. Hyd. Bismostab (b) Total number of injections given (outpatients and in-patients) 765 ... 675 (c) Number of injections included in (b) given to patients who on first attendance at this Centre were suffering from primary and secondary syphilis 295 ... 287 15.Are the tests recommended in Memo. V21 as amended by Memo. V21a followed in deciding as to the discharge of the patient after treatment and observation for syphilis and gonorrhoea ? Yes. Microscopical Serum Tests for spirochetes for gonococci Wassermann Others for Syphilis for Gonorrhoea 16. Pathological Work:— (a) Number of specimens examined at and by the medical officer of the treatment centre 3 ... ... ... ... (b) Number of specimens from patients attending at the centre sent for examination to an ... 747 322 ... ... 156 Table LXXXV. Statement showing the services rendered at the Treatment Centre during the year, classified according to the areas in which the patients resided. Name of County or County Borough (or Country in the case of persons residing elsewhere than in England and Wales) to be inserted in these headings. Croydon Surrey Kent London Oldham Total A. Number of cases in Item 3 from each area found to be suffering from :— Syphilis 45 18 ... ... 1 64 Soft Chancre ... ... ... ... ... ... Gonorrhoea 167 43 7 4 ... 221 Conditions other than venereal 103 21 5 4 ... 133 Total 315 82 12 8 1 418 B. Total number of attendances of all patients residing in each area 6395 1491 232 72 4 8194 C. Aggregate number of " In-patient days " of all patients residing in each area ... ... ... ... ... ... D. Number of doses of arsenobenzene compounds given in the out-patient Clinic and In-patient Department to patients residing in each area 951 485 ... ... ... 1440 157 SECTION VIII. MATERNITY AND CHILD WELFARE. Table LXXXVI infant centres AND CLINICS. Address Whether Sessions are held weekly, fortnightly, etc. Day and time of Meeting Present arrangements for medical supervision Municipal, Lodge Road, Croydon Twice wkly Mon. & Thur. A Doctor and Nurse are in attendance at each Session. Boston Road, Mission Hall Weekly Thur. Sylverdale Road Parish Hall Mon. Wesleyan School-room, Bartlett Street ,, Thur. Parish Hall, Wickham Road. Shirley ,, Mon. St. Luke's Hall, Sping Lane ,, Fri. Wesleyan School Room, Lower Addiscombe Road ,, Tues. Holy Innocents Parish Room, South Norwood Twice wkly. Tues. & Fri. Foresters Hall, Westow Street, S. E. 19 Weekly Wed. All Saints' Parish Hall, Moffatt Road, Thornton Heath ,, Tues. St. Alban's Hall, Whitehorse Lane Twice wkly. Wed. & Fri. St. Paul's Hall, Norfolk Road, Thornton Heath Weekly Mon. Drill Hall, Union Road, Croydon ,, Fri. Wesleyan School Room, London Road, S.W. 16 ,, Wed. Mission Hall, Purley Way, Waddon ,, Wed. Oswald's Hall, Green Lane, Thornton Heath ,, Thar. St. Jude's Hall, Thornton Road ,, Tues. * 2 p.m. 158 Notification of Births Act, 1915. This Act required all births to be notified to the Medical Officer of Health within 36 hours of their occurrence. The whole system of health visiting rests on this Act. Notifications were received from : — Live Births Still Births. Total. Midwives 2038 42 2080 Doctors, parents, and others 1238 59 1297 As the total number of births and still births registered during 1931 was 3,722 (Live 3,601, Still 121), 348 births and 20 still births were not notified in accordance with the provisions of the Act. This is considerably more than in 1930. The relevant section of the Act lays down that it is the duty of the father of the child and of any person in attendance upon the mother at the time of, or within thirty-six hours after the birth, to give notice in writing of the birth to the Medical Officer of Health of the district in which the child is born and any person who fails to give notice of a birth in accordance with the Act shall be liable to a penalty. Maternal Mortality. There were 23 deaths associated directly with pregnancy, as compared with 7 in 1930. The maternal mortality rate was consequently 6.2 per 1,000 births, compared with 2.0 per 1,000 in 1930. In other words, as there were 121 still births, one mother died for every 156 living babies born. The deaths directly associated with pregnancy were caused by: Puerperal Septicaemia, 9 cases; Pulmonary Embolism, 1 case; Post-partum Haemorrhage, 2 cases; Abortion and Haemorrhage, 1 case; Eclampsia, 3 cases; Hyperemesis Gravidarum, 2 cases; Ectopic Gestation, 3 cases; Placenta Praevia, 1 case and Cardiac Thrombosis, 1 case. In the Table below only deaths directly due to pregnancy are included. 159 Table LXXXVII Puerperal Toxæmias. Hæmorrhages. Other Causes. YEAR. BIRTHS. Puerperal Infection. Eclampsia. Hyperemesis. Ectopic Gestation. Placenta Praevia. Post-partum Hæmorrhage. Pulmonary Embolism. Caesarian Section. Shock. Heart Disease. Syncope. Renal Trouble. Other Causes. TOTAL. Maternal Mortality. Infant Mortality. 1918 2626 3 1 ... ... 1 3 ... 1 ... ... ... 3 11 4.2 76 1919 2965 5 1 ... ... ... ... ... ... ... ... ... ... 6 2.0 73 1920 4351 6 2 ... ... 2 ... 2 ... ... 3 1 2 18 4.1 63 1921 3631 4 2 ... ... 1 2 ... ... 2 ... 3 ... 14 3.9 74 1922 3505 8 1 ... ... 1 1 1 ... ... 2 ... 1 15 4.3 64 1923 3373 4 2 ... ... 1 ... ... 2 ... ... ... 1 10 3.0 52 1924 3456 2 1 ... ... ... 3 2 ... ... 1 ... ... 9 2.6 56 1925 3406 5 1 ... ... ... 3 2 1 ... ... 1 ... 13 3.8 55 1926 3477 13 ... ... ... 2 1 1 1 2 1 ... 3 24 6.9 61 1927 3174 5 ... ... ... 1 ... 1 ... ... ... 1 1 9 2.9 55 1928 3374 2 4 ... ... ... 1 3 ... ... ... ... 3 13 3.9 53 1929 3399 4 ... 1 1 1 2 1 ... ... ... ... 1 11 3.2 65 1930 3514 1 ... ... ... ... 2 1 ... ... ... ... 3 7 2.0 48 1931 3400 11 3 2 3 1 2 1 ... ... ... ... ... 23 6.2 57 73 18 3 4 11 19 15 5 4 7 6 1— 183 3.8 61 Puerperal Fever and Puerperal Pyrexia. Twenty-three cases of puerperal fever, and 50 cases of puerperal Pyrexia were notified. This is a rate of 6.7 per 1,000 births for the former and 14.7 per 1,000 for the latter. The death rates were: puerperal fever 3.2 per 1,000 births; there were no deaths attributed to puerperal pyrexia. The following Table gives fuller details concerning these cases:— 160 Table LXXXVIII Puerperal Fever. Puerperal Pyrexia. No. of cases notified 23 50 „ ,, attended by doctor alone at confinement 4 8 ,, ,, attended by doctor and midwife 2 4 „ „ attended by midwife alone 17 38 „ ,, attended in an institution 4 31 ,, ,, attended in Private Nursing Homes 8 8 ,, ,, treated at home only 2 11 „ ,, treated at hospital 3 31 „ „ treated partly at home and partly in hospital 18 8 ,, ,, who died 11 — Under Section 2 (1) of the Midwives and Maternity Homes Act, 1926, a midwife is enabled to claim compensation for loss of practice on account of suspension from work to prevent the possible spread of infection. 3 applications were granted and a sum of £33 8s. paid. The Committee also assist necessitous patients in the payment of the midwife's fee. 5 applications were made for assistance by midwives on behalf of the patient and a total sum of £8 2s. was allowed. Table LXXXIX. Accommodation for Confinement. The following table gives information concerning the accommodation utilized for confinements. Number. Percentage. In Private Houses 2018 62.4 In Public Institutions 546 16.9 Registered Maternity Homes 669 20.7 THE WORK OF THE OBSTETRIC UNIT. Under the scheme of reorganisation, detailed in my report for 1930, a whole time specialist obstetrician who is also an Assistant Medical Officer of Health, was appointed to take clinical charge of the obstetric and gynaecological work of the Council The scheme has been working the full year and it is possible to present herewith details of the work done. Undoubtedly the scheme has succeeded : the work of this department is increasing, 161 and as the statistics show, is achieving important preventive results. It has been of benefit to the mothers and it may be said, without exaggeration, that with the maternity and gynaecological wards of the Mayday Hospital, and the beds retained in the St. Mary's Hospital, the facilities provided are as complete as in any other schemes of the same kind. The work of the Almoner to this department, Miss Kirby, has also been of much assistance. The chief points which arise out of the first year's working of this unit are:— The importance of the Ante-natal accommodation at the Mayday Hospital. The type of case admitted has differed from the Ante-natal cases admitted to the Council's beds at St. Mary's Hospital. The latter have comprised cases sent from the Clinics just prior to labour for induction, version or similar reasons, the former include Ante-natal complications of a grave nature such as pre eclampsic states ; hyperemesis, pyelitis ; such cases, without in-patient facilities, might have proved fatal. The post-natal clinic has shewn its value, and it is a distinct success. The number of attendances of mothers for gynaecological conditions has shown the need for additional institutional beds for these cases. The increase in the number of puerperal fever and puerperal pyrexia cases notified is interesting, and is possibly due to a more accurate ascertainment owing to the increased facilities offered under the scheme, for specialist opinion free of charge to the patient. A series of cases of puerperal fever which occurred during the first half of the year was the subject of a special report by myself to the Public Health Committee and to the Ministry of Health. A distinct increase is shown in the number of consultations both at the Clinic and on the district regarding obstetrical or gynaecological difficulties, with general practitioners which points to an appreciation on their side of this part of the scheme. I am indebted to Dr. D. M. Lindsay, the Assistant Medical Officer of Health for Obstetrics, for the details given below. Ante-natal Supervision. The numbers attending the Ante-natal Clinics at Lodge Road increased during the year to such an extent, that it was ultimately found necessary to hold an additional session per week. Five 162 morning sessions are held weekly, and at three of those sessions the Obstetric Officer attends along with a Lady Medical Officer. This arrangement has proved useful as a double opinion is available in difficult cases. There was a large increase in the number of cases and attendances as compared with the preceding twelve months. The increase in the number of subsequent attendances was due, partly to the actual increased number of new cases and partly to an effort to see all cases once a month during the earlier months of pregnancy, bi-monthly in the penultimate month, and weekly during the last month. The Health Visiting Service was most useful in investigating cases where patients failed to keep the appointments made. There was noted a tendency on the part of some midwives to conduct the general part of Ante-natal care themselves, and to send their cases to the clinic at the eighth month for particular examination. This practice is commendable as it keeps the midwife in more intimate touch with her patient, and gives her, at the same time an obstetric opinion formed at that period of gestation when examination is most informative. Many such cases pay only the single visit. It was gratifying to record an increase in the numbers of patients who came on their own initiative. The figure rose from 266 in 1930 to 875 in the year under review. This increase was effected chiefly at the expense of the cases sent by the Public Health Services, those having fallen from 556 in 1930 to 426 in 1931. It should be pointed out, however, that very many of the patients who came of their own accord were old patients who attended the clinic in earlier pregnancies and who had appreciate'! the help it had been to them. Medical Practitioners sent 124 cases as against 36 in the previous year. In this group again many visited once only for medical opinion or a prognosis. It was possible to trace 936 of the cases to their conclusion, in comparison with the 307 traced in the previous year. In the traced cases there was an abnormality rate of 16.5% which is higher than the 1930 rate of 13.5%. This increase rate is probably due to the greater effort to trace cases, and to the establishment of post natal clinics which encourage the abnormal cases to report back. It should be noted that 717 cases were not traced and it is reasonable to presume that most of those terminated normally. The cases known to have been abnormal would be just over 9% of all cases attending. 163 1931. 1930. Number of sessions held 215 203 Number of individuals who attended 1,653 1,023 Number of 1930 cases continuing attendance 353 Number of new cases 1,300 Total attendances made 6,830 4,124 Average attendance per session 31,77 20,32 Proportion of old to new cases per session— New 6,05 Old 25,72 Source of patients attending— Public Health Service 426 (26%)) 556 (54%) Medical Practitioners 124 (7½%) 36 (3½%) Midwives 288 (13½%) 303 (30%) From other sources or on own initiative 875 (53%) 266 (26%) Number of cases which have been concluded and traced 936 (57%) 307 (40%) Number not concluded or not traced 717 (43%) 715 (60%) Results in known cases:— Confined at. Normal Cases. Abnormal Cases. All Cases. Mayday Hosp 291 (85%) 53 (15%) 344 St. Mary's 441 (83%) 89 (17%) 530 Elsewhere 50 (81%) 12 (19%) 62 Number of normal labours resulting 782 (83½%) 265 (86½%) Numbers of abnormal labours resulting 156 (16½%) 42 (13½%) Cases referred from the clinic to hospital for Ante-Natal hospital care or for some anticipated difficulty in labour 196 (12%) Cases found to be not pregnant 24 164 Cases where the Lady Almoner arranged:— (a) Special hospital accommodation 8 (b) Convalescence 8 Cases referred for dental treatment 147 Cases referred to the Tuberculosis Officer 9 Cases referred to Mayday Hospital for X-ray examination 27 Cases in which urethral smears were taken 46 were negative 22 were positive 68 Cases in which the Wassermann reaction was investigated 27 24 were negative 3 were positive One differential blood count was made. Number of cases sent by Midwives and ultimately admitted to hospital 42 No Midwife's case has been sent in without her knowledge and approval. The greatest care has been taken to avoid cases being taken out of their hands. Those cases were distributed thus:— Mayday Hospital Confinement only 26 Ante Natal treatment and confinement 9 Ante Natal treatment : confinement at home ... 2 Total 37 St. Mary's Confinement only 6 Ante Natal treatment and confinement 1 Total 7 The 196 cases admitted to hospital prior to labour were distributed thus:— To Mayday Hospital 124 To St. Mary's Hospital 69 Elsewhere 3 The two tables which are included here show (a) the reasons for hospital treatment of the cases admitted to hospital prior to labour, and the destination of those cases: and (b) the type of abnormality met with in the cases traced along with the place the confinement. 165 Table XC. table of cases admitted to hospital prior to the onset of labour. Condition requiring admission. Mayday. St. Mary's. Elsewhere. Toxaemias: Albuminuria of Pregnancy 21 14 1 Pre-Eclamptic Toxaemia 5 Hyperemesis Gravidarum 3 — — Toxaemia of obscure type 1 — — —30 —14 — 1 Disproportion : Contracted Pelvis 20 18 — Post Maturity 6 9 — Non-engagement of head 4 4 — —30 —31 — Haemorrhages : Hydatidiform Mole 1 — — Abortion 5 — — Missed Abortion 2 — — Concealed Accidental Haemorrhage 1 — — Central Placenta Praevia 1 — — Threatened Miscarriage 2 — — Twin Miscarriage 1 — — —13 — — Malpresentations : Breech presentations 4 12 — Twin Pregnancy — 2 — — 4 —14 — Infections : Pyelitis of Pregnancy 6 1 — Bacillus Coli Cystitis 6 — 1 Acute Gonorrhoea 7 — 1 —19 — 1 — 2 Circulatory Disturbances : Ante Partum Thrombo Phlebitis 1 1 — Extreme Pressure Oedema — 3 — Acute Vulvar Oedema 1 — — Extreme Varicose Veins 2 — — Pruritis Vulvae 3 — — Cardiac Disease 3 — — —10 — 4 — Respiratory Disturbances : Pulmonary Tuberculosis 2 — — Acute Influenza 2 — — Asthma 1 – — Laryngitis 1 — — — 6 – – Other Unclassified Conditions : Pregnant Fibroid Uterus – 1 — Furunculosis Vulvae 1 — Dyspnoea I — Retroverted Gravid Uterus 4 — Melancholia 1 Pregnancy after Hysterotomy — 2 – Recurrent Premature Labours 1 — — General Debility 1 — — Abdominal Pain : (Obscure origin) — 1 — Pseudocyesis 2 — — Repeated protracted Labours 1 — — False Labour : Emesis 1 — — —12 — 5 — Total 124 69 3 166 Table XCI. table of abnormalities in labour in traced cases. Abnormal Condition. Mayday. St. Mary's. Elsewhere. haemorrhages : Abortion 4 – 1 Missed Abortion 4 – — Miscarriage 8 – 4 Placenta Praevia 5 5 — Accidental Haemorrhage 2 1 — Post Partum Haemorrhage — 1 — —23 — 7 – 5 Malpresentations : Breech 2 19 1 Face — — 1 Extended Head — 1 — Twins 3 6 — — 5 –26 — 2 Contracted Pelvis— Surgical Induction 3 8 — Caesarean Section 4 5 1 Internal Version 1 — — Post Maturity—Surgical Induction 3 6 — —11 —19 — 1 Delayed Labour : Forceps Delivery 3 25 2 Retained Placenta or Membranes 1 5 1 — 4 —30 – 3 Other Unclassified Conditions : Acute Influenza 1 — — Acute Gonorrhoea 1 — — Acute Cystitis 2 — — Acute Pyelitis 3 1 — Extreme Pressure Oedema—Induction — 1 — Albuminuria—Induction — 2 — Old Hysterotomy—Induction — 1 — Melancholia—Induction 1 — — Furunculosis Vulvae 1 — — Macerated Foetus 1 2 1 —10 — 7 — 1 Total 53 89 12 POST NATAL AND GYNAECOLOGICAL CLINICS. Post Natal and Gynaecological Clinics were introduced in January of 1931 and have been increasingly patronised. Good work has been done by the Health Visitors and by the Staffs of Mayday and St. Mary's Hospitals in encouraging patients to attend for investigation and care after confinement. 358 post natal cases were investigated, among whom there were 73 abnormal cases. This high morbidity rate of 20% should be considered with full 167 weight being given to the difficulty of persuading the woman who "never felt better in her life" of the need to attend such centres. The fact that 73 cases required treatment post natally establishes the need there was for such provision. The Public Health Service aims at making the mothers as "Post Natally Minded" as the earlier figures have shown them to be "Ante Natally Minded." The Gynaecological side of this clinic has also developed in a satisfying manner. There were 132 gynaecological consultations, and 44 were admitted to Mayday Hospital for operation or treatment. Judging by the number of individuals who were on the waiting lists of London Gynaecological Hospitals who came to this clinic in order to have their complaints treated without further delay, the available gynaecological beds in the borough were inadequate. This has been remedied by establishing gynaecological beds in Mayday Hospital. Number of sessions held 88 Number of individuals presented 492 Number of subsequent attendances 358 Total number of attendances 850 Average attendance per session 9.66 Number of Post Natal cases 360 Number of Gynaecological cases 132 Table XCII. Total Numbers Dealt with at all Clinics at Lodge Road. New Patients. Full Attendances. Ante Natal Clinics 1,300 6,830 Post Natal Clinics 492 850 Total 1,792 7,680 Table XCIII. TABLE SHOWING source, type, and fate of the post natal cases. After Confinement at Mayday. St. Mary's. Elsewhere. Total attendances 128 188 44 Cases found to be normal 119 136 32 Cases found to be abnormal 9 52 12 Abnormal cases treated at clinic or advised treatment at home 5 41 8 Abnormal cases admitted to Mayday Hospital for treatment 4 11 4 The morbidity among the post natal cases amounted to 20% 168 Table XCIV. table of all abnormal post natal cases. Case Group. Source of cases attending. Percentage of Abnormals. Percentage of all casts. Mayday. St. Mary's. Elsewhere. Retroversion 1 20 8 40% 8% Subinvolution 4 11 2 23% 4½% Trauma 1 15 1 23% 41% Infection 3 2 0 7% 1½% Other causes 0 4 1 7% 1½% Total 9 52 12 100% 20% Note.—The percentages are to the nearest half unit. Table XCV. table of abnormal post natal cases admitted to mayday hospital for treatment. Reason for Admission. Source of Case. Mayday. St. Mary's. Elsewhere. Puerperal Retroversion 0 5 3 Subinvolution 3 2 1 Breast Abscess 0 1 0 Bartholinian Abscess 0 1 0 Pelvic Inflammation 1 0 0 Retroversion and Cystic Ovary 0 1 0 Traumatic Separation of Symphysis Pubis 0 1 0 Number of cases admitted and source 4 11 4 Contraceptive guidance for medical reasons was given in 12 cases. Source of the 132 Gynaecological Cases:— Public Health Services 54 Medical Practitioners 25 Midwives 5 169 Mayday Hospital 15 Elsewhere 33 Cases found normal, 35 Cases found abnormal, 97 Of the abnormal cases 53 were treated at the Clinic or at home and 44 were admitted to Mayday Hospital for treatment. Puerperal Sepsis and Puerperal Pyrexia Admitted to the Borough Hospital. During the year there was a very great increase in the number of Puerperal Infections admitted to the Borough Isolation Hospital at Waddon. There were twenty-seven admissions. Eighteen were examples of true puerperal fever, while nine were cases of puerperal pyrexia. There were eight deaths from puerperal fever in the Borough Hospital and one in Mayday Hospital. It is difficult completely to explain this sharp rise in the frequency of the condition, but two points require mention. Firstly, eleven of the cases came from only three individuals. One midwife had five cases, a second had four, and a practitioner had two. Among these eleven cases there were no fewer than seven of the deaths recorded. The most rigid investigation was conducted but the midwives, who very willingly submitted, were found to be healthy, their preparations and appliances were found faultless, and their establishments in thoroughly clean condition and sanitary. Secondly, three cases were admitted where the diagnosis was made after other diagnoses had been made outside. One of those had been considered to be acute intestinal obstruction, while the other two were being treated as cases of rheumatic fever. Had those three cases died at home they certainly would not have figured as maternal deaths. One naturally asks, also, if the consultative service made available had not something to do with the increase. From the twenty consultations attended by the Obstetric Officer during the year, seven cases were admitted to the Borough Hospital as Puerperal Sepsis. Only three of the admissions were from Municipal units. One case of Puerperal Fever was admitted from St. Mary's Hospital following version for placenta praevia, and two cases of Puerperal Pyexia were admitted from Mayday Hospital, one a pyelo-cystitis, the other an angina simulating diphtheria. Medically it is interesting to record that the cases of true puerperal fever followed the general type. Only two of the eight fatal cases had rigors, and in six of them the pulse rate was 140 per minute or higher. In the ten cases which were discharged well, four had rigors, and in one instance only was a pulse rate of 140 recorded. Blood cultures of haemolitic streptococci were found in three of the fatal cases. Two cases with haemolitic streptococci demonstrated the blood stream recovered. 170 Table XCVI. cases of puerperal sepsis at the borough hospital, 1931. table of fatal cases. No. First seen. Days in Hospital. Rigors. Temperature. Pulse Rate. Cultures. Remarks. Onset. Degree. Uterine. Blood. 1 3rd day 2 Nil 1st day 104.2 110/140 – No growth. Normal labour, no vaginal examinations. No lochia from first day. Sent to Mayday Hospital with diagnosis of acute intestinal obstruction. Born on 15/1/1931. Nurse " A's " first case. 2 3rd day 7 Nil ? 103.8 128/144 Haemolitic Streptococci and B. Welopii Haemolitic Streptococci Born on 7/2/31. Nurse " A's " second case. Forceps delivery with most severe vaginal, cervical and perineal injury. Whole vagina and cervica covered in slough. 3 26th day 12 Nil ? 104 120/140 – Haemolitic Streptococci Born 22/1/31. Nurse " A's " third case. Normal labour, one perineal stitch. This case simulated a rheumatic fever and was being treated as such. 4 7th day 41 5 2nd day 105 110/140 Haemolitic Streptococci No growth Retained membranes and perineal tear. Nurse " B's " first case. 5 7th day 74 12 4th day 107 120/136 – No growth Spontaneous delivery, lacerated perineum. Labial abscesses, parametritis, multiple pyaemic abscesses. Poor physique. 6 11th day 8 Nil ? 104 128/154 – No growth Missed twin and retained membranes. Not recognised till infection established. Dr. " X's " first case. Born 4/12/31. 7 5th day 7 Nil ? 101.2 110/140 – No growth Dr. "X's" second case. Born 11/12/31. Spontaneous deliverv. 8 18th day 2 Nil ? 103.2 110/120 – Haemolitic Streptococci Normal. Born 17/2/32. Nurse " A's " fourth case. 171 Municipal Consulting Service Year 1931. The Assistant Medical Officer of Health for Obstetrics is available for consultation with General Practitioners in cases of difficulty, where the patient's circumstances do not permit of a Consultant's fee. This service is performed free of cost to the patient. During 1931 the officer was called out on twenty such consultations, as against seven in 1930. The cases were as follows:— 1 .—Presumed abortion.—The condition was the return of menstruation after pseudocyesis. Patient was advised. 2.—inspected ectopic gestation.—The pregnancy was normal, and patient was advised. 3—Subinvolution seven -weeks after confinement.—Patient was advised and was treated at home. 4.—Fibrosis Uteri, sub-acute appendicitis, pulmonary tuberculosis. Patient was advised. 5.—Puerperal parametritis.—Patient was admitted to the Borough Hospital. 6.—Puerperal septiccemia.—Simulating rheumatic fever. Patient was admitted to the Borough Hospital. 7— Second consultation relative to above case. 8.—Puerperal septicemia.—Patient was admitted to the Borough Hospital. 9.—Puerperal pyrexia.—Patient was admitted to the Borough Hospital. 10.—Retained lobe of placenta.—Patient was treated at home. 11.—Puerperal infection.—Patient was admitted to the Borough Hospital. 12.—Delayed labour.—Patient was admitted to Mayday Hospital. 13.—Puerperal vulvo vaginitis.—Patient was admitted to the Borough Hospital. 14—Pre-eclampsia, heart disease with failure of compensation. Patient was admitted to Mayday Hospital. 15.—Contracted pelvis and post maturity.—Patient was advised. 16.—Retained adherant placenta.—Patient was treated at home. 17.—Puerperal pyelo-cystitis.—Patient was treated at home. 18.—Post-partum hemorrhage with placenta accreta. Patient was admitted to Mayday Hospital. 19.— Puerperal pyrexia.—Patient was admitted to the Borough Hospital. 20—Abdominal hematoma appearing after labour. Patient was advised and treated at home. Ten of the cases above required hospital treatment, seven of them were admitted to the Borough Hospital and three to Mayday Hospital. 172 Table of Obstetric Cases Investigated by X-Ray at Mayday Hospital 1931. Number of examinations made 38 Number of those cases sent from the Ante Natal Clinics 27 The findings in those doubtful cases were as follows:— Vertex presentations 17 Footling 4 Breech: Legs extended 9 Contracted Pelvis 1 Large Head 1 Transverse Lie 2 Twin Pregnancy 4 In the twin pregnancies the positions were as follows:— Both presenting by the vertex 2 Both presenting by the breech 1 First presenting as a breech, second doubtful 1 RETURN OF OBSTETRIC AND GYNAECOLOGICAL CASES 1931. Mayday Hospital. The Lying-in accommodation at Mayday Hospital comprised twenty-two beds. During the year the unit was considerably improved in the way of equipment, instruments, cots for infants and other ways, but is still far from satisfactory. Plans for a new Maternity building of forty beds have been approved by the Council and it is proposed that the present building should become the gynaecological wards. With the extension of the Ante Natal work and following the opening of Post Natal and Gynaecological Clinics at Lodge Road, it was apparent that additional accommodation for cases from those centres in need of hospital treatment should be found. Such accommodation was found in Mayday Hospital where a ward with a capacity of thirty-five beds was provided. The fifty-seven beds dealt with a large number of cases which Lad passed through one or other of the Municipal clinics, but too many admissions were cases sent in urgently, in many instances having had no Ante Natal care, and too often critically ill. As the figures which fellow show, the abnormal admissions to the hospital reach a very high figure. 173 In the Lying-in block there were 375 registered births or still births, the number of mothers delivered being 369, while the extra beds dealt with 307 cases, 202 obstetric and 105 gynaecological cases. Of the 375 births conducted no fewer than 123 were not normal, an abnormality rate of 33%. Table of Confinements Conducted in Lying-in Ward. Normals 204* Normal with tear 31* Normal with pyrexia 2* Normal prematures 14* *Note:—For the purposes of reaching the percentage of abnormalities, those 252 cases are considered normals. Twins (5 cases) 10 Pyelitis of pregnancy 7 Albuminuria of pregnancy 20 Eclampsia 9 Pre-eclamptic toxaemia 2 Other toxaemias 2 Accidental haemorrhage 9 Placenta praevia 8 Post partum hæmorrhage 4 Retained placenta 5 Retained chorion 2 Surgical induction of labour 5 Cæsarean section 5 Forceps delivery 6 Craniotomy 4 Breech (other than versions) 13 Transverse lie 2 Born before admission 8 Breast abscess 2 During the year there were twenty-four still-births in Mayday Hospital. This represents 6.4% of all births. The following table gives the causes. Foetal Causes. Foetal dropsy and maceration 1 case Maternal Causes. Toxæmias:— Eclampsia or pre-eclamptic toxaemia 7 cases 174 Concealed accidental haemorrhage 1 case Placenta praevia 6 cases Premature placental separation in breech delivery 1 case Delayed second stage of labour 2 cases Failed forceps prior to admission, terminating in craniotomy 3 cases Failed forceps outside terminating in forceps delivery 1 case Contracted pelvis and high forceps delivery 1 case Contracted pelvis, posterior parietal presentation, terminating in version 1 case Eighteen infants died within ten days of birth. This represents approximately 5% of all live births. Fourteen of those died from prematurity and congenital debility. The average birth weight of those cases was three pounds and in no instance did the birth weight exceed four pounds, fourteen ounces. There were four maternal deaths in the Lying-in Ward. The causes were:— 1.—Dystocia, failed forceps outside, post partum haemorrhage. Patient was admitted in a critical condition after repeated attempts at forceps delivery outside. After the necessary craniotomy she remained dangerously ill. Sharp secondary post partum haemorrhage occurred early on the following morning. Death was within twenty-four hours of admission. 2.— Ptierperal Eclampsia.—Admited in deep unconsciousness. There were, in all, 27 fits. Death was on the same day. 3.—Puerperal Eclampsia.—Unconscious on admission. Patient had five fits in hospital. Death was within 12 hours of admission. 4.—Puerperal Eclampsia.—Unconscious on admission. Had seven fits in hospital. Death was within eighteen hours of admission. The three eclamptic cases were remarkably alike. None had attended a Ante Natal Centre. In each the onset was sudden and was unattended by premonitary symptoms. None had oedema, and all developed practically complete anuria. Post mortem examinations showed practically complete destruction of the kidney cortex. In one it was found that one kidney had remained rudimentary. 175 The cases notified from Mayday Hospital as Puerperal Pyrexia numbered fifteen. Two of those were transferred to the Borough Hospital. There were no cases of Puerperal Sepsis. The Pyrexial cases were as follows:— 1.—A normal delivery. 2.—A pyelitis. This was transferred to the Borough Hospital. 3.—A normal delivery. 4.—A breast abscess. 5.—An acute gonorrhoea, with retained placenta. 6.—An acute mastitis. 7.—An angina following anti-streptococci serum. The second case transferred to the Borough Hospital. 8.—An albuminuric. 9.—An eclamptic. 10.—A tubercular pleurisy. 11.—A pre-eclamptic who required craniotomy. 12.—A frank breech presentation. 13.—An acute bronchitis. 14.—A concealed accidental haemorrhage. 15.—A bacilluria. Ante Natal and Gynaecological Cases at Mayday Hospital 1931. The additional accommodation provided at Mayday Hospital to deal with Ante Natal and Gynaecological cases dealt in the year reviewed with 307 cases. Table showing details of cases treated:— Cases in hospital at beginning of the year 11 Cases admitted during the year 296 Number of obstetrical cases 202 Number of gynaecological cases 105 There were two deaths in this group. Those were:— 1.—A case of secondary post partum haemorrhage and acute endocarditis admitted in a dying condition. 2.—A case of acute intesinal obstruction due to carcinomatous change in ovarian cystomata. 176 Table XCVII. Table of Obstetrical Cases Treated. Haemorrhages : Missed abortion 6 Incomplete abortion 30 Inevitable abortion 15 Complete abortion 5 Miscarriage 12 Extra Uterine Pregnancy 6 Hydatidiform Mole 1 Ante-Partum Haemorrhage 5 80 Toxaemias: Pre-Eclampsia 1 Albuminuria of Pregnancy 11 Hyperemesis Gravidarum 5 Hyperemesis with Pyelitis 1 Hyperemesis with Retroverted Gravid Uterus 1 Puerperal Albuminuria 1 Albuminuria with Haematuria 1 Toxic Neuritis 1 Unclassified toxaemia 1 23 Urinary Tract Involvement: Pyelitis of Pregnancy 10 Pyelitis and Broncho-Pneumonia 1 Pyelitis and Acute Endocarditis 1 Pyelitis and Impacted Retroverted Uterus 1 Pyelitis and Intercostal Neuritis 1 Pyelitis and Recurrent Abortion 1 Cystitis (Puerperal) 1 Bacilluria 1 Haematuria 1 18 Circulatory Disturbances: Varicose Veins 2 Ante-Partum Thrombo-Phlebitis 2 Pruitus Vulvae 2 Varicose Ulcer and Placenta Praevia 1 Varicose Veins and Placenta Praevia 1 Phlegmasia Alba Dolens 1 9 Respiratory Disturbances: Acute Bronchitis 2 Pneumonia 2 Tubercular Pleurisy 1 Pulmonary Tuberculosis 1 Laryngitis 1 Asthma and Albuminuria 1 Haemoptysis 1 Influenza 1 10 Infections : Mammary Abscess 7 Anterior Parametritis 1 Pelvic Cellulitis 1 Pelvic Abscess 1 — 10 177 Contracted Pelvis 12 12 Retroverted Gravid Uterus 7 7 Other Unclassified Cases: Cardiacs 3 Breech Presentation 3 Post Maturity 6 Subinvolution 4 Pregnant Fibroid Uterus 2 Puerperal Endometritis 1 Secondary Post Partum Haemorrhage—Endocarditis 1 Puerperal Septicaemia (Transferred) 1 Acute Constipation 1 Debility after Puerperal Septicaemia 1 Debility after Puerperal Parametritis 1 Retained Placenta 1 Severe Burning 1 Ante Partum Haemorrhage—Vulvar Furunculosis 1 Threatened Abortion and Cystitis 1 False Labour 3 Ventral Hernia 1 Diarrhoea and Vomiting 1 - 33 Number of Obstetrical cases 202 178 Table XCVIII. Table of Gynaecological Cases Treated. Uterine Conditions: Carcinoma of Cervix 1 Carcinoma of Body 2 Chronic Metritis or Fibrosis Uteri 12 Fibro-Myomata 3 Chronic Subinvolution 1 Metritis with Sub-Mucous Fibroid Polyp. 1 Fibroid Uterus with Carcinoma of Body 1 Subinvolution 7 — 28 Displacements 15 15 Descent and Prolapse 13 13 Ovarian Conditions : Carcinoma 2 Cystoma 3 Cystic or Polycystic Ovaries 4 Fibroma 1 10 Infections : Salpingitis 4 Vulvitis 3 Bartholinitis 1 Tubo-Ovarian Abscess 1 Pelvis Appendix Abscess 1 10 Other Unclassified Cases: Cervical Lacerations 5 Metrorrhagia 2 Menorrhagia 1 Endometritis 1 Sterility 1 Vaginismus 1 Senile Vaginitis 1 Vulvar Trauma 2 Laceration of Fourchette 1 Urethral Caruncle 1 Pseudocyesis 2 Umbilical Hernia 1 Spontaneous separation of Symphysis Pubis 1 Ulcerative Colitis 1 Abdominal Pain (N.A.D.) 1 Panniculitis : Appendix Adhesions 1 Nephritis 1 CHCL3 Examinations (diagnostic) 1 Complete Perineal Tear 4 — 29 Number of Gynaecological cases 105 During the year 277 operations were performed in the Obstetric Unit at Mayday Hospital. 175 of those operations were obstetrical and 102 were gynaecological. There were no deaths following operation. 179 St. Mary's Hospital. This institution has 32 beds. Thirty of the beds are reserved for cases sent by the Local Authority, for which an annual grant of £3,600 is made. I am indebted to Dr. G. Genge, the physician in charge, for the following particulars:— No. of cases in the Hostel on 1st Jan., 1931 18 No. of cases admitted during 1931 516 Average duration of stay 14 days. No. of cases delivered by (a) Midwives 426 (b) Doctors 64 (12.4%) No. of cases in which medical assistance was sought by the midwife in emergency 60 No. of cases notified as Puerperal Fever or Puerperal Pyrexia 9 No. of cases notified as Pemphigus neonatorum 0 „ ,, ,, Ophthalmia neonatorum 1 No. of infants not entirely breast fed 10 These babies had supplementary feeds to assist breast feeding. No. of maternal deaths 0 No. of foetal deaths (a) Still-born 18 (ft) Within 10 days of birth 8 5 atelectasis, due to premature birth. 1 congenital icterus neonatorum 1 cerebral haemorrhage, due to difficult labour. 1 premature birth—28 week foetus. Between January 1st, 1931, and March 2nd, a series of 22 cases of Impetigo Contagiosa occurred in babies born in St. Mary's Hospital, and whilst they were resident in the Institution. Appropriate measures were taken and in due course the outbreak terminated. This infection when once it gets a hold in a Maternity Hospital proves difficult of eradication, and is the cause of much anxiety. No deaths occurred. A special report on the outbreak was made by the Medical Officer of Health to the Public Health Committee and to the Ministry of Health. The Retreat, Ross Road. This is a home for unmarried mothers and their babies, conducted by the National Free Church Women's Council and aided by a grant from the Croydon Council. Although not bulking largely as a Maternity Hospital, the work done is an important 180 branch of maternal care. Besides the matron and nursing staff, an honorary lady medical officer attends the Home when necessary. The following figures give the main details regarding the work carried out in 1931, and I am indebted to Dr. Sutherland, the Hon. Medical Officer of the Home, for them:— Number of beds for patients 18 Number of cases admitted 27 Total number of cases 32 Average duration of stay 6 months No. of cases delivered by (a) Midwives 21 (b) Doctors 1 No. of cases in which medical assistance was sought by a midwife 14 No. of cases notified as (a) Puerperal Fever, (b) Puerperal Pyrexia 1 No. of infants not entirely breast fed while in the institution 7 No. of cases notified as Ophthalmia Neonatorum Nil No. of maternal deaths Nil No. of foetal deaths (a) Stillborn Nil (b) Within 10 days of birth (due to congenital heart deformity) 1 As is seen the duration of stay much exceeds that in ordinary maternity homes. The girls are kept, with their babies, until suitable situations can be secured for them, and when necessary foster-mothers are found for the babies. Whilst the girls are in the Home they are employed in domestic work. Some of them go out to daily work, but reside in the Home. Still Births. During 1931, 121 still births were registered in respect of Croydon, but of these 11 were outward transfers to other districts. There were 10 inward transfers, giving a total of 120 for the area. Of these 70 were male babies and 50 female; 5 male and 3 female were illegitimate. The proportion of still births to living children was as 1 to 28.3. The still birth rate was 3.5 of the registered live births. The rate in 1930 was 3.0%. The still birth rate, on the same basis as for Infant Mortality was 34.9 per 1,000 births. STILL BIRTHS, 1931. Notified by Midwives 17 „ Doctors, etc. 20 ,, Institutions 58* Attended by Midwives alone 16 ,, Doctors alone 23 ,, Midwives and Doctors 21 ,, Institutions 27 Occurred at 9 months 55 „ 8 months 12 ,, 7 months 23 *Including registered Maternity Homes. 181 An Analysis of 89 Still Births Occurring During the Year. Of the 89 still births investigated 51 were males and 36 females. The causes assigned by the doctor or the midwife in attendance, for the still birth were: Type of Delivery.—In 45 cases the confinement was difficult or prolonged. Normal confinement was noted in 39 cases; no information was obtainable in 5 cases, and one was a precipitate labour. There was an abnormal presentation in 13 cases. Age of Mother.—Under 20 years, 2 ; between 20 and 29 years, 39; between 30 and 39 years, 31; between 40 and 49 years, 15. In two instances the age of the mother was not stated. The Health, of the Mother during her pregnancy was stated to be good in 69 cases and indifferent or poor in 19 cases; no particulars were obtained in 1 case. In 30 instances the mother had attended the Ante-Natal Clinic; 58 cases had never attended the Clinic. Attendance at Confinement.—Sixteen of the still births investigated occurred in the Mayday Road Hospital; 13 in St. Mary's Hospital; 37 were attended in their own homes by a private medical practitioner either alone or in conjunction with a midwife; 17 were attended by a midwife alone, and 2 births occurred before any skilled help was available ; 4 occurred in private nursing homes. Forceps were reported to have been utilised in 28 of the cases, while in 8 no record was available. In 53 cases the baby was born at full term ; in 12 at the 8th month of gestation ; in 19 at the 7th month ; and in 2 under 7 months. One case was stated to be over the 9th month. The baby was apparently a normal child in 60 cases, abnormal in 19, whilst in 10 no record was available. Number of Child in Family.—The still birth was the first pregnancy in 36 instances; the 2nd in 15 ; the 3rd in 16 ; the 4th in 8; the 5th in 2 ; the 7th in 4 ; the 8th in 2 ; the 9th in 1; the 11th in 2 ; the 13th in 1 and the 15th in 1. In 1 case the information was not obtained. A history of injury to the mother during pregnancy was given in 11 cases, and in 1 no details were available. A history of previous still births or miscarriages was obtained in 6 cases. 182 The cause of the still birth was given as due to prolonged and difficult labour in 20 cases; Placenta Praevia, 6 cases; Malpresentation, 12 cases; injury to mother, 7 cases; Prolapse of Cord, 5 cases; Eclampsia, 4 cases; various other causes, 3 cases. In 30 cases no cause was assigned and in 2 cases no record was available. Ophthalmia Neonatorum. Fourteen cases were notified during 1931. The fluctuations in the number of notifications since 1926, the date of the passing of the Ophthalmia Neonatorum regulations, is remarkable. Under these regulations notification by midwives ceased. Prior to 1926 the number of notifications remained fairly uniform, and it would appear as if only the most severe cases are now brought to the attention of the Authority. The following table gives the notifications in Croydon during the past ten years. 1911 1923 1924 1925 1926 1927 1928 1929 1930 1931 No. of cases 21 23 21 22 20 18 7 5 19 14 Rate per 1000 births 6.0 6.8 6.1 6.5 5.8 5.7 28 1.5 5 4 5.6 Results of Treatment. Cases treated. Vision Unimpaired. Vision Impaired. Died. Removed. Notified At home In hospital 14 9 5 9 1 3 1 Infant Mortality. The Infantile Mortality rate was 58 per 1,000 births. This is 10 per 1,000 births more than in 1930. For the past 5 years the numbers of infant deaths have been:— 1927, 178; 1928, 178 ; 1929, 221; 1930, 171; 1931, 196 ; 109 deaths of infants occurred in institutions, including Registered Nursing Homes. 183 Number of deaths within the first month of life:— Year. No. of Deaths. No. of Births. Rate. 1924 101 3456 29/1000 live births. 1925 68 3506 19 ,, ,, ,, 1926 80 3477 23 ,, ,, ,, 1927 83 3174 26 „ „ ,, 1928 66 3374 20 ,, ,, ,, 1929 88 3399 26 ,, ,, ,, 1930 82 3514 23 ,, ,, ,, 1931 88 3400 26 ,, ,, ,, Among the 196 deaths, 115 occurred in boy babies and 81 in girls. 1,811 were males and 1,589 females. The infantile mortality rate for the two sexes was, therefore: Boys, 63 ; girls, 51. The rate of infant mortality amongst illegitimate children was 134 per 1,000. The rate in legitimate children was 54 per 1,000. The following table gives the causes of death during the first two months of life. I. Complications of Labour— Cerebral Haemorrhage 3 Trauma at Birth 2 5 II. Foetal States— Congenital Heart Malformation 7 Other Congenital Deformities 5 Icterus Neonatorum 1 Atelectasis 6 Congenital Debility and Marasmus 13 Purpura Hemorrhagica 1 Lympho-Sarcoma 1 Melsena 1 Syphilis 3 — 38 III. Prematurity 45 — 45 IV. Post-Natal Causes 20 — 20 108 184 The rate of infantile mortality for England and Wales in 1931 was G6, and for the 107 large towns 71. The late for Croydon is therefore considerably lower than the average rate. An analysis of Table XC1X. shows that of the total infant deaths, 14.3% occurred on the first day of life and 44.9% before the completion of the first month and it may reasonably be deducted that these deaths were due to causes operating before birth except in so far as accidents of birth (5) are concerned. It is interesting to note this percentage is very constant throughout England and Wales and does not vary to any great degree with variations in districts. 185 table XCIX. Deaths under one year, arranged in days, weeks and months. CAUSES OF DEATH. 1st day. 2nd day. 3rd day. 4th day. 5th day. 6th day. 7th day. l st-2nd wk. 2nd 3rd wk. 3rd-4th wk. Under 1 month. 1-2 mths. 2-3 mths. 3 4 mths. 4-5 mths. 5-6 mths. 6-7 mths. 7-8 mths. 8-9 mths. 9-10 mths. 10 11 roths. 11-12 mths. TOTAL. All Causes Certified 28 7 8 3 4 3 1 12 11 11 83 19 18 15 14 6 10 5 7 3 5 6 196 Uncertified ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Whooping Cough ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... 1 ... 1 1 ... ... 1 ... 6 Diphtheria and Croup ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tuberculous Meningitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Abdominal Tuberculosis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Other Tuberculous Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3 ... ... ... ... ... ... 3 Meningitis (not Tuberculous) ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 ... ... 1 ... ... 3 Convulsions ... ... 1 ... ... ... ... ... 1 ... 2 ... ... ... ... ... 2 ... ... 1 1 ... 6 Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Bronchitis ... ... ... ... ... ... ... 1 1 ... 2 ... 1 1 ... 1 ... ......... ... ... ... ... 5 Pneumonia (all forms) ... ... ... ... ... ... ... ... ... 1 1 ... 1 2 3 1 5 3 2 1 1 3 31 Diarrhœa and Enteritis ... ... ... ... ... ... ... ... ... 1 1 ... 4 1 2 ... ... ... 2 ... 1 1 12 Gastritis ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... ... ... ... ... ... 2 Svphilis ... ... ... ... ... ... ... ... ... ... 1 2 ... ... ... ... ... ... ... ... ... 1 4 Rickets ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Congenital Malformations 4 1 ... 1 1 ... ... ... 2 1 10 2 1 2 2 ... 1 ... ... ... ... 1 19 Premature Birth 18 4 7 2 2 2 ... 4 2 2 43 2 3 1 ... ... ... ... ... ... ... ... 49 Atrophy, Atelectasis, Debility, and Marasmus 4 ... ... ... 1 ... 1 3 4 2 15 4 4 6 3 ... ... ... ... ... 1 ... 33 Injury at birth 2 1 ... ... ... ... ... 2 ... ... 5 ... ... ... ... ... ... ... ... ... ... ... 5 Other causes ... 1 ... ... ... ... ... 2 1 3 7 1 3 1 1 1 ... 1 3 ... ... ... 18 186 Deaths Under One Month. An anlysis of Table XC1X. shows that 14.3% of the infant deaths occurred before the baby was 24 hours old ; 27.5% during the first week of life ; and 45% before the end of the first month. In 1930 the corresponding figures were 20%, 41%, and 48%. These figures relate to infant deaths due to causes probably operating before birth and do not vary greatly as between different localities in England. The chief individual cause was premature birth which was the assigned cause in 44% of deaths under 1 month of life. In the same group can be placed the second great cause, debility which was the factor in 17%. Injury at birth is rather different inasmuch as it is, by skilled ante-natal and natal attention, avoidable; injury caused 5.7% of the deaths. Deaths under one month due to congenital deformities constituted 11.4% of the whole during this age period. It is interesting to see that conditions probably brought on by faulty feeding played no part in this mortality. This group of deaths contributed 25.9 per 1,000 births towards the infantile mortality rate. Deaths Under Three Months. One hundred and twenty-five babies born died during the first three months of life, a percentage of the total infant deaths of 64%, and an infant mortality rate of 35 per 1,000 births. As the total infantile mortality rate was 58, it is seen that three-fifths of that rate was due to deaths in infants under 3 months of age. A perusal of the causes of death between the end of the period dealt with in the preceding section, and the third month shows an alteration in the chief causes of death; these were Debility (21.6%) and Pneumonia (24.3%). The effects of improper feeding, and exposure to infection, are commencing to make themselves felt, and from this age period onward to the end of the first year of life Pneumonia is the outstanding cause. The Pneumonia deaths occurred in the following months: January 6, February 6, March 4, April 1, May 2, June 1, August 1, October 1, November 3, December 6. Deaths between the 4th month and the end of the first year of life were.caused chiefly by Diarrhoea (9.9%) ; Pneumonia (29-6%' and Debility (14.1%). Taking the figures in the table as a whole, the outstanding features are.— (1) The predominance of premature birth, and conditions classified as debility and marasmus. Between them they accounted 187 [or nearly 42% of the total deaths, and contributed 24.1 per thousand births towards the infantile mortality rate. (2) Next to these come Pneumonia and Diarrhoea with 22% of the total deaths and a contribution of 12.6 per thousand to flie infantile mortality rate. (3) The influence of prenatal causes is exerted mainly during the first two months of life, whilst the influence of environment and nurture, after that time. The causes of death change after the second month in a quite distinct manner. (4) Whooping Cough caused 6 deaths. In 1930 it caused 2 deaths. It is a dangerous foe to infant life. There were no deaths from Measles. Scarlet Fever caused one death. In deaths of children under one year of age, the child who died was a first child in 26%; a second child in 19.9% ; a third child in 12.2% ; a fourth child in 7.1% ; a fifth child in 3.1% ; a sixth child in 2.0% ; a seventh child in 2.5% ; an eighth in 1.0% ; a ninth in 0.5% ; a tenth in 1.0%; an eleventh in 0.5%; and a thirteenth in 0.5%. In 23.5% no data were forthcoming owing to the parents having moved, or the child being a foster child, or for other various reasons. The following table gives the chief causes of infant deaths, as compared with 1930. Table C. Percentage Deaths per Total Infantile Deaths. Deaths per 1,000 Births. 1931. 1930. 1931. 1980. Premature Births 25.0 23.3 14.4 11.4 Respiratory Diseases 18.4 11.7 10.0 5.7 Infectious Diseases (inc. Tuberculosis) 4.6 4.7 2.6 2.3 Debility and Marasmus 16.8 11.1 9.7 5.4 Diseases of Digestion 7.1 15.2 4.1 7.4 Accidental & Congenital 12.2 14.6 7.0 7.4 188 1931 1930 1929 1928 Maternity and Child Welfare—Deaths of Infants under one year of age. Table CI. Births Deaths Mortality per 1000 Births General Birth Rate General Death Rate Mortality per 1000 Births General Birth Kate General Death Rate Mortality per 1000 Births General Birth Rate General Death Rate Mortality per 1000 Births General Birth Rate General Death Rate January 250 22 88 15.1 20.0 42 16.9 11.6 90 15.4 16 0 65 19.7 19.8 February 277 28 101 16.8 18.7 75 14.2 12.9 90 14.1 23.5 100 16.5 14.4 March 229 25 109 13 9 17.5 60 15.1 13.8 100 16 0 20.9 62 14.5 13.0 April 309 17 55 18.7 13 8 44 14.7 11.6 58 16.1 13.1 59 15.8 12.3 May 259 10 38 15.7 10.1 50 20.7 11.7 31 17.6 11.7 44 17.6 10.7 June 269 18 67 16.3 12.3 54 19.8 8.6 28 17.9 8.6 17 19 3 10.3 July 268 11 41 16.2 9.5 26 16 3 8.7 33 16.6 9.4 37 18.0 9.4 August 284 4 11 17.2 10.3 50 16.7 9.3 63 15.8 10.0 66 17.9 8.0 September 246 5 20 14.9 9.0 37 17.4 8.6 76 16.0 7.5 74 14.9 9.1 October 307 16 52 18.6 12.3 44 15.6 10.7 77 14.4 11.7 46 14.7 10.6 November 246 15 61 14.9 12.3 36 16.3 9.7 70 15.7 10.6 33 15.2 10.3 December 287 25 87 17.4 16.8 89 13.7 11.2 65 15.4 11.5 47 14.4 13.0 The Birth Rate was highest in April, October and December, and the infantile morality was lowest during August and September. The death rate was highest i n January, February and March. Infan tile morality was highest during January February, March and December. 189 Infantile Mortality in Wards from 1925 to 1931. Table CII. 1925 1926 1927 1928 1929 1930 1931 Average over 7 years. Upper Norwood 50 54 73 80 70 108 80 73 Norbury 45 58 27 37 20 48 39 39 West Thornton 28 29 34 94 63 29 g6 49 Bensham Manor 55 69 97 45 55 39 72 62 Thornton Heath 71 38 60 75 99 66 66 68 South Norwood 85 81 39 53 64 51 48 59 Woodside 22 50 57 42 59 40 37 44 East 23 22 32 25 63 40 30 33 Addiscombe 56 57 58 45 71 33 47 52 Whitehorse Manor 97 114 75 59 74 62 74 79 Broad Green 24 33 50 48 76 38 46 45 Central 65 93 29 58 42 51 91 61 Waddon 71 85 46 46 63 56 53 60 South 98 83 68 66 61 25 63 66 The wards with the highest average infant mortality over a seven year period are: Upper Norwood, Thornton Heath, Whitehorse Manor and South; the lowest averages are recorded in East, Norbury, Broad Green, West Thornton and Woodside. Any infant death occurring in an institution has been allocated to the Ward in which the infant lived prior to admission. Midwives Acts, 1902 and 1918. 91 midwives notified the Local Supervising Authority of their Mention to practise within the Borough during 1931, 5 of whom were in respect of periods of 2-3 weeks only; 4 cases removed out of the Borough, so that 82 remained on the Register at the end of the year. Of these 78 were trained and held the certificate of the Central Midwives Board, and 1 was a bona-fide midwive, i.e., were in practice as midwives at the time of the passing of the Midwives Act, 1902 while 3 held the certificate of the London Obstetrical Society 190 Confinements Attended by Midwives. Cases attended by midwives alone 1875 i.e., 55% of total births. Cases attended by midwives when a doctor was also engaged 558 Cases attended by midwives when a doctor was also summoned 345 Total 2778 i.e., 81.7% of total births. The number of confinements attended by midwives in 1931 was less than in 1930, when the cases attended by midwives alone constituted 61% of the total. The Rules of the Central Midwives Board lay down that the Local Supervising Authority must be informed, within 36 hours, by a midwife if she has summoned medical help during pregnancy, in a confinement or within ten days afterwards. The following table gives details of the reasons for sending for medical aid. The Council assists in the payment of the midwife's fees for attendance on a necessitous patient in her confinement. No attempt is made in. such cases to recover from the patient. The object of this is that even the poorest mother can engage the services of a competent midwife, whilst the latter will have no cause to hesitate to attend on the grounds that she will probably receive no payment for her services. Midwives are also compensated if they lose a case through its admission to a hospital or maternity home on the advice of the Ante-natal Clinic. The sum of £24 was paid out during the year. For Complications during Pregnancy : Oedema 2 Abortion 5 Albuminuria 9 Other causes 8 — 24 . For Complications during Labour : A.—Mai presentations— Breech 6 Transverse 2 Face 4 Occi pi to-Posterior 4 Extended Breech ... 5 Undiagnosed 2 23 B.—Obstructed Labour 5 5 C.—Delayed Labour— Uterine Inertia 11 Prolonged 23 Delayed 24 — 58 D.—Hœmorrhage Ante-partum 7 Post-partum 13 20 191 E.—Other Causes— Retained Membranes 2 Illness of Mother 2 Adherent Placenta 4 Prolapse of Cord 1 Retained Placenta 4 Twins 2 Torn Perineum 108 — 123 For Complications during Puerperium : Pyrexia 27 Pain in Breasts 3 Pain in Legs 1 Other causes 14 45 For Complications in regard to the Baby : Inflammation of Eyes 33 Premature Birth 4 Still Birth 2 Convulsions 1 Feebleness of Baby 11 Broncho-pneumonia 1 Haemorrhage 2 Other causes 1 55 In accordance with Rule 12a of the Central Midwives Board, the following reasons for the discontinuance of breast feeding were received:— Insufficient supply of milk . 4 Mother returning to business life 2 Baby adopted * 1 Total 7 Inspection of Mid wives. Dr. Falk is the inspector of midwives; she had 2 interviews with midwives at the Town Hall or at the Ante-natal Clinic and paid 177 visits to the homes of midwives. Of these visits 91 proved ineffective, the midwife being out. The cleanliness of the midwives homes and the condition of their bags were satisfactory, whilst the necessary case records and temperature charts were on the whole properly kept. One midwife was reprimanded for various minor lapses, and 3 were interviewed by the Medical Officer of Health. The revised rules of the Central Midwives Board for 1927 impose an obligation oh all certified midwives to take ante-natal records or in lieu thereof to send their cases to an ante-natal clinic, where the records may be made. Midwives have been urged to wail themselves of these facilities and if possible to attend themselves with their patient. When the midwife does not attend she is informed by letter of the findings at the Clinic. The midwives have availed themselves of the facilities offered, 288 mothers were sent for this purpose. Disinfection of Midwives Bags, Etc. This is done by the Local Supervising Authority, free of charge for any midwife asking for it. In 3 instances midwives availed themselves of these facilities. 192 Table CIII. Nursing Homes (Registration) Act, 1927. Maternity Homes. Other Nursing Homes. Combined Maternity and other Nursing Homes. Total. No. of Homes on Register, on 31/12/30 17 14 24 55 No. of Applications for Registration during 1931 5 1 1 7 No. of Homes registered during 1931 2 1 1 4 No. of Orders made : (a) Refusing Registration 3 — — 3 (b) Cancelling Registration 3 — 2 5 No. of Appeals against such Orders 1 — — 1 No. of Cases in which Orders have been : (a) Confirmed on Appeal — — — — (b) Disallowed 1 — — 1 No. of Applications for exemption from registration — 1 — 1 No. of Cases in which exemption has been : (a) Granted — 1 — 1 (b) Withdrawn — — — — (c) Refused — — — — No. of Homes on Register on 31/12/31 16 13 25 54 No. of Beds available 74 197 (a) Mat. beds 54 (a) 128 (A) Other Beds 90 (b) 287 Doctors' Accounts Under Section 15 (1) of the Midwives Act, 1918. 136 accounts were received from doctors for services rendered under the provisions of this section. This compares with 149 in 1930, 112 in 1929, and 131 in 1928. The total amount of the accounts was £224 5s. 6d., £81 18s. 6d. was ultimately recovered from the patients. In 1930 the amount paid to doctors was £270 6s. 3d., and in 1929, £149 8s, 193 The Maternity and Child Welfare Clinics. There are 16 Maternity and Child Welfare Centres, 15 of which are conducted by the Croydon Mothers' and Infants' Welfare Association, and 1 by the Local authority. A total of 19 sessions per week are held and at all of these a doctor and a nurse on the staff of the health department, attend. During 1931, 2,217 new cases under 1 year of age, and 895 over a year of age attended for the first time ; this is an increase of 69 in the first class and of 187 in the second class. The total attendances of babies and infants from 0-5 years increased from 62,299 in 1930 to 67,783 in 1931. Consultations with doctors increased in numbers from 21,697 to 23,068. Three hundred and ninety-eight expectant mothers were seen, a decrease of 133 on 1930, and a total of 1,436 visits to the centres were paid by them. The total of all visits to the Centres was 69,219, an increase of 5,268 over 1930. This is the greatest total yet reached and serves to indicate the appreciation of the services being rendered. The increase in the number of first attendances of infants over one year of age will be noticed. The highest average attendance of mother and babies at each session was recorded at Norbury (98.0), West Croydon (88.2), South Norwood (87.0), and Municipal (82.7). Such large numbers, although indicating an appreciation on the part of the mothers, throw a great strain on the organisation of the centres. It is impossible for the doctor to devote as much time as is desirable to individual cases, whilst the nurse cannot talk to each mother at the length which is sometimes needed. The only remedy is a multiplication either of the number of sessions at each clinic, or an increase in the number of clinics. The foundation of new centres has not, however, had any appreciable effect, in the past, on the attendances at older centres. At some of the centres, situated on the borders of the town, such as Norbury, Upper Norwood and Shirley, a certain proportion of mothers attend from outside the Borough. 194 Attendances at Infant Centres—1931. Municipal. T3oston Road Sylverdale Road South Croydon S-hirley. Woodside. Lr. Addiscombe Road. South Norwood Naseby Road. Moflatt Road. St. Alban's. St. Paul's. St. Oswald's. Union Road. Norbury. Waddon. Total 1931. Total 1930. Total 1929, Total 1928. Total 1927 Infants. Table CIV. New cases under 1 year 346 135 114 137 89 118 143 239 107 77 195 98 77 134 142 66 2217 2148 1991 1918 1712 No. of re-attendances 4484 1477 1525 1791 1265 1889 1773 3863 1378 1279 3601 1507 1644 2119 2395 1247 33237 31418 27431 27059 22211 New cases over 1 year 120 63 35 48 36 45 72 104 64 16 87 27 42 24 51 61 895 708 813 923 795 No. of re-attendances 3331 1775 1411 1686 880 1669 1672 4150 1894 1212 3136 1785 1331 1858 2252 1392 31434 28025 25559 24371 20544 Attendances of children 0-5 8281 3450 3085 3662 2270 3721 3660 8356 3443 2584 7019 3417 3094 4135 4840 2766 67783 62299 55794 54271 45262 Consultations with Doctor 2545 1175 1192 1304 860 1264 1091 2942 1219 1201 2702 1330 1021 1083 971 1168 23068 21697 21088 21243 17773 No. of Sessions 101 51 46 50 48 48 49 98 48 49 99 47 50 47 50 47 928 927 881 885 731 Expectant Mothers. No. of new cases 72 — 6 25 11 20 27 55 39 12 70 21 9 1 14 16 398 531 573 481 494 ,, re-attendances 101 21 7 112 26 1 73 117 150 105 162 53 34 10 44 22 1038 1121 881 1038 987 Total attendances of Expectant Mothers 173 21 13 137 37 21 100 172 189 117 232 74 43 11 58 38 1436 1652 1730 1519 1481 Total attendances 8354 3471 3098 3799 2307 3742 3760 8528 3632 2701 7250 3491 3137 4146 4898 2805 69219 63951 57524 55790 46743 Average attendance per Session 1931 82.7 68.0 673 76.0 48.0 78 0 76.7 87.0 75.7 55.1 73.2 74.3 62.7 88.2 98.0 59.7 74.6 1930 81.2 38.7 68.4 78.0 37.7 06.4 70.9 78.5 73.6 55.8 72.4 74.3 40.3 78.3 93.1 50.0 ... *69.0 1929 72.3 46.2 56.4 67.7 32.9 62.1 66 5 74.3 62.0 59.0 62.8 77.5 34.5 71.2 106.4 47.3 ... ... *65.3 1928 62.5 37.0 60.7 70.0 24.8 55.7 67.9 77.8 68.5 55 8 63.5 84.3 ... 66.3 93.6 38.7 ... ... ... *63.0 * Total average attendance each week at all tlie Centres. 195 Table CV. is intended to show the deaths of babies who at one time or another during their first year attended a clinic, as compared wth deaths among those who had never attended. If a baby only attended once it is included in the clinic returns:— Table CV. Deaths Attended M. & C. W centre Attended at Birth by Full Time Baby Births during the same period Deaths in Institutions Yes No Doctor Midwife Doctor & Midwife Not Known, etc. Yes No Not Known Mayday Road Sick Nursery Regd. Maternity Homes St. Mary's Hostel Other Institutions or Elewhere 153 14 109 21 81 29 22 98 52 3 3400 45 12 8 8 6 '2,217 babies under one year of age attended the clinics during 1931. Within the same period 3,400 babies were born and 19G died; 43 of these latter are not included in the above table as information concerning them was not obtainable. Although the clinic attendance figures and the births and deaths figures do not cover exactly the same periods, the attendances of new cases at the clinics do not fluctuate so greatly as to cause serious error. Of the 153 babies who died, 44 had attended a clinic in Croydon and 109 had not attended, i.e., 29% of the deaths were in clinic babies and "1% in non-clinic babies. Of the 3,400 babies bom approximately ('5% attended or would attend on calculation based on past attendances. The infantile motality, estimated on this basis is 20 per 1,000 births for the "clinic" babies, and 49 per 1,000 births for non-clinic babies. The following table is interesting, especially when the figures for under 1 year are contrasted with those for over 1 year. Approximately 85% of the former group of babies were found healthy on their first visit and were presumably brought because their mothers desired expert opinion and advice quite apart from treatment; in the latter group, however, only 73% were found healthy on the first visit, which may be interpreted to mean when a mother first attends a clinic with a child over a year old she does so because progress is not satisfactory; 67% of babies under 1 year were being breast fed at their first visit, this figure being more than 1930 (65), and 23.8% were on the bottle; 31.9% of the ailing babies were suffering from digestive troubles, 12.1% from respiratory trouble and 9.1% from rickets, 196 The individual centres showing the highest percentage of babies found healthy on their first visit were East Croydon and Woodside (both 98), a result ratter to be expected taking into consideration the district served; Municipal and Boston Road with 96 were next. The centres showing the highest percentage of babies found ailing on their first visit were Norbury and Central, followed by St. Alban's, Upper Norwood and All Saints. Breast feeding seemed most usual in babies living in the Waddon, St. Oswald's, Woodside and St. Paul's districts, and least usual in the Norbury and Shirley districts. In infants over one year of age, attending for the first time, the highest percentages healthy were shown by Municipal (98), East Croydon (95), and Waddon (93) ; the highest percentages found unhealthy were at Svlverdale (65), Norbury, St. Paul's and South Croydon (48), and St. Alban's (45). The largest number of first attendances was recorded at the Municipal Centre, followed by South Norwood. Both these centres hold two sessions weekly. Among the single session weekly centres, the largest number of first attendances was shown by East Croydon and Norbury. 197 The Conditions of Babies on First Attendance at a Maternity and Child Welfare Centre. Table CVI. Babies Under One Year. Infants Over One Year. No. found healthy on 1st visit. Percentage ... No. found ailing on 1st visit Digestive Troubles. Rickets. Respiratory Troubles Other Causes. Babies on Breast Feeding only. Percentage. Babies Bottle fed only. Babies partly breast and partly bottle fed. No. found healthy on 1st visit. Percentage. No. found ailing on 1st visit. Digestive Tuoubles. Rickets. Respiratory Troubles Other Causes. No. still on Breast at 1st visit. No. Weaned and on solid food. Percentage. No. not Weaned and on bottle entirely No. on solid food and the Breast. No. on solid food and the bottle. Total first attendances tabulated. Municipal (2) 334 96 12 2 1 1 8 229 66 86 31 108 98 12 1 2 4 5 2 118 98 0 0 2 466 St. Albans (2) 140 77 43 21 0 6 16 123 66 46 14 38 56 31 5 19 2 15 0 56 82 2 2 9 252 Boston Road 107 96 4 2 0 0 2 78 70 19 14 50 84 8 1 4 0 3 0 58 100 0 0 0 169 East Croydon 140 98 3 2 0 0 1 89 61 40 14 69 95 3 0 0 0 3 0 72 100 0 0 0 215 Norbury 78 71 32 16 0 3 13 61 55 23 26 32 51 30 0 7 4 19 0 57 92 0 0 5 172 St. Paul's 79 83 16 14 0 1 1 71 74 21 3 12 52 11 1 0 3 7 0 23 100 0 0 0 118 All Saints 61 79 16 8 0 0 8 55 71 16 6 10 62 6 I 3 1 1 0 10 62 1 0 5 93 Shirley 53 82 11 7 1 0 3 36 56 20 8 7 87 1 0 0 1 0 0 8 100 0 0 0 72 South Croydon 111 81 26 8 0 1 17 91 66 38 8 25 52 23 2 2 0 19 0 29 60 2 0 17 185 South Norwood(2) 189 80 32 25 0 7 0 149 67 60 12 58 69 26 3 1 10 12 0 83 99 0 0 1 305 Sylverdale Road 83 73 31 4 0 4 23 78 68 29 7 12 34 23 0 7 0 16 0 25 71 1 1 8 149 Upper Norwood 83 1 i 21 13 0 0 9 65 61 32 10 43 67 21 1 3 0 17 0 40 62 0 0 24 171 Waddon 63 95 3 1 0 0 2 54 81 7 5 57 93 4 0 1 1 2 0 61 100 0 0 0 127 West Croydon 90 84 17 12 0 1 4 69 64 28 10 25 81 6 1 2 2 1 0 27 87 0 2 2 138 Woodside 115 98 3 1 0 0 2 89 76 17 12 38 84 7 0 1 2 2 0 45 100 0 0 0 163 St. Oswald's 5S 84 11 6 0 2 3 53 77 10 6 32 78 9 1 2 3 3 0 33 80 0 0 8 110 Totals 1784 85 284 142 2 28 112 1390 67 492 186 616 73 •221 19 44 33 125 2 745 89 6 5 81 2905 198 Clinic Sessions Attended by Health Visitors. Table CVII. Nature of Clinic. Health Visitor—District Number, I. II. III. IV. v. VI. VII. VIII. IX x. XI, XII. XIII. XIV XV. XVI. XVII XVIII XIX. XX. Total. Maternity & Child Welfare Clinics 74 53 46 50 56 33 57 44 9 61 44 46 44 39 89 44 94 21 24 928 Ante-natal and Fost-natal Clinics 1 2 ... 41 33 ... 5 ... ... ... 62 ... ... 217 1 1 26 ... 8 1 398 199 Table CVIII. The Work of the Health Visitors.—Home Visiting.—Maternity and Child Welfare Only I. C.W. II. R.A. III. D.H. IV. B W. V. A.W.W. VI. J.T. VII M.S. VIII. U.G. IX. A.P. X. V.B. XI. A.W. XII. J.C. XIII. E.H. XIV. C.G. XV. A.H. XVI. a.C. XVII. K.T. XVIII. v.c. XIX. E. S- & M. T. XX. M.C, TOTAL VISITS Visits to Expectant Mothers. * † First visits 85 51 89 55 35 63 42 73 25 84 82 23 26 81 40 82 71 29 19 31 1086 Re-visits 57 25 59 16 6 28 29 84 3 59 21 27 37 28 20 55 8 8 7 20 597 Infants under 1 year. First visits 232 120 819 317 102 131 143 109 199 218 350 267 93 281 185 204 209 157 43 165 3744 Re-visits 468 211 687 140 261 205 297 429 365 346 466 563 523 227 644 910 231 461 174 422 8030 Children 1—2 years. First visits 14 3 11 60 3 6 1 1 98 9 22 1 3 5 36 126 11 4 13 427 Re-visits 469 218 519 177 197 301 243 425 187 246 399 399 363 292 394 850 165 404 225 416 6889 Children 2—5 years. First visits 7 1 ... 60 1 4 10 2 6 9 ... 17 ... ... 5 22 172 ... 2 8 326 Re-visits 1106 537 507 282 517 523 561 581 627 239 733 257 597 426 614 864 527 548 286 403 10735 Ophthalmia Neonatorum. First visits ... ... 1 ... ... ... ... ... ... ... ... ... 1 ... 3 ... ... ... ... ... 5 Revisits 5 1 6 1 ... ... ... ... ... 4 9 ... ... 1 2 ... ... ... ... ... 29 Still Births 8 5 7 20 3 1 5 4 9 15 8 17 2 7 5 8 8 2 6 4 144 Milk (Mothers' and Children's Order) 2 53 69 78 ... 11 1 4 13 9 3 1 6 10 6 9 12 6 3 ... 296 Puerperal Fever and Pyrexia Visits ... ... ... ... ... ... ... ... 4 ... ... ... ... ... ... ... ... ... ... ... 4 Houses where deaths of Infants occurred 20 14 15 13 5 1 5 7 12 12 20 4 11 30 10 7 7 4 5 9 211 Miscellaneous Visits 36 9 12 324 49 43 113 21 29 51 40 28 34 40 57 32 65 38 105 12 1138 Inefiective Visits 678 240 338 257 436 401 557 253 483 430 306 384 480 398 360 416 175 572 390 81 7636 Totals—1931 3188 1488 2539 1800 L615 1718 2007 1993 2060 1731 2437 2009 2174 1824 2350 3495 1776 2240 1269 1572 41297 1930 2958 1665 2321 1343 L797 1646 1465 1356 1320 1210 2462 1652 3055 1825 1251 1954 447 738 ... ... 32449 *Appointed during 1931. †On Staff' for short period only. 200 Milk (Mothers and Children) Order. The table below gives the number of families who were in receipt of assistance under the provisions of the above-named order during the year. A revision was made during the year in the previous arrangement whereby the Voluntary Association stood the cost of dried milk distributed at the Voluntary Centres below cost price. The Borough Council now pay for all dried milks sold below cost price or given free whether it is ordered at the Voluntary Centres or at the Municipal Centre. AIL wet milk ordered under cost price is paid for by the Council. On Tan. 1st, 1931. New cases during the year. Cases discontinued. On Dec. 31st, 1931. Free 101 333 209 225 Half-price 67 118 90 9,i Total 168 451 299 320 In cases where there has been a change from free milk to milk at half price it lias been counted as a new case. Assisted Milk Scheme. There has been a notable increase in the amount of milk granted. The number of mothers assisted has risen from 349 to 619, and the amount of milk from 42,630 pints to 80,737 pints. The increase in unemployment is probably responsible for this. Supplied to Families. No. of Pints. Corporation Liability. Milk at l½d. pt. 30049 £ s. d 208 11 11½ Milk Free 50688 672 14 3½ 80737 881 6 3½ Total Number of Families assisted — In receipt on Jan. 1st, 1931 168 New Cases 451 619 Average number of pints supplied weekly 1553 This is an increase of 733 pints supplied over the figures for 1930. 201 I am indebted to Mrs. Chambers, who is in charge of the foods department of the Voluntary Association, for the figures relating to dried milk sold or given, at all the centres with the exception of the Municipal Centre. There is a noticeable increase over 1930 under all three headings, the increase beiDg greatest in the amount of free milk. The increase is also shown in the figures for the Municipal Centre. Table CIX. Dried Milks for Year Ending 1931. Mothers and Infants Welfare Association. (17 sessions per week). Municipal Centre. (2 sessions per week). Free. Halfprice. Full price. Free. Halfprice Full price. January 252 137 1140 23 33 222 February 205 119 1016 22 21 242 March 236 150 1145 39 19 250 April 181 104 1007 28 21 255 May 273 126 1031 27 24 227 June 230 118 1097 34 30 300 July 280 126 1168 44 31 214 August 252 112 968 52 21 274 September 260 100 981 55 11 274 October 334 101 994 57 25 297 November 282 89 1011 47 45 328 December 330 93 1016 53 30 264 Totals 3121 1381 12574 431 311 3177 Sick Nursery, Lodge Road. This institution is for the reception of sick babies and young children up to the age of 5 years. The majority of the admittances are for the correction of dietetic errors, the re-establishment of breast feeding and for weaning. There are 14 cots for babies and 2 beds for nursing mothers. Cases for admission are referred from the infant welfare centres in the majority, but on occasion babies are admitted at the request of the private medical attendant. The parents are expected to contribute towards the expenses of maintenance according to their means; assessment is made on a scale of income. The Hanovia mercury vapour lamp, the gift in 1927 of Mrs. Lewis and the mothers and helpers at the South Croydon Infant Welfare Centre, has been in constant use during the year. Seventy babies and 1 mother were admitted, as compared with 82 babies and 8 mothers in 1930. The average length of stay was 31 days as compared with 48 in 1930. 202 The following table gives particulars:— No. of cases in on 1st January, 1931 14 No. of cases admitted during 1931 70 Average duration of stay 31 days No. of cases discharged 57 (a) In good health 36 (b) Improved 18 (c) No improvement 3 No. of cases who died 15 No. of cases in at end of 1931 12 The chief reasons for the admission of cases were as follows:— Alimentary disorders 9 Marasmus 8 Failure to thrive 32 Rickets 6 Re-establishment of breast feeding 1 Weaning troubles 1 Prematurity 1 Mismanagement 5 Other reasons 7 Total 70 The causes of the deaths were:— Marasmus 8 Heart failure and Bronchial Catarrh 1 Pneumonia 1 Acute dilation of stomach 1 Cellulitis of Scalp 1 Endocarditis 1 Spina Bifida 1 Gastritis 1 Five cases were discharged to other hospitals on account 0f illness outside the scope of the nursery. The diagnosis and destinations of these cases were: one case oT congenital pyloric stenosis and one case of anaemia to Great Ormond Street Hospital; 1 pathological vomiting, 1 pyloric stenosis, 1 feeding difficulty to Mayday Hospital. Four cases were discharged on account of infectious disease and 3 went to the Borough Hospital, all with whooping-cough. This small institution is doing valuable work, its usefulness is becoming more widely known and its results are encouraging in the repeatedly expressed thanks of the parents. Massage Clinic. The massage clinic in connection with the M. and C.W. Scheme is held at Lodge Boad on five afternoons a week. Cases are referred thereto by the doctors at the Infant Welfare Centres. A few cases are also referred from the Orthopaedic Clinic. The following Table summarises the work done, and indicates the tvpe of case referred. Total number of female patients 41 ,, ,, ,, male patients 59 Total 100 203 Table CX. Conditions for which referred. Males. Females. Total. Scoliosis 1 ... 1 General myopathy 1 ... 1 Infantile Paralysis 2 1 3 Weak legs 15 22 37 Bow legs 22 11 33 Knock-knees 12 3 15 Flat-feet Hemiplegia 2 1 3 Inco-ordination ... 1 1 Constipation 1 1 2 Muscular Dystrophy 1 1 Spastic Paraplegia ... 1 1 Erb's paralysis 1 ... 1 Talipes (equino varus) 1 ... 1 Totals 59 41 100 Total number of sessions 251 ,, ,, ,, attendances 1,680 Average attendance per session 7 Cases still under treatment at end of 1931 30 204 Dental Treatment of Maternity and Child Welfare Patients, 1931. I am indebted to Mr. J. F. Pilbeam, L.D.S., the senior dental surgeon, for the particulars which follow. Expectant and Nursing Mothers and Young Children. Table CXI. Expectant. Nursing. Young Children. Total. 1931. 1930. Number Examined 223 234 312 769 980 Referred for Treatment 219 217 257 693 784 Treated 186 182 237 605 649 Attendances 372 585 467 1424 123 Fillings 50 63 210 323 338 Extractions 453 584 336 1373 1271 " Gas " Cases 74 89 95 258 287 Local Anaesthesia 50 53 20 123 143 Scalings 21 33 — 54 42 Dressings and Denture Dress 202 224 18 444 440 AgNo — — 59 59 — 1931. 1930. Sessions at Centres 14 25 Sessions Treatment 125 93 Dentures Supplied 75 85 During the year, more expectant mothers were treated than in 1930. There is a slight decrease in the number of fillings, and extractions show an increase. This is unfortunately due to the fact that mothers attending the centres generally have such bad teeth that conservative treatment is impossible in a large proportion of cases. Pyorrhoea is very prevalent amongst mothers, and in many cases is too far advanced to benefit by local treatment. The reduction in the number of toddlers examined is because all the centres were not visited during the year. Owing to the 205 interregnum with subsequent temporary reduction of staff for several months it was not possible to visit all the centres. Without these inspections, mothers will not bring their young children for treatment until the child suffers from toothache, and it is then too late for conservative treatment. The inspections at centres are of great value, as they provide an opportunity for the dental surgeon to give individual advice to mothers regarding dental matters This is the right type of propaganda. A little talk to the mother helps tremendously in making her "tooth minded" and to understand the importance of oral hygiene for herself and child. Leaflets are given to the mothers on the care of the teeth and prevention of decay. It is interesting to note that mothers have expressed appreciation of the information given in these leaflets. Toddlers are now given rusks at the centre, which are much better than biscuits. The dry rusks stimulates the flow of saliva which is a great help in promoting oral hygiene. Table CXII. Month of pregnancy at which first examined :—2 3 4 5 6 7 8 % of cases seen 1928 13.8 17.3 18.0 19.4 15.9 6.9 8.7 % „ „ 1929 10.2 14.1 17.3 16.5 18.8 9.4 13.3 % „ „ 1930 3.4 15.1 18.6 17.9 17.5 15.1 12.4 % „ „ 1931 2.0 9.5 15.0 17.2 20.5 20.3 15.5 The teeth of the unborn child start to develop at the fourth month of pregnancy and mothers should be treated as early as possible so that full benefit of the treatment is received before the birth of the child. Unfortunately, sometimes mothers do not report to the centres till late in pregnancy. Mothers do not always realise the importance of a correct diet in producing strong teeth and bones. The future health of the child may be affected considerably through failure of the mother to taka sufficient quantities of tooth and bone building foods. Nursing Mothers. Age of baby when mother was first seen:— Under 1 mth. 1-3 mths. 4-6 mths. 7-9 mths. Over 9 mths. % Mothers Seen 1928 5.7 49.4 30.4 10.4 4.1 % „ „ 1928 5.1 31.3 57.9 19.0 6.7 % „ „ 1930 3.6 34.5 34.5 23.2 4.2 % „ „1931 7.7 28.7 35.7 20.0 7.9 Expectant Mothers. 206 The centres at which patients were examined or which they were referred from are given in the following list:— Ante-natal 147 St. Oswald's 6 Addiscombe 6 Thornton Heath (1) 28 Municipal 98 Thornton Heath (2) 48 East (Shirley) 6 Waddon (1) 19 Norbury 31 Waddon (2) 23 Upper Norwood (1) 21 Whitehorse 13 Upper Norwood (2) 26 West Thornton (Boston Road) 24 South Croydon 31 Woodside 28 The Retreat 7 South Norwood 72 Milton House 2 The sum of £41 5s. fid. was received in payment for the attendances made by mothers and children at Lodge Road and Selhnrst Road clinics. Table CXIII. Year. Population. Births. Deaths under 1 year. % of total Deaths Deaths 1—5 years. % of Total Deaths. Deaths over 5 years. % of Total Dealhs. Total Deaths 1924 196000 3456 195 8.6 77 3 4 2008 88.0 3280 1925 199300 3406 187 8.6 80 3.7 1902 87.7 2169 1926 205900 3477 211 9.3 81 3.6 1977 87.1 2269 1927 211700 3174 178 7.2 84 3.4 2182 89.4 2452 1928 214800 3374 178 7.6 96 3.9 2083 88.5 2354 1929 216900 3399 221 7.9 87 3.1 2484 89.0 2792 1930 222300 3514 171 7.3 48 2 0 2118 90.6 2337 1931 233800 3400 196 7.3 63 2.4 2415 90.3 2674 As the result of the medical inspection of the entrant group of school children it is found that a considerable number of children develop maladies between the time of cessation of attendance at Welfare Centres and the time of entering school. Enlarged tonsils and adenoids, and chronic ear discharge are among the commonest ailments discovered. A considerable proportion of the notifiable diseases attack children between these ages. Table II (Vital Statistics Section) emphasises still more the necessity for careful supervision during this period of life. Eight of the deaths from whooping cough occurred in children under 5 years of age. 207 The Babies' Help Committee of the Croydon Mothers and Infants' Welfare Association, I am indebted to Mrs. W. Philpot for the particulars presented herewith. At the beginning of the year the Committee had 8 cases on the books; 16 cases were helped during 1931; 7 remained on the books on the 31st December. One baby was born with deformed feet, was very delicate and died after a few months ; one delicate mother and baby were sent to a cottage home for convalescence. All other babies made good progress. One mother married. The help given varied according to the need and was given at the Welfare Centres through the Health Visitors. Convalescence Committee of the Croydon Mothers' and Infants' Welfare Association. This Committee undertakes the arrangements for convalescence in cases of mothers and children referred for that purpose by the med'cal officers at the various Infant Welfare Clinics. I am indebted to the Convalescence Secretary, for the data given. Children sent away with their mothers to Cottages or Homes 109 Children sent away alone to Convalescent Homes— (a) to Coombe Cliff 38 (b) to Other Homes 14 — 52 A grant of £350 was made by the Council to the Association for this work in 1931. I am indebted to Mrs. W. Horn for the follwing particulars of the cost entailed by the Association. The year is the financial year. Children under 5 sent to Homes. Total No. of weeks Cost. Cost of other forms of convalescence. £ S. d. £ s. d. 1928—1929 18 86 107 10 0 261 10 7 1929—1930 15 68 80 0 0 99 12 p. 1930—1931 31 217 201 7 6 173 o o 1931 (Apr. 1st to Dec. 31st) 86 258 215 5 0 314 5 0 208 COOMBE CLIFF CONVALESCENT HOME. This home has carried out a useful function during the year and has enabled a number of children to be returned to school much sooner than they would have been otherwise. The following is a summary of the cases dealt with. Cases under 5 years of age were sent by the Croydon Mothers' and infants' Welfare Association who contributed 15s. weekly towards their maintenance. No. of cases admitted since establishment: 183. No. of cases discharged: 157. No. of patient days: 51.6 per patient. Table CXIV. Age groups of cases admitted:— 0—1 5—8 9—12 Over 12 Total Male 21 41 17 1 80 Female 24 36 40 3 103 Total 45 77 57 4 183 0—4 5—8 9—12 Male 41.6 53.2 75.7 Female ... 32.5 54.7 55.6 Total 36.7 54. 60.3 Condition on Discharge:— 0-^t 5—8 9- -12 Over 12 Total M. F. M. F. M. F. M. F- M. F. Improved 6 4 6 11 7 8 1 19 24 Much Improved 7 10 21 12 4 26 1 2 33 50 No change 5 2 — 3 — 1 — — 5 b Discharged at parent's request 4 7 5 1 3 — 8 1L Total 18 20 34 31 12 38 1 3 65 92 209 Conditions for which admitted:— 0—4 5—8 9—12 Over 12 Total M. F. M. F. M. F. M. F. M. F. Debility and Malnutrition 7 14 21 15 10 21 1 2 39 52 Heart Disease — — 4 6 4 11 — — 8 17 Diseases of Respiratory System 2 1 4 4 — 2 — — 6 7 Rickets 5 1 5 1 Recuperation from previous illness 2 3 6 6 2 2 — — 10 11 Other conditions 5 5 6 4 1 5 — 1 12 15 Croydon Rescue and Preventive Association. This Association has a home at 34, Morland Road. As the Council now make a yearly financial grant towards its conduction, it is open to periodical inspection by the Council's officers. Prospective mothers from this home attend the Municipal Ante-natal Clinic at Lodge Road. I am indebted to the Superintendent, Miss Hammick, for the subjoined particulars. Number of beds in home, 12. Six beds are reserved for mothers and babies and 4 are reserved for expectant mothers. Total number of cases admitted in 1931, (a) Expectant mothers 24 (b) Mothers and babies 22 Wilford Road, Lighthouse Mission Oeche. The Council give an annual grant of £100 towards the cost of this Creche. An average of 28 children per day have been received and there has been no outbreak of infectious illness. CHILDREN ACT, 1908—PART I. since April 1st, 1930, this Act has been administered by the Health Department. The work has been delegated to the Health, Visitors who are made responsible to the Medical Officer of Health for all foster children and foster mothers in their respective districts. 210 The tables below give figures for 1931. Table CXV. FOSTER CHILDREN. No. as at Dec, 31st, 1930 Notice of Reception of Chidren during the year Notice of Removal 0— Children Adopted Died Children reaching age of 7 No. as at December 3lst, 1931 Parent Another area with Foster Parent Another Foster Mother Public Institution 189 237 100 — 61 19 19 4 18 205 Table CXVI. FOSTER MOTHERS. No. as at Dec. 31st, 1930 Applications for Registration during the year Removals during he year Registration cancelled for other reasons No. as at December 31 st, 1931 With Child Without Child 157 58 1 4 3 207 Blind Persons Act, 1920. Under Section 102 (1) of the Local Government Act, 1929, the Minister of Health was required to make a scheme providing lor payments of contributions of such amounts as might be specified in the scheme to any voluntary association which provided services for the welfare of the blind, by the Councils of Counties and County Boroughs in which are resident blind persons for whose benefit the services are provided. The scheme, which came into force on April 1st, 1930. bas continued during 1931; the sums paid by the Council are based od the (i) Exchequer grants paid for National services to the blind in respect of the standard year and which are now discontinued (ii) the amounts of contributions made by the Council to such associations in the standard year and (iii) upon the developments or alterations of the work which may have been made since the standard year. Under this scheme the Council pays grants to twelve societies, among which by far the largest grant is made to the Croydon Voluntary Association for the Blind. The visitation of home teachers, employees of workshops, home workers and inmates of homes subject to gr.irt are now Carriedout by the Medical Officer of Health who reports from time to time to the Blind Persons Act Committee. 211 Close co-operation has been maintained with the Croydon Voluntary Association for the Blind. The Blind persons residing in Croydon are now visited at regular and frequent intervals by the Health Visitors and any circumstances in their reports justifying further investigation, are followed up by the Deputy Medical Officer of Health. Mr. J. S. Bookless, the honorary oculist to the Association, who is also the part-time specialist for the School Medical Service, is also acting as medical referee for the Corporation. I am indebted to the Secretary of the Voluntary Association for the figures below. Number of blind on Register 310 Number of blind who benefit from instruction in Braille or Moon Type (including those who already read) 60 Number of blind who benefit from part-time instruction 12 Number in remunerative handicrafts— (a) Home workers 25 (b) In workshops 4 Home Teacher 1 The Health Visitors paid 187 vistis to blind persons during the year. The Medical Officer also paid home visits to blind persons during the year. During the year a new hall, named Bedford Hall, was erected for the use of the Blind by voluntary subscriptions. In this fine building are incorporated workshops for various crafts including basket making, brush making and mat weaving. The Hall was opened on October 21st by Sir Keith Prowse. 212 SECTION IX.—MENTAL DEFICIENCY. The stall of the department dealing with the mentally defective consists of the Medical Officer of Health and the Deputy Medical Officer, who are certifying officers ; one whole-time visitor; the teacher at the Occupation Centre, with three helpers. In April, 1929, the Council established a small home at 6, Morland Road, for the reception of 20 low grade mentally deficent boys under the age of 16 years. There are two main administrative groups of mentally defectives, viz.:— (а) The Statutory Cases, who consist of certified mental defectives under 7 and over 16 years of age: ineducable mentally defective children between the ages of 7 and 16 years; and children referred to the Local Control Authority under the Mental Deficiency Act, 1913, as being incapable of further education at a Special School or of being incapable of such education without detriment to other children. (б) Education Cases, who consist of mentally defective children between the age of 7 and 16 who are capable of instruction in a Special School. The former group are dealt with by the Mental Deficiency Committee, and the latter by the Education Committee. The largest number of notifications of children suspected to be suffering from mental defects are received from School Teachers and the School Attendance Officers. Sources of information regarding cases not coming within the category of school children are mainly the Infant Welfare Centres, Health Visitors, and Probation Officers. Table CXVII. Number of known Mentally Defective Persons in the Borough— I. Statutory Cases — 1930. 1931. Aged 0—5 years 7 6 „ 5—16 „ 63 73 Over 16 years 322 350 Total 392 429 213 II. Education Cases— Aged 7—16 years 119 135 Combined Total 511 564 Compared with 1930, the Statutory cases show an increase of 37 and the Education cases an increase of 16. The Statutory cases are distributed as follows:— 1930. 1931. In Certified Institutions 124 120 In Places of Safety or Approved Home 3 6 On Leave from Institutions 4 11 Under Statutory Supervision at Home 213 218 Under Guardianship and 1 on Leave 36 37 In Mental Hospitals 12 12 Cases Under Public Assistance - 25 An unsatisfactory feature of the above figures is the large number of cases under statutory supervision and the number having to be placed under guardianship, brought about by the great difficulty in obtaining institutional accommodation. This is made more acute each year as more and more institutions which formerly took in a limited number of cases from outside authorities, are reserving all their accommodation for their own cases. The task of supervising the guardianship cases adequately is becoming more and more difficult owinff to their increase. The Education cases were distributed as follows:— 1930. 1931. In Certified Residential Schools 6 9 In Certified Day Schools 81 101 At Private Schools 6 12 At Council Schools 14 - At no school, resident at home 11 13 In other Institutions 1 - In connection with mentally deficient cases, the Medical Officers made examinations and paid visits to the number of 112 for Statutory cases and 188 for Education cases, a total of 310. The mental deficiency visitor paid 1,646 visits to Statutory cases and 72-5 to Education cases, a total of 2,371. 214 During the year 48 names have been added to the Statutory list, 11 being new cases; 12 were referred on from the Education Authority—6 as ineducable or no further educable, 6 for supervision on leaving the Special School on attaining the age of 16; and 25 taken over from under the Local Government Act, 1929. Three boys and 2 girls died during the year; three of these deaths occurred in institutions and two in their own homes. Six left the Borough. Four cases chargeable to other Local Authorities are uuder supervision in the Borough There are 4 children under observation, ages from 1|- to 6 years. Twenty-two Statutory cases were dealt with as follows:— Sent to Certified Institutions 5 Placed under Guardianship 4 Sent to Places of Safety 5 Allowed home on long leave 8 Discharged from Order Returned to Institutions Transferred from one Institution to another - 22 The number of cases sent to certified institutions shows a decrease of 8. The difficulty of obtaining places is the explanation of the fall in this figure. Guardianship Cases. There are 36 cases under Statutory guardianship and 1 on leave ; 24 of these are under the care of relatives, and 12 are with guardians who are not relations. Six males andi three females are at. work. Nine cases are out of the Borough: seven under the Brighton Guardianship Society, one with a guardian in Essex, and another in Maidstone. Five boys and four girls attend the Occupation Centre at Grangewood. Cases on Leave from Institution. Six boys are on leave, and of these 2 are in regular employment. Five girls on leave—3 in regular work. 215 St. Christopher's Special School. The Special School at Grangewood is the first pivot around which work amongst mentally defective children revolves. All certifiable children with the exception of the ineducable are drafted there. Their progress at St. Christopher's is closely watched and yearly reports from the scholastic, the physical, and the mental aspects are made. Tims when they reach the age of 16 these children are well known to those whose duty it is to supervise them. Under the Mental Deficiency Act children by virtue of inherent incapability of social adaptation, perhaps aggravated by faulty home environment, may be referred for admission to an Institution or placed under Guardianship. Those who may with safety be so dealt with are put under no restriction except the supervision of the Mental Deficiency Authority which helps in placing such children in suitable occupations and from time to time advises the parents in their difficulties. Mr. Edmunds, the Head Teacher of the School, shows much initiative in his work for the children with very satisfactory results, and I am indebted to him for the account of the work of the School liere given. "1931 has been a very successful year at St. Christopher's Special School. 15 children have left the School while there have been 36 admissions. It is safe to say, that of these new scholars, every one has made some progress, not only in accomplishments, but what is of still greater importance, in an improvement of outlook. The children begin to have confidence in themselves, and to feel that at last they can do something. Usually, the mornings are devoted to the study of the "three R's," with Drawing, Singing, Scripture, including Hymns and General Information. It would surprise many to see what these children can do in Physical Exercises and Games, while the Country and Morris Dancing by the Senior Girls is extremely creditable, and in no way inferior to that of normal children in other schools. The afternoons are given over to less exacting Handwork, such as Sewing, Knitting, Rug-making, Stool-seating and Woodwork, while 12 senior girls receive a day's instruction weekly at the West Thornton Homecraft Centre. This class is extremely popular with the girls, and there is always a waiting list of applicants for vacancies. 216 Perhaps it would not be amiss to mention here the very excellent mid-day meals provided by the Education Committee. Much of the success of the School is due to these meals—the effect on the children's physique is in all cases immediate and most marked. On July 4th, 1931, 40 of the poorest children were taken by charabanc by the Statf to Littlehampton where they spent a glorious day. Many had never seen the sea before, and it is hoped to repeat the excursion in 1932." The Headmaster, Mr. H. J. Edmonds, would be pleased at any time to show visitors over the School, and to explain what is being done in Croydon for the educable mentally deficient child. The number on the School Register on December 31st, 1931, was 101. Town Hall Clinic for Mentally Defective and Backward Children. 103 children were examined during 1931. The classifications arrived at, together with the recommendations made, are sum- asised as under.— I. (a) Certified as Mentally Defective 44 (b) Confirmed as Mentally Defective 8 52 Recommendations— (a) Recommended for Special Day School 40 (b) Recommended for Residential Schools 2 (c) Referred to Occupation Centre 3 (d) Supervision at home pro tem. 2 (e) Examinations re Residential Schools or Pensions Certificates 5 - 52 II. Found to be dull and backward 27 (а) Referred to a Special Class 20 (б) To have treatment at Clinics and re-examination ... 3 (c) Further trial in ordinary class 4 III. Found to be Physically Defective 3 (a) Recommended for Residential School for the Deaf 1 (b) Referred to Hospital 1 (c) Recommended for Day School for Partially Blind Children 1 _ 3 IV. Considered to be of normal intelligence and referred to ordinary school 12 V. Referred for re-examination 9 VI. Mental and physical examinations at St. Christopher's School 128 217 Grangewood Uccupation Centre. The Occupaion Centre is under the control of the Mental Deficiency Committee, and deals only with cases ineducable in a Special School. Miss Stupart, the organiser, has continued during the year the new features introduced in 1929 with gratifying results. The Sale of Work done by the pupils of the Centre revealed an encouraging standard of attainment considering the handicaps under which these unfortunate children labour. The Centre is open for five days a week from 9.30 a.m. to 3.30 p.m. and occupies rooms on the ground floor of Grangewood Museum, the special school occupying the floor above. Younger children attend daily mornings and afternoons (10 sessions) and the senior gills on Monday, Wednesday and Friday afternoons from 2 to 3.30 (3 sessions). Senior boys on Tuesday and Thursday from 2 to 3.30. The premises are not very suitable. The staff consists of a supervisor and three assistants. The subjects taught to the younger children are, rythmic movement, drill baud, rhythmic singing games, singing, sense training memory, colour, sound, numbers, elements of stitching and rug making. As handicrafts are taught cork bead mat making, paper winding, mats, raffia weaving, knitting, ravelling, wool sorting. In addition balancing exercises, team games, country dancing are indulged in. The senior girls have instruction in hemstitching, English embroidery, wool embroidery, knitting of babies' woollies, vests, socks, making of plain frocks for children, overalls, plain sewing of pillow slips, tea cloths. As handicraft work, papier mache bowls, sea grass stools baskets, simple pewer work, are made. Country dancing, drill and singing are also taught. Hie senior boys learn basket making, making wool rugs, sea grass stools, raffia a.nd cane work, papier mache bowls. All grades have domestic duty in preparing meals, washing up, polishing, etc. The Christmas Party was held as usual, tea being provided together with presents off the Christmas tree for 40 children. Three open days for parents were also held open nays tor parents were also neld. Eleven stndents attended at various times to learn the work. Details. Fll Time. Part Time. No. on register January 1st, 1931 35 12 No. of pupils who left during year 6 2 No. of pupils admitted during year 10 2 No. of pupils on register January 1st, 1932 38 14 Total attendances 5210 1061 Average morning attendance 25 (whole-time class) Average afternoon attendance senior girls' class . 6.0 " " " boys' " 4.0 Sessions held 213 218 DENTAL TREATMENT. Occupation Centre. Adults. Total 1931. 1930. Number Examined 24 2 26 18 Referred Treatment 17 2 19 14 Treated 13 2 15 10 Fillings — — — 3 Extractions 48 17 65 34 Scalings 1 — 1 — Gum Treatment — — — — " £as " Cases 9 2 11 17 Attendances 19 7 26 14 There is a considerable increase in the number of extractions, but this is partly due to the fact that extensive conservative treatment for these patients is out of the question. The majority of these cases have swollen and spongy gums, but unfortunately this condition will not respond very well to treatment as the month breathing habit which is the cause of the congested gingivae, is difficult to correct in this type of patient. The Supervisor has arranged for the brushing of teeth after the mid-day meal. This helps considerably not only in preventing a certain amount of decay, but also in impressing on the minds of these people the habit of oral cleanliness. AT 6, MORLAND ROAD. Mental Deficiency Patients. 1931. 1930. Number Examined 17 — Referred Treatment 13 — Treated 13 6 Fillings 2 — Extractions 36 5 " Gas " Cases 8 2 Scalings 8 — Gum Treatment 8 4 Attendances 25 — All the inmates were examined several times during the year, and those referred for treatment were brought by the ambulance to the Lodge Boaid Clinic. This, arrangement greatly facilitated the work as it avoided taking the necessary equipment from Lodge Road. Many patients showed signs of varying degrees of gingivitis, and one case of hypertrophic gingivitis was observed. Considering these patients are mostly mouth breathers such a condition is to be expected. Matron and the staff have helped considerably in teaching these children tl.e elementary principles of oral hygiene, and with the aid of detergent foods, the condition of the teeth on the whole remains comparatively good. 219 SECTION X. ORTHOPAEDIC DEPARTMENT. Cases relerred for Orthopaedic treatment from the Tuberculosis and other branches of the Public Health Department's work, are seen and treated by Mr. A. Todd at the Croydon General Hospital every Thursday. The arrangement is based financially on payment to the Hospital, per attendance. The cases are referred to the Mayday Hospital, and various well-known Orthopaedic institutions for in-patient treatment. In addition to the Clinic at the General Hospital, concerning which the tables below relate to only, there are remedial exercises clinics conducted under the School Medical Scheme (referred to in the school report ) and a massage clinic for children under five years, referred bv medical officers at the Welfare Centres. Table CXVIII. Summary of Cases Attending the Orthopcedic Clinic. Jnn.lst, 1931. New Cases. 1931. Cases Discharged, 1931. Cases on books, Dec. 31st, 1931. M.C.w. S.M.s. Tuberc. m.c.w. S.m.S Tuberc M.C.W S.M.S. Tuberc. M.C.W. S.M.S. Tuberc. 109 388 42 140 191 31 103 226 14 146 253 59 439 362 343 458 The Clinic continues to expand steadily. On January 1st, 1998, there were '2'29 cases on the books, by January 1st, 1930, this figurehad risen to 387 ; on January 1st, 1931, the figure was 439, and on January 1st, 1932, 458 ; 343 cases were discharged as compared with 287 in 1930, and there were 362 new cases compared with 339 in the latter year. The primary aim of the Orthopaedic Scheme is preventive. Many physical defects are easily remedied if taken early and treated skilfully. Unfortunately much of the work is still largely compensatory and ameliorative. This is due to parents and others not appreciating tfce true significance of an apparently minor deviation from the normal mechanical efficiency. Cases of bone, joint and abdominal Tuberculosis in childhood are steadily declining and the number of new cases attributed to Tuberculosis declined from -51 in 1929 to 42 in 1930, and 31 in 1931. 220 They would, in all probability, decline more rapidly if any milk found to contain Tubercle Bacilli could be condemned as unfit for human consumption. Table CXIX. Cases seen by the Orthopcedic Surgeon. Defect. School. M.C.W. Tuberculosis. Total. Cases. Visits paid. Cases. Visits paid. Cases. Visits paid. Cases. Visits paid. Infantile Paralysis 34 118 1 2 ... ... 35 120 Scoliosis 83 165 4 5 ... ... 87 170 Pes Cavus 7 14 1 1 ... ... 6 15 Pes Planus 118 201 39 79 ... ... 157 260 Talipes* 38 61 43 101 ... ... 81 162 Genu Valgum 51 73 62 170 ... ... 113 213 Obstetrical Paralysis 20 39 2 5 ... ... 22 44 ... ... ... ... 32 A 69 A 73 153 Tubercular Joint Disease 35 S 78 S 6 M 6 M Injuries 4-2 116 9 18 ... ... 51 134 Rickets 8 10 54 116 ... ... 62 126 Wry Neck 6 12 5 4 ... ... 11 16 Spastic Paraplegia 10 24 4 10 ... ... 14 34 Other Deformities 62 157 25 32 ... ... 87 189 479 990 249 543 73 153 801 1686 *Includes cases of ankle valgus, spasmodic valgus, and other predisposing causes of flat feet. Summarised, the Table shows 479 school children attended ami made 990 attendances; 249 babies made 543 attendances; and 7.1 tuberculosis cases made 153 attendances, a total of 801 cases, making 1,686 attendances. The following Table shows the number of cases referred direct from the Orthopaedic Clinic for massage, Swedish remedial, and electrical treatment, and also X-Ray examination at the Croydon General Hospital. 221 Table CXX. Cases Referred from Orthopaedic Clinic for Remedial Treatment at Croydon General Hospital. Defects School Cases M.C.W. Cases Tubercmosis Cases Total Casts No. ot Treatment X-Rays Cases .N o. of Treatmen s X-Rays Cases No. ot Tretments X-Rays Cases No. of ments X-Raya ???fartile Paralysis 1 280 ... ... ... ... ... ... ... 12 280 ... ???liosis 27 542 3 ... ... ... ... ... ... 27 542 3 ???Cavus 2 1 1 ... ... ... ... ... 2 1 1 ???Planus 10 101 1 3 18 ... ... ... ... 13 119 1 ???alipes 3 52 ... 2 87 ... ... ... ... 5 139 ... ??? Valgum 5 42 ... 7 41 3 ... ... ... 12 83 3 ???etrical Paralysis ... ... ... ... ... ... ... ... ... ... ... ... ??? Joint Disease 2 ... 2 ... ... ... 26 54 25 28 54 27 ???juris 14 162 9 8 10 0 ... ... ... 22 178 15 ???ckets 1 3 ... 3 8 2 ... ... ... 4 10 2 ??? Neck 5 71 ... ... ... ... ... ... ... 5 71 ??? Paraplegia 2 12 ... ... ... ... ... ... ... 2 12 ??? Deformities 11 68 12 5 21 4 ... ... ... 16 89 16 94 1333 28 28 191 15 26 54 25 148 1578 68 Table CXXI. Cases Sent to Residential Institutions. lane of dilution School Cases M.C.W. Cases Tuberculosis Cases Total ■ C ^ o s I o ■ »-s a*» o • •2d8 •O a> '1 -c <• •v V to 3 a o VI 3 c ** o • . •SjS ^ •o V 1 -C C •u V m a ji (J CO 5 a ■£ ° c . M -c® • CO T3 <U 1 TJ ■H TJ O) M d JZ ■ m Q c ■*£ ° 43 • a . eg "" a 2 . oS •O a •o <• •a V M c6 -C o O ri... i 3 2 4 4 12 7 5 15 14 9 20 kn General i 21 20 1 3 4 2 7 6 4 31 30 5 2 2 2 2 2 24 20 3 7 8 16 14 13 21 45 41 25 222 From this Table it is seen the number of cases in residential institutions was 21 at the beginning of the year and 25 at the end. Institutional treatment is naturally the most expensive part of the scheme, but it is also an essential part if permanently satisfactory results are to be obtained. The following Table shows the conditions for which patients were admitted to Hospitals and the results of treatment. Table CXXII. Condition. In on Jan. 1st, 1931. Admitted. Dischaged In on Jan. 1st, 1932. Cured. Much Improved. Improved. Died. Infantile Paralysis ] 4 1 1 2 ... 1 Talipes ... 1 ... 1 ... ... ... Tuberc. Joir.t Disease 16 16 4 7 3 1 17 Congenital or Pathological Dislocated Hip 1 4 2 3 ... ... Injuries 1 4 1 3 ... ... 1 Rickets 1 4 2 ... ... ... 3 Wry Neck 1 1 2 ... ... ... ... Spastic Paraplegia ... 1 ... ... 1 ... ... Other Deformities ... 10 3 2 2 ... 3 21 45 13 16 11 1 25 The percentage of cures for the whole series of cases was 31.7%, whilst 39.0% were much improved. Table to show number of cases for whom appliances were ordered and how the expenses thereof were met:— Total cases on the books of the Clinic Jan. 1st, 1931 458 Total number actually in receipt of massage, electrical, Swedish remedial on Jan. 1st, 1931 26 New splints and appliances supplied 72 Repair of existing appliances 32 Part cost met by parents 21% Full cost met by parents 54% Full cost met by Local Authorit 25% Number of cases in which Hospital contributions were authorise 38% 223 Mrs. D. B. Connor, the organiser of this department, attended 48 Clinic sessions, interviewed 1,985 people, made 213 enquiries into financial conditions of families, and sent out 1,029 letters in connection with her work. Mrs. Connor's work, though interesting, calls for a considerable degree of tact and sympathy, and, I am happy to record, the success of the Orthopaedic work carried out by the Local Authority is largely attributable to her aptness for the work. Under the Tuberculosis after-care scheme, 64 families were considered by the Tuberculosis After Care Committee. The total amount expended in assisting in various ways was £283 12s. 8d. Maternity and Child Welfare Massage Clinic, Lodge Road. One of the whole-time masseuses devotes 5 sessions a week to this work. The remainder of her time being devoted to the children at St. Giles' School which she attends each morning. ULTRA-VIOLET LIGHT CLINIC. The Clinic is held at the Croydon General Hospital on two days a week under the superintendence of Dr. F. HernamanJohnson. The majority of the cases referred were from the Tuberculosis Dispensary (17), the M. and C.W. Department referred 57 eases and the School Medical 24 children. The following Table gives a summary of the attendances made:— Table CXXIII. Dtputment. No. of Cases. Aggegate duration of treatment in weeks. Average per case. AggregatNo, of Sessions Attended. Average per Case, No. of Patient discharged. No. continuing treatment end of 1932. Sthool Medical 24 273 8.8 608 3.9 17 7 M.& C. W. 57 509 11.2 1437 4.0 46 11 Tuberculosis 17 197 8.6 489 3.5 15 2 98 979 ... 2534 .. 78 20 224 The Table under gives the complaints treated and the results achieved in completed cases. Twenty-two cases ceased attending before completion of treatment and five cases left the district. Table CXXIV. Condition. School Cases. M. & C. W. Cases. Total. Much Improved Improved. Slight Impr. i.s.Q. Much Improved. Improved. Slight Impr,. I.S.Q. Debility ... i ... I i 5 ... ... 8 Asthma ... 2 ... ... ... ... ... ... 2 Bronchitis i 2 ... ... ... ... ... 1 4 Glands ... 1 ... ... i 1 ... ... 3 Rickets ... ... ... ... 2 4 ... ... 6 Miscellaneous ... 4 i l 1 9 ... ... 16 i 10 i 2 5 19 ... 1 39 School Cases. Eleven School cases were still attending the Clinic at the end Slight K.K. and Flabby Muscles, 3 ; Cervical Glands, 1; Failure to Gain Weight, 1; Convex Tibiae, 1; Bronchial Asthma, 1; Throat, 1; Rickets, 1; Post Pneumonia, 1; General Condition, 1. MaJternity and Child Welfare Cases. Seven Maternity and Child Welfare cases were still attending the Clinic at the end of the year. These were suffering from the following conditions, viz.:—Adenitis, 2; Bronchial Asthma, 1; Debility, 1; Rheumatism, I; Cough, 1; Malnutrition and Anaemia, 1. 225 Table CXXV. Much Improved Improvement Slight Improvement I.s.Q. Still attending at end of 1931 Total Lupus ... 2 ... ... 1 3 Adenitis 1 3 ... 2 1 7 Anaemia ... 1 ... ... ... 1 Sinusitis ... 1 ... ... ... 1 Glands 1 ... ... 1 T.B. Kidney and Bladder ... 1 ... ... ... 1 2 8 ... 2 2 14 Of the School cases, 15 were boys and 9 girls; the maternity and child welfare cases, 35 boys and 22 girls, and the Tuberculosis patients, 6 male and 11 female. There has been a tendency in some quarters to exaggerate the therapeutic importance of this form of treatment. All the cases referred to the Clinic had been carefully selected as likely to benefit; of those discharged, 15.7% after completion of treatment, were much improved, 74.4% were improved, and 9.9% were not benefited. These figures show that it is by no means a panacea, though under expert supervision of dosage, exposure, etc., it is capable of assisting natural forces to bring about improvement in bodily health. In unskilled hands it is capable of causing bodily damage. Two types of lamps were used: the Mercury Vapour and the Carbon Arc; the former alone was used in 89 of the cases; the latter alone in 5 cases, and both lamps in 4 cases. VETERINARY INSPECTION. Mr. P. Thrale, the part-time veterinary surgeon, makes quarterly reports on his visits to the farms and his examination of the cattle thereon. During 1931, all the farms were visited for this purpose at least 4 times. A total of 960 cows were inspected during the year. 226 CROYDON AERODROME. Aliens Acts. The London Terminal Aerodrome is situated in the area of Croydon. Medical duties in connection with the Aliens Acts are carried out on behalf of the Ministry of Health by a part-time medical officer on the staff of the Medical Officer of Health. The duties of a medical officer at an Aerodrome differ considerably from those at a seaport; the type of passenger using air transport not being of the kind dealt with by sea-borne traffic. The ma jority of passengers are business people or tourists. The medical officer is on duty six hours daily from April to September inclusive, and two hours daily during the six winter months. He is under the administrative control of the Medical Officer of Health. The public health problems arising from air transport are peculiar to this mode of travel, which has greatly shortened distances and so brought nearer the endemic diseases of the tropics. Some of the medical problems and suggestions as to their solution were dealt with in a paper read by the Medical Officer of Health at the Royal Institute of Public Health's Congress at Frankfurt, and subsequently published in the Institute's Magazine. The arrangements made at the Aerodrome for the convenience of passengers and for the examination of aliens are satistory. During the year one case was taken to Court for an infringement of the Parrots (Prohibition of Importation) Regulations, 1929, and the defendants were fined £30 and costs. On several occasions unsound food conveyed by aeroplane has been seized and destroyed. The arrangements in operation work smoothly and efficiently, and much of this is due to the cordial co-operation and help at all times received from H.M. Immigration Officers, H.M. Customs Officers, and the management staff of the Aerodrome. The Table below gives a summary of the traffic during the year. Owing to the widespread economic depression the traffic figures did not show so great an increase as has been observed in previous years. 227 CROYDON TERMINAL AERODROME. Aliens Act, 1930. Medical Officer's Return for the year ending 31 st December, 1931. Number of Planes. Arrived from Arr. Seen. Paris. Amsterdam. Brussels. Elsewhere. Total: 3,495 1,650 1,917 776 549 253 Passengers. Aliens. Attendances British. Others. Inspected. Exd. of M.O. 13,038 10,296 5,423 29 330 228 MEMBERS OF THE EDUCATION COMMITTEE. NOVEMBER, 1930-1931. The Mayor (Mr. Alderman T. Arthur Lewis, J.P.). Mr. Alderman W. Peet, F.C.A. (Chairman). Capt. J. Stevenson, J.P. (Vice-Chairman). Alderman T. Betteridge, J.P. Alderman H. J. Morlaud, M:A., J.P Alderman A. Peters, C.B.E., J.P. Alderman T. W. Wood Roberts, J.P. Alderman W. West. Councillor E. E. L. Arkell. Councillor E. S. Baker. Councillor A. J. Carpenter. Councillor W. J. Gibbins. Councillor A. H. Harding. Councillor W. G. Higgins. Councillor R. G. P. Howie, M.A. Councillor W. H. Jarvis. Councillor J. Marshall. Councillor Major F. W. Rees. Councillor Mrs. B. J. Roberts. Councillor Dr. A. Sandison, B.A. Councillor A. J. Stubbe. W. A. Clarke, Esq. W. Field. Esq., M.A. Mrs. M. A. Hinke. Capt. H. Lethbridge-Abell, F.Z.S. N. F. Robarts, Esq.. F.G.S., F.R.A.I. Mrs. M. M. Wood Roberts. G. Robinson, Esq. Rev. G. M. Scott, M.A. P. Squire, Esq. The Lord Bishop of Croydon. J. M. Newnham, O.B.E., D.L., LL.D., Clerk to the Local Education Authority. R. B. Morgan, M.A., M.Litt., Education Officer. STAFF OF THE SCHOOL MEDICAL SERVICE. Medical Officer of Health and School Medical Officer: Oscar M. Holden, M.D., D.P.H. Deputy Medical Officer of Health and Deputy School Medical Officer: W. B. Watson, L.R.C.P., L.R.C.S., D.P.H. Assistant Medical Officers of Health and Assistant School Medical Officers: Patrick J. O'Connell, M.D., B.S., D.P.H., B.Hy. F. W. Gavin, M.D., Ch.B., D.P.H. Olive B. Falk, M.B., B.S. Iris Jenkin-Lloyd, M.R.C.S., L.R.C.P., D.P.H. Specialist Part-Time Medical Officers: J. S. Bookless, F.R.C.S. (Ophthalmic Surgeon). J. D. McLaggan, M.A., M.B., Ch.B., F.R.C.S. (Ionization Clinic). Rota of 8 local medical practitioners for surgical treatment of tonsils adenoids. Senior Dental Surgeon: J. F. Pilbeam, L.D.S. Assistant Dental Surgeons: J. K. R. Bryce, L.D.S., and K. C. B. Webster, L.D.S Remedial Gymnasts: Miss F. Davey and Miss M K. Thomas (part time). Mental Deficiency Visitor: Miss E. A. McDougall (part-time). Orthopatdic Work Organiser: Mrs. D. B. Connor (part-time). School Nurses: Two at clinics, 19 district nurses (part-time), and one super. numerary. Clerks: Five full-time and six part-time. 229 SCHOOL CLINICS Name. Purpose. Where held. Times. INSPECTION Special examination of cases referred by teachers, school attendance officers and school nurses and on application of parents. Municipal Clinic, Lodge Road. Wed. and Sat., 9 a.m. MINOR AILMENTS Treatment of Minor Diseases of Skin, etc. Lodge Road. Selhurst Road. Daily, 9 a.m. Mon., Wed. anc Fri., 9 a.m. OPHTHALMIC Treatment of Visual Defects. Lodge Road. Tues. and Fri., 9 a.m. DENTAL Dental Treatment. Lodge Road and Selhurst Road. Daily, 9 a.m. and 2 p.m. IONIZATION Treatment of Chronic Ear Discharge. Lodge Road. Tues., 2 p.m. DEFECTIVE CHILDREN Examination Town Hall. As required. X-RAY Treatment of Ringworm. Dr. Greig's Surgery. By appointment ORTHOPEDIC Treatment of Crippling Defects. General Hospital. Thurs., 10 a.m. THROAT Operative Treatment of Enlarged Tonsils and Adenoids. do. Mon. and Wed. 2 p.m. SYNTHETIC SUNLIGHT Treatment of Rickets, etc. do. Tues. &• Thurs. 2 p.m. REMEDIAL EXERCISES Treatment of Deformities. St. Andrew's Hall, Old Town. Daily. CLEANSING STATION Treatment of Scabies and Cleansing of Verminous Cases. Factory Lane. Arranged as required. TUBERCULOSIS DISPENSARY Treatment of Tuberculosis and Examination of Contacts. 13, Katharine Street. Wed., Thurs.. Fri. and Sat., a.m. RHEUMATISM Examination Lodge Road Thurs. 9 a.m. Fri., 2 p.m. County Borough of Croydon. ANNUAL REPORT of the SCHOOL MEDICAL OFFICER For the Year ending December 31st, 1931. Ladies and Gentlemen, 1 have the honour to present you my report on the work carried out by the School Medical Service in 1931. There have been no expansions of the work other than the initiation of a Scheme for Orthodontic treatment, which was felt to be a true preventive measure. This scheme, commenced by your former senior dental surgeon, Mr. W. G. Senior, has been elaborated by his successor, Mr. J. F. Pilbeam. A section of my report is devoted to details of the amount and kind of work done. Routine Medical Inspections have fallen somewhat in numbers. This is owing to the increasing demand made on the medical officers' time in other ways. The primary function of the School Medical Service is prevention. Routine Medical Inspections and the operation of the various Clinics should be regarded as means towards that end. The ascertainment of defects is not sufficient, the reason for the presence of defects should) also be sought. In the rush of routine inspections there may be sometimes a tendency to forget the essential aim, whilst the opportunities for research into causal factors and the methods of prevention of causes, are very small 230 231 owing to the bulk of the routine work to get through, and the limited time and means that can be directed towards it. It is debatable whether routine medical inspection, as now carried out, could not be modified with benefit, though it must always remain the basis of the work for, obviously, before causes can be investigated their effects must be noted, and this can only be done by a medical inspection. The average attendance of scholars in the Elementary Schools throughout the year was 90 per cent., the same as in 1930. No widespread epidemic occurred, though Chicken Pox and Mumps gave some trouble. Measles, as was expected, did not figure largely in the cases of Infectious Diseases. The year was a satisfactory one as regards the general level of health in school children. Although the actual number of cases of verminous or dirty children are not large, the increase shown in 1931 on 1930 is disquieting. As was mentioned in my report for 1930, certain schools, and certain families whose children attend those schools, are mainly responsible for uncleanliness findings. The majority of the schools maintain a commendably high level of cleanliness. In this connection, the cloakroom provision must be considered, and it certainly seems desirable, more particularly in schools drawing children from unsatisfactory districts, that the cloakroom arrangements should be such that coats and hats should not touch when hanging, there should be a free circulation of air all round the clothes with means, also, for drying wet clothes and boots or shoes. The chief causes necessitating the exclusion of children from school on medical grounds, were the common infectious diseases, which constituted 65% of the total. Impetigo and verminous conditions between them formed 19.4% of the exclusions, and both showed a rise on 1930, when the combined percentage was ten. In connection with cleanliness of scholars the school nurses paid 503 visits to the schools and examined during the year 64,755 children, of whom 3,281 were found unclean at the first inspection and 1,652 at subsequent following-up inspections. In addition 218 visits were paid to children's homes for the same reason. The presence of the habitually dirty child is a very real source of anxiety to teachers and to the parents of clean children, and Persistent efforts have been made to keep the incidence of uncleanliness as low as possible. Although unsatisfactory housing conditions may have an influence on some of the disabilities from which children suffer, it certainlv does not necessarily play anv conspicuous role in the cause of uncleanliness; for dirty children 232 are found coming from quite satisfactory houses in which there are adequate facilities for washing. Home care and family pride are the dominant factors. The School Clinics have had another busy and useful year, the Minor Ailments Clinics showing an increase of nearly 2,000 in the attendances. The subsidiary Clinic opened in 1930 at 206, Selhurst Road for Minor Ailments and Dental needs has again proved its usefulness. The long distance, through and across busy thoroughfares, that some schools are from the Lodge Road premises will necessitate the establishment of one or more subsidiary Clinics when financial conditions permit. There is undoubted difficulty in obtaining the carrying out of necessary treatment, more especially as concerns remedial exercises and minor ailments, owing to the reluctance or inability of parents to travel the distance to a central clinic. A decrease of some importance has occurred in the number of children operated on for the iemoval of Enlarged Tonsils and Adenoids. This is the outcome of a deliberate policy in which the school medical officers have joined. It is felt that there has been, in the past, rather an indiscriminate removal of tonsils which were enlarged but otherwise apparently healthy. Pursuing the main object of the School Medical Service, the reasons for tonsillar enlargement are being sought and the lines on which prevention should be practised. Unfortunately, all the indications point to the causes lying in that vital period of life between 2 and 4 years of age, a period during which at present, there are the scantiest facilities both for supervision and treatment. The tVpes of cases which are now being referred for operative measures are detailed in the bodv of the report (page 45). In connection with the School Dental Service, a new section has been included in the report detailing the Orthodontic treatment now being undertaken. The correction of dental irregularities, besides having an assthetic value, is definitely a preventive measure. Irregularly placed, badly erupted and crowded teeth are prone to early decay; in addition, the absence of a satisfactory "bite" in many of the cases prevents efficient mastication and leads to digestive and nutritional troubles. Once again it has been the ruling principle that it is better to endeavour to prevent dental caries than to pull a tooth out because it is unsaveable owing to decay. It is unfortunate that a proper appreciation of this is not always evident on the parent's side. 233 The routine work of the dental clinics has been dislocated owing to the number of children coming up as urgent cases with toothache; and in some of these it has been ascertained that conservative treatment offered previously had been refused. The special reports on the Rheumatism and Ionization Clinics are again included. It is hoped, if the exigencies of routine work permit, to analyse the findings of these clinics when they have dealt with a sufficient number of cases. The analysis of relatively small numbers is fallacious. In connection with the Rheumatism Clinic the Convalescent Home at Coombe Cliff has been of much service, enabling children not quite fit to return to school to have a period of convalescence, after which they have gone back to school with every prospect of maintaining their health. The summary of findings at Routine Medical Inspections shows that the most common defects necessitating reference for treatment are, in the order of their incidence, defects of the Nose and Throat, Dental Disease, Enlarged Glanas, Defective Vision and Circulatory defects. The first three of these groups of defects are most prevalent in the Entrant group of scholars; the other two increase in incidence as school age increases. It follows, therefore, that if there is to be a decrease in the number of children with unsatisfactory nose and throat conditions, or with dental disease and enlarged glands, preventive measures are required before the statutory school age. The causes of these defects have been in operation since shortly after birth, and, although no specific cause or causes can be dogmatically stated, the remedy lies in medical inspection and the necessary facilities for treatment during this time. The position at the moment for this age period is much the same as the position was for the school child before the inception of routine medical inspection and the formation of school clinics. It is repeatedly put forward as an extenuation that the parents are insufficiently educated as to the necessitv for careful medical supervision of their children before school age is reached, and this explanation no doubt contains much truth, but without the necessary instructors for the parents, and the necessary facilities and guidance, not much real prevention is likely to result. Circulatory defects and defective vision are in a different category and are the results of a different set of causes. These defects 234 increase as school age advances. The first group are largely the aftermath of acute rheumatism, and with the prevention of the latter would diminish much in importance. Defective Vision seems to be directly due to conditions which commence to operate when the eyes are used for more purposeful needs than is the case in the earlier years of life. In quite a number of cases of defective vision the cause underlying the failure of the eyes to stand up to the conditions imposed on them can be traced to hereditary defect or to malnutrition in early childhood. Other cases seem to breakdown and need glasses when a period of intensive strain is undergone, such as hard reading for examinations and insufficient relaxation and sleep. A small number are caused by an attack of one of the infectious diseases, usually Measles, and less often Diphtheria. The correction of defective vision is a simple matter in the majority of cases, but correction by lenses is not sufficient. The cause for the breakdown should be sought out and. if possible, corrected also. The immunization of children against Diphtheria has been continued in several of the residential schools in Croydon, and it is interesting to note that no cases of Diphtheria has occurred in those Schools. A localised outbreak took place in one of the day Elementary Schools, and a meeting of parents was addressed by a School Medical Officer, who put to them the advantages of immunising their children. Although considerable interest was manifested and many questions asked, the resultant number of children put forward for immunisation was meagre. Diphtheria has not been a menace during the year and has been kept in check by careful supervision of contacts and judicious swabbing of throats and noses, but our experience in the St. Olave's schools has shown that diphtheria—a dangerous and insidious diseaseis not necessary. It can be prevented, and, as a practical demonstration, has been prevented in a self-contained community to all the members of whom the process has been applied. The report serves to show that much avoidable illness in school children is due to ignorance of simple physiological functions, and epidemics not seldom arise through a lack of appreciation of the principles underlving honest citizenship, if a child is fully instructed, before leaving school, in the principles of personal and communal hvgiene it is certain that greater good will be done thrn bv the elaboration of schemes of social and Public Health reform which those for whom they are intended do not understand the purport. 235 In conclusion, I tender my thanks to you, ladies and gentlemen, for the consideration and courtesy you have at all times extended to me. 1 wish also to acknowledge my indebtedness to your Education Officer, Mr. Morgan, for his helpful co-operation and advice, and to the members of his staff for their assistance. I also desire to bring to your notice the continued valuable services of the Deputy Medical Officer, Dr. Watson, and others of my colleagues in the School Medical Service. Thev have always had an unwaining enthusiasm for the aims towards the consummation of which the department strives. I am, Yours faithfully, OSCAR M. HOLDEN, School Medical Officer. 236 SECTION I. Co-ordination and School Hygiene. A close co-operation exists between the Public Health Department and the School Medical Service. The Medical Officer of Health is also School Medical Officer, and the assistant wholetime medical officers, with the exception of the Tuberculosis and the Obstetrical Medical Officers, all take part in school work. During 1931 the Maternity and Child Welfare Work has been linked up with the school medical work as far as possible. Difficulties have arisen, the chief of which are that children do not always attend the school which their parents state they will prior to their going; and a comparatively small proportion of entrants have attended in years previously, a Maternity and Child Welfare Centre. A third difficulty is that routine medical inspection cards are kept at the schools. This has other disadvantages also, but is necessary owing to the very limited office room available at the Town Hall. Structural Work and Decorations carried out in the Elementary Schools. I am indebted to the Education Officer for the following particulars of work carried out at the various schools during the past year :— External Painting at the following Schools— Portland. Rockmount. Sydenham. Tavistock.. Winterbourne. Woodside. Internal Painting and Distempering at the following Schools- Portland. Tavistock. Winterbourne. Christ Church. Farish Church (Junior Mixed and Infants'). St. Joseph's. St. Mary's. St. Peter's. Archbishop Tenison's. St. Saviour's. Selhurst Grammar (Boys ) Selhurst Grammar (Girls'). L37 New Schools or Departments Opened— Lanfranc—Senior Boys, Senior Girls' School. Kingsley—Senior Boys, Senior Girls, Junior Mixed, and Infants' School. Oval—Senior Mixed, Junior Mixed and Infants' School. Ashburton—Senior Mixed Sohool. Beulah—-Infants and Junior Mixed School. Alterations and Additions at the following Schools— Ingram—Addition of 4 Class and 1 Domestic Subjects Rooms. Portland—Addition to Handicraft Room and Alterations to form Science and Staff Rooms. Woodside Junior Boys'—Alterations to form Head Teacher's, Staff and Medical Inspection Rooms. West Thornton Junior Boys'—Alterations to form Hall and Medical Inspection Room. Ditto (Infants' and Girls')—Removal of Hut in playground. Alterations of old Handicrafts Room to form Hall. St. Mark's—Reconstruction of w.c.'s and urinal. Davidson—Alterations to form Domestic Subjects Rooms. 238 Table I. Sanitary Accommodation in the Schools. Name of School Number on Roll 31.12.31 No. of Pedestal W.C's. flushed by separate cisterns. No. of Pedestal W.C's. flushed by automatic Flush. No. of urinals with sparge pipes. Ashnurton 668 14 ... 1 Beulah 1176 41 ... 2 British 560 21 ... 3 Davidson 685 28 ... 2 Ecclesbourne 977 10 ... 3 Elmwood 1093 37 ... 4 Gonville 366 14 ... 2 Howard 445 21 ... 2 Ingram 1183 28 ... 2 Kingsley 1413 52 ... 3 Lanfranc 449 22 ... 1 Norbury Manor 875 25 ... 2 Oval 660 26 ... 2 Portland 1057 ... ... 2 Purley Oaks 487 23 ... 2 Rectory Manor ... 25 ... 3 Rockmount 494 ... ... 2 South Norwood 829 26 ... 2 Sydenham 826 25 ... 4 Tavistock 751 32 ... 3 Waddon 1171 41 ... 4 West Thornton 1026 30 ... 3 Whitehorse Manor 947 38 ... 3 Winterbourne 1265 26 ... 2 Woodside 9J8 34 ... 3 Heath Clark (Central) 382 15 ... I St. Christopher's 101 4 ... 1 St. Giles 70 3 ... 1 Myopic 17 2 ... 1 Aldington 62 ... ... 2 All Saints' 374 12 ... 2 Christ Church 487 ... ... t Holy Trinity 265 11 ... 1 Parish Church 546 ... ... 2 St. Andrew's 390 10 ... 1 St. Joseph's 198 7 ... i St. Mark's 146 7 ... 1 St. Mary's 363 15 ... 2 St. Peter's ... ... ... 151 ... ... 1 St. Saviour's 366 ... ... i Shirley 241 5 ... 2 Archbishop Tenison's (Girls and Boy's Central) 398 12 ... 1 St. Michael's (Central) 224 9 ... 1 Trough closets only were in use, flushed by automatic cisterns at Christ Church, Parish Church, St. Peter's and St. Saviour's ; in conjunction with pedestal W.C's, at St. Andrew's. Pail closets only were in use at Addington. The above return does not include the John Ruskin (401) and Lady Edridge (300) Central Schools which are housed in temporary premises. * Rectory Manor School was closed on 23rd December, 1931. 239 The English regulations relating to public elementary schools prescribe the number of closets to be provided for girls and boys respectively as follows :— No. of Children 30 50 70 100 150 200 300 400 No. of closets respectively : Boys 1 2 2 S 3 4 5 6 Girls 3 4 5 6 3 10 14 18 Co-operation of Parents. The presence of parents is always welcomed at the various clinics and routine medical inspections. A parent can assist the examining medical officer very materially, in arriving at accurate conclusions. Advice given personally to a parent by the doctor is always more valuable than when carried second-hand or through the medium of printed notices and instructions. Co-operation of Teachers. The head teachers have been as helpful as in previous years; their co-operation is essential for the efficient carrying out of the work, and as this is recognised by them, matters are made easier than they would be otherwise. Co-operation of the School Attendance Officers. I should like to express my thanks to the Superintendent Attendance Officer for the valuable assistance he has rendered us during the year, in connection with the tracing of cases temporarily lost sight of, in seeing that urgent treatment is carried out. in proceedings against parents whose children are kept in an habitually dirty condition, and also with children on the exceptional children's register. The Voluntary School Care Committees have continued their work of assisting in the provision of treatment, and their interest is not infrequently a deciding factor in the successful issue. The Croydon Council of Social Service gives information and assistance in dealing with necessitous cases for whom provision could not otherwise readily be made. Close co-operation is maintained with the Societv for the pretention of Cruelty to Children, whose inspector has rendered much asistance with a few difficult cases. 14 cases reported by 240 us have been dealt with; these cases were, adenoids and enlarged tonsils, 9; failure to obtain medical or dental treatment, 1; miscellaneous, 4. In addition to visits for preliminary investigation the Society's Inspector paid 52 supervision visits. Cost of the School Medical Service. The gross cost of the medical, dental and nursing services was £10,573; from this an income of £648 should be deducted, making a nett cost of £9,925. The rateable value of the Borough in 1931 was £1,961,171. The Government grant is 50 per cent, of the expenditure, hence the actual cost to the rates was £4,962, i.e., a rate of 0.61 pence. The net cost of these services to the rates for 1931 per child on the school registers was 3s. 11.4d. The figures do not include £300 for Medical Inspection (Higher Education) and for Blind persons £411. Cost of Special Schools. Schools maintained by the Council £4,828; Contributions to schools under other authorities £2,815 ; Other expenses (travelling, etc.) £126, Income from parents' contributions and other receipts £797, giving an actual cost of £6,972, of which £3,488 was payable out of local rates, giving a rate of 0.43 pence. Cost of Milk and Meals. Milk and meals cost £1,054 Is. 8d.; Income from parents' contributions £62 6s. 6d.; giving an actual cost of £991 15s. 2d. SCHOOL POPULATION AND AVERAGE ATTENDANCE. Table II. No. of Schools. No. on Rolls. Average Attendance Percentage Attendance. Boys 17 C. 5760 5357 93 2 N.P. 367 342 93 Girls 18 C. 5908 5378 91 5 N.P. 1205 1100 91 Mixed 14 C. 5213 4726 91 8 n.P. 2258 2000 89 Infants (396 under 5) 14 C. 4502 3902 87 3 N.P. 424 376 88 Schools— Church of England 12 4254 3817 90 Roman Catholic 2 Council .. 27 21383 19363 90 Total 41 25637 23180 90 "C " = Elementary. "N.P. " = Non-provided. 241 There was no closure of schools or school departments in 1931 on account of epidemic infectious disease, and no certificates were issued under Article 23 of the Code of Regulations for Public Elementary Schools, 1926. It is a mistake to think that school closure is a means of controlling epidemic disease. The effect in towns, where there are so many other opportunities of children meeting, is negligible. By closing a school, on the other hand, valuable aids are lost. For example, systematic watch can be kept on class contacts; the School Nurse is made aware immediately of the absence of any child from school, and can consequently call without delay at the home. Parents, however, on hearing of cases of infectious illness in a school, not infrequently keep their children away. Their absence from school is, however, noted, the parents are visited, and the children kept under supervision at home. The family doctor could help the school authorities very considerably in this matter of infectious disease, both in advising the parents as to isolation and quarantine of contacts, and in pointing out the serious effects to other children that any laxity in control might cause. 242 SECTION II. MEDICAL INSPECTION IN SCHOOLS. The four assistant medical officers devote the following proportions of their time to this work :—Dr. Falk 2/11; Dr. JenkinLloyd 3/11; Dr. O'Connell 7/11; Dr. Gavin 9/11. Elder girls in schools are as far as possible examined by the two lady doctors. The Deputy School Medical Officer assists with routine inspections when the need arises. The groups examined have been entrants, usually aged 5-7 years; intermediates 8 years; and leavers 12-14 years. These are the three statutory groups. Examinations of children outside these groups are classified as " others." Children brought forward by head teachers, attendance officers, school nurses, etc., are classified as " specials." Table III. gives a summary of the number of children examined in the various classes in the different schools together with the parental attendance at the examinations. A total of 7,457 children were examined as compared with 8,426 in 1930, and 5,230 parents attended the examinations. The percentage attendance of parents in the entrants group was for boys 80 per cent, and girls 84 per cent.; in the intermediate group, boys 68 per cent., girls 76 per cent.; and in the leavers group, boys 45 per cent., girls 56 per cent. The diminution in the number of routine medical inspections made was due to several factors, the chief being an increase in the number of Clinic sessions held so as to keep pace with the demand and keep the waiting lists down to reasonable proportions. As would be expected the percentage of parents attending is lowest in the leaver group, though this is unfortunate, for at this examination the medical officer can give the parent advice as to suitable future emplovment. With the present lack of continuity and co-ordination between the school medical services and the medical examination of young persons under the Factory Acts, advice given at the school leaving examinations assumes some degree of importance. 243 Table III. Name of School. Entrants. 5 to 6 years of age Intermediates. 8 to 9 years of age. Leavers. Other Ages Number Examined Parents present. Nnmber Examined Parents present. Number Examined Parents present. Number Examined Parents present- M. F. M. F. M. F. M. F. M F. M. F. M. F. M. F. 1 Ashburton 36 38 32 37 32 43 25 39 ... ... ... ... ... ... ... ... 2 Beulah 65 80 54 67 1 69 1 46 46 50 22 27 ... ... ... ... 3 British ... ... ... ... ... ... ... ... 73 96 3J 44 ... 10 ... ... 4 Davidson 41 42 33 40 36 40 17 28 43 29 25 21 ... ... ... ... 5 Ecclesbourne 72 59 63 51 58 43 38 39 89 3! ... ... ... ... 6 Elmwood 80 97 48 76 43 33 22 17 154 43 43 22 ... ... ... ... 7 Gonville 85 83 74 82 50 62 39 51 ... ... ... ... ... ... ... ... 8 Howard 28 22 16 11 29 20 19 13 ... ... ... ... ... ... ... ... 9 Ingrain 62 59 49 50 59 64 43 59 30 50 21 42 ... ... ... ... 10 Kingsley 46 43 38 34 43 17 25 21 40 78 14 3t ... ... ... ... 11 Lanfranc ... ... ... ... ... ... ... ... ... ... ... ... ... ...... ... ... 12 Norbury Manor 63 63 52 61 39 48 25 21 53 59 30 3.- ... ... ... ... 13 Oval 43 16 37 15 30 5 29 5 22 24 14 1C ... ... ... ... 14 Portiand 69 55 61 51 64 56 55 53 98 40 45 If ... ... ... ... 15 Purley Oaks 23 3i 11 21 25 23 13 17 24 15 / 6 ... ... ... ... 16 Rockmount 29 19 24 19 24 24 16 20 24 1 9 1 ... ... ... ... 17 South Norwood 63 49 51 37 78 7b 40 47 22 12 ... ... ... ... 18 Sydenham 50 29 43 22 84 50 56 33 ... ... ... ... 19 Tavistock 34 29 25 19 5 16 5 10 72 97 29 44 ... ... ... ... 20 Waddon 54 61 40 52 40 57 27 38 51 49 19 27 ... ... ... ... 21 West Thornton 144 120 109 94 79 49 39 32 ... ... ... ... 22 Whitehorse M'r 63 52 57 35 52 77 44 52 101 42 ... ... ... ... 23 Winterbourne 93 62 87 58 84 38 64 33 97 38 68 29 ... ... ... ... 24 Woodside 66 62 51 56 63 75 44 59 3S 30 ... ... ... ... 25 Heath Claik ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 26 John Ruskin .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 27LAdy Ed ridge ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 28 Addington 14 3 9 3 3 7 2 5 1 1 1 ... ... ... ... 29All Saints' 25 16 25 14 18 18 17 16 10 14 7 10 ... ... ... ... 30 A rch Tenison's ... ... ...... ...... ... ... ... ... ... 30 ... 19 ... ... ... ... 31 Christ Church 23 29 20 28 23 40 22 35 ... 23 ... lb ... ... ... ... 32 Holy Trinity ... 38 35 41 38 ... ... ... ... ... ... ... 33Parish Church 21 16 18 16 37 30 42 ... 20 ... ... ... ... 34 St. Andrew's 32 24 18 18 23 18 14 7 ... ... ... ... ... ... 35 St.Joseph's 11 5 10 5 21 20 10 14 10 8 6 5 ... 2 ... ... 36 St.Mark's 13 21 10 8 10 11 8 9 ... ... ... ... ... ... 37 St. Mary's 14 8 8 4 26 15 9 8 18 5 4 1 ... ... ... ... 38 Peter's 30 29 29 26 28 35 20 27 ... ... ... ... ... ... 39 St.Saviour's 21 27 14 22 29 36 21 29 13 ... 8 ... ... ... ... 40 Shirley 38 39 32 31 14 13 9 9 19 11 8 7 ... ... ... ... 41 St. Michael's ... ... ... ... ... ... ... ... ... 22 ... 18 ... ... ... ... 1551 1427 1248 1198 1213 1276 818 96.2 1041 932 473 520 1 12 ... 8 2978 2446 2489 1780 1973 993 13 8 80. 5% 83.9% 67. 4% 75. 4% 45.4% 55.8% — 66.6% 82.1% 71 .5% 50. 3% 61.5% 244 FINDINGS AT ROUTINE MEDICAL INSPECTIONS Uncleanliness. Frequent special inspections are made by the school nurses at the schools and the figures obtained by them are naturally less satisfactory than those in Table XIII. The health visitors at their uncleanliness surveys made 463 inspections and examined children. At the primary inspections they found vermin in 297, and nits alone in 2,452 children. On these inspections, 4.3 per cent. of the children showed evidence of infestation as against 4.1 in 1930 and 4.3 per cent, in 1929. In connection with these findings it must be stated that as children in unsatisfactory families are subject to repeated examinations, they naturally raise the total percentage found unclean. Uncleanliness is largely confined to certain families, who are known to the teachers and health visitors. Clothing and Footgear. At routine medical inspections 99.0 per cent, of both boys and girls were clothed and shod properly. Closer scrutiny has been exerted by the medical inspectors and the findings are satisfactory. Nutrition. In the entrants 15.0 per cent. of the boys and 16.3 per cent. of the girls were below average nutrition. In the intermediate 15.5 per cent. of the boys and 17.9 per cent. of the girls were under average; in the leavers 15.4 per cent. boys and 19.0 per cent. girls, giving in the whole school groups examined 14.8 per cent. of the children as under average nutrition. The figures are lower than in 1930. These findings should be taken in conjunction with the more elaborate analysis contained in Table IV. The subject of child nutrition is a complex one and is dependent on many and diverse factors. Investigations carried out in Scotland pointed to efficient mother-care as the dominant 245 influence. This does not mean meticulous solicitation for the child's welfare, but a sensible realisation of the child as a growing, active being, who, although needing protection, will not respond to coddling, and whose thoughts should be directed towards health and not ill-health. Often in cases of malnutrition the condition is more due to an unwise attitude on the part of the parents, whereby the child thinks in terms of sickness, becomes introspective and loses the joy of life. Also considerable malnutrition is due rather to improper food than to too little food. Proteins and fats are relatively expensive, carbohydrates relatively cheap. In times of financial stringency there is a natural inclination to purchase the cheapest foods and consequently the children obtain an undue proportion of carbohydrate food and too little protein and fat. Milk is undoubtedly the most valuable food to make good the protein and fat deficiency, though the milk must be above bacteriological suspicion. The scheme of the National Milk Publicity Council, whereby for the cost of a penny per day, any child whose parents desire it, may obtain a third of a pint of milk, in a sealed bottle, was continued. This is delivered at the school and is drunk in the middle of the morning through a sterilised straw, thus ensuring •hat it is taken slowly. The empty bottles are collected by the milkman. During 1931, with very few exceptions, all schools adopted this scheme which, since its inception in September, 1929, has grown enormously. In 1930, only 8,723 bottles of milk were supplied. In 1931, 946,000 bottles were supplied. This scheme has one defect inasmuch as, owing to financial reasons, children who would benefit most do not get the milk. A number of these, however, are dealt with direct by recommendations from the school medical officers and so come under another scieme by which milk, up to 1 pint, and malt and oil, are given at graduated prices, or free, to malnourished children. Through co-peration of the teachers this extra nourishment is given at school so that the child is sure of a regular supply. A child's state of nutrition has an undoubted effect on his later physical progress. Severe malnutrition in childhood is never 246 really made good in after life. Childhood is the great growing period. Nutrition is a subject of fundamental importance and should always be of concern to parents, doctors and teachers. There is much ignorance among parents on the subject of economical and valuable catering, and it is submitted that good would be done by a course of theoretical and practical instruction to all scholars in their final vear, on this subject of vital importance. It cannot be repeated too often that unsuitable, badlychosen food may cause as much malnutrition as too little food. A growing child needs fresh food; development will not progress satisfactorily on a diet of tinned goods, bread and tea. Table IV. gives the results of an enquiry made to ascertain the average heights and weights of all children examined at routine inspection of 1931. The full value of this table will not be obtained until similar records for ten consecutive years have been analysed; when this is completed the rate of growth can be followed, so far as Croydon children are concerned, throughout school life. 247 Table IV. HEIGHTS AND WEIGHTS. BOYS. GIRLS. Year of Birth. Number Examined Average Height in inches. Average Weight in lbs. Average maximum Height in inches. Average maximum Weight in lbs. Average minimum Height in inches. Average minimum Weight in lbs Number Examined. Average Height in inches. Average Weight in lbs. Average maximum Height in inches. Average maximum Weight in lbs. Average minimum Height in inches. Average minimum Weight in lbs. 1927 59 40.6 38.8 41.9 42.0 39.0 35.7 33 89.4 35.5 40.5 37.9 38.4 33.1 1926 726 44.0 43.1 46.0 50.2 39.8 34.6 613 42.5 40.2 45.6 48.8 38.6 32.9 1925 535 43 9 43.6 48.2 52.7 40.3 36.7 514 43.4 42.0 47.2 51.2 39.9 34.9 1924 169 45.9 47.6 48.9 54.0 44.3 43.7 180 45.4 45.3 47.6 51.2 43.1 39.6 1923 900 48.2 52.6 53.1 65.1 43.3 41 9 955 47.7 50.4 52.9 65.1 42.9 40.0 1922 210 50.4 57.6 53.6 64.9 47.6 50.9 197 49.4 55.4 52.6 64.3 45.8 45.9 1921 62 51.9 61.6 53.7 66.7 49.8 56.3 83 51.7 60.3 53.6 67.8 49.3 53.9 1920 46 48.9 72.3 55.0 82.5 50.4 60.4 40 54.5 66.8 56.6 77.1 51.8 61.8 1919 736 55.4 76.5 62.1 101.8 50.6 59.9 710 56.4 77.9 61.5 108.4 50.9 57.8 1918 178 56.3 78.4 61.7 97.2 52.9 66.5 136 57.5 82.5 61.3 96.7 54. 2 69.7 1917 35 59.6 91.9 62.5 107.8 56.6 78 0 67 57.2 82.1 61.9 100.2 56.7 78.7 1916 1 62.0 89.0 — — — — — — — — — 1915 — — — - — — — 1 62.5 100.0 - — — — 248 Children Born in 1926.—The; boys are 1.5 inches taller and 2.9 lbs. heavier on the average than the girls. The average minimum weight of the boys is 2.3 lbs. more and their average minimum height 0.2 inches taller than the corresponding figures for the girls. The average maximum weight of the boys is 1.4 lbs. more and their average maximum height 0.4 inches taller than for the girls. Boys at this age are accordingly as a group heavier and taller than girls, and exhibit a smaller range between the extremes. This finding is much the same as for 1930, dealing with children born in 1925, though the variations were not so large. Children Born in 1925.—The boys are 0.5 inches taller and 1.6 lbs. heavier on the average than the girls. The average minimum weight of the boys is 1.8 lbs. more than their average minimum height 0.4 inches taller than the corresponding figures for the girls. The average maximum weight of the boys is 1.5 lbs. more and their average maximum height 1.0 inches taller than for the girls. Although heavier, the boys show a general retardation in the rate of increase in stature. These children belong to the same group as were dealt with in last year's report, and comparison shows that the girls are showing more rapid growth than the boys. Children Born in 1923.—The boys are 0.5 inches taller and 2.2 lbs. heavier on the average than the girls. The average minimum weight of the boys is 1.9 lbs. more and their average minimum height 0.4 inches taller than the corresponding figures for the girls. The average maximum weight of the boys is the same as the girls and their average maximum height 0.2 inches taller than for the girls. This group of children are similar in their relationships to the 1924 group. Children Born in 1919.—The boys in this group were 1.0 inches shorter and 1.4 lbs. lighter on the average than the girls. The average minimum weight of the boys is 2.1 lbs. greater and their average minimum height 0.3 ins. shorter than the girls. The average maximum weight of the boys is, however, 6.6 ibs. lighter and their average maximum height 0.4 ins. shorter than for the girls. In this group as a whole the boys are shorter and lighter than the girls, but the former are a more uniform group: the girls exhibiting greater fluctuations around the mean average, The average minima of heights and weights are taken by selecting the shortest and lightest scholar in any particular group for each school and taking the average of the figures so obtained. The average maxima heights and weights are also obtained in the same way. 349 The figures again show that the period of most rapid growth in stature is earlier in boys than in girls, the latter grow most rapidly and put on most weight during the last years of school life; boys, on the contrary, appear to grow most rapidly between 8 and 12 years of age. During the period of growth from 5 years to 8 years the bovs gained on the average 9.5 lbs. in weight and 4.2 inches in height. The girls gained 10.2 lbs. in weight and 5.2 inches in height. From 8 years to 12 years the corresponding gains are 23.9 lbs. gain in weight for bovs and 27.5 lbs. for girls; 7.2 inches gain in heights for boys and 8.7 inches for girls. During the period of growth from 5 years until the end of the 13th year the boys increased by 12.3 inches in height and 35.3 lbs. in weight; the girls increased 15.0 inches in height and 42.3 lbs. in weight. These findings are very similar to last year's figures, except that the total weight increase in both sexes is less, to the extent of 3.7 lb. in boys and 0.6 lbs. in girls. Heart and Circulatory System. The following table summarises the findings. As might be expected the figure rises steadily during school life, and this emphasises the importance of strict ascertainment, supervision and facilities for the necessary treatment of rheumatism. The etiology of acute rheumatism is not yet known, but there is no doubt about the lasting damage it does to cardiac tissue, more especially if it is not discovered early and adequately treated. The Rheumatism Clinic is doing valuable work in this direction. Table V. Entrants Intermediates Leaers. Other Ages. Percentage Boys Girls. Boy's. Girls. Boys Girls Boys. Girls. Organic Disease 12 7 18 31 19 19 ... ... 1.4 functional Disease 42 34 58 54 29 34 1 1 3.4 Animij 41 29 33 49 22 21 ... 1 2.7 ToUls 95 70 109 134 70 77 1 2 7.5 250 Chest Complaints (Other than Tuberculosis). In all groups 0.1 per cent, of the boys and 0.3 per cent, of the girls had some minor affection of the lungs. The nature of diseases of the Respiratory System is such that children suffering therefrom are not often capable of attending school. As growth proceeds lung resistance to minor invasion appears to increase. Deaths from pneumonia are most numerous in the earlier and the later years of life, when lung resistance is at its lowest. Mild Bronchitis is the usual condition found at routine medical inspections. Table VI. TUBERCULOSIS. Children Referred to the Tuberculosis Officer. Boys. Girls. Total. Percentage of all Children examined Positire (Definite) ... ... ... ... Negative (N»n T.B.) 14 14 28 0.38 Doubtfully T.B 2 1 3 0.04 Bone or Joint Tubercle 1 1 0.01 Glands or Skin Tubercle 1 1 2 0.02 Totals 18 16 34 0.45 Rather more than 0.4 per cent, of the total number of children examined were referred for further examination on account of suspected Tuberculosis. Active Pulmonary Tuberculosis in children of school age is an uncommon disease. The accurate diagnosis of Pulmonary Tuberculosis in children during routine medical inspection is an impossibility. The primary object of routine medical inspection is to sort out children with gross and obvious defects for immediate treatment, and to refer for more detailed investigation those who exhibit indefinite physical or mental aberrations. Children referred to the 251 culosis Officer are re-inspected by the School Medical Inspector at each of his subsequent visits to the school department which the child attends. In this way suspected children are kept under dose supervision. In all instances contacts of known cases of Tuberculosis are also kept under supervision and re-examined at each school medical inspection; bv this means if a child who is a contact of a case of Tuberculosis shows evidence of also contracting the disease the appropriate measures can be put into operation without delay and the progress of the complaint checked and finally arrested. Contacts among School Children Examined in 1931. No. of cases under observation beginning of 1931 11 No. of cases added during the year 177 No. of cases discharged from observation during the year 185 No. of cases under observation end of 3 Notifications of, and Deaths from, Tuberculosis in Children of School Age. No. of Primary Notifications. No of Deaths Pulmonary. Non-Pulmonary. Pulmonary. N on-Pulmonary. M F M F M F M F 7 5 8 7 1 1 2 The ages at Death of the Fatal Cases were :—Pulmonary 10-15 years, 1 girl; Non-pulmonary, 1 bov and 1 girl in the 5-10 years age period, and 1 girl in the 10-15 years period. Taking the total school population as 25,637 the mortality rate from Pulmonary Tuberculosis in school children was 4 per 100,000, and the incidence rate 47 per 100,000. For Non-pulmonary Tuberculosis the respective figures were 4 and 12. For the whole population the figures are : Pulmonary mortality rate, 58; pulmonary incidence rate, 146; non-pulmonary mortality rate, 8; non-pulmonary incidence rate, 34. 252 Nose and Throat. Table VII. summarises the findings; in all the groups 62; boys and 576 girls had enlarged tonsils; 30 boys and 32 girls had adenoids only; 292 boys and 291 girls had adenoids and enlarged tonsils; 54 boys and 35 girls were mouth breathers; 356 boys and 327 girls exhibited enlarged glands in the neck. Taking the cases of adenoids, enlarged tonsils with adenoids and mouth breathers, as requiring operative measures, it is seen that 8.6 per cent, of all school children examined in the three groups were in need of surgical attention to the throat and nose. In 1930, dealing with another group of children, the figure was 10.3 per cent. Although the term enlarged tonsils and adenoids is always used, the relative importance on the health of the child is the other way round. Adenoids exert a much more pernicious influence, inasmuch as they impede the proper performance of nasal breathing. Children with enlarged tonsils or an unhealthy nasopharynx are also more liable to develop complications if they contract Scarlet Fever or Diphtheria, by far the most serious of which is inflammation of the middle ear. The removal of healthy, though enlarged tonsils, is inadvisable, and the medical officers do not refer for treatment by operation, children whose tonsils are healthy, even though they are enlarged, unless the enlargement is so gross as to cause obstruction. The operation of choice for enlarged septic tonsils is enucleation. Resection does not get rid of all the infected tonsillar tissue, and the remains may at a later date cause a renewal of the trouble. The importance of training in correct methods of breathing after the removal of adenoids cannot be too stronglv emphasised. All cases after operation are invited to attend the Rreathing Exercises classes held at St. Andrew's Hall, but unfortunately only some 296 of the parents appear to consider it necessarv. However, the success or otherwise of the operative procedure depends on the nose being used for its natural purpose. If the old, incorrect habits are persisted in, the lymphoid tissue around the posterior nares lacks the normal stimulus of the air currents passing over it, and once more grows into the flabby hvpertrophied masses which are known as adenoids. 253 Table VII. NOSE AND THROAT. Entrants. % Intermediates % Leavers. % Other Ages % Totals. % Boys. Girli. Boys. Girls. Boys. Girls. Boys. Girls Boys & Girls Enlarged Tonsils 305 272 19 4 198 193 15-7 124 111 11 9 ... ... ... 1203 15.7 Adenoids 16 17 11 7 10 0.7 7 5 0 6 ... ... ... 62 0.8 Enlarged Tonsils with Adenoids 180 171 118 85 90 7.0 26 28 2-7 1 1 11-8 583 8.3 Mouth Breathers 34 24 1-9 15 8 0.9 4 3 0 4 1 ... 5 9 89 2.3 Nose (Deflected Septum) 2 2 0 2 3 0.1 4 1 0-3 ... ... ... 12 o.a Other 1 leases of the Nose and Throat 78 70 5 0 35 20 2.2 15 11 1-5 ... ... ... 232 2.9 Lnlarged Submaxillary and Cervical Glandi 157 140 100 152 138 12.1 47 49 4 9 ... ... ... 683 9 0 Table VII. shows that the percentage of nose and throat defects steadily diminishes as age advances, and as a general ru'e it is higher in boys at all ages than in girls. Enlarged glands were most commonly found in the intermediate group (aged 8-9 years); enlarged tonsils and adenoids in the entrant group. The leaver group showed the best findings, a result probably of treatment received, and of a tendency for masses of 254 lympoid tissue to contract as age advances. The preponderance of these defects in the entrant group is a commentary on the present insufficient medical supervision of the pre-school child. The majority of these cases could be prevented if taken in hand earlier and proper management in dietary habits and breathing inculcated. Table VIII. SUMMARY. Group. *Nose and Throat Defects. Enlarged Glands. Boys. Girls. Boys. Girls. Entrants 37.5 37.3 10.1 9.8 Intermediates 26.8 24.8 12.5 10.8 Leavers 16.9 17.1 4.5 53 Other Ages 25.0 7 7 .. ... #Does not include mouth breathers, but includes other defects of nose and throat. Defective Hearing, The commonest causes of deafness in children are chronic inflammation of the middle ear and adenoids. Parents are reminded that in cases of discharge from the ears, permanent damage may be inflicted on the delicate ear mechanism by syringing. This treatment, unless carefully and skilfully done, may force infection into the innermost parts of the ear, and set up an inflammation which may lead to serious consequences. A report of the work of the Ionization Clinic is given on page 60. The routine medical inspection figures showed that 0.3 per cent, entrants, 1.8 per cent, intermediates, and 1.7 per cent, leavers had defective hearing. Speech Defects. The findings show that 0.2 per cent, entrants and 0.4 per cent, intermediates showed speech defects. These figures are lower than usually found. There are no special classes for stammerers yet established under the Croydon Educational Scheme. 255 Skin Diseseases. The findings show only the incidence in the groups examined at a specific examination and must not be taken to indicate the total incidence of skin disease in school children. Entrants gave 2.1 per cent, incidence in boys and 2.2 per cent, in girls; intermediate boys 2.1 per cent, and girls 1.6 per cent.; leavers 1.5 per cent, boys, and 0.5 per cent, girls; a total in all groups of 1.9 per cent, boys and 1.5 per cent, girls. Table IX. DEFORMITIES. Entrants Intermediates T.fftvera. Totnl-. Pvrcftntiin Boys Girls Boys. Girls Boys Girl Bovp. Girl* B ys Girl Evidence of Rickets 7 5 5 4 1 13 9 0 3 0.2 Spinal Curvature 76 53 68 78 46 62 190 193 5.0 5.3 Other Deformities 43 34 23 31 31 28 97 93 2.5 2.6 Total 126 92 96 113 7s 80 300 295 7.9 8.1 In the section of the report dealing with treatment, the subject of deformities is dealt with more fully. The above figures relate only to findings at routine medical inspection. THE EYE: External Eye Diseases : Percentages. Table X. Entrants. Intermediates. Leavers Percentage defects all groupa Boys. Girls. Boys, Girls. Boys. Girls Squint 2 1 2 2 1-5 16 0 9 13 1-6 blepharitis 0 4 0-4 08 0 6 07 0 4 0-5 Conjunctivitis 01 01 0-2 0.2 0 1 0 1 01 Corneal Opacity 0 1 01 ... ... 01 Other Defects 0'2 0 3 0-2 0'2 0-3 0'5 0 3 Total 2 7 3 0 2-7 2 6 19 2-5 2 6 Group percentages 2 9 2 7 2'2 For 1930, the group percentages were 2.6, 2.4, and 1.5. Vision. 256 The entrant group is not examined for visual acuity at routine medical inspection. If a child is wearing corrective glasses, the vision is tested with the glasses worn at the time of examination. In the intermediate group 5.1 per cent, of the boys and 7.2 per cent, of the girls had defective vision, and in the leaver group 9.2 per cent, of the boys and 10.8 per cent, of the girls. The leaver group of girls invariably gives the worst figures for vision. .These figures are practically the same as for 1930. There are indications of a gradual increase in the number of cases of defective vision in school children. This may be more apparent than real, as vision is a subject of greater importance than in the earlier years of school medical inspection; and the correction of small defects is obtained in more children than formerly. Whether the cinematograph exerts any deleterious effect on eyesight is a matter difficult of proof in the face of many complicating factors. In the case of Myopes, however, there are substantial reasons for believing that the state of nutrition and the general health are important. Myopia, or the tendency thereto, also seems to be to some extent hereditary. Undoubtedly glare from exposed and high-powered electric lights does produce undue eye-strain, and, if continued, damage to visual acuity. Table XI. Extent of Defect. Intermediates. Leavers. Total. B»ys. Girls. Boys. Girls Roys. Girls No. % No % No. % No. % % % Normal 6/6ths. or 6/9ths. R 1175 96.9 1J01 94.1 983 92.5 854 91.6 94.9 93.1 L 1171 96.5 1188 93.1 986 92.8 851 91.3 94.8 92.3 6/12ths or 6/341)1$ R 35 2.9 70 5 6 68 6.5 71 7.6 4.6 6.4 L 40 3.3 81 6 3 66 6.3 73 7.8 4.7 7.0 6/j6ths. or worse R 3 0.2 5 0.4 10 1.0 7 0.7 0.6 0.5 L 2 0.2 7 0.5 9 0 9 8 0.9 0.5 0.7 257 Table XII. TEETH. Entrants. Intermediates Leavers. Boys. Girls Box s. Girls. Boys Girls. No. % No. % No. % No. % No. % No. o/ /o Perfect set of Teeth 646 41.7 601 42.1 618 50.9 632 49.5 571 54 8 571 61.3 One to four decayed 686 44.2 625 43.8 467 38.5 540 42.3 405 38.9 318 34.1 Four or more decayed 219 14.1 201 14.1 128 10.6 104 8.2 65 6.3 43 4 6 Total 1551 1427 1213 1276 1041 932 The above table gives the findings of the medical inspectors at routine medical inspections. Owing to the greater minuteness of the dentist's examination his findings, given in another section of the report, differ a little from the above. The figures indicate that some 42 per cent, of children entering school have perfect sets of teeth. This is a low percentage and has an important bearing on the relative neglect of the teeth during pre-school age. Children should not enter school with teeth in such an unsatisfactory condition. With proper dental care and the practice of correct dental hygiene this could be obviated. The importance of the pre-school period, which at present is relatively neglected, but is a time of especial importance in connection with the care of teeth, is emphasised. The leaver group gave the best findings, a result brought about by the work of the school dental service. It is interesting to note that 3,639 children of all groups, or 48.8 per cent., were found to have sound teeth at medical inspection. The need for systematic instruction, on the care of the teeth is certainly indicated. 258 Table XIII. SUMMARY OP THE FINDINGS AT ROUTINE EXAMINATIONS. (Percentages.) Condition Entrants. Intermediates. Leavers. Other Age. All Groups Bov! Girl> Boys | Girls Boys Girls Boys Girls Boys Girls Uncleanlincss— (Percentage clean) Head 99.3 98.5 99.2 96. C 99.2 97.5 100.0 100.0 99.2 97.6 Body 99.5 99.4 99.3 99.4 99.0 98.7 100.0 100.0 89.3 99.3 Clothing (satisfactory) 98.8 98.5 99.8 99.8 98.4 98.9 100.0 100. C 99.0 99.0 Footgear do. 98.7 98.5 99.0 99.8 98.8 99. 2 100.0 100.0 99.0 99 0 Nutrition (normal) 85.0 83.7 84.5 82.1 84.6 81.0 100.0 100-0 84 8 85.6 Circulatory System (defects) 6.1 4.9 9.0 10.5 6.7 8.3 25.0 15.4 7.2 7.8 Pulmonary System (defects not 0.3 0.2 0,4 0.1 0.2 0.1 0.3 1 . D, | Defects of Noic and Throat 39.7 39.0 28.0 25.4 17.3 17.4 50.0 7.7 29 6 28.6 Enlarged Cervical Glands 10.1 9.8 12.5 10.8 4.5 5.3 ... ... 9.1 9.0 External Eye Disease 0.7 0.7 1.3 1.8 1.1 1.2 ... 1.0 1.0 Defective Vision 0.7 0.2 5.1 7.2 9.2 10.8 ... 23 1 4.4 5.4 Defective Hearing 0 6 0.1 2.1 1.6 1.5 1.9 ... ... 1.1 1.1 Speech Defects 0.3 0.1 0.7 0.1 0.2 0.1 ... 25.0 0.4 0.1 Dental Disease (more than four decavedl 14.1 14 1 10.7 8.2 6.2 4.6 ... ... 10.8 9.5 Dull and Backward 0.8 0.4 1.8 1.0 0.6 2.0 ... ... 1.1 1.0 Skin Disease 2.1 2.2 2.1 1.6 1.5 0.5 ... ... 1.9 1.4 Total excluding Uncleanline«s, - - ... ... Clothing. Footgear & Nutrition 75.2 71.8 73 5 68.6 48.9 62.3 75.0 71.2 66. 7 65.3 The above table gives in a concise form the results of findings at Routine Medical Inspections. Defects of the nose and throat are once again the commonest defects found. The entrant group is the worst and the leaver the best. Under-nutrition is found in about 15 per cent, of all children examined. Girls showed a rather higher proportion of under-nutrition than boys. The findings for Dental Defects are what might be expected in view of the present lack of systematic supervision of children of pre-school age. It must be noted that, although facilities exist for the detection and treatment of dental disease before school age, parents do not avail themselves of them to any very great extent. Throughout the girls show rather better findings than the boys. Enlarged cervical glands, which have a relation both to dental defects and to under-nutrition, were commonest in the intermediate group, and were more often found in bovs than girls. There is a drop in the percentages as compared with 1930. Defective vision increased as age increased and the effect of scholastic routine, together with the strain of bodily growth must be held to be the main cause of this finding. The girls suffered more than the boys—the usual findinaf—hut as a whole there were fewer cases of defective vision than in 1930. As children who are wearing spectacles which correct vision are included as having normal vision, the more common practice 0 wearing spectacles may mask the actual amount of defective vision. 259 It is a recognised finding that vision is more defective in secondary than in elementary schools. It was, unfortunately, not possible, owing to pressure of routine duties, for the medical officers to conduct any investigation into the relationship between lighting, position of desks, etc., and the amount of visual subnormality. The following Taible was compiled from the findings at routine medical inspections, in order to ascertain the comparative amount of visual defect in the various schools. It relates only to those children who were referred for treament and who were consequently thought to 'be in need of corrective glasses. The Table therefore does not give the actual amount of visual defect, but the amount of uncorrected visual defect. Percentage of Children Examined at Routine Medical Inspection Showing Visual Defect. School. Intermediate Leavers. Toal Boys and Girls School. Intermediates Leavers. Total Boys and Girls Boys Girls Boys Girls Boys Girls Boys Girls Ashburton ... 0.7 ... ... 0.7 Winterbourne ... 0.2 1.2 0.2 1.7 Beulah ... 0.6 0.3 2.2 3.2 Woodside 1.6 3.0 ... 0.7 5.3 British ... ... 1.7 4.3 6.1 Addmgton ... 3.4 ... 3.4 Davidson 1.7 0.4 1.7 1.7 5.6 All Saints 1.0 1.0 ... 3.0 5.0 Ecclesbourne 1.9 1.9 1.6 5.3 Arch. Tenison's ... ... ... 13.3 13.3 Elmwood 0.4 3.1 1.3 4.9 Chri»t Church ... ... ... 2.9 2.9 Gonville 0.4 2.9 ... ... 3.2 Holy Trinity ... 3.8 ... ... 3.8 Howard 1.0 ... ... ... 1.0 Parish Church ... 1.7 3.5 ... 5.2 'ngram 1 2 0.8 1.2 1.2 4.0 St. Andrew's ... ... ... ... Kingsley 1.1 1.5 3.0 4.5 10.1 St. Joseph's ... 2.6 2.6 ... 5.2 Lanfranc ... ... ... ... ... St. Mark's ... 3.6 ... ... 3.6 Norbury Minor ... 0.6 0.3 0.6 15 St. Mary's 2.3 1.2 1.2 ... 3.5 Oval ... ... 2.1 2.9 5.0 St. Peter's ... 4.0 ... ... 4.0 Portland 1.6 1.6 2.4 1.0 6.5 Sr. Saviour's 1.6 3.8 0.8 ... 5.6 PurleyOaks 0.7 0.7 0.7 1.4 3.5 Shirley ... 0.7 0-7 3.7 ... 5.2 Rockmount 0.8 2.5 0.8 4.1 St. Michael s ... ... ... 9.1 9.1 South Norwood 2.8 2.4 ... 0.8 6.0 ... ... ... ... ... Sydenham 1.4 0.5 ... ... 1.9 Tavistock ... ... 3.6 5.1 8.7 Waddon 0.3 0.6 2-2 1.6 4.8 West Thornton ... 1.5 0.8 ... ... 2.3 Whitehorse Manor 1.2 2.0 2.3 ... 5.5 1.3 1.7 3.0 2.9 4.7 From this Table the school with the highest percentage of scholars in the two groups examined who had uncorrected defective vision was Kingsley (10.1). Next came Portland (6.5), and Davidson (5.6). Schools showing a higher percentage than the average for all schools in one or both of the groups examined were Ecclesbourne, Elmwood, Oval, South Norwood, Tavistock, Waddon, Whitehorse, Woodside, All Saints, Parish, St. Joseph's, St. Saviour's, Shirley and St. Michael's. 260 Table XIV. Return of Defects Found in the Course of Medical Inspection 1931, Defects. Boys Girls. No. requiring Treatment. No. referred for Observation. Percentage of total Examined No. lequiring Treaiment. No. referred for Observation j Percentage of total Examined. Malnutrition 30 26 1.47 31 36 1.84 Uncleanliness— Head — 1 0.03 — 1 0.03 Body — — — — - Skin Disease 7 5 0.31 4 4 0.22 Eye Diseases— Defective Vision 163 5 4.41 188 11 5.47 Squint 26 3 0.76 28 5 0.98 External Eye Trouble 9 3 0.31 2 6 0-22 Ear Diskases— Deafness 5 3 0.21 6 4 0.27 Otitis Media 9 2 0.29 13 2 0.41 Other Diseases 3 1 0.11 — — - Nose and Throat— Enlarged Tonsils only 158 10J 6.81 125 84 5.73 Adenoids only 12 12 0.63 7 16 0.68 Enlarged Tonsils & Adenoid* 131 46 4.65 117 51 4.61 Other Conditions 16 6 0.58 11 4 0.41 Enlarged Cervical Glands (not T.B.) — 17 0.46 — 9 0.25 Dental Defects 177 S 4.86 189 19 5.70 Sl'eech Deficts 5 6 0.29 2 1 0.08 Heart and Circulation— Organic 1 32 0.87 42 1.15 Functional 18 0.47 31 0.93 Anaemia 1 24 0.66 3 24 0.74 Bronchitis 4 22 0.68 4 12 0.44 Other Non-T.B. 1 12 0.34 1 io 0.30 Pulmonary Tuberculosis 1 7 0.21 5 0.14 Other Tuberculosh — 1 0.03 — 1 0.03 Nervous System Disorders (including Epilep>y, Chorea, etc.) 1 15 0.42 3 21 0.66 Deformities— Rickets... 1 i 0.06 1 2 0.08 Spinal Curvarure 74 6 2.10 58 22 2.19 Others 30 20 1 .31 36 18 1.48 Other Defects and Diseases 1 34 092 2 45 1. 23 Totals 866 438 34 23 831 489 3618 Y Total Children Examined 3809 3648 261 Table XV. CHILDREN EXAMINED AT ROUTINE INSPECTIONS AND FOUND TO REQUIRE TREATMENT (EXCLUDING UNCLEANLINESS AND DENTAL DEFECTS). Group. No. ..f Children Inspected N referred for treatment. Percentage referred lot treatment Corresponding percertage for 1930. Entrants 2978 475 16.0 18 6 Intermediates 2489 512 20.6 21.7 Leavers 1973 369 18.7 20.1 Other Ages 17 5 29.4 21.8 7457 1361 18.3 20.1 The fact that 16.0 per cent, of the entrants required treatment of some kind is an adverse commentary upon the lack of any complete system of medical and d3ntal supervision of fhe preschool child. Initial slight effects, if unremedied, often lead to further defects as the child grows. Adenoids are a case in point, so also are decayed and septic teeth. The importance of having what may appear to be trivial childish complaints attended to promptly cannot be too strongly or too often impressed upon parents. Table XVI. CHIEF CAUSES OF EXCLUSIONS FROM SCHOOL. Condition. Exclusions during 1931. Percentage of total exclusions. Exclusions during 1930. Percentage of total exclusions. Ringworm—Head 12 0.30 10 0 15 Body 36 0.91 36 0.52 Verminous Conditions 388 9.80 326 4.74 Impetigo 381 9.60 371 8.39 Scabies 32 0.81 19 0.28 Scarlet Fever 279 7.05 358 5.20 Measles 144 3 64 2140 31.11 Diphtheria 127 3.21 236 3.43 Whooping Cough 558 14.10 192 2.79 Chicken Pox 875 22.11 877 12.75 Mumps 594 15.01 1795 26.10 Tuberculosis (all forms 43 1 21 51 0.74 E xternal Eye Disease 14 0.35 23 0.33 Sore Throat 132 3.33 183 2.66 Other Causes 337 8.51 261 3.80 3957 ... 6S78 - 262 There were 2,921 fewer children excluded from school on account of various illnesses than in 1930. The main cause of this drop was the much lower incidence of infectious disease, particularly Measles and Mumps. The chief causes of exclusion were Infectious Diseases, 65.1%, and of these Chicken Pox, Mumps and Whooping Cough gave the most trouble. Exclusions on account of verminous conditions showed an increase from 4.74% to 9.8%. The health visitors examined 64,27-1 children in the schools in connection with the personal cleanliness of the scholars. Impetigo remained much as in the previous year (9.6%). Table XVII. CAUSES OF DEATH IN CHILDREN OF SCHOOL AGE. 1931. 1930. Pneumonia 4 3 Measles — . 8 Respiratory Disease (net Pneumonia or Tuberculosis) — 2 Infectious 1 >isease (not Tubercular) 6 11 Tuberculosis (all forms) 4 8 Diseases of the Digestive Syttem 5 4 "All other causes 20 29 39 65 In the infectious diseases gioup Diphtheria 3, Scarlet Fever 2, Dysertry 1, were the causes of the deaths. * Among; other causes Violent Deaths (8), Organic Heart D sease (3). and Meningitis (2) were the most prominent. Taking the school population as 25,637, the death-rate per 1,000 in school children was 1.5. There were no deaths from Measles, compared with 8 deaths in 1930. 263 SECTION III. INFECTIOUS DISEASE. Notifiable infectious diseases in schools, and also cases of other than statutorily notifiable diseases, brought to the notice of the department by Head Teachers and School Attendance Officers. Table XVIII. Name of School. School population. Notifiable Diseases. Conditions notified by Teachers and School Attendance Officers. Percentage incidence of Infectious Diseases in Schools. Scarlet Fever Diphtheria. Ac. Primary Pneumonia. Measles. Whooping Cough. Chicken Pox. | Mumps. Scabie-. Impetigo. Sore Throats. Ringworm (body). Ringworm (scalp). Indefinite Sickness. 111. Not Infectious. Conjunctivitis Ishburion 668 14 1 ... 4 17 13 34 ... i ... 2 ... 15 35 ... % 12.4 Beulsh 1176 13 ... I 36 13 4 2 21 2 2 1 15 39 ... 5.8 Wdon British 560 3 3 ... ... 1 ... ... 1 ... 3 ... 2 6 ... 1.3 Davidson 685 9 4 ... 3 27 9 4 1 9 1 1 ... 16 36 ... 0.8 Ecclesbournc 977 8 3 ... ... 16 57 32 4 14 2 2 1 11 35 ... 11.9 !lmwood 1093 6 1 ... 1 19 32 5 ... 43 1 ... ... 16 17 ... 5.9 Granville 366 7 ... ... 6 19 9 39 ... ... ... 1 ... 4 6 ... 21.9 Howard 445 2 1 ... ... ... 1 ... ... 2 ... ... ... ... 2 ... 0.9 Anagram 1183 14 32 ... 9 3 130 6 2 29 8 1 1 12 46 ... 16.4 Kings ley 812 7 4 ... 10 11 19 ... ... 26 2 ... ... 8 13 ... 6.3 :amfranc 449 1 1 ... ... ... 1 1 ... 3 2 ... ... 1 4 ... 0.9 Nob bury Manor 875 7 5 ... 3 18 1 ... ... 2 1 ... ... 4 11 ... 3.9 Oval 660 7 1 ... 26 17 4 2 ... 16 1 1 1 10 27 1 8.6 Portland 1057 15 6 ... ... 48 99 52 ... 21 2 1 2 15 29 2 20.8 pur ley Oaks 487 1 2 ... ... 6 10 2 1 7 4 ... ... 1 5 ... 4.3 Rectory Manor 601 5 6 ... 14 9 4 3 3 19 10 ... ... 5 18 6.8 Amount 494 2 2 ... 5 11 5 69 2 6 3 ... 1 ... 11 ... 17.0 South Norwood 829 12 1 ... 20 24 47 61 2 2 4 15 14 2 19.9 Sydenham 826 5 2 ... 1 21 15 18 ... 20 2 5 1 20 38 ... 7.6 Tavistock 751 3 2 ... ... 24 57 4 ... 7 1 2 ... 9 15 ... 12.0 Waddon 1171 17 6 1 2 19 80 13 ... 53 18 8 l 12 80 2 11.8 Twst Thronton 1026 27 5 1 13 12 48 14 1 11 22 1 1 19 55 2 11.6 Whitehorse Manor 947 5 4 ... 9 4 17 66 11 4 2 l 18 25 ... 11.1 Water bourne 1265 8 3 ... 1 36 46 40 2 5 2 ... ... 15 46 2 10.7 Woodside 918 18 4 ... 4 44 21 15 3 10 2 ... ... 19 36 3 ll.0 Addington 62 1 ... ... ... 1 ... 1 ... 3 ... ... ... 1 ... ... 4.8 All Saints' 37* 2 ... ... 1 27 ... 4 ... 1 ... ... l 2 5 ... 9.1 Chirst Church 487 11 ... ... 1 7 4 1 2 2 4 2 ... 5 24 ... 6.2 Holy Trinity 265 2 ... ... 2 17 5 62 ... 1 ... ... ... 13 13 ... 33.2 Parish Church 546 3 13 ... 1 4 34 5 1 7 19 1 ... 12 26 ... 11.0 St. Andrew's 390 3 ... ... 2 2 25 ... ... 11 4 1 ... 7 9 ... 9.2 St. Joseph's 198 1 ... ... ... ... ... 3 ... ... ... ... ... ... ... ... 2.0 St. Mark's 146 13 ... ... 2 10 3 9 ... 3 5 1 ... 1 9 ... 26.0 St. Michal's 363 2 ... ... ... 1 2 ... ... 3 ... ... ... 2 1 ... 1.4 St. peter's 224 1 ... ... ... 1 3 5 ... ... ... ... ... 2 ... 4.5 St. Saviour's 151 4 ... ... ... 18 25 ... ... 2 ... ... ... 12 16 ... 31.1 Shirley 366 2 ... ... 2 18 23 26 2 1 1 1 ... 8 4 ... 19.7 Tenison's 241 2 ... ... ... 10 2 1 ... 3 ... ... ... 2 3 ... 6.7 health Clark 398 4 ... ... ... ... 3 ... 1 4 1 ... ... 1 2 ... 1.8 John Ruskin 382 3 ... ... ... ... 3 3 ... ... ... ... ... ... 4 .... 2.3 Lady Edridge 382 5 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1.3 Sel urst Grammar 322 ... ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... 1.2 St. Giles 974 2 ... ... ... ... 1 ... ... ... ... ... ... ... ... ... 0.3 St. Christopher's 70 ... ... ... ... ... 3 ... ... 1 ... ... ... 1 ... ... 4.3 Nyopic 101 ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... Nil 17 ... ... ... ... ... ... ... ... 1 1 ... ... ... ... ... Nil Totals 279 127 4 144 558 875 594 32 381 132 36 12 337 766 14 Note.- unlive f'cascs un.cn Hum scarier r ever, Diphtheria, Measles, Whooping Cough, Chicken-Pox and Mumps. 264 rtie percentage incidence is calculated on the average school population over the year at each school. Holy Trinity showed the highest incidence (33.2%) of all infectious diseases; this was due to a number of cases of iMumps and Whooping Cough. Next came St. Peter's with 31.1%, due to Chicken Pox and Whooping Cough; then St. Mark's (26%), Gonville (21.9%), and South Norwood (19.9%). The lowest incidence was found in Selhurst Grammar School (0.3%), Howard and Lanfranc (0.9%), Davidson (0.8%) and British (1.3%). Scarlet Fever. Two hundred and seventy-nine cases were notified from the Schools; of these, West Thornton (27), Waddon (IT), Portland (15), and Ingram (14) showed the highest number of cases. Diphtheria. One hundred and twenty-seven cases were notified in the schools, and of these Ingram, with 32 cases, had the largest number, with Parish Church (13cases) next. Thecontinual higher incidence at Ingram is a puzziing phenomenon. For several years past the school has had an undue number of cases of Diphtheria. Although, by universal swabbing and exclusion of carriers, outbreaks are controlled for the time being, the malady is continually reappearing. Sanitary investigations and a thorough survey of the school premises have failed to reveal any contributory factor. It would appear that there must be several intermittent carriers among the scholars, though if every school child attending the schools was swabbed it would be certain that a proportion would have positive findings; yet Diphtheria does not loom so largely in any of the other schools. The Schick testing and immunisation of all the children would end the problem, but, unfortunately, only a small number of parents are willing to have this procedure carried out. A small outbreak occurred in the Parish Church Schnool towards the end of the year, but was soon controlled by swabbing and isolation. A small proportion of the parents accepted the Schick procedure after the Medical Officer had addressed them on the subject. Mumps. Out of a total of 594 cases in all the schools, Holy Trinity (G2), Whitehorse Manor (60) and Rockmount (59) returned the most cases. 265 Small Pox. An outbreak of Small Pox, originating in one of the Common Lodging Houses in the town, spread to 4 schools in the neighbourhood; six cases arose in Rectory Manor School, affecting children from 4 families; 5 cases in Whitehorse Manor School, 4 of whom were members of one family; 1 case at Christ Church School, and 1 at St. Mary's. Eight of the children had never been vaccinated; 5 had just been vaccinated as contacts of other cases, but the vaccination proved too late to prevent the onset of the disease. Chicken Pox. This was the most troublesome infectious disease in the schools during the year. 875 cases came to our notice, and of these 130 occurred at Ingram, 99 at Portland, and 80 at Waddon. Whooping Cough. A total of 558 cases were noted, the highest numbers for individual schools being at Portland (48), Woodside (44), Beulah and Winterbourne (36). Measles, During 1931 the incidence of Measles was very light In view of its epidemic prevalence in 1930, this was to be expected. 1932 will probably show a marked increase. Oval with 26 cases and South Norwood with 20 cases showed the highest numbers. ! he number of cases of Scabies, Impetigo, and of indefinite illness showed a small increase on last year's returns. Schick Testing and Immunisation Against Diphtheria. During 1931 the department has carried out this treatment in two Residential Institutions within the Borough, in addition to treating several cases from private households. Russell Schools (Ballards). Routine testing and Immunisation was continued through the year in these schools. In all, some 61 boys were treated. 15 bovs awaiting re-test from 1930 were done, two being found still positive after three doses of prophylactic, the remainder were negative. 266 These two boys were given a further series of three injections and, at a subsequent test three months later, were shown to be negative. 46 boys were treated for the first time. 33 were positive and 13 negative to the test. Of the 33 positive boys all have received three doses of prophylactic (T.A.M.), 16 have come up for retest and are now negative, and the remaining 17 await retest in 1932. Fidelis Convent, Upper Norwood. Diphtheria broke out in this convent in February of 1931. Several cases were removed to the Borough Hospital and several carriers were shown by swabbing to exist in the school. In spite of these latter being also removed to the Isolation Hospital, cases continued to arise among the children, and in March the authorities were advised to have the whole of the children Schick tested and the susceptible children immunised. 272 childrn were submitted to the test, 119 were positive and 153 negative. All the 119 positive children received three doses of prophylactic (T.A.M.) at fortnightly intervals and, at a subsequent re-test, 73 were found to be negative and thus free from susceptibility. Six children were found to be still positive at re-test and were given three more doses of prophylactic; these, together with Is other children, whose re-test was not due before the end of the year, will be submitted to a further test in 1932. The remaining 22 children, positive at the initial test, left the school during the immunising process. Twelve private cases were Schick tested, all children below the age of ten years, none of whom had had diphtheria. 11 were positive : of these 10 were immunised with three doses of prophylactic and 8 subsequently underwent re-test and were found to ht negative. 267 SECTION IY. FOLLOWING UP. There are 19 Health Visitors, 17 of whom devote 5/11 of their time to school work, and two who are employed whole time in school clinics. In addition there are two masseuses, one of whom devotes all her time to school work and the other half her time, the other half being occupied with Maternity and Child Welfare. There are two whole-time dental assistants. Perhaps the most arduous part of a school nurse's work, and certainly the most important and valuable, is home visiting. This demands perseverance, tact and good nature if satisfactory results are to be achieved. In addition the nurses assist at routine and special medical inspections in the schools and pay periodical visits to schools for cleanliness surveys. With the helpful co-operation of the Chief School Attendance Officer and his staff, one or two of the persistent offenders against cleanliness have been proceeded against m Court, others have been brought before the Committee and warned. Since these steps were taken, the nurses report a decided change for the better in schools which previously gave unsatisfactory findings. There are still, however, certain families which consistently spoil the figures for some of the schools. School Visits. The following table summarises the visits paid, etc., in connection with these duties : — Visits to Schools re Cleanliness 40 Visits to School Departments re Cleanliness 463 Number of children inspected for cleanliness (first inspection) 64274 Number of children inspected (subsequent inspections) 3281 Number of children found unclean (first inspection) 2749 Number of children found unclean (subsequent inspections) 1652 268 Home Visits. Concerning cleanliness 218 Concerning defects found at routine medical inspections 2215 Subsequent visits re defects found at routine medical inspections 1380 Visits re special cases 1235 Visits to dental cases 870 Visits in connection with infectious cases and other visits 13765 These figures show an increase of 3,612 in the number of children inspected for cleanliness, a decrease of 5,092 in visits paid in connection with infectious cases and other visits for miscellaneous reasons; an increase of 107 in the following-up visits to dental cases, and in visits to special cases. An increase of 1,743 in the visits made regarding defects found at routine medical inspections, and of 87 in the home visits regarding uncleanliness. TREATMENT. The Work of the School Clinics. Table XIX. Summary of Attendances. 1931. 1930. Increase or Decrease. Minor Ailmrnts Clinics 11234 9328 + 1906 Inspection Clinic 1380 1566 _ 186 Dental Clinics 13167 13046 + 121 Ophthalmic Clinic 2345 2353 — 8 Orthopedic Clinic 2401 2fi57 — 256 Remedial Exercises Clinic 9229 11454 — 2225 Ear. Nose and Throat Clinic 1524 1811 –287 Ionization C linic 578 516 +62 4185s 42731 –873 Although, owing to the resignation of the Senior Dental Surgeon, dislocation of the work occurred for a period, the work did not decline in volume. A fairlv large decrease was noted in the attendance - at the Remedial Exercises Clinic. It is felt tha' this is due partlv to the practice of certain schools having I hvsical Exercises Classes, and partlv to the Da rents being unable to attend the Central Remedial Exercises Clinic on account of 269 distance or expense. The number of cases referred for removal of adenoids and enlarged tonsils also declined. The aggregate of attendances at the various Clinics shows the extent of their usefulness. It is doubtful if many of the cases dealt with would have obtained the treatment elsewhere. Children are not infrequently referred by medical practitioners to the Clinic to obtain treatment. The Minor Ailments Clinic. This Clinic is held each morning at the Lodge Road premises. One nurse is in attendance for the whole session and a doctor attends daily to see cases referred to him. He does not spend his whole morning here, however, going on either to a school for a medical inspection or to another Clinic. The scope of the treatment given is shown bv the table. Medical cases or rases requiring surgical measures are referred to their private doctor or to hospitals. The aim of this Clinic is to render first aid and to treat the minor disabilities peculiar to school children, and to advise what further measures mav be necessary. A subsidiary clinic is held at 206, Selhurst Road on three occasions weeklv. 423 children made 2,312 attendances during 1931. Table XX. Complaint. 1931. 1930. Cases Attendances. Average No. of Attendances per case Cases. Attendances. Average No. of Attendances per case. Ringworm of Scalp 30 276 9.2 31 197 6.3 . . •• Body 24 183 76 28 413 14.7 Scabies ... 47 346 7.4 37 288 7.8 Imptiigo ... 297 2013 8.8 276 2284 8.3 Other Skin Diseases 103 317 3.1 132 449 3.4 Otorrhcea and other Ear defects 284 4449 15.7 231 2854 12.4 External hve Disease 182 972 5.3 132 781 5.9 Miscellaneous 570 2678 4.7 325 2062 6.4 1537 11234 73 1192 9328 7.8 I'rom this table it is seen that the average number of attendances per child declined from 7.8 to T.3; the total attendances r°se by 1,906, and the number of individual cases by 345. Otorrhoea is one of the most difficult of all minor conditions in school children to cure, this being reflected in the large number °f attendances made for the remedying of this defect. 270 Impetigo still remains troublesome, whilst the cases of scabies attending have also shown a small increase. No attempt has been made to treat ringworm by means of thallium acetate, a drug with the peculiarity when taken by mouth of causing depilation of the scalp. It is not, however, without danger, and should never be given unless the child is kept in hospital or under constant medical supervision. Adenoids and Enlarged Tonsils. During 1931, 301 cases of tonsils only, 21 cases of adenoids only, and 287 cases of adenoids and enlarged tonsils, a total of 609 cases, were recommended for treatment. In 506 cases the Local Education Authority was requested to arrange for the operation. There were 99 operating sessions at the Croydon General Hospital. The work is done by a rota of 8 general medical practitioners working in pairs, as surgeon and anaesthetist, for periods of 3 months, and remunerated by the Education Committee. All other expenses of the Clinic are also borne by the Committee. The cases were examined at the Throat Clinic prior to the operation. 506 children were operated upon, a decrease of 102 on 1930. In 86 cases detention in the hospital was necessary; 420 were conveyed home by ambulance a few hours after the operation, Where possible it is preferable for all children to be kept in hospital for one or two nights after this operation. In all there were 193 non-attendances. In 12 cases the operation was not successful in as much as tonsillar tissue to a greater or less degree was left behind. In 4 of the cases a second operation was succesfully performed. Of the 506 children operated on 296 attended the Remedial Exercises Clinic for post-operative breathing exercises. This is a very important complement to the operation and is of perhaps equal importance. The percentage of children operated on, who attended for exercises, was 59%, compared with 64% in 1930. 105 cases came to the knowledge of the department where the parents had obtained treatment from another source; the majority at a London hospital. In these cases the expenses are defraved bv the parent and not by the Local Education Authority Only the following conditions are considered to warrant the reference of a child for operation, as it is held that lymphoi 271 tissue has definite functions, and proliferation thereof may be a protective measure. Sometimes the proliferation increases to such an extent as to bring about complications of its own. If this occurs then surgical measures may be necessary : — (a) Tonsils which are enlarged and septic, especially if in conjunction therewith the tonsillar glands are also enlarged. (b) Obstruction to breathing through one or both nostrils. (c) The presence of mouth breathing. Strict adherence to these standards obviates the unnecessary removal of tonsils. Provided the tonsils are not interfering with any normal function and are not a focus of septic poisoning, there is no proof that their removal is of any benefit to a child. The number of cases operated on shows a decline. The Inspection Clinic. This is held on Wednesday, Friday and Saturday mornings. Friday is reserved for rheumatic cases, and a special report by Dr. O'Connell respecting the latter is given later in this report. The object of the Inspection Clinic is (a) to examine children referred bv parents or teachers for special examination ; (b) children sent by school attendance officers for an opinion as to their fitness or otherwise to attend school; (c) children referred for examination under the provisions of the Education Act, 1918, Sec. 15; (d) cases in whom a further examination is desired after routine medical inspection; (e) children referred under the luvenile Employment regulations. 1,380 attendances were made by children during the year. TREATMENT OF VISUAL DEFECTS. Table XXI. Number of defects dealt with. Spectacles prescribed Spectacles obtained. Under the Authority's Scheme. Submitted to ictraction by private practitioner or Hospital apart from the Authority's scheme Otherwise. f otal. Under the Authority's Scheme. Otherwise. Under the Authority's Scheme. Otherwise. Errors nf Refraction— Jpementarv Schools 653 32 685 554 32 432 32 Secondary Schools 80 15 96 16 7 13 7 733 47 780 570 39 445 39 272 Orthopaedic Work. The orthopaedic scheme under the Council comprises a diagnostic and treatment clinic under Mr. Alan H. Todd, held at the Croydon General Hospital every Thursday morning. A Remedial Exercises Clinic, is held in St. Andrew's Hall, Pump Pail, daily. Children are referred to this Clinic from the Orthopaedic Clinic at the General Hospital and from the School Medical Officers. Each fortnight the children are seen by a doctor in order to observe the effects of treatment and to order any variation that may be thought necessary. There is also St. Giles' School for physically defective children in Winterbourne Road. Massage is carried out at the Croydon General Hospital, St. Andrew's Hall and St. Giles' School; at the two latter the work is shared between the two full-time masseuses of the school medical and maternity and child welfare departments. Figures relating to the Clinic at the General Hospital are given in the Orthopaedic Section of my Annual Health Report, the figures below relate to Clinics held at places other than the Croydon General Hospital. The numbers attending Mr. Todd's Clinic have increased to such an extent that the session is often prolonged far beyond its proper limits. An alternative scheme for holding subsidiary clinics at St. Andrew's Hall and at Lodcfe Road was not proceeded with owing to economy measures. Table XXII. Spinal and Other Remedial Clinics. Attendances. 1930. Sessions. Av. att. Attendances. 1931. Sessions. Av. alt. Spinal 4,043 430 9.4 .. 3,389 589 5.8 Massage! ... 143 140 1.0 .. 138 138 1.0 Other Remedial 5,979 440 13.1 .. — Flat Feet ... — — — 1,442 193 7.4 Breathing ... — — — .. 2,885 268 10.7 16,165 1,010 7,854 1,188 St. Giles' School. Total number of sessions 206 Total number of attendances 1,375 Average attendance at each session 7 Total number of female patients 16 Total number of male patients 12 Total number of patients 28 273 CONDITIONS FOR WHICH REFERRED. M. F. Total. Infantile paralysis 6 6 12 Hemiplegia 1 2 3 Kyphosis 1 1 2 Lordosis — 1 1 Scoliosis — 1 1 Cretinism — 1 1 Muscular dystrophy 2 — 2 Paraplegia — 2 2 General muscular inco-ordination 1 2 3 Osteo myelitis 1 — 1 12 16 28 Cases still under treatment : 22. THE SCHOOL DENTAL SERVICE. The dental staff consists of three full-time dental surgeons. Owing to the interregnum there were periods during the year when the service was operating with only two dental surgeons. The work of the School Dental Service consists chiefly in the inspection and treatment of school children, and in addition the treatment of patients referred under Maternity and Child Welfare, Tuberculosis, and Mental Deficiency schemes. The Clinic in the South Norwood district has now been operating for over a year, and the results justify its existence. The average number of children served by each dentist is now 7,000. Sir George Newman gives 5,000 as a satisfactory number per dentist under present economic conditions, and 2,300 under ideal conditions. During the year the orthodontic treatment (regulation of the teeth) increased considerably, and further details of this se'vice are given elsewhere. The necessity of a service to deal with treatment for irregularity of the teeth cannot be too strongly urged, as, unfortunately, a considerable number of children suffer from abnormality in position of the teeth. 274 Summary of school children inspected and treated during the year:— Patients examined 23,571 Patients treated 8,138 Attendances 13,167 Fillings 4,482 Extractions 13,489 "Gas" cases 2,606 Other operations 1,518 Locals 1,683 Sessions held :— Inspection 150 Treatment 1,086 Administration 28 Total sessions 1,264 In addition, 151 sessions were occupied in other than school work. £386 15s. 0d. was received from patients for treatment, and £'10 l1s. 8d. voluntary box contributions. The charge for treatment under all the dental schemes is 6d. per attendance and 1s. 6d. if "gas" is administered. Cases of real necessity are treated free. Inspection: 150 sessions were devoted to school inspection, this being practically the same as 1930. The age groups dealt with were 6, 7, 8, 9, 10, 11, 12, 13, 14 years for re-inspection, 5 and 6-year-old entrants, and the whole of the children attending Central Schools. The toal number of children examined was 23,571. of whom 15,028 were found to be in need of treatment, i.e., 65%. The following Table indicates the steadv improvement in tne state of the teeth since 1924. There is an increase in the number of children referred for treatment, but that is because a little more time has been spent during the inspections so that the small "pin-hole" cavities should not be overlooked. Year. 1924 1925 1926 1927 1926 1929 1930 1931 Percentage of Children Referred for Treatment 82 75 68 61 61 63 63 65 275 Table XXIII. Summary of all Examinations. 1931. 1930. Age. Sex. No. Examined. no. Referred for Treatment. % Teeth Sound. No. Examined. No. Referred for Treatment. % Teeth Sound 5 years B 610 417 32.0 872 655 25.0 G 461 366 21.0 786 571 27.0 6 ,, B 1221 884 27.0 1171 829 30.0 G 1105 777 30.0 1262 927 26.0 7 ,, B 1257 877 30.0 1214 823 31.0 G 1137 811 29.0 1374 937 32.0 8 ,, B 1358 948 30.0 1193 795 33.0 G 1176 866 26.0 1061 630 40.0 B 1421 984 31.0 960 597 38.0 G 1446 1048 27.0 1056 640 41.0 10 ,, B 1667 1087 31.0 1354 828 39.0 G 1600 1064 33.0 1368 760 42 0 11 ,, B 1512 1042 31.0 843 524 38.0 G 1442 943 36.0 789 454 42.0 12 ,, B 901 606 33.0 649 381 41.0 G 916 617 33.0 653 390 40.0 13 ,, B 698 445 36.0 620 336 46.0 G 708 469 34.0 644 330 49.0 14 ,, B 414 276 33.0 513 348 32.0 G 432 278 36.0 514 263 49.0 15 ,, B 190 130 32.0 123 60 59.0 G 169 93 42.0 58 19 66.0 Total Boys ... 11149 7696 31.0 9512 6166 35.2 Total Girls ... 10582 7332 31.6 9564 5941 37.8 The above Table includes all the children examined at routine examinations, and therefore comprises (a) children seen for the first time, (b) children treated regularly since 1924, (c) children whose parents had previously refused treatment. The summary varies a little from that of 1930, but that is due to a more detailed examination of the teeth. It will be seen that with one or two exceptions the number of children requiring treatment decreases as the higher age groups are reached. This is because they have been under treatment for a number of years. It is encouraging to see that there is a slight improvement in the dental condition of the 5 and 6-year-old entrants. This may be due to pre-school treatment; continuation of the visits to the Centres will probably produce a greater number of sound 276 tions in the future, as the mothers are beginning to realise the advantage to the child in having treatment when the teeth first show signs of dental caries. Table XXIV. Entrants. Intermediates. Leavers. Boys. Girls. Boys. Girls. Boys. Girls. t No. % No. % No. % No. % No. % No. % Perfect set of Teeth 434 44.5 401 43.4 681 42.2 623 40.6 972 58.8 739 61.5 Dental Caries 973 55.5 924 56.6 930 57.8 918 59.4 678 41.2 462 38.5 Total 1407 1325 1611 1541 1650 1201 These figures cannot be considered accurate, as it was found difficult to transfer all the cards through the re-organisation of the schools. In consequence, some of the above number were inspected as routine cases, but were, in fact re-inspections. Wherever possible this duplication has been corrected. Table XXV. Treatment. The parents of the 15,028 children, found at inspections to require treatment, were notified and advised to obtain treatment either privately or at the Dental Clinic. 8,835 consents requesting clinic treatment were returned—58.8% as against 55.9% in 1930, 57.1% in 1929, 54.8% in 1928, and 52.6% in 1927. of the above number 8,138 received treatment before the close the year —92%. 1928. 1929. 1930. 1931. No. of children requiring treatment 9516 8850 12049 15028 No. of consents to clinics 5219—54.8% 4862—57.1% 6733—55.9% 8835-58.8% No. of private treatments promised 1410—14.7% 1813—18.4% 2596—21.5% 3660-24.3% No. of " no decision," i.e. forms not retd. 1994—20.9% 1898—21.4% 2368—19.6% 2126—14.2% No. of definite refusals 902— 9.6% 277— 3.1% 352— 3.0% 407— 2.7% 277 There is a gradual increase in the number of promises to obtain private treatment, but, unfortunately, in the majority of cases this is evasion. Some parents obtain complete treatment, but in most instances just a few temporary teeth are extracted and other teeth needing attention are left, until the children complain of pain, when the parents bring them up as " Specials." Special Cases. 1,840 "special" cases were treated in addition to routine children. These comprised (a) cases requiring treatment prior to the operation for the removal of tonsils and adenoids, (b) cases referred by the School Medical Officers, (c) cases referred by the Tuberculosis Officer, (d) "casuals" referred by head teachers as needing treatment for acute conditions; the latter group and many of (a) being chiefly those who had previously refused treatment. A portion of two sessions per week—9-10 o'clock Mondays, 2-3 o'clock Wednesdays—is set apart for treating head teachers' special cases. There were 181 such sessions and 1,840 cases attended, compared with 199 and 1,891 for 1930. Full details of sessions and treatment are set out in the Board of Education Table at the end of the Report, while a summary given below is for the purpose of comparison with previous Years : 1926. 1927. 1928. 1929. 1930. 1931. Number of new cases per session 8.3 8.7 8.9 9.2 7.9 7.4 Attendances per session 11.9 13.3 13.8 14.0 12.6 12.1 Fillings 5.7 5.2 6.1 4.6 4.3 4.1 Extractions 13.5 14.2 13.1 14.9 13.7 12.4 Other operations 1.1 1.4 1.8 2.1 1.5 1.4 Gas cases during the year 1495 1894 1638 1791 2395 2605 Local anaesthetics - - - - - 1638 1927. 1928. 1929. 1930. 1931. Permanent teeth extracted ... 1039 1020 1279 2001 2689 Permanent teeth filled ... 1653 2406 1926 2769 3228 Ratio of fillings to extractions ... 1 :0.6 1 :0.4 1 :0.6 1 :0.7 1 :0.8 Temporary teeth extracted ... 8013 8101 9081 12105 10800 Temporary teeth filled ... 1702 1829 1326 1732 1254 Ratio of fillings to extractions ... 1 :4.7 1 :4.4 1 :6.8 1 :6.9 1 :8.6 As noted last year, too much time is devoted to the extraction of teeth rather than to filling, i.e., saving teeth. During the past year this has been due to the inclusion of a large number of 278 children from Central Schools who have not had the opportunity of treatment for a period of years, and who in consequence have required a large number of permanent extractions. The extension of the scheme will no doubt result in an improvement in the ratios shown above. It will be seen that there is an increase in the number of permanent fillings, but, unfortunately, this is off-set by the larger number of extracted permanent teeth. Perhaps a more detailed examination of the teeth at the dental inspections will bring about an improvement in 1932. Special Treatments. Partial dentures to replace lost incisors—3. Appointments. Routine appointments made 15,827 Routine appointments kept 10,121—63% Special appointments made 832 Special appointments kept 553—66% Following Up. In the case of children referred for treatment prior to throat operation and failing to keep appointments, non-attendance forms are issued to the Health Visitors for following up. During the year 242 such forms were issued. Preventive and Educative Measures. Parents are encouraged to attend the Clinic with their children, and opportunity is taken to make clear any points of doubt that might exist regarding treatment. Talks are given to parents in school at the conclusion of inspections of five and sixyear-olds. Leaflets setting out rules for the prevention of decay are given to all parents attending the talks. Selhurst Dental Clinic. The Branch Dental Clinic at 206, Selhurst Road, has now completed its first year, and statistics show the amount of work done. It cannot be correctly said that the Clinic has operated for the whole year, as during the interregnum Mr. Bryce worked 43 sessions at the Dental Clinic, Lodge Road. 279 Table XXVI. Summary of Work Done. 1931. 1930. Attendances 3,486 3,285 Extractions 2,726 3,040 Fillings 1,457 1,035 Patients treated 2,326 Other operations 283 "Gas" cases 545 Local anaesthesia 171 Sessions held : Inspection—48. Treatment—309. Number of new cases per session 7.5 Attendances 11.2 Fillings 4.7 Extractions 8.8 Other operations 0.9 Ratio of fillings to extractions 1:1.8 The results compare favourably with Lodge Road Denta Clinic. ORTHODONTIC SERVICE. The work of the School Dental Service has been augmented by the addition of a comprehensive scheme of orthodontics, and it is beyond dispute that the correction of dental irregularities is of immense value in improving the health of the school child, as one of its most important objects is to ensure proper functioning of the jaws and teeth. Why a School Orthodontic Scheme is Essential. It was observed during the school inspections that a considerable number of children suffered from dental irregularities, and the difficulty of obtaining treatment was evident. Parents of the majority of children attending the elementary schools are not in a position to pay for private treatment, and a scheme has been organised to meet their needs. Other than private treatment, there is only one channel in which these cases can be treated, and that is the Dental Departments of the London Hospitals. Owing to the expense this arrangement is impracticable in a large number of cases. To prevent this and also to give parents and patients confidence in their own School Dental Service to carry out such specialised work, the diagnosis and treatment of each case has been carried out at the Clinic. 280 Parents are very keen on this new branch of public health dentistry, and continually ask for appointments, and its popularity may be judged by the long waiting list. All treatments, except for the initial visit, have been attended to after the routine sessional cases have been completed, but the number of cases is increasing, so that some definite provision with regard to attendance will have to be made in the near future. Cost of the Scheme. Fees so far have been low, and on an experimental basis. All the appliances inserted have been paid for by the parents, so that no expense has been incurred to the Local Authority, save the Dental Surgeon's time. The arrangement in 1931 was that the charge was based on the cost of the appliances, which varied with che different types used. With the experience gained during that year a definite scale of fees is now under consideration. Orthodontia as a Preventive Measure. It is sometimes said that time given to Orthodontia could be spent in conservative treatment, but it cannot be regarded as a scientific procedure to fill teeth in an overcrowded mouth prone to infection. The cause of the condition must be removed before an improvement in the incidence of dental caries can be expected. Irregularly-placed teeth are not only predisposed to decay, but, moreover, in adult life they show a great susceptibility to pyorrhoea. Oral hygiene under these conditions is impossible, as the tongue, lips and muscles are unable to carry out their proper function. Orthodontia is, then, a necessary prophylactic measure; in fact, it is an outpost of preventive dentistry. Chief Causes Producing Dental Deformity. The prevention of irregularity depends to a large extent upon the parent. A healthy mother will produce a healthy child with strong bones, and the growth of these bones is dependent upon correct function and diet. A bottle-fed child will not get proper stimulation and development of the jaws to hold a full complement of teeth. 281 The loss of the deciduous molars is a frequent cause of malocclusion. Behind the temporary teeth erupt the six-year-old molars which have been described as "the key teeth of occlusion." Early extraction of the temporary molars allows these permanent teeth to "drift" too far forward, causing general overcrowding. Prolonged retention of deciduous teeth can also produce abnormality. These teeth, when in a septic condition, remain as foreign bodies and deflect the erupting tooth. That is why inspection and treatment of children's teeth is essential, so as to avoid these unfortunate sequelae. Mouth breathing caused by nasal obstruction such as adenoids and hypertrophied tonsils frequently produces high dental arches, with a general overcrowding of the teeth. All cases of dental deformity due to nasal Obstruction should have surgical attention before dental treatment is commenced. During mouth breathing the mouth is continually open, and tension of the cheek muscles produces pressure on the plastic bones, causing contraction of the arches. When the mouth is closed during normal breathing the tongue exerts pressure against the palate, and this pressure prevents narrowing of the arches, but in the mouthbreather that action of the tongue is lost, and with it the natural stimulation of the development of the jaws. Frequent action of the tongue is necessary for proper formation of the jaws. There is something to be said for the " chatterbox," and mothers of garrulous children may console themselves with the fact that frequent exercise of the child's tongue is invaluable in producing well-formed arches. Bad habits during babyhood must be corrected, such as sucking a "dummy," the thumb, toe or lip, as they push the soft baby bones out of shape. Unfortunately, many parents readily condone such habits, presumably in the hope of keeping the child quiet, but in permitting these habits they seem unaware of the danger of producing malformation of the jaws and subsequent irregularity of the teeth. Better development of the arches could be achieved if mothers would realise that proper function of the child's teeth can only be obtained by giving food which requires thorough mastication. It may be remarked that hereditary influences are often responsible for some cases of irregularity and malformation of the jaws. 282 Selection of Orthodontic Cases. These are selected during the school inspection. After obtaining the parents' consent for treatment the case is called up as a routine appointment. Diagnosis of the condition is made, and the form of treatment decided. Two sets of impressions of the mouth are taken. One set is filed for reference, and the other is sent to the dental mechanic with instructions as to the type of apparatus required. Conditions associated with gross deformity, as in cases of deficient growth of the mandible and extreme cases of inferior retrusion, with secondary proclination of the upper incisors, are not within the scope of Public Health Orthodontics, and are better left alone or referred to a hospital. It is only possible in Clinic work to concentrate on cases where the prognosis is good. Classification of Orthodontic Cases. Treatment is based on the classification of Angle, which, although not adopted by all Orthodontists, is the generallyaccepted form of diagnosis. This classification is based on the position of the six-yearold molars, because these teeth can be regarded as the pillars of the mouth. The position of the permanent teeth is fairly constant, but, of course, when the neighbouring temporary teeth are extracted too early the position of Angle's "key teeth" may move in a forward direction, although a thorough examination of the mouth will enable the operator to observe the classification. Table XXVII. Types of Cases Treated. (a) Abnormality in position of individual teeth— Number of cases treated or undergoing treatment with the following defects. Labioversion 5 Mesioversion 2 Linguoversion 29 Infraversion — Supraversion 1 Torsoversion 3 Distoversion 1 Total 41 283 284 (b) Abnormal relationship of the upper and lower arches. (c) Developmental defects of the jaws. Under these two headings are included treatments for the following conditions : — Superior protrusion. Inferior retrusion. Open bite. Close bite. General overcrowding. Narrow arches requiring expansion. Number of cases treated or undergoing treatment with the above defects 28 285 Table XXVIII. Summary of Treatment Cases. Number of cases completed 21 Number of cases under treatment 48 Number of cases awaiting treatment 67 Total 136 No. of Fixed Appliances. Inclined planes 25 Labial and lingual wire arches with or without attachments for moving individual teeth 10 Metal splints 6 Total 41 No. of Movable Appliances. Plates with screws or pegs 10 Badcock screw expansion plates 5 Vulcanite plates with U-retraction wires 4 Bite plates 10 Inclined planes 3 Total 32 286 There are two types of appliances used, the fixed and movable. The advantage of the fixed appliance is that its action is quicker and very often more reliable than is the case with a movable plate. It, of course, cannot be cleansed quite so easily, but with a well-fitting apparatus this difficulty is easily overcome. The movable plate can, of course, be easily removed and washed, but this facility may sometimes be taken advantage of to an undesirable extent. Orthodontic appliances are not, of course, very comfortable things to wear, and if a parent does not exert a certain amount of authority over a child wearing a movable plate very little, if any, improvement in the condition will result should the child wear the plate only intermittently. Treatment by Extraction. A large number of cases, which are not included in the above totals, have been treated by judicious extraction. Usually the first pre-molars have been removed, and the canine teeth pulled back into the space with the aid of metal splints cemented on suitably-chosen teeth and ligatured. The first permanent molars are only extracted when in a bad carious condition, which is too advanced to benefit by conservative treatment. Extractions are usually symmetrical, but sometimes asymmetrical. Frequently the outstanding teeth go back into position when a space has been created for them in the arch, and further treatment is not required. A properly conducted School Orthodontic Service will prove of much benefit to the health of the school child. Orthodontics also introduce a variation into the work of the School Dental Service, and with it an added interest which stimulates keenness and efficiency. IONIZATION CLINIC. In spite of regular weekly sessions there is still a waiting list of cases, and it has not been possible to arrange for the calling up and re-examination of old cases, the statistics of such cases being obtained at the end of the year bv home visiting. Relapses have been dealt with when reported, but parents do not always notify a relapse. 287 The incidence of chronic otitis media amongst school children is surprisingly high. Ascertainment is difficult on account of the intermittent nature of the discharge, and even if the quiescent case is discovered, in most cases no treatment is indicated at the moment although, of course, the importance of immediate notification of a recurrence can be impressed on the parents. But it is not in the ascertainment and treatment of the chronic case that the rational method lies of dealing with the problem of otorrhoea. The chronic case is difficult to cure permanently, and, once chronicity is established, deafness and cranial complications are very definite possibilities. The chief hope lies in the notification and treatment of early cases. At present, education of parents to notice otorrhoea, to realise its significance, and to seek advice, is the only method of improving matters. On the part of the medical profession there is an obligation to respond by offering immediate adequate treatment. The Ionization Clinic will not be functioning properly until early cases can be dealt with at once without prejudice to other cases on the waiting list and until a proper system of reinspection and treatment of relapses is in being. Probably our efforts to prevent and cure naso-pharyngeal sepsis and blockage are having their effect in lessening the incidence of otorrhoea, but cases arising from acute infections will always occur. These can be much more hopefully dealt with if undertaken in the early stages. Under the arrangement with the Borough Hospital 10 postscarlatinal oases were seen at the Clinic during the year. Of these, 5 were already dry when examined, 1 cleaned up without special treatment, 2 after one ionization, and 1 after two ionizations, one stopped attendance during treatment. The table showing the results of ionization includes all cases to the end of 1931. The percentage dry at the various periods are much the same as in last year's report and, bearing in mind the type of cases and the rigid criteria of cure, are satisfactory. The difficulty of preserving a high percentage of dry cases was Pointed out in last year's report. Some cases which had remained dry until now are active again as a result of Influenza, which is again tending to manifest itself in the ear in both children and adults. 1931. 1930. Number of sessions held 52 51 Number of first attendances 136 95 Number of re-attendances 442 475 288 Cases attending during 1931 may be divided into three groups: — I.—Those found to have no evidence of otorrhæa past or present, or deafness of more than a trivial or temporary nature. Cases of wax, furuncle, and otitis externa (simulating otitis media) come into this group. There were 17 such cases. II.—Cases complaining of deafness only. Some of these were due to old otitis media. Fifteen of these cases attended. III.—Cases of otorrhæa, active, quiescent, or cured, 103. Group II. The diagnosis and disposal of the cases in this group were as follows:— One was due to wax; cured by its removal. Two were due to old middle-ear disease. One of these was recommended for an operation for deviated nasal septum at fifteen years of age, and the other for a tonsils and adenoids operation which has not been carried out owing, the parents state, to contradictory advice from the family doctor. Two were cases of nerve deafness; one was recommended for a special school for the deaf, the other already being in attendance at a special school. Ten were due to catarrh of the middle ear. Three were cured by an operation for tonsils and adenoids, and one improved thereby. Five were slight and required no special treatment at the time. One was recommended for a hard of hearing class. Group III. (a) Found dry and requiring no treatment—34. (b) Found dry, but recommended for accessory treatment such as tonsillectomy—9. (c) Active cases—60. 289 Table XXIX shews the duration of the otorrhoea in Group III and Table XXX gives the causes assigned by the relatives. Table XXIX. Duration of Otorrhoea. Less than 3 months 3-6 months 6 months— 1 year 1 —2 years 2—5 years More than 6 years Unknown 21 (11) 15 (12) 12 (6) 11 (5) 18 (12) 16 (17) 10 (12) The figures in this table refer to the year 1931, those in brackets being the figures for 1930. Thus 64 per cent, of the active cases were ionized. Of the others some required only simple treatment at the Ionization Clinic and cleaned up successfully; others were referred for a mastoid operation or for an operation on the throat, and will return thereafter. The results of treatment are shown only in those cases subjected to ionization. Not all the cases discharged as "dry" are yet available for reporting on even at the end of six months. The figures in brackets in Table XXXI indicate the percentage of the possible in each case. Table XXX. Causes of Otorrhoea (as obtained in history given by parents). Scarlet Fever 11 Mumps 1 Measles 9 A Blow 1 Tons, and Ad. Opn. 2 Whooping Cough 1 "Colds" 8 Pneumonia 1 Diphtheria 2 Teething 2 Influenza 3 Swimming 1 Tonsilitis 3 Unknown 58 Table XXXI summarises the principal work of the Clinic. It deals with those cases falling into Group III (c). 290 Table XXXI. Classification. Total. Other Treatment required Not ionized. Ionized with or without other treatment. Results in Cases Ionized. Discharged Dry. Dry at end of 6 months. Dry at end of Year. Dry at end of 2 Years. Still under Treament. Lost sight of, or stopping attendance. Returned with Relapse. Eventually referred for other treatment. 1 Tympanic conditions— (a) Tympanic Sepsis 66 15 51 44 29 (83 p.c.) 17 (57 p.c.) 9 (56 p.c.) 5 2 9 ... (b) T. S. + Granulations 13 5 8 5 3 (60 p.c.) 2 (40 p.c.) 1 (50 pc.) ... 1 2 1 (c) T. S. + Polypi 13 7 6 2 1 (100 p.c.) 1 (100 p.c.) 1 (100 p.c.) 1 ... 3 (d) T. S. + other conditns. 13 2 10 4 3 (75 p.c.) 1 (33 p.c.) — (0 p.c.) 2 3 3 1 2 Tympanic conditions combined with— (a) Tonsils and Adenoids... 39 15 24 22 16 (76 p.c.) 12 (71 p.c.) 4 (44 p.c.) 1 2 7 ... (b) Nose conditions 7 4 3 3 2 (66 p.c.) 2 (66 p.c.) 1 (33 p.c.) ... ... ... ... 3 Tympanic conditions combined with— (a) Attic Disease 12 9 4 ... ... ... ... ... ... 1 4 Totals 163 57 106 80 54 (78 p.c.) 35 (59 p.c.) 16 (50 p. c.) 9 8 22 9 291 Table XXXII shews the number of applications of ionization required in those eventually discharged as dry. Table XXXII. Number of Applications. One Two. Three. Four. Five. Six. More than Ten. 49 15 6 4 1 1 4 These figures show, perhaps more than any others, the advantage of ionization. Many of the cases responding to one application had previously received prolonged treatment with drops. Table XXXIII. Treatment Recommended. Number advised. Number obtaining Treatment Number awaiting Treatment Number refusing. Removal of Tonsils and Adenoids 59 41 5 13 do. Impacted Cerumen 5 5 ... ... Treatment of Dermatitis & External Otitis 12 12 ... ... Dental attention 5 2 1 2 Mastoid operation 10 7 3 ... Totals 91 67 9 15 Table XXXIII, which includes all cases from the commencement of the Clinic, shows the number of cases recommended for other remedial measures with or without ionization and the number obtaining treatment or refusing. On the whole the figures are satisfactory especially with regard to mastoid operation, for the facilities for which, as well as for its successful accomplishment, the authority is indebted to Dr. McLaggan. RHEUMATISM CLINIC This Clinic continued its work among school children throughout the year. The work was shared by two of the school medical officers, and the figures in the following tables are compiled from their case sheets. 292 As in former years the bulk of the children seen at this Clinic have been drawn from school children coming under medical inspection either at school or at the inspection clinic, but some cases have been referred from the tuberculosis dispensary, and a few from M. and C.W. Centres. General practitioners have sent a few cases for supervision and some have also been sent from Hospital Out-patient Departments. In last year's report comment was made on the shifting age group of those children attending for primary examinatior. The general age of children examined for the first time has been younger than formerly, the bulk being drawn from children in the first age group and coming under medical supervision for the first time at the primary routine medical inspection at school. The figures for this year bear out this observation. Children in older age groups were more infrequently referred, most of the rheumatic subjects in these groups being already under observation. Where older children were asked to attend for the first time it was noted that the onset of symptoms belonged to a later stage in school life. A number of active cases necessitating modification of school curriculum were seen. In some of these active cases the aggravation of their symptoms was so marked as to require their immediate admission to hospital. Dr. Preston, at Croydon General Hospital, was again very helpful in securing the admission of such cases to beds under his control. The amenities of the Convalescent Hospital at Coombe Cliff were exploited to the full by children recovering from acute attacks of rheumatism, and all made a speedy and happy convalescence, benefitting greatly by the change of air and rest. As a consequence of the reduced number of children sent for primary examination, the number of those seen at reinspertion was correspondingly greater than in former years. It was also found much easier to keep in touch with acute cases and cases whose symptoms were puzzling or gave cause for anxiety. Parents were especially grateful for this latter supervision, and many evidences of the appreciation of the work of the Clinic have been received from parents, teachers and practitioners. 393 Cases Examined at Rheumatism Clinic. Total cases examined 207 (for the first time) Total cases examined as re-inspections 376 Total 583 Rheumatic 185—89.37% Non-Rheumatic 22—10.63% Total 207 Classification of Rheumatic cases— Sex—Males 88—47.57% Females 97—52.43% Total 185 Age when examined recorded in 185 cases : — Tabble XXXIV. Ages 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-5 15-6 16-7 Numbers 5 16 18 27 26 18 26 21 17 9 2 1 These figures correspond closely with those of former years, but a definite increase in the number of young children referred is to be noticed. Grouping and Classification. 1-—Symptoms referred to the digestive system and intestinal tract, e.g., abdominal pain, constipation and lack of appetite. 49 exhibited these symptoms. 2-—Symptoms suggesting the presence of a toxaemia, e.g., aching limbs, lassitude, headache. 128 came within this group. —Symptoms relating to disturbance of nervous structure, e.g., irritability, fidgetiness, disturbed sleep, nocturnal enuresis, and nervous unrest generally. 126 cases came under this group. 294 These last two groups include the majority of cases. The groups of symptoms are nearly always in combination, varying in degree with the activity or type of case. Table XXXV.—Grouping of 185 cases. Mild and Potential 86-46.5% Definite Active 22-11.9% Definite Quiescent 77-41.6% Total Definite Cases 99-53.5% This classification follows that of Dr. R. Miller. It appears the most useful, as in it a place is found for all cases irrespective of situation, or character of symptoms. Grouping of Rheumatic cases, in spite of the ever increasing advance in diagnostic methods, still remains a matter of difficulty and one requiring considerable experience in all the diseases of childhood. Perhaps the earliest signs and those which in particular led to the diagnosis of a case as mild and potential were "growing pains" in highly strung children, in associaton with slight irregularities of cardiac sounds or rhythm. Where these signs were present in a case, who also showed some cardiac dilatation accompanied bv breathlessness on exertion, the diagnosis became more certain and passed into the definite and quiescent group. In these cases anaemia was frequently present, being recorded in 36 cases out of a total of 99 definite cases. Malnutrition was frequently noted, and an expression of nervous tension completed a clinical picture whose only counterpart may be seen in children the subjects of glandular, mesenteric, or other forms of tuberculosis. The mistake of diagnosing some of these rheumatic cases as tuberculous must be constantly guarded against. The definite and active group comprised cases of frank Rheumatic carditis, as shown by well marked physical signs with a history, or the presence of rheumatic fever or chorea. Some cases of organic heart disease, whose origin could not be otherwise accounted for, were placed in this group. 4.—Rheumatic manifestations. 295 Table XXXVI.— Total: 185 cases. Rheumatic Pains 128—69.2% Rheumatic Fever 25—13.5% Chorea 28—15.1% Carditis Definite 31—16.8% Carditis Suspected 49—26.5% Tonsilitis 49—26.5% Seven children had had both rheumatic fever and chorea. Rheumatic Fever Cases. There were 25 children who gave a definite history of rheumatic fever. Of these 3 had sound hearts, 15 had definite and 7 suspected carditis. Chorea Cases. There were 28 cases of chorea. Of these 13 had had definite carditis, 7 suspected and 8 sound hearts. Table XXXVII. 185 cases classified by ages at onset of initial symptoms, shown in relation to age-grouping of the same cases at the time of examination. Age Groups 2-3 3- 4 4-5 5-6 6-7 7-8 8-9 9- 10 10-11 11 12 12-13 13- 14 14-15 15- 16 16-17 (1) 2 10 22 19 41 27 26 14 14 8 2 0 0 0 0 (2) 0 0 0 5 16 18 27 26 18 25 21 17 9 2 1 (1) Grouping according to age at onset of initial symptoms. (2) Grouping according to ages at time of examination. In 161 cases (87%) initial symptoms appeared before the age of 11 years. During the age period 2-7 years, 94=50.8% of the children showed symptoms. Family Histories. In the case of 61 families (33%) either the father or the mother had had rheumatic fever or chorea. In 24 other cases (13%) a history of rheumatic fever was obtained in near relatives of the Parents. the case of 31 children (16.8%) their brothers or sisters had had either rheumatic fever or chorea. 37.2% of the cases gave a negative family history. 296 Skin Conditions. Recorded in 185 cases. Table XXXVIII. Fair 133—71.9% Dark 52—28.1% Moist skin, history of liability to sweating, etc., was recorded in 9 cases. A history of flushings in 12 cases and of rashes in 14 cases. Nervous Conditions. Recorded in 186 cases. Table XXXIX. Children recorded as highly strung 126—68.1% History of headaches 91—49.2% Night terrors, etc 58—31.4% Enuresis 13— 7.0% Twitchings 50—27.0% Catarrhs. Various, as distinct from tonsilitis, and mainly referred to the period of infancy and early childhood, viz., 0-5 years. Reported in 25 cases out of a total of 185—13.5% Tonsillectomy. Operation reported in 56 cases—30.3% 376 re-inspections were carried out. In 24 of these, the condition had become worse; 43 were thought to be non-rheumatic; 262 were definitely improved and had become quiescent; and 47 stationary. Environment and other Conditions in Rheumatism Clinic Cases. Wards.—Cases were drawn from all wards in the town to the numbers shown:—Woodside, 16; Whitehorse Manor,19; West Thornton,18; Upper Norwood,8; Broad Green,10; Waddon, 32; Addiscombe, 6; Thornton Heath, 14; East, 17; South Norwood, 14; Bensham Manor, 13; Central, 2; Norbury, 10; South, 6; and Addington, 5. 297 Housing Conditions:Subsoil.—No relationship was found to exist between the type of subsoil and the incidence of rheumatic infection. This finding was similar to the findings of the three previous years. Drainage of Subsoil.—64 of the houses were sufficiently drained and 65 were well drained; and in 40 drainage was problematical. 144 of the houses showed no signs of dampness; 12 showed traces; 14 were damp and none was very damp. Aspect.—The commonest aspects of the houses were : S.E., 29;S.W.,26; E.,22; N.E.,21; N.W.,26; S.,19; N.,19; W., 26. The bulk of houses in which cases occurred were ordinary terrace houses (112) or semi-detached (63), and definite overcrowding was found in no family. The economic status of the families from whom patients came was: poor in 11; average working class, 89; better working class, 43; clerical work, 33; and professional, 17. The interior home conditions could be classified as: clean, 121; moderately clean, 33; superior, 35; and in no instance definitely unsatisfactory. Open-Air Education. There is as yet no open-air school in Croydon. Playground classes were held during the summer months at Woodside School. There was no extension of these classes during 1931. Blind, Deaf, Defective and Epileptic Children. Full statistical details are given in Table III. of the Tables required by the Board of Education, Appendix III. Blind Children. 1 boy and 3 girls are resident at special schools for the blind, The institutions which these children attend are as follow: Royal formal College for the Blind, 1 boy ; Hants and Isle of Wight Blind School, 1 girl; Chorley Wood Blind College, 1 girl; and Barclay Blind School, Brighton, 1 girl; these are residential; 17 children attend the Special Class for Myopic Children; 1 girl attends the Elm Court Blind (Day) School, West Norwood. 293 Deaf Children. 4 boys and 7 girls are resident at special schools for the deaf; 1 boy and 1 girl attend special day schools. The institutions which these children attend are Royal School for the Deaf, Margate, 4 boys and 7 girls; this is residential. L.C.C. (Deaf) Schools, 1 boy at the Hearnville School, Balham, and 1 girl at Oak Lodge Clapham. Epileptic Children. 3 boys and 4 girls are resident at special schools, namely at Lingfield Epileptic Colony, 2 boys and 2 girls; Soss Moss Epileptic School, Cheshire, 1 boy; Chalfont Epileptic Colony, 2 girls. Mentally Defective Children. A full account of the activities at St. Christopher's School is given in the section of my Annual Report dealing with Mental Deficiency In addition to the day accommodation provided at St. Christopher's School, one girl is resident in the Monyhull M.D. School, Birmingham ; 2 girls are at Knotty Ash M.D. School, Liverpool, and 2 boys and 1 girl at Sandlebridge, Cheshire ; 1 boy at Besford Court, Worcestershire. Physically Defective Children. The Education Authority have crippled children in the undermentioned special schools: St. Vincent's Cripple Home and School, 1 girl; Heritage Craft Cripple School, Chailey, 2 boys. The Committee maintained 2 girls at West Wickham Heart Home, a special school for Cardiac Cripples. School Camps. A school camp was again held during the summer months at Pilgrim Eort, near Caterham. The camp, which is provided with a piped water supply from the East Surrey Water Company, is provided with permanent buildings. Blankets, tents, stretchers, etc., for sleeping purposes, and a fully equipped cookhouse are provided. The sanitary arrangements are satisfactory. 495 boys and girls from the elementary schools went to the Camp during 1931 in parties of 20 or 40, each party going for one week. The following are the departments which sent parties. 299 All the children are medically inspected before proceeding to camp. Woodside, 20 boys; Davidson, 20 boys; Whitehorse Manor, 40 boys; Oval, 40 girls and 40 boys; Portland, 40 boys; Beulah, 40 boys; Ecclesbourne, 20 boys; Rectory Manor, 40 boys and 40 girls; Elm wood, 25 boys; West Thornton, 30 girls; Sydenham, 20 boys; Oroydon British, 40 girls ; Tavistock, 40 boys. Juvenile Employment Return. The following numbers of children were examined by the medical officers during 1931 as to their fitness to follow the part time employment indicated. There has been a decrease of 134, chiefly noticeable in the delivery of newspapers. For the past four years there has been a steady decrease in the number of children examined for this purpose. 1931. 1930 1929. 1928. Delivery of Goods for Shopkeepers 102 140 158 237 Delivery of Newspapers 227 328 329 280 Delivery of Milk 33 28 40 56 362 496 527 573 Six girls were medically examined, and subsequently licensed by the Education Authority to take part in public entertainments. The Provision of Meals and Milk and Cod Liver Oil and Malt. The arrangements for the provision of meals have been on the same lines as in previous years; milk, and cod liver oil and malt have also been provided for children suffering from maJnutrition. This is given in school. Recommendations for extra nourishment are made by the School Medical Officer, Teachers, Attendance Officers and Care Committees and are considered by the School Canteen Sub-Committee. Re-examinations are made by the medical officers in cases referred on medical grounds, when a renewal or discontinuance is decided on. This recurrent examination acts also as a useful check on the general physical health of the child, enabling obvious defects to be pointed out to the parents for remedy. The places of refreshment which supply the children with |heir midday meals have been inspected regularly by the sanitary inspectors; the standard of cleanliness has been satisfactory. In Host instances, advice given as to improvement has been accepted and acted upon. 300 A scheme, suggested originally by the National Milk Publicity Council, and which had been introduced into various schools in other areas, was tried during the year in Croydon. By this scheme a third of a pint of pasteurised milk is delivered in bottles daily for each child in school whose parents are willing to pay a penny per bottle. The scheme is working smoothly and continuous throughout the year and has undoubtedly had beneficial results. At the end of 1931, some 9,000 penny bottles per day were being delivered at the schools, an increase of 272 over 1930. A total of 946,000 bottles of milk containing a third of a pint were supplied to school children during the year. This supply is available for all elementary school children irrespective of any medical recommendation. 1930. 1931. Number of Children who received Free Dinners 329 327 ,, Free Dinners provided 24,986 22,380 pints pints No. of Ghildren who received Free Milk 122—11,241 101—9,816 ,, ,, Milk (part payment) 37— 2,663 27—1,732 ,, Milk (whole payment) 44— 3,145 31—1,707 issues issues „ „ Free Malt 17— 1,319 22—1,413 ,, ,, Malt (whole payment) 40— 2,990 38—2,762 synopsis of hygiene teaching in public elementary schools in croydon. The teaching of Hygiene is laid down by the Board of Education as a part of the instruction in all elementary schools. All schools have a written syllabus which embodies the actual principles and subject matter to be taught; the actual syllabus varies as between school and school. The responsibility for the teaching is not confined to the Head Teacher, as each class teacher is responsible for the proper inculcation of good habits in the children under his or her immediate care. Although the teaching of Hygiene is on the curriculum, there is no systematic course taken, the methods and extent of the teaching varying widely in different schools. The great majority of the teachers are keen about the health of the children under their care and very observant of incipient defects. It seems that systematic teaching is not universally undertaken because the 301 ject does not receive official prominence in the curriculum. This is already so full that instruction in personal and communal hygiene is rather crowded out. Under modern conditions of living in crowded towns, the importance of inculcating a sense of personal and communal health cannot be too strongly urged. The greater number of persons are dependent for their livelihood upon their physical fitness, and any adverse conditions of environment or of incorrect modes of living react upon the individual, leading ultimately to a reduction or total abolition of earning capacity. In times of particular industrial stress and of keen commercial competition, that country leads whose population is the fittest mentally and physically to bear the strain- The chief objects aimed at in such specialised instruction should be the following:— (a) The inculcation of a high standard of domestic and civic cleanliness. (b) The counteraction of ignorance and carelessness in matters of health, more especially regarding the spread of communicable diseases. (c) To give instruction in the broad principles of healthy living and to instruct, in the cardinal signs of a departure from that condition. (d) To instruct in the chief social causes of illness and to indicate the ways in which these causes may be counteracted. (e) To extend the knowledge of the work of Public Health departments so as to gain the co-operation to a greater extent of the coming generation. It is felt that if the older children are told about the social services and their aims explained, a greater appreciation of them will become manifest and a greater readiness to take a part in voluntary activities whose concern is with the health of the populace. nursery schools. No nursery schools have been yet established in the borough. 302 PHYSICAL TRAINING IN SCHOOLS. Detailed reports have been presented by the Inspector of Schools and the Organiser of Physical Training to the Education Committee, and the following is only a precis of these reports. Boys. In the Junior schools daily lessons of 20 minutes are almost universal. In Senior schools, the introduction of gymnastic apparatus has necessitated longer periods of work in order that the fullest benefit may be derived therefrom. These lessons are from 30-40 minutes and in order to allow for them in the time table the daily lesson has had to be abandoned in some instances. Organised games, swimming and general sports all find a place in actual school periods. The importance of correct posture, apart from the actual exercises, is stressed and in this connection well-designed desks are of fundamental importance. During the winter months many outdoor periods are lost. This is not so serious in the case of those schools which possess halls large enough for physical exercises. In other schools, the classroom has to be used. Team work is encouraged in every lesson. The organised games in the school prayground provide an opportunity for useful activity. Most schools practice these games with good results. The marking of the playgrounds suitably has fostered the growth of this side of the work. The introduction by the Committee of the Swedish gymnastic apparatus into the Senior schools has been a great success. It has made possible a more even progression than is feasible with free gymnastic exercises alone, and has added to the interest of the work. The Croydon Schools Athletic Association has continued its activities and the enthusiasm shown by this Association is worthy of the highest praise. Girls. The same difficulty of finding a place in an already over full curriculum for physical training is felt with the girls as with the boys. In most schools 100 minutes a week has been managed. Swimming in both Junior and Senior departments is additional owing to the difficulties of organising this subject. 303 Facilities for physical training have greatly improved and there are now only 14 departments in which there is no indoor accommodation for physical exercises. All the reorganised Senior Mixed and Senior Girls' departments have access to hall, playing fields and swimming bath, with the exception of Ingram Senior Girls for whom no playing field is at present available. Classes of girls from all Senior Mixed and Girls' Schools and from all Junior Departments but four, attended the swimming baths from May till October and the standard of proficiency was well maintained. 714 new swimmers' certificates were obtained as compared with 616 in 1930, but there was a decrease in the 100 yards and the Eoyal Life Saving Society's certificates. This was undoubtedly due to the reorganisation of the schools, many of the girls who would have qualified for these certificates changing schools in the middle of the swimming season. Organised games were continued, the activities falling into three groups: (a) Playground activities; (b) Lessons in school playing fields or recreation grounds; (c) League matches and tournaments as "out of school" activities. Netball continues to be the major game amongst girls, but it is hoped to develop the plavins? of Rounders as a summer same now that most of the girls in Senior schools have playing field facilities. Corrective Classes have been carried on in eight schools and the classes have been examined by the School Medical Officers periodically. Children in these classes are instances of minor deficiencies in deportment and any child exhibiting any gross deviation from normal physique is referred by the School Medical Officer for orthopaedic or remedial exercises treatment. Folk dancing is included in the physical training time-table in practically all Senior departments and many Junior departments. INSTRUCTION IN SPECIAL SUBJECTS. In the time-table for the year ending 31st March, 1932, the following provision is made for the instruction of older girls in Special Subects, e.g., Cookery, Homecraft, Housewifery, Domestic Science:— Intensive Housewifery Centres— Sydenham. Tavistock 304 Cookery and Homecraft Centres— West Thornton (Cookery, Homecraft and Domestic Science). Howard (Domestic Science). Ingram (Cookery and Homecraft). South Norwood (Domestic Science). Sydenham (Cookery, Homecraft and Domestic Science). Woodside (Cookery, Homecraft and Domestic Science). Special Rooms reserved for School named—- Ashburton (Domestic Science). Davidson (Domestic Science). Ecclesfoourne (Domestic Science). Elmwood (Domestic Science). Kingsley (Domestic Science). Oval (Domestic Science). Tavistock (Domestic Science). Nonbury Manor (Cookery and Homecraft. Waddon (Domestic Science). Archbishop Tenison's (Domestic Science). Lady Edridge (Domestic Science). Heath Clark (Domestic Science). Central Polytechnic (for Croydon British) Advanced Cookery. When the scheme of reorganisation of the Elementary Schools in Croydon is completed, as it is anticipated it will be by April. 1932, Centres for Domestic Subjects will practically cease to exist as such. Instead, special rooms will be available for each Senior Girls' School whereby the older girls in such schools will be able to receive the necessary instruction in Domestic Subjects as part of the normal school curriculum and, generally speaking, on the school premises. secondary schools. The usual arrangements for the medical examination of secondary school children were continued in 1931; 1,723 children were examined, 1,067 of whom were boys and 656 girls. Table XXXV. gives the detailed findings. 116 boys (10.9 per cent.) ami 117 girls (10.9 per cent.) were found to require treatment, the most usual defect in the boys being dental defects and in the girls defective vision. Treatment is not provided at the Council's School Clinics for these children except under special circumstances of financial need. Although the figures are small, a table similar to that given for elementary school children and relating to nutrition has been included below. 305 SECONDARY SCHOOLS. HEIGHTS AND WEIGHTS. BOYS. GIRLS. Year of Birth. Number Examined. Average Height in inches. Average Weight in lbs. Average maximum Height in inches. Average maximum Weight in lbs. Average minimum Height in inches. Average minimum Weight in lbs. Number Examined. Average Height in inches. Average Weight in lbs. Average maximum Height in inches. Average maximum Weight in lbs. Average minimum Height in inches. Average minimum Weight in lbs. 1925 ... ... ... ... ... ... ... 5 43.3 45.2 45.0 47.0 40.0 42.0 1924 ... ... ... ... ... ... ... 4 45.9 52.5 49.0 58.0 43.5 49.0 1923 ... ... ... ... ... ... ... 4 51.0 59.6 52.5 69.0 49.5 54.0 1922 ... ... ... ... ... ... ... 9 50.0 56.8 53.0 65.0 48.0 45.5 1921 6 54.2 73.3 57 85.5 51 62.5 26 54.6 72.2 56.8 93.3 51.0 64.8 1920 154 56.1 77.2 60.2 98.7 51.7 61.0 116 56.1 75.9 61.6 111.5 52.0 58.7 1919 194 57.1 81.0 63.7 120.6 52.7 57.0 146 58.2 82.4 64.5 109.8 52.4 61.3 1918 153 58.7 86.3 65.3 135.6 53.1 61.6 120 59.3 89.3 64.8 120.8 54.3 69.8 1917 189 61.4 98.5 67.9 143.5 54.4 71.6 95 61.1 99.2 64.0 120.3 54.5 73.0 1916 214 63.6 110.6 69.6 162.6 55.1 73.0 114 62.5 107.8 66.8 134.4 60.4 90.3 1915 132 65.4 121.3 70.0 147.4 57.6 89.6 54 63.6 113.6 65.8 131.0 60.5 101.5 1914 20 67.9 127.2 68.3 140.7 65.3 100.0 15 63.3 110.9 63.2 103.3 61.2 93.3 1913 1 70.0 155.7 70.0 155.7 70.0 155.7 2 64.5 107.0 65.0 111.0 64.0 103.0 306 Mental Deficiency (Notification of Children) Regulations, 1928. Statement of the number of Children notified during the year ended 31st December, 1931, by the Local Education Authority to the Local Mental Deficiency Authority. Total number of children notified: 12. Analysis of the above Total. Diagnosis. Boys. Girls. 1.—Children incapable of receiving benefit or further benefit from instruction in a Special School: (a) Idiots — — (b) Imbeciles 1 — (c) Others 2 3 2.—Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 4 2 3.—Feeble-minded children notified under Article 3, i.e., "special circumstances" cases — 4.—Children who in addition to being mentally defective were blind or deaf — — Grand Total 7 5 307 ELEMENTARY SCHOOLS. Year ended 31st December, 1931. Table I. RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections— Year 1931. Year 1930. Entrants 2978 2979 Intermediates 2489 2880 Leavers 1973 2466 Total 7440 8325 Number of other Routine Inspections 17 101 7457 8426 B.—Other Inspections. Year 1931. Year 1930. Number of Special Inspections 4766† 737* Number of Re-inspections 8885 † 3140* Total 13651 3877 Total Visits to Elementary Schools 429 494 *Refer to medical inspections only. †Refer to all inspections. 308 TABLE II A.— Return of Defects found by Medical Inspection in the Year ended 31st December, 1931. defect or disease. Routine Inspections Number of defects. Special Inspections. No. of defects- Requiring treatment. Requiring to be kept under observation but not requiring treatment Requiring treatment. Requiring to be Kept under observation but not requiring treatment. (l) (2) (3) (4) (5) Malnutrition 61 62 7 3 Uncleanliness ... ... ... ... (See Table IV.—Group V.) Skin— Ringworm: Scalp ... ... ... ... Body ... ... ... ... Scabies ... ... 1 ... Impetigo 5 2 2 ... Other diseases (non-tuberculous) 6 7 3 1 Eye— Blepharitis 5 6 1 ... Conjunctivitis 1 1 3 ... Keratitis 1 ... ... ... Corneal Opacities ... ... ... ... Defective vision (excluding squint) 351 16 112 3 Squint 54 8 9 ... Other conditions 4 2 2 1 Ear— Defective hearing 11 7 10 1 Otitis media 22 4 13 ... Other ear diseases 3 1 4 1 Nosr & Throat— Enlarged tonsils only 283 186 18 1 Adenoids only 19 28 2 ... Enlarged tonsils & adenoids 248 97 39 2 Other conditions 27 10 3 2 Enlarged Cervical Glands— (Non-tuberculous) ... 26 1 2 Defective Speech 7 7 8 2 Teeth - Dental Diseases 366 27 27 ... (See Table IV.—Group IV. Heart & Circulation — Heart disease: 9 Organic 1 74 1 1 Functional ... 52 ... 10 Anaemia 4 48 2 Lungs— Bronchitis 8 34 ... 7 Other non-tuberculous diseases 2 22 ... ... Tuberculosis— Pulmonary—Definite ••• 1 ... ... ,, Suspected 1 11 1 ... Non-pulmonary—Glands ... 1 1 ... ,, Spine ... 1 ... ... ,, Hip ... ... ... ... „ Other Bones & Joints ... ... ... ... ,, Skin ... ... ... ... ,, Other Forms ... ... ... ••• Nervous System— Epilepsy 1 8 ... 2 Chorea 2 11 2 2 Other conditions 1 17 ... 4 Deformities — Rickets 2 3 ... ... Spinal curvature 132 28 8 ... Other forms 66 38 13 2 Other Defects & Diseases 3 79 5 10 309 B.—Number ok Individual Children Found at Routine Medical. Inspection to Require Treatment (Excluding Uncleanliness and Dental Disease). Group. (1) Number of Children. Percentage of Children found to require treatment. (4) Year 1930 (5) Inspected. (2) Found to require treatment. (3) Code Groups— Entrants 2978 401 13.5 18.6 Intermediates 2489 440 17.9 21.7 Leavers 1973 324 16.4 20.1 Total (Code Groups) 7440 1171 15.7 20.1 Other Routine Inspections 17 5 29.4 21.8 310 TABLE III. Return of all Exceptional Children in the Area. Boys. Girls. Total. Children suffering from the following types of Multiple Defect, i.e., any combination of Total Blindness, Total Deafness, Mental Defect, Epilepsy, Active Tuberculosis, Crippling (as defined in penultimate category of the Table), or Heart Disease 2 1 3 The actual combination of defects and the type of School, if any, attended should be indicated on a separate sheet. BLIND (including partially blind.) (i) Suitable for training in a school for the totally blind. At Certified Schools for the Blind 2 4 6 At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution 1 ... 1 (ii) Suitable for training in a school for the- partially blind. At Certified Schools for the Blind or Partially Blind 12 5 17 At Public Elementary Schools 7 ... 7 At other Institutions ... ... ... At no School or Institution 1 ... 1 DEAF (including deaf and dumb, and partially deaf). (i) Suitable for training in a school for the totally deal or deaf and dumb. At Certified Schools for the Deaf 4 6 10 At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... 2 2 (ii) Suitable for training in a school for the partially deaf. At Certified Schools for the Deaf or Partially Deaf 1 2 3 At Public Elementary Schools 1 1 2 At other Institutions ... ... ... At no School or Institution ... ... ... MENTALLY DEFECTIVE Feebleminded At Certified Schools for Mentally Defective Children 58 52 110 At Public Elementary Schools 3 3 6 At other Institutions ... ... ... At no School or Institution 7 6 13 Notified to the Local Mental Deficiency Authority during the year. Details should be given on Form 307 M. ... ... ... EPILEPTICS. Suffering from severe Epilepsy. At Certified Schools for Epileptics 3 3 6 At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 1 ... 1 At other Institutions ... ... ... At no School or Institution 1 1 1 Suffering from Epilepsy which is not severe. At Public Elementary Schools 10 14 24 At no School or Institution 1 ... 1 311 Table III.—Continued. Boys. Girls. Total. Active Pulmonary Tuberculosis (including pleura and intrathoracic glands). At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 4 2 6 At Certified Residential OpenAir Schools ... ... ... At Certified Day Open-Air Schools ... ... ... At Public Elementary Schools At other Institutions ... ... ... At no School or Institution ... ... ... Quiescent or Arrested Pulmonary Tuberculosis (including pleura and intrathoracic glands). At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 1 1 2 At Certified Residential OpenAir Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools ... 1 1 At other Institutions ... ... ... Tuberculosis of the Peripheral Glands. At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board 3 2 5 PHYSICALLY DEFECTIVE. At Certified Residential OpenAir Schools ... ... ... At Certified Day Open-An Schools ... ... ... At Public Elementary Schools 1 ... 1 At other Institutions ... ... ... At no School or Institution ... ... ... Abdominal Tuberculosis At Sanatoria or Sanatorium Schools approved by the Ministry of Health or the Board ... ... ... At Certified Residential OpenAir Schools ... ... ... At Certified Day Open-Air Schools ... ... ... At Public Elementary Schools . ... ... ... At other Institutions 1 ... 1 At no School or Institution ... ... ... Arrested Tuberculosis of the Peripheral (Glands. At Ordinary School 2 7 9 At other Institutions 1 ... 1 Tuberculosis of Bones and Joints (not including deformities due to old tuberculosis). At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board 7 7 14 At Public Elementary Schools 3 2 5 At other Institutions 1 3 4 At no School or Institution ... 1 1 312 Table III.—Continued. Boys. Girls. Total. PHYSICALLY DEFECTIVE. Tuberculosis of other Organs (skin, etc.) At Sanatoria or Hospital Schools approved by the Ministry of Health or the Board ... ... ... At Public Elementary Schools ... ... ... At other Institutions ... ... ... At no School or Institution ... ... ... Delicate Children all children (except those included in other groups) whose general health renders lt desirable that they should be specially selected for admission to an Open Air School. At Certified Residential Cripple Schools ... ... ... At Certified Day Cripple Schools ... ... ... At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 7 3 10 At other Institutions ... ... ... At no School or Institution 1 1 2 Crippled Children (other than those with active tuberculous disease), who are suffering from a degree of crippling sufficiently severe to interfere materially with a child's normal mode of life. At Certified Hospital Schools ... 1 1 At Certified Residential Cripple Schools 2 ... 2 At Certified Day Cripple Schools 31 46 77 At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 11 11 22 (6)* At other Institutions 2 2 4 At no School or Institution 1 4 5 (4)* Children with Heart Disease e.g., children whose defect is so severe as to necessitate the provision of educational fa cilities other than those of the public elementary school At Certified Hospital Schools ... ... ... At Certified Residential Cripple Schools ... 1 1 At Certified Day Cripple Schools ... ... ... At Certified Residential Open Air Schools ... ... ... At Certified Day Open Air Schools ... ... ... At Public Elementary Schools 7 8 15 At other Institutions ... 1 1 At no School or Institution 4 4 8 MULTIFLE DEFECTS. Crippling and Mentally Defective—Two boys attending Certified School for Mentally Defectives. Crippling and Epilepsy—One girl attending Certified Day Cripple School. *The figures in parenthesis indicate the number of these children who should be receiving special school education. 313 TABLE IV.—Return of Defects Treated During the Year Ended 31st December, 1931. Group I.—Minor Ailments (excluding uncleanliness, for which see Group V) Disease or Defect. (1) number of defects treated or under treatment during the year. Year 1930. (5) Under the Authority's Scheme. (2) Otherwise. (3) Total. (4) Skin— Ringworm, Scalp 30 ... 30 31 Body 23 ... 23 28 Scabies 46 ... 46 37 Impetigo 295 ... 295 276 Other skin diseases 102 ... 102 132 Minor Eye Defects— (External and other, but excluding cases falling in Group II) 179 ... 179 132 Minor Ear Defects 277 ... 277 231 Miscellaneous— (e.g. Minor injuries, bruises, sores, chilblains, etc.) 562 ... 562 325 Total 1514 ... 1514 1192 Group 11. - Defective Vision and Squint (excluding minor eye defects treated as minor ailments.—Group I.) Disease or Defect (1) NUMBER OF DEFECT6 DEALT WITH. Year 1930. (6) Under the Authority's Scheme. (2) Submitted to refraction by private practitioner or at hospitals apart from the Authority's scheme. (3) Otherwise- (4) TOTAL. (5) Errors of refraction (including squint) Other defect or disease of the eyes (excluding those recorded n Group 1) 653 32 685 708 ... ... ... ... ... Total 653 32 685 708 Total number of children for whom spectacles were prescribed— Year 1930 (a) Under the Authority's scheme 554 539 (b) Otherwise 32 25 Total number of children who obtained or received spectacles— Year 1930 (a) Under the Authority's scheme 432 554 (b) Otherwise 32 25 314 Group III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received operative treatment. Received other forms of treatment. (4) Total Dumber treated. (5) Under the Authority's scheme in clinic or hospital. (1) By private practitioner or hospital apart from the Authority's scheme. (2) TOTAL. (3) 506 105 611 ... 611 Year 1930 608 76 684 ... 684 TABLE IV. GROUP IV.—Dental Defects. (l)Number of Children who were— Year 1930 (a) Inspected by the dentist:— Aged 5-6 1083 165 ,, 6-7 2032 243 ,, 7-8 2259 2588 ,, 8-9 2491 2254 ,, 9-10 2756 2015 Routine Age groups. ,, 10-11 3055 Total—21731 2722 ,, 11-12 3219 1622 ,, 12-13 1940 1302 ,, 13-14 1540 1264 ,, 14-15 960 1027 ,, 15 up 396 181 Specials ... ... ... 1840 1634 Grand Total ... 23571 20700 Year 1930 (b) Found to require treatment 15028 13663 (c) Actually treated 8138 8131 (2) Half-days devoted to Inspection 150 151 „ „ Treatment 1086 1027 1236 — 1178 (3) Attendances made by children tor treatment 13167 13046 (4) Fillings—Permanent teeth 3228 2769 Temporary teeth 1254 1732 4482 4501 (5) Extractions—Permanent teeth 2689 2001 Temporary teeth 10800 12105 13489 14106 (6) Administrations of general anaestetics for extractions 2605 2395 (7) Other operations—Permanent teeth 1006 675 Temporary teeth 512 959 1518 1634 697 children awaiting treatment at 31st December. 28 sessions in addition devoted to administration. In addition 32 special secondary school cases were examined and referred for treatment at the Dental Clinic; 58 attendances were made; 50 extractions and 19 fillings were carried out; 20 gas administrations, 4 local anesthetics, 1 gum treatment, 1 scaling and 7 dressings. GROUP V.—Uncleanliness and Verminous Conditions. Year 1930 (i) Average number of visits per school made during the year by the School Nurses (including subsequent visits) 12.2 9.0 (ii) Total number of examinations of children in the Schools by School Nurses 64274 60662 (iii) Number of individual children found unclean on first examination 2749 2505 (iv) Number of children cleansed under arrangements made by the Local Education Authority 23 — (v) Number of cases in which legal proceedings were taken:— (a) Under the Education Act, 1921 — — (b) Under School Attendance Bye-laws 1 3 315 SECONDARY SCHOOLS. Year ended 31st December, 1931. Table I. RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections— Year 1931. Year 1930. Age 11 or under 298 183 12 333 127 13 240 105 14 276 124 15 337 142 16 200 64 17 36 13 18 or over 3 4 Total 1723 762 B.—Other Inspections. Year 1931. Year 1930. Number of Special Inspections 30 8 Number of Re-inspections 418 191 Total 448 199 Visits to Secondary Schools 100 44 316 SECONDARY TABLE II.—A.—Return of Defects Found by Medical Inspection in the Year Ended 31st December, 1931. DEFECT OR disease. Routine Inspections. Number of defects. Special Inspections. Number of defects. Requiring treatment. Requiring to be kept under observation but not requiring treatment. Requiring treatment. Requiring to be kept under observation but not requiring treat ment. (1) (2) (3) (4) (5) Malnutrition 1 6 ... ... Uncleanliness ... ... ... ... (See Table IV.—Group V.) Skin— Ringworm Scalp ... ... ... ... Body ... ... ... ... Scabies ... ... 1 ... Impetigo ... 1 ... ... Other diseases (non tuberculous) 1 2 ... ... Eye— Blepharitis ... ... ... ... Conjunctivitis ... 1 ... ... Keratitis ... ... ... ... Corneal opacities ... ... ... ... Defective vision (excluding squint). 148 12 8 ... Squint 3 ... ... ... Other conditions ... ... ... Ear— ... Defective hearing 1 ... ... ... Otitis media 2 ... ... ... Other ear diseases 1 ... ... ... Nose and Throat— Enlarged tonsils only 30 34 1 ... Adenoids only 1 3 1 ... Enlarged tonsils and adenoids 7 4 ... ... Other conditions ... 2 ... ... Enlarged Cervical Glands 1 2 ... 1 (Non Tuberculous) Defective Speech ... 1 ... ... Teeth—Dental Disease l11 12 ... ... (See Table IV.—Group IV). Heart and Circulation— Heart Disease— Organic ... 25 1 4 Functional 1 12 ... ... Anaemia ... 16 ... ... Lungs— Bronchitis ... ... ... ... Other non-tuberculous diseases ... 1 ... ... Tuberculosis— Pulmonary— Definite ... ... ... ... Suspected ... 1 ... ... Non-pulmonary— Glands ... 1 ... ... Spine ... ... ... ... Hip ... ... ... ... Other bones & joints ... ... ... ... Skin ... ... ... ... Other forms ... ... ... ... Nervous System— Epilepsy ... ... ... ... Chorea ... 3 ... ... Other conditions ... 7 ... ... Deformities— Rickets ... ... ... ... Spinal curvature 22 31 2 1 Other forms 19 14 ... 2 Other Defects and Diseases ... 10 ... 2 317 B.-Number of Individual Children Found at Routine Medical Inspection to Require Treatment (Excluding Uncleanliness and Dental Disease.) Group. Number of Children. Percentage of children found to require treatment. Inspected, Found to require treatment. (1) (2) (3) (4) 11 or under 298 35 11.7 12 333 44 13.2 13 240 38 15.8 14 276 38 13.8 15 837 55 16.3 16 200 22 11.0 17 36 18 and over 3 1 33.3 1723 233 13.5 TABLE IV.—Return of Defects treated during the year ended. 31st December, 1931. Group I. —Minor Ailments (excluding uncleanliness, for which see Group V). Diseases or Defect. number of defects treated, ok under treatment during the year (1) Under the Authority's scheme. (2) Otherwise. (3) Total (4) Skin— Ringworm (scalp) ... ... ... M (body) 1 ... 1 Scabies 1 ... 1 Impetigo 2 ... 2 Other skin disease 1 ... 1 Minor Eye Defects- (External and other, but excluding cases filling in Group II) 3 ... 3 Minor Ear Defects— 7 ... 7 Miscellaneous— e.g.- minor injuries, bruises, sores, chilblains, etc.) 8 ... 8 Total. 23 ... 23 318 Group II.—Defective Vision and Squint (excluding minor eye defects treated as minor ailments.—Group I.) NUMBER OF DEFECTS DEALT WITH. Defects or Diseases Under Authority's Scheme. Submitted to refraction by private practitioners or at Hospital apart from the Authority's scheme. Otherwise. Total. Year 1930 (1) (2) (3) (4) (5) (6) Errors of refraction (including squint) 80 15 95 31 Other defects or disease of the eyes (excluding those recorded in Group I.) Total 80 15 95 31 Total number of children for whom spectacles were prescribed:— (a) Under the Authority's scheme 69 (b) Otherwise 15 Total number of children who obtained or received spectacles:— (a) Under the Authority's scheme 61 (b) Otherwise 15 Group III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received operative treatment. Received other forms of treatment. Total number treated. Year 1930 Under the Authority's scheme in clinic or hospital. By private practitioner or hospital apart from the Authority's scheme. TOTAL. (1) (2) (3) (4) (5) (6) 14 3 17 ... 17 4