CR0 35 County Borough of Croydon ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH AND SCHOOL MEDICAL OFFICER For the Year 1933 OSCAR M. HOLDEN, M.D., D.P.H. CROYDON: Printed by the Croydon Times Ltd., 104, High Street. 2 PUBLIC HEALTH COMMITTEE. NOVEMBER, 1932—1933. The Worshipful the Mayor (Alderman W. Peet, J.P.) Alderman H. J. Morland, M.A., J.P. (Chairman). Councillor Mrs. Roberts (Vice-Chairman). Alderman T. Arthur Lewis, J.P. Alderman W. B. Southwell, J.P. Councillor E. E. L. Arkell. Councillor A. L. Boddington. Councillor W.J. Gibbins. Councillor Miss M. H. Glazier. Councillor Mrs. Heighton, J.P. Councillor B. Holden. Councillor George Lewin. Councillor W. H. Parry. Councillor Major F. W. Rees, L.R.I.B.A. Councillor H. Regan. Councillor Mrs. Squire. For purposes of Maternity and Child Welfare— Mesdames Hicks, Horn, Leech, Lewis, and Southwell. 3 COUNTY BOROUGH OF CROYDON ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and SCHOOL MEDICAL OFFICER For the Year 1933. To the Chairman and Members of the Public Health Committee. Ladies and Gentlemen, I have the honour to present herewith my Sixth Annual Report, being the thirty-fourth of the series, on the health of Croydon. The general arrangement follows that of the last report. The contents have been compiled in compliance with Circular 1346 of the Ministry of Health, dated 2nd October, 1933, and the report is an ordinary, not a survey report. VITAL STATISTICS. The Birtih Rate showed a further decrease and reached the lowest figure yet recorded, whilst the Death Rate showed a slight rise over 1932. It remained, however, considerably below that for the whole of England and Wales. The steadily diminishing birth-rate is leading to a gradual rise in the average age of the population, and in consequence any further reduction in the death-rate is unlikely. A small rise in the death-rate is a natural corollary and has no practical bearing on the state of health of the town. 4 It is satisfactory to record a further diminution in the infant mortality rate, the figure for 1933 being the lowest yet recorded. This rate is usually taken as being the truest reflection of the general healthiness of a district, and Croydon has one of the lowest infantile mortality rates among the large towns. In view of the town's changing character from being largely residential to industrialisation, the continued reduction in the loss of infant life is gratifying. The common infectious diseases showed an increase in incidence, but their mortality remained as low as in 1932. Infectious diseases exhibit more or less cyclical waves of incidence, and so far as Scarlet Fever and Diphtheria are concerned there seem to be definite indications of a commencement of a wave of higher incidence. Measles exhibits a two-yearly cycle, and in 1933 the peak of the wave occurred during the first half of the year. Influenza was not troublesome. The report, being divided into sections, presents the statistical details of each phase of the work under the appropriate heading. Additional information has been incorporated dealing with the extensions contemplated and already commenced at Mayday Hospital. The prominent place taken by Slum Clearance in the public eye has warranted a statement of the Council's proposals with respect to the five-years programme which was required to be submitted to the Minister of Health in September. When considering this programme it should be remembered that, with certain of the areas which have not as yet been the subject of my representation, the figures are only approximate. Additionally, it may be found necessary to include areas not already included, or, on the other hand, it may be found more expeditous to deal with certain areas, or parts of areas, in a different manner to that suggested. The great problem at the present is concerned rather with the re-housing of displaced tenants, than with the representation of Slum Areas or individual unfit houses. It is unpractical to bring forward clearance proposals until adequate provision has been made for re-housing persons displaced. Another of the 4a difficulties experienced has been with overcrowding in large houses which are divided into tenements. This is becoming more prevalent, and it is not possible to do anything effective under present housing legislation. A section has been devoted to the Obstetric Service conducted by Officers of the Council. This scheme is one of the most comprehensive in operation and fulfils practically all the fundamental requirements of an adequate maternity service, as formulated in the final report of the Departmental Committee of the Ministry of Health on Maternal Mortalty. Its influence on maternal mortality and morbidity in Croydon will depend upon the use made of its facilities by that section of the population for whom it is intended. The figures given, and the scope of the sections detailed indicate to what an extent the Public Health Service has become an integral part of the civic economy. There are few aspects in the life of citizens which are not, in some way or other, concerned in its activities. As the density of population increases it becomes more than ever imperative to maintain a high level of sanitation and of efficiency if the present position of the Public Health is to be maintained. Lack of interest in, and ignorance of, the duties of health authorities, are the greatest obstacles to further progress and a proper valuation of the value of the services which they maintain. It is better, and in the end more economical, to prevent than to cure. This object must always be kept in mind, and it will be fatal to success if the curative functions, which have been transferred to Health Authorities under the Local Government Act, are allowed to overshadow the original function of prevention. May I tender my thanks to the Chairman and Members of the Committee, the Chairman and Members of the Mental Deficiency Committee, the Housing Committee, and the various SubCommittees for the sympathetic consideration they have given to Proposals submitted to them and for the interest they have taken in the work of the department. 4b The staff of the department have carried out their duties in a satisfactory manner, and especially I would like to mention the Deputy Medical Officer of Health, Dr. W. B. Watson, whose continued co-operation at all times has been of great value; the Chief Sanitary Inspector, Mr. R. J. Jackson, and the clerical staff, whose duties are steadily increasing. I am, Yours faithfully, OSCAR M. HOLDEN. Medical Officer of Health. 5 CONTENTS A.-PUBLIC HEALTH REPORT. page Acts, Adoptive 54 Ambulance Service 16 Amusement Houses 72 Animals, Keeping of 72 Ante-natal Clinic 171 Aerodrome 235 Babies Help Committee 216 Bacteriological Examination 121 Bakehouses 68 Births 44 Blind Persons 219 Borough Hospital 108 Bye-laws and Regulations 55 Cancer 97 Chicken Pox 102 Contacts, Tuberculosis 143 Cowkeepers 85 Croydon Nursing Service 143 Children Acts 218 Convalescence 216 Coombe Cliff Convalescent Hospital 217 Créche 217 Dairies, Cowsheds and Milkshops 85 Deaths 49, 51 Dental Treatment—M. & C.W. 213 Diphtheria 101 Disinfection 73 Dispensary, Tuberculosis 124 Dried Milk 210 Drainage and Sewage 12 Enteric Fever 116 Expectant Mothers 171 Factories & Workshops Acts 67 Fertilisers & Feeding Stuffs Act 73 Foods, Inspection of 82 Food & Drugs Acts, Sale of 92 Foster-Mothers 218 Foster-Children 218 Gynaecological Clinic 187 Health Visitors, Work of 209 Home Nursing143 Homework 68 Hospitals 13 Hospital, St. Mary's (Maternity) 189 Houses Let in Lodgings 71 Housing 65 Housing Act, 1930 62 Illegitimacy 9 Infant Welfare Clinics, Municipal 163, 203 ,, ,, ,, Voluntary 163, 203 Infant Mortality 193 Infectious Diseases 100, 116 PAGE Laboratory Work 119, 121 Local Acts 54 Local Government Act 18 Lodging Houses, Common 70 Massage Clinic 212, 232 Maternity Homes 202 Maternity Homes, Registration 202 Mayday Hospital 19 Measles 101 Meat Inspection 78 Medical Help Records 200 Meteorology 43 Mental Deficiency 221 Midwives 199 Mid wives Act, Section 14 202 Milk, Provision of 210 Milk, Tuberculous 87 Milkshops 85 Mortality in Child-birth 164 Mothers' and Infants' Welfare Association 163 Mumps 103 Neo-natal Deaths 193 Notification of Births Acts 163 Nuisances 57 Nursing Arrangements 143 „ Homes 202 Observation Nursery 211 Obstetrical Unit 166 Occupation Centre (Grange Wood) 226 Offensive Trades 71 Ophthalmia Neonatorum 182 Orthopaedic Department 228 Overcrowding 66 Poisons & Pharmacy Act 73 Poor Law Relief 16 Population 53 Post-natal Clinic 187 Public Laboratory 121 Puerperal Sepsis and Pyrexia 116, 165 Rag Flock Acts 72 Rats & Mice (Destruction) Act 74 Rent Restriction Acts 62 Rivers and Streams 12 Sanatorium, Cheam 155 Sanatoria, Treatment in 139 Sanitary Administration 54 Sanitary Certificates 61 Sanitary Inspectors, Work of 55 Scarlet Fever 100 Schools 73 St. Christopher's Special School 224 Shop Hours Acts 69 6 PAGE Slaughterhouses 78 Social Conditions 11 Smoke Observations 72 Sputum, Examination 137 Staff 7 Still-births 191 St. Mary's Maternity Hospital 189 Tuberculosis—After Care 146 „ Contacts 143 Deaths 128 „ Dental Treatment 147 „ Notifications 125 „ Home Nursing 144 Home Visits 143 Tables 147 Pneumothorax 124, 155 ,, Institutional Treatment 139 PAGE Unmarried Mothers 190, 217 Ultra-Violet Light 232 Vaccination 122 Venereal Diseases 157 Verminous Persons 74 Veterinary Inspection 85 Vital Statistics 9,44 Watercourses 73 Water Supply 11 Whooping Cough 101 Workplaces 67 Workshops 68 X-ray Examination 124,138 B.—SCHOOL MEDICAL REPORT. PAGE Accommodation 241 Adenoids 229,263 Blind Children 284 Cleansing of Children 244 Clinics 237, 262 Clothing and Footgear 244 Committee 236 Cost 240 Crippling Defects 265 Deaths 256 Deaf Children 284 Defective Children 285 Deformities 250 Dental Disease 251 Dental Treatment 266 Domestic Subjects 290 Ear Clinic 277 Ear Disease 250 Epileptic Children 284 Exclusions 257 Eye Clinic 265 Eye Disease 250 Following up 261 Health Visitors, Work of 261 Heights and Weights 246 Infectious Diseases 256 Inspection Clinic 264 Inspections, Routine 242 Inspections, Special 242 PAG Juvenile Employment 28 Lungs, Diseases of 248 Malnutrition 244 Massage Clinic 265 Meals, Provision of 286 Mentally Defective Children 285 Milk, etc., Provision of 286 Minor Ailments 262 Open-air Classes 284 Orthopaedic Work 265 Orthodontic Service 276 Physical Training 287 Physically Defective Children 285 Remedial Exercises 265 Rheumatism clinic 280 Schick Test 259 School Camps 285 Schools, Special 285 Secondary Schools 290 Skin Affections 250 Speech 250 Staff 236 Statistical Tables 293 Surveys, Uncleanliness— 244 Tonsils, Enlarged 229, 263 Treatment 262 Tuberculosis 248 Uncleanliness 244 Vision Defective 251 7 STAFF OF THE HEALTH DEPARTMENT. The staff of the Public Health De partment on the 31st December, 1933, 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. Win. B. Watson, L.R.C.P., L.R.C.S., D.P.H., Deputy Medical Officer of Health, Deputy School Medical Officer and Medical Officer under the Mental Deficiency Act. J. C. McMillan, M.B., Ch.B., B.A.O., B.Sc., D.P.H., Assistant Medical Officer of Health for Tuberculosis. A. L. Gunn, M.D., F.R.C.S., B.Sc., M.C.O.G., Assistant Medical Officer of Health for Obstetrics. B. Anthony Dormer, M.B., B.S., D.P.H., B.Hy., 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 Officer. 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 Officer. J. Todesoo, 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. H. W. Southgate, M.B., B.S., B.Sc., Pathologist. (b) Part-time :— J. B. Draper, B.A., M.B., Medical Inspector of Aliens, Assistant M.O. M.C.W. and S.M.S. Mary McDougall, M.B., C.M., Assistant Medical Officer, Maternity and Child Welfare. L. Ruth Dimond, M.B., Ch.B., Assistant Medical Officer, Maternity and Child Welfare. J. S. Bookless, B.A., M.B., F.R.C.S.—Ophthalmic Surgeon (School Medical Service). Rota of 4 local medical practitioners for surgical treatment of tonsils and adenoids. Dental Staff.— Senior Dental Surgeon: J. F. Pilbeam, 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 Sanitary 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 4 disinfectors, 1 rat-catcher, and 5 assistants to the Sanitary Inspectors. Health Visiting Staff.— 19 District Health Visitors; 2 Special Visitors; 1 Tuberculosis Nurse; 1 Clinic Nurse; 1 Almoner and 3 Dental Attendants. Also 2 whole-time Masseuses and Remedial Gymnasts. Clerical Staff.— Twenty-four full-time clerks. Veterinary Inspector (Part-time).— Peter R. A. Thrale, O.B.E., M.R.C.V.S. Analyst (Part-time).— Edward Hints, B.Sc., F.I.C., F.C.S. 8 Transferred Officers under Local Government Act, 1929.— MAYDAY HOSPITAL— Arnold Gilray, M.B., Ch.B. (N.Z.), Medical Superintendent. John Joseph Walsh, M.B., Ch.B., F.R.C.S. (Eng.), Assistant Medical Superntendent. Edmund Trafford Clifton, M.R.C.S., L.R.C.P., Assistant Medical Officer. Allan Ernest Treweek, M.R.C.S., L.R.C.P., L.D.S., Assistant Medical Officer. District Medical Officers.— William Vaudrey Braddon, M.B., Ch.B., L.S.A. Ernest Philip Chennells, M.B., M.R.C.S., L.R.C.P. Thomas Archibald Dukes, M.B., B.Sc., M.R.C.S., L.R.C.P. Henry Fleming Hamilton, M.B., Ch.B., F.R.C.S. Charles Aloysius McGuire, M.B., Ch.B. Alan Pride, M.D. Stewart Septimus Simmons, M.R.C.S., L.R.C.P. Austin Stafford, L.R.C.P.I. & L.M., L.R.C.S.I, & L.M. Public Vaccinators.— William Vaudrey Braddon, M.B., Ch.B., L.S.A. Patrick Francis O'Hagan, L.R.C.P., L.R.C.S. Walter Hugh Montgomery Smith, M.R.C.S., L.R.C.P. Harold Trafford, M.R.C.S., L.R.C.P. Sydney Duke Turner, M.D., D.P.H. Gilbert Charrington Wellish, M.B., Ch.M., F.R.C.S. Vaccination Officer.— Gerald H. Huggins, Cert. R.S.I. Mayday Hospital, Croydon Borough Hospital, Croydon Borough Sanatorium, Sick Nursery, Coombe Cliff Convalescent Home and 6, Morland Road. Nursing and Domestic Staffs. 9 SUMMARY OF VITAL STATISTICS FOR 1933. Area 12,617 acres. Population (Census 1931), 233,115. Population (estimated middle of 1933), 239,950. Number of Inhabited Houses (1931 Census), 56,429. Rateable Value (1st April, 1933), £2,070,619. Product of a Penny Rate (1932-3), £8,064. Rate in the £ (1932-33), 9/10. Gross expenditure on Health Services (administered by Medical Officer of Health) £110,631 18 5 Income on Health Services (including transfers) £7,486 19 11 Net expenditure on Health Services £103,144 18 6 Expressed as a Penny Rate, 12.79 pence in the pound. Live Births— M. F. Total Legitimate 1,556 1,459 3,015 Illegitimate 74 58 132 Birth-rate per 1,000 of the estimated resident population, 13.2. Still Births—92. Rate per 1,000 total (live and still) births, 28.3. Deaths—2,721. Death-rate per 1,000 of the estimated resident population, 11.3. Deaths from diseases and accidents of pregnancy and childbirth : From sepsis, 7; other causes, 5. Death-rate of Infants under one year of age : — All infants per 1,000 live births 47 Legitimate infants per 1,000 legitimate live births 43 Illegitimate infants per 1,000 illegitmate live births 144 10 Deaths from Measles (all ages) 13 ,, ,, Whooping Cough (all ages) 3 ,, ,, Diarrhoea (under 2 years of age) 19 ,, ,, Diphtheria (all ages) 17 Per 1,000 of the population. Deaths from diseases of Cardiac and Circulatory System (including Cerebral Haemorrhage) 3.69 ,, ,, diseases of the Respiratory System (including Tuberculosis) 2.28 ,, ,, diseases of Renal System 0.51 ,, ,, diseases of Digestive System 0.68 ,, ,, Suicide and Accidents 0.42 ,, ,, Old Age 0.41 11 SECTION I. SOCIAL CONDITIONS, HOSPITAL ACCOMMODATION AND VITAL STATISTICS. Croydon is largely a dormitory town, but is becoming increasingly industrialised. The chief industries are iron foundries (bell casting), engineering and building. The London Terminal Aerodrome is within the County Borough boundary. Croydon is an aggregation of townships, each of which shows its own characteristics. Bad housing conditions are met with in various districts, and there are individual streets in nearly every ward in which the standard of house property is low, when compared with the average type of 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 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. The 1931 Census gave a total enumerated population of 233,115. The estimated population middle of 1933 is 239,950. In, the 1931 Census returns 5.59 was the average number of rooms per dwelling and 1.16 the average number of families in each dwelling, which gives 1.27 rooms per person. In 1931, 3.35% of the population was living more than two persons per room, a decrease of nearly 1% on the 1921 Census. A special report was made by the Medical Officer of Health during the year, upon the Census figures, in which comparisons with other towns of similar size were set forth. From these figures Croydon is by no means badly situated. 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. 12 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, 16.8 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 2,247,541,827 Metropolitan Water Board in Bulk 568,568,000 2,816,109,827 gallons. The low rainfall caused some anxiety but at no time during the year was it necessary to curtail the supply. This works out, on an average population basis of 247,000 (1933), at a consumption of 31.23 gallons per diem per head. Rivers 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 drains and a further loan for £23,580 for additional sewage work in the Borough is being sought. At the sewage disposal works at Beddington. three Activated Sludge plants are in operation dealing with 3½ to 5 million gallons per day. 13 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. (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 £4,500 from the Council as 30 of the beds are reserved for cases referred by them. The Local Authority collects patients' fees which amounted approximately to £1,600. (3) Children. (a) Observation 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. (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. 14 (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 and other Hospitals 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. Other 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 are: (a) Tonsils and Adenoids Clinic; (b) Orthopaidic Clinic; (c) Venereal Diseases Clinic; (d) Ultra-Violet Ray Clinic. The Council's Pathological and Bacteriological Laboratory is also within the 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. 15 The number of in-patients treated during 1933 was 2,576; the average stay of each in hospital being 16.5 days. The number of out-patient attendances, including casualties, was 125.754. The bed accommodation remained unchanged, but the work is well in hand for the addition of 65 beds and it is hoped to open these in June, 1934. Mayday Hospital. The institution provides the following accommodation:— Male Beds Surgical 32 Medical 64 Tuberculosis 32 Mental 32 Female Beds Surgical 32 Medical 128 Tuberculosis 32 Mental 32 Children's Beds 60 Maternity Beds 22 with 14 cots additionally. Total 466 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) 20 beds; Children 8 beds; Maternity 6 beds; together with 6 private wards; a total of 50 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 Hospital and at various Children's Homes. Unmarried mothers are admitted to Mayday Hospital; and to St. Mary's Hospital for the first confinement only, as well as to a maternity home at Norwood, established by the Free Church Council. Two other Voluntary Institutions also offer facilities for unmarried mothers, namely, The Mission of 16 Hope, Birdhurst, 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 21 cases were dealt with. The reasons for reference were: neglect to obtain medical or dental attention, 15; for miscellaneous reasons, 6. 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 ambulances 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, 1933 3,891 persons ; 1,442 cases (including lst July, 1933 3,863 „ 1,431 ,, „ bodied). 1st January, 1934 4,089 ,, 1,545 ,, ,, Number of Croydon poor persons relieved in the Mayday Hospital on 1st January, 1934, and in the Queen's Road Homes on the same date— Mayday Hospital 144 Queen's Road Homes 425 Expenditure on Out-relief to Croydon cases during the 12 months ended 30th September, 1933:— Half-year ended 31st March, 1933 £27,556 19 11 Half-year ended 30th Sept., 1933 £26,266 18 7 17 QUEEN'S ROAD HOMES. This is an Institution maintained under the Poor Law Act. Beds available for Sick, Maternity and Mental Cases— (a) For Men 50 (b) For Women 50 100 Table showing the classification of the accommodation and the number of beds occupied on the 31st December, 1933— Classification Number of Wards. Men. Women. Children (under 16 yrs of age) Total. Provided. Occupied. Provided. Occupied. Pro. vided Occupied. Provided. Occupied. Chronic Sick 4 50 48 50 48 100 96 Infirm 11 99 95 115 87 214 182 Other 183 124 193 109 71 33 447 266 Total 332 267 358 244 71 33 761 544 IN-PATIENTS. Total number of admissions (including infants born in hospital): 87. Total number of deaths: 71. Total number of discharges (including infants born in hospital): 19. Duration of stay of patients— (a) Four weeks or less : 14. (b) Exceeding four weeks but under thirteen weeks : 11. (c) Thirteen weeks or more: 65. Number of beds occupied— (a) Average during the year : 95. (b) Highest: 100. (c) Lowest: 92 (on 9th February, 1933). Classification of In-Patients who were discharged from or who died in the Institution during the year ended 31st December, 1933— Men and Women. Dis_ Disease Groups. charged. Died. Malignant disease 1 Rheumatism— Non-articular manifestations of so-called "rheumatism" (muscular rheumatism, fibrositis, lumbago and sciatica) 3 18 Mental diseases— Senile Dementia — 1 Senile Decay 18 52 Disease of the Nervous System and Sense Organs — 1 ,, „ Respiratory System — 3 Other diseases 1 10 Totals 19 71 THE LOCAL GOVERNMENT AGT, 1929 In Croydon the delegated duties under this Act comprise the carrying out of the duties under the Children's Acts and the Vaccination Acts, for which the Public Health Committee is now responsible. In addition modified arrangements were made in connection with Maternity, Tuberculosis, and Mentally Deficient patients. The Mayday Hospital was appropriated by the Public Health Committee under Section 137 of the Public Health Act, 1875, on April 1st, 1932. 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 receive assistance direct from the Council, which was formerly given by the Ministry of Health. The grants were originally fixed for a three year period, and were revised and renewed for a further four years as from April 1st, 1933. The grants for the last four years have been as follows:- Croydon Mothers' and Infants' Welfare Association— 1930/31. 1931/2. 1932/3. 1933/4 £ £ £ £ (a) Hostel (net) 2,700 3,600 2,350* 4,500 (b) Infant Welfare Centres 700 700 750 850 (c) Convalesence 300 350 400 500 (d) Care-work (Unmarried mothers) 100 100 100 150 (e) Home Helps 50 75 100 100 £3,850 £4,825 £3,700 £ 6,100 19 Other Grants— £ £ £ £ The Retreat, Ross Road 787 650 650 650 Wilford Road Creche. 100 100 100 100 Croydon Rescue and Preventive Assoc. — 100 100 100 "The Shrubberies" — — — 230 £4,737 £5,675 £4,550 £7,180 *Originally fixed at £3,600 and reduction of £1,290 agreed to by Association. †Less Hostel Contributions. MAYDAY HOSPITAL. This Public Assistance Hospital was, as already stated, appropriated by the Public Health Committee on April 1st, 1932, and is now administered as part of the public health services of the Council. The medical staffing of the Hospital remains the same, viz:— a medical superintendent, 3 other resident medical staff and 7 visiting staff. The nursing staff consists of Matron; 20 sisters (including 2 X-Ray), 13 trained nurses (including 2 ambulance nurses); 7 assistant nurses, 66 probationer nurses and 6 male attendants. The Specialist services supplied comprise Ophthalmic, Dental, Radiological, Orthopaedic, Ear, Nose and Throat and Tuberculosis. Beds available for sick, maternity, and mental cases on 31st December, 1933:— (a) For Men 160 (b) For Women 246 (c) For Children (under 16 years of age) 60 Local Govarnment Act, 1929. It is the duty of a local authority under the provisions of the above named Act to see that the reasonable hospital needs of their community are satisfied, though they need not meet the need entirely themselves. 20 In order to ascertain the position with regard to any future extensions contemplated by the voluntary institutions in the town, a Conference was called between the local authority's representatives and those of the three voluntary hospitals in Croydon. Of the three hospitals only the Croydon General Hospital contemplated extending their accommodation. This extension has now materialised and makes provision for 65 additional beds so that there are at the present time in Croydon in general or cottage hospitals 246 medical and 150 surgical beds for adults, 83 beds for children, and the 65 beds which have not yet actually been put into use at the Croydon General Hospital. The Voluntary Hospitals admit cases from outside the Borough to a very considerable extent; in fact the Purley War Memorial Hospital is to a much greater extent a Purley Hospital than a Croydon hospital although situated on the Croydon side of the boundary between Croydon and Purley. In addition to general medical and surgical and other beds, Mayday Hospital provides 128 beds for cases not ordinarily admitted to a general hospital, but for whom there is no alternative provision in the Borough at the present time, e.g., cases of tuberculosis and mental cases. The population of Croydon is growing rapidly, averaging an increase of 3,000 to 4,000 persons per annum. At the last census the increase was 22% over the census of 1921. When Mayday Hospital was established in 1885 the population of Croydon was estimated at 88,800 and of the other parishes of the then Croydon Union at 41,200, a population of approximately 130,000. It is now 239,950 for Croydon alone, while the number of beds provided in the hospital remains the same as in 1885, except for the addition of 40 beds for children. On a basis of four hospital beds per 1,000 population the number of general hospital beds in Croydon should be 960; it is at present 479. The proximity of London, with its numerous large Voluntary Hospitals, relieves somewhat a position which would otherwise be perturbing. An aggravation of the need is the present day tendency for more and more people to sees institutional treatment, possibly on account of (a) lack of facilities at home, or (b) the rising complexity and expense of medical treatment. As the administration of the Hospital was delegated to the Public Health Committee on the 1st April, 1932, the Hospital should be in a position to admit any inhabitant of Croydon seeking admission on account of illness, in addition to the public assistance cases which must be admitted. The demand for beds other than 21 through the Public Assistance Committee will steadily increase. If insufficient beds are available either (a) patients who should properly be treated in hospital must be turned away, or (b) there must be gross overcrowding of the hospital, a circumstance strongly against the best interests of the patients and the proper administration of the Institution. In addition to the steady influx of chronie cases from the Public Assistance Committee through relieving officers there is a decided increase in the number of acute cases admitted on the order of the Medical Officer of Health or the Medical Superintendent. These latter cases now constitute nearly two-thirds of the whole. When the limits of accommodation are reached it is the latter cases that will have to be turned down, as none of the other hospitals in the area can meet the need, working as they are already at their full capacity. Each of the twelve main wards at Mayday Hospital has on floor area recognised in hospital practice, six beds too many, but the present bed accommodation at Mayday Hospital, namely, 466, is on this overcrowded basis. With excess, over and above the bed accommodation, amounting at times to as many as 100 patients, the already overcrowded conditions are much aggravated. For a general hospital the number of chronic cases in Mayday Hospital is high. This is owing to the lack of sufficient accommodation in the chronic wards in the Queen's Road Homes. The consequent lessened rate of turn-over ties down the number of beds which could otherwise be used for a succession of cases. The original idea was to build a hospital block for chronic cases at Queen's Road. This proposal was not proceeded with, however, owing to the events of August, 1931, but it was agreed that the Mayday Hospital should be extended in accordance with the original plan, with one extra ward block for acute cases, and that for the present the chronic cases should be retained there. A summary of the extensions contemplated to the Mayday Hospital is as follows, viz:— A three storey block, consisting of three wards of twenty beds each and six side wards of one bed each on the women's side. The wards could be used for acute medical and surgical cases, and some of the existing wards be reserved for the chronic sick whom it was originally thought might be transferred to a new block at the Queen's Road Homes. The demand for beds on the female side is much greater than on the male side. At present one of the wards on the male side is occupied by females. 22 A new Maternity Block—this will be a two storey building to contain 40 beds. This is considered to be an urgent matter as the existing maternity block is inadequate in accommodation and obsolete in arrangement and structural equipment. The present maternity block will be adapted to form a gynæcological block. By this arrangement the maternity block and the gynaecological block would be contiguous and would form one obstetrical unit. This block, which will contain twenty beds, will free one of the wards now used for gynaecological cases, for general medical or surgical purposes. A one storey pavilion block for infants and young children, on lines similar to those of the two now existing. This block will be the same size as the existing blocks, namely 20 beds. The three blocks will then form a subsidiary children's hospital of sixty beds. The erection of this block will enable the Observation Nursery in Lodge Road to be discontinued. On account of its small size this institution is costly to maintain. The premises it now occupies could be utilised for the purpose of child welfare and school clinics for which more commodious accommodation is very urgently required. A new receiving ward block at the Hospital Main entrance in Bridge Road. This block will contain ten single bedded cubicle wards, five for males and five for females, with a doctor's room, nurses duty room, store room and the necessary sanitary arrangements. At present there is no proper receiving block and its provision is of importance, more especially in preventing outbreaks of infectious disease in the Hospital, and for the better allocation of patients to various wards. The present Receiving Block will be converted into a special departments block and will be enlarged. In any general hospital the provision of modern X-Ray plant for diagnostic and therapeutic purposes; clinical laboratory facilities; orthopaedic, dental, ophthalmic, massage, diathermy and remedial departments is essential. The facilities which exist are quite inadequate. An Observation Block for acute mental cases, of sixteen beds. Each of the ten existing day rooms will be converted into a four bedded and a one bedded ward with bath room and sink room accommodation, and provision of day room recesses to existing wards will be provided. 23 Under these extensions there will be available:— Four blocks of 75 beds each 300 beds. One block of 66 beds 66 „ One maternity block of 40 beds 40 „ One gynaecological block 20 „ Conversion of present day rooms 50 „ 476 In addition there would be:— Three children's blocks of 20 beds each 60 beds. Receiving block 10 ,, Mental observation block 16 „ 86 A total bed accommodation of all kinds of 562 beds. This accommodation should be divided:— *Male beds 175 beds. *Pemala beds 301 ,, including 50 maternity beds Children's beds 60 „ *Not including Receiving Block and Mental Observation Block. In addition to the purely medical and surgical aspects, it was found that the whole of the heating arrangements throughout the hospital were inefficient and this has necessitated the installation of a complete modern hot water heating system, together with a central boiler and engine house. The order in which the extensions and alterations at Mayday Hospital will be carried out is as follows:— Firstly, the Boiler House together with the whole of the new heating system. This is already well in hand. Before the heating system, however, is completed the new ward block will be begun. 24 The new ward block must be completed and ready for occupation before any alterations to the heating in the other ward blocks can be commenced, otherwise the hospital's work would be seriously disorganised. In a hospital which is working above it full capacity it is obvious to close down a block containing 75 beds is impracticable. On the other hand, the alterations to the old ward blocks and the installation of new heating in those blocks cannot be carried out if they are occupied. The erection of the new maternity block at the same time is necessary as the present maternity block is quite inadequate. In addition, the erection of this block would release the present maternity block for use for other purposes, and the excess :f patients disturbed owing to the alterations to the old blocks an] who cannot be accommodated in the new block would be accomnx dated in the present maternity block. Following on this primary group the new nurses' home will be commenced as the previous group is nearing completion ami before the erection of the second group. No new staff will be immediately necessary during the erection of the new ward block, nor for some time after that block is completed, as the total accommodation of the hospital will not be materially increase:!. When the maternity block is finished the accommodation of the hospital will be increased by 40 beds. This will necessitate a small preliminary increase m staff. The second group of buildings to be erected, or to which structural alterations will be made, are the old ward blocks, togethr with the conversion of the day rooms into side wards, and the building out of day room recesses, the children's block, the new admission block, the waiting rooms for patients' relatives and the adaptation of the present admission and X-Ray block as a specif departments block. By the time that these latter works are nearin? completion there should be available the full contemplated extra accommodation in the new nurses' home. Owing to the existing X-ray plant showing serious defects and the probability that it requires extensive and costly repairs, it has been decided to bring forward the erection of tlie new X-ray department and installation of new plant, so that this will be p|!i in hand shortly. 25 Table I. Table shewing the Classification of the accommodation for the sick and the number of beds occupied on the 31st December, 1933— ALL CASES. Classifica'ion of Wards. (1) N umhet or Wards. (2) REDS MEN WOMEN CHILDREN flintier 16 years of age) Total Provided. (3) Occupied (4) Provided (5) Occupied (6) Provided (7) Occupied (8) Provide d (9) Occupied (10) 1. Medical 2 32 31 32 34 ... ... 64 65 2. Surgical 2 32 27 32 34 ... ... 64 61 3. Chronic sick 3 32 37 64 73 ... ... 96 110 4. Children 2* ... ... ... 70 63 70 63 5. Venereal ... ... 1 ... 2 ... ... ... 3 6. Tuberculosis 2 32 21 32 13 ... ... 64 34 7. Isolation ... ... ... ... ... ... ... ... ... 8. Maternity 1 ... ... 22 14 ... 13+ 22 27 9. Mental 2 32 38 32 31 ... ... 64 69 10. Gynaecological 1 ... ... 32 20 ... ... 32 20 Total 15 160 155 246 221 70 76 476 452 * Plus 4 day-rooms attached to adult wards, t Infants. Table II Statistics relating to the Year ended 31st December, 1933. in-patients. Croydon. 1.—Total number of admissions (including infants born in hospital) 3899 2.—Number of women confined in hospital 424 3.—Number of live births 395 4.—Number of still births 29 5. Number of deaths among the newly born (i.e., under 4 weeks of age) 15 5.- Total number of deaths of children under one year 45 7.-Total number of maternal deaths 7 8.—Total number of deaths 672 9. Number of patients discharged ... 3224 10. Duration of stay of patients included in 8 and 9 above : (a) Four weeks or less 2396 (b) Exceeding 4 weeks, but under 13 weeks ... 1169 (c) Exceeding 13 weeks 331 11- Number of beds occupied : (a) Average during the year 450 (b) Highest (on 24-1-33) 527 (c) [Lowest (on 15-9-33) 385 Number of surgical operations under general anaesthetic (excluding dental operations) 677 13.- Number of abdominal sections 299 OUT-PATIENTS : Nil. 26 Table III. Classification of ln-Patients who were Discharged from or who Died in the Institution during the year ended. 31st December, 1933. Disease Groups. Children (under 16 years of age). Men ;ind Women. Discharged Died Discharged Died A.—Acute infectious disease.. 25 19 B.—Influenza 7 1 33 7 C.—Tuberculosis : Pulmonary 2 3 59 46 Non-pulmonary 4 3 9 2 D.—Malignant disease 34 79 E.—Rheumatism— (1) Acute rheumatism (rheumatic fever) together with subacute rheumatism and chorea 13 1 25 11 (2) Non-articular manifestations of socalled "rheumatism" (muscular rheumatism, fibrositis, lumbago and sciatica) - - 17 1 (3) Chronic arthritis - - 36 — F.—Venereal disease 2 1 29 1 G.—Puerperal pyrexia - — 20 — H.—Puerperal fever— (a) Women confined in the hospital — — 1 1 (b) Admitted from outside — — — — I.—Other diseases and — — — — dents connected with — — — — pregnancy and childbirth — — 188 5 J.—Mental diseases— — — — — (a) Senile dementia 8 — 263 15 (b) Other — — — — K.—Senile decay — — 46 40 L.—Accidental injury and violence 39 1 147 17 In respect of cases not included above : M.—Disease of the Nervous System & Sense Organs. 29 — 69 8 N. ,, Respiratory „ 89 18 130 106 O. ,, Circulatory „ 7 6 130 170 P. ,, Digestive ,, 137 16 309 32 Q. ,, Genito-urinary 10 3 173 3u R.—Disease of the Skin 54 4 68 10 S.—Other diseases 38 1 86 6 T.—Mothers and infants discharged from Maternity Wards and not included in above figuresMothers — — 446 6 Infants 380 15 — — U.—Anv persons not falling under any of the above headings 43 Totals 887 73 2337 599 27 The following details, kindly supplied by the Medical Superintendent, Dr. A. Gilrav, refer to patients treated during the year. Table IV. Diagnoses In Cases Treated Medical. Surgical. Total Cured Died Cured Relieved Unrelieved Died A. Alimentary System. Colic 1 — — — — — 2 Stomatitis 4 — — — — — 4 Enteritis 34 9 — — — — 49 Hernia — — 20 7 2 4 33 Appendicitis — — 146 7 3 7 163 Peritonitis — — 3 — — 3 6 Constipation 14 — — — — — 19 Fistula in ano — — 3 — — — 3 Haemorrhoids — — 5 5 — — 10 Gastric and Duodenal Ulcer 8 8 6 — 1 1 40 Gastritis 7 — — — — — 12 Intussusception — — 2 — — — 2 Dyspepsia 4 — — — — — 4 Cholecystitis — — 6 13 1 1 21 Intestinal Obstruction — — 1 — — 3 4 Pyorrhoea — — 7 4 — — 11 Colitis 2 1 — — — — 4 Jaundice 6 2 — — — — 9 Abdominal Pain (? Cause) — — — — — — 1 Hare Lip and Cleft Palate — — — — 1 — 1 Diverticulitis — — — — — 1 1 Pancreatic cyst — — 1 — — — 1 Abdominal Tumour — — — 1 — — 1 Colelithiasis — — — 1 — 1 2 Prolapse of Rectum — — 1 1 — — 2 Ischio-rectal abscess — — 1 — — — 1 Cirrhosis of Liver — 1 — — — — 2 38 Diagnoses In Cases Treated Medical. Surgical. Total[/##] Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Coeliac Disease 1 — — — — — — — 1 Pyloric Stenosis — — — — 1 — — 1 2 Collapse 3 1 — — — — — — 4 Diabetes 3 11 2 7 — — — — 23 General Debility 2 9 — 2 — — — — 13 Malnutrition 3 — — — — — — — 3 Marasmus 3 1 — 2 — — — — 6 Rectal Polypus — — — — 1 — — — 1 Totals Group A 95 52 9 32 204 39 8 22 461 G. Bones and Joints. Rheumatoid Arthritis 5 17 5 — — — — — 27 Osteo Arthritis — 4 2 — — — — — 6 Infective Arthritis — — — — 2 3 1 — 6 Villous Arthritis — 1 — — — — — — 1 Acute Rheumatism 21 11 1 12 — — — — 45 Muscular Rheumatism — 2 — — — — — — 2 Osteo Myelitis — — — — 7 2 1 — 10 Bursitis — — — — 6 — — — 6 Sciatica 2 1 — — — — — — 3 Synovitis 3 — — — — — — — 3 Pleurodynia 2 — — — — — — — 2 Tenosynovitis — — — — 1 — — — 1 Talipes Varus — — — — — — 1 — 1 Spina Bifida — — — — — — — 1 1 Lumbago — 1 — — — — — — 1 Pes Planus — — — — — 1 — — 1 Myositis 2 — — — — — — — Fibrositis — — 1 — — — — — 1 Bilateral Hallux Valgus — — — — — 1 — — 1 Hammer Toes — — — — — 1 — — 1 Totals Group G 35 37 9 12 16 8 3 1 121 29 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died C. Circulatory System. Myocarditis 4 15 6 27 — — — — 52 Arterio-Sclerosis 2 10 4 52 — — — — 68 Mitral Disease 1 4 — 1 — — — — 6 Mitral Stenosis 2 14 — 1 — — — — 17 Myocardial Degeneration — 13 1 49 — — — — 63 Auricular Fibrillation — 4 — 4 — — — — 8 Rupture of Aorta — — — 1 — — — — 1 Cerebral Haemorrhage — 8 — 14 — — — — 22 Mitral Regurgitation — — — 2 — — — — 2 Angina Pectoris 1 3 — 1 — — — — 5 Mitral Incompetence — 1 — 3 — — — — 4 Phlebitis 6 2 1 3 — — — — 12 Valvular Disease — 6 — 1 — — — — 7 Disseminated Sclerosis — 1 — 4 — — — — 5 Cerebral thrombosis — 2 — 7 — — — — 9 Aortic Regurgitation — 2 — — — — — — 2 Varicose Veins 2 — — — — — — — 2 Endocarditis 1 3 1 2 — — — — 7 Pericardial Effusion — 1 — — — — — — 1 Heart Block — 1 — — — — — — 1 Congenital Heart Disease — 1 1 1 — — — — 3 Stokes Adams Disease — 1 — — — — 1 Cardiospasm 1 — — — — — — — 1 Aneurysm — — 1 1 — — — 2 Hodgkins Disease — — — 1 — 1 Hyperpiesia — 3 — — — — — — 3 Hypertension — 1 — — — — — — 1 Anaemia 4 6 — 2 12 Septicaemia 2 — — 5 — — — — 7 Totals Group C. 26 102 15 182 — — — — 325 30 Diagnoses in Cases T reated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died M. Cancer. Carcinoma of— Axilla — — — — — — — 1 1 Bladder — — — — — — 2 3 5 Brain — — — — — — — 1 1 Breast — — — — — 1 3 13 17 Bowel — — — — 6 1 2 13 22 Cervix — — — — — 1 1 2 4 Glands — — — — — — — 1 1 Larynx — — — — — — — 1 1 Lip — — — — — — — 1 1 Liver — — — — — — — 2 2 Lung — — — — — — — 1 1 Kidney — — — — — — — 1 1 Mouth — — — — — — — 2 2 Neck — — — — — — 1 — 1 Oesophagus — — — — — — — 1 1 Ovaries — — — — 1 — 1 1 3 Pancreas — — — — — — — 1 1 Pelvis — — — — — — 1 2 3 Prostate — — — — — — — 4 4 Sternum — — — — — 1 — — 1 Stomach — — — — 1 1 5 20 27 Supra-renal — — — — — — — 1 1 Tongue — — — — — — 1 2 3 Spine — — — — — — 1 2 3 Skin — — — — — — — 1 1 Testis — — — — — — — 1 1 Uterus — — — — 1 3 2 6 12 Vulvae — — — — — — — 1 1 Epithelioma of Skin — — — — — — 1 — 1 Rodent Ulcer of Face — — — — — — — 1 1 Totals Group M. — — — — 9 8 21 86 124 31 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died F. Gynaecological. Ovarian Abscess — — — — — 1 — — 1 Ovapan Cyst — — — — 7 — — — 7 Acute Salpingitis — — — — 6 3 — — 9 Chronic Salpingo-Oophoritis — — — 7 2 — — 9 Pyosalpinx — — — 1 — — — 1 Tuberculous Salpingitis — — — — — 1 — — 1 Tubo-Ovarian Cyst — — — — 1 — — — 1 Chronic Metritis — — — — 9 — — — 9 Chronic Endometritis — — — — 4 — — — 4 Chronic Cervicitis — — — — 14 2 — — 16 Erosion of the Cervix — — — — 1 — — — 1 Subinvolution — — — 4 1 — — 5 Deficient Pelvic Floor and Prolapse — — — 1 15 2 — — 18 Uterine Fibromyoma — — — — 3 — — — 3 Cervical Polypus — — — — 1 — — — 1 Acute Vaginitis — — — — — 2 — — 2 Vaginal Cyst — — — — 1 — — — 1 Rigid Hymen — — — — 3 — — — 3 Urethral Caruncle — — — — — 2 — — 2 Bartholin's Cyst — — — — 1 — — — 1 Bartholin's Abscess — — — — 1 — — — 1 Amenorrhoea — — — — — — 1 — 1 Dysraenorrhoea — — — — — 1 — — 1 Metrorrhagia — — — — — 1 — — 1 Menopausal neurosis — 1 — — — — — — 1 Sterility — — — — 1 3 — — 4 Hyperemesis Gravidarum 5 — — 1 — — — — 6 Retroverted Gravid Uterus — — — — 1 2 — — 3 Abortion — — — — 112 2 — — 114 32 Diagnoses in Cases Treated Medical. Surgical. Tom Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Ectopic Gestation — — — — 3 — — 1 4 Pyelitis of Pregnancy (discharged undelivered) 5 4 — — — — — — 9 Albuminuria (discharged undelivered) 7 5 — — — — — — 12 Eclampsia 2 — — 2 — — — — 4 Puerperal Fever — — — — 3 — — 3 6 Puerperal Pyrexia — — — — 1 — — — 1 Mastitis — — — — 6 6 Totals Group F. 19 10 — 4 206 25 1 4 269 I. Eye. Astigmatism 1 — 1 Loss of Eye — — 1 — — — — — 1 Blepharitis 1 1 Cataract — — — — — 1 — — 1 Conjunctivitis 1 1 — — — — — — 2 Glaucoma 1 — — 1 Iridocyclitis — — — 1 — — — — 1 Ophthalmia 3 — 1 — — — — — 4 Strumous Keratitis — 1 — — — — — — 1 Totals Group I. 5 2 3 1 — 2 — — 13 • B. Respiratory System. Bronchitis 54 64 6 48 — 172 Empyema 9 — — — — — — — — Emphysema — — 1 — — — — — — Bronchiectasis — — — 2 — — — — — Fibrosis of Lungs — 3 — — — — — — 3 Laryngitis 2 — — — — — — — — 33 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Asthma 1 11 2 6 — — — — 20 Pleurisy 10 2 1 3 — — — — 16 Pheumonia 100 13 3 73 — — — — 189 Tracheitis — 1 — — — — — — 1 Totals Group B. 176 94 13 132 — — — — 415 E. Genito-Urinary System. Cystitis — — — — 6 4 1 1 12 Pyelonephritis — — — 8 — — — — 8 Pyonephrosis — — — — 1 1 — — 2 Uraemia — — — 9 — — — — 9 Nephritis 11 9 3 12 — — — — 35 Retention of Urine — — — — 1 6 1 3 11 Renal Calculi — — — — 1 2 1 — 4 Hydro-nephrosis — 1 — — — — — — 1 Pyelitis 6 6 2 — — — — — 14 Renal Glycosuria — 1 — — — — — — 1 Epididymo-orchitis — — — — 1 2 — — 3 Ureteric Calculi — — — — 1 3 — — 4 Urethral Stricture — — — — 2 4 — 1 7 Haematuria — — 2 — — 1 — — 3 Enlarged Prostate — — — — 2 16 — 10 28 Sepsis of Penis — — — — — 1 — — 1 Mobile Kidney — — — 1 — — — — 1 Oxaluria 1 — — — — — — — 1 Perinephric Abscess — — — — 1 — — — 1 Totals Group E. 18 17 7 30 16 40 3 15 146 84 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died H. Skin. Cellulitis — — — — 8 1 — — 9 Boils 8 — — — — — — — 8 Scabies 7 — — — — — — — 7 Impetigo 33 2 — — — — — — 35 Pediculi Capitis 2 — — — — — — — 2 Dermatitis 27 6 2 3 — — — — 38 Scalds and Burns — — — — 8 5 — 1 14 Ulcers — — — — 14 7 2 3 26 Eczema 5 2 1 — — — — — 8 Abscesses — — — — 11 2 — — 13 Seborrhoea — 2 — — — — — — 2 Herpes Labialis 1 — — — — — — — 1 Urticaria 1 — — — — — — — 1 Carbuncle — — — — 4 — — — 4 Ringworm 4 — — — — — — — 4 Whitlow — — — — 1 — — — 1 Herpes Zoster 1 — — — — — — — 1 Cheiropompholyx 1 — — — — — — — 1 Alopaecia 1 — — — — — — — 1 Insect Bite 1 — — — — — — — 1 Totals Group H. 92 12 3 3 46 15 2 4 177 Q. Venereal Disease. Gonorrhoea — — — — 1 6 — — 7 Syphilis — — — — 1 22 3 3 29 Totals Group Q. — — — — 2 28 3 3 36 35 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died K. Infectious and Contagious Diseases. Influenza 34 5 — 8 — — — — 47 Measles — — 2 — — — — — 2 Whooping Cough — 1 4 — — — — — 5 Meningococcal Meningitis — — 1 1 — — — — 2 Cerebro-spinal Fever — — 1 — — — — — 1 Erysipelas 1 2 9 2 — — — — 14 Mumps — — 1 — — — — — 1 Diphtheria — — 6 — — — — — 6 Scarlet Fever — — 7 — — — — — 7 Typhoid — 1 1 — — — — — 2 Dysentery — 7 1 — — — — — 8 Chicken Pox 1 — 1 — — — — — 2 Infantile Paralysis — — 1 — — — — — 1 Totals Group K. 36 16 35 11 — — — — 98 D. Central Nervous System. Hemiplegia —— 10 — 10 — — — — 20 Hysteria 5 5 — — — — — — 10 Neuritis 1 2 — 1 — — 4 Teething 2 — — — — — — — 2 Neurosis 1 3 — — — — — — 4 Neurasthenia 1 12 3 — — — — — 16 Paralysis Agitans — — 3 2 — 5 Chorea 3 1 — — — — — — 4 Paraplegia — — 1 — — — — — 1 Meningitis — — — 3 3 Tabes Dorsalis — — — 1 1 Infantile Diplegia — 1 — — — — — — 1 36 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Syringomyelia — 1 — — — — — — 1 Post Encephalitic Parkinsonian — 1 — — — — — — 1 Neuralgia — 1 — — — — — — 1 Convulsions 1 1 — — — — — — 2 Juvenile Tabes — 2 — — — — — — 2 Totals Group D. 14 40 7 17 — — — — 78 J. Ear, Nose and Throat. Mastoiditis — — — — 14 1 1 — 16 Meatitis — — — — — 1 — — 1 Meatal Boil — — — — 1 — — — 1 Menier's Disease — _ 2 — — — — — — 2 Otitis Media — — — — 25 6 — 1 32 Sinusitis — — — — 1 — — — 1 Acute Rhinitis — — — 1 — — — — 1 Epistaxis 2 — — — — — — — 2 Enlarged Tonsils — — — — 51 6 — — 57 Tonsillitis 15 6 — — — — — — 21 Quinsy — — — — 3 — — — 3 Totals Group D. 17 8 1 95 14 1 1 137 L. General. Adenitis 13 1 2 — 18 — — 1 35 Adenomatous Goitre — — — — 1 — — — 1 Exophthalmic Goitre — 1 2 1 — — — — 4 Hyperthyroidism — 1 — — — — — — 1 Lymphangitis 1 — 1 — — — — — 2 87 Diagnoses In Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died Lymphatic Leukaemia — — 1 — — — — 1 Simple Tumour — — — — 1 — — — 1 Ganglion — — — — 1 — — — 1 Contusion — — — — 24 — — — 24 Dislocations — — — — — 2 — — 2 Fractured Limb — — — — 46 21 5 2 74 Fractured Skull — — — — 17 4 — 3 24 Fractured Jaw — — — — — 1 — — 1 Foreign Body Swallowed — — — — 5 1 — — 6 Concussion — — — — 56 7 3 — 66 Abrasions — — — — 13 2 — — 15 Sprains — — — — 3 1 — — 4 Minor Injuries — — — — 4 1 — — 5 Shock — — — — 1 — — — 1 Lacerations — — — — 19 6 2 — 27 Poisoning 6 1 — 3 — — — — 10 Totals Group L. 20 4 6 4 209 46 10 6 305 N. Tuberculosis. Lungs 2 51 10 44 — — — — 107 Bowel — — — — — 2 — — 2 Meninges — — — 5 — — — — 5 Spine — — — — 1 7 — — 8 Epididymo-orchitis — — — — 1 — — — 1 Peritonitis — — — — — 1 1 1 3 Pleurisy — 1 — — — — — — 1 Kidneys — — — — — 1 — — 1 Bladder — — — — — 1 — — 1 Salpingitis — — — — — 2 — — 2 Glands — 1 — — — — — — 1 Arthritis — — — — 1 — — — 1 Totals Group N. 2 53 10 49 3 14 1 1 133 38 Diagnoses in Cases Treated Medical. Surgical. Total Cured Relieved Unrelieved Died Cured Relieved Unrelieved Died P. Mental. Alcoholism — 4 — — — — — — 4 Epilepsy — 13 12 2 — — — — 27 Petit Mai 1 1 Mental Deficients — 3 9 1 — — — — 13 Loss of Memory — 1 — — — — — — 1 Cerebral Tumour — — 2 — — — — — 2 Certified and sent to Mental Hospital — — 142 1 — — — — 143 Cases not Certified 3 81 20 4 — — — — 108 Senile Decay — 32 13 60 — — — — 105 Totals Group P. 4 134 198 68 — — — — 404 0. Maternity — — — — 448 — — 2 450 Births — — — — 385 — — 23 408 Total Group 0. — — — — 833 — — 25 858 Totals of all Cases Treated 559 581 315 546 1639 239 53 168 4100 The total death rate of the Hospital during the year was 174 per 1,000 i.e. one patient out of every 5.8 patients adnvtted died. 39 OPERATIONS PERFORMED IN THE MAYDAY HOSPITAL DURING THE YEAR. OBSTETRICAL. Operation Performed. Number. Forceps delivery 21 Breech extraction 4 Internal version 6 Embryotomy 3 Manual removal of placenta 4 Vaginal packing 2 Anaesthesia for examination, external version, etc. 5 Abortion, evacuation of uterus 23 Abortion, evacuation of uterus and glycerine drainage 47 Induction of abortion 2 Abdominal hysterotomy and sterilisation 3 For ectopic gestation 3 Caesarean section 4 Caesarean hysterectomy 2 Surgical induction of labour 11 Drainage of puerperal peritonitis 1 GYNAECOLOGICAL. Excision of urethral caruncle 2 Excision of Bartholins cyst 2 Excision of vaginal cyst 1 Plastic hymenectomy 3 Perineorrhaphy 6 Anterior and posterior colporrhaphy 2 Anterior and posterior colporrhaphy and amputation of cervix 7 Amputation of cervix 8 Trachelorrhaphy 1 Removal of cervical polypus and exploration of uterus 1 Removal of tissue for section 6 Dilatation of cervix 3 Dilatation of curettage 2 Glycerine drainage for subinvolution 3 Exploration of uterus 2 Ovariotomy 7 Laparotomy for ovarian carcinoma 2 Myomectomy 2 Wertheims hysterectomy 2 Total hysterectomy 13 Sub-total hysterectomy 8 Sterilisation 3 Salpingectomy 1 Salpingography 1 Laparotomy for tuberculous salpingitis 1 Salpingo-oophorectomy 7 Examination under anaesthesia, etc 15 EAR, NOSE AND THROAT. Removal of nasal polyp 1 Removal of tonsils 61 Removal of adenoids 34 Mastoidectomy 15 Exposure of mastoid antrum 1 Nasal examination 1 Sub mucous resection of nasal septum 2 Myringotomy 1 Paracentesis of ear 1 40 Operation Performed. Numbir. EYE. Iridectomy 2 Evisceration of eye 1 BONES AND JOINTS. Drainage for acute purulent arthritis 1 Drainage for sinus beneath knee 1 Reduction of fractured limbs 3 Application of caliper 1 Application of plasters 14 Resetting of fractures 2 Transfixion pins through tibia 6 Transfixion pins through os calcis 2 Arthrodesis 2 For Osteo myelitis 2 Wiring of fractured patella 1 Manipulation of limbs ® Amputation of limbs 2 Bone graft1 Sequestrectomy 4 ABDOMINAL. Operation Performed. Numbir. Appendicectomy 150 Drainage of appendix abscess 13 Drainage for general peritonitis . 3 Gastro-jejunostomy 5 Ruptured rectus abdominis 1 Paracentesis abdominis Cholecystectomy " Intussusception ' Sigmoidoscopy * Laparotomy " Suture of perforated duodenal ulcer " Suture of perforated gastric ulc J Colostomy * Caecostomy • Ligature of haemorrhoids Excision of haemorrhoids Rectal examination J Pancreatic cyst j Closure of faecal fistula ' Resection of colon Repair of ventral hernia : Repair of anal fissure Radical cure of strangulated hernia ® Herniotomy . Removal of rectal polyp. Partial gastrectomy 2 Enterostomy [41 GENITO-URINARY. Operation Performed. Number. Drainage for pyonephrosis 1 Pyelo-nephrolithotomy 1 Nephrectomy 2 Cystoscopy 44 Pyelography 7 Cystostomy 3 Dilatation of urethral stricture 14 Supra pubic puncture 1 Supra pubic prostatectomy 3 Circumcision 14 Insertion of catheter 2 Tapping of hydrocele 3 Orchidectomy 2 MISCELLANEOUS. Injection of anti-tetanic serum 1 For cellulitis of arm 1 Paracentesis thoracis 7 Incisions (abscesses, whitlows, etc.) 116 Removal of toe nail 1 Removal of F.B 2 Excision of rodent ulcer 1 Excision of ganglion, cysts, glands, etc. 13 Plastic operation on toes 1 Sutures 11 A.P. induction 6 A.P. refills 12 Lumbar puncture 18 Exploration and aspiration of chest 50 Cleansing of burns 1 Tannic acid treatment for scalds 1 Rib resections 16 Skin graft 2 Partial thyroidectomy 1 Lung puncture 1 Blood transfusion 2 Number of patients who had teeth extracted 263 1,287 42 RADIOLOGICAL DEPARTMENT. NUMBER OF X-RAY FILMS TAKEN DURING THE YEAR 1933. Spine 103 Long bones 273 Pelvis 8 Skulls ... 156 Chests (including lungs) 294 Barium Meals= 172 Barium Enemata 23 Urinary Tracts 148 Gall-bladder 44 Teeth 21 Abdominal (? F. B.) 13 Maternity Cases 146 Total, 1,401 43 Months. Air Temperature in Degrees Fahrenheit. Rainfall Total. Bright Sunshine. Table V. METEOROLOGICAL RECORD. Hrs. per day. Percenage. Means of Mean of A. & B. A. Max. B. Min. DailjjMean °F. °F. °F. in. mm. hrs. January 41.3 33.7 37.5 1.79 45 1.52 18 February 45.3 36.9 41.1 2.63 67 2.11 21 March 55.0 38.3 46.7 3.09 79 6.04 51 April 58.1 41.1 49.6 0.67 17 5.72 41 May 63.9 47.0 55.5 2.80 71 5.21 34 June 70.8 51.8 61.3 1.73 44 8.53 52 July 74.7 56.9 65.8 1.80 46 7.71 48 August 76.0 57.0 66.5 0.78 20 8.14 56 September 69.0 52.8 60.9 2.52 64 6.33 50 October 57.8 46.1 51.9 1.89 48 3.55 33 November 47.3 39.0 43.1 1.08 27 1.21 14 December 37.7 30.5 34.1 0.40 10 0.90 11 Means and Totals for Year 58.1 44.3 51.2 21.16 537 4.76 39 The observations were made at the Aerodrome, which is 217 feet above mean sea level. 44 VITAL STATISTICS. Marriages.—The number of marriages solemnised was 2,241, compared with 2,134 in 1932; 2,212 in 1931; 2,112 in 1930; 1,982 in 1929; and 1,874 in 1928. The marriage rate was 9 per 1,001) of the population; 993 were solemnised in Established Churches, 242 in other places of worship, 1,007 in the Register Office; one ceremony was performed under Jewish ritual, and one under ritual of the Society of Friends. Births.—The births registered were 3,015 legitimate and 132 illegitimate. The birth-rate consequently was 13.2. For England and Wales the rate was 14.4, and in the 118 Great Towns it was 14.4. The illegitimate births in Croydon were 4.2% of the total, compared with 4.9% in 1932, 4.8% in 1931, 5.1% in 1930, 4.8% in 1929, and 4.4% in 1928. The total male births numbered 1,630, the female 1,517 being a proportion of 1,074 males to 1,000 females. The subjoined table gives the vital statistics for the Wardsin the Town. It is seen that the Wards with the highest birth-rates were Waddon (16.5), Whitehorse Manor (16.2) and Thornton Heath (15.2). Those with the lowest were : Norbury and East (7.8), South (8.9), Upper Norwood (9.7), and Central (9.8). Deaths.—The deaths numbered 2,721, compared with 2,556 in 1932. For 1933 the death-rate was 11.3. For 1932 it was 10.8. The death-rate for England and Wales was 12.3, and for the 118 Great Towns 12.2. For London the death-rate was 12.2. The male death-rate was 11.6, the female 11.1 for the Borough. There were 166 inquests held by Coroners in respect oi Croydon residents during 1933, and 132 findings by Coroners after post-mortem examination without inquest. Wards with the highest death-rates were: South (14.2). South Norwood (13.7), Whitehorse Manor and Waddon (13-3). and Addiscombe (13.1); lowest in Norbury (8.3), Bensham Manor (9.2), East (9.5), and Thornton Heath (9.8). 45 Natural Increase.—The excess of births over deaths was 426, or 1.8 per 1,000 of the population. A comparison with previous years is given below. Immigration is playing a larger part than natural increase in the rapid increase of population. 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 such a rapidly growing district, a five-yearly census is most necessary if statistics are to be reasonably accurate. 46 Table VI. WARDS. Estimated Population. 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. Dea^h 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 (1933). Natural Increase or Decrease of Population. Upper Norwood 22380 216 239 9.7 10.7 67 0 13 0. 04 1.56 0.53 0 09 3 75 0.45 1 .60 20 1 —23 Norbury 15993 125 133 7.8 8.3 30 0.06 0.94 0.56 0 06 2.44 0 31 1.38 29.2 —8 West Thornton 20066 259 209 12 9 10.4 33 0 15 0.10 1 15 0.69 0 05 3 64 0.35 1.20 42.2 50 Bensham Manor 16084 201 148 12.5 9.2 19 0.19 0. 19 0 99 0.49 — 3.29 0.25 118 49.8 53 Thornton Heath 16616 235 153 15.0 9.8 44 006 0..13 1.41 103 0 06 2.56 0.26 1.47 50.5 82 South Norwood 17717 249 242 14 1 13 7 42 0.24 0. 06 1.86 0 56 0 06 5 13 0.67 1.62 28.8 7 Woodside 15654 185 175 118 11.3 50 0.38 0. 06 1.50 0.88 0 13 3.64 0 44 1.47 36.7 10 East 18035 140 171 7.8 9.5 46 Oil 0.11 0 .67 0.33 — 3 27 061 1.77 9 6 —31 Addiscombe 14458' 189 189 131 131 35 014 .... 1 .80 1 04 0.07 4 56 0 62 1.87 48.8 Whitehorse Manor 16754 272 223 16.2 13.3 62 0 24 0 29 1.79 1.24 0 06 3 46 077 1.55 62.9 49 Broad green . 15370 213 179 13 9 11 6 57 0 13 0 13 1.50 0 72 0.07 4 03 0 65 1.36 68.9 34 Central 1.2209 120 122 9.8 10 0 15 0 08 0 08 1.23 0.33 0.08 3.44 0.41 1.56 33 .3 —2 Waddon 21839 361 290 16 5 13 3 63 0.28 0 18 2.11 0.64 0.23 3 80 0 64 1.46 22.2 71 South ... 14901 13*2 211 8 9 14.2 91 0.13 0.13 1 08 0.55 0.20 4.63 0 85 2 50 12.5 —79 Aldington 2875 56 26 19.5 9 0 18 0.08 0.35 1 39 2 09 1 08 1 .74 0.80 30 The Borough 1 239050 1 3147. 27121 19. 1 11 .a 47 0 .17 0.11 1.42 0.68 0.09 3.69 0.59 1.56 .... .... ,,,,, 47 Comments on Table VI. Corrections have been made for deaths of infants in institutions. A death under such circumstances has been allocated to the Ward in which the parents reside. Infantile mortality was highest in South (91), Waddon (63), Whitehorse Manor (62), and Upper Norwood and Broad Green (57); lowest in Central (15), Bensham Manor (19). The Infantile Mortality rate was above the average for the whole Borough in the following Wards: Upper Norwood, Woodside, Whitehorse Manor, Broad Green, Waddon and South. Birth.rates were highest in Waddon, Whitehorse Manor, and Thornton Ileath; lowest in Norbury, East, South, Upper Norwood and Central. The general death-rate was highest in South, South Norwood, Whitehorse Manor, Waddon and Addiscombe; lowest in Norbury, Bensham Manor, East, and Thornton Heath. The death-rate was above the average for the whole Borough in the following Wards : South Norwood, Addiscombe, Whitehorse Manor, Broad Green, Waddon and South. Most persons to the acre in Broad Green, Whitehorse Manor, Ihornton Heath, and Bensham Manor; least in East, South, and Ipper Norwood. Addington, owing to its relatively scanty population, has not been included for purposes of comparison. The birth-rate is the lowest yet recorded. The death-rate from Zymotic diseases was' highest in WoodS|de, Waddon, South Norwood, and Whitehorse Manor; from Diarrhoea in Whitehorse Manor, Bensham Manor, and Waddon; from Bronchitis and Pneumonia in Waddon, South Norwood, \ddiscombe, and Whitehorse Manor; from Pulmonary Tuberculosis in Whitehorse Manor, Addiscombe and Thornton Heath; 'ram Non-Pulmonarv Tuberculosis in Waddon and South; from diseases of the Heart and Circulation in South Norwood, South, ,ind Addiscombe; from Nervous Diseases in South and White!|wse Manor; from Cancer in South and Addiscombe. 48 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 1911 3748 22.0 2069 121 170,451 9.8 1679 1921 3631 18.9 2054 10.7 191,500 8.2 1577 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 3400 14.6 2674 11.4 233,800 31 7.2S 1932 3311 14.0 2556 10 8 237.186 32 765 1933 3147 13.2 2721 11.3 239,950 1.8 416 Table VIII. Year. Population estimated to Middle of each Year. Births. Total Deaths Reg. in the District. Transferable Deaths Nett deaths bklo^g to the of Non.residents registered in the District. of Residents not registered in the District. Under 1 Year of Age. At a" Uncorrected Number. Nett. Number. Rate. Number. Rate per 1,000 Nett Births. Number. Rate Number. Rate. 1921 181,500 3713 3631 18. 9 2115 11. 0 283 222 269 74 2054 10.7 1922 192,800 3616 3505 18.2 2469 12..8 337 255 224 64 2387 12.4 1923 193,400 3445 3370 17.4 2082 12.5 284 209 176 52 2007 10.6 1924 196,000 3536 3456 17 .6 2384 121 317 213 195 56 2280 10.9 1925 199,300 3521 3406 17.1 •2262 11.4 336 243 187 55 2169 12.6 1926 205,900 3569 3477 16..9 2340 11.4 318 247 211 61 2269 12.5 1927 211,700 3329 3174 15 .0 2542 12.1 384 294 176 55 2452 10.5 1928 214,800 3501 3374 15..7 2439 11.4 389 301 178 53 2354 10.5 1929 222,300 3553 3399 15.3 29 j 4 13.3 463 301 221 65 2792 11.4 1930 222,300 3703 3514 15.8 2407 10.8 364 294 171 48 2337 11.4 1931 233,800 3601 3400 14 .5 2719 11.6 331 300 196 58 2674 10.8 1932 237,186 3607 3311 14.0 2500 10.5 242 298 161 49 2556 11.3 1933 239,950 3391 3147 13.2 2612 10.9 257 366 148 47 2721 49 Table IX. DEATHS REGISTERED DURING THE CALENDER YEAR 1933. 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 " or " non-1 Residents " in Institutions in the District. All ages. Under 1 year. 1 and under 2 years. 2 and under 5 years. 5 and under 1 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 1 4 5 6 7 8 9 10 n i] :3 All Causes • Certified 2719 148 19 29 g5 90 114 167 294 416 1377 1519 Uncertified 2 ... ... ... ... ... ... ... ... ... 2 ... Enteric Fever ... ... ... ... ... ... ... ... ... ... ... ... Small Fox ... ... ... ... ... ... ... ... ... ... ... ... Measles 13 3 5 3 2 ... ... ... ... ... ... 8 Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... Whoopi.ng Cough 3 1 ... 2 ... ... ... ... ... ... ... 1 Diphtheria and Croup 17 ... ... 7 7 2 ... ... 1 ... ... 17 Influenza (excl. Influenzal Pneu'nia) 58 ... ... ... ... 3 ... 10 5 10 30 8 Erysipelas 8 1 ... ... ... ... 1 ... 3 ... 3 7 Eetanus 1 ... ... ... 1 ... ... ... ... ... ... 1 Pulmonary Tuberculosis 162 ... ... ... 1 34 45 37 28 13 4 91 Tuberculous Meningitis 10 2 ... 3 5 ... ... ... ... ... ... 10 Other Tuberculous Disease 12 2 ... ... ... 2 1 2 ... 5 ... 11 Cancer, Malignant Disease 374 1 ... ... ... 2 11 16 59 108 177 200 Acute Rheumatism and Rheumatic Fever 4 ... ... ... ... 1 ... ... 1 1 1 3 Cerebro-Spinal Meningitis 2 ... ... 1 ... 1 ... ... ... ... ... 2 Ecephalitis Lethargica ... ... ... ... ... ... ... ... ... ... ... ... Other Forms of Meningitis (notT.B.) 7 2 ... 1 2 1 1 ... ... ... ... 6 Poliomyelitis 1 ... ... ... ... ... ... 1 ... ... ... ... Locomotor Ataxy 7 ... ... ... ... ... ... ... 2 2 3 3 Gegeneral Paralysis ot the Insane 9 ... ... ... ... ... ... 2 2 ... 1 7 Cerebral Hæmorrhage 158 ... ... ... ... 2 2 2 16 31 105 83 Other Diseases of the Nervous Sys'm 107 1 ... 1 1 ... 1 7 12 13 71 47 Senile Decay 99 ... ... ... ... ... ... ... ... 1 98 48 Diabetes 24 ... ... ... 1 1 ... ... 3 5 15 14 Orgabuc Heart Disease 627 ... ... ... 10 7 17 55 86 444 279 Arterio-Sclerosi 63 ... ... ... ... ... ... ... ... 6 57 41 Ancurism 2 ... ... ... ... ... ... 1 ... ... 1 ... Other Diseases of the Circulatory System 36 ... ... ... 1 2 2 5 8 10 7 21 Bronchitis, Acute 37 3 1 ... ... ... ... 2 4 6 21 7 Bronchitis, Chronic 93 ... ... ... ... ... ... 1 5 9 78 38 Influenzal Pneumonia 45 1 1 1 2 1 3 9 6 8 13 20 Pneumonia (other forms) 210 25 6 3 6 9 13 18 32 98 143 Other Diseases of the Respiratory System 22 1 ... ... 1 1 1 ... 6 4 8 11 Diarrhœa and Enteritis 26 18 1 ... 1 ... ... ... 1 ... 6 22 Ppendicitis, Typhlitis, and Peritonitis 44 ... ... 4 7 4 1 7 10 4 7 45 Cirrhosis of the Liver 6 ... ... ... ... ... ... ... 1 3 2 3 Alcholism ... ... ... ... ... ... ... ... ... ... ... ... OtherDiseases of the Digestive Sy'm 62 1 2 ... 3 ... 3 7 15 18 13 55 Nephritis and Blight's Disease 78 ... ... ... 2 ... 1 2 13 18 42 31 OtherDiseases of the Urinary Svs'm 44 ... ... 1 ... ... 2 3 4 9 25 36 Puerperal Fever 7 ... ... ... ... 1 2 4 ... ... ... 7 Puerperal Pyrexia ... ... ... ... ... ... ... ... ... ... ... ... Other Diseases and Accidents of Pregnancv and Parturition 5 ... ... ... ... 2 2 1 ... ... ... 5 Congenital Debility and Malforma'n 19 16 2 1 ... ... ... ... ... ... ... 9 Premature Birth 47 47 ... ... ... ... ... ... ... ... ... 35 Venerea Diseases 3 2 ... ... ... ... ... ... 1 ... ... 3 Other Diseases of the Reproductive System (Non-Malignant) 9 1 ... ... ... ... ... ... ... ... 8 4 Violent deaths (excluding Suicide) 70 1 ... 1 7 14 11 2 5 4 25 53 Suicide 30 ... ... ... ... 6 1 5 6 7 5 45 All other defined Diseases 56 19 1 ... 3 2 5 8 5 2 11 37 Diseases Ill-defined or unknown 8 ... ... ... 1 1 1 3 1 1 2 All Causes 2721 148 19 29 65 90 114 167 294 416 1379 1519 The deaths entered in the last column include deaths of non-residents of the Borough. 60 Comparisons with 1932. (i) Measles, which was prevalent during the first half of the year, showed an increased mortality. All the deaths occurred under 15 years of age. (ii) Whooping Cough showed a decreased fatality in the first five years of life, (iii) An increase in the number of deaths from diphtheria, (iv) Deaths from influenza remained much the same, (v) Deaths from pulmonary tuberculosis, which are largely concentrated between 15 and 45 years of age, showed an increase, (vi) Cancer deaths increased with a preponderance of deaths over 45 years of age, as in 1932. (vii) Deaths attributed to senile decay remained much the same, (viii) Organic heart disease was ithe chief cause of death, (ix) A decrease in deaths from acute and chronic bronchitis, (x) An increase of 1 only in infantile deaths from diarrhoea, (xi) A slight decrease in deaths from nephritis, (xii) A decrease in the number of suicides. Deaths from violence and suicide combined now loom sufficiently conspicuous in the causes of death to assume importance from Public Health aspects. Comments on Table IX. (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, followed by cancer, (iii) Heart disease took the place of cancer as 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 (444), Cancer (177), Cerebral Hasmorrhage (105), Pneumonia (98). (v) Pneumonia still showed its maxima at boih extremes of life as in previous years. The most dangerous time of life until the 45—55 age is reached is the first year, (vii) Violent death overtakes the older groups of the population rather more often than the younger groups, though in 1930, 1931, 1932 and the year under review the age-group 15—25 had a large number of fatalities from this cause. Suicide was commonest between 45 and 65 as in previous years. There are a few points of difference between Table IX and the short list of causes of death supplied by the RegistrarjGeneral. The causes of the differences are due to ,the different methods of classification when more than one cause of death is given on the death certificate. For example, in the abbreviated table of the Registrar-General there are 736 deaths from Heart Disease, whilst Table IX gives only 627. There are, however, given in the latter table 99 deaths from Senile Decay as against 46 in the Registrar- 51 General's table, and 42 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 5.4. Deaths under 15 years, 9.6% ; deaths under 65 years, 49.3%; deaths over 65 years, 50.7%. Table x. CLASSIFICATION OF DEATHS ACCORDING TO DISEASE OVER A PERIOD OF 12 YEARS. Cause of Death. 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 Total Deaths Total Deaths. Total Deaths Total Deaths. Total Deaths. Total Deaths Total Deaths. Total Deaths. 1 Otal Deaths. Total Deaths. Total Deaths. Total Peaths Death Rate. Enteric Fever 1 ... 2 ... 1 2 ... 1 ... ... 2 ... ... Malaria 1 ... ... 1 1 ... ... ... ... ... ... ... ... Small Pox ... ... ... ... ... ... ... ... ... ... ... ... ... Measles 19 9 4 7 13 6 30 1 22 ... 2 13 0.054 Scarlet Fever 6 2 2 1 ... 3 5 4 2 3 ... ... ... Whooping Cough 11 11 11 9 9 21 14 24 3 9 12 3 0.013 Diphtheria and Croup 27 21 8 8 32 10 32 23 14 5 11 17 0.071 Influenza (including Influenzal pneumonia) 101 20 89 63 44 118 38 199 32 84 100 103 0.429 Dysentery ... ... ... ... ... ... ... 1 1 ... ... ... Erysipelas 2 2 4 5 5 5 3 8 7 4 3 8 0.033 Cerebru-Spinal Fever 2 2 ... ... ... 2 ... 2 3 2 2 0.008 Pulmonaiy Tuberculosis 183 153 157 151 171 165 167 170 154 155 144 162 0.675 Tuberculous Meningitis 14 22 12 17 17 10 13 10 7 11 9 10 0.042 Other Tuberculous Disease 12 15 19 13 20 28 26 19 14 11 13 12 0.050 Cancer, Malignant Disease 252 259 293 319 330 344 327 330 339 342 341 374 1.563 Rheumatic Fever 7 5 9 8 11 6 6 5 4 7 4 4 0.016 Meningitis 12 8 6 6 2 9 11 17 14 15 9 7 0.029 Organic Heart Disease 324 254 305 273 281 346 405 308 375 490 469 627 2.613 Bronchitis, Acute and Chronic 194 139 142 130 100 92 92 226 125 200 145 130 0.542 Pneumonia 183 144 182 140 138 200 158 272 199 258 238 210 0.875 Other Diseases of the Kespiratory Organs 40 36 33 32 34 33 33 21 16 20 15 22 0.092 jwrhcea and Enteritis 37 36 32 36 34 24 28 45 32 15 25 26 0.108 Appendicitis and Typhlitis 15 21 28 20 14 17 16 27 23 23 28 44 0.183 Cirrhosis of Liver 14 11 7 12 3 9 11 10 5 5 8 6 0.025 Allcholism 1 3 3 1 2 3 3 4 3 1 1 ... ... Nepnritis and Bright s Disease 47 59 70 65 81 77 79 117 45 60 81 78 0.325 Pueraerperal Fever 6 4 2 5 11 4 2 6 1 8 2 7 0.029 Other Diseases and Accidents of Pregnancy & Parturition 10 6 8 8 13 5 11 5 6 14 5 5 0.021 Congenital Debility and formation 52 32 37 36 52 30 26 42 42 49 27 19 0.079 Premature Birthg 38 39 54 42 40 48 32 47 40 49 48 47 0.196 Violent deaths (excluding Suicide) 48 49 66 65 71 83 75 64 74 92 75 70 0.292 Suicide 19 23 23 23 33 30 35 29 19 33 43 30 0.125 Other Defined Diseases 687 624 670 672 703 720 664 748 713 706 684 677 2.821 Disease ill-defined or unknown 22 ... ... 1 3 4 10 10 4 1 10 8 0.033 Total 2387 2007 2280 2169 2269 2452 2354 2792 1 2337 2674 2556 2721 11.3 52 1933 showed an increase in the general death-rate; a further diminution in the birth-rate; and a further decline in the infant mortality rate, which reached the lowest yet recorded in Croydon. In view of the decreasing birth-rate, the average age of the whole population is steadily rising; consequently, sooner or later there will be an increase in the death-rate quite apart from Public Health conditions. It would seem this point has been reached, and any further decline in the death-rate is not to be expected. Causes of Death. The chief causes of death during 1933 were:—Organic bean, disease, 027 deaths, death-rate 2.01; Cancer, 374 deaths, deathrate 1.56; All forms of Tuberculosis, 184 deaths, death-rate 0.77; Pneumonia (including influenzal pneumonia), 255 deaths, deathrate 1.06; Arterio Sclerosis and Cerebral Haemorrhage, 221 deaths, death-rate 0.92. Taking diseases of bodily systems and group diseases to which deaths were definitely assigned we find:— per 1,000 population. Circulatory System (including Atheroma and Cerebral Haemorrhage) 886 or 3.69 Cancer 374 1.56 Respiratory System (not Tubercular) 362 1.51 Tuberculosis (all forms) 184 0.77 Diseases of the Digestive System (excluding Cancer and Tuberculosis) 162 0.68 Diseases of the Nervous System (not Tubercular) 126 0.53 Diseases of Renal System 122 0.51 Infectious Diseases (excluding Tuberculosis but including Influenza) 102 0.43 Suicides and Violent Deaths 100 0.42 Old Age 99 0.41 Congenital Debility and Prematurity 66 0.28 The greatest single group of causes of death as in 1932 was diseases of the Circulatory system, and of this group Organic Heart Disease was the most prominent member (627 deaths). Rheumatism in childhood is indubitably a cause of cardiac breakdown later in life, more particularly if the original attack of rheumatism has been overlooked or disregarded. 53 Arteriosclerosis (63 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. Cerebral Haemorrhage, which caused, incidentally, 1-58 deaths, is one of the sequelae of Arterio-sclerosis, combined with excessive blood pressure. Arterio-sclerosis and Cerebral Haemorrhage between them caused 221 deaths. Influenza was the most fatal infectious disease; the majority of deaths occurring over 65 years of age. Diphtheria came second and Measles third. Excluding Influenza the infectious diseases ;~a group were not a prominent cause of death. 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, whilst for 1933 the estimated population is 239,950. 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 accelerated. Such an increase of population gives rise to peculiar health problems, not the least of which is the 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 towns 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 and the relatively low rates are also exerting an influence. 54 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, 1933, 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. ,, ,, 3905. ,, ,, 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. 1905, 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). 55 Regulations. Regulations as to connections with sewers, 1911. „ for securing the proper ventilation and ing of rooms to which Section 18 (1) of the Housing Act, 1925, applies and the Protection thereof against Dampness, Effluvia or Exhalation. 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, 1929, 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. ,, Nuisances from Dogs, 1932. 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) 4742 No. of houses inspected under the Housing (Consolidated Regulations) 1925 2936 No. of Houses inspected under the Rent Restrictions Act, 1920 115 No. of Houses inspected where zymotic diseases have occurred 640 House drains tested with smoke (primary) 1227 £6 House drains tested with smoke (on application) 80 No. of smoke tests during repair 551 Inspection of drainage work during construction 3784 No. of water tests during repair 461 Final tests of drains after repair 78 Final tests of drains when completely relaid 107 Length of new drains tested with water yards 2744 Inspections of yards, stables and manure pits 662 ,, Passages 148 ,, Public Conveniences 734 Pigstyes 85 „ Tents, Vans, and similar structures 61 ,, Theatres, Cinemas, Halls, etc 160 ,, Ponds and Ditches 58 ,, Schools 7 „ School Lavatories 107 ,, Common Lodging Houses (including night visits) 88 ,, Houses let in lodgings 149 ,, Premises where offensive trades are conducted 228 Smoke Observations 32 No. of Visits re Infectious Diseases 1779 Inspections of Shops (under Shops Acts) 3168 Special Early Closing Patrols 100 Special Evening Inspections under Shop Hours' Act ... 60 Inspections under Fertilisers and Feeding Stuffs Act 70 ,, under Pharmacy and Poisons Act 17 341 ,, Dairies ,, Farms and Cowsheds 134 ,, Milkshops 620 ,, Premises where food is prepared er sold 8732 ,, Slaughterhouses 1215 ,, Factories 725 „ Factory Laundries 31 ,, Workshops 806 ,, Workshop Laundries 19 ,, Workplaces 317 ,, Factory Bakehouses 286 ,, Workshop Bakehouses 142 „ Outworkers Premises 170 Visits to Employers of Outworkers 32 Reinspections of Work in Progress 26464 Sundry Inspections and Visits 4969 Appointments kept with Owners, Builders, etc. 3471 Complaints from puhlic investigated (for purposes other than 3858 spection of House) 1120 Examination of Building Plans 2393 Informa' Notices outstanding 31/12/32 ,, ,, served 11672 ,, ,, complied 10585 No. of Informal Notices referred for Statutory Orders 689 Informal Notices outstanding (including 384 overcrowding) 2791 Statutory Notices outstanding 31/12/32 156 ,, ,, served 636 „ ,, complied 618 Total number of complaints received 3723 Interviews with callers 4051 Letters received 4051 Letters and other intimations, etc., sent (not including notices) 8056 57 Nuisances, Infringements of Acts, Byelaws, Regulations or Orders, ascertained by the Sanitary Inspectors during the year 1933 and for which action was taken to enforce compliance:— (1) NUISANCES AND HOUSING DEFECTS AT HOUSES, &c. Insufficient means of ventilation— Defective sashcords I49*i „ windows 1124 Want of windows or ventilators 8 Conditions causing dampness— Defective roofs 1374 ,, gutters 737 downspouts 348 ., walls, etc. 1114 Deposits of refuse causing dampness 8 Want of proper damp proof course 105 Other internal defects and nuisances— Defective plaster 1671 Cleansing and limewashing required 2073 Defective floors 800 Insufficient ventilation under floor 29 Defective stoves and fireplaces 453 Defective sanitary fittings— Defective sinks 434 ,, waste pipes 328 Abolition of drinking water cisterns 19 Defective w.c.'s 1099 ,, drainage 770 Stoppage in drains 210 Domestic nuisances— Want of cleanliness 30 Dirty w.c. pans 21 Other nuisances— Bad smells 13 Offensive accumulations 115 Insufficient accommodation for sub-tenants 3 Defective manure receptacles 13 Want of manure receptacles 6 Defective sanitary conveniences 12 Dirty sanitary conveniences 4 Smoke nuisances 4 Sundry nuisances or defects 1182 Limewashing of stables 7 Defective stables 2 Defective stable drainage 3 Dirty stable floors 2 Accumulation of manure 13 Particulars not inserted in Rent Book 383 58 (2) FACTORIES, WORKSHOPS & WORKPLACES— Cleansing and whitewashing required 127 Additional ventilation 11 Dustbins required 38 Drainage of floors 5 Repairs to floors 12 Repairs to paving 16 Overcrowding 1 Ventilation of stoves 2 Infringements of drinking water supply regulations 11 Sundry other nuisances or defects 80 Outworkers lists not in accordance with Act 2 Abstract not exhibited 6 W.c.'s— Insufficiently screened 13 Insufficient 11 Defective 119 Not kept clean 132 Not separate for sexes 1 Want of intervening ventilated space (3) INFRINGEMENTS OF CROYDON CORPORATION ACT, 1924— Food cupboards defective or required 252 Dustbins required 1480 Verminous conditions 60 (4) INFRINGEMENTS OF PUBLIC HEALTH ACT, 1925 (S.72—75) AND INFRINGEMENTS OF FOOD BYELAWS— Cleansing of walls and ceilings 184 „ ,, floors 53 ,, ,, utensils 24 ,, ,, counters, shelves, fixtures, &c. 78 „ „ w.c.'s 54 Food storage bins required 15 Defective plaster 8 Animals kept in food store 4 Drain inlet in food store 2 Dirty yards 92 Accumulation in food store 43 Refuse bins left uncovered 35 Food in uncovered vehicles 9 23 Food not kepi covered Renewal of swill bins 8 Food improperly kept or manufactured 51 Premises not suitable for food stored 19 Want of provision of towels 17 Provision of cloak rooms 57 Overalls required 13 Illegal wrapping of food 4 Washing in food store 6 Want of ventilation in food store 5 ,, intervening ventilated space between w.c. and food store 1 59 Defective floors 17 „ sink waste pipes 13 „ sanitary fittings 74 Want of proper water supply 3 „ sink accommodation 2 Other infringements 19 (5) INFRINGEMENTS OF PUBLIC HEALTH ACTS (AMENDMENT) ACT, 1907— Defective yard paving 719 Rain water pipes used as ventilation pipes 1 (6) INFRINGEMENTS OF SHOPS ACTS— Mixed shop notices required 175 Assistants Weekly Half-Holiday notices required 190 Employment of Young Persons notices required 90 Infringements of Weekly Half-holiday Closing Order 2 „ ,, evening closure 12 „ „ meal times 3 ,, ,, Hairdresser's (Sundav Closing) Act 1 (7) INFRINGEMENTS OF COMMON LODGING HOUSE BYELAWS Additional wash basin required 1 Dustbins required 2 Dirty conditions 1 Defective sashcords 5 ,, sanitary fittings 5 (8) INFRINGEMENTS OF HOUSES LET IN LODGINGS BYELAWS— Additional cooking and sink accommodation 10 Want of food storage accommodation 20 Provision of washing accommodation 13 Want of w.c. accommodation 5 ,, artificial lighting to common staircase 16 External fire escapes required 9 Handrail required to stairs 8 Cleansing required 56 Defective windows and sashcords 29 (9) INFRINGEMENTS OF OFFENSIVE TRADE BYELAWS. Fishfrying premises— Limewashing required 13 Cleansing of utensils and bins 2 Bins not kept covered 1 Want of bins for waste matter 3 Yards and floors require paving 1 Want of proper pans 1 Want of hood over pans 1 Other premises— Defective floors and yards 2 Offensive accumulation 1 Defective walls and ceilings 1 Storage bins required 1 Cleansing and whitewashing required 10 60 (10) INSPECTION OF AMUSEMENT HOUSES— Defective sanitary fittings 7 ,, wall plaster 1 Cleansing and lime washing 4 W.c. required cleansing 2 W.c. windows defective 1 Dustbins required 1 (11) KEEPING OF ANIMALS— Other nuisances in connection with the keeping of pigs 5 Nuisances arising from the keeping of other animals 24 (12) INSPECTION OF WATERCOURSES, etc.— Pond sprayed with formalin owing to prevalence of mosquitoes 1 Cleansing of watercourses 1 (13) INFRINGEMENTS OF PHARMACY & POISONS, &c., ACT- Article not labelled in accordance with the Act 2 (14) INFRINGEMENTS OF FERTILISERS & FEEDING STUFFS ACT, Sec. 1 (1) (11) 1? (15) INFRINGEMENTS OF RATS & MICE DESTRUCTION ACT— Infestations of rats in yards of business premises 4 ,, ,, on premises where food is prepared or sold 12 Accumulations of refuse, etc., harbouring rats 4 Domestic accumulations harbouring rats 2 Rats on premises where animals are kept i Defective drainage 2 Structural defects allowing ingress of rats into dwellin houses 2 (16) INFRINGEMENTS OF MERCHANDISE MARKS ACT & AGRICULTURAL PRODUCE & MARKING ACT— Apples not marked 123 Tomatoes ,, 136 Eggs „ 2 Salmon ,, 6 Imported Butter not marked 11 Currants ,, . 45 Sultanas ,, 36 Raisins ,, 25 (17) INSPECTION OF SCHOOL LAVATORIES— 4 1 Defective Sanitary fittings Defective Drains I 1 Structural defects in school lavatories (18) INFRINGEMENTS OF OTHER BYELAWS— Noisy loud speakers 1 Noisy animals 15 61 Refuse deposited in streets 2 Washing down shop fronts 1 Offensive washing up water thrown over footpath 4 Fouling footpaths by dogs 2 Swill tubs not covered in slaughter-house 1 Lime-washing required 2 (19) INFRINGEMENTS OF PUBLIC HEAILTH (MEAT) REGULATIONS— Want of receptacles for the storage of scraps 1 Scraps not kept in receptacles 4 Food not protected 1 (20) INFRINGEMENTS OF FOOD AND DRUGS (ADULTERATION) ACT, 1928— Margarine not marked 11 (21) SALE OF FOOD ORDER, 1921— Meat not marked 82 (22) INFRINGEMENTS OF MILK & DAIRIES REGULATIONS, &c.— Defective walls 1 ,, ,, dairy floors and paving 6 ,, ,, sanitary fittings 1 ,, drainage 4 Dirty dairies 13 ,, utensils in dairies 5 ,, conveniences 1 Unsuitable storage for bottles 1 Milk improperly kept 6 Illegal bottling of milk 2 Dairy improperly lighted and ventilated 1 Vehicles not labelled 1 Bottles not labelled 1 Dirty milking appliances 1 Cows requiring grooming 1 Cowshed requiring limewashing 2 ,, ,, lighting 1 SANITARY CERTIFICATES On application, an intending or actual occupier or owner, may have a sanitary survey made of the house, to ascertain wnether 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 1933 requests were made in connection with 77 houses. 3 schools. Total 80. 02 The following defects were ascertained in consequence of these inspections :— Defective gutters 1 ,, downspouts 3 ,, drains 20 ,, sanitary fittings 17 ,, roofs 1 ,, fireplace 1 ,, plasterwork * 2 ,, yard paving 2 Dampness 3 Food cupboards required 1 RENT RESTRICTION ACTS. A number of applications were received for certificates as to the condiition of repair of the houses concerned. In 44 instances where the Acts applied certificates were granted. In nine instances certificates were given to owners stating that the work had been carried out. LEGAL PROCEEDINGS TAKEN REGARDING NUISANCES, ETC. Offence. Result Tota 1. Fines. Costs. £ s. d. £ s. d £ s. d. Using as dwelling house premises not constructed for human habitation Order to vacate— Case wit hdrawn. — HOUSING ACT, 1930. Five Years Slum Clearanoe Programme. The following Areas have, up to the present been scheduled as Clearance Areas. The Old Town Area has been approved b;> the Ministry of Health, but with respect to the Leighton Street i East Area, the necessary Local Enquiry has not yet been held.:-" Total number of houses in Area. No. of houses to be demolished. No. of persons to bo displaced from house: to be demolished. No. of persons to bf displaced to abate overcrowding- (1) Old Town 108 91 490 (2) Leighton Street East 34 34 157 63 The following Improvement Areas have already been approved by the Council, and with respect to Dickenson's Place and Ely Road, the Ministry of Health approval had been obtained at the time of this report Total number of houses in Area. No. of houses to be demolished. No. of persons to be displaced from ho>use9 to be demolished. No. of persons to be displacedHtjo abate overcrowding. (1) Dickenson's Place 21 9 28 1 (2) Ely Road and Holmesdale Road 46 8 102 37 (3) Leighton Street East and West 107 11 37 86 (4) Albion Street 32 2 8 10 Fourteen individual houses have up to the present been recommended for demolition, the number of persons who will be displaced thereby being 50. In addition to the above, and in consequence of informal action, 15 houses were demolished voluntarily. Further, 27 houses have been demolished in the Old Town Area for street widening, and approximately 132 persons were displaced. One house outside this area was closed on representation, and will be pulled down; 5 persons were displaced. I'urther contemplated action under the Five Year Plan is as follows. It must be understood that there are other areas in the town under survey, though no representations have as yet been Nade. It has been decided to see how the Improvement Area clauses operate in actual practice in the areas already scheduled Wore putting forward more areas. It may be found that quicker and more effective action can be taken under Sections 17 and 19 (Individual Unfit Houses). 64 Areas to be put forward to be dealt with either under Section 1 or under Section 7, and the approximate number of persons affected : — Total number of houses in Area. No. of houses to be demolished. No. of persons to be displaced from houses to be demolished. No. of persons to be displaced to) abate overcrowding. (1) Upper Norwood: Victory Place & Stoney Lane 26 23 75 - (2) Paddock Gardens & Albert Terrace 25 11 36 6 (23) Napier & Magdala Roads. 67 — — 17 (4) Wilford Road & Forster Road 132 — — 55* "This figure is only very approximate. The steps so far taken with respect to the Areas scheduled are : — (1) Old Town Clearance Area.—The clearance of the site is complete and re-building is in hand. (2) Leighton Street Clearance Area.—The resolution declaring this Area to be a Clearance Area was passed on the 23rd April, 1934. The next step is for the Council to make a Clearance Order. (3) Dickenson's Place Improvement Area.—The formal resolution as approved by the Minister of Health was passed on the 29th January, 1934. Notices to repair W houses will be served immediately. Demolition Orders have recently been made in respect of 8 houses on the ground of unfitness, but will not operate before August next. (4) Ely Road Improvement Area.—Notices will be served for the repair of 38 houses. Steps will be taken to make Demolition Orders in respect of fi houses to be demolished on the ground of unfitness and to acquire ~ houses to open up the Area. It is estimated that during the next five vears, 150 individual houses in various parts of the town will be the subject of representations under Section 19 for demolition. 65 As the housing shortage, judging from the number of persons whose names are on the waiting list for Corporation houses, has not been made up, apart from any action resulting from slum clearance, perhaps the most urgent problem at present in Croydon is the supply of houses at rentals which persons of the labouring classes can afford. There does not seem much useful purpose in making representations for Clearance and Improvement Areas until there is a prospect that the representations will take effect, and persons displaced owing to demolitions or to abate overcrowding, re-housed within a reasonable time. Croydon is becoming built up. The finding of sites near the scheduled areas is a difficult matter, whilst the purchase of available sites at a price which will enable rents of 7s. or 8s. a week to be charged for houses erected thereon, is even more difficult. To re-house occupants of Clearance Areas on sites situated on the outskirts of the Borough is unwise. In all probability there would commence a steady drift back. Overcrowding might be abated immediately, but aggravated ultimately. The following table gives particulars as to Housing during 1933 under the headings prescribed by the Ministry of Health : — 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) 4,742 (b) Number of inspections made for the purpose 4,742 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Consolidated Regulations, 1925 2,936 (6) Number of inspections made for the purpose 2,936 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 14 (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 habitatior 3,073 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 3,011 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 154 66 (2) Number of dwelling houses which were rendered fit after service of formal notices :— (a) By owners †75 (b) By local authority in default of owners 5 B. Proceedings under Public Health Acts :— (1) Number of dwelling houses in respect of which notices were served requiring defects to be remedied 209 (2) Number of dwelling houses in which defects were remedied after service of formal notices: — (a) By owners *183 (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 14 (2) Number of dwelling houses demolished in pursuance of Demolition Orders 4 (3) Insanitary houses have been demolished in anticipation of formal procedure under Section 19 15 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 1 Ihis number does not include 38 houses in regard to which notices were served in 1932 and complied with in 1933. + Not including 37 houses concerning which notices were served in 1932 and complied with in 1933. OVERCROWDING. During the course of a systematic inspection of 4,742 houses between 1st January and 31st December, 19-33, 89 or 1.87 per cent, were found to contain one or more overcrowded rooms. A family is 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. 133 families occupied these 69 houses and 91 or 68.4 per cent, of these families were found to be overcrowded. In 54 houses of the 89 houses it was found possible to abate overcrowding without producing corresponding overcrowding elsewhere. 91 notices were served to abate overcrowding. 67 Table XI. FACTORIES, WORKSHOPS, AND WORKPLACES. 1. Inspection. Premises. N umber ot Inspections. Written Notices. Prosecutions FACTORIES. (including Factory Laundries) 756 178 ... WORKSHOPS. (including Workshop Laundries) 825 190 ... WORK PLACES. (other than Outworkers premises) 317 34 ... Total 1898 402 ... Table XII. 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 127 86 ... ... Want of Ventilation 11 4 ... ... Overcrowding 1 ... ... ... Want of Drainage of Floors 5 ... ... ... Other Nuisances 165 119 ... Sanitary Accommodation— Insufficient 11 4 ... ... Unsuitable or Defective 275 215 ... ... Not sep irate for sexes 1 1 ... ... 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 ... ... 16 ... Total ... 596 429 16 ... 68 3. List of Registered Workshops. Trades. Totals Bakers and Confectioners 55 Tailors 106 Dressmakers 91 Building Trades 80 Milliners 27 Upholsterers 52 Laundiies 1< Cycle Works 26 Blacksmiths 18 Bootmakers 78 Watchmakers 17 Motor Engineers 78 Coaehbuilders 13 Photographers 8 Picture Framers 7 Umbrella Makers and Repairers 2 Saddlers 6 Ladder and Barrow Makers 3 Wig Makers 3 Scale Makers 2 Blind Makers 2 Furriers 2 Marine Stores 8 Cabinet Makers 18 French Polishers 6 Embroidery 2 Sign Writers 12 Miscellaneous Trades 151 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 Byelaws. For details of Crovdon Corporation Act, see under Food Inspection. Number of bakehouses on Register, 31st December, 1933 106 Number of underground bakehouses (included in above) 6 Visits made to bakehouses during the year 428 Defects found 97 Notices issued 54 Notices complied 50 5. Home Work. Lists of home-workers are sent in twice yearly, and last year contained the names of 189 outworkers residing within the Borough. 170 visits were paid to outworkers and 32 visits were paid to premises of employers of outworkers to examine lists and for other purposes. 69 Table XIII. NATURE OF EMPLOYMENT OF WORKERS ON THE REGISTER, 31st DECEMBER, 1933. Nature of Work. Number employed. Outwork in infected premises. Outwork in unsatisfactory premises. Remarks. Making, cleaning, altering and repairing wearing apparel 151 2 ... ... Upholstery work 4 ... ... ... Lace goods 1 ... ... ... Other classes or work 33 ... ... ... 189 2 ... ... REGISTERED AND LICENSED PREMISES IN THE BOROUGH, 31st DECEMBER, 1933. Slaughterhouses (not including Public) 3 Bakehouses 108 Common Lodging Houses 11 Houses Let in Lodgings 90 Dairies and Milkshops 365 Cowsheds 26 Offensive Trades 118 Wholesale Dealers in Margarine, etc. 35 Registered Workshops 889 Premises registered under Artificial Cream Act, 1929 Premises registered for preparation or manufacture of potted, pressed, pickled or preserved meat, fish, or other food intended for the purpose of sale for 0 human food 125 SHOP HOURS ACTS. 3,328 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). 70 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 Is., the cost of a weekly ticket is 6s. for seven nights. The number of men accommodated during the year was 31,588. The number of men lodgers exceeded 86 per night throughout the year. The receipts and expenditure for the last ten years are as follows:— Receipts. Expenditure. £ s. d. £ s. d. 3924 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 1932 1517 8 4 1547 5 5 1933 1437 2 6 1544 7 10 2. Private Common Lodging Houses. There were 13 common lodging houses on the register at tl beginning of 1933, but two were discontinued during the year. During 1933, 66 day and 22 night inspections were made. Notices were served for the conditions and defects as set oi in the summary of defects found (paragraph 7). Table XIV. The following table gives the situation of and the accommoda tion 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.. 30 75 men and women 11 and z 2, Princess Road 10 39 men and women II 60 172 men and women 71 HOUSES LET IN LODGINGS. There are 90 houses registered under the Byelaws. 149 visits were made for inspection purposes. 97 notices were served for various amendments. 89 notices were complied with. Table XV. The following table gives the situation of these premises: — Road. Nio. of Houses Let in Lodgings. Beulah Grove 1 Frincess Road 1 Queen's Road Croydon) 1 Ely Road 7 Forster Road 13 Holmesdale Road 4 Wilford Road 31 Donald Road 1 Canterbury Road 2 London Road 2 Whitehorse Lane 1 Nursery Road 1 Mayday Road 1 Queen's Road, South Norwood 1 Lodge Road 1 Sydenham Road 1 Tamiworth 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 St. Peter's Road 2 Alexandra Road 1 Whitehorse Road 2 Grange Road 1 Penge 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. 228 inspections were made of premises where such trades were carried on and notices issued requiring amendments in accordance with the byelaws. 72 The following are on the register:— Rag and Bone Dealers 40 Gut Scrapers 2 Fish Friers 74 Rabbit Skin Drier 1 Fellmonger 1 118 rag flock acts, 1911 AND 1928. Seven samples were obtained and subjected to analysis, the results being as follows:— No. 1 contained 7 parts of Chlorine per 100,000 „ 2 „ 7 „ „ „ „ 3 „ 8 „ „ „ „ 4 „ 6 „ „ „ „ 5 „ 3 „ „ „ „ 6 „ 4 „ „ „ „ 7 „ 4 „ „ „ The seven 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 32 observations were made of factory chimneys for the purpose of detecting offences under the Act. 4 notices were sent and amendments carried out to stop the nuisance. amusement houses. 160 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. 109 inspections were made in connection with the keeping of animals. There were 40 premises, including institutions, where pigs were known to be kept in the Borough. 73 5 notices were served to abate nuisances arising from various causes in connection with the keeping of pigs and 24 notices were served to abate nuisances arising from the keeping of other animals. schools. 114 inspections of schools or school lavatories were made during 1933. In one instance the drains were found defective, and there were four instances of defective sanitary fittings, and one lavatory structurally defective. The water supply in all cases is from the mains. inspection of watercourses, etc. During the year 58 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. pharmacy and poisons act, 1933. This Act consolidates the Poisons and Pharmacy Acts from the year 1852. The object is to regulate the sale of certain poisonous substances and the Act contains important provisions. The number of licences renewed under the Act was seven, and in addition seven licences were renewed under the Order-in-Council dated November 10th, 1911, to assistants in the employ of persons already holding licences. Two infringements of the Act were found. fertilisers and feeding stuffs act, 1926. Seventy inspections of premises where fertilisers and feeding stuffs were sold were carried out during the year. Seventeen infringements of the Act were found. 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. 74 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 32,792 By Formalin gas 3,461 By Formalin spray 728 36,981 In addition 1,198 articles were destroyed on request. Disinfection after infectious or contagious disease was carried out in 2,442 rooms at 1,645 houses. 76 class rooms. 4 hospital wards. 3 vehicles. 1 hut. 7 bags. 27 W.C.'s. 2 lobbies and corridors. 1 office. 1 school hall. cleansing of verminous persons, etc. During the year 1 adult was cleansed for verminous conditions, and fifteen adults and twenty-two children for scabies, also one adult after contact with infectious disease. 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 the District Sanitary Inspectors. 75 The following is a summary of the visits paid during 1933, under the Rats and Mice (Destruction) Act, 1919. Table XVI. Premises. No. of Visits made. No. of Poison and other baits laid. No. of Rats Killed. Private Houses 1295 Butchers 37 Other premises where food is prepared or sold 162 3728 791 Other premises 229 Total 1723 3728 791 In addition to the above, 2,638 rats were killed at Corporation refuse tips by employees of another department. 76 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 constant vigilance 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 77 A larger number of articles are packed in hygienic containers and this method facilitates handling and prevents contamination. 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 fresh 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 entails 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 43,615 animals slaughtered for human consumption, these figures being a decrease of 6,155 on those for the year 1932. 78 The following table shows the premises in the Borough at which foodstuffs are known to be sold, manufactured or stored:— General Shops 210 Grocers and Provision Shops 606 Greengrocers and Fruiterers 475 Confectioners, Bakers, and Pie Makers 575 Ice¬Cream Shops 291 Hotel and Restaurant Kitchens and Dining Rooms 252 Butchers 228 Fishmongers (including Fried Fish Shops) 147 Ham and Beef Shops 76 Sweet Manufacturers 7 Other Food Premises 26 2,893 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 XVII The following animals were slaughtered at the Public Slaughterhouses during 1933:— Pitlake. Public Slaughterhouses- Cattle. Sheep. Pigs Calves. Total. Public section 49 418 2478 371 3316 Private section 663 12866 15950 3089 32568 Totals 712 13284 18428 3460 35884 79 The whole of the meat and offal is examined before it leaves the premises. The following meat and offal from the Public Slaughterhouses was surrendered and destroyed during the year 1933:— Description. Cause. 4 beef carcases and offal General tuberculosis. 5 „ forequarters Localised tuberculosis. 1 „ hindquarter Traumatism, etc. 2 „ forequarters „ „ 3 „ parts Localised tuberculosis. 12 sets beef lungs Inflammatory, etc. 34 „ beef lungs Localised tuberculosis. 16 beef heads „ „ 23 „ various offals „ „ 4 „ heads and tongues Actinomycosis. 5 „ parts Inflammatory conditions, etc. 154 „ various offals „ „ 11 veal plucks Tubercular. 6 „ various offals „ „ 67 „ various offals Inflammatory, etc. 1 „ carcase and offal Jaundice. 1 „ carcase Traumatism. 4 „ plucks Inflammatory conditions. 14 „ heads Various causes. 13 pig carcases and offals General tuberculosis. 13 „ quarters Localised tuberculosis. 18 „ various parts „ „ 294 „ heads „ „ 123 „ plucks „ „ 70 „ various offals „ „ 17 „ carcases and offals Swine fever. 24 „ carcases and offals Inflammatory conditions, etc. 10 „ quarters „ „ 566 „ plucks „ „ 16 „ heads „ „ 290 „ various offals and 21 parts „ „ 4 sheep carcases and offals Inflammatory, etc. 8 „ parts Inflammatory, traumatic, etc. 24 „ plucks Parasitical, etc. 183 „ various offals „ „ 3 „ carcases and offals Emaciation and Dropsical. 2 „ carcases Parasitical, etc. Total weight destroyed: 22,747 lbs. private slaughterhouses and meat inspection At the end of 1933 there were 3 registerel slaughterhouses in the Borough. Registered Private Slaughterhouses have in recent years gradually been reduced from 6 to 3. In two instances they have been accommodated at the Public Slaughterhouses. The number of visits paid to the Private Slaughterhouses for the purpose of inspecting the meat during 1933 was 1,215. 80 Table XVIII. The number of animals slaughtered in the Private Slaughterhouses during the year was:— Cattle. Sheep. Pigs. Calves. Total. 81 2252 3403 1998 7,731 The following meat and offal from Private Slaughterhouses was surrendered and destroyed during 1933:— Description. Cause. 1 beef head Localised tuberculosis. 2 sets beef lungs „ „ 1 set beef lungs Inflammatory conditions, etc. 5 beef various offals „ „ 1 veal pluck Localised tuberculosis. 1 set veal lungs Inflammatory. 1 set veal various offals „ „ 46 pig heads and 4 parts Localised tuberculosis. 36 „ plucks „ „ 16 „ sundry offals „ „ 11 „ plucks Inflammatory, etc. 24 „ offals (various) 12 sheep offals (various) Parasitical, etc. Total weight destroyed: 946½ lbs. Table XIX. Total number of animals slaughtered for human consumption in the Borough during 1933:— Cattle. Sheep. Pigs. Calves. Total. 793 15,536 21,828 5,458 43,615 81 Table XX. Summary of whole carcases destroyed with the reasons for such destruction. Class of Animal. Tuberculosis. Emaciated and Dropsical. Inflammatory Conditions. Traumatism. Jaundice. Swine Fever. Asphyxiation. Parasitical. Parturient. Mastitis. Total carcases. Cattle 4 ... ... ... ... ... ... ... ... ... 4 Calves ... ... ... 1 1 ... ... ... ... ... 2 Sheep ... 3 2 ... ... ... ... 2 1 1 9 Pigs 13 ... 16 ... 7 17 1 ... ... ... 54 Totals 17 3 18 1 8 17 1 2 1 1 69 Table XXI 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) 4 20 48 72 Pigs 18 340 159 512 Total 17 360 207 584 82 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 2133 Fishmongers 308 Fried Fish Shops 190 Grocers 1153 Greengrocers 878 Poultry and Game Dealers 62 Cooked and Prepared Meat Shops 336 Bakers' Premises 293 Confectioners' Premises 785 Markets 694 Hawkers' Carts and Barrows 306 Hotel and other Kitchens, etc 708 Ice Cream Manufacturers and Vendors 388 General Shops 446 Other premises 58 8,732 The following articles of food were surrendered and destroyed during 1933:— 1 beef foreqftiarter (Imiportled) Unsound 11 „ hindquarters „ do. 81 „ parts and trimmings „ do. 39 „ kidneys „ do. 9 „ livers, etc. „ do. 5 mutton parts „ do. 2 lamb carcases „ do. 160 lbs. lambs' liver „ do. 1 pork carcase „ do. 10 pork pants „ do. 2 veal parts „ do. 260 lbs. pig kidneys, livers, etc. do. 27 lbs. sheeps' hearts „ do. 94 rabbits do. 469 lbs. mackerel, skate, etc. do. 40 lbs. ducks do. 176 tins salmon, etc. do. 34 tins sardines do. 1764 tins cherries, loganberries, plums, etc. do. 54 lbs. pears 56 lbs. apples 1 lb. tomatoes 213 tins milk do. 525 lbs. sugar, confectionery, etc. do. 50 jars jam, syrup, etc. do 22 jars pickles, etc. do. 54 doz. eggs 19 tins soup 19 lbs. bacon, etc 92 tins cooked ham, etc 5 bags winkles 50 lbs. tripe do. Total weight destroyed: 11,758¼ lbs. 83 Table XXII. General Summary of Meat and other articles destroyed during the year 1933. ARTICLES. Weight in lbs. Remarks. Diseased. Unsound. Total. Beef 3,092 4,363i 7,455¾ Including 4 carcases. Veal 140 156 296 „ 2 „ Mutton 460 1,504 2,164 „ 9 „ Pork 11,083 842 11,925 „ 54 „ Offal 8,146½ 961½ 9,108 „ imported offal. Fish ... 525 525 Haddocks, Mackerel, Skate, etc. Fruit & Vegetables ... 266 266 Pears, Apples, etc. Tinned Goods ... 3,195 3,195 2,198 tins, 69 jars. Sundries ... 717 717 Rabbits, Ducks, Sugar, Confectionery, etc. 22,921½ 12,530¼ 35,451¾ 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. 84 Mechanical refrigeration and cooling is used by increasing numbers of dairymen in the Borough as part of their equipment. Enquiries show that approximately 18,441 gallons of milk are sold daily in the Borough. Of this amount 92.9% is bottled, 1.% is retailed as loose milk, the remaining 6.1% being sold wholesale to large consumers. These figures are interesting in view of the fact that ten 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, 13,061 gallons is graded milk. This 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, which entirely eliminates the costly bottle, appears to appeal to the public, judging by the increasing amount which is being sold. 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. It is interesting to note that the bacteriological examination in all grades of milk shows a reduced total bacterial count on the previous year, and the majority of milk distributed in the Borough is uniformly of excellent quality. This, unfortunately, does not apply to the milk as it is delivered by the farmer, which shows unnecessarily high bacterial counts, etc. This low standard makes it necessary for the vendors to provide and maintain elaborate and expensive plant to eliminate something which should be kept out at the source. 85 MILK AND DAIRIES (CONSOLIDATION) ACT, 1915, THE MILK AND DAIRIES AMENDMENT ACT, 1922, AND THE MILK AND DAIRIES ORDERS, 1926. Cow keepers, 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 (1932) 9 „ added to the register (1933) — „ discontinued (1933) — Net 9 Cowsheds on register (1932) 26 „ added to the register (1933) — „ discontinued (1933) — Net 26 Number of cows provided for 241 Average number of cows in sheds (1933) 218 No. of dairies and purveyors of milk on register (1932) 327 No. of dairies and purveyors of milk added to register (1933) 79 No. of dairies and purveyors of milk discontinued during 1933 41 Net 365 Grand total of cowsheds, dairies and purveyors of milk on register, 31st December, 1933 391 During the year 1,095 inspections were made of dairies, cowsheds and milkshops. 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 1933 all the farms were visited for this purpose at least 4 times. A total of 892 cows were inspected during the year. 86 Milk (Special Designations) Order, 1923. The following licences were granted during the year under this Order and were in force on the 31st December, 1933:— Description of Licences. No. (1) Producers' Licences to use the designation "Grade A" — (2.) Dealers' Licences to use the designation "Certified" 15 (3) Dealers' Licences to use the designation "Grade A" (Tuberculin tested)— (a) Bottling establishments 1 (b) Shops 17 (4) Dealers' licences to use the designation "Grade A"— (a) Bottling establishments — (b) Shops 2 (5) Dealers' Licences to use the designation "Grade A Pasteurised"— (a) Shops 4 (6) Dealers' licences to use the designation "Pasteurised"— (a) Pasteurising establishments 1 (b) Shops 49 (7) Dealers' Supplementary Licences to use the designation— (a) Certified 3 (b) Grade A T.T. 4 (c) Grade A 3 (d) Pasteurised 4 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 7 87 Grade A (Tuberculin Tested) and Grade A Milks. Licensed country producers of Grade A (Tuberculin Tested) milk supplying milk to licensed local dairymen 13 Licensed country producer of Grade A milk supplying milk to a licensed local dairyman — Pasteurised Milk. Samples from licensed dealers 136 The following tables summarise the result of the bacteriological examinations of Certified, Grade A (Tuberculin Tested), Grade A and Pasteurised samples, from lst January to 31st December, 1933:— Table XXIII. 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 ... 7 Total number of bacteria ... 7 Bacillus Coli ... 7 Blood ... 7 Pus ... 7 Detritus ... 7 7 7 7 7 7 7 The above 7 Certified Milk samples contained total bacteria Per c.c. as follows:— 0—1,000 3 1,000—5,000 2 5,000—10,000 2 7 Under the Regulations Certified Milk must not contain more than 30,000 bacteria per c.c. 88 Table XXIV. 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.  Tubercle bacillus ... 13 Total number of bacteria ... 13 Bacillus coli 2 11 Blood ... 13 Pus ... 13 Detritus 18 ... 13 ... 13 2 11 ... 13 ... 13 ... 13 The 13 Grade A (Tuberculin Tested) and Grade A milks con tained bacteria per c.c. as follows:— 0—1,000 2 1,000—5,000 6 5,000—10,000 2 20,000—30,000 1 50,000—100,000 1 100,000—200,000 1 13 Under the Regulations Grade A (Tuberculin Tested) or Grade A milk must not contain more than 200,000 bacteria per c.c. The following tables summarise the results of the bacteriological examinations of Pasteurised milk samples from 1st January to 31st December, 1933:— Table XXV. PASTEURISED MILK, (licences granted under the Milk (Special Designations) Order, 1923). Present. Absent. Over 100,000 per c.c. Under 100,000 per c.o. Present. Absent. Present. Absent. Present. Absent. Exceeding trace. Not exceeding a trace. Tubercle bacillus ... 136 Total number of bacteria 4 132 Bacillus coli 37 99 Blood ... 136 Pus ... 136 Detritus ... 136 ... 136 4 132 37 99 ... 136 ... 136 ... 136 89 The above 136 Pasteurised Milk samples contained bacteria per c.c. as follows:— Under 1,000 5 1,000—5,000 52 5,000—10,000 40 10,000—20,000 14 20,000—30,000 7 30,000—50,000 11 50,000—100,000 3 Over 100,000 4 136 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 1933. Bacillus Coli was absent in each case, and the bacterial content was as follows:— 1 sample contained 20 bacteria per c.c. 1 sample contained 80 bacteria per c.c. MILK AND DAIRIES ORDERS 1926. Two offences were discovered under the above Orders, namely:— Bottling milk on other than the Registered premises. The roundsmen were prosecuted and fines and costs amounting to £3 12s. were incurred. PROVISION AS TO MILK SUPPLY. During the year 360 samples of ordinary milk were procured and submitted to examination for tuberculosis in accordance with the Milk and Dairies (Consolidation) Act, 1915. 90 These samples were taken as follows:— Samples taken at cowsheds in the Borough 92 Samples in course of delivery from country cowsheds to local dairymen and purveyors of milk in the Borough 18 Samples taken at dairymen's premises in the Borough 70 Samples taken in course of delivery by local dairymen or milk sellers on their rounds in different parts of the Borough 170 Other samples taken 10 360 Nineteen samples proved to be tuberculous, but of these nine were obtained in group or individual testing of cows on a farm in the Borough, in consequence of which three cows were slaughtered under the Tuberculous Order, 1925, and found to be affected. Four samples were from a creamery in Somerset which obtained its supplies from a considerable number of farms, and it was not possible to trace the source of infection. One sample was from a farm in the Borough, but it was not possible to discover the infected animal, as this may have been sold. Two samples were from supplies coming from Sussex; a considerable number of cows were examined by the Authority's Veterinary Officers, suspected animals isolated, and samples taken. As the result of their investigations two animals were dealt with under the Tuberculosis Order, 1925. Three samples were taken from supplies coming from Surrey, and again, after a considerable number of cows had been examined by the Authority's Veterinary Officers, suspected animals isolated and samples taken. As the result of their investigations two animals were dealt with under the Tubecrulosis Order, 1925. 91 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, 1933:— Table XXVI. ORDINARY MILK. Present. Absent. Over 200,000 per c.c. Under 200,000 per o.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 19 342 Total No. of bacteria 79 281 Bacillus Coli 141 219 Blood ... 360 Pus ... 360 Detritus ... 360 19 342 79 281 141 219 ... 360 ... 360 360 The 360 samples of Ordinary Milk contained total bacteria per c.c. as follows:— 0—1,000 5 1,000—5,000 57 5,000—10,000 38 10,000—20,000 43 20,000—30,000 36 30,000—40,000 13 40,000—50,000 10 50,000—100,000 48 100,000—150,000 16 150,000—200,000 15 200,000—250,000 10 250,000—500,000 22 500,000—750,000 9 750,000—1,000,000 7 1,000,000—2,000,000 12 Over 2,000,000 19 360 92 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 281 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 360 samples taken under the Milk and Dairies (Consolidation) Act, 1915, were samples of milk which had produced in the following areas:— Table XXVII. Areas. No. obtained. No. Tuberculous. Croydon 92 10 Kent 1 ... Surrey 1 3 Sussex 20 2 Dorset 1 ... Somerset 4 4 Unclassified 238 ... Totals 360 19 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 433 samples of milk (432 new, 1 condensed) and 453 other samples were taken. In 13 instances the vendors were warned. 23 samples of Ice Cream were taken during the year. The Public Analyst reports that 11 of these samples contained fat in amounts varying from 2.1% to 9.1%. The remaining twelve contained fat in amounts varying from 10.0% to 17.8%. 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. 93 Summary of Samples. During 1933 samples were obtained and submitted to the Public Analyst as follows:— Table XXVIII. Samples of Total Samples. Genuine. Not Genuine. Prosecutions. Convictions. Cautions. Milk 432 420 12 4 4 8 Condensed Milk 1 1 Tinned Cream 2 2 Arrowroot 8 8 Aspirin Tablets 1 1 — — — Baked Beans 1 1 — — Bacon 5 5 Baking Powder 8 8 — Brawn 10 10 Bread 9 9 Bun Flour 1 1 Butter 15 15 Black Pudding 3 3 — — — — Castor Oil 4 4 Cheese 1 1 Cocoa 9 9 Cod Liver Oil 1 1 Coffee 4 4 „ and Chicory 3 3 - — — — „ Essence with Chicory 3 3 - Coffee Essence 1 1 - Corned Beef 1 1 Confection of Senna 2 2 Corn Flour 4 4 Cream of Tartar 6 6 Custard Powder 4 4 Cherry Ciderade 2 2 - Chutney Sauce 1 1 - Demerara Sugar 4 4 - Dripping 5 5 - Faggots 8 8 Fish Paste 10 10 Flour (including Self¬raising) 9 9 - — Fish Cakes 1 1 Ginger Ale 3 3 Ginger Beer 5 5 Glycerine 2 2 Golden Syrup 4 4 - Ground Almonds 8 8 Ground Ginger 6 6 Ground Rice 6 6 Gelantine 1 1 - Honey 8 8 - ___ Ice Cream 23 23 Jam 14 13 1 1 Lard 7 7 - - Lemonade 1 1 - - - - Lemonade Powder 5 5 - - Lemon Squash 1 1 Liquorice Powder Compd. 3 3 - Lemon Curd 1 1 - - - Margarine 9 9 - - - Meat Paste 12 12 - - — — Carried forward 698 685 13 4 4 9 94 Samples of Total Samples. Genuine. Not Genuine. Prosecutions. Convictions. Cautions Brought forward 698 685 13 4 4 9 Mincemeat 4 4 _ - - Mint Sauce 1 1 - - - - Mustard 4 3 1 - - Mustard Mixture 1 1 - - Meat Roll 1 1 - - - - Meat Pie 1 1 - Minced Beef 2 2 - Olive Oil 1 1 - _ Pearl Barley 5 5 - - - - Pepper (Black) 5 5 - - - - Pickles—Onions 5 5 - - - „ Mixed 2 2 - Polonies 1 1 - - - Rissoles 1 1 - - Rochelle Salt 1 1 - - Rum Essence 1 1 - - - Sausage, Beef 18 17 1 - - 1 „ Breakfast 9 9 - - - „ Pork 12 12 - „ Luncheon 7 7 - - - „ Preserved 8 8 - - „ Breakfast Preserved 1 1 - - Saveloys 7 7 - - - — Shredded or Chopped Beef Suet 4 4 - - - - Sweets 24 21 3 2 Syrup of Figs 1 1 — - - — Spice, Ground 2 2 — - - — Sugar 1 1 — - - — Tea 12 12 — - - — Tinned Tomatoes 1 1 — - - — Tinned Beans 6 6 — - - — Tinned Peas 12 12 — — Treacle 5 5 — - - — Tincture of Rhubarb Comp. 2 2 — - - — Tinned Asparagus 2 2 — - - — Vinegar, Malt 12 11 1 - - 1 Whiskey 6 6 - - - - Totals 886 867 19 4 4 13 2. Result of Analysis of New Milk Samples. SOLIDS NOT FAT. (Legal standard is 8.5%). 6.9 7.6 7.9 8.3 8.4 8.5 8.6 8.7 8.8 8.9 9.0 9.1 1 1 1 1 3 15 33 107 111 92 45 16 9.2 9.3 9.4 Total 432 4 1 1 95 MILK FAT. (Legal standard is 3%). 2.6 2.8 2.9 3.0 3.1. 3.2 3.3 3.4 3.5 3.6 3.7 3.8 1 2 4 2 13 33 61 75 81 55 37 22 3.9 4.0 4.1 4.2 4.3 4.4 4.5 4.7 5.1 5.5 Total 432 17 753164111 Total Samples of New Milk 432 The Samples of Milk (including Separated Milk) for analysis were obtained as follows:— Country Milk in course of delivery by train to Local Dairymen 6 Country Milk in course of delivery by motor lorry to Local Dairymen 12 On Milk Rounds (Sundays) ... 16 „ „ (Week-davs) 290 Cowsheds — At Shops 98 Taken at Institutions 10 "Appeal to Cow" Samples taken at farms outside Borough — 432 AVERAGE COMPOSITION OF NEW MILK SAMPLES. Solids not Fat 8.8% Milk Fat 3.5% Percentage of New Milk Samples below legal standard: 2.8% Adulterated Samples. The following is a detailed statement of the adulterated samples and action taken:— Adulteration or No. Sample. Deficiency. Remarks. 811. Boiled Sweets Contained 0.114 percent. of sulphur dioxide equal to 1140 parts per million by weight. Wholesalers ordered stock to be withdrawn. Fur¬ther sample proved genuine. 789. Blackberry with Apple Jelly Jam (Full Fruit Standard). Sample contained not more than 15 percent. of blackberry fruit. Not of full Standard. Manufacturers warned. Further sample proved genuine. 652. New Milk 1 percent. added water. Vendor warned. Further sample proved genuine. 738. New Milk Not less than 2 or 3 percent of added water. Vendor warned. Further samples proved genuine. 773. New Milk 4 percent. deficient in fat. Vendor warned. Further samples proved genuine. 96 Adulteration or No. Sample. Deficiency. Remarks. 722. Mustard No notice of admix¬ture given. Sample contained 20 percent. of wheaten flour. Vendor removed before re¬sult of sample came to hand. Vendor and manu¬facturer could not be traced. 820. Beef Sausage Contained a trace of boric acid-too small to admit of quantitive deter¬mination Vendor warned. Further sample proved genuine. 642. Malt Vinegar Sample was an arti¬ficial vinegar, con¬sisting of dilute acetic acid, coloured and flavoured. Sold as malt vinegar in error. Explanation ac¬cepted and warning given. Further sample proved genuine. 966. New Milk 8 percent. deficient in fat. See Samples 969 and 971 and 971 below. 968. New Milk 2 percent. deficient in fat. Vendor warned. Further sample proved genuine. 969. New Milk 6 percent. deficient in fat. Taken subsequently in the course of delivery. Warning given. Further sample proved genuine. 971. New Milk 2 percent. deficient in fat. Taken subsequently in the course of delivery. Warning given. Further sample proved genuine. 1077. Boiled Sweets Contained suphur dioxide 0.007 percent. Equal to 70 parts per million by weight. Matter take up with manufacturers and warning given. 77. Boiled Sweets Contained sulphur dioxide 0.019 percent. Equal to 190 parts per million by weight. Matter take up with manufacturers and warning given. 1147. New Milk 6 percent. of added water. Proceedings taken and conviction secured. Vendor fined £5. 6d. incurred. 1187. New Milk 2 percent. of added water. Further Sample proved genuine. Vendor warned. 28. Grade "A" Milk 19 percent. of added water. Consignor prosecuted and conviction secured. Fined £2 and costs of £1 16s. incurred. 29. Grade "A" Milk 11 percent. of added water. From same consignor as Sample 28. Proceedings taken and conviction secured. Fined £2 and costs of £1 16s. incurred. 187. New Milk 14 percent. deficient in fat. Vendor proceeded against. Conviction secured. Fined £5 5s. and costs of £4 19s. incurred. 97 SECTION IV. CANCER. Deaths from Cancer numbered 374 as compared with 341 in 1932; 342 in 1931; 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 previous 10 years are as follows:— 1923 1.34 (259) 1928 1.54 (327) 1924 1.50 (293) 1929 1.48 (330) 1925 1.60 (319) 1930 1.52 (339) 1926 1.60 (330) 1931 1.46 (342) 1927 1.62 (344) 1932 1.44 (341) For 1933 the rate is 1.56 (374). Deaths From Cancer in Municipal Wards. Table XXIX. Ward. Male. Female. Total. Death-rate Estimated Population. Mid 1933. Male. Female. Upper Norwood 9 26 35 1.56 10122 12258 bury 10 12 22 1.37 7240 8753 East Thornton 11 13 24 1.20 9402 10664 Ransham Manor 8 11 19 1.18 7518 8566 Bornton Heath 12 11 23 1.48 7450 8165 South Norwood 12 15 27 1.52 8077 9640 Foodside 10 13 23 1.47 7432 8222 Yeast 17 15 32 1.77 7927 10108 discombe 15 12 27 1.87 6688 7770 Hitehorse Mnr 11 15 26 1.55 7995 8759 oad Green 11 10 21 1.37 7304 8066 Contral 11 8 19 1.56 5432 6777 Paddon 11 21 32 1.47 10387 11452 South 10 27 37 2.48 6332 8569 Paddington 2 3 5 1.74 1426 1449 fixed abode. 1 1 2 — — — Total 161 213 374 1.56 110732 129218 98 Table XXX. 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 2 3 100779 .029 25 and under 35 years 2 9 11 35996 .306 35 and under 45 years 7 9 16 38388 .417 45 and under 65 years 68 99 167 47991 3.480 65 years and over 83 94 177 16796 10.538 161 213 374 239,950 1.559 Table XXXI. Sites of Fatal Cancer. Site. Male. Female. Total. Percentage of Total. Brain - 1 1 0.26 Skin 3 3 6 1.60 Tongue and Mouth 5 2 7 1.87 Lip 1 — 1 0.26 Oesophagus 6 4 10 2.67 Stomach 33 37 70 18.72 Liver 2 10 12 3.21 Bowel 23 33 56 14.97 Rectum 26 9 35 9.36 Bladder 7 1 8 2.14 Prostate 10 — 10 2.67 Larynx 4 1 5 1.34 Uterus — 20 20 5.35 Breast 1 42 43 11.49 Ovary — 13 13 3.48 Pancreas 9 5 14 3.74 Gall Bladder and Duct. 1 9 10 2.67 Bones 3 4 7 1.87 Mediastinum 4 — 4 1.07 Lungs 10 5 15 4.01 Kidneys 4 3 7 1.87 Glands 4 5 9 2.41 Other Reproductive 2 4 6 1.60 Pharynx 1 2 3 0.80 Not defined 2 - 2 0.53 161 213 374 99 Comments on Foregoing Tables. (1) Deaths from Cancer increase as age advances; this in 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 73.3% of the total deaths fall within these groups and in females 88.7%. In both sexes Cancer of the digestive system is the commonest situation, amounting to 65.8% in males and 51.1% in females. Cancer of the reproductive system caused 37.5% of the total deaths in females. Cancer of the larynx, tongue and mouth is commoner in males than females, 9 deaths occurring in males as compared with 3 in females. The organs most often attacked in descending order of incidence are, in males the Rectum and Bowels (30.4%); the Stomach (20.5%); the Prostate, and Lungs (6.2%); in females, the Bowels and Rectum (19.7%); the Breast (19.7%); Stomach (17.4%); and the Uterus (9.4%). This is slightly different from the incidence in 1932. 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. Although much research has been made and is continuing into ike causation of Cancer, the reason why certain cells suddenly become abnormally active and reproduce themselves excessively, with resultant invasion of surrounding tissues, has not yet been elucidated. The Cancer cell is an ordinary tissue cell which has tacome invested with abnormal properties. Why this should happen is not yet understood. 100 SECTION V. PREVALENCE AND CONTROL OF INFECTIOUS DISEASE. Table XXXII gives the figures for ages and wards. Scarlet Fever was more prevalent than in 1932; the largest incidence has been in East, Upper Norwood, Addiscombe and Waddon Wards. Based on the estimated ward populations, the case rate for these wards was respectively, 471, 371, 432, 275; and 264 per 100,000 of the population, The age group 5-15 years, as usual, suffered most , cases in this group comprising 53.4% of the total. Diphtheria was also more prevalent than in 1932, most cases occurred in Waddon (43) and Addiscombe (29). Once again the age group 5-15 years gave tne highest figures. Three cases of Small Pox occurred in the Upper Norwood Ward. There were 13 cases of Puerperal Fever and 39 of Puerperal Pyrexia; 18 occurred in the age group 16-25 years and 34 in the age group 26-45 years. A majority of the cases occurred in women having their first confinement. The incidence of the commoner infectious diseases in Croydon during the past ten years is of interest. 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 and 1931, the incidence was relatively constant, with a slight decline in the number of cases in August and September. During 1932 there was a steady increase in cases until the beginning of May when the incidence fell rapidly and remained low until the beginning of a new wave in November. In 1933 the incidence remained fairly steady throughout the year, the highest number of cases notified during a week was 23 (week ending July 22nd, and the lowest 4 (week ending August 19th). The weekly average of cases throughout the year was 10.5, being 2.2 higher than in 1932. 101 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, roaching 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. In 1932 there was a slight rise in March, and again in mid September and the end of November. During 1933, there was a steady upward trend in incidence as the year advanced, with only a slight remission during April and May. The weekly average of cases was 4.1 as compared with 2.2 in 1932. 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. A wave of increased incidence occurred in 1932, commencing the second week in April and persisting until the end of July. Two small waves showed themselves during 1933, the first commencing early in February and persisting until the beginning of August; the second beginning in late October and continuing until the end of the year. 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, and was followed, after a fall, by a further and more prolonged rise from October, 1925, to May, 1926. 102 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; but in 1932 there was a sharp rise in cases the second week in April which reached a maximum in the last week in June, falling then rapidly. The beginning of another wave showed itself at the end of November and the cases were steadily increasing in number for the rest of the year. The measles waves therefore were as follows: the first half of 1924, the second half of 1925, and the first quarter of 1926; first half of 1928, the first half of 1929, the first half of 1930, and the first half of 1932. Measles was rather prevalent during the first quarter of 1933, dropping rapidly during the second quarter and not becoming noticeable again until December. 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 of 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. In 1931 Chicken Pox was prevalent until the end of June, when the number of cases declined and remained low until November, when the cases again rose. During 1932 the incidence remained steady until the end of March when a rise occurred, persisting until the end of August. After the vacation the disease practically died out for the remainder of the year. Chicken Pox rose during the first, half of the year to reach a maximum early in July. It then dropped rapidly and did not show any signs of recrudescence until the end of November, 103 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 and in 1932 the incidence was very low. The very low incidence of Mumps continued during 1933. The waves showed their maxima in March, 1924; May, 1925; March, 1926; May, 1927; March, 1928 and May, 1930, and their minima in September, 1924; September, 1925; September, 1926; and September, 1927. 104 Table XXXII. CASES OF NOTIFIED INFECTIOUS DISEASE, 1933 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. 1932. At all Ages. At ages—years. Upper Norwood. Norbury West Thornton. Bensham Manor. Thornton Heath. South Norwood. Wood side. 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 3 ... ... 3 ... ... ... ... 3 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... Cholera ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria (inc. Membranous Croup) 222 1 57 111 26 23 4 ... 16 8 20 8 15 19 14 9 29 19 12 3 42 4 4 225 17 54 62 Erysipelas 105 2 1 10 11 40 27 14 2 9 27 5 9 4 3 6 3 7 9 3 14 4 ... ... 6 32 43 Scarlet Fever 633 e 169 338 65 45 10 ... 83 24 37 29 37 28 35 85 62 56 39 18 60 38 2 533 ... 199 242 Typhus Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Enteric Fever (including Paratyphoid) 24 ... 3 10 6 5 ... ... 3 1 3 ... 1 ... ... 6 1 ... 4 ... 3 2 ... ... ... 7 5 Puerperal Fever 13 ... ... ... 5 8 ... ... 1 3 2 1 ... ... 1 1 ... 2 1 1 ... ... 14 7 ... 13 Puerperal Pyrexia 39 ... ... ... 13 26 ... ... 2 1 19 1 ... 2 2 3 ... 1 4 1 1 1 1 ... ... ... 33 Cerebro-Spinal Meningitis 3 ... 1 1 1 ... ... ... ... ... 2 ... ... ... ... ... ... ... 1 ... ... ... ... 3 2 7 2 Ophthalmia Neonatorum 10 10 ... ... ... ... ... ... 2 ... 4 1 ... ... ... ... 1 1 ... ... ... 1 ... 2 ... 14 7 Poliomyelitis 4 ... 2 2 ... ... ... ... ... ... ... ... ... ... 1 ... ... ... 2 ... 1 ... ... 4 1 5 1 Encephalitis Lethargica 3 ... ... ... ... 2 1 ... ... ... 2 1 ... ... ... ... ... ... ...... ... ... ... ... 5 ... 2 1 Dysentery 12 ... 4 7 ... ... 1 ... 3 ... 7 ... 2 ... ... ... ... ... ... ... ... ... ... 8 ... ... ... Malaria ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Ac. Primary and Ac. Inf. Pneumonia 73 2 4 10 9 27 13 8 9 l 20 3 3 6 4 4 5 7 2 1 3 5 ... ... 45*† 61 50 Polio Encephalitis 1 ... 1 ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... *Influenzal Pneumonia only. †Not accommodated at Borough Hospital. 105 Table XXXIII. 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. 1933 1932 Small Pox 0.012 0.004 — 3 — — 3 Diphtheria 0.92 0.49 2 178 7 35 222 Erysipelas 0.44 0.32 1 70 7 27 105 Scarlet Fever 2.65 1.88 7 489 49 88 633 Enteric Fever (inc. Paratyphoid) 0.096 0.051 — 15 3 6 24 Puerperal Fever 0.054 0.055 — 8 — 5 13 Puerperal Pyrexia 0.162 0.141 — 12 1 26 39 Cerebro-Spinal Meningitis 0.012 0.038 — — — 3 3 Ophthalmia Neonatorum 0.042 0.09 — 6 — 4 10 Poliomyelitis 0.016 0.025 — 2 1 1 4 Encephalitis Lethargica 0.012 0.0125 — 2 - 1 3 Acute Primary or Acute Influenzal Pneumonia 0.305 0.47 1 47 5 20 73 Dysentery 0.048 — — 5 — 7 12 Polioencephalitis 0.004 - - — — 1 1 The highest incidence of notifiable infectious diseases was in houses of 4-5 rooms. The 1931 Census showed that houses of 1-3 rooms formed 4.7% of the total number of houses; those of 4-5 rooms 51.4% and those with over 5 rooms 43.9.% 106 Table XXXIV. 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 Cases 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 1 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 759 335 4 .54 714 3 0.42 1930 681 306 2 .29 679 2 0.29 1931 527 225 3 .57 528 2 0.38 1932 441 186 1† .23 387 1 0.26 1933 633 264 ... ... 599 1 0.17 *Cases admitted to the Borough Hospital from Penge are included in arriving at the figures in Cols. 6 to 8. † Death not due to Scarlet Fever. There was an increase in the number of cases notified and admitted to Hospital in 1933 as compared with 1932. The type was mild and the case mortality was nil. The attack rate (Colfor England and Wales was 321. Croydon shows a lower figure. 107 Table XXXV. 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 8.2 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 1.1 168 21 1.3 1919 429 223 36 8.3 388 38 .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 1932 116 49 9 7.8 162 9 5.6 1933 222 93 17 7.7 236 18 7.6 *Cases from Penge are included in Cols. 6 to 8. 148 The incidence of diphtheria showed a considerable increase in 1933, and the mortality was 7.7%. The type of the disease was moderately severe. Thirty-four 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 lib. Croydon's rate is therefore lower than for the whole country. BOROUGH HOSPITAL The table below gives a summary of all cases treated in Hospital in 1933, 1,128 patients were admitted and discharged during the year, whilst including patients in at the commencement of 1933 (111) 1,239 cases were dealt with. Thirty-six died, giving a case mortality for the whole hospital of 3.1%, an increase of 0.3% over 1932. The average number of days of each patient in hospital for all classes of patients was 31.2 as against 30.9 in 1932. Penge Urban District Council has an agreement with the Corporation to send their cases to the hospital. During 1933 a total of 80 cases were admitted from this district, these cases are included in the table. The hospital is a recognised training school for fever nurses and during the year 4 probationers passed the preliminary and i the final examination of the General Nursing Council. The accommodation in the hospital remained as for 1932. The new operating theatre was put into use during the year and twelve cases were operated upon for removal of tonsils and adenoids, one case for acute mastoiditis and one for empyema. 109 Complaint for which Admitted. Patients remaining in Hospital on Jan. 1st, 1933. Patients admitted and discharged in 1933. Patients Remaining in Hospital on Jan. 1st, 1934. Analysis of all Cases admitted in 1933 whether discharged or not during the year. Table XXXVI. Total. Recovered Died. Total. Recovered Died. Total. Recovered Died. Total Recovered Died. Case Mortality. Average No. of days in Hospital. Scarlet Fever 69 68 1 599 509 1 89 89 ... 599 598 1 0.2 40.6 Diphtheria 18 18 ... 236 185 16 35 33 2 236 218 18 7.6 31.0 Typhoid Fever 1 1 ... 8 7 ... 1 1 ... 8 8 ... ... 37.5 Paratyphoid Fever ... ... ... 10 10 ... ... ... ... 10 10 ... ... 30.7 Erysipelas 2 2 ... 62 54 3 5 5 ... 62 59 3 4.8 14.1 Measles 13 13 ... 68 60 7 1 1 ... 68 61 7 10.0 22.1 Puerperal Fever 2 2 ... 14 10 4 ... ... ... 14 10 4 28.6 30.0 Puerperal Pyrexia ... ... ... 1 1 ... ... ... ... 1 1 ... ... 30.0 Encephalitis Lethargica ... ... ... 5 3 2 ... ... ... 5 3 2 40.0 15.0 Whooping Cough 1 ... 1 16 15 ... ... ... ... 16 16 ... ... 34.4 Cerebro-Spinal Meningitis 2 1 1 3 2 1 ... ... ... 3 2 1 33.3 39.0 Chicken Pox 1 1 ... 51 51 ... ... ... ... 51 51 ... ... 21.8 Mumps 1 1 ... 9 9 ... ... ... ... 9 9 ... ... 20.4 Ophthalmia Neonatorum ... ... ... 2 2 ... ... ... ... 2 2 ... ... 15.6 Infantile Palsy ... ... ... 4 4 ... ... ... ... 4 4 ... ... 16.5 Pemphigus ... ... ... 1 ... 1 ... ... ... 1 ... 1 100.0 3.0 White Leg ... ... ... 2 2 ... ... ... ... 2 2 ... ... 17.0 Typhoid Carriers ... ... ... 3 3 ... ... ... ... 3 3 ... ... 20.5 Dysentery (Flexner type) ... ... ... 8 8 ... ... ... ... 8 8 ... ... 18.4 Vincent's Angina ... ... ... 1 1 ... ... ... ... 1 1 ... ... 34.0 Septicaemia* ... ... ... 1 ... 1 ... ... ... 1 ... 1 100.0 4.0 German Measles ... ... ... 5 5 ... ... ... ... 5 5 ... ... 13.5 No Disease 1 1 ... 19 19 ... ... ... ... 10 19 ... ... ... Total 111 108 3 1128 960 36 132 130 2 1128 1090 38 ... ... *This was really a case of lobar pneumonia. 110 SCARLET FEVER. The total number of cases of Scarlet Fever admitted during tlie year was 599, an increase of '212 on 1932. 533 cases were admitted from the Borough and 66 cases from Penge. The type of disease during the year was of average severity there being a fair number of adult cases as is shown in the subsequent table. There were three return cases. The following complications and sequelae occurred amongst the 580 true cases of the disease of whom 208 received serum treatment:— Serum cases. Non-serum cases. Adenitis 19 (9.1%) 30 (8.1%) Otorrhœa 15 (7.2%) 31 (8.3%) Rhinorrhœa 16 (7.7%) 26 (7.0%) Albuminuria — 2 (0.54%) Nephritis 1 (0.48%) 1 (0.27%) Rheumatism 2 (0.96%) 3 (0.8%) Relapses — 1 (0.27%) Secondary Sore Throat 1 (0.48%) 3 (0.8%) Abscesses and boils 1 (0.48%) 5 (1.35%) Endocarditis 1 (0.48%) — Septicaemia — 1 (0.27%) Retro-pharyngeal abscess - 1 (0.27%) Quinsy 1 (0.48%) 2 (0.53%) Total 57 (27.4%) 106 (28.5%) Average stay in Hospital: Serum cases, 41.2 days; non-serum cases, 40.1 days. Complications: Serum cases, 26.8%; non-serum cases, 25.6% 11 cases sent in as Scarlet Fever were found not to be suffering from the disease, whilst 8 others were not cases of Scarlet Fever but as follows:— Measles 3 Pneumonia 2 Diphtheria 1 Tonsillitis 1 Eczema 1 111 No deaths occurred amongst the Scarlet Fever cases. One fatal case admitted as Scarlet Fever was really a Puerperal Septicaemia. Ages and Sexes of Scarlet Fever Patients Admitted. The following table shows the ages and sexes of Scarlet Fever patients admitted:— Table XXXVII. Age. Males. Females. Totals. 0—1 2 1 3 Pre-school period 23.8 % 1—2 9 12 21 2—3 19 6 25 3—4 11 18 29 4—5 29 31 60 5—10 109 119 228 School periods 59% 10—15 46 68 114 15—20 16 20 36 Post-school period 17.2 % 20—30 10 28 38 30 & over 7 19 26 Total 1933 258 322 580 Total 1932 179 208 387 Monthly Admissions of Scarlet Fever Patients to the Hospital. Table XXXVIII. Month. Cases admitted. Cases notified. 1932. 1933. January 33 44 53 February 27 47 54 March 39 51 50 April 40 40 47 May 37 58 64 June 18 49 51 July 22 55 56 August 19 24 26 September 17 44 45 October 37 52 47 November 44 58 62 December 54 77 78 Total 387 599 633 Only one true relapse occurred, in a girl aged 6, admitted on 3rd day of disease, the relapse was on '29th day. She was not given serum. 112 DIPHTHERIA. 236 cases were admitted with a diagnosis of diphtheria, an increase of 74 cases on 1932. Of these 12 were found not to be cases of diphtheria and 34 were positive swabs without clinical symptoms, leaving 190 cases of true diphtheria as against 115 true cases in 1932. Analysis of the 190 diphtheria cases:— Faucial diphtheria 153 Nasal diphtheria 19 Laryngeal diphtheria 15 Faucial and nasal diphtheria 2 Faucial and laryngeal diphtheria 1 190 Of the 15 laryngeal cases tracheotomy was necessary in 7 cases and 4 died, one being moribund on admission, and two dying subsequently from heart failure and intercurrent disease. The following complications and sequelae occurred amongst the diphtheria patients:— Adenitis 11 Quinsy 3 Otorrhœa 6 Paralysis: Ocular 3 Rhinorrhœa 15 Paralysis: Palatal 5 Secondary sore throat 12 Paralysis diaphragm and intercostals 1 Albuminuria 3 Paralysis: Facial 1 Cardiac failure 12 In 5 cases the disease was not confirmed and 7 were other diseases, viz.— 1 bronchitis. 1 measles. 3 tonsillitis. 1 simple laryngitis. 1 pneumococcal septicæmia. 113 Ages and Sexes of Diphtheria Cases Admitted. Table XXXIX. Age. Males. Females. Totals. Deaths. Mor- tality. % Pre-school period, 23.7 % School 0—1 2 - 2 1 50.0 1—2 2 3 5 - — 2—3 8 3 11 2 18.2 3—4 8 6 14 2 14.3 4—5 8 5 13 1 7.7 period, 54.2 % 5—10 42 30 72 4 5.6 10—15 12 19 31 1 3.2 Post-school period 22.1 % 15—20 6 5 11 2 18.2 20—30 5 14 19 — — 30 & over 3 9 12 1 8.3 Total 1933 96 94 190 14 7.4 Total 1932 84 78 162 9 5.5 The type of diphtheria which occurred in 1933 was rather more severe than in 1932. The death rate has shown a steady increase during the past three years. Admissions of Diphtheria Cases to the Borough Hospital in 1933. Table XL. Month. Cases notified. Cases admitted. 1933. 1932. January 19 19 4 February 11 12 16 March 21 16 16 April 10 16 22 May 9 8 10 June 14 17 9 July 17 17 10 August 16 17 15 September 22 29 14 October 30 30 13 November 27 28 23 December 26 27 10 Total 222 236* 162† † Including 16 cases from Penge. * Including 11 cases from Penge. Among the cases admitted are patients who had positive swu:> results but showed no clinical symptoms and were not notified as diphtheria. 114 Table XLI. Particulars of Fatal Cases Name. Day of Disease. Condition on Admission. Subsequent progress. Date of Death Days after Admission. (1) C.W. (F.) 45 years. 2 Cyanosed; sloughing membrane Over whole pharynx; glands of neek + +; wandering. Received no serum before admission. Condition grew progressively worse; died on 3rd day in semi-coma. 3 days. (2) R.P. (F.) 34 years. 6 Sloughing membrane over whole pharynx; glands enlarged; signs of acute bronchopneumonia; cyanosed. Increasing heart failure with rapid irregular pulse. 21 hours. (3) C.S. (F.) 6 years. 3 Croupy; aphonia, some recession; colour poor; pulse weak and rapid; throat clean. Received no serum before admission. Laryngeal. Increasing heart failure; death within 10 hours of admission. 10 hours. (4) R.C. (M.) 3½ years. 5 Croupy; membrane over both tonsils; glands of neck + +; some recession. Received no serum before admission. Laryngeal. Owing to increasing restlessness tracheotomy performed with relief. Had a heart attack in early morning and collapsed suddenly 1½ hours later. 19 hours. (5) H.H. (F.) 2 8/12 yrs. 4 Cyanosed; bleeding from lips; membrane over both tonsils; Bull neck; showed signs of heart failure on admission. Received no serum before admission. Condition grew steadily worse; collapsed suddenly on 5th day after admission. 5 days. (6) R.S. (M.) 16 years. 5 Throat covered with membrane; Bull neck; profuse rhinorrhoea; restless. Received 16,000 A.D.S. day before admission. Condition steadily worse; oedema of throat; heart sounds weak and rapid. Collapsed on 4th day after admission. 4 days. 115 Name. Day of Disease. Condition on Admission. Subsequent progress. Date of Death Days after Admission. (7) W.T. (M.) 5 years. 2 Croupy; bilateral recession; cyanosis; throat clean; tonsils + +. Received no serum before admission. Tracheotomy performed owing to increasing obstructions, with relief, soon after admission. Developed signs of pneumonia and collapsed on 3rd day. 3 days. (8) M.H. (M.) 2 2/12 yrs. 6 Sloughing membrane over whole pharynx; rhinorrhoea + +; foetor glands of neck + +.; heart failure on admission. Severe epistaxis 2nd day after admission; very restless at times. Collapsed suddenly on 2nd day after admission. 2 days. (9) C.C. (M.) 6 years. 4 Whole pharynx covered with membrane; difficulty of breathing. Received no serum before admission. Tracheotomy performed soon after admission, but patient died soon after; moribund on admission. 10 hours. (10) R.G. (M.) 16 years. 4 Extensive membrane over pharynx, and oedema; Bull neck; cyanosis; foetor; signs of heart failure. Received no serum before admission. Died by progressive heart failure 3 hours after admission. 3 hours. (11) L.G. (M.) 8½ years. 7 Membrane over both tonsils; blood-stained rhinorrhoea. Received no serum before admission. Developed signs of heart failure day after admission which was progressive until death. 8 days. (12) J.R. (F.) 3 11/12 yrs. 3 Extensive membrane over whole throat; Bull neck; colour poor; toxic; signs of heart failure. Received no serum before admission. Rapidly increasing heart failure; died same night. 9 hours. (13) M.P. 11 years. 3 Extensive membrane over whole throat. Bull neck; rhinorrhoea + +: toxic. Received no seram before admission. Condition grew steadily worse, and patient collapsed a few hours after admission. 3½ hours. (14) M.C. (P.) 6 years. 1 (?) Croupy; some recession; colour poor; pulse weak and rapid. Received no serum before .admission. Laryngeal. Sudden heart attack during night and collapsed. 8 hours 116 Only three cases had received serum before admission. Intra-muscular injections of serum between 24,000—72,000 units were given to cases. One case received 20,000 units intravenously. The beneficial effect of large doses of serum when given late was less marked than when given at the onset of the disease, the patient having already absorbed large doses of toxin in the system which, becoming fixed in the tissue cells, cannot be neutralised by the anti-toxin administered. This was the cause of the rapid onset of heart failure. Enteric Fever. Eight cases of enteric fever and 10 cases of para-typhoid B were admitted compared with 3 enteric and 5 para-typhoid patients in 1932. The following in as analysis of the cases. Sent in as enteric and diagnosis confirmed 7 Sent in as enteric and really tubercular meningitis 1 Sent in as para-typhoid B and diagnosis confirmed 9 Sent in as paratyphoid B and really bac. coli infection 1 18 The cases were of moderate severity. The one death was due to tubercular meningitis and not typhoid fever. Puerperal Fever and Pyrexia. Thirteen cases were sent in as Puerperal Fever: of these 1 was a case of influenza only. 1 a case of constipation only. 1 a case of ante-partum hæmorrhage and thrombo-phlebitis of femoral vein. 1 a case of abortion and septicaemia. In 9 cases the diagnosis was confirmed. One case of puerperal pyrexia was sent in and the diagnosis was confirmed. 117 Four deaths occurred amongst the puerperal fever cases; one due to thrombo-phlebitis of femoral vein and ante-partum haemorrhage, and three were severe cases of general septicaemia, one following abortion. Erysipelas. There were 62 cases of erysipelas admitted, an increase of 23 cases on 1932. The disease was of a particular severity as a whole. Three deaths occurred. One was a case of cancer of jaw complicated by erysipelas and two were senile cases in whom the erysipelas was a terminal condition. Measles. There were 68 cases of measles, a decrease of 90 on 1932. The disease was of average severity and there were six fatal cases, due to broncho-pneumonia. All occurred in young children, the eldest being five years old. Whooping Cough. Fifteen cases of whooping cough were admitted, a decrease of 33 on 1932. The disease was mild as a whole and no fatal cases occurred. Cerebro-Spinal Meningitis. Three cases only of this disease were admitted and the diagnosis was confirmed: one case proved fatal. Encephalitis Lethargica. Four cases were admitted: in three cases the diagnosis was confirmed. The fatal case was a post-influenzal encephalitis. Infantile Paralysis (Poliomyelitis). Four cases were admitted: of these one was a case of chorea and not of infantiie paralysis. No deaths occurred. Dysentery. Eight cases were admitted from Mayday Hospital. The organism isolated from the stools being of the Flexner type. The cases were all mild in character and recovered rapidly. 118 Ophthalmia Neonatorum. Two cases were admitted, but only in one was the. diagnosis confirmed: the other was a case of simple ophthalmia. Table XLII. Other Diseases. Age Group 0—1 1—2 2—5 5-15 15—25 25-35 35—45 45 & up. Totals Deaths Disease M F M F M F M F M F M F M F M F Enteric Fever ... ... ... ... ... 2 3 1 ... 2 ... ... ... ... ... ... 8 ... Paratyphoid B ... ... ... ... ... 2 3 ... ... 1 ... 3 ... 1 ... ... 10 ... Puerperal Fever ... ... ... ... ... ... ... ... ... 3 ... 6 ... 5 ... ... 14 4 Puerperal Pyrexia ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... 1 ... Erysipelas 1 ... ... ... ... 1 1 2 2 2 1 11 12 4 18 7 62 3 Measles 6 4 6 7 17 13 5 4 1 1 2 2 ... ... ... ... 67 7 German Measles ... ... ... ... ... 1 2 2 ... ... ... ... ... ... ... ... 5 ... Encephalitis Lethargica ... ... ... ... ... ... 1 ... ... ... ... 1 ... ... ... ... 5 2 Cerebro-Spinal Meningitis ... ... ... ... ... ... 1 ... 2 ... ... ... ... ... ... ... 3 1 Whooping Cough 3 3 3 i 2 4 ... ... ... ... ... ... ... ... ... ... 16 ... Chicken Pox 2 1 1 2 16 16 4 7 1 1 ... ... ... ... ... ... 51 ... Ophthalmia Neonatorum 1 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... Mumps ... ... ... ... ... ... 3 1 4 ... ... ... ... ... ... ... 9 ... Septicemia* ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... ... 1 1 Infantile Palsy ... ... 1 ... 1 2 ... ... ... ... ... ... ... ... ... ... 4 ... Pemphigus 1 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... White Leg ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 ... ... 2 ... Typhoid Carriers ... ... ... ... ... ... 1 1 ... ... ... ... ... l ... ... 3 ... Vincent's Angina ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... Dysentery ... ... ... ... 1 3 2 l ... ... ... ... ... ... ... ... 8 ... No disease ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 19 ... Totals 14 9 11 10 37 44 26 19 10 11 3 24 12 13 21 10 292 18 * This was really a case of Lobar Pneumonia. 119 Table XLIII. Out of Borough Cases. Disease. Males. Females. Totals. Deaths. Scarlet Fever 34 32 66 — Diphtheria 5 6 11 1 Puerperal Fever — 2 2 — Baby with Mother — 1 1 — Croydon Borough Hospital Laboratory Report. Table XLIV. DIPHTHERIA. Nose and Throat swabs examined. New cases swabbed on admission. Convalescent Cases. Negatives. Total. + + — 81 96 3,281 3,458 FÆCES EXAMINED FOR DYSENTERY. — + Total. 15 — 15 FÆCES EXAMINED FOR ENTERIC GROUP. — + Total. 26 — 26 DREYER'S AGGLUTINATION TEST FOR ENTERIC GROUP. — + Total. 3 3 6 1— Positive B. Typhoid. 2— Para.-Typhoid B. 120 Other Examinations. Specimens of blood for culture 8. 2 Fluids Weichselbaum's Diplococcus obtained in pure culture. 3 specimens Pneumococcus obtained in pure culture. 1 specimen Para Typhoid B obtained in pure culture. 2 specimens were proved sterile. Specimens of Pus for Organisms. 5 specimens Streptococcus obtained. Cerebro Spinal Fluids: 5 examined. 2 Fluids Weichsebaum'p Diplococcus obtained in pure culture. 1 Fluid B. Tuberculosis seen in stained smear from fluid. 2 Fluids were proved sterile. Eye swabs for examination: 2. 1 eye swab proved positive for Gonorrhoea. 1 eye swab Streptococcus brevis obtained. Fluids from chests for examination: 2. Urines cultured for organisms: 8. Specimens of Lochia examined for Hemolytic Streptococcus: 3. 2 specimens Hæmolytic Streptococcus obtained in pure culture. 1 specimen was proved to be sterile. Culture Media. Leoffler's Blood Serum: 250 doz. tubes. Agar Agar: 4,300cc Peptone Broth 3,300cc Litmus Milk 400cc Peptone Water 900cc Hiss' Serum Water 150cc 121 BACTERIOLOGICAL EXAMINATIONS. I am indebted to the Borough Pathologist, Dr. H. W. Southgate, for the figures given in the appended tables: — Table XLV. I. At the Laboratory, Croydon General Hospital. For private practitioners Mayday Hos. For Borough Hospital For Tab. Dispensary For School Medical Other Instns. of Corporation Other Institutions Total Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg. Pos. Neg Pos. Neg. Pos. Neg. Pos. Neg. Swabs for Diphtheria 111 1336 7 144 ... ... ... 3 60 2559 ... 5 8 248 186 4295 Virulence tests for Diphtheria ... ... ... 1 ... ... ... ... 2 5 ... 1 2 ... 4 7 Sputum for Tub Bac. 112 569 166 205 ... ... 256 379 ... ... ... 1 13 88 547 1242 Pus for Tub. Bac. ... 2 6 450 ... ... ... ... ... ... ... 40 ... ... 6 492 Pus for Gonococci ... ... 17 71 ... ... ... ... ... ... 4 67 ... ... 21 138 Pus for other organisms ... 2 ... 494 ... ... ... ... ... ... ... ... ... 44 ... 540 Blood for Typhoid Groups 7 19 4 10 ... ... ... ... ... ... ... ... 4 1 15 30 Blood for Wassermann ... 1 26 116 ... ... ... 2 ... ... ... 1 ... 2 26 122 Material for Spirochaetes ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Faeces for Typhoid Group 3 5 7 27 ... 1 ... ... ... ... 1 10 ... ... 11 43 Hair for Ringworm ... 1 5 4 ... ... ... ... ... ... 3 2 ... 1 8 8 Examination of Urine 2 282 ... ... ... ... 38 ... 322 Examination of Pleural Fluid ... 30 ... ... ... ... ... ... 30 Examination of C.S. Fluid ... 25 ... ... ... ... 1 ... 26 Other Examinations ... 467 4 ... ... ... 32 7 510 122 Examinations Done Under National Health Insurance Act. Table XLVI. Nature of Examination. Nature of Examination. Pus for Gonococci 10 (5 pos.) Urine for Chemical Exam. 3 Pus for other organisms 7 Urine for Microscopical Exam 3 Pus for Tubercle B. 6 Urine for Tubercle B 3 Blood for Wassermann 24 (4 pos.) Urine for Cultural Exam. 3 Complete Blood counts 5 Other Examinations 11 Bacteriological Examination of Milk. Table XLVII. Number of Samples submitted for Counts 517 Number under 10,000 per cc 224 No. over 10,000 but under 50,000 per cc 129 Over 50,000 but under 100,000 per cc 50 Over 100,000 but under 500,000 per cc 65 Over 500,000 but under 1,000,000 per cc 18 Over 1,000,000 per cc 31 Bacillus Coli Content— Not found in 0.1 cc 243 „ „ 0.01 cc 117 „ „ 0.001 cc 63 Present in 0.001 cc 94 Higher dilutions not made. Tubercle Bacilli— No. of samples of mile submitted. 517 No. found positive by inoculation test 18 VACCINATION ACTS. I am indebted to Mr. Huggins, the Vaccination Officer, for the particulars in the returns in subjoined Table. Table XL VIII. Registration Sub-Districts in V.O. District. Births Registered. Vaccinated. Insusceptible. Statutory Declarations. Died Unvaccinated. P.P.O. Transferred tootherV.Os. Not traced Removals. In Default. Overage when Registered. South Sub-Disirict 916 330 9 371 34 17 46 20 89 ... West „ 1849 523 6 898 71 26 11 38 275 1 North „ 686 248 8 280 19 8 10 8 104 1 3451 1101 23 1549 124 51 67 66 468 2 123 During the year 2,095 Forms Q were sent to parents, and 501 Forms K. Form Q is the form drawing' attention to the requirements of the Vaccination Acts and Form K refers to cases in default. 1,071 names were sent on the H lists to Public Vaccinators to be visited. 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, 1933:— Table XLIX. 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 100 9 109 8 No. 2 Area 159 15 174 9 No. 3 Area 69 4 73 6 No. 4 Area 100 18 118 4 No. 5 Area 128 27 155 19 Addington 8 1 9 — Queen's Road Homes 5 — 5 — Mayday Road Hospital — — — — Children's Homes — 1 1 — Shirley Schools — — — — 569 75 644 46 124 SECTION VI. PREVENTION AND CONTROL OF TUBERCULOSIS. The Tuberculosis Clinic is situated at 13, Katharine Street. The premises are not suitable, being cramped and noisy. Sessions are held daily in the mornings and afternoons except on Monday mornings and Thursday afternoons. An evening session is held on Tuesdays. The Clinic is primarily a diagnostic and advisory centre. 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. I am indebted to Dr. J. C. McMillan, the Assistant M.O.H. for Tuberculosis, for the greater part of this section of the report. An efficient Clinic dealing with Tuberculosis should have an X-ray plant on the premises. Although the facilities for obtaining X-ray reports and films are good, the medical officer in charge of the Clinic loses the great advantage of making his own screen observations and taking his X-rays. The patients also are put to some inconvenience by the present arrangements. For the carrying out of Collapse Therapy X-ray control is absolutely essential, consequently the Clinic is unable to undertake artificial Pneumothorax refills. As this treatment is being used at the Cheam Sanatorium it would be advantageous to the patients if they could, on their discharge from the Sanatorium, obtain necessary refills in Croydon, instead of. as at present, having to go up to London or to Cheam. Undue Fear of Tuberculosis. One French authority on Tuberculosis published an article designed to put the public on its guard against undue fear of the disease. He states that by the number of placards urging the avoidance of contagion by refraining from spitting in public places a veritable psychosis has been created in the minds of persons who were predisposed. The fear of tuberculosis contagion haunts them. They take ridiculous precautions. As soon as they cough they consult a doctor, demanding that they be examined and radiographed, or they use self-medication recommended by advertisements in the daily press. They go from one doctor to another until they finally encounter a charlatan who exploits their credulity. Another class are those who have a tuberculous patient in the family. They go to extremes in protecting the patient, 125 ing him, whereas he may not be contagious at all. These overworried persons communicate their phobia to those about them. In workrooms they demand the dismissal of an employee who coughs. He points out that the worst part of the situation is that persons who are actually tuberculous, feeling themselves the object of surveillance, seek to conceal their condition for fear of losing their employment; neglect to visit a Dispensary for fear of being observed there, and fail to take proper care of themselves. He stresses the point that contagion is rare between adults, except in certain circumstances, and the need of establishing immunity in childhood. Notification of Tuberculosis. Two hundred and thirty-three cases of Pulmonary tuberculosis and 33 of Non-Pulmonary tuberculosis were notified on Form A (primary notifications), of these 116 males and 117 females were pulmonary cases, 18 males and 15 females non-pulmonary. In addition 63 pulmonary cases and 17 non-pulmonary came to our notice as new cases otherwise than by notification. Notification in Previous Years. Table L. Pulmonary NonPulmonary 1926 244 140 1927 231 97 1928 314 75 1929 250 68 1930 262 54 1931 282 48 1932 254 50 1933 233 33 The total number of new cases of tuberculosis coming to the knowledge of the Medical Officer of Health during 1933 by notification or otherwise, was 346, as compared with 369 in 1932, 412 in 1931, 387 in 1930, 390 in 1929 and 449 in 1928. 296 of these cases were Pulmonary Tuberculosis. 137 in males and 159 in females. There were 28 fewer cases of Pulmonary Tuberculosis in males, and 25 more in females than in 1932. 126 There were 25 cases of Non-Pulmonary Tuberculosis among children under 15 years as compared with 28 in 1932. The number of cases in adults was 25 as compared with 42 in 1932. Of the cases notified in 1933 28 males and 20 females died from the pulmonary form of the disease during the year, equal to 20.6% of those notified, and 1 male and 4 females from the non-pulmonary. The incidence rate of Tuberculosis of all forms was 1.44 per 1,000 of the population, for Pulmonary Tuberculosis 1.23 and for Non-Pulmonary 0.21 per 1,000 population. The Notification rate was 1.11 per 1,000. Public Health (Tuberculosis) Regulations 1930. Summary of Notifications during the period from the 1st January, 1933, to the 31st December, 1933:— Table LI. Age periods Notifications on Form A. No. of Primary 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 ... 2 ... 2 16 23 19 25 17 8 4 116 136 „ Females ... ... ... 3 16 31 29 21 11 2 4 117 137 Non-pulmonary Males ... 2 5 2 3 2 1 1 1 ... 1 18 20 „ „ Females ... 1 4 ... 3 2 2 1 2 ... ... 15 17 Table LII. New cases of Tuberculosis coming to the knowledge of the Medical Officer of Health during the period from the 1st January, 1933, to the 31st December, 1933, otherwise than by formal notification. Age periods 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 Cases Pulmonary Males ... ... ... ... ... 4 6 6 3 1 1 21 „ Females 1 ... ... ... 5 14 11 4 4 2 1 42 Non-Pulmonary Males 3 1 3 1 ... ... ... 1 ... 1 ... 10 „ „ Females ... ... 2 1 ... 2 ... ... ... 2 ... 7 127 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 from local Registrars 8 7 Transferable Deaths from Registrar General 2 4 "Transfers" from other areas (other than transferable deaths) 46 5 Posthumous notifications 2 ... Other Sources—Form I. 5 1 Notification Register. Number of cases of Tuberculosis remaining on the Notification register on the 31st December, 1933:— Table LIII. PULMONARY NON-PULMONARY Total Cases Males Females Totsl Males Females Total 599 540 1,139 155 154 309 1,448 Number of cases removed from the Registers during the year and the reasons for such removal. Pulmonary. Non-Pulmonary. Total Cases. Males. Females. Total. Males. Females. Total. 1. Withdrawal of Notification 6 9 15 4 4 8 23 2. Recovery from the Disease 29 34 63 34 33 67 130 3. Death 94 74 168 15 11 26 194 128 Housing Statistics of Patients. Table LIV. 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 22 8 7 37 15 years and over 460 104 372 936 482 112 379 973 Number of Non-Pulmonary cases: Under 15 years 39 42 34 115 15 years and over 40 22 39 101 79 64 73 216 Totals 561 176 452 1,189 The above table gives a summary of the housing conditions found in notified cases. It is seen that 49.5% of the pulmonary cases and 36.5% of the non-pulmonary cases were occupying a separate bedroom. In 38.9% of the pulmonary and 33.8% of the non-pulmonary the sleeping arrangements were not satisfactory inasmuch as the patient did not have a separate bed. 52 patients, who are definite cases of pulmonary tuberculosis on the Dispensary Register at the end of 1933, resided in houses built and let by the Corporation. 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 162 deaths during 1933, 29 (17.9%) were either not notified at all or only notified within a month prior to death. In 1932 this figure was 25 or 17.3%. Of these, 11 were not notified during life; 5 of whom were cases of fulminating or complicated cases of Tuberculosis; and 6 cases were certified by the Coroner. 129 Early notification is of great importance from both the preventive and curative sides of Tuberculosis work. It is unfortunate that in some cases its onset is so insidious that it passes unnoticed until considerable damage has been done; whilst in others, the patient in an endeavour to remain at work, and in the hope that the trouble will pass off, ignores symptoms until after the stage of curability has passed. The periodic medical examination of the whole population, as is now applied to public Elementary School children would, in the case of this one disease alone, probably be an economic asset. The success of a Tuberculosis Scheme may be judged on the number of persons dying from Tuberculosis without having been notified, or only notified shortly before death. The Croydon figure is a fairly satisfactory one but it can be improved upon. In a certain number of predisposed persons periodic medical examination might lead to apprehension. The early detection of disease is, nevertheless, of paramount importance. In 27.7 % 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 54.5%. In other words, out of a total of 22 deaths, 12 were not notified during life; only 2 of these 12 cases died at home, one of whom was certified by a Coroner. The other 10 cases died in Hospital. Of the total deaths from Tuberculosis of all forms, 23 or 12.5%, were not notified prior to death, compared with 12% in 1932. Interval Between Notification and Death From Pulmonary Tuberculosis in Cases Dying in 1933. Table LV Not Notified Under 1 week 1-2 weeks 2-4 weeks 1-2 months 2-3 months 3-6 months 6-12 months 11 6 6 6 9 6 12 24 One Year Two Years Three Years Four Years Five Years Six Years Seven Years Eight years and over 32 14 11 10 4 1 2 8 130 Ages at Death from Pulmonary Tuberculosis. Table LVI. Year. 0—5 5—15 15—25 25—45 45—65 Over 65 Total 1921 ... 2 40 66 36 5 149 1925 ... 4 30 60 44 10 148 1926 ... ... 34 81 45 9 169 1827 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 1932 1 1 39 65 32 6 144 1933 ... 1 34 82 41 4 162 The most fatal period is between 25 and 45 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, a.nd 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 1933 the death-rate from all forms of Tuberculosis was 0.77 per 1,000 population „ „ Pulmonary Tuberculosis 0.68 „ „ „ Non-Pulmonary Tuberculosis 0.09 „ Similar figures for 1932 were 0.7; 0.61 and 0.093. Deaths from Non-Pulmonary Tuberculosis. During 1933, 22 deaths were certified to be due to Non-Pulmonary Tuberculosis, compared with 22 in 1932; 19 in 1931; 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 6 4 10 Tb. Peritonitis 0 2 2 Tb. Kidneys, Bladder, etc. 3 0 3 Tb. Intestines 0 3 3 Tb. Spine 1 0 1 Miliary and General Tb. 1 2 3 11 11 22 131 Table LVIII. 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 239,950. The death rate for the whole Borough was 0.77. Table LVII. The following were the Wards from which new patients came:— Ward. Density of Population persons per acre. Pulmonary Non-Pulmonary Total Incidence Rate per 1000 Death Kate per 1000 Upper Norwood 20.1 31 3 34 1.5 0.62 Norbury 29.2 21 1 22 1.4 0.62 West Thornton 42.2 22 3 25 1.2 0.14 Ben ham Manor 49.8 14 2 16 1.0 0.49 Thornton Heath 50.5 29 4 33 2.1 1.09 South Norwood 28.8 21 3 24 1.4 0.62 Woodside 36.7 19 5 24 1.5 1.01 East 9.6 15 2 17 0.9 0.44 Addiscombe 48.8 14 3 17 1.2 1.11 Whitehorse Manor 62.9 23 7 30 1.8 1.30 Broad Green 68.9 20 3 23 1.5 0.79 Central 33.3 14 2 16 1.3 0.41 Waddon 22.2 31 5 36 1.6 0.87 South 12.5 18 5 23 1.5 0.75 Addington 0.8 3 1 4 1.4 ... No fixed abode ... 1 1 2 ... ... 296 50 346 1.4 0.77 The Wards showing the highest incidence of new patients in 1933 were: Thornton Heath (2.1), and Whitehorse Manor (1.8). The highest death-rates were in Whitehorse Manor (1.30) and Addiscombe (1.11). With the relatively small figures available, these rates are subject to wide annual variations. 132 TABLE LVIII. TUBERCULOSIS. (Summary of Notifications and Deaths at various age periods). Age periods. 1933 Population at age period, (estimated) Pulmonary, Non-Pulmonary. New Cases. All Cases. New Cases. All Cases. Number. Incidence Rate. Deaths. Death Rate (based on 1933 figures). Number. Incidence Rate. Deaths. Death Kate (based on 1933 est. figs.) M F M F M F M F M F M F M F M F M F Under one year 2124 1952 ... 1 ... 0.51 ... ... ... ... 3 1.41 ... 3 1 1.41 0.51 1— 5 years 6882 7242 2 ... 0.29 ... ... ... ... ... 3 1 0.44 0.14 2 1 0.29 0.14 5—10 „ 11243 10348 ... ... ... ... ... ... ... ... 8 6 0.71 0.58 1 3 0.09 0.29 10—15 „ 11899 11326 2 3 0.17 0.26 ... 1 ... 0.09 3 1 0.25 0.09 1 ... 0.08 ... 15-20 „ 9789 10562 16 21 1.64 1.99 5 7 0.51 0.66 3 3 0.31 0.28 1 „ 0.10 ... 20—25 „ 7596 9832 27 45 3.55 4.58 9 13 1.18 1.32 2 4 0.26 0.41 ... 1 ... 0.10 25—35 „ 15537 20456 25 40 1.61 1.95 22 23 1.42 1.12 1 2 0.06 0.10 ... 1 ... 0.06 35—45 „ 17303 21083 31 25 1.79 1.19 20 17 1.16 0.81 2 1 0.12 0.05 1 1 0.06 0.05 45-55 „ 13816 15861 20 15 1.45 0 94 20 8 1.45 0.50 1 2 0.07 0.13 ... ... ... 55—65 „ 8241 10061 9 4 1.09 0.40 12 1 1.46 0.10 1 2 0.12 0.19 2 3 0.24 0.29 65 and upwards 6302 10495 5 5 0.79 0.48 2 2 0.32 0.18 1 ... 0.16 ... ... ... ... ... Totals 110732 129218 137 159 1.24 1.23 90 72 0.81 0.56 28 22 0.25 0.17 11 11 0.10 0.09 In the above table the death rate is based upon the total deaths in 1933, and not on deaths in New Cases only. 133 Pulmonary Tuberculosis. In 1933 there were fewer deaths from Pulmonary Tuberculosis up to the 25th year of life than in 1932, but in the next five years there were many more deaths. The age group 25—30 had the greatest number of deaths, greater in fact than in any other age group. From the 30th year onwards there was a gradual fall in the number of deaths, the number being greater than in the preceding year. With regard to the sexes, in females the highest peak was reached in the 20-25 age group whereas in males it was in the 25-30 age group. After the 40th year the male deaths exceed those in females. This is probably connected with the fact that women lead a more sheltered existence than men in the later years of life. The number of new cases of Pulmonary Tuberculosis in 1933 was greatest in the age group 20-25 years, whereas in 1932 the greatest number was in the age group 25-35 years. In the other age groups the number of new cases was approximately the same as in 1932. 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 35 years there was a greater number of new cases among women but after 35 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 but not so marked as in 1932. This year the peak of new cases was in the 20-25 age group, compared with the peak in deaths being in the age group 25-35 years in 1932. The figures indicate that Pulmonary tuberculosis is a rare disease in the first ten years of life. Non-Pulmonary Tuberculosis. Non-pulmonary Tuberculosis shows its highest incidence under the 20th year of life; the greatest number of cases occurring, as in 1932, in the 5-10 years group. 50% of the deaths occurred under the age of 10 years. 134 Table LIX. The diagnoses of the new cases entered in Notification Register during 1933 were as follows:— Male. Female. Hip 4 1 Spine 3 2 Left Ankle 1 — Knee 5 — Finger, Skin and Left Cheek 1 — Right Great Toe — 1 Spine and Urinary Tract — 1 Left Shoulder — 1 Chest and Toe — 1 Abdomen — 1 Ovaries and Tubes — 1 Peritoneum — 2 Peritoneum and Intestines — 1 Genito Urinary 1 — Urinary Tract — 1 Epididymis 1 — Skin — 1 Meninges 5 4 Kidney 2 — Miliary 2 1 Ilium — 1 Glands 3 2 28 22 CLASSIFICATION OF NEW PATIENTS. Pulmonary Tuberculosis. During 1933, 190 new patients were examined at the Clinic and were found to be in the undermentioned stages of the disease on the first examination:— T.B. minus (sputum negative or absent) 65 or 34.2% T.B. plus 1 (early cases, sputum positive) 12 or 6.3% T.B. plus 2 (intermediate cases, sputum positive) 84 or 44.2% T.B. plus 3 (advanced cases, sputum positive) 29 or 15.3% 190 or 100.0% It is well known that Tuberculosis officers do not see many of the new cases in the early stages of the disease. The trouble about early diagnosis is that the disease can hardly ever be detected until it 135 has begun to produce symptoms and not always with certainty even then. The insidious onset of Pulmonary Tuberculosis and the fact that often considerable damage to the lungs is present before any definite symptoms develop makes it very difficult to detect it in its early stages. In the majority of cases, once symptoms have developed, the disease cannot be regarded as in an early stage. The initiative to seek treatment when ill rests with the patient himself, and the remedy partly lies in the education of the public as to the symptoms and common dangers of Tuberculosis and the need for securing early treatment. It is unfortunate that 59.4% of the new cases were more or less advanced in the disease. Non-Pulmonary Tuberculosis. There were 23 cases examined at the Clinic and found to have Non-pulmonary Tuberculosis in the following forms:— Bones and Joints 10 Abdominal 5 Other Organs 4 Peripheral Glands 4 23 Tables LXVI. and LXVII. summarise the condition of all patients whose records are at the Clinic at the end of 1933. These tables show that of patients who came under treatment for Pulmonary Tuberculosis before 1926, 376 adults and 103 children have been discharged as recovered. Of these all but 14 were early cases. Of the 1926 cases, 19 adults, and of the 1927 cases, 21 adults, have recovered. Of patients who first attended in 1933, 13 have been lost sight of or otherwise removed from the Clinic Register. Of the 1932 cases 38 were lost sight of. Of patients wno attended prior to 1926, 241 adults and 13 children are known to have died ; since 1926, 684 adults and 13 children are known to have died. Of patients attending for the first time in 1933 31 have died. It will be seen that in the years 1926 to 1933 there have only been 41 cases of Pulmonary Tuberculosis in children—12 of these 136 had a positive sputum, and of the latter only 3 of these are alive. It is fortunate that such cases are very rare as remarkably few ever recover. In sufferers from Non-pulmonary Tuberculosis who first attended prior to 1926, 43 adults and 555 children have been discharged as recovered, and of those first attending in 1926 and following years, 23 adults and 104 children. 13 adults and 9 children died in the pre-1926 class; 28 adults and 15 children died in the 192G and following years group. One adult and one child attending for the first time in 1933 died during the year. 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. Co-ordination with Medical Practitioners, and Other Branches of the Health Department. During the year 233 cases of suspected Tuberculosis were referred by private medical practitioners for the Tuberculosis Officer's opinion ; 91 were diagnosed as suffering from Tuberculosis and were subsequently notified. In addition, 23 children were referred by the School Medical Service, and 15 cases from the Maternity and Child Welfare section of the Public Health Department. 79.3% of all notified cases were sent for examination to the Clinic or were seen at the request of the medical attendant at the patient's home, as compared with 78.9% in 1932, 81.2% in 1931 and 72.7% in 1930. The number of reports sent in by Insurance medical practitioners on their domiciliary cases (Form G.P. 36) was 632. This is a duty laid on all Medical men accepting service under the National Health Insurance Act. Pregnancy and Tuberculosis. Women suffering from Pulmonary Tuberculosis who become pregnant are referred to the Assistant Medical Officer of Health for Obstetrics and recommended for admission to the Mayday Hospital under his care. After their confinement these patients are transferred to a sanatorium to the mutual benefit of the mother and baby. If interference with the course of pregnancy is not considered necessary or advisable and the patient requires sanatorium treatment this is arranged for a period prior to admission to the Hospital. 137 The Clinic Register of Cases. The number of cases of tuberculosis under the supervision of the Clinic at the end of the year was 942. This is equivalent to 8.93 persons per 1,000 of the population. The Clinic Register has been revised yearly during the past six years, so as to make it a correct record of the cases in the Borough who are under the supervision of the Clinic. This has necessitated a lot of work in following up old cases, some of whom had not been seen for a number of years. By this yearly revision the Register is kept a "live" one. By these means the number of persons on this register has been reduced from 1,965 on 1st January, 1928, to 963 on 31st December, 1933. During the year 141 Clinic cases died; of this number, 33 or 23.4% were seen for the first time in 1933. Examination of Sputum. This is done by the Council's Bacteriologist in the Laboratory at the Croydon General Hospital. For each 100 new cases and contacts examined at the Clinic 94 specimens of sputum were examined. The 769 examinations include a number from the Croydon General Hospital, in addition to those sent in by General Practitioners. 1933, however, shows a very slight increase in the number of examinations of sputa made for General Practitioners. It is difficult to understand why this simple test is not always made in any doubtful chest condition. The results of examinations made in 1933 are as follows:— For Clinic. For General Practitioners. For Mayday Hospital. Totals. Positive (i.e., tubercle bacilli present) 367 109 97 573 Negative (i.e., tubercle bacilli absent) 434 660 168 1,262 Total 801 769 265 1,835 138 Too much reliance should not be 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. 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. These examinations are also useful in avoiding undue delay in reaching a definite diagnosis and in assessing the progress of cases already under treatment. Without a good X-ray plate, properly interpreted, suspected tuberculosis can never be ruled out. Ordinary physical examination can find tuberculosis, but it cannot, except rarely, find early tuberculosis. It cannot demonstrate pathological changes and cannot follow accurately the progress of disease or of healing. X-ray plates, however, must be well made and accurately interpreted or they become a source of diagnostic errors. 258 X-ray examinations were made during the year. This is equivalent to 30.4 for every TOO new cases and contacts seen, and compares with a rate of 22.6 for every 100 new cases and contacts seen in 1932, and 21.4 per 100 new cases and contacts seen in 1931. In addition a certain number of cases who have already been examined at various Hospitals are referred to the Clinic. There were also a number of new cases examined in Mayday Hospital whose X-ray examinations are not counted. Extra Nourishment. Provision of special nourishment in the form of milk was granted to a number of selected cases for varying periods. 139 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. When convenient to be used they form a useful continuation of Sanatorium practice for a conscientious patient. INSTITUTIONAL TREATMENT. Table LX. Cases of Pulmonary Tuberculosis Treated in Institutions, 1933. In at beginning of 1933 Admitted during 1933 Discharged during 1933 Died during 1933 In at end of 1933 Adults C Adults C Adults C Adults C Adults C M F M F M F M F M F Croy. Boro' San., Cheam 55 31 ... 91 77 ... 83 68 ... 20 6 ... 43 34 Mayday Hospital 16 7 ... 57 41 3 34 22 2 22 17 1 17 9 ... Grosvenor 6 2 ... 1 1 ... 6 3 ... ... ... ... 1 ... ... Burrow Hill Colony ... ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... Brompton 1 1 ... 11 4 1 9 1 ... ... 1 ... 3 3 1 Papworth 2 1 ... ... ... ... 1 1 ... ... ... ... 1 ... ... East Anglian San. ... ... 1 ... ... 1 ... ... 1 ... ... ... ... ... 1 Harpenden ... ... 1 ... ... 1 ... ... 2 ... ... ... ... ... ... Farmwood 2 ... ... ... ... ... 2 ... ... ... ... ... ... ... ... Midhurst 4 ... ... ... ... ... 4 ... ... ... ... ... ... ... ... Prior Place ... ... ... 1 ... ... ... ... ... ... ... ... 1 ... ... 86 42 3 161 123 6 139 95 6 42 24 1 66 46 2 This Table shows that, compared with last year, 35 fewer Patients were admitted to institutions during the year and 17 fewer cases remained in institutions at the end of the year. 140 Table LXI. Oases of Non-Pulmonary Tuberculosis Treated in Institutions, 1933. In on 1st Jan., 1933 Admitted during 1933 Discharged during 1933 Died during 1933 In on 31stDec., 1933 Adults c Adults c Adults c Adults c Adults c M f M f M f M f m F Mayday Hospital 2 1 2 4 6 3 5 4 3 ... 1 1 1 2 1 Royal Sea Bathing Hosp. 4 1 ... 4 2 ... 2 2 ... ... ... ... 6 1 ... St. Anthony's Hosp. 2 1 ... 1 1 ... 1 2 ... 1 ... ... 1 ... ... St. Nicholas Hosp. ... ... 2 ... ... 1 ... ... 3 ... ... ... ... ... ... Tait Convalescent Home ... ... ... ... 3 ... ... 3 ... ... ... ... ... ... ... Treloar Cripples' Hosp ... ... 1 ... ... ... ... ... 1 ... ... ... ... ... ... King George's San. 2 ... ... 2 ... ... 2 ... ... ... ... ... 2 ... ... Croydon General Hosp. ... ... ... ... 1 1 ... 1 1 ... ... ... ... ... ... Pyrford ... ... 10 ... ... 7 ... ... 7 ... ... ... ... ... 10 Heatherwood Hospital ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Heritage Craft School ... ... 1 ... ... 1 ... ... ... ... ... ... ... ... 2 Royal National Orthopaedic Hospital ... 1 ... ... 1 ... ... 1 ... ... ... ... ... 1 ... 10 4 17 11 14 13 10 13 15 1 1 1 10 4 14 The Immediate Results of Institutional Treatment. Table LXV. Form T. 145 (G) of the Ministry of Health summarises the immediate results of treatment of patients discharged from institutions during the year. From this table it is seen that among the Pulmonary cases 25.2% were classified as early cases; the percentage of early cases receiving treatment in institutions was in women, 10.5%; in men, 12.8%. 48.8% of the total cases were intermediate cases, the males showing an excess in this group—28.2% males to 20.6% females—and 25.9% were definitely advanced. Of the total Pulmonary cases treated in Institutions 78.5% were potentially infectious. 155 males, 105 females and 6 children, suffering from Pulmonary Tuberculosis, were discharged from or died in Institutions in connection with the Croydon Scheme during 1933. 141 Types of Cases Treated. In Class T.B. Minus, 20 males, 17 females and 4 children were discharged with the disease in a quiescent condition, i.e., 71.9% of the total cases in this class; 4 males and 10 females were not in a quiescent condition, 24.5%; 1 male and 1 child died, 3.5%. In Class T.B. Plus, Group I., the corresponding figures were 4 males quiescent, 40% ; 5 males and 1 female were not quiescent, 60% ; there were no deaths in this group. In Class T.B. Plus, Group II., 13 males and 5 females quiescent, 13.8% ; 46 males and 38 females not quiescent, 64.6%; and 16 males and 12 females died, 21.5%. In Class T.B. Plus, Group III., or advanced group, 1 female was discharged quiescent, 1.4%; 21 males and 9 females and 1 child not quiescent, 44.9%; and 25 males and 12 females died, 53.6%. Taking all groups together, 24% of cases were discharged aquiescent ; 50.7% as not quiescent; and 25.1% died. An increase is recorded in the percentage of infectious cases, mostly advanced cases, dying in institutions. Prom the public health point of view this is to be desired as it keeps these patients away from their homes at a time when they are most infectious and most dangerous to those with whom they would normally come into contact. This factor, in conjunction with the removal of the strain and worry of nursing these cases at home, should help to reduce the incidence of new cases among the contacts. 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. Non-Pulmonary Tuberculosis.—32 patients were discharged during the year and 56.2% of these were quiescent. 143 Tuberculosis deaths in dream Sanatorium and Mayday Hospital during 1933, according to sex and stage of the disease:— Classification. CHEAM. MAYDAY. Males. Females. Males. Females. T.B. minus 1 — — 1 T.B. plus 1 Nil T.B. plus 2 9 3 7 8 T.B. plus 3 10 3 15 9 Total 20 6 22 18 General Observations on the Results of Treatment. 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, but the occupation must be governed by the medical needs. The greater number of 'Tubercular persons are unable to compete on equal footing with healthy persons. If this is remembered and the principle of subsidization of these patients accepted, they can be made productive units of industry, with benefit to themselves and the community. Subsidization of Blind persons has been universally approved, and it is difficult to understand the non-recognition of the principle in another Class of handicapped persons. Colonies for Tubercular patients, such as Papworth, or Preston Hall, are sensible expositions of this and are carrying on wonderfully effective work, which points the, way along which any expansion of Anti-Tuberculosis campaigns should go. Sickness benefit under the National Health Insurance Act could serve as subsidy for tubercular persons 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. It is gradually becoming recognised that Sanatorium treatment of Pulmonary Tuberculosis requires to be supplemented by other methods of treatment. Eventually it will probably be necessary to have a Surgeon who has specialised in thoracic surgery an a Consultant on the staff of every sanatorium. 143 In this connection it is interesting to note that many Authorities are of the opinion that most of the sanatoria in this country are too small, and that it would be better in the interests of the patients to have much larger institutions, with say 250 to 1,000 beds. Such institutions could more easily be provided with specialists in the different branches of the work and be equipped to carry out every form of treatment and investigation, and would possibly be more efficient without increasing expenditure. Such proposals would necessitate various local Authorities combining. This method is at present in force in Wales where the treatment of Tuberculosis for the whole of the Principality is under one Authority. It, however, causes some dislocation of co-ordination with the rest of Public Health work and in so doing is disadvantageous. The Medical Officer of Health and the Tuberculosis Officer visited the institutions belonging to other authorities in which Croydon patients were being treated (in addition to weekly visits to the Borough Sanatorium at Cheam by the Medical Officer of Health). In addition, the Tuberculosis Officer paid 45 visits to Mayday Hospital, in a consultative capacity, and there examined 106 patients. The Tuberculosis Clinic and Home Visiting. Table LXIII. gives a summary of the work done in connection with the Clinic. 466 new cases were examined during the year: this is equal to 253.2 for each 100 deaths from the disease. 197, or 42.3 for each 100 deaths, were found to be definitely tuberculous. The contacts of definite cases are urged to attend the Clinic for examination (and subsequent supervision). This is an important preventive measure. During the year 383 contacts were examined, equal to 208 for each 100 deaths, compared with 464 in 1932, or 279.5 per 100 deaths. Of these, 14 were considered to be tuberculous. This is equal to a tuberculosis rate per 1,000 contacts of 36.5, compared with 1.44 per 1,000 of the general population. In 210 adult contacts examined the tuberculosis rate per 1,000 contacts was 66.6. Included in the 14 contacts found to be tuberculous are 4 who had been under observation from previous years. 144 The total number of attendances at the Clinic was 5,596. The Tuberculosis Officer paid 207 home visits, and the district health visitors 4,085 visits for Clinic purposes. In addition, the health visitors made 289 primary visits for the purpose of the Notification Register. Patients requiring home nursing or surgical dressings are attended to by nurses from the Croydon Nursing Service, by arrangement with that organisation, and 468 such visits were made during the year. The number of contacts examined and the number of patients visited in their homes by the Tuberculosis Officer shew a decided decrease below those for 1932. This year shews a considerable falling off in both these branches of the Clinic'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 preventive and play an important role in any Tuberculosis scheme. SUMMARY OF CLINIC STATISTICS FOR 1933. No. of persons on Clinic Register, January 1st, 1933 1,028 „ Notified Cases examined for the first time 50 ,, Cases sent for an opinion 304 ,, First attendances, including 41 transfers in 890 ,, Consultations of T.O. with private practitioners 30 ,, Visits paid by T.O. to homes of patients 207 ,, Visits paid by T.O. to Mayday Hospital 45 ,, Patients examined by T.O. at Mayday Hospital 106 ,, Visits paid to homes of patients by Health Visitors & Nurses 4,374 ,, Attendances of patients at the Clinic— Men 1,643 Women 2,448 Children 1,505 Total 5,596 No. of patients under Domiciliary Treatment at end of year— Pulmonary 208 Non-Pulmonary 5 Total 213 No. of reports received from Panel Practitioners (G.P.36) 632 ,, report forms sent to Panel Practitioners (G.P.36) 869 ,, reports received from Panel Practitioners on forms G.P.17 and 35 Nil ,, X-rays taken 258 ,, reports made to Ministry of Pensions by the T.O. on general progress of Tuberculous Discharged Ex-Service men 13 ,, cases referred for "Light" Treatment 4 ,, cases referred to Orthopaedic Clinic ,, cases receiving extra nourishment at end of year 46 145 PULMONARY TUBERCULOSIS. Table LXII. Shewing the Condition at the end of 1933 of cases discharged from Sanatoria during the years indicated. 1929. 1930. 1931. 1932. 1933. Totals. T.b. t.b. + T.B. T.B. + t. b. t.B. + t.B. T.B. + t.b. t.B. + t.b. t.b. + Dead 2 75=71.4% 5 70=65.4% 2 56=42.7% 1 36= 28.3% 1 15=16.1% 11 252= 44.7% 63.6% 56.4% 36.0% 22.8% 11.8% 36.9% Working or Fit for Work 13 10=9.5% 20 18=16.3% 24 32=24.4% 31 43=33.8% 34 41=44.1% 122 144=25.6% 19.0% 28.6% 34.8% 45.6% 55.1% 37.3% Not able to Work 1 20=19.0% 1 19=17.8% 4 43= 32.8% 3 48 = 37.8% 8 37= 39.8% 17 167= 29.6% 17.4% 15.0% 29.2% 31.4% 33.1% 25.8% Left Dislrict 5 27 6 22 8 13 7 18 6 13 32 93 21 132 32 129 38 144 42 145 49 106 182 656 146 Of the cases whose records are at the Clinic, it will be seen that of the total number that received sanatorium treatment during the past five years only 37.3% 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 25.6% or just over a quarter are working or fit for work. 656, or 78.2% of the total cases discharged, were T.B.+ cases; 125, or 14.9% of the total cases discharged, have removed from the Borough, and as we have no information about their condition at the end of 1933 they have been ignored in working out the above percentages. From consideration of the above Table and similar reports that have been obtained in previous years, it would appear that the time is not far distant when it might be advisable for another Royal Commission to be held, to assess the value of present Tuberculosis schemes and also to consider whether any alterations could be made which would lead to greater success. Tuberculosis Care Committee Report. During the year 1933 more use than formerly was made of the facilities afforded by the Tuberculosis Care Committee. Assistance and advice are particularly valuable at early stages of disability, for not only is the patient suffering from the shock of finding himself Tubercular but he has to grapple with a collection of difficult and unfamiliar problems at a time when he is mentally and physically upset. There are domestic problems, such as keeping the home together and the disposal of children when the patient is away; financial problems, such as the continuance of building society instalments and insurance premiums, and the like. Some require direct financial assistance, but there are a number of difficulties soluble by the patients themselves if they only knew the right course of action. It is surprising how ignorant many people are in these matters. Even when patients have been put into touch with the proper quarters, there may be gaps to be tided over and arrears to be made up. There are many opportunities for helping patients at this stage by sympathetic advice and assistance, and if is satisfactory to note how knowledge of the Committee's work is filtering through the Borough. As a tangible result of their efforts, 974 interviews involving advice and assistance took place during the year, and 80 families were helped financially. Financial inquiries numbered over 175, and £300 was disbursed. 147 Dental Treatment. Considering the difficulties under which dental treatment is carried out, and the fact that some patients when called up do not feel fit, and treatment has to be postponed for sometimes a week or even longer, the statistics for the year are very gratifying. Patients Referred From Tuberculosis Dispensary. Males. Females. Total. Attendances 34 57 91 Extractions 48 51 99 Fillings 3 12 15 Dressings — 4 4 Scalings 1 10 11 Denture Dressings 11 13 24 Dentures Fitted 3 8 11 No. of cases referred—14. £l 2s. 6d was received from patients for treatment. Table LXIII. (A) Return showing the work of the Dispensary. Diagnosis. Pulmonary. Non-Pulmonary. Total. Grand 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 90 80 1 3 7 8 7 1 97 88 8 4 197 (b) Diagnosis not completed - - - - - - - - 7 4 2 1 14 (c) Non-tuberculous - - - - - - - - 64 99 43 49 255 B.—Contacts examined during year:— (a) Definitely tuberculous 4 10 - - - - - - 4 10 - - 14 (b) Diagnosis not completed - - - - - — - - 1 5 - 1 7 (c) Non-tuberculous - - - - - - - - 69 121 86 86 362 C.—Cases written off the Dispensary Register as (a) Recovered 18 16 1 5 5 4 17 18 23 20 18 23 84 (b) Non-tuberculous (including any such cases previously diagnosed and entered on the Dispensary Register as tuberculous) 139 231 135 141 646 D.—Number of Cases on Dispensary Register on December 31st:— (a) Definitely tuberculous 400 324 13 22 34 41 62 46 434 365 75 68 942 (b) Diagnosis not completed - - - - - - - - 8 9 2 2 21 148 1. Number of cases on Dispensary Register on January 1st 1,028 2. Number of cases transferred from other areas and cases returned after discharge under Head 3 in previous years 59 3. Number of cases transferred to other areas, cases not desiring further assistance under the scheme, and cases "lost sight of" 102 4. Cases written off during the year as Dead (all causes) 141 5. Number of attendances at the Dispensary (including Contacts) 5,596 6. Number of Insured Persons under Domiciliary Treatment on the 31st December 213 7. Number of consultations with medical practitioners:— 8. Number of visits by Tuberculosis Officers to homes (including personal consultations) 207 (a) Personal 30 10. (b) Other 570 Number of:— 9. Number of visits by Nurses or Health Visitors to homes for Dispensary purposes 4,085 (a) Specimens of sputum, etc., examined 801 (b) X-ray examinations made in connection with Dispensary work 258 11. Number of "Recovered" cases restored to Dispensary Register, and included in A (a) and A (b) above 1 12. Number of "T.B. plus" cases on Dispensary Register on 31st December 486 (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 (C) Number of beds available for the treatment of Tuberculosis on the 31st December In Institutions belonging to the Council Name of Institution. For Pulmonary Cases For Non-Pulmonary Cases Total. Adults Children under 15 Adults Children under 15 Croydon Borough Sanatorium, North Cheam, Surrey 93 ... ... ... 93 Mayday Hospital, Mayday Road, Thornton Heath Beds reserved for used for P ulmonary tients, as Tuberculosi s cases are or Non-Pul monary parequired. 64 149 (d) 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 - 7 4 - 3 Adult females — 7 7 — — Children — 2 2 — — Total — 16 13 — 3 Number of definitely tuberculous patients admitted for treatment: Adult males 96 138 118 43 73 Adult females 46 120 91 25 50 Children 20 17 19 2 16 Total 162 275 228 70 139 Grand Total 162 291 241 70 142 It will be seen that only 275 definitely Tubercular patients have been admitted to institutions during the year, compared with 357 during 1932. The difference is not so great as would appear, as in the previous year if a case was transferred from one institution 'to another it was counted as a new admission, whereas this year such cases were not counted as fresh admissions. For the same reason the difference in discharges appears greater than is actually the case. In spite of this new method of recording fewer cases received institutional treatment than in 1932. Table LXIV. Return showing the results of observation 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 1 1 - 1 1 - - - - - - - 2 2 - Non-tuberculous 2 1 1 — 4 1 - - - - - - 2 5 2 Doubtful - - - - - - - - - - - - - - - Totals 3 2 1 1 5 1 - - - - - - 4 7 2 150 LXV. 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. Classification on admission to the Institution. Condition at time of discharge. Duration of Residential Treatment in the Institution. Under 3 months. 3-6 months. 6-12 months. More than 12 months. Totals. Grand Totals M. F. Ch. M. F. Ch. M. F. Ch. M. F. Ch. M. F. Ch Class T.B. minus. Quiescent 3 2 1 9 12 - 8 3 2 — - 1 20 17 4 41 Not quiescent - 5 - 1 2 - 2 3 - 1 - - 4 10 - 14 Died in Institution 1 — 1 - - - - - - - - - 1 — 1 2 Class T.B. plus Group I. Quiescent - - - 2 - - 1 - - 1 - - 4 - - 4 Not quiescent - - - 2 - - 2 1 - 1 - - 5 1 - 6 Died in Institution - - - - - - - - - - - - - - - - Class T.B. plus Group II. Quiescent 1 1 - 5 1 - 5 2 - 2 1 - 13 5 - 18 Not quiescent 16 10 15 13 - 5 9 - 10 6 46 38 - 84 Died in Institution 8 6 — 6 1 — 1 2 - 1 3 — 16 12 - 28 Class T.B. plus Group III. Quiescent - - - - 1 - - - - - - - - 1 — 1 Not quiescent 4 3 - 9 2 - 8 3 - - 1 1 21 9 1 31 Died in Institution 16 5 — 1 3 — 8 4 - — — — 25 12 - 37 Totals (pulmonary) 49 32 2 50 35 — 40 27 2 16 11 2 155 105 6 266 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 2 - - 1 1 1 4 2 2 9 13 Not quiescent 1 2 - - - - - - - - 1 2 1 3 2 6 Died in Institution - - - - - - 1 - - - — - 1 - - 1 Abdominal. Quiescent - - - 1 1 - - - - - - - 1 1 - 2 Not quiescent - 1 - - - - - 1 - - - - - 2 - 2 Died in Institution - - - - - - - - - - - - - 1 - 1 Other Organs. Quiescent - - - - - - - - - - - - - - - - Not quiescent - - - - 1 - 1 1 - - - - 1 2 - 3 Died in Institution - - 1 - - - - - - - - - - - 1 1 Peripheral glands. Quiescent - - - - - - - - 2 - - 1 — - 3 3 Not quiescent - - - - - - - - - - - - - — - - Died in Institution - - - - - - - - - - - - — - - - Totals (non-pulmonary) 1 3 3 2 4 2 2 2 3 1 2 7 6 11 15 32 151 152 TABLE LXYI. 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 1932 1933. Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Class T.B. minus Class T.B. plus Group 1 Group 2 Group 3 Total (ClassT.B. plus) Group 1 Group 2 Group 3 Total (ClassT.B. plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 Group 2 Group 3 Total (Class T.B. plus) Group 1 Group 2 Group 3 Total (ClassT.B. plus) Group 1 Group 2 Group 3 Total (ClassT.B. plus) (a) Remaining on Dispensary Register on December 31st. Disease Arrested Adults M 7 4 3 1 8 1 2 3 — 5 1 5 2 — 7 4 1 5 — 6 7 4 4 — 8 13 3 4 — 7 2 1 - 1 — — — — — — - - - - F 10 8 7 — 15 3 — 1 — 1 2 - 2 — 2 15 3 1 — 4 9 2 1 — 3 15 — 4 — 4 6 — — - — — — — — — — — — — — Children 4 - - - - - - - - - - - - - - 1 - - - - 3 - 1 - 1 1 - - - - - - - - - - - - - - - - - - - Disease not Arrested Adults M — 14 15 3 32 — 3 2 — 5 1 4 1 — 5 1 6 13 1 20 2 3 10 1 14 6 4 15 2 21 12 4 28 4 36 15 9 45 6 60 24 8 33 8 49 F 1 7 9 3 19 — — 3 — 3 — 1 4 — 5 1 1 3 1 5 1 1 8 — 9 3 1 15 1 17 12 1 22 1 24 23 4 21 4 29 29 3 34 4 41 Children - - - - - - - - - - - - - - - - - - - - - - - - - 6 - - - - 5 - - - - 3 1 - 1 2 3 — — — — Condition not ascertained during the year 1 — 1 2 3 1 1 1 - 2 1 — — — — 2 — — — — 3 1 1 — 2 4 2 3 — 5 8 — 1 - 1 — — 3 - 3 — — — — — Total on Dispensary Register at 31st December 23 33 37 9 79 5 6 10 - 16 5 10 9 — 19 24 11 22 2 35 26 11 25 1 37 48 10 41 3 54 45 5 52 5 62 41 14 69 11 94 56 11 67 12 90 (b) Not now on Dispensary Register and reasons for removal therefrom. Adults Discharged as Recovered M 176 23 5 1 29 6 6 1 — 7 7 6 - - 6 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - F 154 9 6 2 17 5 1 — — 1 6 2 — — 2 5 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Children 102 1 - - 1 - - - - - 2 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -ost sight of, or otherwise removed from Dispensary Register 218 42 44 8 94 31 17 28 7 52 18 19 16 1 36 33 13 15 - 28 33 5 26 — 31 22 10 27 6 43 15 3 24 6 33 17 — 20 1 21 4 — 9 — 9 Adults Dead M 19 27 46 49 122 4 23 26 12 61 2 10 33 8 51 1 4 27 7 38 3 3 38 16 57 5 — 30 11 41 5 2 23 30 55 1 — 17 14 31 4 — 6 9 15 F 17 5 23 55 83 9 15 19 14 48 2 3 22 15 40 3 1 29 8 38 2 2 29 9 40 5 2 18 10 30 3 1 23 22 46 7 2 18 6 26 - 1 2 8 11 Children 3 1 3 6 10 — — 1 — 1 — — 2 2 4 1 — — — — 1 — 1 — 1 — — 2 2 — — 1 — 1 1 - — — — 1 — - — — Total written off Dispensary Register 689 108 127 121 356 55 62 75 33 170 37 40 73 26 139 43 18 71 15 104 39 10 94 25 129 32 12 75 29 116 23 6 71 58 135 26 2 55 21 78 9 1 17 17 35 Grand Totals 712 141 164 130 435 60 68 85 33 186 42 50 82 26 158 67 29 93 17 139 65 21 119 26 166 80 22 116 32 170 68 11 123 63 197 b7 16 124 32 172 65 12 84 29 125 153 154 Table LXVII. 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 1932. 1933. 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 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 Bones and Joints Abdominal Other Organs Peripheral Glands Total Bones and Joints Abdominal Other Organs Peripheral Glands Total Bonse and Joints Abdominal Other Organs Peripheral Glands Total (a) Remaining on Dispensary Register on December 31st. Disease Arrested Adults M 1 — — — 1 1 — — — 1 — — 1 — 1 1 — — — 1 1 1 1 — 3 2 - 1 — 3 3 1 — — 4 1 1 — 2 4 — 1 — — 1 F — - 3 2 5 1 — — — 1 2 — — — 2 — — — — — — 4 1 5 — 3 1 3 7 1 — — 2 3 2 1 2 — 5 — 2 — — 2 Children 7 — — 5 12 1 — — 7 8 3 — — 4 7 8 — — 11 19 4 1 — 4 9 5 1 — 10 16 3 1 — 4 8 2 1 — 1 4 — — 1 1 Disease not Arrested Adults M — — 1 — 1 — - — — — — - — — — — — — — — - — — — — — 1 — - 1 1 — 1 — 2 4 — 2 — 6 4 — — 1 5 F 2 — 2 - 4 - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - 1 2 1 1 — 4 Children 1 — — — 1 — - — — - 1 — — — 1 1 — — — 1 1 — — — 1 1 — — — 1 2 — — 1 3 2 — — 3 5 3 — 1 2 6 Condition not ascertained during the year 2 — — — 2 — - - 1 1 — — — — — - — — 1 1 — 1 — — 1 — — — — — - — — 1 1 - - - - - - - - - - Total on Dispensary Register at 31st December 13 — 6 7 26 3 — — 8 11 6 — 1 4 11 10 — — 12 22 6 3 5 5 19 9 5 2 13 29 10 2 1 8 21 12 3 4 6 25 9 4 2 4 19 Transferred to Pulmonary 1 - - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (b) Not now on Dispensary Register and reasons for removal therefrom. Discharged as Recovered Adults M 7 — 4 2 13 3 — — — 3 2 1 — 1 4 1 - - - 1 - - - - - - - - - - - - - - - - - - - - - - - - - F 14 5 4 7 30 1 — — 4 9 1 1 — 3 5 - — — 3 3 1 - - - - - - - - - - - - - - - - - - - - - - - - Children 36 4 5 510 555 5 3 2 48 58 1 1 — 29 31 — — — 10 10 1 — 1 1 3 — — — 2 2 — — — — — — — — — — — — — — - Lost sight of, or otherwise removed from Dispensary Register 19 10 10 133 172 4 6 4 25 39 6 3 2 20 31 4 1 - 6 11 4 — 3 3 10 4 - 1 3 8 3 2 1 2 8 3 1 — 1 5 1 — 1 — 2 Dead Adults M 3 1 3 1 8 2 - 1 1 4 2 - 1 - 3 2 1 1 - 4 1 - - - 1 - - - - - - - 1 - 1 2 - 1 - 3 - - - - - F 3 — 1 1 5 1 — — 1 2 — 1 — — 1 1 — 2 — 3 — 1 — — 1 1 - 1 — 2 — 2 — — 2 — — — — — — 1 — - 1 Children 5 1 1 2 9 — 2 1 3 6 — — 1 - 1 2 2 1 1 6 - - - - - - 1 - - - - - - - - - - - - - - - 1 - 1 Total written off Dispensary Register 87 21 28 656 792 16 11 8 82 117 12 7 4 53 76 10 4 4 20 38 7 1 4 5 17 5 1 2 5 13 3 4 2 2 11 5 1 1 1 8 1 1 2 - 4 Grand Totals of (a) and(b)(excluding those transferred to Pulmonary). 100 21 34 663 818 19 11 8 90 128 18 7 5 57 87 20 4 4 32 60 13 4 9 10 36 14 . 6 4 18 42 13 6 3 10 32 17 4 5 7 33 10 5 4 4 23 155 CHEAM SANATORIUM. Table LXVIII. Authority. In-patients on Jan 1st, 1933 Admitted during year 1933. Discharged during year 1933. including deaths * In on Jan. 1st 1934 Died during year 1933 Croydon c.B M F M F M F M F M F 55 31 91 79 103 76 43 34 20 6 55 31 91 79 103 76 43 34 20 6 No. of Artificial Pneumothorax cases begun 23 No. of Refills given 611 No. of X-ray Screenings 570 No. of Films taken 105 No. of Sputum tests 923 No. of Gas Replacements 4 Immediate Results of Treatment. Group Total number of cases discharged 1933. Quiescent Improved No Material Improvement. Died in institution Average duration of stay in days Discharged before completion of treatment M F M F M F M F M F M F Class T.B. Minus 13 23 6 7 6 12 ... 2 1 ... 133 ... 2 Class T.B. Plus. Group I 7 3 2 ... 5 2 ... ... 150 ... 1 „ „ „ Group II 36 23 2 ... 24 14 8 6 ... ... 218 2 3 „ „ „ Group III 39 16 ... ... 4 5 14 4 19 6 173 2 1 Observation Non T B. 2 3 ... ... ... ... ... ... ... ... ... ... ... 97 68 10 7 39 33 22 12 20 6 4 7 At the beginning of 1933 there were 86 patients in Cheam. During the year 170 were admitted and 153 discharged, whilst 26 died, thus leaving 77 patients in at the beginning of 1934. There were 9 observation cases sent in, 4 males, 5 females. Of the 4 males 2 were not Tubercular, and of the 5 females 2 were 156 not Tubercular, therefore there were 5 observations in Non-Tuberculars which are shown above, the 4 that were Tubercular are in with the Tubercular cases and are not shown as observation. Artificial Pneumothorax cases discharged but still under treatment,6 males,8 females,see above, making total discharges males 103, females 76. These 14 Artificial Pneumothorax cases only refer to cases discharged in 1933, those discharged in 1932 and still having refills have not been included. Cheam Sanatorium Dental Report. Of the patients in Cheam Sanatorium examined during the year, 77% were found to be suffering from dental disease. The number of patients who availed themselves of treatment was 41. The number of attendances totalled 363. This at first glance may seem a large number of attendances for the patients treated, but it must be realised that dental treatment for tuberculosis patients is a most difficult form of dentistry. A certain amount of the treatment time is sometimes taken up by the need of explaining dental attention. Treatment for these patients is divided into two classes (a) those cases in the acute wards suffering from toothache in which, in view of their condition, treatment is limited to the relief of pain, and (b) those in which the prognosis of the case is good. In these cases an effort is made to complete all the treatment necessary. Males. Females. Total. Number Examined 34 19 53 Referred for Treatment 27 14 41 Treated 34 19 53* Attendances 189 174 363 Extractions 123 80 203 Fillings 31 40 71 Dressings 4 7 11 Scalings and Gum Treatments 45 49 94 Denture Dressings 18 34 52 Dentures Fitted 6 9 15 * Including 12 from previous year. Sessions—36. 157 SECTION YII. 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 nostels ; the cost being apportioned among the ten participating authorities in the scheme on a basis of user. Table LXIX. Attendances at the Croydon Clinic. 1925. 1926. 1927. 1928. 1929 1930. 1931. 1932. 1933. New male patients 116 141 45 121 101 196 263 235 242a New female patients 156 192 160 158 94 171 205 241 214a Attendances, male patients 2713 2360 2643 3502 3581 5050 4923 4691 4978a Attendances, female patients 1230 1351 1417 1632 2127 3029 3271 2724 2677a a Includes 118 new cases and 1640 total attendances by patients from outside areas. Attendances of Croydon Patients at various London Hospitals under the General Scheme. 1925. 1926. 1927. 1928. 1929. 1930. 1931. 1932. 1933. New patients 138 130 132 139 131 125 139 119 134 Total attendances 2648 2767 3160 3080 3089 3150 2384 2835 2407 Of the 134 new patients in 1932, 16 had syphilis, 1 soft chancre, 46 gonorrhoea, and 71 were not suffering from venereal disease. Attendances of Patients at Venereal Diseases Clinic at the Croydon General Hospital. Authority 1928 1929 1930 1931 1932 1933. InPatients (days) OutPatients InPatients (days) OutPatients InPatients (days) OutPatients Inpatients (days) OutPatients Inpatients (days) Out- Patients InPatients (days) OutPatients. Croydon 74 3586 132 3998 ... 6159 ... 6395 159 5405 ... 5615 Surrey C.C 137 1451 46 1676 ... 1686 ... 1491 ... 1512 ... 1280 Kent C.C. 40 77 ... 11 ... 184 ... 232 ... 74 ... 87 London C.C. ... 2 ... 23 - 46 ... 72 ... 426 ... 255 Other Authori ties ... ... ... ... ... 4 ... 4 ... 19 ... 18 251 5116 178 5708 ... 8079 ... 8194 159 7436 ... 7255 Two Croydon patients were admitted to an approved hostel under the L.C.C. scheme, with an aggregate of 80 days in residence. Tests lor practitioners Tests for Clinics Pathological Examinations at London Hospitals for Croydor, Patients. 1069 642 1925. 799 542 1926. 667 540 1927. 570 716 1928. 932 924 1929. 2197 715 1930. 3198 829 1931. 1680 900 1931. 1775 855 1933. 158 159 Table LXX. Croydon Cases attending London Hospitals. Hospital Cases seen for the first time. Conditions other than Venereal Total No. of Attendances Aggregate No- of InPatient Days No. of doses of N.a.B. compounds Syphilis Gonorrhoea Soft Chancre St. Thomas's 7 27 1 40 1259 22 29 Gay's 6 10 ... 12 520 ... 60 King's College 2 2 ... 2 151 28 18 Great Ormond Street ... ... ... 10 108 ... 70 Royal Free ... 1 ... 1 15 ... ... S.London Hospital for Women ... ... ... 1 132 ... ... Whitechapel Clinic (L.C.C.) ... ... ... ... 98 ... ... St. Paul's 1 2 ... 4 119 ... 2 Westminster Hospital ... 1 ... 1 5 ... ... Children's Home, Waddon ... 2 ... ... ... 44 ... Total 16 46 1 71 2407 94 179 Table LXXI. Bacteriological Examinations carried out at London Hospitals for Croydon Patients. Hospital Detection of Spirochetes Detection of Gonococci Wassermann Re-action Other Exams. For Clinic For Priv. Prac. For Clinic For Prac. For Clinic For Prac. For Clinic For Prac Total St. Thomas's 7 ... 293 4 113 ... 40 ... 457 Great Ormond Street ... ... 4 1 29 1 15 ... 50 South Lon on Hospital for Women ... ... 25 1 ... 1 ... ... 27 Royal Free ... ... 6 ... ... ... 2 ... 8 King's College ... ... 14 ... 9 ... ... ... 23 Whitechapel Clinic, L.C.C. ... ... 32 ... 2 ... 5 ... 39 Miller Green ... ... ... ... ... 2 ... ... 2 Westminster Hospital ... ... 3 ... 1 2 1 5 12 St. Paul's ... ... 4 ... 3 ... ... ... 7 Gays Hospital 1 ... 124 981 56 391 66 386 2005 Total 8 ... 505 987 213 397 129 391 2630 160 Table LXXII Return relating to all persons who were treated at the Treatment Centre at Croydon General Hospital during the year ended the 31st December, 1933. 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 46 40 ... ... 25 24 5 2 76 66 142 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 ... ... ... 4 ... 4 ... 11 ... 1 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 4 ... ... ... ... ... ... ... 4 ... 4 „ secondary 2 ... ... ... ... ... ... ... 2 ... 2 „ latent in 1st year of infection ... ... ... ... ... ... ... ... ... ... ... „ all later stages 15 21 ... ... ... ... ... ... 15 21 36 „ congenital 6 1 ... ... ... ... ... ... 6 1 7 Soft Chancre ... ... ... ... ... ... ... ... ... ... ... Gonorrhoea, 1st year of infection ... ... ... ... 112 48 ... ... 112 48 160 „ later ... ... ... ... 4 ... ... ... 4 ... 4 Conditions other than venereal ... ... ... ... ... ... 70 127 70 127 197 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 6 7 ... ... 17 9 6 1 29 17 46 Totals of Items 1, 2, 3 and 4 82 69 ... ... 162 81 85 130 329 280 609 5. Number of cases discharged after completion of treatment and final tests of cure (see Item 15) 15 1 ... ... 53 26 82 127 150 154 304 6. Number of cases which ceased to attend before completion of treatment and were, on first attendance suffering from:— Syphilis, primary 4 ... ... ... ... ... ... ... 4 4 „ secondary 1 2 ... ... ... ... ... ... 1 2 3 „ latent in 1st year of infection ... ... ... ... ... ... ... ... ... ... ... „ all later stages 11 7 ... ... ... ... ... ... 11 7 18 „ congenital 2 ... ... ... ... ... ... ... 2 ... 2 Soft Chancre ... ... ... ... ... ... ... ... ... ... ... Gonorrhoea, 1st year of infection ... ... ... ... 30 9 ... ... 30 9 39 „ later ... ... ... ... 1 1 ... ... 1 1 2 7. Number of cases which ceased to attend after completion of treatment but before final tests of cure (see Item 15) ... 2 ... ... 29 12 ... ... 29 14 43 8. Number of cases transferred to other centres or to institutions, or to care of private practitioners 7 8 ... ... 10 11 ... ... 17 19 36 9. Number of cases remaining under treatment or observation on 31st December 42 49 ... ... 39 22 3 3 84 74 158 Totals of Items 5, 6, 7, 8 and 9 (These totals should agree with those of Items 1, 2, 3 and 4) 82 69 ... ... 162 81 85 130 329 280 609 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 2 2 ... ... ... ... ... ... 2 2 4 „ congenital ... ... ... ... ... ... ... ... ... ... ... 11. Number of attendances:— (a) for individual attention of the medical officers 1425 1091 ... ... 1036 398 102 171 2563 1660 4223 (b) for intermediate treatment, e.g., irrigation, dressing 36 9 ... ... 1966 1004 13 4 2015 1017 3032 Total Attendances 1461 1100 ... ... 3002 1402 115 175 4578 2677 7255 161  Syphilis Soft Chancre Gonorrhoea Conditions other than venereal Totals M F M F M F M F M F Ttls 11 In-patients:— (n) Total number of persons admitted for treatment during the year ... ... ... ... ... ... ... ... ... ... Nil (b) Aggregate number of "in-patient days" of treatment given ... ... ... ... ... ... ... ... ... ... Nil Under 1 year I 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 1 3 ... 6 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 f injections given (outpatients and in-patients) 852 ... 531 (c) Number of injections included in (b) given to patients who on first attendance at this Centre were suffering from primary and secondary syphilis 279 ... 218 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. 16. Pathological Work:— Microscopical Serum Tests for spirochetes for gonococci Wassermann Others for Syphilis for Gonorrhoea (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 approved laboratory ... 694 523 ... 6 162 Table LXXIII. 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 Essex Bradford. Total A. Number of cases in Item 3 and 4 from each area found to be suffering from:— Syphilis 47 11 1 3 ... ... 62 Soft Chancre ... ... ... ... ... ... ... Gonorrhoea 127 43 5 14 1 ... 190 Conditions other than venereal 164 29 2 7 1 1 204 Total 338 83 8 24 2 1 456 B. Total number of attendances of all patients residing in each area 5615 1280 87 255 17 1 7255 C. Aggregate number of "In-patient days" of all patients residing in each area Nil ... ... ... ... ... ... D. Number of doses of arsenobenzene compounds given in the out-patient Clinic and In-patient Department to patients residing in each area 591 246 ... 15 ... ... 852 163 SECTION VIII. MATERNITY AND CHILD WELFARE. Table LXXIV. 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, Spring Lane „ Fri. Wesleyan School Room, Lower Addiscombe Road „ Tues. Holy Innocents Parish Room, South Norwood Twice wkly. Tues. & Fri. Wed. Forester's Hall, Westow Street, S.E. 19 Weekly 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. Salvation Army Hall Whitehorse Road „ Fri. Wesleyan School Room, London Road, S.W. 16 „ Wed. St. George's Hall, Barrow Road, Waddon „ Wed. St. Oswald's Hall, Green Lane, Thornton Heath „ Thur. St. Jude's Hall, Thornton Road „ Tues. 2 p.m. Notification of Births Act, 1915. This Act requires 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 Still Births. Births. Total. Midwives 2,404 77 2,481 Doctors, parents, and others 779 14 793 As the total number of births and still births registered during 1933 was 3,490 (Live 3,391, Still 99), 208 births and 8 still births were not notified in accordance with the provisions of the Act. The relevant section of the Act lays down that it is the duty of the 164 father of the child or 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 12 deaths associated directly with pregnancy, as compared with 7 in 1932. The maternal mortality rate was consequently 3.7 per 1,000 births, compared with 2.1 per 1,000 in 1932. In other words, one mother died for every 262 living babies born. The deaths directly associated with pregnancy were caused by: Puerperal Eclampsia, 2 cases; Puerperal Septicemia, 5 cases; Hyperemesis, 1 case; Ectopic Gestation, 1 case; Pulmonary Embolism, 1 case; Pyelitis, 1 case; Miscarriage, 1 case. In the I able below only deaths directly due to pregnancy are included. Table KXXV. Puerperal Toxaemias. Haemorrhages. Other Causes. YEAR. BIRTHS. Puerperal Infection. Eclampsia. Hyperemesis. Ectopic Gestation. Placenta Praevia. Post-partum Haemorrhage. Pulmonary Embolism. Caesarian Section. Shock. Heart Disease. Syncope. Renal Trouble. Other Causes. TOTAL. Maternal Mortality. Infant Mortality. 1918 2626 3 1 ... ... 1 2 ... 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 19-25 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 1932 3311 2 3 ... ... ... ... ... ... 1 ... ... 1 7 2.1 49 1933 3147 5 2 1 1 ... ... 1 ... ... ... 1 1 12 3.8 47 80 23 4 5 11 19 16 5 5 7 7 20 202 165 Puerperal Fever and Puerperal Pyrexia. Thirteen cases of Puerperal Fever, and 39 cases of Puerperal Pyrexia were notified. This is a rate of 4.0 per 1,000 births for the former and 12.0 per 1,000 for the latter. The death-rates were:—Puerperal Fever, 2.16 per 1,000 births. There were no deaths attributed to Puerperal Pyrexia. The following Table gives fuller details concerning these cases. Table LXXVI. Puerperal Fever. Puerperal Pyrexia. No. of cases notified 13 39 „ ,, attended by doctor alone at confinement 3 16 „ ,, attended by doctor and midwife 2 2 „ ,, attended by midwife alone 5 20 „ „ B.B.A 3 - „ ,, attended in an institution 3 16 „ ,, attended in Private Nursing Homes 2 6 „ „ treated at home only 3 16 „ ,, treated at hospital 4 16 „ „ treated at Private Nursing Home 2 4 „ ,, treated partly at home and partly in hospital 4 11 „ ,, who died — — 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. Two applications were granted, and a sum of £3 18s. paid. The Committee also assist necessitous patients in the payment of the midwife's fee. 14 applications were made for assistance by midwives on behalf of the patients, and a total sum of £23 19s. was allowed. Table LXXVII. Accommodation for Confinement. The following table gives information concerning the accommodation utilized for confinements. Number. Percentage. In Private Houses 1540 46.9 In Public Institutions 1109 33.7 Registered Maternity Homes 637 19.4 There is a distinct trend towards confinement taking place in an institution or maternity home. 166 THE OBSTETRIC SERVICE. The obstetric scheme in Croydon is perhaps the most complete of any of the schemes conducted by local authorities. It aims at, and to a very large extent achieves, the ideal of complete ante-natal, natal and post-natal medical supervision under the same whole time medical officer. It has proved its workability and its public health usefulness. From the mother's first visit to her last the aim is prevention and where for some reason or other preventive measures fail, then immediate treatment. The ante-natal clinics, Mayday Hospital and St. Mary's Maternity Hospital, and the postnatal clinics are all links in the chain, working with one another under the clinical guidance of the specialist Assistant Medical Officer of Health for Obstetrics. The Ante-Natal Clinics are held in the Centre in Lodge-road on four mornings a week. There are in attendance one lady assistant Medical Officer of Health, the lady almoner and one health visitor who is assisted by a second on two mornings a week. The obstetric officer attends each session for part of the time to see abnormal cases. Pupil midwives from Mayday Hospital and from St. Mary's Maternity Hospital a.ttend for instruction on three mornings a week. The expectant mothers are sent to these clinics from a variety of sources. In 1933, 10% were directed by other departments of the Public Health Service, 14% were sent by midwives, 8% came from medical practitioners and the remaining 68% were from other sources or came on their own initiative. Of this remainder, a large number of mothers had been cared for by the service in previous pregnancies. An income limit is made for those booked to be delivered in the Council's beds, and this in the case of a couple without other children or monetary commitments is £300 per annum. Most of the cases are supervised throughout the ante-natal period from about the 20th week; the remainder come for one consultation at the 36th week, a time when an obstetric opinion can be given and when examination is most informative. The patients who attend the ante-natal clinics arrange for their confinements to take place at Mayday Hospital, at St. Mary's Maternity Hospital, or at their own homes in the care of private medical practitioners or midwives. 167 Mayday Hospital is the Croydon Public Health general hospital and the Lying-in ward has 22 beds. In addition, two wards consisting of 3b beds are utilised for ante-natal, post-natal and gynecological cases. The hospital is recognised by the General Nursing Council as a training school and by the Central Midwives Board. About 12 pupil midwives are trained each year. The clinical work in these, beds is directed by the Obstetric Officer. Normal maternity cases are now discharged on the fourteenth day. St. Mary's Maternity Hospital is a 32 bedded hospital in which 30 beds are retained by the Borough Council. All the cases booked there are now supervised in the Council's ante-natal clinics. The hospital is autonomous and fully equipped with two labour theatres, nurseries, sterilization plant, isolation flat and laundry. It is recognised by the Central Midwives' Board and takes about 12 pupil midwives each year. The in-patients are in the care of the obstetric officer except for abnormalities of labour. These are treated by a rota of six medical officers who are practitioners in the town. The obstetric officer submits cases, in whom abnormal labour is anticipated, to the medical officer on the rota for the week and the hospital midwives call upon the rota medical officer when aid is required during labour. Normal cases are discharged on the 14th day. There is no external midwifery service conducted by the Council. Information regarding the confinements that take place in the patients' own homes following supervision in the Council's ante-natal clinics is supplied by doctors and midwives in a space provided on the patients' attendance cards. All the patients attending the ante-natal clinics are instructed to attend the post-natal clinic six weeks after delivery. The postnatal clinic holds two sessions a week and is conducted by the Obstetric Officer. Abnormal cases are treated as out-patients at these clinics or as in-patients in the Mayday Hospital. All mothers with babies are passed on to the Infant Welfare Centres if they desire this assistance. The whole of the Council's obstetric service is thus in the clinical control of the Obstetric Officer, except the actual confinements and their complications in St. Mary's Maternity Hospital. His duties comprise a daily ward round of the obstetric and gynæcological wards at Mayday Hospital, a daily ward round at St. Mary's Maternity Hospital, the supervision of the ante-natal clinics 168 on five mornings a week, the conduct of one morning and one afternoon session of the post-natal clinic, and operations at Mayday Hospital on three afternoons a week. He directs the Puerperal Infection unit at the Borough Hospital and visits maternity cases in other institutions of the Council. As Borough Consulting Obstetrician, he is called into consultation by practitioners whose patients are unable to pay for the services of a specialist. This scheme approaches very nearly the requirements of a complete obstetric service. It works smoothly and well and ensures a continuity of supervision which influences mothers to use it to their full advantage. The disinclination of many mothers to avail themselves of expert guidance before and after confinement is one of the chief factors in the persistence of a high maternal mortality and morbidity. In the following report, an effort is made to indicate the relation of the Obstetric service to the obstetric activity of the whole borough. The form of the report is that recommended by the Committee of the Section of Obstetrics and Gynaecology of the Royal Society of Medicine for the Unification of Clinical Reports of Maternity Hospitals (1928). This is intended to facilitate the compilation of aggregate statistics which include all the hospitals, and to compare the results obtained by hospitals situated in different parts of the country and dealing with populations working under different industrial conditions. The small number of abnormalities diminishes the intrinsic value of the tables and percentages, but the method of setting out the results brings out many striking facts ; and as the same tables will be repeated over a period of years, valuable statistics will be obtained. Some of the tables are probably of interest only to the medical and nursing professions. One salient feature is that the cases are divided into "Booked" and "Emergency" groups. A case that attends the ante-natal clinic more than once is a "Booked" case. An "Emergency" case is one sent into hospital severely ill or with some complication, by an outside doctor. The patients themselves signify whether they wish to book for Mayday Hospital or for St. Mary's Maternity Hospital. Apart from this, five special groups of abnormal "Booked" cases are dealt with only at Mayday Hospital; and if they have already booked for St. Mary's, they are transferred to the Mayday Hospital list. These are:— 169 (1) Cases supervised by the Ante-Natal Clinics for delivery at home under the care of doctors or midwives. (2) Cases referred to the Service by doctors because of some ante-natal abnormality or anticipated difficulty, and supervised by the Ante-Natal Clinic before delivery in hospital. These appear in the "Mayday Hospital Booked" list. (3) Cases who are delivered before 28 weeks. (4) Cases of venereal disease or other infectious disease. (5) Cases of special difficulty requiring X-Ray or other investigation or special medical or surgical treatment by a resident medical officer. Cases admitted more than once during the same pregnancy are counted as one case only, for all statistical purposes. Twenty-eight weeks is taken as the dividing line between abortion and labour except when a foetus of less than 28 weeks breathes. In this case, no matter what the duration of pregnancy may have been, the delivery is labelled as premature labour. In the year 1933 the service has continued along the lines pursued in previous years. The new obstetric officer took up his duties on 28th April. In the ante-natal clinics, a system of giving each patient an appointed time to attend has been instituted, thus avoiding much tedious waiting. In accordance with modern medical views the blood pressure of each patient is now taken at every visit. In the latter half of the year, posterior positions of the vertex have been treated at the 38th week with Buist's pads. This has given good results and difficult "posterior" labours have been fewer. The supervision of expectant mothers at the ante-natal clinics is not yet as detailed as is desirable. This has been due to insufficient nursing staff. The lady medical officer has been obliged to do work that a nurse usually does, so that she has not been able to devote sufficient time to the medical and obstetric part of the examination. With the additional health visitor to be appointed in 1934, this will be remedied. The other deficiency in the Ante-Natal work is the lack of a Mothercraft scheme organised and conducted by a trained staff to instruct and assist expectant mothers in their preparations. For this, it is essential to have instructresses who have had special training in Mothercraft work. 170 Towards the end of the year, two other innovations were made at Mayday Hospital. The length of stay of normal cases was increased by one day so that normal cases now go home on the 14th day. For some years all mothers have received postural treatment to encourage normal involution of the uterus. The assistance of the Massage Department of Mayday Hospital has now been obtained to give lying-in cases exercises and treatment to improve the abdominal and pelvic musculature. During the first four months of 1933 when the Obstetric Officer's post was filled by a locum tenens, the Post-Natal Clinic was very poorly attended. After that, the attendance gradually rose, and at the end of the year about two-thirds of mothers attended the post-natal clinic six weeks after their confinements. General Statistics for 1933. Number of Births Registered in the Borough of Croydon 3,391 Number of Stillbirths registered in the Borough of Croydon 99 Total 3,490 Number of Expectant Mothers who attended the Borough Ante-Natal Clinics 1,045 Number of cases delivered in Mayday Hospital as Booked Cases 368 Number of cases delivered in Mayday Hospital as Emergency Cases 144 Total cases delivered at Mayday Hospital 512 Number of cases delivered in St. Mary's Maternity Hospital as booked Cases 598 Number of cases delivered in St. Mary's Maternity Hospital as Emergency Cases — Total cases delivered in St. Mary's Maternity Hospital 598 Number of cases admitted to the Puerperal Infection Unit, Borough Hospital and Mayday Hospital Isolation Wards, including four from Mayday Hospital and two from St. Mary's Maternity Hospital 28 Number of Maternal Deaths in Borough of Croydon 13 Number of Maternal Deaths in Booked Cases from Borough AnteNatal Clinics 2 Number of Maternal Deaths in Emergency Cases Mayday Hospital 5 Number of Maternal Deaths in cases admitted as Puerperal Sepsis per se 6 171 The total number of patients treated by the Obstetric Service was— (a) In Mayday Hospital 558 (b) In St. Mary's Maternity Hospital 601 (c) In the Borough Hospital (Puerperal Infection) and Mayday Hospital Isolation Wards, excluding four from (a) and 2 from (6) 22 (d) At the Ante-Natal Clinics and delivered outside the above Hospitals 380 (e) At the Post-Natal Clinics, excluding those included in (a), (6), (c), and (d) 27 (f) At the Ante-Natal Clinics and undelivered on December 31st, 1933 388 1,976 ANTE-NATAL SUPERVISION. 1932. 1933. Number of Sessions of Ante-Natal Clinics held 254 252 Number of individuals who attended 1,729 1,645 Number of previous year's cases, continuing Attendance 343 322 Number of New Cases 1,386 1,323 Number of cases undelivered on December 31st 322 388 Total Attendances made 7,820 8,518 Average Attendance per Session 30.8 33.8 Proportion of Old to New Cases per session— New 5.46 5.25 Old 25.34 28.55 Number of Cases delivered in Hospital as Booked Cases 966 Number of Cases delivered at other places under the care of Private Doctors or Midwives 380 Number of Patients found not to be pregnant 33 Number of Patients referred to Hospital for Ante- Natal Treatment 169 The condition for which these were admitted can be ascertained by reference to the "Rooked" columns of the Numerical Summary of Cases. MAJOR ANTE-NATAL CONDITIONS TREATED AT CLINIC. Breech Presentation. External version successful 62 External version unsuccessful 16 Referred to Hospital for external version under Anaesthesia 14 Allowed to go to term as breech 10 Not recognised as breech before labour 8 Posterior Positions of the Vertex. Cases. Successful Correction with Buist's pads at about 38 weeks 30 Buist's pads unsuccessful 7 Correction not attempted (since treatment instituted) 8 172 Dental Treatment. Number of cases referred to Borough dental surgeon 186 Number of cases referred to private dental surgeons 66 Number of cases refusing dental treatment 72 Number of cases seen too late for necessary dental treatment 14 Tuberculosis. Referred by Tuberculous Officer because of pregnancy 9 Referred to Tuberculous Officer 7 X-Ray Examinations. 58 cases were referred to Mayday Hospital X-Ray Department and 87 films were used. Reasons for reference were: — Breech for attitude 20 cases For attitude, presentation, etc. 22 ,, Twins 10 ,, Renal calculus 4 ,, Maturity 2 ,, Pathological Investigations. Blood for Wassermann and Kahn Reactions 48 Blood for Gonococcus Fixation test 8 Catheter urine for routine examination 15 Urine for Aschhiem—Zondek test 2 Urethral smears for Gonococci 64 Cervical smears for Gonococci 12 Venereal Disease. Gonorrhoea—Total cases 8 Transferred to Borough V.D. Clinic 3 „ ,, Mayday Hospital 4 ,, ,, Special Hospital for delivery 1 Syphilis—Total cases 7 Transferred to Borough V.D. Clinic 2 ,, ,, Mayday Hospital 5 ,, ,, Special Hospital for delivery — All the cases, except one, were delivered in Mayday Hospital in Isolation Wards, and all were transferred to the Borough V.D. Clinic on discharge. Other Conditions Treated as Out-Patients. No. of Cases, Retroverted Gravid Uterus 3 Chronic Rheumatic Carditis 5 Cervical Polypus 1 Parenchymatous Goitre 2 173 Midwives' Cases. 14 Midwives' cases were ordered into Hospital for delivery on medical grounds as follows: — No. of Indication. Cases. Breech for version 1 Disproportion 4 Albuminuria 3 Abortion 2 Missed abortion 1 Exophthalmic goitre and heart disease 1 Home conditions unsuitable 2 IN-PATIENT TREATMENT. A.—Patients "Booked" in the Ante-Natal Department. Mayday Hospital. St. Mary's Maternity Hospital. Total. (1) Delivered in Hospital after 28th week 358 598 956 (2) Delivered in Hospital before 28th week 10 — 10 (3) Admitted after delivery 6 1 7 (4) Discharged undelivered after ante-natal treatment and not subsequently delivered in Hospital 4 2 6 (5) Died undelivered 1 — 1 Totals 379 601 980 B.—"Emergency" Patients sent into Hospital with some complications by outside doctors or midwives. No "Emergency" Cases were sent to S£. Mary's Maternity Hospital. Mayday Hospital. (1) Before Labour— (a) Delivered in Hospital after 28th week 28 (b) Delivered in Hospital before 28th week 6 (c) Discharged undelivered 12 (d) Died 4 (2) In Labour— (а) Delivered in Hospital after 28th week 27 (б) Delivered in Hospital before 28th week 83 (c) Died — (3) After Delivery 16 (4) Ectopic Pregnancy 3 Total 179 174 Table LXXVIII. A Numerical Summary of Cases admitted for treatment, delivered in Hospital or admitted after delivery. Some cases appear in more than one category in the Summary. Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Maternity Hospital Booked. Total. 1. Conditions chiefly Ante-Natal. Albuminuria 24 13 27 64 Eclampsia — 4 2 6 Persistent vomiting of Pregnancy — 6 1 7 Chorea Gravidarum 2 — — 2 Pyelitis and Urinary Infection 11 7 5 23 Malnutrition, Debility, Simple Anaemia, etc 15 1 2 18 Ante - partum thrombo - phlebitis 3 1 3 7 Breech presentation for version 8 2 6 16 Disproportion 13 3 23 39 Post-maturity 8 2 17 27 Retroverted Gravid Uterus — 3 — 3 2. Intercurrent Diseases. Chronic Nephritis 3 3 3 9 Pulmonary Tuberculosis 4 2 - 6 Venereal Disease 14 3 — 17 Pneumonia 1 3 — 4 Chronic Rheumatic Carditis 2 2 — 4 Ovarian Tumour — 1 — 1 Exophthalmic Goitre 2 — — 2 Insanity 3 2 — 6 3. Conditions chiefly Natal. Presentations at Delivery— Anterior Positions of the Vertex 308 34 514 856 Posterior Positions of the Vertex 35 4 62 101 Breech 13 11 21 45 176 Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Maternity Hospital Booked. Total. Shoulder 2 4 — 6 Face and Brow — — — — Complex — 2 3 5 Caesarean Section 4 2 5 11 Twins 5 2 7 14 Accidental Haemorrhage 4 5 5 14 Placenta Praevia 2 7 3 12 Hydramnios — — 4 4 Prolapse of Cord — 3 2 5 Retained Placenta 2 2 9 13 Post - Partum Haemorrhage 2 2 3 7 B.B.A 6 16 1 23 Lacerated Perineum 76 9 118 203 Obstructed Labour — 4 1 5 Precipitate Labour 2 — — 2 Premature Labour 28 20 36 84 Abortion 18 96 — 114 Ectopic Gestation — 3 — 3 4. Conditions chiefly Post-Natal excluding re-admissions from Post-Natal Clinic. Retroversion 6 4 20 30 Delayed Involution 17 3 8 28 Post-partum Nephritis 6 1 8 15 Breast Abscess 3 1 1 5 Puerperal Pyrexia 3 13 4 20 Puerperal Fever 2 2 2 6 In addition 6 cases of Puerperal Fever per se were admitted to Mayday Hospital Isolation Wards and 16 cases to the Puerperal Infection Unit at the Borough Hospital. 176 Cardiac Disease. There were four cases. One mother died, an "emergency" case at Mayday Hospital: a mortality of 25 per cent. One infant was undelivered when the mother died. Hydramnios. There were four cases all "booked" at St. Mary's Maternity Hospital. There were no maternal deaths and two infants were still-born: a foetal mortality of 50 per cent. Cases of Albuminuria. Every patient attending the Ante-Natal Clinic has the urine tested and the blood pressure recorded at each visit. All cases of albuminuria (confirmed by catheter specimen) or hypertension with a diastolic blood pressure of 90 or over, are admitted to hospital. The routine treatment adopted in hospital was rest, meat-free diet with a high vitamin content, copious fluids, alkalies and aperients. Labour was induced if the symptoms and signs did not disappear in about 10 days, or if they become progressively worse. Table LXXIX. Mayday Hospital Booked. Mayday Hospital Emergency St. Mary's Maternity Hospital Booked. Total. Number of Cases 23 14 27 64 Number of Stillbirths and Infant Deaths 2 1 3 6 Foetal and Infant Mortality 8.7% 7.1% 11.1% 9.4% Number of Maternal Deaths — 2 — 2 Maternal Mortality — 14.3% — 3.1% Number of Cases— Responded to treatment and delivered spontaneously near term 10 - 11 23 Responded to treatment and discharged to return abnormal 1 1 1 3 Responded to treatment and discharged to return normal 3 - 1 4 Responded to treatment and discharged, delivered elsewhere — 2 1 3 Spontaneous premature labour 4 4 6 14 Not responding to treatment and labour induced 5 2 7 14 Not responding to treatment, abortion per vaginam induced - 1 - 1 Not responding to treatment, hysterectomy performed — 1 — 1 Died undelivered — 1 — 1 177 Eclampsia. Mayday Booked, Hospital. Emergency. St. Mary's Mty. Hpl. Booked. Total. Number of Cases 0 4 2 (1 twins) 6 Maternal Deaths 0 2 0 2 Maternal Mortality 0 50% 0 33% Number of Foetal and Infant Deaths 0 4 0 4 Foetal and Infant Mortality 0 100% 0 67% Accidental Ante-Partum Haemorrhage. Total. Mayday Booked. Hospital. Emergency. St. Mary's Mty. Hpl. Booked. No. of Cases 14 4 5 5 No. of Stillbirths and Infant Deaths 6 1 3 2 Foetal and Infant Mortality 43% 25% 60% . 40% Method of Treatment— Mayday Hospital. St. Mary's Hospital. Booked. Booked, Emergency. No. of Cases Deaths. No. of Cases Deaths. No. of Cases Deaths. Mother Child Mother Child Mother Child Sedatives, no intervention, eliminative, etc. 3 - 1 5 - 3 4 - 1 Rupture of membranes. 1 — — — — — — - — Cesarean Section - - - - - - 1 1 1 There was one maternal death in a St. Mary's Hospital booked case. Placenta Praevia. Total. Mayday Hospital. St. Mary's Mty. Hpl. Booked. Booked. Emergency. No. of Cases 12 2 7 3 No. of Stillbirths and Infant Deaths 8 1 6 1 Foetal and Infant Mortality 66.7% 50% 85.7% . 33.3% There were no maternal deaths. Contracted Pelvis (including relative disproportion between the pelvis and the foetal head). 39 cases of contracted pelvis or disproportion were treated during the year. There were no maternal deaths and three infants were still born, or died, an infant mortality of 8%. 178 In first degree contractions "booked" cases at Mayday Hospital (including those sent to the obstetric service because of pelvic contraction) were treated by trial labour, while in "booked" cases at St. Mary's Maternity Hospital induction of premature labour was generally employed. Yertex Presentations at Delivery. The number of deliveries in which the occiput was anterior at the beginning of labour including 30 corrected before labour by Buist's pads 856 The number of deliveries in which the occiput was posterior at the beginning of labour 101 Table LXXX. Treatment and Results of Posterior Position. A.—Booked Cases Mayday Hospital. Mode oj Delivery. No. of Cases. Result to Mother. Result to Child. Remarks. L. D. L. S.B. D. Spontaneous Rotation and Delivery 23 23 - 23 - - Spontaneous Delivery Face to Pubes 2 2 - 1 1 - Spontaneous Rotation Forceps Delivery 2 2 - 2 - - Manual Rotation, Forceps Delivery 2 2 - 2 - - Forceps Rotation and Delivery 6 6 - 5 1 - Kielland's forceps Forceps Delivery Face to Pubes - - - - - - Internal Version and Extraction - - - - - - Caesarean Section - - - - - - Craniotomy - - - - - - Totals 35 35 — 33 2 — Two infants were still-born: a foetal mortality of 5.7 per cent. There were no maternal deaths. 179 B.—Emergency Cases Mayday Hospital. Mode of Delivery. No. of Cases. Result to Mother. Result to Child. Remarks. L. D. L. S.B. D. Spontaneous Rotation and Delivery - - - - - - Spontaneous Delivery Face to Pubes - - - - - - Spontaneous Rotation Forceps Delivery - - - - - - Manual Rotation, Forceps Delivery 1 1 - 1 - - Forceps Rotation and Delivery 2 2 - 2 - - Kielland's forceps Forceps Delivery Face to Pubes - - - - - - Internal Version and Extraction - - - - - - Caesarean Section - - - - - - Craniotomy - - - - - - Totals 3 3 — 3 — — There were 110 maternal or foetal deaths. C.—Booked Cases St. Mary's Maternity Hospital. Mode of Delivery. No. of Cases. Result to Mother. Result to Child. Remarks. L. D. L. S.B. D. Spontaneous Rotation and Delivery 35 35 - 35 - - Spontaneous Delivery Face to Pubes 12 12 - 11 - 1 Premature Infant died. One twin. Spontaneous Rotation Forceps Delivery 7 7 - 6 1 - Manual Rotation, Forceps Delivery 5 5 - 5 - - Forceps Rotation and Delivery - - - - - - Forceps Delivery Face to Pubes 2 2 - 2 - - Internal Version and Extraction - - - - - - Caesarean Section - - - - - - Craniotomy 1 1 — — 1 — Contracted pelvis Induction. Totals 62 62 — 59 2 1 There were no maternal deaths. Two stillbirths and one neonatal death made the infant mortality 4.8 per cent. 180 Breech Delivery. (Ante-Natal treatment of breech cases, see page ). Table LXXXI. Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Maternity Hospital Booked. Total. Number of Breech Deliveries 13 11 21 45 Number of Stillbirths and Infant Deaths 5 10 5 20 Foetal and Infant Mortality 39% 91% 24% 44% Maternal Deaths — — — — An uncomplicated breech delivery is one where an additional risk to the life of the foetus is not present—such conditions as ante-partum haemorrhage, prematurity, monstrosity, prolapse of the cord, etc. Table LXXXII. Mayday Hospital Booked. Mayday Hospital Emergency. St. Mary's Maternity Hospital Booked. Total. Number of Uncomplicated Breech Cases 8 1 12 21 Number of Stillbirths and Infant Mortality 2 1 2 5 Foetal and Infant Mortality 25% 100% 16.7% 24% Number of Complicated Breech Cases 5 10 9 24 Number of Stillbirths and Infant Deaths 3 9 3 - Foetal and Infant Mortality 60% 90% 33.3% 62.5% 181 Face and Brow Presentation. There were no cases. Shoulder Presentations. There were six cases, two "booked" and four "emergency" cases at Mayday Hospital. No mothers died. Four infants were stillborn, a mortality of 66.7%. Prolapse of Cord. There were five cases, two "booked" cases at St. Mary's Maternity Hospital and three "emergency" at Mayday Hospital. No mothers died. Three infants were stillborn, a mortality of 60%. Post-Partum Haemorrhage. There were two cases in Mayday Hospital "booked" cases; two in Mayday Hospital "emergency" cases and three in St. Mary's Hospital "booked" cases. There were no maternal deaths and no infants died or were stillborn. Abortion. The service dealt with 114 cases of abortion during the year; all were treated at Mayday Hospital (18 booked cases and 96 emergency), none at St. Mary's Maternity Hospital and none in the puerperal sepsis unit at the Borough Hospital. There were no maternal deaths. In addition 3 cases of incomplete abortion were admitted to Mayday Hospital Isolation wards as puerperal sepsis and are recorded in the puerperal fever section (one maternal death). Conditions for which abortion was induced:— Pulmonary tuberculosis 3 cases Chronic nephritis 2 cases 182 Ectopic Pregnancy. Three cases of ectopic pregnancy were treated, all "emergency" cases at Mayday Hospital. There was one maternal death, giving a maternal mortality of 33%. Laceration of Perineum. The perineum was lacerated in 203 cases. Place of Delivery. lsi and '2nd degree. 3rd degree. Total. Mayday Hospital—Booked 75 1 76 Mayday Hospital—Emergency (2 B.B.A.) 8 1 9 St. Mary's Maternity Hospital—Booked 116 2 118 203 Induction of Labour. Labour was induced 68 times; 47 were medicinal and '21 instrumental. 13 were in Mayday Hospital "booked" cases; 5 in Mayday Hospital "emergency" cases and 49 in St. Mary's Hospital "booked" cases. One mother died owing to eclampsia, one baby was stillborn and two died after birth in Mayday Hospital "emergency" cases; and one baby was stillborn in a St. Mary's Maternity Hospital "booked" case. Forceps Delivery. Forceps were applied 46 times (16 Mayday Hospital "booked," 5 Mayday Hospital "emergency" and 25 St. Mary's Maternity Hospital "booked" cases). In 4 cases, forceps were applied after induction of labour (all St. Mary's Hospital cases). There were no maternal deaths. 1 baby was stillborn and none died at Mayday Hospital, an mfant mortality of 5%. 1 baby was stillborn and none died at St. Mary's Maternity Hospital, an infant mortality of 4%. 183 Table LXXXIIT. ANALYSIS OF FORCEPS CASES. No. of Cases. Indication. Mother. Result. Child. L. D. L. S.B. Mayday Hospital Booked. 4 Disproportion 4 — 4 — 8 Persistent Occipito-Posterior 7 — 6 1 2 Rigidity of Soft Parts 2 — 2 — 1 Foetal Distress 1 — 1 — 1 Prolonged 2nd Stage R.O.P. 1 — 1 — 1 Threatened Inertia 1 — 1 — Mayday Hospital Emergency. 3 Disproportion 3 — 3 — 2 Persistent Occipito-Posterior 2 — 2 — St. Mary's Maternity Hospital Booked. 2 Disproportion 2 — 2 — 7 Persistent Occipito-Posterior 7 — 7 — 4 Rigidity of Soft Parts 4 — 4 — 3 Foetal Distress 3 — 3 — 2 Threatened Inertia 2 — 2 — 2 Maternal Distress 2 — 2 — 3 Prolonged 2nd Stage R.O.P. 3 — 2 1 1 Prolapsed Hand (2nd Twin) 1 — I — 1 Eclampsia 1 — 1 — 184 Caesarean Section. Caesarean Section was performed 11 times, 4 "booked" and 2 "emergency" cases at Mayday Hospital and 5 "booked" cases at St. Mary's Maternity Hospital. In 6 cases on account of contracted pelvis ; 1 placenta praevia; 1 ovarian cancer; 1 concealed accidental haemorrhage; 1 large fibroids and 1 chronic nephritis. There was one maternal death and two babies died, all in "booked" cases at St. Mary's Maternity Hospital. Caesarean Hysterectomy was performed twice, once for fibroids at term and once for recurrent albuminuria due to chronic nephritis at 24 weeks. Both these cases were at Mayday Hospital. Bipolar and Internal Version. Internal version was performed 6 times, 2 "booked" and 4 "emergency" cases at Mayday Hospital: for shoulder presentation in a second twin, on one occasion ; for shoulder presentation in three cases ; for shoulder presentation and placenta praevia in one case and for placenta praevia in one case. There was no maternal death. Infant mortality' for internal version 67%. Embryotomy Embryotomy was performed four times, thrice in "emergency" cases admitted with obstructed labour to Mayday Hospital and once in a "booked" case at St. Mary's Maternity Hospital. There were no maternal deaths. Manual Removal of Placenta. Manual removal was performed 13 times, twice in Mayday Hospital "booked" cases, twice in Mayday Hospital "emergency" cases and 9 times in St. Mary's Maternity Hospital "booked" cases. There was no maternal death. Maternal Morbidity. All cases of pyrexia and all maternal deaths after delivery are included as morbid except cases dealt with for the first time as puerperal fever after delivery elsewhere. These are given in the puerperal fever section. In the 966 "booked" cases there were 7 cases of pyrexia and no deaths without a rise of temperature. The morbidity rate for "booked" cases was 0.72 per cent. (Mayday Hospital 0.81 per cent.; St. Mary's Maternity Hospital 0.67 per cent.). 185 In the 144 "emergency" cases at Mayday Hospital, there were 13 cases of pyrexia and no deaths without a rise of temperature. The morbidity rate for Mayday Hospital "emergency" cases was 9.0 per cent. The Strassburg Convention standard of pyrexia as adopted by the Ministry of Health has been used, namely, "a temperature of 100.4 degrees F. or more, sustained during a period of 24 hours or recurring during that period." Puerperal Fever. 28 cases of puerperal fever were admitted after delivery to the Borough Hospital Puerperal Infection Unit (18 cases) or to the Isolation Wards at Mayday Hospital (10 cases) including 4 cases delivered at Mayday Hospital and 2 cases delivered at St. Mary's Maternity Hospital. One case (No. BH/116) died of Broncho-pneumonia caused by a fracture of the base of the skull which brought on premature labour (not a maternal death). 7 of the other 27 patients died, a mortality of 25.9 per cent. No. of cases admitted to Service's beds as Puerperal Fever per se... 22 No. of deaths in admissions 6 Mortality 27.3 No. of cases delivered in Service's beds and transferred to isolation beds with Puerperal Fever 5 No. of deaths in these cases 1 Mortality 20% Mortality Cases. Deaths. Rate. Source of the Cases (with mortality rates)— From Maydav Hospital—Booked cases 2 — — ,, ,, „ Emergency cases.. 2 — — From St. Mary's Maternity Hospital— Booked cases 2 1 50% From other Hospitals— (1) (1) (Fractured skull). From Private Doctors—delivered in Nursing Homes 3 1 33.3% From Private Doctors—delivered at home. 18 5 27.8% Hay of Admission after Labour— 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th After -144332 — 4 — 7 24 cases followed labour with 6 deaths (25.0%) 3 cases followed abortion with 1 death (33.3%) 186 Maternal Mortality. These cases are dealt with in two categories, the first including all cases delivered in the care of the Service or attended bel'oie delivery and the second those cases admitted after delivery as puerperal sepsis per se and treated at Mayday Hospital or in the Borough Hospital Puerperal Infeotion Unit. (See page 185 for second category). Maternal deaths excluding cases admitted as puerperal sepsis per se:— Booked cases 2. Mortality : 2.1 per 1,000. Emergency cases 5. Mortality: 34.7 per 1,000. Total deaths 7. Total Mortality : 6.3 per 1,000. The maternal deaths were due to the following conditions. (All the cases were undelivered except the second case). BOOKED. (1) Bilateral purulrnt pyelitis and pyelonephritis (P.M.) (2) Concealed accidental haemorrhage. Caesarean Section and Pulmonary Embolus. EMERGENCY. (3) Eclampsia. (4) Chronic rheumatic carditis. (5) Ectopic gestation—cardiac failure. Foetus weighed 8 lbs. 14 ozs. (6) Persistent vomiting of pregnancy. P.M. showed chronic nephritis, old pleural adhesions and broncho-pneumonia. (7) Eclampsia. Infants. St. Mary's Mayday Hospital. Mty. Hpl. Rooked. Emergency. Booked. Dotal. Per cent. Total number of Live Births, Still Births, and Infants admitted with mother (B.B.A.) 368 64 606 1,038 100 Livinsj—alive on discharge from Hospital 347 38 587 972 93.6 Stillborn (Fresh) 9 10 6 25 2.4 Stillborn (Macerated 4 6 5 15 1.4 Died (born alive, but died in Hospital) 8 10 8 26 2.5 Infant Feeding and Weight on Discharge from Hospital. In both hospitals normal infants were breast fed every four hours, omitting the early morning feed. 187 Of 385 infants discharged from Mayday Hospital '248 were up to or over birth weight (64.4 per cent.). Of 587 infants discharged from St. Mary's Maternity Hospital 363 were up to or over birth weight (61.8 per cent.). Twins and Triplets. St. Mary's Mayday Hospital. Mty. Hpl. Booked. Emergency. Booked. Total. No. of Cases 5 ... 2 ... 7 ... 14 No. of Infants discharged alive 10 ... 2 ... 14 ... 26 No. of Still Births and Infant Deaths 0 ... 2* ... 0 ... 2 Foetal Mortality 0 ... 50% 0 ... 7.7% *Both dead before admission. There were no maternal deaths. Ophthalmia Neonatorum. There were four cases of ophthalmia, two in Mayday Hospital "booked" cases, two in Mayday Hospital "emergency" cases and none at St. Mary's Maternity Hospital. Three of the cases were transient; only the lids being affected. One Mayday Hospital emergency case was severe and was transferred to the Borough Hospital. POST-NATAL AND GYNAECOLOGICAL CLINIC. As in former years, it has to be assumed that the incidence of abnormality in those who absented themselves from the PostNatal Clinic is less than in those who did attend. The number of those attending fell while the Obstetric Officer's post was vacant. During the latter six months of the year it has risen higher than ever before; this is partly due to the system introduced of giving each case a definite appointment. The proportion of abnormality in cases attending has become considerably less, probably because since May, 1933, all cases from both hospitals have been examined before being discharged and many were detained for further treatment. Number of .Sessions held 86 Number of individuals presented 683 Number of subsequent attendances 529 Total number of attendances 1,212 Average attendance per session 14.1 Number of Post-Natal Cases 611 Number of Gynaecological Cases 72 188 Table LXXXIV. POST-NATAL CASES. After confinement at Total. Mayday Hospital. St. Mary's Hospital. Elsewhere. Total Cases 216 342 53 611 Cases found to be normal 139 241 22 402 Cases found to be abnormal 77 101 31 209 Cases treated as Out-patients. 58 89 21 168 Cases admitted to Mayday Hospital 16 6 7 29 Table LXXXY. CLASSIFICATION OF ABNORMAL POST-NATAL CASES. Case Group. Source of cases attending Percentage of Abnormals. Percentage of all cases attending. Mayday Hospital. St. Mary's Hospital. Elsewhere. Retroversion 34 46 7 41.6 14.2 Delayed Involution 11 13 8 15.3 5.2 Trauma 11 21 7 18.7 6.4 Infection 5 8 7 9.6 3.3 Chronic Nephritis 7 8 2 8.1 2.8 Other 9 5 0 6.7 2.3 Totals 77 101 31 100.0 34.2 END RESULTS. 605 cases were treated to their termination (other than death) during the year, and the results were classified as follows:— Result I.—Health unimpaired as a result of recent confinement (i.e., no symptoms and no anatomical or functional disability). Result II.—Health slightly impaired as a result of recent confinement (i.e., no symptoms or disability, but anatomical damage likely to lead to disability in the future, particularly if increased by further pregnancies. This group includes cases impaired by previous confinements and further impaired by the recent confinement so as to make the total impairment, due to all previous confinements, equal to that described in Result III.). 189 Result III.— Health seriously impaired as a result of recent confinement (i.e., symptoms or disability present due to trauma, infection, etc., or damage to vital organs, as in chronic nephritis). Mayday St. Mary's Hospital. Hospital. Elsewhere. Totals. Result 1 183 286 43 512 Result II 25 38 6 69 Result III 7 13 4 24 Totals, treated to conclusion 215 337 53 605 OBSTETRIC CONSULTATIONS. As Consulting Obstetrician to the Borough, the Assistant Medical Officer of Health for Obstetrics was called in by medical practitioners to see 20 patients who could not afford to pay a private consultant. The cases were as follows:- Placenta Praevia, Threatened Abortion, Puerperal Fever, Pre-eclampsia, Puerperal Fever, Puerperal Pyelitis, Pyelitis of Pregnancy, Puerperal Pyelitis, Puerperal Pyelitis, Femoral Thrombo-phlebitis, Prolonged Labour due to Posterior Position, Prolonged Labour due to Contracted Pelvis, Foetal Death, Prolonged Labour due to Posterior Position, Placenta Previa, Suspected Disproportion, Retained Placenta and Haemorrhage, Chronic Nephritis and Pre-eclampsia, Threatened Abortion, Threatened Abortion. In addition, he was asked by the Medical Superintendent of Mayday Hospital to give an opinion on the obstetric and gynaecological aspects of 17 cases in the general, medical and surgical wards of the Hospital. St. Mary's Maternity Hospital. This institution has 32 beds. Thirty of the beds are reserved for cases sent by the Local Authority, for which a grant of £2,350 was made. I am indebted to Dr. G. Genge, the physician in charge, for the following particulars:— No. of cases admitted during 1933 624 Average duration of stay 14 days. No. of cases delivered by (a) Midwives 564 (b) Doctors 40 (6.6%) 190 No. of cases in which medical assistance was sought bv the midwife in emergency ... 100 (including 83 for suturing perineum). No. of cases notified as Puerperal Fever or Puerperal Pyrexia 4 No. of cases notified as Pemphigus neonatorum 0 ,, ,, ,, Ophthalmia neonatorum— No. of infants not entirely breast fed 31 No. of maternal deaths 0 No. of infant deaths (a) Still-born 12 (b) Within 10 days of birth 8 Prematurity, 5. Atelectasis, 2. Convulsions and Meningitis, 1. 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 an annual grant of £650 from the Croydon Council. Although not bulking largely as a Maternity Hospital, the work done is an important branch of maternal care. Besides the matron and nursing staff, an honorary lady medical officer attends the home when necessary. i The following figures give the main details regarding the work carried out in 1933, and I am indebted to Dr. Sutherland, the Hon. Medical Officer of the Home, for them:— No. of beds for patients 19 No. of cases admitted 28 Average duration of stay 4/5 months No of cases delivered by (a) Midwives 20 (b) Doctor 1 No. of cases in which medical assistance was sought by a midwife 8 No. of cases notified as (a) Puerperal Fever, (b) Puerperal Pyrexia Nil No. of infants not entirely breast fed while in the institution 5 No. of cases notified of Ophthalmia Neonatorum Nil No. of cases notified as Pemphigus Neonatorum Nil No. of maternal deaths Nil No. of infant deaths (a) Still-born Nil (b)within 10 days of birth 2 (due to convulsions and congenital malformation and prematurity) 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. 191 It is becoming increasingly difficult to get the girls to stay the requisite period; many of them wanting to take up their former work or new work after two months' stay. Although undesirable, owing to the dislocation in breast feeding which results, the Authorities of the Home have had to reduce the length of stay in several cases. Still Births. During 1933, 99 still births were registered in respect of Croydon, but of these 16 were outward transfers to other districts. There were 9 inward transfers, giving a total of 92 for the area. Of these 47 were male babies and 45 female; 5 male and 5 female were illegitimate. The proportion of still births to living children was as 1 to 34. The still birth rate was 2.8 of the total registered births. The rate in 1932 was 3.4%. The still birth rate, on the same basis as for Infant Mortality was 28.4 per 1,000 births. STILL BIRTHS, 1933. Notified by Midwives, Home Cases 15 ,, Doctors Home Cases 10 ,, Institutions (Doctors or Midwives) ... 38* Attended by Midwives alone 26 ,, Doctors alone 7 „ Midwives and Doctors 32 Occurred at 9 months 45 ,, 8 months 12 ,, 6-7 months 11 *Including registered Maternity Homes. An Analysis of 68 Stilt Births Occurring During the Year. Of the 68 still births investigated 31 were males and 37 females. Type of Delivery.—In 39 cases the confinement was difficult or prolonged. Normal confinement was noted in 26 cases; no information was obtainable in 3 cases. There was an abnormal presentation in 7 cases. Age of Mother.—Under 20 years, 2; between 20 and 29 years, 29; between 30 and 39 years, 27 : between 40 and 49 years, 7. The Health of the Mother during her pregnancy was started to be good in 60 cases and indifferent or poor in 6 cases; no particulars were obtained in 2 cases. In 7 cases, however, the mother 192 had had a shock or a fall before the still birth. In 28 instances the mother had attended the Ante-Natal Clinic. 40 cases had never attended the Clinic. Attendance at Confinement.—Twenty-five of the still births investigated occurred in the Mayday Hospital; 10 in St. Mary's Hospital; 21 were attended in their own homes by a private medical practitioner either alone or in conjunction with a midwife; 6 were attended by a midwife alone, and 3 births occurred before any skilled help was available; 3 occurred in private nursing homes. Forceps were reported to have been utilised in 16 of the cases, while in 5 no record was available. In 44 cases the baby was born at full term; in 12 during the 8th month of gestation ; in 10 during the 7th month; and in 1 under 7 months. One case was stated to be over the 9th month. The baby was apparently a normal child in 39 cases, abnormal in 9, whilst in 20 no record was available. The still birth was the first pregnancy in 25 instances; the 2nd in 14; the 3rd in 7; the 4th in 9; the 5th in 2; the 6th in 4; the 7th in 5; the 8th in 1 ;and beyond in 1. Previous still births had occurred in 8 cases. Ophthalmia Neonatorum. Ten cases were notified during 1933. 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 eleven years:— Table LXXXVI 1923 1924 1915 1926 1927 1928 1929 1930 1931 1932 1933 No. of cases 23 21 22 20 18 7 5 19 14 21 10 Kate per 1000 births 6.8 6.1 6.5 5.8 5.7 28 1.5 5.4 5.6 6 3 3.2 193 Results of Treatment. Cases treated. Vision Unimpaired. Vision Impaired. Died, Removed Remaining under Treatment. Notified At home In hospital 10 4 6 5 0 1 3 1 Infant Mortality. The Infantile Mortality rate was 47 per 1,000 births. This is 2 per 1,000 births less than in 1932, and is the lowest rate yet recorded in the Borough. For the past 5 years the numbers of infant deaths have been : 1929, 221; 1930, 171; 1931, 196; 1932, 161; 1933, 148. 85 deaths of infants occurred in institutions, including Registered Nursing Homes. Among the 148 deaths, 93 occurred in boy babies and 55 in girls. Of the births 1,630 were males and 1,517 females. The infantile mortality rate for the two sexes was, therefore:—Boys, 57 ; girls, 36. Neo-Natal Mortality. Number of deaths within the first month of life:— Year. No. of Deaths. No. of Births. Rate. 1925 68 3506 19/1000 live births. 1926 80 3477 23 ,, „ ,, 1927 83 3174 26" " " 1928 66 3374 20" " " 1929 88 3399 26" " " 1930 82 3614 23 ,, „ 1931 88 3400 26 " " " 1932 82 3311 25 ,, „ „ 1933 83 3147 26 „ „ „ 194 The rate of infant mortality amongst illegitimate children was 144 per 1,000. The rate in legitimate children was 43 per 1,000. The following table gives the causes of death during the first month of life:— I. Complications of Labour— 1 Cerebral Haemorrhage 3 Trauma at Birth 2 5 II. FOetai. States— Congenital Heart Malformation 3 Other Congenital Deformities 3 Atelectasis 9 Congenital Debility and Marasmus 3 Purpura Hsemorrhagica 1 Syphilis 2 21 III. Prematurity 46 46 IV. Post-Natal Causes 11 1 83 The rate of infantile mortality for England and Wales in 1933 was 64, and for the 118 large towns 67. The rate for Croydon is therefore considerably lower than the average rate. An analysis of Table LXXXVII shows that, of the total infant deaths, 18.9% occurred on the first day of life and 56.1% before the completion of the first month, and it is probable that these deaths were due to causes operating before birth except in so far as accidents of birth (5) are concerned. 196 Table LXXXVII. Deaths under one year, arranged in days, weeks and months. CAUSES OF DEATH 1st day. 2nd day. 3rd day. 4tb day. 5th day. 6th day. 7th day. lst-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 mths. 11-12 mths. total. All Causes Certified 28 7 9 1 3 2 1 16 10 6 83 11 7 7 5 5 4 8 4 6 4 4 148 Uncertified - - - - - - - - - - - - - - - - - - - - - - - Chicken-pox - - - - - - - - - - - - - - - - - - - - - - - Measles - - - - - - - - - - - - - - - - - - - 1 - 1 3 Scarlet Fever - - - - - - - - - - - - - - - - - - - - - - - Whooping Cough - - - - - - - - - - - - - - - - - 1 - - - - 1 Diphtheria and Croup - - - - - - - - - - - - - - - - - - - - - - - Tuberculous Meningitis - - - - - - - - - - - - - - - - 1 - - - - 11 2 Abdominal Tuberculosis - - - - - - - - - - - - - - - - - - - - - - - Other Tuberculous Diseases - - - - - - - - - - - - - - - - 1 - - - 1 - 2 Meningitis [not Tuberculous) - - - - - - - - - - 1 - - - - - - 1 - - - - 2 Convulsions - - - - - - - - 1 - 1 - - - - - - - - - - - 1 Laryngitis - - - - - - - - - - - - - - - - - - - - - - - Bronchitis - - - - - - - - 1 - 1 1 - - - - - 1 - - - - 3 Pneumonia (all forms) - - - - - - - 2 1 1 4 3 2 5 2 - l 3 2 2 1 25 Dianboea and Enteiitis - - - - - - - - l - 1 4 1 1 3 2 l 1 1 3 - - 18 Gastritis - - - - - - - - - - - - - - - - - - - - - - - Syphilis 1 - - - - - - 1 - - 2 - - - - - - - - - - - 2 Rickets - - - - - - - - - - - - - - - - - - - - - - - Congenital Malformations - 1 - - - - - 4 1 - 6 1 - 1 - 2 - - 1 - - - 11 Premature Birth 18 4 8 1 2 - 1 5 5 2 46 - 1 - - - - - - - - - 47 Atrophy, Atelectasis, Debility, and Marasmus 7 1 1 - 1 - - 1 - 1 12 l l - - - - - - - - - 14 Injury at birth 2 1 - - - 1 - 1 - - 5 - - - - - - - - - - - 5 Other causes - - - - - - - 2 - 2 4 1 2 - - 1 - 1 1 - 1 1 12 196 Deaths Under One Month. An analysis of Table LXXXVII shows that 18.9 of the infant deaths occurred before the baby was 24 hours old; 34.4% during the first week of life; and 56.1% before the end of the first month. In 1932 the corresponding figures were 21%, 38%, and 51%. 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 57% of deaths under 1 month of life. In the same group can be placed debility which was the cause of 14%. Injury at birth is rather different, inasmuch as it is, by skilled ante-natal and natal attention, avoidable ; injury caused 6.0% of the deaths. Deaths under one month due to congenital deformities constituted 6.0% of the whole during this age period. It is interesting to see that conditions probably brought on by faulty feeding played practically no part in this mortality. This group of deaths contributed 12.1 per 1,000 births towards the total infantile mortality rate. Deaths Under Three Months. One hundred and one babies died during the first three months of life, a percentage of the total infant deaths of 68%, and an infant mortality rate of 32 per 1,000 births. As the total infantile mortality rate was 47, it is seen that two-thirds 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 end of the third month shows the chief of these to be : Diarrhoea, 5 deaths and Pneumonia, 5 deaths. The effects of improper feeding, and exposure to infection, are commencing to make themselves felt, and Pneumonia is the outstanding cause of death. Deaths between the 4th month and the end of the first year of life were caused chiefly bv Diarrhoea (25.5%) and Pneumonia (34.0%). The Pneumonia deaths occurred in the following months:— January 5, February 3, March 4, April 1, June 1, July 1, September 1, October 1, November 2, December 6. 107 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 for 41% of the total deaths, and contributed 19.4 deaths per 1,000 births towards the infantile mortality rate. (2) Next to these come Pneumonia and Diarrhoea with 36% of the total deaths and a contribution of 16.8 per 1,000 to the infantile mortality rate. (3) The influence of pre-natal 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 only 1 death. In 1932 it caused 8 deaths. There were 3 deaths from Measles. (5) In the tabulated deaths of children under 1 year of age, the child who died was a first child in 36.1% ; a second child in 20.5% ; a third child in 13.1% ; a fourth child in 12.3% ; a fifth child in 6.6% ; a sixth child in 3.3% ; a seventh child in 1.6% ; an eighth in 0.8% ; a ninth in 1.6% ; a tenth in 0.8% ; and a fourteenth in 0.8%. In 2.5% of total deaths no data were forthcoming owing to the parents having moved, or for other reasons. The following table gives the chief causes of infant deaths, as compared with 1932:— Table TiXXXVIII. Percentage Deaths per Total Infantile Deaths. Deaths per 1,000 Births. 1933. 1932. 1933. 1932. Premature Births 31.8 29.8 14.9 14.5 Respiratory Diseases 18.9 21.7 8.9 10.6 Infectious Diseases (inc. Tuberculosis) 5.4 5.6 2.5 2.7 Atelectasis, Debility and Marasmus 9.5 10.6 4.4 5.1 Diseases of Digestion 12.2 10.6 5.7 5.1 Accidental & Congenital 11.5 13.0 5.4 6.3 198 Maternity and Child Welfare—Deaths of Infants under one year of age. Table LXXXIX. Births Deaths 1933 1932 1931 1930 Moitality per 1000 Births General Birth Rate General Death Kate Mortality per 1000 Birt s General Birth Rate General Death Kate Mortality per 1000 Births General Birth Rale General Death Kale Mortality per 1000 Births General Birth Rate General Death Rate January 261 20 78 14.5 17.9 79 15.5 15.9 88 15.1 20.0 42 16.9 11.6 February 255 17 72 14.2 19.5 49 14.9 16.3 101 16.8 18.7 75 14.2 12.9 March 337 16 48 15.0 11.8 45 15.0 14.0 109 13.9 17.5 60 15.1 13.8 April . 294 19 61 16.3 10.9 39 16.8 10.4 55 18.7 13.8 44 14.7 11.6 May 276 5 19 15.1 8.6 33 16.0 9.6 38 15.7 10.1 50 20.7 11.7 June 378 9 24 16.6 7.9 15 18.0 8.3 67 16.3 12.3 54 19.8 8.6 July 259 5 20 14.2 7.6 26 17.3 7.7 41 16.2 9.5 26 16.3 8.7 August 347 4 12 15.2 7.1 43 16.9 8.5 14 17.2 10.3 50 16.7 9.3 September 269 8 35 14.7 7.7 42 13.8 8.6 20 14.9 9.0 37 17.4 8.6 October 235 8 36 12.9 9.4 27 14.2 8.6 52 18.6 12.3 44 15.6 10.7 November 263 12 45 11.5 10.6 31 14.9 9.0 61 14.9 12.3 36 16.3 9.7 December 217 12 54 11.8 14.7 60 13.5 10.9 87 17.4 16.8 81 13.7 11.2 The Birth Kate was highest in March, April, June, and August, and the Infantile Mortality was lowest during May, June, July and August. The Death Rate was highest in January, February and December. Infantile Mortality was highest during January, February, 199 Infantile Mortality in Wards from 1927 to 1933. Table XC. 1927 1928 1929 1930 1931 1932 1933 Average over 7 years. Upper Norwood 73 80 70 108 80 76 57 78 Norbury 27 37 20 48 39 27 30 33 West Thornton 34 94 63 29 66 75 33 56 Bensham Manor 97 45 55 39 72 28 19 51 Thornton Heath 60 75 99 66 66 69 44 68 South Norwood 39 53 54 51 48 32 42 46 Woodside 57 42 59 40 37 30 50 45 East 32 25 63 40 30 68 46 43 Addiscombe 58 45 71 33 47 31 35 46 Whitehorse Manor 75 59 74 62 74 48 62 65 B oad Green 50 48 76 38 46 60 57 54 Central 29 58 42 51 91 22 15 44 Waddton 46 46 63 56 53 55 63 55 South 68 66 61 25 63 34 91 98 The wards with the highest average infant mortality over a seven year period are: Upper Norwood, Thornton Heath, and Whitehorse Manor; the lowest averages are recorded in Norbury, East and Central. 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. 93 midwives notified the Local Supervising Authority of their intention to practise within the Borough during 1933; 17 ceased practising in the Borough, so that 76 remained on the Register at the end of the year. Of these 72 were trained and held the certificate of the Central Midwives Board, and 1 was a bona-fide midwife, i.e., she was in practice as a midwife at the time of the passing of the Midwives Act, 1902, while 3 held the certificate of the London Obstetrical Society. 200 Confinements Attended by Midwives. Cases attended by midwives alone 2188 i.e., 66.8% of total births. Cases attended by Midwives when a doctor was also engaged 496 Cases attended by midwives when a doctor was also summoned 318 Total 3002 i.e., 91.7% of total births. 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 admission to a hospital or maternity home on the advice of the Ante-natal Clinic. The sum of £39 11s. 0d. was paid out during the year. For Complications during Pregnancy : Albuminuria 2 Threatened Abortion 4 Abortion 2 Other causes 3 — 11 For Complications during Labour : Breech 7 Foot 2 Face 4 Occipito-Posterior 2 Extended Breech 5 Prolapsed Cord .. 3 Transverse 3 Undiagnosed 8 — 34 Obstructed Labour 4 4 Delayed Labour— Uterine Inertia 3 Prolonged 42 Delayed 31 — 76 Hemorrhage— Ante-Partum 14 Post-Partum 7 — 21 Other Causes— Adherent Placenta 13 Illness of Mother 13 Retained Placenta 2 Twins 1 Torn Perineum ... 80 Eclampsia 2 — 1ll 201 For Complications during Puerperium: Pyrexia 14 Pain in Breasts 3 Pain in Legs 1 Other causes 3 — 21 For Complications in regard to the Baby : Inflammation of Eyes 9 Convulsions 2 Still-birth 1 Deformities 9 Feebleness 8 Skin Eruptions 4 Hemorrhage ... 1 Other causes 8 Premature Birth 4 — 46 In accordance with Rule 12a of the Central Midwives Board, the following reasons for the discontinuance of breast feeding were received:— Illness of Mother .3 Mother returning to business Weakness of Baby ... 1 life 4 Total 8 Inspection of Midwives. Dr. Falk is the inspector of midwives; she had 1 interview with a midwife at the Town Hall and paid 183 visits to the homes of midwives. Of these visits 96 proved ineffective, the midwife being out. The cleanliness of the midwives' homes and the condition of their bags were on the whole satisfactory. The keeping of case records and temperature charts were not always found kept upto-date. The Rules of the Central Midwives Board impose an obligation on 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 avail 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, 191 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 7 instances midwives availed themselves of these facilities. 202 Table XCI Nursing Homes (Registration) Act, 1927. Maternity Homes. Other Nursing Homes. Combined Maternity and other Nursing Homes. Total. No. of Homes on Register, on 31/12/32 16 13 25 54 No. of Applications for Registration during 1933 1 - 1 2 No. of Homes registered during 1933 1 - 1 2 No. of Orders made : (a) Refusing Registration — — — — (b) Cancelling Registration. 3 — 1 4 No. of Appeals against such Orders No. of Cases in which Orders have been : (a) Confirmed on Appeal - - - -- (b) Disallowed — — — — No. of Applications for exemption from registration - - - - No. of Cases in which exemption has been : (a) Granted — — — — (b) Withdrawn (c) Refused — .— — — No. of Homes on Register on 31/12/33 14 13 25 52 No. of Beds available 64 197 (a) Mat. beds 54 (a) 118 (b) Other Beds 90 (b) 287 Doctors' Accounts Under Section 14 (1) of the Midwives Act, 1918. 140 accounts were received from doctors for services rendered under the provisions of this section. This compares with 153 in 1932, 136 in 1931, 149 in 1930, and 112 in 1929. The total amount of the accounts was £225 0s. 0d. £52 5s. 6d. was ultimately recovered from the patients. In 1932 the amount paid to doctors was £230 1s. 6d., and in 1931, £224 5s. 6d, 203 The Maternity and Child Welfare Clinics. There are 17 Maternity and Child Welfare Centres, 16 of which are conducted by the Croydon Mothers' and Infants' Welfare Association, and 1 by the Local Authority. A total of 20 sessions per week are held and at all of these a doctor and a nurse on the staff of the Health Department attend. During 1933, 2,194 new cases under 1 year of age, and 1,027 over a year of age attended for the first time; this is a decrease of 84 in the first class and of 25 in the second class. The total attendances of babies and infants from 0.5 years increased from 73,136 in 1932 to 77,463 in 1933. Consultations with doctors increased in numbers from 24,652 to 25,251. Three hundred and five expectant mothers were seen, a decrease of 29 on 1932, and a total of 1,211 visits to the centres were paid by them. The total of all visits to the Centres was 78,674, an increase of 4,169 over 1932. This is the greatest total yet reached and serves to indicate the appreciation of the services rendered. The highest average attendance of mother and babies at each session was recorded at Lower Addiscombe Road (108.6), West Croydon (107.8), Municipal (98.7), and Norbury (96.5). 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 foundation of new centres has not 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 Norburv, Upper Norwood and Shirley, a certain proportion of mothers attend whose place of residence is outside the Borough. In order to curtail the numbers, instructions were given that mothers livingf outside the Borough should not be permitted to see the doctor or to obtain dried milk, etc., at the centres. Some of the centres have shown, in consequence, a reduced attendance. 204 Table XCII. Attendances at Infant Centres—1933. Municipal. Boston Road. Sylverdale Road South Croydon. Shirley. Woodside. Lt. Addiscombe Road. South Norwood. Westow Street. Moffatt Road. St. Alban's. St. Paul's. St. Oswald's. West Croydon. Norbury. Waddon. St. Jude's. Total 1933. Total 1932. Total 1931. Total 1930. Total 1929. Infants: New cases under 1 year . 343 93 101 120 72 121 154 210 77 69 208 75 66 151 121 95 118 2194 2278 2217 2148 1991 No. of re-attendances 5335 1205 1549 1944 955 1667 2364 3831 1424 1229 3669 1560 1336 2527 2275 1473 2277 36620 35161 33237 31418 2743 New cases over 1 year 137 69 43 48 30 58 91 81 61 25 104 31 18 40 44 97 50 1027 1052 895 708 813 No. of re-attendances 3905 2371 1633 1775 1164 1669 2473 3990 1803 1542 4103 1745 1545 2529 2331 1897 1147 37622 34645 31434 28025 25559 Attendances of children 0-5 9720 3738 3326 3887 2221 3515 5082 8112 3365 2865 8084 3411 2965 5247 4771 3562 3592 77463 73136 67783 62299 55794 Consultations with Doctor 2864 1013 1208 1235 836 1450 1570 2692 1280 1270 2781 1296 1047 1355 927 1233 1194 25251 24652 23068 21697 21088 No. of Sessions 100 50 48 50 48 48 48 99 50 47 100 48 48 49 50 48 48 979 972 928 927 881 Expectant Mothers : No. of new cases 77 — 2 2 14 7 29 32 22 19 43 20 9 3 16 4 6 305 334 398 531 573 No. of re-attendances 78 49 30 6 34 1 102 117 79 91 106 53 24 34 36 38 28 906 1035 1038 1121 881 Total attendances of Expectant Mothers 155 49 32 8 48 8 131 149 101 110 149 73 33 37 52 42 34 1211 1369 1436 1652 1730 Total attendances 9875 3787 3358 38t5 2269 3523 5213 8261 3466 2975 8233 3484 2998 5284 4823 3604 3626 78674 74505 69219 63951 57524 Average attendance per Session 1933 98.7 75.7 70.0 77.9 47.3 73.4 108.6 83.4 69.3 63.3 82.3 72.6 62.5 107.8 96.5 75.1 75.5 *80.4 1932 88.0 79.2 71.4 71.1 46.4 79.4 97.1 78.4 74.4 66.6 74.6 68.0 67.7 98.1 102.3 70.6 52.9 ... *76.7 1931 82.7 68.0 67.3 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 58.7 68.4 78.0 37.7 66.4 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 1 66.5 74.3 62.0 59.0 62.8 77.5 34.5 71.2 106.4 47.3 ... ... ... ... ... *65.3 * Total average attendance each week at all the Centres. 205 The following table is intended to show the deaths of babies who at one time or another during their first year attended a clinic, as compared with deaths among those who never attended. If a baby only attended once it is included in the clinic returns : — Table XCIII. Deaths Attended M. & C. W centre Attended at Bi rth 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 Hospital Sick Nursery Kegd. Maternity Homes St. Mary's Hospital Other Institutions or Elsewhere 122 25 97 28 49 40 5 71 51 - 3147 44 3 4 6 8 2,194 babies under one year of age attended the clinics for the first time during 1933. Within the same period 3,147 babies were born and 148 died ; 26 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 122 babies who died, 25 had attended a clinic in Croydon and 97 had not attended, i.e., 20.5% of the deaths were in clinic babies and 79.5% in non-clinic babies. Of the 3,147 babies born, approximately 70% attended or would attend on calculation based on past attendances. The infantile mortality, estimated on this basis is only 11.6 per 1,000 births for the "clinic" babies, and 101.8 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 89% 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, only 80% were found healthy on the first visit, which may be interpreted to mean that when a mother first attends a clinic with a child over a year old she does 206 so because progress is not satisfactory; 69% of babies under 1 year were being breast fed at their first visit, this figure being less than 1932 (70), 36.3% of the ailing babies were suffering from digestive troubles, 13.1% from respiratory trouble, and 8.6% from rickets. The individual centres showing the highest percentage of babies found healthy on their first visit were East Croydon (100) and Woodside (99). Waddon and Municipal, with 98 and 95 respectively, were next. The centres showing the highest percentage of babies found ailing on their first visit were Upper Norwood, All Saints' and St. Alban's, followed by South Croydon, Central, and Shirley. Breast feeding seemed most usual in babies living in the St. Paul's, South Croydon, Municipal, East Croydon, and St. Oswald's districts, and least usual in the Shirley, Central, and Boston Road districts. In children over one year of age, attending for the first time, the highest percentages healthy were shown by East Croydon (97), Municipal (96), and Woodside (95); the highest percentages found unhealthy were at Sylverdale (53), All Saints' (52), South Crovdon (45), tipper Norwood (39), and St. Alban's (37). The largest number of first attendances was recorded at the Municipal Centre, followed by South Norwood, East Crovdon, and St. Alban's. These centres hold two sessions weekly, with the exception of East Croydon. 207 The Conditions of Babies on First Attendance at a Maternity and Child Welfare Centre. Babies Under One Year Children Over One Year. Table XCIV. 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 Tioubles. | Rickets. j Respiratory Troubles Other Causes. No. still on Breast at 1st visit. No. Weaned and on solid food. Percentage. | No. not Weaned and on bottle entirelv No. on solid food and the Breast. No. on solid food and the bottle. Total first attendances tabulated. Municipal (2) 279 95 14 8 0 1 5 225 76 45 23 115 96 5 1 0 1 3 2 117 97 0 1 0 413 St. Albans (2) 138 78 35 18 0 3 14 111 68 46 6 38 63 22 6 1 3 12 2 53 88 0 0 5 223 Boston Road 64 88 8 6 1 1 0 42 58 20 10 41 80 10 2 5 3 0 0 44 86 1 1 5 123 West Croydon 112 88 14 8 0 1 5 90 71 30 6 41 79 11 3 2 3 3 0 45 86 0 1 6 178 Norbury 86 86 14 7 0 1 6 60 60 16 24 31 70 13 2 4 0 7 0 44 100 0 0 0 144 St. Paul's 53 87 8 7 0 0 1 48 79 10 3 19 87 3 1 0 1 1 0 22 100 0 0 0 83 All Saints 49 77 14 6 0 1 7 39 62 20 4 15 48 16 3 2 2 9 0 23 74 0 1 7 94 Shirley 58 83 12 1 1 0 10 40 57 20 10 20 74 7 1 1 0 5 0 27 100 0 0 0 97 South Croydon 94 82 20 8 0 2 10 89 78 21 4 23 55 18 2 4 1 11 1 31 75 0 1 8 155 South Norwood(2) 167 90 19 14 0 4 1 134 70 42 10 49 80 12 4 0 0 8 0 59 96 1 1 0 247 Sylverdale Road 9'2 82 20 8 1 0 6 64 57 36 12 9 47 10 1 2 2 5 0 17 89 0 0 2 131 Upper Norwood . 43 76 13 4 0 4 5 35 62 15 6 35 61 22 3 5 2 12 0 47 82 1 1 8 113 101 98 2 1 1 0 0 76 72 12 15 58 92 5 1 1 2 1 0 57 90 3 3 0 166 East Croydon 147 1(10 0 0 0 0 0 109 74 11 27 94 97 3 0 2 0 1 6 90 93 0 0 1 244 Woodside 142 99 2 1 0 0 1 102 71 26 16 40 95 2 0 0 0 2 0 39 93 1 1 1 186 St. Oswald's 56 92 5 3 0 1 1 45 73 11 5 14 93 1 0 0 0 1 0 10 67 0 0 5 76 St. Judes 91 86 15 7 0 2 6 69 65 25 12 51 86 8 2 0 4 2 0 51 86 0 0 8 165 Totals 1762 89 215 107 4 26 78 1378 69 406 193 693 80 168 32 29 24 83 11 776 90 7 11 56 2838 203 Clinic Sessions Attended by Health Visitors. Table XCV. Nature of Clinic. Health Visitor—-District Number. i. ii. iii. iv. v v, vii. viii ix x. xi. xii. xiii. xiv xv. xvi xvii xviii xix. xx. Total. Maternity & Child Welfare Clinics 95 48 36 53 54 44 55 12 51 51 56 40 3 49 53 17 83 51 54 43* 979 Ante-natal and P'ost-natal Clinics ... ... ... 2 ... ... 44 ... 61 ... ... ... 264 ... ... ... ... ... ... ... 371 Temporary visitors 209 Table XCVI. The Work of the Health Visitors.—Home Yisiting.—Maternity and Child Welfare Only. I c.w. II. r.a. III. d.h. IV. b.w. v. a.ww vi. j.t. vii m.s. viii. a..p. ix. v.b. x. a.w. xi. j.c. xii. e.h. xiii. c.g. xiv. a.h. xv. a.C. xvi. k. r. xvii. v.c. xviii. L.M & k-h. xix. m.C. xx. r.s. TOTAL VISITS Visits to Expectant Mothers. First visits 32 6 12 10 25 14 21 2 29 11 12 5 34 5 27 14 7 6 48 1 321 Re-visits. 20 5 19 16 6 6 17 ... 9 1 3 16 12 1 33 2 6 11 25 1 209 Infants under 1 year. First visits 256 104 145 61 115 202 108 110 232 328 193 84 230 236 102 210 142 64 325 196 3443 Re-visits 418 272 529 204 299 364 217 306 394 380 558 784 214 602 525 247 384 216 798 476 8187 Children 1—2 years. First visits 7 ... 1 1 1 7 2 61 6 1 25 1 5 8 23 63 10 2 2 5 231 Re-visits 470 289 422 232 232 407 256 120 229 385 396 693 302 368 447 190 391 205 814 563 7411 Children 2—5 years. First visits 5 ... ... ... 1 4 2 24 16 ... 10 6 1 8 20 92 10 5 12 3 219 Re-visits 1082 567 361 650 613 665 630 549 279 753 271 897 425 537 554 608 493 473 777 1114 12298 Ophthalmia Neonatorum. First visits ... 1 1 ... ... ... 1 ... 1 1 ... ... 1 1 ... ... ... ... 1 ... 8 Re visits ... ... 1 19 ... 1 1 ... 1 4 ... ... 3 4 ... 2 ... ... ... ... 36 Still Births 7 1 1 8 1 7 1 2 3 11 3 1 8 5 ... 9 3 3 9 4 87 Milk (Mothers' and Children's Order) 4 37 76 33 ... 4 4 1 12 9 6 15 11 5 ... 13 2 16 9 97 354 Puerperal Fever and Pyrexia Visits ... ... ... ... ... ... ... ... ... ... 9 ... ... ... ... ... ... ... ... ... 9 Houses where deaths of Infants occurred 19 5 3 17 5 12 3 6 6 16 1 6 11 8 1 10 14 5 17 25 190 Miscellaneous Visits 21 33 11 355 15 96 141 1 23 21 38 10 32 23 2 109 6 15 10 5 967 Ineffective Visits 405 300 319 457 511 470 575 402 421 339 362 402 299 267 169 244 488 282 264 963 7999 Post Natal Visits ... ... 3 ... ... ... 13 ... 75 101 ... 1 ... ... ... ... ... ... ... ... 193 Totals—5933 2806 1620 1904 2063 1824 2259 1992 1584 1736 2361 1887 2921 1588 2078 1903 1813 1956 1303 3111 3453 42162 1912 1942 1662 2112 1766 2107 2854 1949 2123 2034 1443 2826 1609 2533 3757 2298 2278 349 2843 42512 210 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. The Borough Council 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. All wet milk ordered under cost price is paid for by the Council. Table XCVII. On Dee. 31st, 1932. New cases during the year. Cases discontinued. On Dec. 31st, 1933. Free 479 751 864 366 Half-price 109 184 217 76 Total 588 935 1081 442 The effect of the depressed industrial conditions is reflected in the increase in the number of free cases over 1932. In cases where there has been a change from free milk to milk at half-price it has been counted as a new case. Assisted Fluid Milk Scheme. There has been an increase in the amount of free milk granted from 117,089 pints to 121,392 pints. Supplied to Families. No. of Pints. Corporation Liability. £ s. d Milk at 1½d. pt. 23090 164 16 9½ Milk Free 98302 1316 15 5 121392 1481 12 2½ Dried Milks for Year 1933. 1 am much indebted to Mrs. Chambers, of the Croydon Mothers' and Infants' Welfare 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 1932 in the amount of driedmilk given free, and a decrease in the amount sold at full or half-price. 211 Table XCVIII. Mothers and Infants Welfare Association. (17 sessions per week). Municipal Centre. (2 sessions per week). Free. Halfprice. Full price. Free. Halfprice Full price. January 430 82 973 146 8 284 February 461 74 982 140 14 259 March 421 81 971 135 15 255 April 467 79 993 113 6 219 Mav 378 87 997 141 7 218 June 302 89 985 118 — 171 July 351 113 1003 130 — 181 August 393 136 901 143 2 179 September 336 119 919 103 13 198 October 372 113 953 111 16 217 November 354 129 963 134 17 221 December 341 105 971 108 15 175 Totals 4.576 1207 11614 1522 113 2637 Observation Nursery. 110 babies and 8 mothers were admitted, as compared with 76 babies and 2 mothers in 1932. The average length of stay was 30 days, as compared with 38 days in 1932. The following table gives particulars: — No. of cases in on 1st January, 1933.. 10 No. of cases admitted during 1933 ... 110 Average duration of stay 30 days No. of cases discharged 98 (a) In good health 85 (b) Improved 9 (c) No improvement 4 No. of cases who died 3 No. in at end of 1933 10 Three cases were transferred to Mayday Hospital for: — (1) Glands of neck; (2) Syphilis; (3 Pyloric stenosis. The causes of death were: — Prematurity, 1; Cyst at base of tongue, 1; Gastroenteritis (baby moribund on admission), 1. The chief reasons for the admission of cases were as follows: — Alimentary disorders 19 Acute gastro-enteritis 1 Failure to thrive 36 Prematurity 8 Re-establishment of breast feeding 2 Jaundice 1 Pyloric obstruction 1 Mismanagement 10 Congenital syphilis 1 Marasmus 2 Cyst of tongue 1 Rickets 14 Teething 2 Weaning troubles 2 Limitted from St. Mary's with mother 6 Congenital deformities 2 Convulsions 2 Total 110 212 Massage Clinic. The massage clinic in connection with the M. and C.W. Scheme is held at Lodge Road 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 type of case referred. Total number of female patients 45 ,, ,, male patients 41 Total . 86 Table XCIX. Conditions for which referred Males. Females. Total. Mouth Breathing 1 ... 1 Scoliosis 1 1 General backwardness 2 1 3 Infantile Paralysis 2 1 3 Weak legs 7 7 14 Bow legs 15 15 30 Knock-knees 7 7 14 Flat-feet Hemiplegia 1 ... 1 Torticollis ... 1 1 Scar tissue ... ... 1 1 Valgus ankles 2 7 9 Spastic Paraplegia 2 1 3 Weak back 2 1 3 Congenital dislocation of hip ... 1 1 Constipation ... 1 1 Totals 41 45 86 Total number of sessions 251 ,, ,, attendances 1,575 Average attendance per session . 7 Cases still under treatment at end of 1933 25 213 Dental Treatment of Maternity and Child Welfare Patients. Expectant and nursing mothers and young children requiring treatment are referred by the Medical Officers attending the ante;ind post-natal Clinics. The dental surgeons also visit the Centres and give talks to mothers and inspect the teeth of young children. It is to be regretted that it was impossible to visit all the Centres during the year, as these visits afford the dental surgeon a unique opportunity of educating the mothers in dental matters. EXPECTANT MOTHERS. Month of pregnancy at which mother first examined : — Up to 3 4-6 7 & 8 months. months. months. % of cases seen in 1932 10.3 53.9 35.8 ,, ,, 1933 12.9 56.7 30.4 The above table shows that there is a decided improvement in the number of mothers who attend in the early months of pregnancy. A study of the table shows that 69.6% were examined and treated before the seventh month, compared with 64.2% in 1932. There appears to be every indication that women are beginning to realise the value of dental treatment before the child is born. It is, of course, unfortunate that treatment has to be obtained during pregnancy, but as the majority of mothers have not had previous opportunities of having their teeth treated dental attention at such a time is inevitable. In most cases mothers have marked oral sepsis, and it is essential that dental disease should be eradicated to prevent a menace to the mother's health and that of the unborn child. 214 Table C. Expectant. Nursing. Young Children. Total. 1933. 1932. Number Examined 181 158 212 551 643 Referred for Treatment 151 145 208 504 553 Treated 128 140 206 474 467 Attendances 355 798 589 1742 1689 Fillings 60 110 207 377 376 Extractions 668 898 838 2404 1846 "Gas" Cases 91 115 151 357 310 Local Anaesthesia 87 86 130 303 184 Scalings 23 50 4 77 99 Dressings 42 95 34 171 566 Denture Dressings 36 233 — 269 Gum Treatment 9 17 1 27 53 AgNo3 — — 43 43 14 Sessions at Centres—12. Number of Dentures fitted—95. The number of expectant and nursing mothers and young children examined decreased from 643 in 1932 to 551 in 1933. 1 he number actually treated was 474, which was practically the same as the previous year. It is very gratifying that the attendances have increased and that the amount of conservative treatment has been maintained. Local anæsthesia shows an upward trend, due to its more frequent use in filling operations. The extractions show an increase, but this is inevitable, as so many mothers have teeth which are beyond any type of conservative dentistry. It should be borne in mind that these mothers have had little, if any, treatment since they left school; consequently, their teeth show much evidence of neglect. The sessions devoted to treatment totalled 129, compared with 135 in 1932. This reduction in the number of treatment sessions is due to the illness of one of the dental surgeons. 215 NURSING MOTHERS. Age of baby when mother was first seen: — 1-3 4-6 7-9 Over 9 months. months. months. months. % Mothers seen 1932 36.7 36.2 18.3 9.8 1933 38.7 32.0 18.6 10.7 There are some mothers who seem to be alarmed at undergoing treatment during pregnancy, and wait until the nursing period before attending the Clinic. In such cases treatment must be confined to the elimination of pain and sepsis. The scheme was organised for the benefit of the child, and if mothers do not seek treatment during pregnancy, dental treatment must be restricted accordingly. THE PRE-SCHOOL CHILD. The dental examination of young children in many cases reveals very advanced dental disease. Some of the dentitions are so ravaged by dental decay that impairment of health must result if the condition is not treated. It would appear from a brief study of the number of young children examined that some mothers are not taking full advantage of the facilities for dental treatment of their children. There are mothers who forget that child welfare centres are institutions for the education and supervision of the health of the child up to the age of five years. It seems that mothers are particularly keen on bringing their children to see the dentist up to the age of two years, and they appear very concerned about small defects that usually right themselves, but when the child gets older such attendance and keenness at the Centres appears to decline. This apathy on the part of mothers throws an unnecessary burden on the School Dental Service, and it accounts for the high incidence of dental defects in the entrant school child. Only 10% of the entrant school children in 1933 were brought to the Clinic for dental treatment during the pre-school period. 216 The Centres at which patients were examined, or from which they were referred, are given in the following list: — Ante-natal 146 Thornton Heath (1) 13 Addiscombe (East) 29 Thornton Heath (2) 38 Municipal 50 Waddon (1) 23 Shirley . 4 Waddon (2)23 Norbury 10 West Croydon 12 Upper Norwood ... 25 West Thornton (Boston Moffatt Road . 31 Road) . 23 South Croydon 24 St. Jude's 19 Woodside 31 The Retreat 5 South Norwood 48 Milton House. 4 St. Oswald's10 The sum of £46 13s. 6d. was received in payment for the attendances made by mothers and children at Lodge Road and Selhurst Road Clinics. 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; 15 cases were helped during 1933; 9 remained on the books. 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 medical 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 138 Children sent away alone to Convalescent Homes— (а) to Coombe Cliff 29 (b) to other Homes 18 — 47 In addition, 5 children, with mothers, were sent away to relations. 217 A grant of £450 was made by the Council to the Association for this work in 1933. I am indebted to Mrs. W. Horn. Hon. Secretary of the Association, for the following patriculars 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 6 1930—1931 31 217 201 7 6 173 0 0 1931—1932 42 341 296 6 1 378 7 6 1932 (Apr. 1st to Dec. 31st) 32 291 219 11 7 302 2 3 1933 47 361 322 18 11 379 7 7 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 1933: — (a) Expectant mothers 19 (b) Mothers and babies 13 Wilford Road, Lighthouse Mission Creche. The Council give an annual grant of £100 towards the cost of this Creche. A total of 6,464 attendances was recorded. The premises in which the Creche is conducted are cramped and unsuitable. COOMBE CLIFF CONVALESCENT HOSPITAL. 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. 218 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 during year : 143. Total number of cases discharged : 151. No. of patient days : 67.7 per patient (1933 cases). Table CI. Age groups of cases admitted:— 0—4 5—8 9—12 Over 12 Total Male 19 29 20 2 70 Female 20 26 23 4 73 Total 39 55 43 6 143 Average length of stay in similar age groups:— 0-4 5—8 9—12 Over 12 Total (days) Male 61.6 58.3 59.4 43.5 59.1 Female 72.4 84.8 71.8 59.0 75.9 Total 67 3 70.8 66.0 53.8 67.7 Condition on Discharge:-— 0-4 5-8 9-12 Over 12 Total M. F. M. F. M. F. M. F. M. F. Improved 9 9 13 7 12 11 1 35 27 Much Improved 3 7 14 12 6 9 2 3 25 31 No change 5 3 5 4 4 4 — 2 14 13 Discharged at parent's request 1 1 2 — — 1 — 1 3 3 Total 18 20 34 23 22 25 3 6 77 74 CHILDREN'S ACTS, 1908—1933. 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. 219 The tables below give figures for 1933. Table CI I. FOSTER CHILDREN No. as at Dec, 3»st, 1933 Notice of Reception of Children during the year Notice of Removal to— Children Adopted Died Children reaching age of 0 No. as at December 3ltt, 1033 Parent Another area with Foster Parent Another Foster Mother Public Institution 244 279 93 6 83 26 29 3 9 274 Table CIII. FOSTER MOTHERS. No. as at Dec. 31st, 1933 Applications for Registration during the year Removals during the year t Registration cancelled for othet reasons No. as at December 31st, 1933 With Child Without Child 258 69 5 22 93 207 The Health Visitors paid 3,058 visits to Foster Mothers for the purposes of supervision. 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 for payments of contributions of such amounts as might be specified ir, 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, has continued during 1933. 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 greart are now carried out by the Medical Officer of Health who reports from time to time to the Blind Persons Act Committee. 220 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. I am indebted to the Secretary of the Voluntary Association for the figures below. Number of blind on Register 335 Number of blind who benefit from instruction in Braille or Moon Type (including those who already read) 71 Number of blind who benefit from part-time instruction 38 Number in remunerative handicrafts— (a) Home workers 25 (b) In workshops 8 Home Teacher 1 The Health Visitors paid 1,051 visits to blind persons during the year. The Medical Officer also paid home visits to blind persons during the year. 221 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 deficient boys under the age of 16 years. The population in this small institution does not vary much. During the year 6 patients were admitted and one discharged on leave. The average number in was 18. The difficulties inherent in the conduction of a small institution of this kind have bean various, more particularly in the matter of staffing, and the Committee will close the Home as soon as suitable alternative accommodation can be found for the inmates. There are two main administrative groups of mentally defectives, viz.:— (a) 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. (b) 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. 222 Table CIV. Number of known Mentally Defective Persons in the Borough— 1. Statutory Cases — 1932. 1933. Aged 0—5 years 4 4 „ 5—16 ,, 83 71 Over 16 years 351 385 Total 438 460 II. Education Cases— Aged 7—16 years 136 152 Combined Total 574 612 Compared with 1932, the Statutory cases show an increase of 22 and the Education cases an increase of 16. The Statutory cases are distributed as follows:— 1932. 1933. In Certified Institutions 122 125 In Places of Safety or Approved Homes 6 4 On Leave from Institutions 14 9 Under Statutory Supervision at Home 216 217 Under Guardianship and on Leave 41 47 In Mental Hospitals 12 13 Cases Under Public Assistance 27 28 Observation Cases — 17 460 The Education cases were distributed as follows:— 1932. 1933. In Certified Residential Schools 11 10 In Certified Day Schools 103 110 At Private Schools 7 5 At Council Schools (10 waiting for vacancies at St. Christopher's) 6 14 At no school, resident at home 8 13 In other Institutions 1 — 152 223 In connection with mentally deficient cases, the Medical Officers made examinations and paid visits to the number of 101 for Statutory cases and 237 for Education cases, a total of 338. The mental deficiency visitor paid 1,531 visits to Statutory cases and 700 to Education cases, a total of 2,231. During the year 37 names have been added to the Statutory list, 13 being new cases; 24 were referred on from the Education Authority—14 as ineducable or not further educable, 9 for supervision on leaving the Special School on attaining the age of 16; and 1 for Institutional care or Guardianship. Three boys and 3 girls died during the year; three of these deaths occurred in institutions, the other deaths were of cases: 1 guardianship, and 2 others at home under supervision; 5 left the Borough, viz., 2 boys and 3 girls. Four cases chargeable to other Local Authorities are under supervision in the Borough. There are 9 children under observation, ages from 1½ to 6 years. Thirty Statutory cases were dealt with as follows:— Sent to Certified Institutions 5 Placed under Guardianship 9 Sent to Places of Safety 4 Allowed home on long leave 2 Transferred from one Institution to another 8 Discharged from Order 2 30 The number of cases sent to certified institutions shows a decrease of 5, owing to the difficulty of finding institutions with vacancies. Guardianship Cases. There are 45 cases under Statutory guardianship and 2 on leave; 25 of these are under the care of relatives, and 20 are with guardians who are not relations. Eight males and 5 females are at work. Thirteen cases are out of the Borough: ten under the Brighton Guardianship Society, one with a guardian in Essex, one in Suffolk, and another in Maidstone. Six boys and six girls attend the Occupation Centre at Grangewood. Sixteen of the Guardianship cases are doing useful work and fifteen are quite unemployable one lad died, one was removed to a. mental hospital and one absconded and has not yet been traced. 224 Cases on Leave from Institution. There are 9 cases on licence from institutions. Five are boys, and of these 3 are in regular employment and 2 are in Mayday Hospital. Four girls—2 in regular work, and 2 on trial in Homes. St. Christopher's Special School. The year 1933 opened with 105 scholars on the roll. During the year 29 children have been admitted, and 24 have left, giving a number of 110 on December 31st—65 boys, 45 girls. This is a School for Mentally Deficient children of the educable type, and in general appearance and behaviour they compare very favourably with normal children attending the Council's elementary schools. The School has now been in existence for over 21 years, but 1933 marks a great advance in the work and status of the School In October the School was moved from the Grange Wood Mansion to the old Rectory Manor School premises. These have been re-decorated and re-conditioned, and though, perhaps the School does not present a modern exterior, yet, the interior is now a satisfactory school building with a large hall, class-rooms, kitchen, bathroom and staff-rooms, etc. There is ample playground space, and each class has its own garden. The move has been a wise one, and it has been particularly interesting to observe the reaction of the children to their new environment, and to note that, unconsciously perhaps, they now take a pride in their School, and this is reflected in their demeanour, and in their attitude to work. They frequently remark:—''We have a School of our own now." The year has been one of good steady progress. The teachers have been helped by the scholars' good attendance. It is very seldom that children are absent, except for some really good reason. The children have had several outings in 1933. About 50 had a long day at Littlehampton in July, and visits were also made to the Zoo and Windsor Castle. These are very popular, and is far as possible, the poorest children are taken on these excursions. The children's prowess in Country Dancing is especially to be commended. It would be an "eye-opener" to many to see what they can do in this part of their training. The School now forms a group with a few elementary schools. and the children frequently attend Country Dance Parties, and take part in the dances. The Head Teacher would welcome visitors to see the games and dancing. 225 Mention must be made of the very excellent mid-day meals provided by the Education Committee. There is much variety in the menu, and the provision of these meals is an important factor in the progress and happiness of the children. It is suggested in the best interests of the School and the scholars that, although officially a School for the mentally defective, popularly it might always be referred to by its name, St. Christopher's, and thought of rather as a School for educationally backward children. Quite a number of the pupils pass out to do general work and become useful citizens. Town Hall Clinic for Mentally Defective and Backward Children. 93 children were examined during 1933. The classifications arrived at, together with the recommendations made, are marised as under:— I. (a) Certified as Mentally Defective 51 (b) Confirmed as Mentally Defective 4 55 Recommendations— (a) Recommended for Special Day School 40 (b) Recommended for Residential Schools 1 (c) Referred to Occupation Centre or Institution 8 (d) Supervision at home pro term. 6 55 II. Found to be dull and backward 24 (a) Referred to a Special Class 18 (b) Further trial in Ordinary Class 6 24 III. Found to be Physically Defective 3 (a) Recommended for Residential School for Deaf and Dumb 1 (b) Recommended for Residential School for Blind 1 (c) Recommended for Hospital Treatment. No School pro tem. 1 3 IV. (a) Considered to be of normal intelligence and referred to ordinary school 2 (b) Considered to he of normal intelligence and referred to work 1 3 V. Referred for re-examination 8 VI. Mental and physical examinations at St. Christopher's School 144 226 Grange wood Occupation Centre. The Occupation Centre is under the control of the Mental Deficiency Committee, and deals only with cases ineducable in a Special School. 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 Grange wood Museum. The special school which occupied the floor above removed to new premises at the old Rectory Manor School, Mitcham Road, toward the end of the year. Younger children attend daily mornings and afternoons (10 sessions) and the senior girls 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, as there are insufficient rooms available to allow of proper separation of the different grades of children. The premises vacated by the special school will be occupied by the Centre, by the permission of the Roads Committee, who however, have only granted the lease for one year. The Mental Deficiency Committee are considering the matter of alternative and more suitable accommodation. The staff consists of a supervisor and three assistants. The subjects taught to the younger children are, rhythmic movement drill band, rhythmic singing games, singing, sense training memory, colour, sound, numbers, elements of stitching and rag 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 pewter work, are made. Country dancing, drill and singing are also taught. The senior boys learn basket making, making wool rags, sea grass stools, raffia and cane work, papier mache bowls. All grades have domestic duty in preparing meals, washing up, polishing, etc. 227 The Christmas Party was held as usual, tea being provided together with presents off the Christmas tree for the children. Three open days for parents were also held. 1933. Details. Full Time. Part Time. No. on register January 1st, 1933 35 10 No. of pupils who left during year 6 — No. of pupils admitted during year 16 — No. of pupils on register January 1st, 1934 45 10 Total attendances 5809 790 Average morning attendance 28 (whole-time class) Average afternoon attendance senior girls' class 5 „ „ „ boys' „ 2 Sessions held 207 204 228 SECTION X. ORTHOPÆDIC DEPARTMENT. Cases referred for Orthopaedic treatment from the Tuberculosis, the School Medical 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 Orthopædic institutions for in-patient treatment. The after care organiser of the Department attends at each session. In addition to the Clinic at the General Hospital, concerning which only the tables below relate, 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 by medical officers at the Welfare Centres. Table CV. Summary of Cases Attending the Orthopœdic Clinic. Jan. 1st, 1933. New Cases, 1933. Cases Discharged, 1933. Cases on books, Dec. 31st, 1933. 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. 149 280 54 143 192 21 100 193 12 192 279 63 483 356 305 534 The Clinic continues to expand steadily. On January 1st, 1928, there were 229 cases on the books, by January, 1934, this figure had risen to 534; on January 1st, 1931, the figure was 439, on January 1st, 1932, 458; and on January 1st, 1933, 483; 305 cases were discharged as compared with 254 in 1932, and there were 356 new cases compared with 279 in the latter year. 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, to 31 in 1931. to 13 in 1932. In the year under review there was a small increase in the number, which was 21. 229 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 CVI. Cases seen by the Orthopœdic Surgeon. Defect. School. M.C.W. Tuberculosis. Total. Cases. Visits paid. Cases. Visits paid. Cases. Visits paid. Cases. Visits paid. Infantile Paralysis 31 71 7 25 ... ... 38 96 Scoliosis 57 108 4 7 ... ... 61 115 Pes Cavus 4 6 1 1 ... ... 5 7 Pet Planus 187 353 62 130 ... ... 249 483 Talipes* 15 25 37 113 ... ... 52 138 Genu Valgum 42 81 78 139 ... ... 120 220 Obstetrical Paralysis 16 25 1 1 ... ... 16 26 Tubercular Joint Disease ... ... ... ... 33a 73 36s 82 75 159 6m 4 Injuries 36 37 9 12 ... ... 45 49 Rickets 6 7 42 76 ... ... 48 83 Wry Neck 7 7 5 9 ... ... 12 16 Spastic Paraplegia 10 26 7 11 ... ... 17 37 Other Deformities 62 90 39 79 ... ... 101 169 472 836 292 603 75 159 839 1598 *Includes cases of ankle valgus, spasmodic valgus, and other predisposing causes of flat feet. Summarised, the Table shows 472 school children attended and made 886 attendances; 292 babies made 603 attendances ; and 75 tuberculosis cases made 159 attendances, a total of 839 cases, making 1,598 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. 230 Table CVII. Cases referred from Orthopaedic Clinic for Remedial Treatment and X-ray at Croydon General Hospital. Defects School Cases M.C.W. Cases Tuberculosis Cases Total Cases No. of Treatmerits X-Rays Cases No. of Treatments X-Rays Cases No. of ments X-Rays Cases No. of Treatments X-Rays Infantile Paralysis 6 148 1 4 108 ... ... ... ... 10 256 1 Scoliosis 29 645 3 2 69 2 ... ... ... 31 714 5 Pes Cavus 1 23 ... ... ... ... ... ... ... 1 23 ... Pes Planus 35 518 ... 1 23 ... ... ... ... 36 541 ... Talipes 2 30 ... 9 175 1 ... ... ... 11 205 1 Genu Valgum 7 98 2 4 55 2 ... ... ... 11 153 4 Obstetrical Paralysis 2 29 ... ... ... ... ... ... ... 2 29 ... Tuberc. Joint Disease ... ... ... ... ... ... 27 17 30 27 17 30 Injuries 15 48 10 4 ... 4 ... ... ... 19 48 14 Rickets ... ... ... 4 ... 4 ... ... ... 4 ... 4 Wry Neck 1 3 ... 4 45 ... ... ... ... 5 48 ... Spastic Paraplegia 5 69 ... 2 2 ... ... ... ... 7 71 ... Other Deformities 21 98 17 12 160 14 ... ... ... 33 258 31 124 1709 33 46 637 27 27 17 30 197 2363 90 Table CVIII. Cases Sent to Residential Institutions. Name of Institution School Cases M.C.W. Cases Tuberculosis Cases Total No. in on Jan 1st. 1934. No. in on Jan. 1st, 1933 Admitted Discharged No. in on Jan. 1st, 1933. Admitted Discharged No. in on Jan. 1st, 1933. Admitted Discharged No. in on Jan. 1st, 1933- Admitted Discharged Pyrford 2 5 2 ... 3 1 11 8 8 13 16 11 18 Croydon General 1 13 13 1 9 10 ... 7 7 2 29 30 1 3 18 15 1 12 11 11 15 15 15 45 41 19 231 The following Table shows the conditions for which patients were admitted to Hospitals and the results of treatment. Table CIX. Condition. In on Jan. 1st, 1933 Admitted. Cured. Discharged In on Jan. 1st, 1934. Much Improved. Improved. Died. Infantile Paralysis 2 2 ... ... 3 ... 1 Talipes ... 5 ... 2 3 ... ... Tuberc. Joint Disease 11 16 4 3 8 ... 12 Congenital Dislocated Hip ... 1 1 ... ... ... ... Observation Joint Disease ... 5 1 ... ... ... 4 Injuries 1 1 1 ... 1 ... ... Rickets ... 5 4 ... ... ... 1 Wry Neck ... 1 1 ... ... ... ... Spastic Paraplegia ... 2 ... ... 2 ... ... Other Deformities 1 5 4 1 ... ... 1 Scoliosis ... 2 1 ... ... 1 ... 15 45 17 6 17 1 19 The percentage of cures for the whole series of cases was 41.5%, whilst 14.6% were much improved. Table to show number of cases for whom appliances were ordered and how the expenses thereof were met:— Total cases on books of the Clinic Jan. 1st, 1934 534 Total number actually in receipt of massage, electrical Swedish remedial treatment on Jan. 1st, 1934 31 New splints and appliances supplied 83 Repair of existing appliances 11 Part cost met by parents 20% Full cost met by parents 42% Full cost met by Local Authority 37% Number of cases in which Hospital contributions were authorised 29 232 Mrs. D. B. Connor, the organiser of this department, attended 48 Clinic sessions, interviewed 2,134 people, made 312 enquiries into financial conditions of families, and sent out 954 letters m 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. 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 is 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. Cases were referred from the Tuberculosis Dispensary (4), the M and C.W. Department (46), and the School Medical Service (30). The following Table gives a summary of the attendances made: — Table CX. Department. No. of Cases. Aggregate duration of treatment in weeks. Aggregate No. of Sessions Attended. No. of Patients discharged. No. continuing treatment end of 1933. School Medical 30 285 897 23 7 M. & C. W. 46 374 1091 37 9 Tuberculosis 4 40 94 3 1 80 699 2082 63 17 233 The Table under gives the complaints treated and the results achieved in completed cases. Nine cases ceased attending before completion of treatment, one case was transferred to Mayday Hospital, and one went to a Convalescent Home. Table CXI. 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 4 4 ... ... 7 6 2 ... 23 Asthma 1 1 1 ... 2 ... ... ... 5 Bronchitis 2 1 ... ... ... 1 1 ... 5 Glands 1 ... ... ... 4 ... ... ... 5 Rickets ... ... ... ... 1 1 ... ... 2 Miscellaneous 3 1 ... ... 2 2 1 ... 9 11 7 1 ... 16 10 4 ... 49 School Cases. Seven School cases were still attending the Clinic at the end of the year. Asthma, 1: Alopecia, 1; Bronchitis, 2; General Debility, 2; Chronic Pulmonary Catarrh, 1. Maternity and Child Welfare Cases. Nine Maternity and Child Welfare cases were still attending the Clinic at the end of the year. These were suffering from the following conditions, viz.:—Debility, 3; Rickets, 2; Asthma, 1; Bronchitis, 1; Anaemia, 2, 234 Table CXII. Much Improved Improvement Slieht Improvement I.S.Q. Still attending at end of 1933 Total Lupus ... ... ... 1 1 2 Adenitis 1 ... ... ... ... 1 Sinusitis ... ... 1 ... ... 1 1 ... 1 1 1 4 Of the School cases, 17 were boys and 13 girls; the maternity and child, welfare cases, 24 boys and 22 girls, and the Tuberculosis patients, 2 male and 2 female. There is a tendency sometimes 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, 37.8% after completion of treatment, were much improved, 31.3% were improved, and 30.9% 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 60 of the cases; the latter alone in 7 cases, and both lamps in 13 cases. The use of artificial sunlight lamps in bathrooms is fraught with considerable risk and their installation should only be made under strict expert supervision. 235 SECTION XI. 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 majority 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 arrangements made at the Aerodrome for the convenience of passengers and for the examination of aliens are satistory. The arrangements 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. Table CXIII. LONDON TERMINAL AERODROME. Aliens Act, 1930. Medical Officer's Return for the year ending 31st December, 1933. Number of Planes. Arrived from Arr. Seen. Paris Amsterdam. Brussels. Elsewhere. Total: 4,437 2,018 2,573 1,037 582 245 Passengers. Attendances of M.O. British. Others. Inspected. Exd. 26,751 17,790 19,245 32 ... 364 These figures show a considerable increase on last year's figures both in the number of machines arriving and departing and in the number of passengers carried. This expeditious and safe method of travel is becoming steadily more popular. 236 MEMBERS OF THE EDUCATION COMMITTEE. NOVEMBER, 1932-1933. The Mayor (Alderman W. Peet, J.P.). Alderman A. Peters, C.B.E., J.P. (Chairman). P. Squire, Esq. (Vice-Chairman). Alderman T. Betteridge, J.B. Councillor Major F. W. Rees. Alderman H. J. Morland, M.A., J.P. Councillor H. Regan. Alderman T. W. Wood Roberts, J.P. Councillor Dr. A. Sandison, O.B. E. Alderman W. West. Councillor Rev. A. J. Stubbs. Councillor E. E. L. Arkell. V. Boys, Esq. Councillor E. S. Baker, O.B.E., J.P. W. A. Clarke, Esq. Councillor A. J. Carpenter. Mrs. R. L. Gurner. Councillor A. H. Harding. Mrs. M. A. Hinks. Councillor Eng.-Rear-Admiral Harrison. Capt. H. Lethbridge-Abell, F.Z.S. Councillor Mrs. Heighton, J.P. Mrs. R. Lewis. Councillor W. G. Higgins. Mrs. M. M. Wood Roberts. Councillor W. H. Jarvis. * G. Robinson, Esq. Councillor G. Lewin. Rev. G. M. Scott, M.A. Councillor J. Marshall. 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: Basil A. Dormer, M.B., B.S., D.P.H., B.Hy. Olive B. Falk, M.B., B.S. Iris Jenkin-Lloyd, M.R.C.S., L.R.C.P., D.P.H. J. R. Draper, B.A., M.B. (part-time). Specialist Part-Time Medical Officers: J. S. Bookless, F.R.C.S. (Ophthalmic Surgeon). Rota of i local medical practitioners for surgical treatment of tonsils and 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). Orthopaedic Work Organiser: Mrs. D. B.Connor (part-time). School Nurses: Two at clinics, 19 district nurses (part-time), and one supernumerary. Clerks: Five full-time and six part-time 237 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. and 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. EAR Treatment of Chronic Ear Discharge. Lodge Road. Alternate Tues., 2 p.m. DEFECTIVE CHILDREN Examination Town Hall. As required. X-RAY Treatment of Ringworm- Dr. Greig's Surgery. By appointment. ORTHOPÆDIC 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 ot Rickets, etc. do. Tues., 2 p.m. & Fri., 9 a.m. REMEDIAL EXERCISES Treatment of Deformities. St. Andrew's Hall, Pump Pail. 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 Alternate Thurs., 9 a.m. 238 County Borough of Croydon. ANNUAL REPORT of the SCHOOL MEDICAL OFFICER For the Year ending December 31st, 1933. Ladies and Gentlemen, I have the honour to present to you my sixth annual report on the work carried out by the School Medical Service. The form of the report follows that adopted last year. The number of routine medical inspections has been maintained by the employment of a part-time medical officer for four sessions a week; and the actual number of children inspeoted exceeds the figure for 1932 by 21. The number of Clinic sessions, however, has had to be restricted. The whole-time professional staff has remained unchanged during the greater part of the year. Dr. O'Connell, however, left the service of the Council in September, and his post was filled by the appointment of Dr. Dormer, who commenced his duties in November. 239 Co-ordination with Other Health Services. Close co-operation exists between the Public Health Department and the School Medical Service, as all the officers of the latter service are also engaged for a part of their time in Public Health work. Endeavours have been continued to obtain a closer continuity between the Maternity and Child Welfare work and the School Medical Service, but there appear to be inherent difficulties under the present system. If the facilities offered by the School Medical Service, in the way of routine medical and dental examinations, could be extended to the pre-school. child much closer working, with consequent decrease in the number of defects found in the Entrant group of school children, would accrue. At present there does not seem, however, much chance of such an extension. The gap which exists between the actual —as opposed to the theoretical—supervision of the Maternity and Child Welfare Service and the commencement of the School Medical supervision, is a most unfortunate one, leading, as the figures in my report show clearly, to an unduly high incidence of defects found in the five year old group. The continued co-operation of the Head Teachers and of the School Attendance Officers has been a valuable help without which much of the medical work and following up would have been difficult of proper fulfilment. As can be seen by the figures in Table I. parents have attended at the routine medical inspections whenever home duties allowed, and their presence at the examination is helpful because the doctor can explain personally any instructions he desires carried out. The Voluntary School Care Committees, and the Croydon Council of Social Service have also co-operated in the work. The Society for the Prevention of Cruelty to Children have, through Mr. Brown, their inspector, rendered assistance with a few difficult cases. 21 cases have been dealt with and of these 15 have been brought to a satisfactory conclusion, whilst 6 still remain under supervision. The inspector paid 47 visits during the year. 240 Structural Work and Decorations Carried Out in 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— Central Polytechnic. South Norwood Polytechnic. North Park Stores and Workshop. Internal Painting and Distempering at the following Schools— Purley Oaks. South Norwood. Sydenham. Rockmount. Addington (St. Mary's). New Schools or Departments Opened— St. Giles' (P.D.) School, Addington. St. George's Hall, Waddon (Temporary) South Norwood (Temporary). Alterations and Additions at the following Schools Christ Church—Reconstruction of W.C.'s. St. Christopher's—Adaptation of ground floor of Rectory Manor School.. Cost of the School Medical Service. The gross cost of the medical, dental and nursing services was £10,009; from this an income of £641 should be deducted, making a nett cost of £9,368. The rateable value of the Borough in 1933 was £2,070,619. The Government grant is 50 per cent, of the expenditure, hence the actual cost to the rates was £4,684, i.e., a rate of 0.54 pence. The nett cost of these services to the rates for 1933 per child on the school registers was 3s. 5.5d. The figures do not include £300 for Medical Inspection (Higher Education) and for Blind persons £490. Cost of Special Schools. Schools maintained by the Council £5,735; Contributions to schools under other authorities £3,403; Loans charges, £364; Other expenses (travelling, etc.), £24; Income from parents' contributions and other receipts, £854; giving an actual cost of £8,672, of which £4,410 was payable out of local rates, giving a rate of 0.51 pence. 241 Cost of Milk and Meals. Milk and meals cost £2,290 4s. 4d.; Income from parents' contributions £19 18s. 7d.; giving an actual cost of £2,270 5s. 9d. There has been a decrease in the cost of the actual medical services rendered in the Public Elementary Schools from 0.58 in 1932 and 0.61 of a penny rate in 1931 to 0.54 of a penny rate in 1933. The cost of maintenance in Special Schools has risen from 0.43 of a penny rate in 1932 to 0.51 in 1933. The cost of milk and meals has risen by £1,127. The Elementary Schools are now classified as Senior, boys, girls and mixed; Junior, boys, girls and mixed and Infants. The Table below gives the number of schools and the number of pupils in attendance thereat. The school population as given bv the average number on the registers has increased by 595. The average attendance was 90.0 per cent. Table I. No. of Schools. Average number on the Registers. Average attendance. ge attendance per cent. Senior Boys 11 C. 3556 3282 92 2 N.P. 451 426 95 Senior Girls 11 C. 3608 3262 90 2 N.P. 399 373 94 Senior Mixed 6 C. 2402 2221 93 4 N.P. 1288 1130 88 Junior Boys 7 C. 2723 2505 92 Junior Girls 8 C. 2916 2636 91 3 N.P. 726 653 91 Junior Mixed 8 C. 3452 3107 90 4 N.P. 889 769 87 Infants (216 under 5) 16 C. 4237 3663 86 3 N.P. 436 362 85 Schools— Church of England 13 4189 3713 89 Roman Catholic 2 Council 30 22894 20676 90 Total 45 27083 24389 90 "C"—Council. "N.P."—Non-Provided. 242 School closure has been proved in urban districts to have no influence on the spread of an epidemic. It is definitely disadvantageous in as much as a valuable means of keeping a close watch on the children is lost. Medical Inspection in Schools. Some rearrangement of duties has been carried out, as the assistant medical officer who left at the end of 1931, and who spent 9/llths of his time on school work, was not replaced. The deputy medical officer, Dr. Watson, relinquished some of his other work and devoted 5/llths of his time to medical inspections; Dr. Falk devoted 2/llths; Dr. Jenkin-Lloyd 3/llths; Dr. O'Connell 7/llths; whilst Dr. Draper acted as part-time medical officer for half the year, devoting 4 sessions a week to school medical inspections. Dr. O'Connell, however, left in September, and his successor did not commence his duties until the end of November. 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 II. 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 8,936 children were examined as compared with 8,532 in 1932, and 5,729 parents attended the examinations. The percentage attendance of parents in the entrants group was for boys 75 per cent., and girls 79 per cent.; in the intermediate group, boys 65 per cent., girls 71 per cent.; and in the leavers group, boys 37 per cent., girls 60 per cent. 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 employment. With the present lack of continuity between the school medical services and the medical examination of young persons under the Factorv Acts, advice given at the school leaving examinations assumes some degree of importance. The gap which also exists at present between the school leaving age of 14, and the adolescent coming under National Health Insurance Act at 16, is an unfortunate one. This period of life is one which may have an important bearing upon subsequent health both physical and mental. 243 The increase in the number of routine medical inspections was achieved by a reduction in the number of special treatment and inspection clinics. Table II Name of School. Entrants 5 to 6 years of age- Intermediates. 8 to 9 years of age. Leavers. Other Ages. Number Examined Parents present. Number 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 13 35 20 35 52 26 36 21 42 23 17 18 ... ... ... ... 2 Beulah 71 97 60 79 93 104 47 76 ... ... ... ... 55 44 31 34 3 British ... ... ... ... ... ... ... ... 169 97 55 60 ... ... ... ... 4 Davidson 37 39 29 34 37 44 27 29 57 67 18 37 ... 6 ... 3 5 Eccleibourne 39 35 32 29 56 50 38 26 ... 127 ... 62 ... ... ... ... 6 Elmwood 77 53 49 34 80 13 32 6 113 67 33 33 ... ... ... ... 7 Gonville 29 34 27 33 42 40 29 37 ... ... ... ... ... ... ... ... 8 Howard 22 20 13 18 15 21 14 14 ... ... ... ... ... ... ... ... 9 Ingram 32 28 25 22 28 100 20 85 120 120 67 79 23 19 11 13 10 Kensington 31 34 20 21 35 36 26 32 ... ... ... ... ... ... ... ... 11 Kingsley 130 143 105 119 95 63 46 52 94 64 25 24 7 11 7 8 12 Lanfranc ... ... ... ... ... ... ... ... 124 125 29 82 5 5 ... 2 13 Norbury Manor 21 14 2 12 109 88 91 76 136 100 44 69 9 11 3 7 14 Oval 50 38 47 33 57 35 45 30 54 51 34 39 1 ... 1 ... 15 Portland 45 30 30 27 47 55 39 50 125 88 22 40 ... ... ... ... 16 Purley Oaks 29 18 20 11 23 22 11 13 82 48 18 16 ... ... ... ... 17 Rockmount 31 17 16 12 17 15 12 9 34 26 3 18 ... ... ... ... 18 South Norwood 55 40 36 27 37 55 22 36 ... 1 ... 1 6 6 6 3 19 Sydenham 32 25 26 16 38 6 24 2 ... ... ... ... 10 ... 4 ... 20 Tavistock 36 29 24 14 28 29 16 18 101 120 40 61 ... ... ... ... 21 Waddon 100 82 78 60 80 65 52 31 99 100 63 78 ... ... ... ... 12 West Thornton 84 89 55 67 80 119 49 70 ... ... ... ... ... 2 ... 2 23 White horse M'r 65 59 51 45 41 50 25 33 92 ... 47 ... ... 29 ... 16 24 Winter bourne 90 75 79 57 96 41 87 34 ... 3 ... 3 11 27 11 24 .") Wood side 71 66 37 33 84 37 54 19 ... 23 ... 23 5 ... 4 ... 26 Addington ... 2 ... 2 6 1 1 1 ... ... ... ... ... ... ... ... 27 All Saints' 31 51 27 43 31 19 26 16 34 24 18 18 ... ... ... ... 23 Arch. Tenison's ... ... ... ... ... ... ... ... ... 46 ... 33 ... ... ... ... 29 Christ Church 42 39 31 38 24 28 ... 11 ... ... ... ... ... ... ... ... 30 Holy Trinity ... 60 ... 53 ... 36 ... 15 ... ... ... ... ... 3 ... 2 31 Parish Church 44 40 34 41 37 28 29 28 37 ... 29 ... ... 4 ... 2 32 St. Andrew's 12 19 8 16 23 ... 11 ... ... 3 ... ... ... ... ... ... 33 St. Joseph's 2 1 2 1 8 9 6 7 3 7 ... 5 6 10 2 7 34 St. Mark's 9 10 8 24 1 14 1 9 ... ... ... ... ... ... ... ... 3J St. Mary's 8 16 8 12 13 7 5 2 4 17 ... 5 ... ... ... ... 36 St. Peter's 31 26 26 21 20 17 17 11 ... ... ... ... ... ... ... ... 31 St. Saviour's 42 70 31 41 46 35 16 22 ... ... ... ... ... ... ... ... 8s Shirley 27 20 21 15 38 36 30 33 ... ... ... ... ... ... ... ... 1438 1455 1077 1145 1517 1344 984 954 1520 1347 562 804 138 177 80 123 2893 2222 2861 1938 2867 1366 315 203 PERCENTAGE OP PARENTS PRESENT AT MEDICAL INSPECTIONS. Entrants Boys 74.9 76.8 64.1 „ Girls 78.7 Intermediate Boys 64.9 67.7 „ Girls 71.0 Leavers Boys 37.0 47.6 „ Girls 59.7 Other Ages Boys 58.0 64.4 „ Girls 69.5 244 FINDINGS AT ROUTINE MEDICAL INSPECTIONS Uncleanliness. Frequent special inspections are made by the school nurses in the schools. For these unclean liness surveys the health visitors made 473 visits to schools. At the primary inspections they found vermin in 229, and nits alone in 2,187 children. On these inspections, 3.6 per cent. of the children showed evidence of infestation as against 4.0 in 1932 and 4.3 in 1931. 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. The figures are an improvement upon the 1932 findings. Clothing and Footgear. At routine medical inspections 98.9 per cent. of the boys and 99.1% girls were clothed and shod properly. Close scrutiny has been exerted by the medical inspectors and the findings are satisfactory. The findings are the same as for 1932. Nutrition. In the entrants 13.8 per cent. of the boys and 9.5 per cent. of the girls were below normal nutrition for the area. In the intermediate group 15.5 per cent. of the boys and 18.3 per cent. of the girls were under average; in the leavers group 13.0 per cent. boys and 16.4 per cent. girls, giving in the whole school groups examined 14.6 per cent. boys and 15.3 girls. The figures are higher than in 1932. These figures, especially those relating to the entrant group, which show the highest increase in subnormal nutrition, appear to point to the effects of prolonged unemployment among the parents. These findings should be taken in conjunction with the more elaborate analysis contained in Table III. The subject of child nutrition is a complex one and is dependent on many and diverse factors. Efficient mother-care is the dominant influence. This means a sensible realisation of the child as a growing, active being, who, although needing protection, will not benefit by coddling, and whose thoughts should be directed towards health and not ill-health. 245 Malnutrition may be due to improper food, although the total amount taken is adequate. Proteins and fats are expensive, carbohydrates relatively cheap. In times of financial stringency the cheapest foods must be bought, and thus 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 pprotein and fat deficiency, though the milk must be above bacteriological suspicion. If every child attending the Elementary Schools could be given one pint of milk per day in school, the benefit would amply repay any cost on the public funds. During 1933, with very few exceptions, the scheme of the National Milk Publicity Council which commenced in September, 1929, was continued in the schools. In 1933 some 5,000 bottles of milk per day were supplied. This is a drop of 2,000 bottles per day on 1932. This scheme has one grave defect inasmuch as, owing to financial reasons, children who would benefit most do not get the milk. This probably accounts for the drop in the number of bottles of milk supplied. A number of these, however, are dealt with direct by recommendations from the school medical officers and so come under another scheme by which milk, up to 1 pint, and malt and oil, are given at graduated prices, or free, to malnourished children. Through the co-operation of the teachers this extra nourishment is given at school so that the child is sure of a regular supply. Severe malnutrition in childhood leaves an indelible mark on physique. Childhood is the great growing period. Nutrition is a subject of fundamental importance and should always be of concern to parents, doctors and teachers. Much of the widespread ignorance among parents on economical and efficient catering would be dispelled in a future generation if every girl and boy was soundly grounded in the subject of food values and the science and art of cooking before leaving school. It cannot be repeated too often that unsuitable, badly chosen food may cause as much malnutrition as too little food. The science of buying wisely is one which deserves acknowledgment in educational curricula. Heights and Weights. Table III. gives the results of an enquiry made to ascertain the average heights and weights of all children examined at routine inspection of 1933. 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. 246 Table III. 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. 1929 24 41.2 39.1 42.6 41.4 40.9 37.9 40 40.6 38.6 42.0 39.6 S8.9 35.4 1928 734 41.7 41.3 46.6 50.9 40.7 34.3 769 41.2 39.7 46.4 48,7 38.8 32.4 1927 519 44.1 43.5 47.3 52.3 40.5 36.4 504 43.7 42.3 44.2 50.7 39.8 35.5 1926 150 45.8 47.5 48.2 53.7 44.1 42.3 173 45.6 45.9 48.6 53.6 43.4 39.5 1925 1109 48.6 53.7 53.1 61.1 44.1 42.6 985 49.1 51.3 53.1 69.2 43.4 40.2 1924 336 50.2 57.3 54.1 68.0 47.6 50.8 346 49.8 56.1 53.0 65.4 46.5 46.5 1923 97 52.4 63.7 54.8 74.1 50.1 65 9 91 52.1 60.4 54.5 69.7 49.4 54.3 1922 93 54.7 72 0 56.0 78.6 53.2 69 0 63 54.6 69.1 56.6 78.9 52.8 62.3 1921 901 56.2 76.8 62.1 104.6 51.4 59.1 771 57.1 81.3 63.7 110.5 52.1 56.2 1920 489 57.5 81.6 62.5 109.5 51.6 63.9 452 58.5 85.6 64.0 115.6 53.1 63.3 1919 89 58.3 88.7 63.9 112.2 56.2 79.0 61 59.5 90.3 61.0 96.5 56.0 74.9 247 Children Born in 1928.—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 1.9 lbs. more and their average minimum height 1.9 inches taller than the corresponding figures for the girls. The average maximum weight of the boys is 2.2 lbs. more and their average maximum height 0.2 inches taller than for the girls. Children Born in 1927.—The boys are 0.4 inches taller and 1.2 lbs. heavier on the average than the girls. The average minimum weight of the boys is 0.9 lbs. more and their average minimum height 0.7 inches taller than the corresponding figures for the girls. The average maximum weight of the boys is 1.6 lbs. more and their average maximum height 3.1 inches taller than for the girls. Children Born in 1925.—The boys are 0.5 inches shorter and 2.4 lbs. heavier on the average than the girls. The average minimum weight of the boys is 2.4 lbs. more and their average minimum height 0.7 inches taller that the corresponding figures for the girls. The average maximum weight of the boys is 2.6 lbs. more than the girls and their average maximum height is the same as for the girls. Children Born in 1921.—The boys in this group were 0.9 inches shorter and 4.5 lbs. lighter on the average than the girls. The average minimum weight of the boys is 2.9 lbs. greater and their average minimum height 0.7 ins. shorter than the girls. The average maximum weight of the boys is 6.0 lbs. lighter and their average maximum height 1.6 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. 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. 248 During the period of growth from 5 years to 8 years the boys gained on the average 12.4 lbs. in weight and 6.9 inches in height. The girls gained 11.6 lbs. in weight and 7.9 inches in height. From 8 years to 12 years the corresponding gains are 23.1 lbs. for boys and 30.0 lbs. for girls; 7.6 inches for bovs and 8.0 inches for girls. During the period of growth from 5 years until the end of the 12th year the boys increased by 14.5 inches in height and 35.5 lbs. in weight; the girls increased 15.9 inches in height and 41.6 lbs. in weight. Heart and Circulatory System. At routine medical inspections among the entrant group 12 boys and 9 girls were found to have organic disease. In the Intermediate group, the figures were 29 boys and 15 girls and in the Leaver group 23 boys and 28 girls. Functional disease was found in 61 boys and 35 girls in the Entrants; 22 boys and 39 girls in the Intermediate; 23 boys and 56 girls in the Leaver group. Anaemia was present in 99 boys and 53 girls in the Entrant group; 32 boys and 27 girls in the Intermediate, and 41 boys and 66 girls in the Leavers. The percentage of all Heart and Circulatory defects among children examined at routine medical inspection was 7.7. Chest Complaints (Other than Tuberculosis). In all the groups combined 3.6 per cent. of the boys and 3.5 per cent. of the girls had some minor affection of the lungs. This was usually a mild Bronchitis. Tuberculosis. Twenty-three children were referred to the Tuberculosis Officer for further examination. No case was diagnosed as definitely tuberculous on further examination. All contacts of known cases of Tuberculosis are kept under supervision and re-examined at each school medical inspection. 68 children were under such surveillance at the beginning of the year, 97 were added during the year, 38 were discharged, leaving 127 under observation at the end of the year. Five cases of pulmonary Tuberculosis and 11 cases of nonpulmonary Tuberculosis in children of school age were notified to the Medical Officer of Health during the year. One child died of pulmonary Tuberculosis and 5 of non-pulmonary Tuberculosis. The ages at death of these cases were: Pulmonary, 13 years; NonPulmonary, 5 (two), 6, 8 and 11 years. The 5 Non-Pulmonary deaths were certified to be due to Tuberculous Meningitis. 249 Taking the total school population as 27,083 the mortality rate from Pulmonary Tuberculosis in school children was 4 per 100,000, and the incidence rate 18 per 100,000. For Non-pulmonary Tuberculosis the respective figures were 7 and 40. Nose and Throat. In all the groups 587 boys and 596 girls had enlarged tonsils; 66 boys and 48 girls had adenoids only; 297 boys and 337 girls had adenoids and enlarged tonsils; 53 boys and 28 girls were mouth breathers; 666 boys and 578 girls exhibited enlarged glands in the neck. Taking the two groups of cases of adenoids, and enlarged tonsils with adenoids 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 1932, dealing with another group of children, the figure was also 8.6 per cent. The importance of training in correct methods of breathing after the removal of adenoids and tonsils cannot be too strongly emphasised. All cases are invited to attend Breathing Exercises Classes held at St. Andrew's Hall and 216 attendances were made. Of all children examined at Routine Medical Inspection, in the Entrant group 18.1% had enlarged tonsils; 1.8% had adenoids alone; 11.7% enlarged tonsils and adenoids, and 21.3% had enlargement of the submaxillary or cervical glands. In the Intermediate group the respective percentages were 12.5%, 1.2%, 6.0% and 12.7%; and in the Leaver group, 8.7%, 0.7%, 3.0% and 7.8%. The percentages for the three groups, in relation to the total number of children examined, were 13.1%, 1.2%, 7.3% and 14.0%. Table IV. gives in summary the percentage of Nose and Throat defects and of enlarged glands in the various groups examined. Table IV. SUMMARY. Group. Nose and Throat Defects. Enlarged Glands. Boys. Girls. Boys. Girls. Entrants 83.2 33.0 22.6 20.1 Intermediates 20.4 22.2 12.1 13.4 Leavers 12.7 17.7 9.1 6.4 Other Ages 25.4 20.3 14.5 11.3 *Does not include mouth breathers, but includes other defects of nose and throat. 250 Defective Hearing The commonest causes of deafness in children are middle ear disease and adenoids. Routine medical inspection showed that 0.4% entrants, 0.4% intermediates and 0.5% leavers in the children examined had defective hearing. Speech Defects. There are no special classes for stammerers in the Croydon Educational Scheme. Routine medical inspection findings showed in the Entrant group 0.9% children defective, in the Intermediate group 0.6% and 0.2% in the Leaver group. Skin Diseases. 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 3.5 per cent. incidence in boys and 2.1 per cent. in girls; Intermediate boys 1.8 per cent. and girls 2.3 per cent.; Leavers 2.9 per cent. boys and 1.4 per cent. girls; a total in all groups of 2.8 per cent. boys and 1.9 per cent. girls. Deformities. Among children examined at Routine Medical Inspection 0.7 per cent. of the boys and 0.5 per cent. of the girls showed evidences of rickets; 3.0 per cent. boys and 4.3 per cent. girls had some abnormal degree of spinal curvature, and 4.2 per cent. boys and 4.0 per cent. girls showed some other physical deformity. External Eye Diseases. Squint was present in 1.2 per cent. of all children examined in the various groups and was most frequently found in the Entrant group (1.4 per cent. boys and 2.1 per cent. girls). Its incidence declined as age advanced. Blepharitis occurred in 1.5 per cent. of all the children, being most prevalent in the Intermediate group (1.7% boys and 1.7% girls); Conjunctivitis was present in 0.2 per cent. of all the children, and other external eye defects were noted in 0.4 per cent. The total percentages of eye defects in the various groups was 3.7 for Entrants; 3.5 for Intermediates; and 2.7 for Leavers. For 1932 the corresponding figures were 2.8, 2.7 and 1.5. 251 Vision. 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 4.3 per cent. of the boys and 5.2 per cent. of the girls were referred for treatment or observation for defective vision, and in the Leaver group 7.5 per cent. of the boys and 8.2 per cent. of the girls. The Leaver group of girls invariably gives ithe worst figures for vision. Table V. Extent of Defect. Intermediates. Leavers. Total. Boys Girls. Boys. Girls Boys. Girls No. % No % No. % No. % % % Normal R 1457 96.0 1279 95.2 1420 93.4 1249 92.7 94.4 93.9 6/6ths. o 6/9ihs. L 1462 96.4 1284 95.5 1426 93.8 1242 92.2 95.1 93.9 6/l 2ths or 6/24ths R54 3.6 59 4.4 90 5.9 92 6.8 4.1 5.6 L 50 3.3 52 3 .9 82 5.4 94 7.0 4.3 5.4 6/36ths. or worse R 6 0.4 6 0.4 10 0.7 6 0.5 0.5 0.5 L 5 0.3 8 0.6 12 0.8 11 0.8 0.6 0.7 Table VI. TEETH. Entrants. Intermediates. Leavers. Boys Girls Boys. Girls. Boys. Girls. No. % No. % No. % No. % No. % No. % Perfect set of Teeth 499 34.7 519 35.7 654 43.1 542 40.3 939 61 8 823 61.1 One to four decayed 541 37.6 576 39.6 644 42.5 576 42.9 612 33.7 458 34.0 Four or more decayed 398 27.7 360 24 7 219 24.4 226 16.8 69 4.5 66 4.9 Total 1438 1455 1517 1344 1520 1347 It is interesting to note that 3,976 children of all groups, or 44.5 per cent., were found to have sound teeth at medical inspection. The percentage of sound teeth found by the Dental Inspectors was 32.3 per cent. The need for systematic instruction on the care of the teeth is certainly indicated. 252 The figures indicate that some 35 per cent. of children entering school have perfect sets of teeth. This is a low percentage and is the outcome of the relative neglect of the teeth during pre-school age. The importance of this period cannot be loo strongly emphasised. The school medical service, in this regard, as in others of a similar character, is a receiver of damaged goods. With a proper system of inspection and treatment of the pre-school child much avoidable ill-health and physical defect in young school children would be abolished. The proper care of the teeth before school age is reached would lead to much less attention being necessary during school age. The Leaver group gave the best findings, a result brought about by the work of the School Dental Service. Table VII. SUMMARY OP THE FINDINGS AT ROUTINE EXAMINATIONS. (Percentages.) Condition Enti ants. Intermediates. Leavers. Other Ages All Groups Boys Girl Hoys Girls Boys Girls Boys Girls Boys Girls Cleanliness— (Percentage clean) Mead 99.8 98.1 99.3 98.4 99.5 98.2 97.1 98.9 99.5 88.7 Body 99.4 99.7 99.3 99.8 99.3 99.7 97.1 99.4 99.3 99.7 Clothing (satisfactory) 99.6 99.0 97.8 99.1 99.3 99.2 97 .8 98.3 98.9 99.1 Footgear do. 99.7 99.1 97.8 99.1 99.0 99.3 97 1 98.3 98.8 99.1 Nutrition (normal) 86.2 90.5 84.5 81.7 87.0 83.6 67.4 68.4 85.4 84.7 Defects — Circulatory System 12 0 6 6 5 5 6.0 5 7 11.1 5.8 6.8 7.6 7.9 Pulmonary System (defects not t.B.) 5.4 5.7 3 7 3 4 1.9 1.3 2 2 2.3 3.6 3 5 Skin Disease 3 5 2.1 1.8 2.3 2.9 1.4 1.4 2.8 2.7 2.0 Defects of Nose and Throat 33.9 33.6 22 0 23.1 13.6 17.9 29 0 22.0 23.2 25.0 Enlarged Cervical Glands 22.5 20.1 12.1 13.4 9 1 6.4 14.5 11.3 14.4 13.4 External Eye Disease 1.8 2.1 2.0 2.7 2.8 1.3 1.4 1.7 2.2 2.0 Defective Vision ... ... 4.3 5.2 7.6 8.2 7.2 5.1 6.0 66 Defective Hearing 0.3 0 4 0.5 0.4 0.6 0.4 2.2 1.7 0.5 0.5 Speech Defects 1.0 0.7 0.9 0.3 0.3 0.1 1.4 1.1 0.7 0.4 Dental Disease (more than lour decayed) 27.7 24 7 14.4 16.8 4.5 4.9 8.7 15.8 15.1 15.7 Dull and Backward 0.6 0.3 1.0 1 1 0.9 0.8 5.1 2.8 1.0 0 8 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, though there is a slight drop on last year's findings. The Entrant group is the worst and the Leaver the best. Undernutrition is found in about 15 per cent. of all children examined. 253 Girls showed a slightly higher proportion of under-nutrition than boys, the worst groups being the Intermediate girls and the Leaver girls groups. 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, the Entrant group being by far the worst. Enlarged cervical glands, which have a relation both to dental defects and to under-nutrition, were commonest in the Entrant group, and were more often found in boys than girls. 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. As children who are wearing spectacles which correct vision are included as having normal vision, the wearing of spectacles masks the actual amount of defective vision. Vision is more defective in the Secondary Schools than in the Public Elementary. The following Table was compiled from the findings at routine medical inspections, in order to ascertain the amount of visual defect in the particular children examined in the various schools. It relates only to children who were referred from routine medical inspections for treatment or observation and who were consequently thoughtto be in need of spectacles. Table VIII. School. Intermediates. Leavers. School. Intermediates. Leavers. Boys Girls Boys Girls Boys Girls Boys Girls Asbburton 3.8 3.9 11.9 17.4 Whiteborse Manor 4.9 8.0 7.6 ... Beulah 2.2 5.9 ... ... Winterbourne 2.1 9.8 ... ... British ... ... 7.7 9.3 Woodside 8.3 2.7 ... ... Davidson 5.4 11.4 7.0 4.5 Addington 16.6 - ... ... Ecclesbourne 3.6 2.0 ... 3.9 All Saints' - - 5.9 4.2 Elm wood 6.2 7.7 4.4 4.5 Arch. Tenison's-. ... ... ... 17.4 Gonville 2.4 2.5 ... ... Christ Church 2.5 2.8 ... ... Howard - 9.5 ... ... Holy Trinity ... 5.6 ... ... Ingram 3.6 5.0 8.3 9.2 Parish Church - - 5.4 ... Kensington 8.6 2.8 ... ... St. Andrew's 4.3 ... ... ... Kingsley 5.3 4.8 9.6 14.1 St. Joseph's - 111 - 14.3 Lanfranc ... ... 9.7 8.0 St. Mark's - 7.1 ... ... Norbury Manor 0.9 4.5 3.7 3.0 St. Mary's - - 50.0 6.9 Oval 10.5 11.4 3.7 3.9 St. Peter's 5.0 23.5 ... ... Portland 8.5 1.8 13.6 9.1 St. Saviour's 2.2 2 9 ... ... Purley Oaks 4.3 4.5 11.0 18.8 Shirley - - ... ... Rockmount 5.9 6.7 5.9 3.8 South Norwood 8.1 5.5 ... ... Sydenham 2.6 - ... ... Tavistock 3.6 3.4 6.9 12.5 Waddon 1.2 - 2.0 6.0 West Thornton 2.5 2.5 ... ... Note.—Where a dash is placed, children were examined, but no visual defects were found. The figures for the St. Mary's School may appear unduly high. This is due to the fact that out of four Leavers examined, two had defective vision. 254 Table IX. Return of Defects Found in the Course of Medical Inspection 1933. Defects Boys. Girls. No. requiring Treatment. No. referred for Observation. Percentage of total Examined No. requiring Treatment. No. referred for Observation Percentage of total Examined. Malnutrition 14 22 0.78 18 19 0.86 Uncleanlinkss- Head 1 1 0 04 1 - 0.02 Body Skin Disease 5 1 013 2 - 0.05 Eye Diseases- Defective Vision 186 8 4.21 178 16 4.49 Squint 14 2 0.35 25 5 0.69 External Eye Trouble 5 4 0.20 3 1 0.09 ear Diseases- Deafness 3 3 0.13 1 2 0.07 Otitis Media 7 6 0.28 5 6 0.25 Other Diseases 2 2 0.09 - - - Nose and Throat— Enlarged Tonsils only 53 107 3.47 65 120 4.28 Adenoids only 36 15 1.11 20 10 0.69 Enlarged Tonsils & Adenoids 160 32 4.16 173 36 4.83 Other Conditions 19 7 0.56 8 9 0.39 Enlarged Cervical Glands (not T.B.) 1 14 0.32 - 17 0.39 Dental Defects 71 3 1.60 56 3 1.36 Speech Defects 3 2 0.11 1 4 0.12 Heart and Circuiation— Organic 6 46 1.13 3 45 1.11 Functional - 48 1.04 - 54 1.25 Anaemia 6 16 0.48 2 13 0.35 Bronchitis 6 21 0.59 6 10 0.37 Other Non-T.B. 2 2 0 .09 1 3 0.09 Pulmonary Tuberculosis 1 2 0.06 2 7 0.21 Other Tuberculosis - 2 0.04 - 1 0.02 Nervous System Disorders (including Epilepsy, Chorea, etc.) - 9 0.20 1 20 0.49 Deformities — Rickets - 1 0.02 3 2 0.12 Spinal Curvature 42 18 1.30 65 49 2.64 Others 63 18 1.76 50 8 1.34 Other Defects and Diseases 16 25 0.89 13 16 0.67 Total 722 437 25.12 702 476 27.25 Total Children Examined 4613 4123 255 Table X. CHILDREN EXAMINED AT ROUTINE INSPECTIONS AND FOUND TO REQUIRE TREATMENT (EXCLUDING UNCLEANLINESS AND DENTAL DEFECTS). Group. No. of Children Inspected No. referred for treatment. Percentage referted for treatment Corresponding percentage for 1932 Entrants 2893 343 11.9 11.9 Intermediates 2861 319 11.8 15.2 Leavers 2867 484 16.9 15.7 Other Ages 315 47 14.9 10.3 8936 1213 13.6 14.0 The fact that 11.9 per cent. of the children examined shortly after entering school at 5 years of age required treatment of some kind is an adverse commentary upon the lack of any system of medical and dental supervision of the pre-school child. To leave medical and dental supervision in the hands of parents has been proved repeatedly to be insufficient. Besides, the parent cannot be expected to recognise those early departures from health which, if dealt with promptly, are easily put right. When a noticeable breakdown happens, the child is taken to a doctor, who endeavours to remedy a condition which should never have occurred. In other cases the study of cumulative departure from normal is so insidious that irreparable consequences have supervened before the parent takes any steps. Initial slight defects, if unremedied, often lead to further defeats as the child grows. 256 Table XI. CHIEF CAUSES OF EXCLUSIONS FROM SCHOOL. Condition. Exclusions during 193a. Percentage of total exclusions Exclusions during 1932. Percentage of total exclusions. Ringworm — Head 11 0.26 11 0.24 ,, Body 23 0.54 35 0.76 Verminous Conditions 542 12.71 448 9.5 Impetigo 230 5.39 306 6.52 Scabies 49 1.15 44 0.94 Scarlet Fever 282 6.61 227 4 .84 Measles 1215 28.49 1679 35.80 Diphtheria 115 2.70 62 1.32 Whooping Cough 404 9.47 575 12.26 Chicken Pox 870 20.40 550 11.73 Mumps 66 1.55 49 1.05 Tuberculosis (all forms 37 0.87 43 0.91 External Eye Disease 14 0.33 33 0.70 Sore Throat 203 4.76 209 4 .46 Other Causes 204 4.78 419 8.93 4265 ... 4690 ... There were 425 less children excluded from school on account of various illnesses than in 1932. The chief causes of exclusion were Infectious Diseases, 69.0 per cent. Exclusions on account of verminous conditions were higher than in 1932 or 1931, and constituted 12.71 per cent. of the total exclusions. The health visitors examined 66,758 children in the schools in connection with the personal cleanliness of the scholars. Impetigo was less prevalent than in 1932. CAUSES OF DEATH IN CHILDREN OF SCHOOL AGE. Taking the school population as 28,241, the death-rate per 1,000 in school children was 2.3. There were two deaths from Measles, compared with one death in 1932. There were 65 deaths in children of school age; those caused by Infectious Diseases, 9; Pneumonia, 6; Tuberculosis, 6; Disease of the Digestive System, 4; other causes, 40. In the Infectious Diseases group the causes were Diphtheria 7 and Measles 2. Among "other causes" of death were violent deaths (accidents), 7; organic heart disease, 10; and appendicitis and peritonitis, 7. 257 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 XII. Name of School. School population. Notifiable Diseases. Conditions notified by Teachers and School Attendance Officers. Percentage incidents of Infectious Diseases! in Schools. Scarlet Fever Diphtheria. Ac. Primary Pneimonia. Measles. Whooping Cough. Chicken Pox. Mumps. Scabies. Impetigo. Sore Throats. Ringworm (body). Ringworm (seald). Indefinite Sickness. 111. Not Infectious. Conjunctivitis Ashburton 859 7 ... 1 110 2 2 1 ... 2 ... ... ... 3 7 ... % 14.3 Beulah 1241 25 9 ... 20 49 25 2 4 22 7 ... ... 26 15 1 10.5 Croydon British. 536 1 ... ... 3 ... 1 1 1 6 ... ... 5 5 ... 0 .9 Davidson 776 35 3 ... 5 1 94 1 3 9 17 ... ... 25 21 1 17 .9 Ecclesbourne 1017 7 4 ... 39 48 11 ... 8 14 2 ... 1 11 7 ... 10.7 Elmwood 1144 26 4 ... 24 7 31 1 4 12 3 4 ... 7 15 ... 8.1 Gonville. 373 4 ... ... 25 4 16 ... ... ... ... ... ... 5 3 ... 13.1 Howard 396 5 ... ... ... ... 2 1 ... 2 2 ... ... 4 3 ... 2 .0 Legram 902 13 4 ... 11 6 15 4 2 8 13 ... ... 8 11 ... 6.1 Kensington Av 377 4 ... ... 39 2 2 ... ... 2 ... ... ... 1 7 ... 12.5 Kingsley 1674 14 10 ... 12 20 24 4 3 25 50 1 1 9 33 ... 5.0 Lanfranc 663 I 1 ... 2 ... 1 ... ... 1 5 ... 1 3 7 ... 0.7 Norbury Manor 1106 7 2 ... 1 6 29 ... ... 5 ... 1 ... ... 3 ... 4.1 Oval 711 9 18 ... 62 3 12 2 ... 6 36 3 ... 2 17 3 15.2 Portland 961 7 6 ... 54 7 9 2 1 12 8 ... 1 5 12 ... 8.9 Purley Oaks 513 10 1 ... 1 7 4 3 1 8 5 ... ... 3 4 ... 5.1 Rock mount 576 6 ... ... 9 18 78 1 ... ... ... ... ... 3 10 ... 19.4 South Norwood 882 6 9 ... 32 2 6 ... 1 ... 2 ... ... 2 6 ... 6.2 Sydenham 738 6 2 ... 58 28 10 2 2 6 5 3 ... 4 25 1 14.3 Tavistock 855 7 2 ... 33 3 5 ... 3 6 7 1 ... 2 20 ... 5.8 Waddon 1523 7 12 ... 45 17 6 3 4 27 4 3 1 3 63 ... 5.9 West Thornton 957 8 6 ... 78 16 26 3 ... 8 15 ... ... 27 10 ... 14.3 Whitehorse Manor 933 5 2 ... 107 24 10 1 2 8 ... ... 1 8 24 2 16.0 Wnter bourne 1129 10 1 ... 115 8 181 1 1 3 ... ... ... 3 20 2 28.0 Woodside 919 9 2 ... 157 16 109 7 1 7 ... ... 1 10 10 2 32.6 Heath Clark 420 3 ... ... 3 ... 4 2 ... 2 ... ... ... 1 2 ... 2 .9 John Ruskin 389 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Lady Edridge 324 ... 2 ... ... 1 ... ... ... ... ... ... ... ... ... 1 0.9 St. Christopher's 108 ... 2 ... ... ... 1 ... ... 8 1 ... ... ... 4 ... 3.7 St. Giles 75 1 2 ... ... ... ...1 ... ... ... ... ... ... ... 3 ... 5.3 Myopic Class 20 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 6.0 Mdington St. Mary's 42 ... ... ... ... ... 8 ... ... ... 2 ... ... 2 2 ... 19.0 All Saints' 372 2 ... ... 43 54 1 1 ... ... ... 1 2 3 18 ... 27.1 Arch Tenison's 400 3 1 ... 2 ... ... ... ... 1 ... 1 ... ... ... 1.5 Christ Church 461 2 2 ... 7 9 29 1 2 3 4 ... ... 2 7 ... 10.9 Holy Trinity 268 4 ... ... 19 15 5 1 ... 1 ... 1 ... 2 8 ... 16.4 paiish Church 538 7 2 ... 31 2 7 ... 1 ... 2 1 ... 6 12 ... 9.1 St. Andrew's 400 1 ... ... 38 6 8 ... ... 10 2 1 1 2 8 1 13.2 St. Joseph's 215 3 ... ... 1 4 2 ... ... ... ... ... ... ... ... ... 4.7 St. Mark's 152 ... 1 ... 2 2 23 1 2 ... ... ... ... ... 2 ... 19.1 St. Mary's 380 3 1 ... 2 1 1 ... ... 4 ... ... 1 ... 3 ... 2.1 St. Peter's 128 1 1 ... ... ... 23 21 ... 4 3 ... ... 2 4 ... 35.9 St Saviour's 351 6 2 21 2 2 ... 1 ... 2 ... ... 3 3 ... 9.4 Shirley 264 ... ... ... 2 14 46 ... ... 2 ... ... ... 2 4 ... 23.5 S'. Michael's 218 1 1 ... 1 ... ... ... ... 1 ... ... ... ... 1 ... 1.4 Sel urst Grammar 955 6 ... ... ... ... ... ... ... ... ... ... ... ... ... ... 0.6 Totals 28241 282 115 6 1315 404 870 66 49 230 203 23 11 204 439 14 Note.—Percentage incidence of Infectious Diseases taken from Scarlet Fever, Diphtheria, Primary Pneumonia, Measles, Whooping Cough, Chicken-Pox and Mumps. 258 The percentage incidence is calculated on the average school population over the year at each school. The highest incidence in relation to children in attendance at the school was in St. Peter's (35.9) due chiefly to Chicken Pox and Mumps; next was Woodside (32.6) due chiefly to Measles and Chicken Pox. The lowest incidence was in the Selhurst Grammar (0.6), Lanfranc (0.7), and British and Lady Edridge (0.9). In view of the age distribution of these schools this was to be expected. Scarlet Fever. Two hundred and eighty-two cases were notified from the schools. Davidson (35), Elmwood (26) and Beulah (25) had the most cases. There were no cases in the John Ruskin School. Diphtheria. One hundred and fifteen cases were notified from schools. This is a considerable increase on 1932. The Oval with 18 cases, Waddon with 12 cases, and Kingsley with 10 cases, had the highest individual numbers. Mumps. Only 66 cases were notified from schools. St. Peter's had the highest individual number. Chicken Pox. Eight hundred and seventy cases occurred in schools and were notified therefrom. Winterbourne (181), Woodside (109), Davidson (94), and Rockmount (78) showed the highest incidence. Whooping Cough. Four hundred and four notifications were received from schools. The highest numbers for individual schools were All Saints' (54), Beulah (49), and Ecclesbourne (48). Measles. As was expected, Measles was troublesome during the first quarter of the year, but afterwards its incidence was low throughout the year, showing, however, a tendency to rise in December. The reorganisation of schools as advocated in the Hadow Report, with the consequent grouping of children of the most susceptible ages into Junior, Mixed and Infants Schools, has led to a higher incidence of all the common infectious diseases in these schools 259 than occurred under the former arrangements. However desirable the re-grouping recommended by the Hadow report may be educationally, it will probably be found not to be advantageous from the medical aspect. SCHICK TESTING AND IMMUNISATION AGAINST DIPHTHERIA. The following Table shows the work done during 1933. The tabular form is used for convenience, and does not represent a statistically complete piece of work. Work on the children in the various groups was not necessarily begun and ended during the year, so that the numbers in the various columns do not balance, but the two columns of percentages are approximately accurate. All children positive on re-testing were given a second immunising course, and none was positive after that. One child with a history of Diphtheria had a positive Schick reaction. The immunising material used was Diphtheria Prophylactic (T.A.M.) B. W. & Co. 260 Lett UncomDistrict No.Schick- Percen- No. given No. Percen- pleted beforecom- Group. tested. No. tage full course No. re- Negative tage at end pleted, or (Primary) Positive. Fositive. of T.A.M. tested. on re-test. Negative. of year. Defaulted. , Private Cases 7 7 100 6 — — — 5 2 P.A.C. Homes 56 31 55.4 28 73 62 85 25 7 Do.—Queen's Road 18 9 50.0 10 5 5 100 9 5 Russell School 34 26 76.5 26 29 29 100 3 — Gordon Boys' Home 6 2 33.3 2 2 2 100 2 - Totals 121 75 62 72 109 98 90 44 14 261 FOLLOWING UP. There are 19 Health Visitors, 18 of whom devote 5/llths of their time to school work, and one who is 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 three whole-time dental assistants. The nurses also 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, persistent offenders against cleanliness have been proceeded against in Court, others have been brought before the Committee and warned. There are still, however, certain families who consistently spoil the cleanliness records of some of the schools. School Visits. The following table summarises the visits paid, etc., in connection with these duties:- Visits-to Schools re Cleanliness 43 Visits to School Departments re Cleanliness 473 Number of children inspected for cleanliness (first inspection) 66,758 Number of children inspected (subsequent inspections) 3,973 Number of children found unclean (first inspection) 2,451* Number of children found unclean (subsequent inspections) 2,416 *Representing 1,961 individual children. Home Visits. Concerning uncleanliness 76 Concerning defects found at routine medical inspections 1,709 Subsequent visits re defects found at routine medical inspections 756 Visits re' special cases 1,129 Visits to dental cases 333 Visits in connection with infectious cases and other visits 10,840 262 These figures show an increase of 1,637 in the number of children inspected for cleanliness; a decrease of 1,928 in visits paid in connection with infectious cases and other visits for miscellaneous reasons; an increase of 128 in the following-up visits to dental cases, and in visits to special cases; decreases of 32 in the visits made regarding defects found at routine medical inspections, and of 22 in the home visits regarding uncleanliness. Sickness among the school nursing staff has unfortunately caused a drop in the amount of visitation paid to the homes of children for the purpose of following up defects. TREATMENT. The Work of the School Clinics. Table XIII. Summary of Attendances. 1933. 1932. Increase or Decrease. Minor Ailments Clinics 11740 12800 1060 Inspection Clinic 1207 1181 + 26 Dental Clinics 13444 13348 + 96 Ophthalmic Clinic 2797 2870 — 73 Orthopedic Clinic 2637 2413 + 224 Remedial Exercises Clinic 8003 7508 + 495 Ear, Nose and Throat Clinic 1148 846 + 302 Ionization Clinic 386 350 + 36 Rheumatism Clinic 193 227 34 41555 41543 + 12 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 when possible 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. Medical cases or cases 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 may be necessary. A subsidiary clinic is held at 206, Selhurst Road on three occasions weekly. 474 children made 2,402 attendances during 1933. 263 Table XIV. Complaint. 1933. 1932. Cases. Attendances. Average No of Attendances per case Cases. Attendances. Average No of Attendances per case. Ringworm of Scalp 18 74 4.1 15 57 3.8 Body 28 151 5.4 30 285 9.5 Scabies 88 264 3.0 62 301 4.9 Impetigo 257 1568 6.1 288 1748 6.1 Other Skin Diseases 121 448 3.6 103 422 4.1 Otorrhœa and other Ear defects 294 4332 14.7 323 4088 12.7 External Eye Disease 192 1258 6.5 175 1779 10.2 Miscellaneous 642 3645 5.7 521 4120 7.9 1643 11740 7.1 1517 12800 8.4 From this table it is seen that the average number of attendances per child decreased from 8.4 to 7.l; the total attendances fell by 1,060, and the number of individual cases decreased by 74. Otorrhoea is one of the most difficult of ail minor conditions in school children to cure, this being reflected in the large number of attendances made for the remedying of this defect. Impetigo still remains troublesome, whilst the cases of scabies attending showed a further increase. Adenoids and Enlarged Tonsils. During 1933, 140 cases of tonsils only, G3 cases of adenoids only, and 367 cases of adenoids and enlarged tonsils, a total of 570 cases, were recommended for treatment. In 422 cases the Local Education Authority was requested to arrange for the operation. There were 69 operating sessions at the Croydon General Hospital. The work is done by a rota of 4 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 the week prior to the operation and a week after. 264 402 children were operated upon, an increase of 115 on 1932. The cases referred have all come within the terms of the three definitions given below. All cases are kept in hospital for at least one night after the operation unless the parent expressly desires otherwise and is prepared to take all responsibility. All children are conveyed home by ambulance. 381 children were detained for the night after the operation. In all there were 129 nonattendances. Of the 402 children operated on 216 attended the Remedial Exercises Clinic for post-operative breathing exercises. This is a very important complement to the operation. The percentage of children operated on, who attended for exercises, was 54 per cent., compared with 57 per cent. in 1932. The percentage is by no means as high as might be wished. The distance some of the children have to come is a deterrent. 58 cases came to the knowledge of the department for whom the parents had obtained treatment from another source; the majority at a London hospital. In these cases the expenses are defrayed by the parent and not by the Local Education Authority. Only the following conditions are considered to warrant the reference of a child for operation:- (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 Inspection Clinic. This is held on Wednesday and Saturday mornings. The object of the Inspection Clinic is (a) to examine children referred by 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 265 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 Juvenile Employment regulations. 1,207 attendances were made by children during the year. Treatment of Visual Defects. Table XV. Number of defects dealt with. Spectacles prescribed. Spectacles obtained. Under the Authority's Scheme. Submitted to etractiou by private practitioner or Hospital apart from the Authority's scheme Otherwise. Total. Under the Authority's Scheme. Otherwise. Under the Authority's Scheme. Otherwise. Errors of Refraction— Elementary Schools 780 19 799 593 19 402 19 Secondary Schools 99 8 107 71 8 73 8 879 27 906 664 538 27 Orthopaedic Work. The orthopaedic scheme continues on the same lines as described in my report for 1931. The units comprising the scheme are (a) The outpatient clinic held by Mr. Alan Todd at the Croydon General Hospital. (b) The Remedial Exercises Clinic held in St. Andrew's Hall, Pump Pail; (c) The St. Giles' School, Addington. Table XVI. Spinal and Other Remedial Clinics. Attendances. 1933. Sessions. Av. att. Attendances. 1932. Sessions. Av. att. Spinal 3,003 607 5.0 2,454 597 4.1 Massage 59 59 1.0 168 168 1.0 Flat Feet 1,625 189 8.6 1,433 193 7.5 Breathing 2,182 241 9.0 2,221 268 8.3 6,875 1,096 6,276 1,226 206 St. Giles' School, Addington. Total number of sessions 202 Total number of attendances 1,128 Average attendance per session 6 Total number of females 12 Total number of males 12 Total number of patients 24 Still under treatment 21 Complaints. Male. Female. Total. Scoliosis — 2 2 Kyphosis 2 1 3 Spastic Diplegia 2 — 2 Hemiplegia — 2 2 Infantile Paralysis 6 4 10 Lordosis — 1 1 Athetosis — 1 1 Inco-ordination 1 — 1 Muscular dystrophy — 1 1 Osteomyelitis 1 — 1 12 12 24 THE SCHOOL DENTAL SERVICE. I am indebted to the Senior School Dental Surgeon, Mr. Pilbeam, for the particulars contained in this section of the report. The work of the School Dental Service consists chiefly in the inspection and treatment of school children. In addition, the treatment of patients referred under the Maternity and Child Welfare, Tuberculosis and Mental Deficiency Schemes is undertaken by the same dental staff. Figures relating to these sections of the work is dealt with under the appropriate headings. The number of children attending the Public Elementary Schools is approximately 27,030. Of this number 18,087, i.e., 66 per cent., were actually inspected, and 13,029, i.e., 72 per cent. of the number inspected, were referred for treatment. Parents of 8,121 children consented to treatment, and 7,773 were actually treated, so that 95 per cent. of those children whose parents desired Clinic treatment were actually treated. The age groups dealt with were 6, 7, 8, 9, 10, 11, 12, 13 and 14 years for re-inspection, 5 and 6-year-old entrants, and the whole of the children attending Central Schools. 207 The staff of the School Dental Service consists of three fulltime dental officers. Therefore, each dental surgeon has over 9,000 children allocated to his care, and, unfortunately, this proportion is more than twice as many as one dental surgeon can inspect and treat efficiently each year. Sir George Newman states that it is on the whole a wiser plan to provide annual inspection for the continuous care of a limited number of children than to attempt to deal with a larger number by extending the period between one inspection and the next. The number of children whom each dental surgeon can inspect and treat annually is approximately 3,500, and it is therefore apparent that if every child in the Borough is to have annual inspection, and treatment if required, the staff must be considerably augmented. It will be observed that the dental surgeons were able to inspect only 66 per cent. of the children in the Elementary Schools, which means that it will take at least 18 months to carry out the complete inspection of all the children with the existing staff. Dental disease is the most prevalent of all diseases, and one inspection and treatment in 18 months is not enough to reduce the incidence of dental caries, as is shown bv a study of the following table. As the aim of the School Dental Service is prevention, it is, unfortunately, unable to fulfil its aim. This Table indicates the state of the teeth since 1927:- Year. 1927 1928 1929 1930 1931 1932 1933 Percentage of Children Peferred for Treatment 61 61 63 63 65 68 72 In 1027, when the scheme was confined to annual inspection and treatment of certain age groups, 61 per cent. were referred for treatment, but as more children were brought into the scheme without a corresponding increase in staff the incidence of caries gradually increased each year, until in 1933 it is seen that 11 per cent. more children required treatment than in 1027. This Table nroves that dental disease cannot be controlled unless there is annual inspection and treatment of all the scholars. 268 The school dental surgeons spend a great part of their time doing reparative work, and unless this is followed up by annual inspection, so that further defects may be noted and corrected, the time and money spent on treatment has to a large extent been wasted. With the present staff this can only be prevented by restricting the number of schools or age groups inspected and treated each year, or by eliminating after the first inspection all children whose parents refuse treatment. Table XVII. Summary of all Examinations. Age. Sex. 1933. 1932. No Examined. No. Referred for Treatment. % Teeth Sound No. Examined. No. Referred for Treatment. % Teeth Sound. 5 years B 525 402 21.4 757 514 32.1 G 401 351 23.9 647 470 30.2 6 ,, B 809 572 29.3 1015 749 26.2 G 704 507 27.9 1043 774 25.8 7 „ B 890 649 27.0 966 713 26.1 G 838 655 21.8 1042 748 28.2 8 ,. It 8'21 622 24.2 1078 778 27.8 G 822 63 1 23.2 962 705 26.7 9 ,. B 816 575 29.5 1260 905 28.1 G 1016 755 25.6 956 691 27.7 10 „ B 934 644 31.0 1281 877 31.5 G 1001 735 26.6 1035 734 29.0 11 B 877 614 30.0 1199 811 3?.4 G 1090 767 29 6 1213 697 42.5 12 B 1143 800 30.0 1070 709 33.7 G 947 705 25.5 1128 709 37.1 13 „ B 1519 1099 27.6 652 447 31.4 G 1196 864 27.7 702 421 40.0 14 " B 620 411 33.7 314 210 33.1 G 634 424 33.1 408 248 39.2 15 " B 192 101 47.4 127 89 29.9 G 232 146 37.0 122 74 39.3 Total Boys 9146 6489 29.0 9713 6802 30.0 Total Girls 8941 6540 26.8 9258 6271 32.2 With few exceptions, the age groups show a reduction in percentage of sound dentitions compared with 1932. This Table cannot be construed as showing a marked deterioration of the teeth, but rather as proving that by infrequent inspections dental disease cannot be reasonably controlled. 269 It is gratifying to see that, with the exception of the 14-yearold girls' group, the Leavers have a higher percentage of sound dentitions than in the previous year. If children would only view a good dental report with the same satisfaction as they do a favourable school report, and take pride in having healthy teeth, the percentage of sound dentitions would undoubtedly be greater than it is at present. Inspection. The annual inspection of school children is essential, so that all defects may be recorded. Even so, children may be found at one inspection to have a sound dentition and at the next to have one or more teeth so diseased that extraction is sometimes the only treatment. There appear to be three periods in a child's school career when caries is particularly active, namely, at 6, 9 and 12 years. These ages correspond to the time when the teeth usually erupt in pairs. As a preventive measure dental inspections should be carried out twice yearly. A compromise, however, can be effected by inspecting all the age groups annually, and the 6, 9 and 12-year-old groups twice a year. With such a method it would be possible to diagnose early defects and thus reduce the number of extractions of permanent teeth to a very low figure. Unfortunately, this cannot be done at present. The number of sessions devoted to inspection totalled 109, which is 13 fewer than in 1932. The number of children examined was 18,087, compared with 18,977 in the previous year. The average number of childrern inspected each session was 16G. Obvious defects only are noted at the routine dental inspections, and when the child is called up for treatment a more thorough examination is carried out at the Clinic. A very careful examination is made of those children at routine inspections who show evidence of sound dentitions. Treatment. Full details of sessions and treatment are set out in the Hoard of Education Table at the end of the Report, while a 270 summary given below is for comparison with previous years:— 1930. 1931 1932. 1933. Number of new cases per session 7.9 7.4 7.5 7.1 Attendances per session 13.7 12.4 13.6 12.3 Killings per ordinary session 4.3 4.1 4.5 5.4 Extractions 13.7 12.4 13.6 13.0 Other operations 1.5 1.4 2.0 2.0 Gas cases during the year 2,395 2,605 2,322 2,125 Local anaesthetics - 1,638 3,914 3,881 Permanent teeth extracted 2,001 2,689 2,702 2,707 Permanent teeth filled 2,769 3,228 3,896 4,795 Ratio of fillings to extractions 1 :0.7 1 :0.8 1 :0.69 1 :0 5 Temorary teeth extracted 12,105 10,800 11,707 10,740 Temporary teeth filled 1,732 1,254 874 829 Ratio of fillings to extractions 1:6.9 1:8.6 1:13.3 1:12.5 Special Treatments. Partial Dentures to replace incisors—7. 1 obturator was fitted. Review of the Work Done. During the year 30 more sessions were devoted to treatment than in 1932; the amount of conservative treatment shows progressive improvement, and the number of attendances still increases. The ratio of permanent fillings to permanent extractions has improved considerably from 1:0.8 in 1931 to 1:0.5 in 1933. While the extractions of permanent teeth remain practically the same as last year there is a considerable reduction in the number of temporary teeth extracted. Owing to the large number of children attending the Central Schools, who were brought into the Scheme a few years ago, it has been difficult to reduce the number of extractions of permanent teeth. These children in many instances appear to have rampant caries, and it is unfortunate that not infrequently the second permanent molars are so decayed that they are beyond all means of conservative treatment Administrations of general anaesthetics were given to 2,125 children, a reduction in the number as compared with last vear. The dental officers devoted 93 half-davs to gas administration, and medical officers administered gas at 43 sessions at the Selhurst Road Clinic. Nitrous oxide is administered by dental surgeons at the Lodge Road Treatment Centre, where a doctor is always in attendance at another Clinic in the same building, in case a parent wishes to have the child medically examined before being given an anaesthetic. 271 Other operations totalled 2,154, which is slightly more than last year. These operations include root dressings, scalings, gum treatments, prophylactic treatments, silver nitrate applications, temporary fillings of zinc oxide, sedative dressings for pulp preservation and pulp cappings. The Orthodontic Clinic is still making progress, and 68 cases were completed during the year. Summary of school children inspected and treated during the year:— Patients examined 19,903 Patients treated 7,773 Attendances 13,444 Fillings 5,624 Extractions 13.447 "Gas" cases 2,125 Other operations 2,154 Locals 3,881 Sessions held- Inspection 109 Treatment 1,087 Administration 20 Orthodontia 42 Gas administrations by Total sessions 1,396 dental surgeons) 93 Gas administrations medical officers) ... 44 Conservative Treatment. All filling work is carried out whenever possible before the extractions are completed. Silver and copper amalgam is used in posterior teeth, and synthetic porcelain in anterior cavities. The use of copper amalgam in school dentistry has been the subject of a good deal of criticism, but if the correct technique is adopted it will, in certain cases, withstand the action of caries to a greater extent than silver alloy. Copper amalgam should not be used when it is obvious that silver amalgam would prove a more serviceable filling. In anterior teeth in which the pulps have suffered traumatic injury, and in exposures produced by dental caries, root canal treatments have been undertaken in a number of cases. Sensitive teeth which require conservative treatment are anaesthetised by local or interosseous injections. Deciduous Teeth. The number of temporary teeth extracted during the year is considerably fewer than in 1932. 272 While admitting that the conservative treatment of permanent teeth is of paramount importance in school dentistry, especially under present conditions when there is so much work to be done for the permanent dentition, it is nevertheless unfortunate that the time available for restoring temporary teeth to a healthy condition is so restricted. In this effort of mass concentration on the permanent teeth the value and function of deciduous dentition must not be lost sight of. If the premature extraction of the temporary molars produced only the minor disability of the forward movement of the six-year-old molars, it would be justifiable to adopt such a line of treatment, but the other functions of the first teeth, those of speech, deglutition, digestion, and development of the jaws and permanent teeth, must be remembered. Persistent Refusals. The work of the Clinic is upset considerably bv applications for urgent treatment on account of toothache in children whose parents have previously refused treatment advised. If after the third inspection parents who have had a special warning notice, and having received a personal visit from the school nurse, do not realise the value of dental treatment, the only effective way of dealing with them is to circularise the head teachers of the schools which the children attend with the names of such children, so that the teacher will have authority to refuse to give an emergency form. If parents realise that casual treatment cannot be obtained after refusing routine treatment it will, at least, serve as useful propaganda to encourage others to accept treatment. This procedure is now being adopted. Acceptances. The number of acceptances for Clinic treatment was 8,121, or 54.7 per cent. of those referred for treatment. Parents of 3,891 children, i.e., 26.2 per cent., promised to obtain private treatment, but, unfortunately, in many cases this is merely evasion. The number of "no decision" forms was 2,548, i.e., 17.2 per cent., and the definite refusals 285, i.e., 1.9 per cent. The chief causes of non-acceptance of treatment are: (a) infrequent inspections; (b) inspecting undulv large numbers or children during each session; (c) indifference; and (d) fear of dental treatment. 273 Early calling-up for treatment after a school inspection is the best way to increase the number of acceptances. The inspection of very large numbers of children at each session should be avoided, as it may result in an omission to note certain defects that should be recorded, and also because too rapid examination does not impress parents with the importance of dental diagnosis, and, for that reason, they may fail to sign consent forms. There are, unfortunately, a number of people who appear absolutely indifferent to the value of dentistry and its relation to health, and it is difficult to educate them. Sympathy, tact and good dentistry can help considerably to reduce fear of treatment. Foliwing Up. The following up of some cases has brought good results, but there are some parents who agree to have treatment for their children as an excuse for getting rid of the visitor, and then fail to send their children to the Clinic when an appointment is made. 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 141 such forms were issued. Eight cases of persistent refusals by parents whose children had marked suppuration of the teeth from chronic abscesses, resulting from neglect of dental treatment, and were suffering in health thereby, were referred to the National Society for the Prevention of Cruelty to Children. The intervention of the Society's Inspector was successful in obtaining the subsequent attendance of six children. In addition, 165 sessions were occupied in other than school work (vide sections of the report dealing with Maternity and Child Welfare, Tuberculosis and Mental Deficiency). £361 l1s. 6d. was received from patients for treatment and in 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. Special Cases. It is necessary to provide some facilities for special cases and for the relief of pain. These comprise (a) cases requiring treatment 274 prior to the operation for the removal of tonsils and adenoids; (b) cases referred by the School Medical Officer; (c) children referred from the Tuberculosis Dispensary; (d) "casuals" referred by head teachers as needing treatment for acute conditions; the last-mentioned group and many of group (a) consist of children for whom treatment had been previously refused. During the year 1,816 special emergency forms were issued. Pre-School Children. A considerable number of children when they enter school have dentitions so ravaged by disease that conservative treatment is impossible. Some of these children have had opportunities for treatment, but the parents have not realised the necessity; nevertheless, there are numbers who would have had treatment but were ineligible through non-attendance at the Child Welfare Centres. Inspection and treatment for the pre-school child is restricted to those who attend the Child Welfare Centres, but unfortunately only about 50 per cent. attend. The solution appears to rest entirely in the extension of dental inspection and treatment to all children during the pre-school period. A comprehensive scheme of treatment for the pre-school child would reduce considerably the time now spent on the 5 and 6-year-old entrant groups of school children and permit more time to be devoted to other age groups. Preventive and Educative Measures. The prevention of dental disease is a greater achievement than its correction by treatment, and it is only by preventive methods that the incidence of dental disease can be reduced. As the school dental officers are so occupied in treatment, they have, unfortunately, very little time to devote to dental education. The teaching of dental health in schools by the teachers would help immensely. The teacher's influence on the child's mind is in many ways greater than that of the parents. If thev could, among their multifarious duties, add another, namely, the imparting of a knowledge of oral hygiene to the children in their care, the results would soon be seen in an improved standard of dental hygiene. The Dental Surgeons can help by giving talks at Clinics and Centres; and Health Visitors in carrying out home visitations have a unique opportunity for promoting knowledge for prevention of dental disease. 275 Dental Board Exhibit. During the year the Dental Board kindly sent a demonstrator to visit some of the schools and give a talk to the children. These talks were illustrated with exhibits, and the children appeared to enjoy the demonstration very much. Unfortunately, those schools visited, which were inspected soon afterwards, did not produce an increase in acceptances, but it is possible that the effect of the Dental Board exhibit may be felt when the schools are next inspected. Selhurst Road Clinic. The review of the work at Selhurst Road Clinic shows great progress during the year. The numbers of fillings and attendances have increased considerably, and extractions show a great reduction. The number of patients treated was slightly less than last year, but this is because an increased volume of work has been done for those treated. Summary of Work Done. 1931 1932. 1933. Attendances 3,486 3,604 3,831 Extractions 2,726 3,728 3,102 Fillings 1,457 1,667 2,002 Patients treated 2,326 2,006 1,811 Other operations 283 96 261 "Gas" cases 545 779 553 Local anaesthesia 171 490 999 New cases — 2,280 2,520 Sessions held : Inspection—49. Treatment—337. 1931 1932. 1933. Number of New Cases per Session 7.5 7.3 7.5 Attendances 11.2 11.6 11.4 Fillings 4.7 5.4 5.9 Extractions 8.8 12.02 9.2 Other operations 0.9 0.31 0.77 Ratio of Fillings to Extractions 1:1.8 1 :2.2 1 :1.4 Mr. Bryce also held 49 sessions at Lodge Road Clinic, and these figures do not include the work done at the Selhurst Clinic. 276 THE ORTHODONTIC SCHEME. During the year this branch of the work continued to progress, and since the Scheme started 368 cases have been treated or are undergoing treatment. Of this number 263 have been treated by fixed and removable appliances, and 105 cases by extraction only. New cases dealt with during the year have been fewer than in previous years because so many new cases were taken in 1932. The 68 cases that were completed during the year will enable more new cases to be dealt with in 1934. In some of the completed cases which showed gross deformity before treatment the children are wearing retention plates to prevent relapse. Percentage of Malocclusion. At dental inspections 188 children were found to be suffering from irregularity of the teeth, this being approximately 1 per cent. of the total number of children inspected. The percentage of deformity associated with the jaws and teeth is higher than that in any other part of the body, and chiefly as a result of that maldevelopment, disease is more prevalent in the mouth. The Cost of the Scheme. The charge for treatment is on a flat rate basis of 12s. 6d. per case. This charge includes the fitting and making of all the necessary appliances, and the dental mechanic is paid four-fifths of this charge for making appliances. Small deposits are asked for the use of Friels lip discs and Badcock screw spanners; these deposits are refunded when the treatment is completed. The Scheme has been self-supporting, and there has been no charge on the rates. Age for Treatment. Most of the children are treated between the ages of 8 and 11 years. A few have been fitted with suitable appliances at an earlier age, chiefly when the deformity has been caused by bad habits. In the case of treatment under 8 years muscle exercises are tried at first, and if improvement is not progressing as quickly as is required appliances are fitted, but exercises are still continued to aid treatment. 277 Muscle Exercises. The types of cases which benefit considerably by muscle training are in posterior occlusion Division 1, and in irregularities produced by thumb sucking. Malocclusion in these cases is associated with mouth breathing. With the aid of appliances we are able to correct the deformities, but muscle exercises are needed to re-tone the muscles and restore their suppleness, so that nasal breathing may result. Review of Work Done. During the year 42 sessions were devoted to orthodontic treatment, and 410 routine attendances were made. Extra verbal appointments seen after routine sessions totalled 889. The number of cases treated by extraction was 39, which shows that 20 per cent. of the cases referred for malocclusion were treated without the aid of appliances. The number of permanent teeth extracted to relieve overcrowding was 60, which is an average of 1.5 permanent teeth extracted per child. Fixed appliances were fitted in 15 cases and 169 removable appliances were inserted. Several cases were referred for X-ray, which included three cases of torsoversion and four cases for diagnosis of the presence or absence of supernumerary teeth. Sir George Newman states in the Report of the Health of the School Child, 1932, that the treatment of irregularities is of value provided that a proper perspective is maintained. Two dental surgeons devote part of a session on Monday mornings, from 10.30 to 12 noon, to the work, which may be reasonably said to be a proper proportion, having regard to the amount and urgency of the routine dental work. EAR CLINIC. In previous reports this Clinic has been called the Ionization Clinic, but in the process of time, the scope of the Clinic has extended, and actual ionization is now only a part of its function. Any children complaining of ear symptoms are now referred to this Clinic. 1933. 1932. Number of Sessions held 39 35 Number of first attendances 100 79 Number of re-attendances 286 273 278 There were 14 names on the waiting list at the end of the year. The classification of cases shows a remarkable similarity to that of previous years in the numbers in the respective groups, viz.:— (1) No evidence of otorrhœa past or present, or deafness of more than a trivial or temporary nature 15 (2) Deafness only. Some of these were due to old otitis media 13 (3) Otorrhœa, active, quiescent or cured 72 Group 2.—13 cases. Eleven were catarrhal in type and two were cases of nerve deafness. Of the catarrhal cases, three did not require any special treatment at the time; three required the removal of tonsils and adenoids; three required breathing exercises, and two required treatment by the Eustachian catheter. One of the nerve cases was "stone" deaf after cerebro-spinal meningitis and was recommended for a school for the deaf; the other was referred to the Croydon General Hospital for further investigation. Group 3.—(a) Found dry and requiring no treatment 29 (b) Found dry but recommended for accessory treatment such as tonsillectomy 8 (c) Active cases 35 Of the active cases only 9 were considered to be uncomplicated cases of tympanic sepsis (the type most amenable to local applications such as ionisation). The 35 cases were dealt with as follows:—Four were referred to the General Hospital; 7 were recommended accessory treatment with or without treatment of the ears; 2 were lost sight of; 5 are still under treatment; and 24 were discharged with ears dry. Only 7 of these were ionised, 5 were treated with iodine and boric powder, 2 had operations for tonsils and adenoids, and 11 cleared up without any special treatment. All 7 cases ionised were discharged dry within short periods. One or two cases continuing treatment from the previous year failed to clear up and were eventually referred for the mastoid 279 operation. Where one hesitates to advise operation, prolonged conservative treatment without benefit makes operation easier to recommend and more acceptable to the parents. There are several children attending the Clinic at present with otorrhoea continuing after the conservative mastoid operation. Perseverance in an effort to obtain a dry ear is made, but if the ear does not heal soon after operation the chances of success without recourse to the radical operation seem slight. In two cases this further operation has been recommended. As regards the type of case now attending for the first time, many give a short history of otorrhoea, but on careful inquiry it is usually found that there was otorrhoea in infancy and sometimes at intervals afterwards. Ionisation is applied in all cases where benefit is though likely to accrue and where it is safe to apply it, but in assessing the value of any treatment regard must be had to the figure shown above of 11 drying up without any special treatment. Most of the cases, of course, were subjected to much more frequent cleansing after starting to attend the ear clinic. The use of iodine and boric powder has been extended, and a very favourable opinion formed of its antiseptic, astringent and healing properties. Especially in old-standing cases or ears failing to heal after the conservative mastoid operation, it effects a remarkable improvement in reducing the granulations and lessening the amount of discharge. In less complicated cases it seems to be instrumental in completely drying up the ear. It is easily applied and its application is especially suitable where the dry method is desired. Greater success would be attained by the co-operation of the mother in obtaining and using the insufflator at home, but this is seldom possible. Four children with a relapse after previous ionisation applied for further treatment during the year. One of these had mastoiditis and was referred for immediate operation. The value of this Clinic becomes more manifest each year. 280 RHEUMATISM CLINIC During 1933 it has been impossible to hold this Clinic more often than once a fortnight—24 times in all. This is not often enough, and it is a pity, for although all new cases had been seen and the waiting list reduced to nil at the end of the year, re-examinations were much too infrequent, and many cases have been waiting over a year for re-examination which ought to have taken place a few weeks after the previous examination. The Clinic is not held for treatment, but is a supervisory centre. It cannot function as such if re-examinations are at such infrequent intervals. The supervision of rheumatic children is good preventive work which is not likely to be undertaken by the general practitioner amongst elementary school children. It is not true economy for the Clinic to be held at such infrequent intervals that its proper functions cannot be carried out. The number of new cases is almost the same as in 1932. It is much smaller than the numbers in the first four years of the Clinic, and it will be interesting to see if the figure is now stabilised. Dr. Preston, at the Croydon General Hospital, has again been very helpful in seeing doubtful and difficult cases and giving his advice on cases sent to him at his Out-Patients Clinic. The Convalescent Home at Coombe Cliff is a great boon for children requiring prolonged rest which they are not likely to get at home. Parents are certainly being educated about the rheumatism of childhood and are coming to recognise the symptoms and appreciate their significance. Growing pains are much less often ignored than formerly. When juvenile rheumatism and the rheumatism of grown-ups are given different names, a great stride forward will have been taken in the prevention and supervision of the former. At present it is inevitable that parents who have never been instructed to the contrary will associate rheumatic pains in their children with their own chronic aches and attach little importance to what, in their case, is little more than an annoyance, but in children may lead to lifelong invalidity. 381 Cases Examined at Rheumatism Clinic. 1933. 1932. Primary 71 76 Re-examinations 109 151 Total 180 227 Rheumatic 65 (91.5%) 65 Non-Rheumatic 6 (8.5%) 11 Total 71 76 Classification of Rheumatic cases— Sex—Males 25 (38.5%) Females 40 (61.5%) Total 65 Age when examined recorded in 63 cases:— Ages 4 5 6 7 8 9 10 11 12 13 Numbers 1 6 3 7 11 3 9 11 4 8 There has been evidence in the last two reports of a definite increase in the number of young children referred. This is an indication that parents are noticing the signs of rheumatism more than formerly. An encouraging sign. Grouping and Classification. This followed the scheme laid down in the report for 1931. Under Group I. were placed 9 children. Under Group II. were placed 56 children. Under Group III. were placed 23 children. The 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. 382 Grouping of 65 cases. Mild and Potential 32 (49.2%) Definite Active 17 (26.2%) Definite Quiescent 16 (24.6%) Total Definite Cases 33 (50.8%) 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. 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 association with slight irregularities of cardiac sounds or rhythm. The percentage of Mild and Potential cases has arisen. Probably due to the greater watchfulness and understanding of the parents. The definite and active group comprised cases of frank rheumatic carditis, as shewn 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. Group IV.—Rheumatic manifestations. Total : 65 cases. Rheumatic Pains 52 (80%) Rheumatic Fever 9 (13.8%) Chorea 12 (18.5%) Carditis Definite 25 (38.5%) Carditis Suspected 9 (13.8%) Tonsillitis 16 (24.6%) Rheumatic Fever Cases. There were 9 children who gave a definite history of rheumatic fever. Of these 2 had sound hearts, 7 had definite carditis. Chorea Cases. There were 12 cases of chorea. Of these 4 had definite carditis, 4 suspected, and 4 sound hearts. 283 Family Histories. In the case of 9 families (13.8%) either the father or the mother had had rheumatic fever or chorea. In 4 other cases (6%) a history of rheumatic fever was obtained in near relatives of the parents. In the case of 13 children (20%) their brothers or sisters gave a history of rheumatism or chorea. Skin Conditions. Recorded in 46 cases. Fair 38 (82.6%) Dark 8 (17.4%) Moist skin, history of liability to sweating, etc., was recorded in 4 cases. A history of flushings and rashes in 7 cases. Nervous Conditions. Recorded in 65 cases. Children recorded as highly strung 47 (72%) History of headaches 20 (31%) Night terrors, etc 8 (12%) Enuresis 5 (8%) Twitchings 14 (21%) Some children exhibited more than one of the above symptoms. Catarrhs. A history of various catarrhs, as distinct from tonsillitis, and mainly referred to the period of infancy and early childhood, viz., 0-5 years, was reported in 9 cases out of a total of 65 (14%). Tonsillectomy. Operation reported in 13 cases (20%). One hundred and nine re-inspeotions were carried out. In 6 of these, the condition had become worse; 9 were thought to be non-rheumatic; 72 were definitely improved and had become quiescent; and 22 stationary. 284 Environment and Other Conditions in Rheumatism Clinic Cases. Wards.—Cases were drawn from all wards in the town to the numbers shown:—Woodside, 8; VVhitehorse Manor, 6; West Thornton, 6; Upper Norwood, 4; Broad Green, 2; Waddon, 8; Addiscombe, 4; Thornton Heath, 7; East, 1; South Norwood, 4; Bensham Manor, 5; Central, 2; Norbury, 3; South, 2; and Addington, nil. 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.—41 of the houses were sufficiently drained and 8 were well drained; and in 13 drainage was problematical. 25 of the houses shewed no signs of dampness; 27 shewed traces; 5 were damp; and 1 was very damp. Aspect.—The commonest aspects of the houses were : S.E., 6; S.W., 6; E., 7; N.E., 12; N.W., 11; S., 6; N., 7; W., 14. The bulk of houses in which cases occurred were ordinary terrace houses (34) or semi-detached (14), and definite overcrowding was found in one family. The economic status of the families from whom patients came was: poor in 7; average working class, 24; better working class, 17; clerical work, 6; and superior, 5. The interior home conditions could be classified as : clean, 37; moderately clean, 15; superior, 8; 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 1933. 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. Six boys and 3 girls are resident at special schools for the blind. The institutions which these children attend are as 285 follows:—Royal Normal College for the Blind, 3 boys; Chorley Wood Blind College, 1 girl; Barclay Blind School, Brighton, 2 girls; Abbotskerswell, Devon, 1 boy; Sunshine Home, East Grinstead, 2 boys; (these are residential); 20 children attend the Special Class for Myopic Children. Deaf Children. Eight boys and 9 girls are resident at special schools for the deaf; 1 boy attends a special day school. The institutions which these children attend are : Royal School for the Deaf, Margate, 8 boys and 9 girls (this is residential); L.C.C. Day (Deaf) School, 1 boy, at Hearnville Road, Balham. Epileptic Children. Two boys and 4 girls are resident at special schools, namely, at Lingfield Epileptic Colony, 2 boys and 4 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, 3 girls are resident in the Monyhull M.D. School, Birmingham; 2 girls are at Knotty Ash M.D. School, Liverpool; and 3 boys and 1 girl at Sandlebridge, Cheshire: 1 boy at Besford Court, Worcestershire. Physically Defective Children. The Education Authority have, in addition to those accommodated at St. Giles' School, crippled children in the undermentioned special schools:—The Heritage Craft School, Chailey, 4 boys and 1 girl; Treloar Cripples' Home, Alton, 1 boy; Suntrap, Havling Island, 1 bov and 1 girl; St. Patrick's, Havling Island, 1 boy; Lancing Convalescent School, 1 boy. The Committee maintained 2 girls at West Wickhani Heart Home, a special school for cardiac cripples. SCHOOL CAMPS. A school camp was again held during the summer months at Pilgrim Fort, 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, 286 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 1933 in parties of 20 or 40, each party going for one week. All the children are medically inspected before proceeding to camp. The following are the departments which sent parties:—Ashburton, 20 boys; Davidson, 20 girls and 40 boys; Whitehorse Manor, 40 boys; Portland, 40 boys; Ecclesbourne, 20 boys; Howard, 35 boys; Kingsley, 40 boys and 40 girls; Lanfranc, 20 boys; Norbury Manor, 40 girls; Elmwood, 20 boys; West Thornton, 20 girls; Sydenham, 40 boys; Croydon British, 20 girls; Tavistock, 40 boys. JUVENILE EMPLOYMENT RETURN. The following numbers of children were examined by the medical officers during 1933 as to their fitness to follow the parttime employment indicated. There has been a decrease of 42, chiefly noticeable in the delivery of newspapers. For the past five years there has been a steady decline in the number of children examined for this purpose:— 1933. 1932. 1931. 1930. 1929. Delivery of Goods for Shopkeepers 105 119 102 140 158 Delivery of Newspapers 163 178 227 328 329 Delivery of Milk 24 37 33 28 | 40 292 334 362 496 527 Seven girls and 1 boy 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 were reorganised in October last. Children are now provided with free dinners at the Domestic Subjects Centres, as follows:—Davidson, Ecclesbourne, Elmwood, Howard, Ingram, Kingsley, Sydenham, Tavistock, Waddon, West Thornton and Woodside. Milk and cod 287 liver oil and malt have also been provided for children suffering from malnutrition. 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 every three months, if practicable, by the medical officers in cases referred on medical grounds, when 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 scheme originally suggested by the National Milk Publicity Council has been working smoothly and continuously throughout the year and has undoubtedly had beneficial results. At the end of 1933 some 5,000 penny bottles per day were being delivered at the schools. This supply is available for all elementary school children irrespective of any medical recommendation. 1932. 1933. No. of Children who received Free Dinners 748 967 ,, ,, Free Dinners provided 57,856 104,190 pints pints No. of Children who received Free Milk 118—9,126 120—9,249 ,, ,, Milk (part payment) 23—1,231 15—1,318 ,, ,, Milk (whole payment) 11—600 8—151 issues issues Free Malt 30—1,753 34—2,187 ,, „ Malt (whole payment) 22—1,250 14—1,623 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 Senior Schools the work has been mainly directed towards the consolidation of schemes introduced during the past two or three years. It has resulted in an improved carriage and bearing on the part of the boys. The teaching of Sword and Morris dancing is becoming more general in these Schools. Gymnastic shoes are now almost universally worn ; superfluous clothing is discarded, and, in many cases, the boys change into gymnastic costume. The new syllabus of Physical Training has just been introduced into the Junior Schools, and has aroused the interest of all teachers concerned. 288 The past year has been an excellent one for swimming in both Senior and Junior Schools. The number of proficiency certificates awarded constitutes a record. There has been more interest taken in Life-saving. Organised games on the playing fields and athletic training and sports take place in school time. Teachers have had opportunities to attend courses in Sword and Morris dancing, the use of the portable Swedish apparatus, and Life-saving. The monthly meetings of the specialist teachers are still held. The Croydon Schools Athletic Association has continued its excellent work of organising inter-schools competitions in cricket, football, boxing, swimming, and general athletics. This voluntary work on the part of the teachers is extremely valuable. Girls. (Central, Senior and Junior Mixed, Senior and Junior Girls and Infants). The outstanding event of the year 1933 was the issue by the Board of Education of the new Syllabus of Physical Training for Schools. This syllabus had been expected for some months, and when, by the courtesy of the Board, an advance copy was received in September, courses for both Junior and Infants' teachers were immediately arranged, and the Syllabus is already being introduced into most of the Schools, with an enthusiastic response from both teachers and pupi's. A demonstration of typical exercises in the new syllabus was arranged for Head Teachers— classes of boys and girls of the 6-7, 8-9, 9-10 and 11-12 age groups demonstrating. This demonst: ation, which was well attended, was followed by a Conference on the scope of the syllabus and its application to the Schools, the Chairman of the Education Committee presiding. Swimming again proved one of the most popular and valuable means of Physical Training from Mav till October. Well over 1,000 girls learned to swim for the first time, while the number of certificates gained exceeded all records as, with the boys' figures included, 100 per cent. increase on last year's figures was reached. All Central, Senior and Junior Departments, with the exception of three, sent girls' classes to the Baths regularlv throughout the season. Twenty Schools organised their own Swimming Galas. 289 Organised Games, particularly Netball and Rounders, were carried on throughout the year. The decision of the Netball Section of the Croydon Schools' Athletic Association to abandon all League matches and Tournaments for the year, in order to give all Schools greater opportunities of inter-house and class games, is worthy of mention, as each Department was thus enabled to provide play for all girls wishing to take part, instead of much time being spent in special coaching of selected teams for inter-school play. In place of the annual League Tournaments a special half-day was devoted to inter-house tournaments in each School. Twenty-eight Schools held sports afternoons. Folk Dancing is now an established branch of Physical Training in all but four Senior and Junior Departments, and the Schools were well represented both at the Folk Dance Party kindly given by Captain and Mrs. Lethbridge-Abell in February in connection with the competition for the Lethbridge-Abell Folk Dance Trophy and Cup, and also at the Children's Festival of Folk Dance and Song, arranged by the East Surrey Rranch of the English Folk Dance and Song Society at Ashburton Park in July. Corrective Classes, for the special treatment of cases of faulty posture were held in nine schools. During the year, three of these classes (Winterbourne, Ingram and Ashburton Junior) had to be discontinued on account of staffing and other difficulties, but two new classes were started, viz., at Kingsley and Norbury Manor. There were six classes working at the end of the year. Eleven Schools sent parties of girls either to camp or for a School Journey during the year. Of this number, five Schools went to Pilgrim Fort, the remaining six going farther afield, e.g., Seaford, Broadstairs, etc. From February to July, the Organiser of Physical Training conducted physical training classes at the Juvenile Instruction Centre for Unemployed Girls, at the Centre at Princess Road. These classes were held twice weekly. Refresher Courses and Demonstrations for Teachers held during the vear included Folk Dances, Organised Games for Junior Schools, Physical Training for Senior Schools, Courses on new Syllabus for Junior and Infants' Schools, Swimming for 290 A.S.A. Teachers' Certificate, Lecture on Swimming, and Head Teachers' Conference and Demonstration of the new Syllabus. instruction in special subjects. In the time-table for the year ending 31st March, 1934, the following provision is made for the instruction of older girls in Special Subjects, e.g., Cookery, Homecraft, Housewifery. Domestic Science:— Intensive Housewifery Centres— Tavistock. Cookery and Homecraft Centres— Howard (Domestic Science). Ingram (Domestic Science and Homecraft). Sydenham (Cookery, Homecraft and Domestic Science) Special Rooms or Centres reserved for School named— Ashburton (Domestic Science). Davidson (Domestic Science). Ecclesbourne (Domestic Science). Elmwood (Domestic Science). Kingsley (Domestic Science. Lanfranc (West Thornton Centre—Domestic Science). Ova! (Domestic Science). Portland (Woodside Centre—Domestic Science). Tavistock (Domestic Science and Homecraft). Norbury Manor (Domestic Science). Rockmount (Domestic Science). Waddon (Domestic Science). Archbishop Tenison's (Domestic Science). Lady Edridge (Domestic Science). Heath Clark (Domestic Science). Centres for Domestic Subjects have now practically ceased to exist as such. Instead, special rooms or Centres are available for each Senior Girls' School, whereby the older girls in such schools are 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 1933; 1,455 children were examined, 628 of whom were boys and '827 girls. Table II of Appendix gives the detailed findings. 56 boys (8.9 per cent.) and 172 girls (20.8 per cent.) were found to require treatment, the most usual defects being dental and defective vision. Although the figures are small, a table similar to that given for elementary school children and relating to nutrition has been included below. SECONDARY SCHOOLS. HEIGHTS AND WEIGHTS. Table XXIV. 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 ... ... ... ... ... ... ... 2 44.0 43.0 45.0 45.0 43.0 41.0 1926 ... ... ... ... ... ... ... 3 49.7 59.0 52.0 66.0 46.0 45.0 1925 ... ... ... ... ... ... ... 5 51.2 63.2 53.0 70.0 47.5 57.0 1924 ... ... ... ... ... ... ... 11 52.0 62.5 56.0 87.0 47.5 48.0 1923 8 55.4 78.4 61.0 98.0 51.0 56.7 27 54.4 69.3 60.3 112.5 50.3 52.0 1922 52 56.7 78.1 63.0 94.5 52.0 60.7 110 57.1 77.7 63.8 111.6 53.3 60.0 1921 64 58.1 82.1 64.3 117.4 53.3 64.5 211 58.7 83.9 66.5 133.3 53.0 60.2 1920 105 58.9 86.3 63.7 117.9 53.8 66.4 173 60.7 93.7 65.1 138.7 55.3 65.5 1919 178 61.2 99.1 68.9 153.5 54.9 70.9 91 62.0 101.7 65.6 121.6 58.5 79.2 1918 133 63.8 111.4 69.9 160.8 57.2 81.5 88 62.7 108.3 66.6 134.6 57.6 78.9 1917 83 66.3 124.1 70.7 154.5 59.6 90.8 13 63.5 118.1 66.0 128.8 61.8 105.5 1916 27 67.1 127.9 71.5 159.3 63.9 98.3 37 63.4 115.5 67.0 141.0 58.5 82.7 1915 1 70.0 141.5 — — — — 10 63.4 125.5 65.0 142.2 62.0 106.7 1914 ... ... ... ... ... ... ... 5 64.2 123.4 66.5 132.5 62.0 108.0 291 292 In conclusion, the report shows that much avoidable illness in school children is due to ignorance or neglect of simple physiological functions, and it is certain that if a child was fully instructed, before leaving school, in the fundamental principles of communal, personal, and domestic hygiene the health of the school children of the next generation would show a notable improvement. I beg to tender my thanks to you, ladies and gentlemen, for the consideration you have at all times extended to me. I wish to acknowledge my indebtedness to the Education Officer and members of his staff for their helpful co-operation. I desire also to bring to your notice the continued valuable services of Dr. Watson, the deputy medical officer, and others of mv colleagues in the School Medical Service. I am, Yours faithfully, OSCAR M. HOLDEN, School Medical Officer. 293 Mental Deficiency (Notification of Children) Regulations, 1928. Statement of the number of Children notified during the year ended 31st December, 1933, by the Local Education Authority to the Local Mental Deficiency Authority. Total number of children notified: 24. Analysis of the above Total. Diagnosis. Boys. Girls. 1.- -(i) Children incapable of receiving benefit or further benefit from instruction in a Special School: (a) Idiots ... 1 (b) Imbeciles 2 3 (c) Others 1 7 (ii) Children unable to be instructed in a Special School without detriment to the interests of other children: (a) Moral defectives — — (b) Others — — 2.- —Feeble-minded children notified on leaving a Special School on or before attaining the age of 16 3 6 3.- —Feeble-minded children notified under Article 3, i.e., "special circumstances" cases 1 — 4.- —Children who in addition to being mentally defective were blind or deaf — — Totals 7 17 294 ELEMENTARY SCHOOLS. Year ended 31st December, 1933. Table I. RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections— Entrants Year 1933. 2893 Year 1932. 3119 Intermediates 2861 2876 Leavers 2867 2352 Total 8621 8347 Number of other Routine Inspections 315 185 8936 8532 B.—Other Inspections. Number of Special Inspections Year 1933. 4182 Year 1932. 4847 Number of Re-inspections 6980 4810 Total 11162 9657 Total Visits to Elementary Schools 426 416 295 TABLE II A. — Return of Defects found by Medical Inspection in the Year ended 31st December, 1933. 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 32 41 ... 2 Uncleanliness 2 1 (See Table IV.—Group V.) Skin — Ringworm: Scalp ... ... ... ... Body ... ... ... ... Scabies 6 ... ... ... Impetigo ... ... 2 ... Other diseases (non-tuberculous) Eye— 1 1 ... ... Blepharitis 4 4 1 ... Conjunctivitis 1 1 ... ... Keratitis ... ... ... ... Corneal Opacities 1 ... ... ... Defective vision (excluding squint) 364 24 94 2 Squint 39 7 5 2 Other conditions 2 ... ... ... Ear— Defective hearing 4 5 4 ... Otitis media 12 12 2 2 Other ear diseases 2 2 5 Nose & Throat— Enlarged tonsils only 118 227 12 5 Adenoids only 56 25 5 1 Enlarged tonsils & adenoids 333 68 34 4 Other conditions 27 16 4 1 Enlarged Cervical Glands— (Non-tuberculous) 1 31 3 3 Defective Speech 4 6 ... ... Teeth Dental Diseases 127 6 5 ... (See Table IV.—Group IV.) Heart & Circulation— Heart disease: Organic 9 91 ... 4 Functional ... 102 ... 2 Anaemia 8 29 ... 2 Lungs— Bronchitis 12 31 ... ... Other non-tuberculous diseases 3 5 ... 2 Tuberculosis— Pulmonary—Definite ... ... ... ... ,, Suspected 3 9 ... 1 Non-pulmonary—Glands ... 2 ... ... ,, Spine ... ... ... ... ,, Hip ... ... ... ... ,, Other Bones & Joints ... ... ... ... ,, Skin ... ... ... ... ,, Other Forms ... 1 ... ... Nervous System — Epilepsy ... 4 1 2 Chorea ... 12 3 1 Other conditions 1 13 ... ... Deformities— Rickets ... ... 3 3 ... ... Spinal curvature 107 67 6 2 Other forms 113 26 16 2 Otmer Defects & Diseases 29 41 4 8 296 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. Year 1932. Inspected. Found to require treatment. (1) (2) (3) (4) (5) Code Groups— Entrants 2893 343 11.9 11.9 Intermediates 2861 339 11.8 15.2 Leavers 2867 484 16.9 15.7 Total (Code Groups) 8621 1166 13.5 14.1 Other Routine Inspections 315 47 14.9 10.3 297 TABLE III. Return of all Exceptional Children in the Area. Children Suffering from Multiple Defects. Number of children suffering from combination of defects BLIND CHILDREN. A blind child is a child who is too blind to be able to read the ordinary school books used by children. In this Section only children who are so blind that they can only be appropriately taught in a school for blind children are included. At Certified Schools for the Blind. At Public Elementary Schools. At Other Institutions. At no School or Institution. Total. 11 ... ... ... 11 PARTIALLY BLIND CHILDREN. Only children who, though they cannot read ordinary school books or cannot read them without injury to their eyesight, have such power of vision that they can appropriately be taught in a school for the partially blind are included. Children who are able by means of suitable glasses to read the ordinary school books used by children without fatigue or injury to their vision are not included in this Table. At Certified Schools for the Blind. At Certified Schools for the Partially Blind. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. ... 22 4 ... ... 26 DEAF CHILDREN. Only children who are so deaf that they can only be appropriately taught in a school for the deaf are included. At Certified Schools for the Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 12 ... ... ... 12 PARTIALLY DEAF CHILDREN. Only children who can appropriately be taught in a school for the partially deaf are included. At Certified Schools for the Deaf. At Certified Schools for the Partially Deaf. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. ... 3 2 ... ... 5 298 MENTALLY DEFECTIVE CHILDREN. Feeble-Minded Children. Mentally Defective children are children who, not being imbecile and not being merely dull or backward, are incapable by reason of mental defect of receiving proper benefit from the instruction in the ordinary Public Elementary Schools but are not incapable by reason of that defect of receiving benefit from instruction in Special Schools for mentally defective children. This category includes only those children for whose education and maintenance the Local Education Authority are responsible, and excludes all children who have been notified to the Local Authority under the Mental Deficiency Act. At Certified Schools for Mentally Defective Children. At Public Elementary Schools. At Private Schools. At no School or Institution. Total. 120 14 5 13 152 EPILEPTIC CHILDREN. Children Suffering from Severe Epilepsy. Only children are included who are epileptic within the meaning of the Act, i.e., children who, not being idiots or imbeciles, are unfit by reason of severe epilepsy to attend the ordinary Public Elementary Schools. At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. 6 7 ... ... 13 PHYSICALLY DEFECTIVE CHILDREN. Physically Defective children are children who, by reason of physical defect, are incapable of receiving proper benefit from the instruction in the ordinary Public Elementary Schools, but are not incapable by reason of that defect of receiving benefit from instruction in Special Schools for physically defective children. A. Tuberculous Children. In this category are placed only cases diagnosed as tuberculous and requiring treatment for tuberculosis at a sanatorium, a dispensary, or elsewhere. Children suffering from crippling due to tuberculosis which is regarded as being no longer in need of treatment are recorded as crippled children, provided that the degree of crippling is such as to interfere materially with a child's normal mode of life. All other cases of tuberculosis regarded as being no longer in need of treatment are recorded as delicate children. I—Children Suffering from Pulmonary Tuberculosis. (Including pleura and intra-thoracic glands.) At Certified Special Schools. At Public Elementary Schools. At other Institutions. At no School or Institution. Total. nil nil nil nil nil 301 Group III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received operative treatment. Received other forms of treatment. Total number treated. 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) (i) (ii.) (iii) (iv) (i) <ii) (iii) (iv) (i) (ii) (iii) (iv) 3 46 350 - 14 40 1 17 46 390 1 ... 454 Year 1932 281 75 356 ... 356 (i) Tonsils only. (ii) Adenoids only, (iii) Tonsils and adenoids. (iv) Other defects of the nose and throat. GROUP IV.—Orthopaedic and Postural Defects. Under the Authority's Scheme. (1) Total number treated. Residential treatment with education. (i) Residential treatment without education. (ii) Non-residential treatment at an orthopaedic clinic. (iii) Number of children treated 27 20 508 520 TABLE IV. GROUP V.—Dental Defects. (l)Number of Children who were— Year 1932 (a) Inspected by the dentist:— Routine Age groups. Aged 5-6 986 Total—18087 1431 „ 6-7 1513 2031 „ 7-8 1728 2008 „ 8-9 1643 2040 „ 9-10 1832 2216 „ 10-11 1935 2316 „ 11-12 1967 2412 „ 12-13 2090 2198 „ 13-14 2715 1354 „ 14-15 1254 722 „ 15 up 424 249 Specials 1816 1864 Grand Total 19903 20841 Year 1932 (b) Found to require treatment 14845 14837 (c) Actually treated 7773 7928 (2) Half-days devoted to Inspection 109 122 „ „ Treatment 1087 1055 1196 1177 (3) Attendances made by children for treatment 13444 13348 (4) Fillings—Permanent teeth 4795 3896 Temporary teeth 829 874 5624 4770 (5) Extractions—Permanent teeth 2707 2702 Temporary teeth 10740 11707 13447 14409 (6) Administrations of general anaesthetics for extractions 2125 2322 (7) Other operations—Permanent teeth 2077 2093 Temporary teeth 77 28 2154 2121 302 GROUP VI.—Uncleanliness and Verminous Conditions. Year 1932 (i) Average number of visits per school made during the year by the School Nurses (including subsequent visits) 11.0 11.9 (ii) Total number of examinations of children in the Schools by School Nurses 66758 65121 (iii) Number of individual children found unclean on first examination 1961 2633 (iv) Number of children cleansed under arrangements made by the Local Education Authority Nil 1 (v) Number of cases in which legal proceedings were taken :— (a) Under the Education Act, 1921 — — (b) Under School Attendance Bye-laws 5 303 SECONDARY SCHOOLS. Year ended 31st December, 1933. Table I. RETURN OF MEDICAL INSPECTIONS. A.—Routine Medical Inspections. Number of Code Group Inspections— Year 1933. Year 1932. Age 11 or under 221 319 12 290 445 13 286 295 14 265 273 15 219 296 16 96 181 17 62 29 18 or over 16 — Total 1455 1838 B.—Other Inspections. Year 1933. Year 1932 Number of Special Inspections 129 19 Number of Re-inspections 327 274 Total 456 293 Visits to Secondary Schools 69 87 304 SECONDARY TABLE II.—A.—Return of Defects Found by Medical Inspection in the Year Ended 31st December, 1933. 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 8 ... ... Uncleanliness ... ... ... ... (See Table IV.—Group V.) Skin— Ringworm Scalp ... ... ... ... Body ... ... ... ... Scabies ... ... ... ... Impetigo ... ... ... ... Other diseases (non tuberculous) ... ... ... ... Eye— Blepharitis ... 1 ... ... Conjunctivitis 1 ... ... ... Keratitis ... ... ... ... Corneal opacities ... ... ... ... Defective vision (excluding squint). 83 12 9 ... Squint 1 ... ... ... Other conditions 1 ... ... ... Ear- Defective hearing ... 1 ... ... Otitis media ... 1 ... ... Other eat diseases ... ... ... ... Nose and Throat Enlarged tonsils only 10 18 ... ... Adenoids only 2 1 ... ... Enlarged tonsils and adenoids ... 3 ... 1 Other conditions 2 3 ... 1 Enlarged Cervical Glands (Non Tuberculous) ... ... ... ... Defective Speech ... 1 ... ... Teeth—Dental Disease 83 3 ... ... (See Table IV.—Group IV). Heart and Circulation— Heart Disease — Organic ... 7 ... ... Functional ... 11 ... ... Anæmia 1 21 ... ... Lungs— Bronchitis ... ... ... ... Other non-tuberculous diseases ... ... ... ... Tuberculosis— Pulmonary— Definite ... ... ... ... Suspected 1 ... ... ... Non-pulmonary— Glands ... ... ... ... Spine ... ... ... ... Hip ... ... ... ... Other bones & joints ... ... ... ... Skin ... ... ... ... Other forms ... ... ... ... Nervous System— Epilepsy ... ... ... ... Chorea ... 6 ... 1 Other conditions ... 9 ... ... Deformities— Rickets ... ... ... ... Spinal curvature 31 4 / ... ... Other forms 6 7 1 2 Other Defects and Diseases 3 8 ... ... 305 SECONDARY 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. h ound to require treatment. (1) (2) (3) (4) 11 or under 221 24 10.9 12 290 41 14.2 13 286 33 11.5 14 265 19 7.2 15 219 23 10.5 16 96 1 3.1 17 62 2 3.2 18 and over 16 ... ... 1455 145 10.0 TABLE IV. — Return of Defects treated during the year ended. 31st December, 1933 Group I.—Minor Ailments (excluding uncleanliness, for which see Group V). Disease or Defect. NUMBER of defects treated, or UNDER treatment during the year. Under the Authority's scheme. Otherwise. Total (1) (2) (3) (4) Skin— Ringworm (scalp) ... ... ... ,, (body) ... ... ... Scabies ... ... ... Impetigo ... ... ... Other skin disease ... ... ... Minor Eye Defects— (External and other, but excluding cases falling in Group II) ... ... ... Minor Ear Defects— ... ... ... Miscellaneous— (e g. minor injuries, bruises, sores, chilblains, etc.) 8 ... 8 Total. 8 ... 8 306 SECONDARY Group II.—Defective Vision and Squint (excluding minor eye defects treated as minor ailments.—Group I.) Defect ox Diseases NUMBER OF DEFECTS DEALT WITH. Under Authority's Scheme. Submitted to refraction by private practitioner- or at Hoppital apart from the Authority's scheme. Otherwise. Total Year 1932 (1) (2) (3) (4) (5) ( 6) Errors of refraction (including squint) 99 8 107 52 Other defects or disease of the eyes (excluding those recorded in Group I.) ... ... ... ... Total 99 8 107 52 Total number of children for whom spectacles were prescribed:— (a) Under the Authority's scheme 71 (b) Otherwise 8 Total number of children who obtained or received spectacles:— (а) Under the Authority's scheme 73 (b) Otherwise 8 Group III.—Treatment of Defects of Nose and Throat. NUMBER OF DEFECTS. Received operative treatment. Received other forms of treatment. Total number treated. Year 1932 Under the Authority's scheme in clinic or hospital. By private practitioner or hospital apart from the Authority's schema. TOTAL (1) (2) (3) (4) (5) (6) (1) (2) (3) (4) (1) (2) (3) (4) (1) (2) 1(3) (4) ... 8 10 - - 3 - 1 - 3 1 1 - 6 1 (1) Tonsils only; (2) Adenoids only; (3) Tonsils and Adenoids, (4) Other Defects of Nose and Throat.